Publications by authors named "Zena Moore"

100 Publications

Wound cleansing for treating venous leg ulcers.

Cochrane Database Syst Rev 2021 03 10;3:CD011675. Epub 2021 Mar 10.

School of Nursing & Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland.

Background: Leg ulcers are open skin wounds that occur below the knee but above the foot. The majority of leg ulcers are venous in origin, occurring as a result of venous insufficiency, where the flow of blood through the veins is impaired; they commonly arise due to blood clots and varicose veins. Compression therapy, using bandages or stockings, is the primary treatment for venous leg ulcers. Wound cleansing can be used to remove surface contaminants, bacteria, dead tissue and excess wound fluid from the wound bed and surrounding skin, however, there is uncertainty regarding the effectiveness of cleansing and the best method or solution to use.

Objectives: To assess the effects of wound cleansing, wound cleansing solutions and wound cleansing techniques for treating venous leg ulcers.

Search Methods: In September 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

Selection Criteria: We considered randomised controlled trials (RCTs) comparing wound cleansing with no wound cleansing, or RCTs comparing different wound cleansing solutions, or different wound cleansing techniques.

Data Collection And Analysis: We screened studies for their appropriateness for inclusion, assessed their risk of bias using the Cochrane 'Risk of bias' tool, and used GRADE methodology to determine the certainty of evidence. Two review authors undertook these tasks independently, using predetermined criteria. We contacted study authors for missing data where possible.

Main Results: We included four studies with a total of 254 participants. All studies included comparisons between different types of cleansing solutions, and three of these reported our primary outcomes of complete wound healing or change in ulcer size over time, or both. Two studies reported the secondary outcome, pain. One study (27 participants), which compared polyhexamethylene biguanide (PHMB) solution with saline solution for cleansing venous leg ulcers, did not report any of the review's primary or secondary outcomes. We did not identify any studies that compared cleansing with no cleansing, or that explored comparisons between different cleansing techniques. One study (61 participants) compared aqueous oxygen peroxide with sterile water. We are uncertain whether aqueous oxygen peroxide makes any difference to the number of wounds completely healed after 12 months of follow-up (risk ratio (RR) 1.88, 95% confidence interval (CI) 1.10 to 3.20). Similarly, we are uncertain whether aqueous oxygen peroxide makes any difference to change in ulcer size after eight weeks of follow-up (mean difference (MD) -1.38 cm, 95% CI -4.35 to 1.59 cm). Finally, we are uncertain whether aqueous oxygen peroxide makes any difference to pain reduction, assessed after eight weeks of follow-up using a 0 to 100 pain rating, (MD 3.80, 95% CI -10.83 to 18.43). The evidence for these outcomes is of very low certainty (we downgraded for study limitations and imprecision; for the pain outcome we also downgraded for indirectness). Another study (40 participants) compared propyl betaine and polihexanide with a saline solution. The authors did not present the raw data in the study report so we were unable to conduct independent statistical analysis of the data. We are uncertain whether propyl betaine and polihexanide make any difference to the number of wounds completely healed, change in ulcer size over time, or wound pain reduction. The evidence is of very low certainty (we downgraded for study limitations and imprecision). The final study (126 participants) compared octenidine dihydrochloride/phenoxyethanol (OHP) with Ringer's solution. We are uncertain whether OHP makes any difference to the number of wounds healed (RR 0.96, 95% CI 0.53 to 1.72) or to the change in ulcer size over time (we were unable to conduct independent statistical analysis of available data). The evidence is of very low certainty (we downgraded for study limitations and imprecision). None of the studies reported patient preference, ease of use of the method of cleansing, cost or health-related quality of life. In one study comparing propyl betaine and polihexanide with saline solution the authors do not report any adverse events occurring. We are uncertain whether OHP makes any difference to the number of adverse events compared with Ringer's solution (RR 0.58, 95% CI 0.29 to 1.14). The evidence is of very low certainty (we downgraded for study limitations and imprecision).

Authors' Conclusions: There is currently a lack of RCT evidence to guide decision making about the effectiveness of wound cleansing compared with no cleansing and the optimal approaches to cleansing of venous leg ulcers. From the four studies identified, there is insufficient evidence to demonstrate whether the use of PHMB solution compared with saline solution; aqueous oxygen peroxide compared with sterile water; propyl betaine and polihexanide compared with a saline solution; or OHP compared with Ringer's solution makes any difference in the treatment of venous leg ulcers. Evidence from three of the studies is of very low certainty, due to study limitations and imprecision. One study did not present data for the primary or secondary outcomes. Further well-designed studies that address important clinical, quality of life and economic outcomes may be important, based on the clinical and patient priority of this uncertainty.
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http://dx.doi.org/10.1002/14651858.CD011675.pub2DOI Listing
March 2021

Facial pressure injuries and the COVID-19 pandemic: skin protection care to enhance staff safety in an acute hospital setting.

J Wound Care 2021 Mar;30(3):162-170

School of Nursing and Midwifery and Skin Wounds and Trauma Research Centre, RCSI University of Medicine and Health Sciences, Dublin.

Objectives: The aim of this study was to determine the impact of a specially designed care bundle on the development of facial pressure injuries (PI) among frontline healthcare workers wearing personal protective equipment (PPE) during the COVID-19 pandemic. The primary outcome of interest was the incidence of facial PIs. The secondary outcomes of interest were facial pain while wearing PPE and ease of use of the care bundle.

Methods: This study used a voluntary survey by questionnaire, supplemented by a qualitative analysis of interviews from a small purposive sample that took place in one large Irish hospital over a two-month period in 2020. The hospital was a city-based public university teaching hospital with 800 inpatient beds. The intervention was a care bundle consisting of skin protection, face mask selection, material use, skin inspection, cleansing and hydration developed in line with international best practice guidelines. All staff working in COVID-19 wards, intensive care units and the emergency department in the hospital were given a kitbag containing the elements of the care bundle plus an information pamphlet. Data were collected via a survey and interviews.

Results: A total of 114 staff provided feedback on the use of the care bundle. Before using the care bundle 29% (n=33) of the respondents reported developing a facial PI, whereas after using the care bundle only 8% (n=9) of the respondents reported developing a facial PI. The odds ratio (OR) of skin injury development was 4.75 (95% confidence interval (CI): 2.15-10.49; p=0.0001), suggesting that after the care bundle was issued, those who responded to the survey were almost five times less likely to develop a skin injury. Interviews with 14 staff determined that the bundle was easy to use and safe.

Conclusion: Among those who responded to the survey, the use of the bundle was associated with a reduction in the incidence of skin injury from 29% to 8%, and respondents found the bundle easy to use, safe and effective. As with evidence from the international literature, this study has identified that when skincare is prioritised, and a systematic preventative care bundle approach is adopted, there are clear benefits for the individuals involved.
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http://dx.doi.org/10.12968/jowc.2021.30.3.162DOI Listing
March 2021

Non-cancer-related lower limb lymphoedema in complex decongestive therapy: the patient experience.

J Wound Care 2021 Mar;30(3):225-233

School of Nursing and Midwifery and Skin Wounds and Trauma Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland.

Objective: Lymphoedema is a debilitating condition that results in the swelling of one or more limbs, leading to a significant impairment of mobility. From a psychosocial perspective, body image and quality of life (QoL) are also adversely affected. To date, non-cancer lymphoedema has been under-researched. The primary objectives of this study were to explore QoL and limb volume in patients with primary and secondary non-cancer-related lower limb lymphoedema during the intensive, maintenance and self-care phases of complex decongestive therapy over a 24-week period. Secondary objectives included exploring patients' experiences of living with lymphoedema and the challenges of self-care maintenance.

Method: A sequential mixed methodology, using quantitative and qualitative methods, was used. The quantitative part of the study involved the use of tape measurements at 4cm intervals to ascertain limb volume alterations. Measurements were taken during the intensive phase at weeks 1, 2, 3 and 4; and during the maintenance phase at weeks 8, 16 and 24. QoL was measured using the lymphoedema QoL (LYMQOL) leg, at baseline and weeks 8 and 24. The qualitative part of the study involved the use of semi-structured interviews with patients at week 8. Interviews explored the experiences of patients living with lymphoedema and their experiences of complex decongestive therapy.

