The Road to Better Wound Care

Use data and evidence to find the right dressings, sutures and irrigation solutions for your practice.

The person at ASCs charged with overseeing practices to prevent surgical site infections (SSIs) usually has another role (or three), so it’s crucial for centers to count on the latest wound-care evidence and follow current guideline recommendations for how to treat incisions after they’re closed, according to two infection prevention experts.

Blueprint to guide you

Consider the following recommendations from independent infection prevention consultant Maureen Spencer, MEd, BSN, RN, CIC, FAPIC, and Peter Graves, BSN, RN, CNOR, an independent clinical perioperative consultant.

• Stop using staples. The data is clear: There’s roughly a fourfold risk of infection when staples are used to close surgical wounds, according to Ms. Spencer. “I don’t get why surgeons think it’s OK to puncture skin on top of an implant. As a nurse, that makes no sense to me,” she says. “If staples are used, they should at least be covered with a transparent dressing so nothing will get down into the implant.”

Like wound care overall, Ms. Spencer says the issue isn’t dealt with proactively.

“There’s often no gatekeeper. It’s an issue that nobody wants to take on,” she says. “Many surgeons, especially at new surgery centers that don’t have full-time infection preventionists, are going to use staples because they can be faster and sometimes cheaper.”

Ms. Spencer suggests using photos of things such as blood seeping from staple holes to help persuade those skeptical of alternatives.

• Always use antimicrobial sutures. Making this switch in all surgical cases provides an opportunity to achieve a 30% to 60% reduction in SSIs, says Ms. Spencer.

Sutures coated with antimicrobial features are absorbable and are not more expensive than uncoated standard sutures. Facilities should standardize which type of sutures they purchase and use them for all procedures, she says.

“I can’t emphasize the importance of standardizing your sutures and your dressings enough,” says Mr. Graves. “When you have variability between practitioners and nobody’s doing it the same way, how do you measure your outcomes?”

Mr. Graves suggests having materials management personnel involved in all these decisions, which can reduce the possibility of them purchasing a variant of the new product that has been chosen for consistent use.

• Convert to antimicrobial dressings. Dressings with silver or another antimicrobial or antiseptic agent impregnated into their matrixes can help prevent infections in the days after surgery. Standardizing the type of dressings used for each procedure is a good practice.

“The status of the wound will determine whether standard dressings or these types of advanced dressings are appropriate,” says Mr. Graves. There are many issues to consider when choosing which type to use, including whether patients are allergic to adhesives, adds Ms. Spencer.

“It’s a challenge to corral surgeons in an effort to standardize the types of dressing they use,” says Ms. Spencer. “It takes a physician champion to say, ‘This is what we’re going to do now.’ It takes teamwork, so wound care nurses and clinical educators should also be involved.”

Noting that standardization saves money is always a good way to get the attention of physician-owners, she adds.

There are also many types of negative pressure wound therapy devices on the market that use vacuum suction dressings. Mr. Graves says studies vary on how effective they are in reducing infections.

• Investigate irrigation options. For quite some time, surgeons were using irrigants that included antibiotics in an effort to keep wounds infection-free. Some still do.

“It’s an inappropriate use of an antibiotic, which The Joint Commission and the CDC agree with. Splashing antibiotics into incisions isn’t the way antibiotics work,” says Ms. Spencer. “Facilities should say to the surgeons, ‘No more antibiotics. We now have antiseptics you can use that are prepackaged and ready to go.’” Mr. Graves agrees, saying, “Doctors want to do good and they’re trying to give the wound the best chance to heal fully, but the bottom line is antibiotics in surgical irrigation aren’t effective.”

Fortunately, there are many alternatives on the market. From simple saline to solutions that include low concentrations of chlorhexidine gluconate, povidone-iodine, polyhexaethylene biguanide or acetic acid, facilities have options for what to use to keep wounds free from debris and bacterial contaminants.

“There’s a lot of noise out there around the whole topic of what irrigation is best. They’re not one-size-fits-all: Some are for certain kinds of patients, and some for certain kinds of surgeries,” says Mr. Graves. “With all the different opinions, you should look at all the options and go back to the data to see which one has the best level of evidence to support it.”A key to saving money is to not rely on what your favorite rep is selling. Some products cost $400, while some cost $60 for what could be an equal or better product.

“There’s often no gatekeeper. (Wound care) is an issue that nobody wants to take on.”
Maureen Spencer, MEd, BSN, RN, CIC, FAPIC

“Some of the new solutions are very expensive. Some are actually moving the needle on infections, and some are not,” says Mr. Graves.

• Prehabilitate. To get patients to what Mr. Graves calls “the promised land of no infections,” providers need to optimize patients via diet, exercise and smoking cessation. “Wound care starts before surgery,” he says. OSM