THIS WEEK'S ARTICLES
The Mental Aspects of Wound Healing
Calmer, more informed patients are better equipped to handle their wounds before and after surgery.
Pain management and wound healing are tightly bound. Recent studies address the reality that managing patients' pain from surgical wounds means managing and mitigating their mental pain, too.
According to an article in the Wounds journal, "Analgesic requirements as well as patient-centered and clinical outcomes can be affected by psychological interventions as explored by considerable research." The menu of psychological interventions comprises the following:
- Procedural. Telling patients about the wounds that will result from their surgery
- Sensory. Describing how the wound will feel
- Behavioral. Telling patients what to do to facilitate recovery
- Cognitive. Coaching patients how to think more positively about the wound
- Relaxation. Systematic muscle relaxing and/or breathing techniques
- Hypnosis. Suggesting changes in patient perceptions
- Mindfulness. Techniques based on meditation or contemplation
- Emotional. Methods of coping with wound-related stress
- Patient-generated narratives. Seeing the patient's pain through their eyes, not the providers'.
The journal examined two recent systematic reviews that explored whether psychological interventions improve patient experiences or clinical outcomes for surgical patients. The first examined studies published from 2000 through 2019 that applied psychological interventions to adult patients scheduled for elective abdominal or urologic surgery, and measured pain and/or anxiety outcomes. The researchers concluded perioperative psychological interventions were effective in improving patients' anxiety, distress and pain, and that it is realistic to apply them perioperatively during abdominal or urologic surgeries.
The second reviewed the effects on postoperative outcomes of psychological preparation of adult patients planning to undergo elective surgery under general anesthesia. Unlike the first study, these researchers didn't believe the evidence they found was of high enough quality to make a definitive statement. They concluded that psychological interventions may improve post-op pain, behavioral outcomes, anxiety or distress, but based on the evidence they could only positively say that interventions are unlikely to harm patients.
Author Laura Bolton, PhD, concluded the two reviews "suggest the merit of psychological interventions in reducing pain, anxiety, distress and opioid use following surgery," but that the data still isn't robust enough to quantitatively assess its efficacy, and that there still hasn't been enough investigation of how the interventions work in conjunction with pain medications.
"Perioperative psychological interventions may trim hospital stays and help improve surgical pain, analgesic use, anxiety, depression and functional activities of daily living," wrote Dr. Bolton. "There will be definitive confirmation once studies standardize measures documenting these postoperative outcomes. Imagine the strides that could be made in advancing wound practice and science if the same clinically relevant, reliable, valid terms and measures to document wound care outcomes were used."
Even though the data isn't quite there, it's clear that employing all or some of the interventions listed above can contribute to a better patient experience, and might already be part of the patient experience at your facility.
Keeping Surgical Wounds Infection-Free
Tips on preventing scarring while minimizing SSIs.
Surgical incisions invite bacteria and other contaminants to enter patients' bodies, so efforts to prevent post-op infections shouldn't end until wounds are properly cleaned, closed and covered. Here are some tips on performing the safest and most effective wound closures:
- Tight layering. Surgeons should perform tightly layered wound closures that don't leave areas below the skin surface open, which can lead to abscesses and, eventually, infections. Their closing methods must be strong enough to completely close each layer of the wound until it is completely healed. "Infection prevention really starts at the deeper tissue layers," says Jon Minter, DO, an orthopedic surgeon in Alpharetta, Ga.
- Proper irrigation. Irrigating the wound during a layered closure is vital to flush out bacteria debris. Otherwise, bacteria will pool to create an abscess and an infection. "The classic statement is, 'The solution to pollution is dilution,'" says Dr. Minter. "Irrigation of the wound is part of the continuum of care in most surgical cases because foreign debris or planktonic bacteria can be removed through the use of irrigating solutions." A standard approach to wound irrigation should be considered for even the most routine surgical procedures as part of an overall antisepsis care program in the OR, according to Dr. Minter. Unlike saline or diluted betadine solutions, newer wound irrigates destroy biofilm without harming good tissue.
- Proper dressing. Correct application of wound gel and sterile adherent dressings to the incision prevents infection and reduces scarring. "A lot of the dressings we use now are silver impregnated, which are very inhibitory to bacteria, so we apply them to create a sterile environment," says Dr. Minter. "We'll leave them on our outpatient hip and knee patients for five to seven days, and by then the wound has healed up quite nicely. These dressings also allow patients to shower without getting the wound wet."