Results: A total of 20 patients were recruited, two male and 18 female, with a mean age of 58.8 years (standard deviation (SD): 16 years), and all receiving complex decongestive therapy. At baseline, for all patients, the mean QoL score was 4.3 (SD: 2.4); and 8 (SD: 1.5) after 8 weeks of complex decongestive therapy. Mean difference was 4.00 (95% confidence interval: 2.76-5.24; p=0.00001) indicating a positive treatment effect. Limb volume measurements demonstrated a reduction in oedema from baseline to week 8. However, there were fluctuations in limb volume over the maintenance period of four months after treatment as the patients endeavoured to engage in self-care. Analysis of the interviews identified themes pertaining to lack of knowledge of lymphoedema among health professionals, a negative impact of living with lymphoedema and the positive therapeutic effect of complex decongestive therapy.

Conclusion: Lower limb lymphoedema is a chronic condition that impacts negatively on the individual. Complex decongestive therapy improves QoL and reduces oedema. However, given the fluctuations in oedema post-treatment, individuals need greater support to maintain active engagement in effective self-care strategies.
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http://dx.doi.org/10.12968/jowc.2021.30.3.225DOI Listing
March 2021

Patient and lay carer education for preventing pressure ulceration in at-risk populations.

Cochrane Database Syst Rev 2021 02 24;2:CD012006. Epub 2021 Feb 24.

School of Nursing & Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland.

Background: Pressure ulcers (PUs) are injuries to the skin and underlying tissues that occur most commonly over bony prominences, such as the hips and heels as a result of pressure and shear forces. PUs cause pain, discomfort, longer hospital stays, and decreased quality of life. They are also very costly to treat and consume substantial parts of healthcare budgets. PUs are largely preventable, and education targeted at patients and their carers is considered important.

Objectives: To assess the effects of patient and/or lay carer education on preventing pressure ulceration in at-risk people, in any care setting.

Search Methods: In June 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase; Ovid PsycINFO and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies.  There were no restrictions with respect to language, date of publication or study setting.

Selection Criteria: We included randomised controlled trials (RCTs) that recruited people of any age at risk of pressure ulceration, and RCTs that recruited people who informally care for someone at risk of pressure ulceration.

Data Collection And Analysis: Two review authors independently performed study selection, data extraction, 'Risk of bias' assessment, and GRADE assessment of the certainty of the evidence.

Main Results: We included 10 studies with 11 publications (2261 participants analysed). Seven targeted their intervention at people at risk of ulceration and measured outcomes on these at risk people; two targeted those at risk and their family carers and measured outcomes on the at risk people cared for by their families; and one targeted lay carers only and measured outcomes on the at risk people they cared for. There were two main types of interventions: the provision of information on prevention of pressure ulcers, and the use of different types of education programmes. Provision of information on the prevention of pressure ulcers Three studies (237 participants) reported data for this comparison: two provided information directly to those at risk and their carers, and the third provided information to lay carers. As data could not be pooled we present individual study data. The evidence for primary outcomes is of very low certainty (downgraded twice for study limitations and twice for imprecision). We are uncertain whether the combined use of a self-instruction manual and one-to-one patient training and counselling versus a self-instruction manual alone reduces the proportion of at risk people developing a new PU (risk ratio (RR) 0.40, 95% confidence interval (CI) 0.14 to 1.18), or whether carer self-instruction and one-to-one counselling versus self-instruction alone reduces the proportion of at risk people developing a new PU (RR 2.05, 95% CI 0.19 to 21.70). We are uncertain whether the use of home-based training, compared with routine ward-based training, reduces the proportion of at risk people developing a new PU (RR 0.53, 95% CI 0.27 to 1.02). One study explored the secondary outcome patient knowledge of pressure ulcer prevention; however, as usable data were not provided, we were unable to carry out further analysis, and no effect estimate could be calculated. Educational programmes on the prevention of pressure ulcers Seven studies (2024 participants analysed) provided data for this comparison. In all studies the intervention was aimed at people at risk of ulceration. Risk of pressure ulceration One secondary report of an included study reported the primary outcome as time to PU development or occurrence and three studies and one secondary report of an included study reported this as the proportion of at risk people developing a new PU. One study reported the secondary outcome grade of PU and five studies and one secondary report of an included study reported on patient knowledge. There is low certainty evidence of there being no clear difference in the proportion of participants developing a new PU between use of a pressure ulcer prevention care bundle (PUPCB) and standard care: HR 0.58, 95% CI 0.25 to 1.33 (downgraded twice for imprecision). One secondary report of an included study explored whether individualised PU education and monthly structured telephone follow-up reduces the mean time to PU occurrence. Not all participants in this study developed a pressure ulcer, therefore the mean time to pressure ulcer occurrence could not be calculated from the data. We are uncertain whether the following three interventions reduce the proportion of at risk people developing a new PU as we assessed the certainty of evidence as very low: individualised PU education and monthly structured telephone follow-up (RR 0.55, 95% CI 0.23 to 1.30), education delivery (RR 3.57, 95% CI 0.78 to 16.38), (downgraded twice for risk of bias and twice for imprecision); and computerised feedback and one-to-one consultations (no clear data provided), (downgraded twice for risk of bias and once for indirectness). Grade of pressure ulcer There is low certainty evidence that use of a PU prevention care bundle may make no difference to the severity of new PU development when compared with standard care. Patient knowledge We are uncertain whether the following interventions improve patient knowledge: enhanced educational intervention and structured follow-up (mean difference (MD) 9.86, 95% CI 1.55 to 18.17); multi component motivational interviewing/self-management with a multi component education intervention (no clear data provided); Spinal Cord Injury Navigator programme (no clear data provided); individualised PU education and monthly structured telephone follow-up (no clear data provided); computerised feedback (no clear data provided), structured, patient-centric PU prevention education event (MD 30.15, 95% CI 23.56 to 36.74). We assessed the certainty of the evidence for this outcome as low or very low (downgraded for risk of bias, imprecision, or indirectness).

Authors' Conclusions: We are uncertain whether educational interventions make any difference to the number of new PUs that develop, or to patient knowledge based on evidence from the 10 included studies, which we assessed as of low or very low certainty due to problems with risk of bias, serious imprecision and indirectness. The low certainty of evidence means that additional research is required to confirm these results.
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http://dx.doi.org/10.1002/14651858.CD012006.pub2DOI Listing
February 2021

The quality and clinical applicability of recommendations in pressure injury guidelines: A systematic review of clinical practice guidelines.

Int J Nurs Stud 2021 Mar 23;115:103857. Epub 2020 Dec 23.

School of Nursing & Midwifery, Griffith University, Brisbane, QLD, Australia; Menzies Institute of Health Queensland, Griffith University, Brisbane, QLD, Australia. Electronic address:

Background: Pressure injuries are one of the most frequently occurring, yet preventable hospital-acquired adverse events. Given there are many clinical practice guidelines available on the prevention and treatment of pressure injuries, it is useful to understand the quality of these guidelines and the clinical application of their recommendations.

Objective: To critically evaluate the quality and applicability of the recommendations in pressure injury prevention and treatment clinical practice guidelines.

Design: Systematic review, reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Data Sources: We systematically searched the literature published from 2005 to 2020 using MEDLINE, EMBASE, CINAHL, the Cochrane Library, ProQuest and PubMed electronic databases, and nine guideline repositories.

Review Methods: We assessed overall quality using the validated Appraisal of Guidelines for Research and Evaluation II (AGREE II) and AGREE Recommendation Excellence (AGREE-REX) tools. Overall % mean scores across AGREE II and AGREE-REX domains were calculated for each guideline. Clinical practice guidelines were then ranked in tertiles based on "high", "moderate" or "low" quality. The review protocol was registered in the International Prospective Register of Systematic Reviews.

