Sound Evidence - November 2008 - (Page 58) assessed through changes in wound dimensions. The author manually abstracted and analyzed data from patient charts. Results Study participants included six patients (two men and four women, age range 61 to 92 years), each with one Stage II PU located over the pelvic bone or coccyx or on the back or lower extremity. All patients were LTC residents with various comorbidities and severely restricted mobility (see Table 1). Patients received three to four APWT treatments of 3 to 4 minutes weekly for an average of 4 weeks (see Table 1). Three weeks after wound onset and APWT initiation, one wound completely healed and the surface area of four of the six wounds decreased 46% to 81%. After five to 13 APWT treatments, four of the six wounds were healed (see Table 1). The average time to healing was 22 days. One patient stopped APWT after 37 treatments when the wound area was reduced by 95%; this wound completely healed within a few weeks of APWT discontinuation. Treatment continued for another patient who suffered a relapse due, in part, to hospitalizations that interrupted his APWT treatments.4 During hospitalization, the wound area increased by 85%; however, in the 2 weeks following a second hospitalization and resumption of APWT, the wound area decreased by 79%. healing PUs before they progress to Stage III is essential for both the patient and the LTC facility. In addition to regulatory and reimbursement demands, PUs exact a heavy economic burden. In 1999, US hospitals spent an estimated $2.2 to $3.6 billion in the treatment of 16 million PUs. Treatment costs for Stage III or Stage IV PUs were between $14,000 and $23,000 each.9 Some ulcers never heal and require surgery to close. Implementing therapies that can decrease time to healing and subsequently decrease cost are much needed. Conclusion In a retrospective case series of six LTC patents, APWT as an adjunct to standard of care was shown to result in accelerated healing of Stage II PUs. When prevention efforts fail to eliminate PUs, strategies to thwart escalation into higher stages, as well as to facilitate healing, need implementation. Further study to this end is warranted. - OWM Acknowledgment The author thanks Tracey Fine, MS, ELS for editorial assistance. References 1. 2. National Pressure Ulcer Advisory Panel. Special report from the NPUAP: pressure ulcer stages revised by the National Pressure Ulcer Advisory Panel. Ostomy Wound Manage. 2007;53(3):32–42. Department of Health and Human Services. CMS Manual System. State Operations: Provider Certification. Centers for Medicare & Medicaid Services (CMS) Guidance to Surveyors for Long-Term Care Facilities. Transmittal 4. November 12, 2004. DHHS Pub. 100-07. Available at http://www.cms.hhs.gov/transmittals/Downloads/R4SOM.pdf. Accessed September 16, 2008. Cuddigan J, Ayello EA, Sussman C, Baranoski S, eds. Pressure Ulcers in America: Prevalence, Incidence, and Implications for the Future. Reston, Va: National Pressure Ulcer Advisory Panel; 2001. Bergstrom N, Smout R, Horn S, Spector W, Hartz A, Limcangco MR. Stage II pressure ulcer healing in nursing homes. J Am Geriatr Soc. 2008;56(8):1252–1258. Lai J, Pittelkow MR. Physiological effects of ultrasound mist on fibroblasts. Int J Dermatol. 2007;46(6):587–593. Unger P. Low-frequency, noncontact, nonthermal ultrasound therapy: a review of the literature. Ostomy Wound Manage. 2008;54(1):57–60. Gehling ML, Samies JH. The effect of noncontact, low-intensity, low-frequency therapeutic ultrasound on lower-extremity chronic wound pain: a retrospective chart review. Ostomy Wound Manage. 2007;53(3):44–50. VanGilder C, MacFarlane GD, Meyer S. Results of nine international PU prevalence surveys: 1989 to 2005. Ostomy Wound Manage. 2008;54(2):40–54. Beckrich K, Aronovitch SA. Hospital-acquired pressure ulcers: a comparison of costs in medical vs surgical patients. Nurs Econ. 1999;17(9):263–271. Discussion Under stricter federal guidelines and enforcement,2 LTC facilities have increased their vigilance regarding the prevention and treatment of PUs. Treatment guidelines for PUs have remained essentially unchanged over the past decade4; novel, low-cost treatments that prevent worsening and encourage healing of Stage II PUs are needed. Therefore, healing rates of standard treatment as found in the literature were compared to APWT used as an adjunct to standard treatment. The median rate to heal a small PU (1 cm2 or less) is 33 days4; two small PUs with an average size of 0.23 cm2 in this case series healed in 9 and 24 days, respectively. The median rate for a medium-sized PU (1 cm2 to 4 cm2) has been reported at 53 days; the medium-sized PU in this case series healed in 28 days. Large PUs (>4cm2) are reported to heal in 28 days. When prevention efforts fail, as they sometimes do,8 3. 4. 5. 6. 7. 8. 9. 58 OstomyWound Management http://www.cms.hhs.gov/transmittals/Downloads/R4SOM.pdf http://www.cms.hhs.gov/transmittals/Downloads/R4SOM.pdf
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