THIS WEEK'S ARTICLES
5 Tips for Wound Care at Home
Give patients enough information and support so they feel as if you're right there with them.
Surgical teams do everything they can to encourage proper wound healing for their recovering patients. Unfortunately, they aren't there to continue managing wounds after patients are back at home. That means patients need to know the do's and don'ts of wound care to reduce scarring and prevent infection. Here are five tips to give them what they need.
- Educate. Don't wait until after procedures to discuss wound management. Nancy Strand, MPH, RN, manager of surgical patient education for the American College of Surgeons (ACS), says it's not ideal to give that information at discharge. "They're dealing with so much emotional and physical strain and stress that cognitively it's not a time for learning or remembering," she notes. Kathy Gallagher, DNP, APRN-FNP, CMC, UMC, BC, WCC, CWS, FACCWS, coordinator of the Acute Surgical Wound Service at Christiana Care Health Services in Newark, Del., adds that the person who'll provide care to the patient at home should also be present for this education, which should account for that patient's specific background and needs.
- Show and tell. Before surgery, the patient and caregiver should come into the surgeon's office to see exactly how the dressing should be changed. This gives them time to prepare. Reinforce that in-person instruction with videos about changing dressings and cleaning wounds. ACS' wound home skills tool kit and checklist can help caregivers assess their capabilities. The idea is for the patient and caregiver to feel confident about their ability to treat the wound well in advance of surgery, and certainly before they get home.
- Provide clear instructions. There are thousands of dressing options from which to choose, and sometimes a combination of products is needed. The patient and their caregiver need your help in procuring the proper supplies. Provide specific instructions about when the patient will be due for a dressing change and the supplies they'll need. Dr. Gallagher says some patients unnecessarily change dressings daily, without realizing that every time a dressing is removed, it takes the wound about 4 hours to get back to the ideal temperature for healing. "The idea is to keep a perfectly moist environment that's not too wet and not too dry," she says.
- Keep it simple. Give patients a packet of key information to bring home. A good discharge form puts all the essential information in one place and gives patients a reference to lean on. This simple act can make their self-care feel more manageable. Include provider contact info, patient-specific wound cleaning and dressing instructions, guidance about the supplies they'll need and details about pain medication considerations before cleaning a wound or changing a dressing. Break it all down for the patient in the simplest possible terms so it's a definitive resource upon which they can rely.
- Provide assistance. The education and information you provide should address what the patient and caregiver must do if the wound shows signs of infection at home. It should also describe what the warning signs of infection are. Give patients a phone number for the provider they can call when they have concerns. A proactive response can make the difference between a wound that can be managed at home and one that requires hospitalization or becomes chronic.
A wound care plan that starts before surgery sets patients up for success when they head home. By prepping patients in advance, they'll leave your facility with the confidence to take care of themselves, and make fewer trips to the hospital with infections.
Personalized Dressings Delight Kids
A surgeon sends young patients home with drawings that show he cares.
Like most surgeons, Robert Parry, MD, FACS, director of pediatric general surgery at Akron (Ohio) Children's Hospital, has outside interests. And in one of those rare and rewarding instances where the personal and the professional coalesce, he's using one of his outside interests to brighten the lives of his young patients.
Dr. Parry enjoys sketching and drawing in his free time, and he's figured out a way to bring that talent to the OR. During pre-op clinic visits, he asks patients what kinds of characters or other drawings they'd like him to make on the bandages he'll place over their scars after surgery, and he makes a note of it.
"In the OR, as the rest of the team is preparing to move the patient to recovery, I pull up the character or image on an iPad and begin to draw the design on the bandage with my personal set of colored pens and pencils," he says. The drawings usually take about five minutes to complete.
Each patient he operates on leaves the OR with a personalized wound dressing. "I've drawn Mickey Mouse in scrubs, Snoopy, football helmets for most college and pro teams, and countless SpongeBobs," says Dr. Parry, who estimates he's done drawings for more than 10,000 patients. "I have fun making the art and the kids light up when they see their requests come to life."
To an outside observer, this might seem like a superfluous task. But the reality is that it can contribute to improved patient experiences and even improved outcomes by putting the patient in a better state of mind.
"Covering kids' surgical scars with an image that makes them smile is incredibly fulfilling and lets them know I care about them as a person, not just as another patient," explains Dr. Parry, who encourages other facilities to adopt the practice. "There's no need to worry if you don't have an artistic flair. It doesn't take a great artist to make a child smile during what is often a scary time for them and a nerve-wracking time for their parents."
Watch Dr. Parry at work as both an artist and clinician in this YouTube video.
High-Risk Joint Replacement Surgeries Find Some Closure
Negative Pressure Wound Therapy Offers a Solution for Elective Joint Replacement Surgery's Highest Risk Patients
The need for hip and knee replacement procedures continue to grow exponentially in the United States. Patient choice and reimbursement changes are driving more of these types of surgeries to surgery centers and outpatient facilities, which need to focus on how to maximize patient outcomes.