Results: Initial combined database and repository searches yielded 3247 documents. Of these,73 full text documents were reviewed. The final analysis included 12 complete guidelines and 14 related documents. Overall AGREE II scores ranged from 32% to 96% while AGREE-REX scores were generally lower ranging from 10% to 75%. Combined % mean scores across AGREE II and AGREE-REX criteria suggest that four guidelines were ranked as "high" (range 69% to 85%) and are recommended without modification. These included; the 2019 International Guideline, the 2016 Canadian Guideline, the 2014 NICE Guideline, and the 2013 Belgian Guideline.

Conclusions: There is disparity in the quality of the included guidelines, however four high quality guidelines are available. These guidelines could ideally be implemented in daily practice and adapted to local policies.
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http://dx.doi.org/10.1016/j.ijnurstu.2020.103857DOI Listing
March 2021

Dressings for preventing pressure ulcers: how do they work?

J Wound Care 2021 Jan;30(1):33-39

School of Nursing and Midwifery, Royal College of Surgeons in Ireland University of Medicine and Health Sciences.

Pressure ulcers (PUs) negatively affect quality of life (QoL) and cause problems for patients, such as pain, distress and often specific difficulties with treatments used to manage the wound. Thus, it is important to implement appropriate prevention strategies in order to achieve high-quality care, thereby reducing the burden of PUs on patients, the healthcare system and society as a whole. PU development arises due to the adverse effects of pressure, shear, friction and moisture at the skin/surface interface. Preventive interventions typically include risk assessment, reducing pressure and minimising shear and friction. More recently, certain wound dressings, as a potential additional protective strategy for preventing PUs, have been introduced. This review explores the mechanisms of action of dressings for preventing PUs. Findings from the review indicate that decreasing frictional forces transmitted to the patient's skin is achieved by use of a dressing with an outer surface made from a low friction material. Furthermore, the ability of dressings to absorb and redistribute shear forces through good adhesion to the skin, high loft and lateral movement of the dressing layers is important in reducing shear forces. This is achieved when the dressing reduces pressure transmitted to the patient's tissues by the propriety of high loft/thickness and padding that allows a degree of cushioning of bony prominences. Further, dressings may reduce humidity at the skin/dressing interface, i.e., the dressing is absorbent and/or permits moisture to evaporate quickly. As part of an established PU prevention protocol, dressings may help decrease PU incidence.
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http://dx.doi.org/10.12968/jowc.2021.30.1.33DOI Listing
January 2021

The economic impact of pressure ulcers among patients in intensive care units. A systematic review.

J Tissue Viability 2020 Dec 30. Epub 2020 Dec 30.

Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Belgium; Lida Institute, Shanghai, China; University of Wales, United Kingdom.

Background: The incidence and prevalence of pressure ulcers in critically ill patients in intensive care units (ICUs) remain high, despite the wealth of knowledge on appropriate prevention strategies currently available.

Methods: The primary objective of this systematic review was to examine the economic impact of pressure ulcers (PU) among adult intensive care patients. A systematic review was undertaken, and the following databases were searched; Medline, Embase, CINAHL, and The Cochrane Library. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was used to formulate the review. Quality appraisal was undertaken using the Consensus on Health Economic Criteria (CHEC)-list. Data were extracted using a pre-designed extraction tool, and a narrative analysis was undertaken.

Results: Seven studies met the inclusion criteria. Five reported costs associated with the prevention of pressure ulcers and three explored costs of treatment strategies. Four main PU prevention cost items were identified: support surfaces, dressing materials, staff costs, and costs associated with mobilisation. Seven main PU treatment cost items were reported: dressing materials, support surfaces, drugs, surgery, lab tests, imaging, additional stays and nursing care. The overall validities of the studies varied between 37 and 79%, meaning that there is potential for bias within all the included studies.

Conclusion: There was a significant difference in the cost of PU prevention and treatment strategies between studies. This is problematic as it becomes difficult to accurately evaluate costs from the existing literature, thereby inhibiting the usefulness of the data to inform practice. Given the methodological heterogeneity among studies, future studies in this area are needed and these should use specific methodological guidelines to generate high-quality health economic studies.
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http://dx.doi.org/10.1016/j.jtv.2020.12.004DOI Listing
December 2020

Subepidermal Moisture and Pressure Injury in a Pediatric Population: A Prospective Observational Study.

J Wound Ostomy Continence Nurs 2020 Jul/Aug;47(4):329-335

Barbara M. Bates-Jensen, PhD, RN, WOCN, FAAN, School of Nursing and David Geffen School of Medicine, University of California, Los Angeles.

Purpose: To describe relationships between subepidermal moisture (SEM) and visual skin assessment of pressure injury (PI) in children.

Design: Prospective descriptive study.

Subjects And Setting: Twenty-four participants aged 8 to 16 years recruited from a pediatric orthopedic unit in a children's hospital in Ireland.

Methods: Subepidermal moisture measured with the SEM scanner (Bruin Biometrics, Los Angeles, California) ranged from 0 to 7 picoFarads [pF], and visual observation of trunk and heels occurred daily for 3 days after admission to the unit and/or after surgery. Skin was assessed for discoloration categorized as blanchable erythema, stage 1 PI, or deep tissue injury (DTI). Any open wound PI was classified as stage 2, 3, 4, or unstageable. Demographic, medical, and pain data were collected. Chi-square test, t tests, analysis of variance, and regression were used to describe data and examine relationships.

Results: Participants were pediatric patients; 100% (n = 24) were white, 62% (n = 15) were female, 8 to 16 years of age (mean = 12.5 ± 2.5 years), and 29% (n = 7) had fractures and 71% (n = 17) surgery diagnoses. Blanchable erythema incidence was 21% (n = 5) and stage 1 PI incidence was 42% (n = 10); nearly all at heels. Deep tissue injury incidence was 4% (one sacral DTI). Stage 2 or greater PI incidence was 4% (one heel stage 2 PI). For skin that was assessed as normal in this pediatric population, SEM for trunk was 2.65 to 2.76 pF and for heels 2.37 to 2.41 pF. Subepidermal moisture for blanchable erythema and stage 1 PI was higher (range, 3.2-3.7 pF) and significant at trochanters and heels (left trochanter: P = .003; right trochanter: P = .02; right and left heels: P = .000). Nominal regression, controlling for participant and assessment day, showed SEM a predictor of erythema and stage 1 PI at heels. We also found that SEM was higher with pain (significant at sacrum and heels).

Conclusions: In this pediatric population, SEM values over skin assessed as normal are lower than SEM values reported for normal skin in adults, 2.37 to 2.76 pF. Subepidermal moisture was significantly higher for blanchable erythema and stage 1 PI at trochanters and heels, and with the presence of pain at sacrum and heels. We recommend that SEM should be examined for detecting PIs in pediatric populations; SEM and pain should be explored in larger pediatric and adult populations.
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http://dx.doi.org/10.1097/WON.0000000000000654DOI Listing
December 2020

What is the Impact of Outreach Services on Medication Adherence for COPD Patients? A Systematic Review.

COPD 2020 12 26;17(6):732-741. Epub 2020 Oct 26.

School of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin 2, Ireland.

Chronic obstructive pulmonary disease (COPD) patients have been known to have poor medication adherence rates. The purpose of this systematic review was to assess if outreach services could impact on medication compliance rates. CINAHL, Medline, Clinical Key and Cochrane library were all searched electronically along with grey literature for all eligible studies conducted on COPD patients in a non-acute hospital setting. Systematic review methodology was followed for data selection, extraction and risk of bias, validity testing and data analysis. Eight studies met all inclusion criteria. 4 randomised control trials and 4 quantitative intention-to-treat studies. 2 of the studies failed validity testing but due to a lack of articles, were included in the synthesis. Given the heterogeneity of data, a narrative synthesis was adopted. All 8 studies demonstrated the ability for an outreach service to improve medication adherence in the community setting. Secondary to this result, this systematic review showed the ability to reduce hospital admissions of exacerbations of COPD due to increased medication adherence. Quality of life was assessed but did not improve but importantly did not decrease. Medication adherence has the potential to be improved from an outreach programme but requires more high-quality research in the area to develop a standardised plan of care to identify the most effective way of educating patients on medication adherence. Medication adherence education should not be a once-off assessment, this systematic review has shown it must be continuous, re-checked and re-educated regularly.
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http://dx.doi.org/10.1080/15412555.2020.1833852DOI Listing
December 2020

Repositioning for preventing pressure ulcers: a systematic review and meta-analysis.