- Postoperative management. The normal inflammatory response takes three to four days, so a patient who sees their incision a few days after surgery will likely observe a site that is red, hot and swollen. Matthew Regulski, DPM, a foot and ankle surgeon and medical director at the Wound Care Institute of Ocean County in Toms River, N.J., doesn't see his patients for five to six days after surgery to allow the normal inflammatory response time to dissipate. "Surgical centers, however, should call the patient the next day to see how they're feeling and to make sure the bandage is clean, dry and intact," he says.
That last point ties into the patient experience and managing the entire episode of care. A key aspect of successful wound care strategies is setting the patient's expectations preoperatively, particularly educating them about the nature of the wounds their surgeries will generate, how to care for them, and what signs of infection might look like. Dr. Regulski gives his patients the long version of every potential problem. "My list of complications has about 40 on it, so patients know exactly what could happen," he says. Don't wait until the day of surgery to provide this information, however, as most patients are too nervous or too sedated to remember.
Soft Tissue Injury Management
Avoiding skin grafts with a versatile tool offers new options for a number of wound types.
A recent article, "Multidisciplinary Application of an External Tissue Expander Device to Improve Patient Outcomes: A Critical Review," offers an important review of continuous external tissue expansion (CETE), a versatile tool in soft tissue injury management that could be an addition to the traditional reconstructive ladder in surgery.1
CETE is becoming more widely used by surgeons of different specialties. Numerous reports describing its efficacy and safety in wound management have been published. Surgeons using CETE must follow the correct technique and select patients carefully to achieve optimal outcomes. However, there is no single source of information or consensus recommendations regarding CETE application.
The hierarchy of surgical techniques traditionally used by reconstructive surgeons is depicted in the "reconstructive ladder."2 According to the authors, "Surgical developments, like CETE, may provide opportunities to add new rungs to the traditional reconstructive ladder. Furthermore, the simplicity of these devices makes them accessible to subspecialties outside plastic surgery."1
CETE uses the viscoelastic properties of the skin. Mechanical strain induces cellular proliferation, leading to an increase in tissue surface area through generation of new tissue. The authors note, "Although the exact mechanism by which mechanical strain induces proliferation of new tissue is still being elucidated, several factors have been linked to stress and/or mechanical strain.3
This article review discusses the principles and application of CETE, covering a company-sponsored consensus meeting on this emerging technology and highlighting the DermaClose_ (Synovis Micro Companies Alliance, Inc., Birmingham, AL) device's unique approach to soft tissue injury management.
According to the authors, "There is clinical evidence to support the use of CETE in the management of a number of wound types, including fasciotomy, trauma, amputation, and flap donor sites. The device can be applied to open wounds, potentially avoiding the need for a skin graft or other more complex or invasive reconstruction options. DermaClose applies constant tension without restricting blood flow and does not require repeated tightening."1
CETE capitalizes on the viscoelastic properties of the skin. It allows surgeons to achieve primary closure in a range of wound types that are not primarily closable, avoiding the need for more complex procedures. Although CETE is becoming more widely used by surgeons from different specialties, information and recommendations regarding its use are limited. Using the correct technique results in fewer complications and improved outcomes for patients.
According to the authors, "Given the paucity of published data, this critical review may serve as a meta-analysis for CETE as it details methods for CETE application, clinical evidence for its use in a number of settings, and the authors' recommendations, specifically related to DermaClose, based on their clinical experience."1
Prospective evidence on the efficacy and safety of CETE in clinical practice is required to communicate the best techniques and share important experiences. This will help to solidify its place in the reconstructive ladder as a valuable additional option for surgeons. The authors note, "CETE can be used for wound management in multiple settings, and could be an addition to the traditional reconstructive ladder. Unlike other systems and devices, DermaClose applies constant tension and does not require tightening. There is clinical evidence supporting the use of this device in a number of wound types, and its use could avoid the need for a skin graft or other more invasive procedures."1
Note: For more information, go to https://www.synovismicro.com/html/products/dermaclose_external_tissue_expander.html
1. Brendan J. MacKay, Anthony N. Dardano, Andrew M. Klapper, Selene G. Parekh, Mohsin Q. Soliman, and Ian L. Valerio, “Multidisciplinary Application of an External Tissue Expander Device to Improve Patient Outcomes: A Critical Review,” Advances in Wound Care, 2020; Published by Mary Ann Liebert, Inc.
2. Boyce DE, Shokrollahi K. Reconstructive surgery. BMJ 2006;332:710–712.
3. De Filippo RE, Atala A. Stretch and growth: the molecular and physiologic influences of tissue expansion. Plast Reconstr Surg 2002;109:2450–2462.
New Wound Closure Technologies Disrupt Traditional Methods
Breakthroughs in safety, efficiency and cosmesis sway set-in-their-ways surgeons.