J Wound Care 2020 09;29(9):496-508

School of Nursing and Midwifery and Skin Wounds and Trauma Research Centre, Royal College of Surgeons in Ireland University of Medicine and Science, Ireland.

Objective: The aim of this systematic review was to assess the effects of different repositioning regimens on pressure ulcer (PU) incidence in at-risk adult individuals without existing PUs.

Method: Using systematic review methodology, randomised controlled trials (RCTs), including cluster-RCTs, prospective non-RCTs, pre-post-studies and interrupted-time-series studies were considered. Specifically explored was the impact of the frequency of repositioning, use of repositioning systems and use of turning teams. The search was conducted in January 2019, using PubMed, CINAHL, SCOPUS, Cochrane and EMBASE databases. Data were extracted using a pre-designed extraction tool and analysis was undertaken using RevMan.

Results: A total of 530 records were returned, of which 16 met the inclusion criteria. Half of studies were conducted in intensive care units (50%). The mean sample size was 629±604 participants. Frequency of repositioning was explored in nine studies. PU incidence was 8% (n=221/2834) for repositioning every 2-3 hours, versus 13% (n=398/3050) for repositioning every 4-6 hours. The odds ratio (OR) was 0.75 (95% confidence interval (CI): 0.61-0.90, p=0.03), suggesting that there is a 25% reduction in the odds of PU development in favour of more frequent repositioning. Use of a repositioning system was explored in three studies. PU incidence was 2% (17/865) for the repositioning system, versus 5.5% (51/926) for care without using the repositioning system. The OR was 0.26 (95% CI: 0.05-1.29, p=0.10); this finding was not statistically significant. Use of a turning team was explored in two studies. PU incidence was 11% (n=22/200) with use of a turning team versus 20% (n=40/200) for usual care. The OR was 0.49 (95% CI: 0.27-0.86, p=0.01) suggesting that there is a 51% reduction in the odds of PU development in favour of use of a turning team. Using GRADE appraisal, the certainty of the evidence was assessed as low.

Conclusion: The results of this systematic review indicate that more frequent repositioning and use of a turning team reduce PU incidence. However, given the low certainty of evidence, results should be interpreted with caution.
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http://dx.doi.org/10.12968/jowc.2020.29.9.496DOI Listing
September 2020

Sub-epidermal moisture measurement: an evidence-based approach to the assessment for early evidence of pressure ulcer presence.

Int Wound J 2020 Dec 19;17(6):1615-1623. Epub 2020 Jul 19.

School of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland.

This paper aims to discuss the literature pertaining to early pressure-shear induced tissue damage detection, with emphasis on sub-epidermal moisture measurement (SEM). The current method for pressure detection is visual skin assessment (VSA); however, this method is fraught with challenges. Advances in early detection of pressure ulcers are reported in the literature and mainly involve measuring inflammation markers on weight-bearing anatomical areas in order to capture the first signs of tissue damage. One novel technique currently in use is SEM measurement. This biophysical marker is the product of plasma that leaks as a response to local inflammation arising due to pressure-shear induced damage over bony prominences. The early detection of tissue damage is beneficial in two different ways. First, it enables early intervention when the damage is still microscopic and reversible and, therefore, has the potential to prevent further aggravation of healthy surrounding tissue. This arises by avoiding the causation of the problem and stopping the knock-on effect of inflammation, especially when the rapid pressure ulceration pathway of deformation is in place. Second, when the slow ischaemic-reperfusion related mechanism is undergoing, cell death can be avoided when the problem is identified before the cell reaches the "death threshold," completely averting a pressure ulcer.
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http://dx.doi.org/10.1111/iwj.13437DOI Listing
December 2020

Nutritional interventions for treating foot ulcers in people with diabetes.

Cochrane Database Syst Rev 2020 07 17;7:CD011378. Epub 2020 Jul 17.

School of Nursing & Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland.

Background: Foot ulcers in people with diabetes are non-healing, or poorly healing, partial, or full-thickness wounds below the ankle. These ulcers are common, expensive to manage and cause significant morbidity and mortality. The presence of a wound has an impact on nutritional status because of the metabolic cost of repairing tissue damage, in addition to the nutrient losses via wound fluid. Nutritional interventions may improve wound healing of foot ulcers in people with diabetes.

Objectives: To evaluate the effects of nutritional interventions on the healing of foot ulcers in people with diabetes.

Search Methods: In March 2020 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

Selection Criteria: We included randomised controlled trials (RCTs) that evaluated the effect of nutritional interventions on the healing of foot ulcers in people with diabetes.

Data Collection And Analysis: Two review authors, working independently, assessed included RCTs for their risk of bias and rated the certainty of evidence using GRADE methodology, using pre-determined inclusion and quality criteria.

Main Results: We identified nine RCTs (629 participants). Studies explored oral nutritional interventions as follows: a protein (20 g protein per 200 mL bottle), 1 kcal/mL ready-to-drink, nutritional supplement with added vitamins, minerals and trace elements; arginine, glutamine and β-hydroxy-β-methylbutyrate supplement; 220 mg zinc sulphate supplements; 250 mg magnesium oxide supplements; 1000 mg/day omega-3 fatty acid from flaxseed oil; 150,000 IU of vitamin D, versus 300,000 IU of vitamin D; 250 mg magnesium oxide plus 400 IU vitamin E and 50,000 IU vitamin D supplements. The comparator in eight studies was placebo, and in one study a different dose of vitamin D. Eight studies reported the primary outcome measure of ulcer healing; only two studies reported a measure of complete healing. Six further studies reported measures of change in ulcer dimension, these studies reported only individual parameters of ulcer dimensions (i.e. length, width and depth) and not change in ulcer volume. All of the evidence identified was very low certainty. We downgraded it for risks of bias, indirectness and imprecision. It is uncertain whether oral nutritional supplement with 20 g protein per 200 mL bottle, 1 kcal/mL, nutritional supplement with added vitamins, minerals and trace elements, increases the proportion of ulcers healed at six months more than placebo (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.42 to 1.53). It is also uncertain whether arginine, glutamine and β-hydroxy-β-methylbutyrate supplement increases the proportion of ulcers healed at 16 weeks compared with placebo (RR 1.09, 95% CI 0.85 to 1.40). It is uncertain whether the following interventions change parameters of ulcer dimensions over time when compared with placebo; 220 mg zinc sulphate supplement containing 50 mg elemental zinc, 250 mg magnesium oxide supplement, 1000 mg/day omega-3 fatty acid from flaxseed oil supplement, magnesium and vitamin E co-supplementation and vitamin D supplementation. It is also uncertain whether 150,000 IU of vitamin D, impacts ulcer dimensions when compared with 300,000 IU of vitamin D. Two studies explored some of the secondary outcomes of interest for this review. It is uncertain whether oral nutritional supplement with 20 g protein per 200 mL bottle, 1 kcal/mL, nutritional supplement with added vitamins, minerals and trace elements, reduces the number of deaths (RR 0.96, 95% CI 0.06 to 14.60) or amputations (RR 4.82, 95% CI 0.24 to 95.88) more than placebo. It is uncertain whether arginine, glutamine and β-hydroxy-β-methylbutyrate supplement increases health-related quality of life at 16 weeks more than placebo (MD -0.03, 95% CI -0.09 to 0.03). It is also uncertain whether arginine, glutamine and β-hydroxy-β-methylbutyrate supplement reduces the numbers of new ulcers (RR 1.04, 95% CI 0.71 to 1.51), or amputations (RR 0.66, 95% CI 0.16 to 2.69) more than placebo. None of the included studies reported the secondary outcomes cost of intervention, acceptability of the intervention (or satisfaction) with respect to patient comfort, length of patient hospital stay, surgical interventions, or osteomyelitis incidence. One study exploring the impact of arginine, glutamine and β-hydroxy-β-methylbutyrate supplement versus placebo did not report on any relevant outcomes.

Authors' Conclusions: Evidence for the impact of nutritional interventions on the healing of foot ulcers in people with diabetes compared with no nutritional supplementation, or compared with a different dose of nutritional supplementation, remains uncertain, with eight studies showing no clear benefit or harm. It is also uncertain whether there is a difference in rates of adverse events, amputation rate, development of new foot ulcers, or quality of life, between nutritional interventions and placebo. More research is needed to clarify the impact of nutritional interventions on the healing of foot ulcers in people with diabetes.
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http://dx.doi.org/10.1002/14651858.CD011378.pub2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7388930PMC
July 2020

'Smart' wound dressings for advanced wound care: a review.

J Wound Care 2020 Jul;29(7):394-406

Royal College of Surgeons in Ireland, School of Nursing, 123 St. Stephen's Green, Dublin 2 Dublin, Ireland.

Hard-to-heal wounds are a common side-effect of diabetes, obesity, pressure ulcers and age-related vascular diseases, the incidences of which are growing worldwide. The increasing financial burden of hard-to-heal wounds on global health services has provoked technological research into improving wound diagnostics and therapeutics via 'smart' dressings, within which elements such as microelectronic sensors, microprocessors and wireless communication radios are embedded. This review highlights the progress being made by research groups worldwide in producing 'smart' wound device prototypes. Significant advances have been made, for example, flexible substrates have replaced rigid circuit boards, sensors have been printed on commercial wound dressing materials and wireless communication has been demonstrated. Challenges remain, however, in the areas of power supply, disposability, low-profile components, multiparametric sensing and seamless device integration in commercial wound dressings.
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http://dx.doi.org/10.12968/jowc.2020.29.7.394DOI Listing
July 2020

Best of colleagues, worst of times.

Authors:
Zena Moore

J Wound Care 2020 Jul;29(7):377

Professor and Head of the School of Nursing and Midwifery, Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Ireland.

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http://dx.doi.org/10.12968/jowc.2020.29.7.377DOI Listing
July 2020

Prevention and treatment of pressure injuries: A meta-synthesis of Cochrane Reviews.

J Tissue Viability 2020 Nov 28;29(4):227-243. Epub 2020 Jun 28.

School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia. Electronic address: https://twitter.com/WChaboyer.

Background: There are many high-quality systematic reviews to inform practice around pressure injury (PI) prevention and treatment. However, they are often unable to provide recommendations for practice and research due to low quality trials.

Objectives: To evaluate current systematic review evidence on the prevention and treatment of PI.

Methods: This meta-synthesis was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only Cochrane Reviews were included. Evidence from reviews was independently screened and assessed for risk of bias and certainty using Grading of Recommendations, Assessment, Development and Evaluations by two authors, with a third resolving discrepancies. Methodological quality of included reviews was assessed using the second version of A Measurement Tool to Assess Systematic Reviews, and a narrative synthesis undertaken.

Results: Twenty-five Cochrane Reviews were included; eight for PI prevention and 19 for PI treatment. Prevention reviews included 102 studies (27,933 participants). Treatment reviews included 154 studies (over 16,936 participants). Three prevention reviews and nine treatment reviews reported risk of bias, judging the included trials as having low or very low certainty evidence. Two reviews reported moderate certainty evidence. Methodological quality of the systematic reviews was rated as high for eight reviews (7/19 for treatment and 1/6 for prevention). Recommendations for prevention included repositioning, nutrition and support surfaces. Recommendations for treatment focused on nutrition and repositioning.

Conclusions: This meta-synthesis confirms the low-certainty of PI prevention and treatment trials, resulting in few recommendations to inform clinical practice. Generation of high-quality evidence on PI prevention and treatment is imperative.
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http://dx.doi.org/10.1016/j.jtv.2020.05.004DOI Listing
November 2020

Risk Prediction for Adverse Outcomes for Frail Older Persons with Complex Healthcare and Social Care Needs Admitted to a Community Virtual Ward Model.

Clin Interv Aging 2020 22;15:915-926. Epub 2020 Jun 22.

School of Nursing and Midwifery, Royal College of Surgeons Ireland, Dublin, Ireland.

Purpose: Population ageing is challenging healthcare systems with limited resources, necessitating the development of new care models to address the needs of older, frail community-dwellers. Community Virtual Wards (CVW) reduce adverse events in these patients. We examined the effect of an established CVW on pre-defined health trajectories (between "stable", "deteriorating", and "unstable" states) and characteristics that increased the likelihood of adverse healthcare outcomes (hospitalization, institutionalization and death).

Patients And Methods: We collected prospective data on frail patients admitted to a CVW in a single centre in Ireland. Relationships between risk scores, health states and adverse outcomes at 30, 60 and 90 days after admission were examined using multinomial regression analysis.

Results: In total, 88 community-dwellers, mean (±SD) age of 82.8 ±6.4 years, were included. Most were severely frail on the Rockwood Clinical Frailty Scale (mean 6.8/9 ±1.33). Reaching stability ("stable" state) within 30 days was a predictor for stability at 60 and 90 days and remaining at home. Stability was also associated with fewer care episodes (<2) (p=<0.001), a requirement for fewer healthcare professionals (HCP) (<7) (p<0.001) and lower risk of delirium (p<0.001). By contrast, being "unstable" at 60 days increased the numbers of HCP referrals (>7) and was predictive of more acute episodes (>2) and institutionalization or death (p<0.001). Predictors of adverse outcomes of either institutionalization or death included frailty status, function, mobility, nutrition, pressure ulcer risk and cognition.

Conclusion: A CVW model can provide a framework for monitoring and case management to support older people to remain at home or identify those at risk of institutional care. The use of defined health states helped to stratify those at lower or higher risk in an already high-risk frail population. Level of frailty, function, mobility, nutrition, pressure ulcer risks and cognition were predictive of remaining at home and reaching a level of stability or instability/deterioration and institutional care.
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http://dx.doi.org/10.2147/CIA.S236895DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7320026PMC
November 2020

Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the COVID-19 emergency.

J Wound Care 2020 Jun;29(6):312-320

School of Nursing and Midwifery, Royal College of Surgeons in Ireland.

Objective: Pressure ulcers (PUs) involve the destruction of skin and underlying tissue due to prolonged pressure and shear forces. These ulcers are painful and significantly reduce a person's quality of life. PUs are also expensive to manage and impact negatively on the achievement of cost-effective, efficient care delivery.

Method: Prone positioning is a postural therapy that aims to enhance respiratory function through increasing oxygenation levels. In contemporary clinical practice, ventilation in the prone position is indicated for patients with severe acute respiratory distress syndrome. However, despite its advantages in terms of respiratory function, several studies have examined complications of prone position ventilation and have identified PUs (facial PUs as well as PUs on other weight-bearing areas of the body) as a frequent complication in patients who are already in a precarious medical situation. International data suggest that up to 57% of patients nursed in the prone position develop a PU. The aim of this clinical review is to identify and review evidence-based recommendations developed to facilitate the selection and application of preventive interventions aimed at reducing PU development in patients ventilated in the prone position. Given the current COVID-19 crisis, this review is timely as intensive care unit (ICU) patients with COVID-19 require ventilation in the prone position at a level that is disproportionate to the general intensive care population. Up to 28% of patients admitted to the ICU with confirmed infection due to severe COVID-19 are cared for in the prone position. The scope of this review is limited to adult individuals only.

Results: The skin assessment should be undertaken before proning and following positioning the patient back into the supine position. Although it is essential to keep the skin clean and moisturised, using pH-balanced cleansers, there is inconsistency in terms of the evidence to support the type of moisturiser. Use of positioning devices in addition to repositioning is recommended to offload pressure points on the face and body. Further, using dressings such as hydrocolloids, transparent film and silicone may be of benefit in decreasing facial skin breakdown.