When many surgeons think about wound closure, sutures and staples immediately come to mind — along with wrapping up the case to turn the room over. The patient's cosmesis often gets lost in the shuffle, which can sometimes lead to ugly scars when the wound heals.
That's an outcome that can lead to unhappy patients and lower patient experience scores. "The scar is often the only thing patients remember about their surgeries," says Jeffrey S. Freed, MD, MPH, FACS, a clinical professor in the department of surgery at the Icahn School of Medicine at Mount Sinai in New York City.
Fortunately, the wound closure market is moving in the direction of technologies that minimize patients' scarring while also saving time. Many newer products, such as adhesives, adhesive/tension-distributing combos and external tissue expanders, are non-invasive devices. Here are five key points to consider when evaluating these next-generation tools:
- Know your options. When evaluating emerging wound-care devices, analyze randomized, controllable studies on the efficacy of each product. Keep a close eye on what's in the pipeline and identify products that show promise.
- Cost. Will adding one of these new products save your facility money? It depends. You need to properly assess the true cost of wound closure, including time savings that can offset higher upfront costs of the newer wound closure options when compared with traditional sutures or staples. Saving mere minutes on procedures really adds up over time and could enhance your overall profitability. "Find ways to demonstrate to surgeons that new devices yield better results and greater efficiency, which translates to money in the bank," says Dr. Freed.
- Efficiency in practice. Some newer technologies purport to be so simple and intuitive to use that physician assistants, nurse practitioners or perioperative nurses can close incisions while the surgeon prepares the next patient for surgery. This potentially increased case efficiency is appealing, but your OR teams need to put the products to the test first to determine whether the promises come true in reality.
- Enhanced safety. One safety benefit tied into the efficiency angle is limiting staff exposure to patients potentially carrying the coronavirus. "Every patient contact is a worrisome event for caregivers who put themselves at risk," says Dr. Freed. "When it comes to not having a contagion transmission in the OR, time is of the essence." Another COVID-related safety benefit is that newer wound closure technology eliminates the need for patients to schedule post-op appointments to have staples or sutures removed, which, Dr. Freed notes, are time-consuming, non-reimbursable events. On the whole, non-invasive wound closure options are the safer option, and don't traumatize tissue like traditional methods can.
- Enhance patient satisfaction. Even patients who claim they don't care about post-op cosmesis would prefer their skin showed little evidence of surgery. In addition to better wound healing, patients don't need to take time out of their days to have sutures or staples removed.
Although surgeons may initially balk at changing their routines, it's well worth the effort to present these new solutions to them for evaluation and trialing. At the end of the day, wound closure is all about patient and surgeon satisfaction. As such, safer and more efficient new techniques for a bread-and-butter task like wound closure should be closely examined.
Questions About Silver's Role in Wound Care
Signs of silver-resistant bacteria raise a red flag regarding widely used products.
New research has called the continued use of silver-impregnated wound dressings and topical agents into question. The reason is the possible development of acute silver resistance.
The U.S. Food and Drug Administration has provided marketing clearance for many of these products, which are used globally due to silver's strong antimicrobial activity. An American research team decided to test the efficacy of previously identified silver-resistant clinical bacteria (Klebsiella pneumoniae and Enterobacter cloacae) against a variety of commercially available silver-based wound dressings, and published its findings in the Journal of Wound Care.
Multiple time-course and repeat-challenge tests were conducted with nine dressings using a panel of silver-resistant and silver-sensitive microorganisms. "Both silver-resistant strains were largely unaffected and exhibited phenotypic resistance even when exposed to the high silver concentrations found in commercially available wound dressings," the researchers say. "In stark contrast, the majority of the dressings were able to maintain a high degree of efficacy over the course of 72 hours and during repeated bacterial challenges against silver-sensitive microorganisms."
The researchers say its findings provide additional evidence that clinically significant silver-resistance has emerged in the clinical setting. "These findings suggest that the further development and dissemination of these resistance mechanisms could significantly impact current practices in wound healing," they say.
This is one of the latest of a wide variety of studies surrounding silver's use in wound care. A 2019 comprehensive review entitled "Silver in Wound Care: Friend or Foe?" called the published literature on the use of silver in wound care "very heterogeneous" and its quality "poor," making it difficult to generate useful guidelines.
That study concluded that the use of silver might be more appropriate for acute wounds rather than surgical wounds. "In infected wounds, silver is beneficial for the first few days/weeks, after which non-silver dressings should be used instead," the authors write. "For clean wounds and closed surgical incisions, silver confers no benefit."