Conclusion: Given the importance of PU prevention in this cohort of patients, adopting a focused prevention strategy, including skin assessment and care, offloading and pressure redistribution, and dressings for prevention may contribute to a reduction in the incidence and prevalence of these largely preventable wounds.
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http://dx.doi.org/10.12968/jowc.2020.29.6.312DOI Listing
June 2020

Pressure ulcer/injury classification today: An international perspective.

J Tissue Viability 2020 Aug 1;29(3):197-203. Epub 2020 May 1.

Curtin University, School of Nursing, Midwifery and Paramedicine, Australia; LaTrobe University, Australian Centre for Evidence Based Aged Care, School of Nursing and Midwifery, Australia; Australian National University, ANU Medical School, Academic Unit of General Practice, Australia.

There has been an ongoing debate in the healthcare community about what pressure ulcers/injuries are, and how to name, define and classify them. The aim of this discussion paper is to provide a brief theoretical background about pressure ulcer/injury classification, to explain the approach the Guideline Governance Group has taken during the 2019 update of the International Guideline for 'Prevention and Treatment of Pressure Ulcers/Injuries' and to share views on how to best implement pressure ulcer/injury classification. First formal pressure ulcer/injury classifications were introduced in the 1950s and today various pressure ulcer/injury classification systems are used worldwide. Dissimilarities between commonly used classification systems may be considered a limitation that impedes clinical and scientific communication. However, the conceptual meaning of pressure ulcer/injury categories described within the various classification systems is comparable and the current evidence does not indicate that one classification is superior to another. Therefore, the Guideline Governance Group created a crosswalk of the major pressure ulcer/injury classifications in common use across different geographic regions. Clinicians are encouraged to use the classification system adopted by their healthcare setting in the most consistent way. The validity of pressure ulcer/injury classification is closely linked to its intended purpose. Studying measurement properties of pressure ulcer/injury classification systems must follow state-of-the-art methods. Structured educational interventions are helpful for improving diagnostic accuracy and reducing misclassification of pressure ulcers/injuries. Implementation of innovative skin and soft tissue assessments and revised pressure ulcer/injury classifications are only worth implementing, when the diagnostic information improves clinical care.
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http://dx.doi.org/10.1016/j.jtv.2020.04.003DOI Listing
August 2020

Impaired mobility and pressure ulcer development in older adults: Excess movement and too little movement-Two sides of the one coin?

J Clin Nurs 2020 Aug 25;29(15-16):2927-2944. Epub 2020 May 25.

School of Nursing and Midwifery, Skin Wounds and Trauma - SWaT Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland.

Aim: To identify how activity and mobility lead to pressure ulcer development, using two objective assessments, one for mobility and one for early pressure ulcer detection.

Methods: 150 older persons from long-term settings were followed up for 20 days, using an observational, quantitative, prospective study design. The study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology statement. Visual skin assessment and sub-epidermal moisture assessments were undertaken daily. Activity was measured using the Braden subscale. Further, a mobility profile of the participants was identified using a piezoelectric motion sensor which provided a "movement score" (mean number of movements/hour). Movement scores from 22 healthy participants were also measured to better understand the mobility profile in a healthy population.

Results: Pressure ulcer incidence using visual skin assessment was 12.7% (low movers = 6.7%; high movers = 6%) and 78.7% using sub-epidermal moisture assessment (low movers = 40.0%; high movers = 38.7%). Sub-epidermal moisture assessment detected pressure ulcers on average 8.2 days before they appeared visually on the skin's surface. Pressure ulcer detection was 25 times greater using sub-epidermal moisture compared to visual skin assessment. Considering the results of the "movement level" assessment using the motion sensor technology, of all those who were determined to be immobile by Braden, 18.8% were assessed as high movers.

Discussion & Conclusion: Pressure ulcers occurred both in low and high movers, which was unexpected as a similar finding has not been previously reported in the literature.

Relevance To Clinical Practice: The traditional focus on low movers/immobile individuals may detract from the identification of those making an abnormally high frequency of unsafe movements. Pressure ulcer assessment can be enhanced through a combination of sub-epidermal moisture assessment and visual skin assessment, and through the identification of both individuals with impaired mobility and those abnormally high movements, such as among those who are agitated.
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http://dx.doi.org/10.1111/jocn.15316DOI Listing
August 2020

Accuracy of Transcutaneous Bilirubin Versus Serum Bilirubin Measurement in Preterm Infants Receiving Phototherapy: A Systematic Review.

Adv Neonatal Care 2020 Dec;20(6):E118-E126

University Hospital Galway, Ireland (Ms Hynes); School of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland (Drs Moore, Patton, and Nugent and Mr O'Connor).

Background: Jaundice is a common condition among preterm infants in the neonatal intensive care unit (NICU). Total serum bilirubin (TSB) offers a gold standard tool for measurement, but blood sampling can be costly, time-consuming, and not without risks of infection and pain. Transcutaneous bilimeter (TcB) allows for noninvasive assessment of bilirubin. However, due to questions of accuracy the use of the TcB in preterm infants receiving phototherapy has not been widely adapted in the NICU.

Purpose: To systematically review studies that measure TcB versus TSB bilirubin in preterm infants who are receiving phototherapy.

Methods: A systematic electronic search of databases (CINAHL, EMBASE, Cochrane, Medline, PubMed) was completed for English language publications. No date limitation was placed on the search. Inclusion criteria were based on preterm infants that were in the NICU receiving or had recently received phototherapy.

Results: Nine studies of different quantitative study designs were reviewed. A good to strong correlation between TcB and TSB in preterm infants receiving phototherapy was demonstrated. There was a stronger correlation found in studies that examined TcB in unexposed skin areas during phototherapy.

Implications For Practice: TcB may allow for a reduction in blood sampling, which would reduce painful procedures, reduce the risk of infection and anemia resulting from repeated blood sampling. It also acts as a more time and cost-efficient measurement tool.

Implications For Research: Larger scaled quantitative studies on the accuracy of TcB in preterm infants receiving phototherapy are needed to provide more evidence-based data and guide clinical practice on this topic.
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http://dx.doi.org/10.1097/ANC.0000000000000738DOI Listing
December 2020

The impact of implementing speech recognition technology on the accuracy and efficiency (time to complete) clinical documentation by nurses: A systematic review.

J Clin Nurs 2020 Jul 7;29(13-14):2125-2137. Epub 2020 May 7.

School of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin 2, Ireland.

Introduction: Speech recognition technology (SRT) recognises an individual's spoken word signals through a microphone and subsequently processes the user's words into digital text by means of a computer. SRT remains well established and continues to grow in popularity among the various health disciplines. Many studies have been done to examine the effects of SRT on nursing documentation, however, no previous systematic review (SR) on the effects of SRT on accuracy and efficiency of nursing documentation was identified.

Aims And Methods: To systematically review the impact of speech recognition technology on the accuracy and efficiency of clinical nursing documentation. A SR was conducted that measures the accuracy and efficiency (time to complete documentation) of SRT on nursing documentation. An extensive search of the literature included Web of Science, CINAHL via EBSCO host, Cochrane Library, Embase, MEDLINE and Google Scholar. The PRISMA checklist screened eligible papers. The quality of each paper was critically appraised, data extracted and analysed/synthesised.

Results: A total of 10 studies were included. Various devices and systems have been used to examine the accuracy, efficiency and impact of SRT on nursing documentation. A positive impact of SRT with significant advances in accuracy/productivity of nursing documentation at the point of care was found. However, a substantial degree of initial costing, training requirements and studied interface modification to individual healthcare units are needful in incorporating SRT systems.

Conclusions: Speech recognition technology when applied to nursing documentation could open up a promising new interface for data entry from the point of care, though the full potential of the technology has not been explored.

Relevance To Clinical Practice: The compatibility/effectiveness of SRT with existing computer systems remains understudied. SRT training, prompt on-site technical support, maintenance and upgrades cannot be underestimated towards achieving high-level accuracy and efficiency (time to complete documentation) with SRT.
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http://dx.doi.org/10.1111/jocn.15261DOI Listing
July 2020

A comparison of faculty led, mentorship program and peer mentoring on nursing students wound dressing clinical skills.

Nurse Educ Today 2020 Jun 19;89:104378. Epub 2020 Feb 19.

RCSI School of Nursing and Midwifery, Deublin Ireland; Skin, Wounds and Trauma Research (SWaT) Centre, RCSI, Dublin Ireland; Fakeeh College of Health Sciences, Jeddah, Saudi Arabia; Faculty of Science, Medicine and Health, University of Wollongong, Australia.

Background: The promotion of clinical nursing education requires using modern educational methods to develop students' knowledge and skills. There are however many different models by which education can be delivered with a wealth of literature supporting varying approaches. This is of particular relevance to clinical education where to date no singular approach has been identified as being the most appropriate.

Objectives: This study aimed to compare and investigate the effect of a peer education method, a mentor-led education method versus a traditional faculty-led method for instruction regarding surgical wound care skills among nursing students.

Design: This study used an experimental three-group pre- and post-test design.

Settings: The research was conducted within two surgical wards of a university-affiliated hospital in the west of Iran.

Participants: A total of 102 nursing students (first and second year) were assigned to three groups; peer-led learning group (n = 34), mentorship-led group (n = 34) or a faculty-led control group (n = 34).

Methods: To ascertain performance in surgical dressing skill, data was collected in each group before and after the respective educational intervention. Data was collected using a surgical dressing skills checklist made by the research team which was piloted prior to the study. All statistical analysis was performed using SPSS v.22.0 (SPSS Inc., Chicago, IL).

Results: Based on findings, after the intervention, the mean (SD) scores of surgical dressing and wound care skills were 28.24 (4.63), 31.76 (4.89), and 29.12 (5.33) for the peer-led, mentor-led and faculty-led groups, respectively. There was no significant difference between mentor group and faculty group or between peer group and faculty group (P > 0.05). However, the findings did demonstrate statistical difference in performance in surgical dressings and wound care techniques in the mentorship group method compared to the peer method (P = 0.006).

Conclusions: Although participants in the mentor group performed best of all groups, our findings demonstrate that those in the peer method group performed as well as those in the faculty-led group in surgical dressing performance. Therefore, it is recommended that peer and mentor learning methods are given consideration by curriculum planners in for use in the development of student nurse clinical skill and competence in surgical wound care.
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http://dx.doi.org/10.1016/j.nedt.2020.104378DOI Listing
June 2020

An international consensus on device-related pressure ulcers: SECURE prevention.

Br J Nurs 2020 Mar;29(5):S36-S38

Advanced Nurse Practitioner in Paediatric Skin and Wound Management and Head of the Paediatric Skin Centre, University Children's Hospital Zurich, Switzerland.

and colleagues present the findings of their review, ccna2@juno.com.
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http://dx.doi.org/10.12968/bjon.2020.29.5.S36DOI Listing
March 2020

Comparison of dronedarone versus flecainide in the maintenance of sinus rhythm, following electrocardioversion in adults with persistent atrial fibrillation - a systematic review and meta-analysis.

Eur Heart J Cardiovasc Pharmacother 2020 Mar 10. Epub 2020 Mar 10.

Royal College of Surgeons in Dublin, Ireland (RCSI).

Aims: To compare flecainide and dronedarone for sinus rhythm (SR) maintenance following electrocardioversion of persistent atrial fibrillation (AF), in patients with minimal or no structural heart disease (HD).

Methods: A systematic search of publications using EMBASE, CENTRAL, CINAHL and MEDLINE (1989 to 2019), identified a total of 595 articles. No limitations were applied.

Results: Nine articles met the inclusion criteria (5 randomised controlled trials (RCTs) and 4 cohort studies), encompassing 1,349 persistent AF candidates. Two retrospective studies compared flecainide with dronedarone, indicating a 6% reduced risk of AF recurrence with flecainide, however results were not statistically significant (RR 0.94, 95% CI 0.71-1.24, p = 0.66). One RCT compared dronedarone to placebo, demonstrating a 28% reduced risk of AF recurrence at 6 months (RR 0.72, 95% CI: 0.58-0.90, p = 0.004). Two RCTs compare flecainide to placebo, when a 16% decreased risk of AF recurrence at 6-12 months was indicated, however these results were not statistically significant (RR 0.84, 95% CI: 0.66-1.07, p = 0.16). Within a 6-12 month follow-up period, a combined recurrence rate of AF was examined, in which flecainide and dronedarone maintained SR in 50% and 42% respectively. Four articles satisfied quality appraisal, one of which focused on flecainide data.

Conclusion: Dronedarone and flecainide displayed similar efficacy in maintaining SR in patients following electrocardioversion for persistent AF. The SR maintenance was numerically but not statistically significant in the flecainide group. Side-effects uncovered similar pro-arrhythmic activity. However, in light of the deficiency of volume and quality of available evidence, the writer acknowledges the requirement for future research.
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http://dx.doi.org/10.1093/ehjcvp/pvaa018DOI Listing
March 2020

The relationship between common risk factors and the pathology of pressure ulcer development: a systematic review.

J Wound Care 2020 Mar;29(Sup3):S4-S12

15 School of Nursing and Midwifery, Royal College of Surgeons in Ireland.

Objective: The aim of this systematic review was to examine the associations and relationship between commonly cited risk factors and the pathology of pressure ulcer (PU) development.

Method: Using systematic review methodology, original research studies, prospective design and human studies written in English were included. The search was conducted in March 2018, using Ovid, Ovid EMBASE and CINAHL databases. Data were extracted using a pre-designed extraction tool and all included studies were quality appraised using the evidence-based librarianship critical appraisal.

Results: A total of 382 records were identified, of which five met the inclusion criteria. The studies were conducted between 1994 and 2017. Most studies were conducted in hospital and geriatric wards. The mean sample size was 96±145.7 participants. Ischaemia, recovery of blood flow and pathological impact of pressure and shear was mainly found as the cited risk factor and PU aetiology.

Conclusion: This review systematically analysed five papers exploring the relationship between risk factors for PU development and aetiology. It identified many risk factors and underlying pathological mechanisms that interact in the development of PU including ischaemia, stress, recovery of blood flow, tissue hypoxia and the pathological impact of pressure and shear. There are several pathways in which these pathological mechanisms contribute to PU development and identifying these could establish potential ways of preventing or treating the development of PU for patients.
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http://dx.doi.org/10.12968/jowc.2020.29.Sup3.S4DOI Listing
March 2020

Patient education for preventing recurrence of venous leg ulcers: a systematic review.

J Wound Care 2020 Feb;29(2):79-91

School of Nursing and Midwifery, Skin Wounds and Trauma Research Centre, Royal College of Surgeons in Ireland.

Objective: To investigate the impact of patient education interventions on preventing the recurrence of venous leg ulcers (VLU).

Method: A systematic review was undertaken using the following databases: Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library); Ovid; Ovid (In-process and Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL. Trial registries and reference lists of relevant publications for published and ongoing trials were also searched. There were no language or publication date restrictions. Randomised controlled trials (RCTs) and cluster RCTs of patient educational interventions for preventing VLU recurrence were included. Review authors working independently assessed trials for their appropriateness for inclusion and for their risk of bias, using pre-determined inclusion and quality criteria.

Results: A total of four studies met the inclusion criteria (274 participants). Each trial explored different interventions as follows: the Lively legs programme; education delivered via a video compared with education delivered via a pamphlet; the Leg Ulcer Prevention Programme and the Lindsay Leg Club. Only one study reported the primary outcome of incidence of VLU recurrence. All studies reported at least one of the secondary outcomes: patient behaviours, patient knowledge and patient quality of life (QoL). It is uncertain whether patient education programmes make any difference to VLU recurrence at 18 months (risk ratio [RR]: 0.82; 95% confidence interval: [CI] 0.59 to 1.14) or to patient behaviours (walked at least 10 minutes/five days a week RR: 1.48; 95%CI: 0.99 to 2.21; walked at least 30 minutes/five days a week: RR 1.14; 95%CI: 0.66 to 1.98; performed leg exercises: RR: 1.47; 95%CI: 1.04 to 2.09); to knowledge scores (MD (mean difference) 5.12, 95% CI -1.54 to 11.78); or to QoL (MD: 0.85, 95% CI -0.13 to 1.83), as the certainty of evidence has been assessed as very low. It is also uncertain whether different types of education delivery make any difference to knowledge scores (MD: 12.40; 95%CI: -5.68 to 30.48). Overall, GRADE assessments of the evidence resulted predominantly in judgments of very low certainty. The studies were at high risk of bias and outcome measures were imprecise due to wide CIs and small sample sizes.

Conclusion: It is uncertain whether education makes any difference to the prevention of VLU recurrence. Therefore, further well-designed trials, addressing important clinical, QoL and economic outcomes are justified, based on the incidence of the problem and the high costs associated with VLU management.
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http://dx.doi.org/10.12968/jowc.2020.29.2.79DOI Listing
February 2020

The effect of thermoregulation quality improvement initiatives on the admission temperature of premature/very low birth-weight infants in neonatal intensive care units: A systematic review.

J Spec Pediatr Nurs 2020 04 7;25(2):e12286. Epub 2020 Jan 7.

School of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland.

Purpose: The purpose of this review was to ascertain the impact of thermoregulation quality improvement initiatives (QIs) on the admission temperatures of premature/very-low-birth-weight infants in neonatal intensive care units (NICUs).

Methods: A systematic search of databases Cumulative Index to Nursing and Allied Health Literature, Medline, Embase, and the Cochrane library was carried out. Specific inclusion and exclusion criteria were adhered to, with no publication date limitations added. The chosen studies were examined for quality, data were extracted and analysed, before a narrative synthesis was performed. The last search occurred on January 7, 2019, with PRISMA flow diagrams completed for identified studies.

Results: Ten studies of varying methodology design were included in this review. Variations of thermoregulation interventions were included in the 10 studies. Nevertheless, all of them demonstrated that admission temperature rates can be significantly improved by implementing a thermoregulation QI. The multidisciplinary team and ongoing education were seen as much needed components to the overall sustainability, and continuing success of the QI's.

Practical Implications: This systematic review determines that thermoregulation QIs can positively impact the admission temperatures of premature/very-low-birth-weight infants in the NICU. Prevention of hypothermia is aimed at reducing the risks of developing major neonatal morbidities. The pooling of the results from the 10 studies helps in the sharing of outcome measures and thus, improving quantitative synthesis. More frequent monitoring of the axillary temperature would help in preventing hypothermia and hyperthermia occurring. Ongoing education and staff training are essential for managing thermoregulation successfully. Examining the compliance rates to such quality initiatives, and the variations in interventions would benefit from further research to ensure better standardisation of clinical practice.
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http://dx.doi.org/10.1111/jspn.12286DOI Listing
April 2020

Do we still need to assess nurses' attitudes towards pressure ulcer prevention? A systematic review.

J Wound Care 2019 Dec;28(12):795-806

School of Nursing and Midwifery, Royal College of Surgeons in Ireland (RCSI), Skin Wounds and Trauma Research Centre, RCSI.

Objective: To critically appraise and synthesise existing research literature pertaining to nurses' attitudes towards pressure ulcer (PU) prevention.

Method: Using systematic review methodology, published quantitative studies focusing on nurses' attitudes towards PU prevention measured by psychometric tests were included. The search was conducted in May 2019 using PubMed, CINAHL, Scopus, Cochrane and EMBASE databases, and returned 442 records, of which 21 met the inclusion criteria. Data were extracted using a pre-designed extraction tool and all included studies were quality appraised using the checklist.

Results: Of the included studies, 20 employed a cross-sectional design and one author employed a validation study. In measuring nurses' attitudes toward PU prevention two distinct instruments were used: the 'Moore and Price Attitude Scale' and the 'Attitude towards Pressure Ulcer Prevention Instrument'. The mean attitude score within the studies was 73% (standard deviation=9.2%). The lowest attitude score was 51%, while the highest score was 89%. The results obtained from the studies indicated that 86% (n=18) yielded positive attitude results.

Conclusion: The findings suggest that, overall, nurses are positively disposed towards PU prevention. However, it is important to highlight that the nurses have difficulties translating this positive attitude into actual PU prevention strategies.
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http://dx.doi.org/10.12968/jowc.2019.28.12.795DOI Listing
December 2019

Development and psychometric evaluation of the patient knowledge of, and attitudes and behaviours towards pressure ulcer prevention instrument (KPUP).

Int Wound J 2020 Apr 10;17(2):339-350. Epub 2019 Dec 10.

School of Nursing and Midwifery, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland.

The Patient Knowledge of, and Attitude and Behaviour towards Pressure Ulcer Prevention Instrument (KPUP) was developed and validated using a two-stage prospective psychometric instrument validation study design. In Stage 1, the instrument was designed, and it is psychometrically evaluated in Stage 2. To establish content validity, two expert panels independently reviewed each item for appropriateness and relevance. Psychometric evaluation included construct validity and stability testing of the instrument. The questionnaire was administered to a convenience sample of 200 people aged more than 65 years, living independently in the community; reliability and stability were assessed by test/retest procedures, with a 1-week interval. Mean knowledge scores at 'test' were 11.54/20 (95% CI = 11.10-11.99, SD: 3.07), and 'retest' was 12.24 (95% CI = 11.81-12.66, SD: 2.93). For knowledge, correlation between the test/retest score was positive (r=. 60), attitude section-inter-item correlations ranged from r = -.31 to r = .57 (mean intraclass correlation coefficient of r = .42), and internal consistency for the retest was the same as the test (α = .41 for the eight items). For health behaviours, individual inter-item correlations for test items ranged from r = -.21 to r = .41 for the 13 standardised items. Psychometric testing of the KPUP in a sample of older persons in the community provided moderate internal consistency and general high test-retest stability.
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http://dx.doi.org/10.1111/iwj.13278DOI Listing
April 2020

Preoperative and postoperative recommendations to surgical wound care interventions: A systematic meta-review of Cochrane reviews.

Int J Nurs Stud 2020 Feb 22;102:103486. Epub 2019 Nov 22.

School of Nursing and Midwifery and Menzies Health Institute Queensland, Griffith University, Australia.

Background: The increasing numbers of surgeries involving high risk, multi-morbid patients, coupled with inconsistencies in the practice of perioperative surgical wound care, increases patients' risk of surgical site infection and other wound complications.

Objectives: To synthesise and evaluate the recommendations for nursing practice and research from published systematic reviews in the Cochrane Library on nurse-led preoperative prophylaxis and postoperative surgical wound care interventions used or initiated by nurses.

Design: Meta-review, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Data Sources: The Cochrane Library database.

Review Methods: All Cochrane Systematic Reviews were eligible. Two reviewers independently selected the reviews and extracted data. One reviewer appraised the methodological quality of the included reviews using A MeaSurement Tool to Assess Systematic Reviews 2 checklist. A second reviewer independently verified these appraisals. The review protocol was registered with the Prospective Register of Systematic Reviews.

Results: Twenty-two Cochrane reviews met the inclusion criteria. Of these, 11 reviews focused on preoperative interventions to prevent infection, while 12 focused on postoperative interventions (one review assessed both pre-postoperative interventions). Across all reviews, 14 (63.6%) made at least one recommendation to undertake a specific practice, while two reviews (9.1%) made at least one specific recommendation not to undertake a practice. In relation to recommendations for further research, insufficient sample size was the most predominant methodological issue (12/22) identified across reviews.

Conclusions: The limited number of recommendations for pre-and-postoperative interventions reflects the paucity of high-quality evidence, suggesting a need for rigorous trials to address these evidence gaps in fundamentals of nursing care.
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http://dx.doi.org/10.1016/j.ijnurstu.2019.103486DOI Listing
February 2020