As the population ages, it is not surprising that the number of patients choosing elective joint replacement increasingly includes those at higher risk. While the emphasis on optimizing medical co-morbidities has improved the general recognition of outcomes associated with specific patient factors, some co-morbidities simply cannot be eliminated and can only be optimized.
The first step in maximizing patient outcomes is to identify those that will be at high risk after surgery is completed and work to minimize perioperative and postoperative complications.
More than 8 million people are at risk for surgical site complications annually.1 These outcomes are responsible for nearly 10 billion dollars in the US healthcare system each year. Surgical site infections result in lengths of stay of 7 to 11 days.2 In addition, SSI patients are five times as likely to be readmitted.3
Some surgeons note that one of the most overlooked aspects of joint replacement is the surgical closure itself. While this part of the procedure is often responsible for a significant portion of the overall time spent on any surgical case, often it is not the focus compared to the actual procedure.
However, attention to surgical closure is critical. Maximizing wound healing and minimizing infection risk is important to ultimately reach positive patient outcomes. In fact, studies such as Lonner et al., have shown that prolonged wound drainage increases the risks of infection.4
New developments in incision management are paving the way to tackle these challenges, especially for high-risk patients.
One of the most promising developments is negative pressure wound therapy (NPWT) dressings, which protect closed incisions and provide mechanical reinforcement to wound edges. As much as 50% of suture line tension can be reduced and tensile forces normalized to be more similar to non-traumatized tissue with NPWT.5 In addition, by remaining in place for 7 consecutive days, this dressing acts as a barrier to external sources and can further optimize the wound healing environment through mechanical and physical methods.
On the market today is the PREVENA™ 125 Therapy Unit and PREVENA PLUS™ 125 Therapy Unit by 3M, which are the first and only medical devices indicated by the FDA to aid in the reduction of superficial surgical site infections in Class I and II wounds in patients at high risk for postoperative infection. In addition, studies have shown a marked improvement in SSCs for patients when treated with PREVENA™ Therapy. That's good news for the patient and their recovery from joint replacement surgery.
The benefits also include a number of patient-friendly characteristics, specifically the fact that these dressings are shower-friendly and are designed to conform to articulating joints, allowing movement.
Additionally, this product enables the even distribution of -125mmHg of negative pressure, and the adhesive film creates a barrier to external contaminants. By helping hold incision edges together and decreasing the lateral tension, the PREVENA™ System offers a neat solution for high-risk patients in multiple sizes and configurations. For more information, please see the PREVENA™ Therapy Resources. (https://www.mykci.com/healthcare-professionals/us-product-catalog/catalog/prevena-incision-management-system)
1. Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA internal medicine. 2013;173(22): 2039-2046.
2. Anderson D, et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology. 2014; 35(6): 605-627.
3. Canadian Patient Safety Institute. SSI Audit Recap Report. http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/SSI-Audit-Recap-Report-2016-12.aspx. Updated February 2016. Accessed November 4, 2020.
4. Lonner J and Lotke P. Aseptic complications after total knee arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 1995;7(5): 311-324.
5. Wilkes R, Kilpadi D, Zhao Y, Kazala R, McNulty A. Closed incision management with negative pressure wound therapy (CIM) biomechanics. Surgical innovation. 2012;19(1): 67-75.
NOTE: Specific indications, limitations, contraindications, warnings, precautions and safety information exist for these products and therapies. Please consult a clinician and product instructions for use prior to application. Rx only.
© 2020 3M. All rights reserved. 3M and the other marks shown are marks and/or registered marks. Unauthorized use prohibited. PRA-PM-US-02842 (11/20)
Simple Stickers Protect Incision Sites
Leave behind reminders for patients to trust the healing process.
We've all been there: It must be time to remove or replace that annoying bandage, right? We do it all the time in our daily lives when we apply bandages on a small cut. "That's been on there long enough by now," we tell ourselves about the bandage after it's been applied for barely a few hours.
Now take that blasé attitude and apply it to bandages on surgical sites, which require more patience and care than your typical paper cut. For many patients, the thought of taking that bandage off is driven by a mix of curiosity and impatience.
"You can tell patients to keep wounds fully covered for a full day after they leave your facility and include a reminder in discharge directions, but they're often tempted to peel back bandages for a quick peek or, worse, remove them to shower," says Kimberly Davis, MD, MBA, FACS, FCCM, a professor of surgery and vice chairman for clinical affairs at the Yale School of Medicine Department of Surgery in New Haven, Conn.
When a surgical patient removes a bandage at home too early, it can not only have an adverse effect on the healing process, but it can expose the wound to infection. The science says it takes about 24 hours for enough epithelial cells to proliferate across surgical wounds to protect the area from infection. The problem is, of course, that your clinicians aren't in a patient's home to stop them from removing the bandage too early.
Yale School of Medicine added an extremely simple solution to its SSI prevention bundle to remind patients when it's safe to remove surgical dressings: "do not remove until" stickers from an online office supply retailer. PACU nurses simply note the next day's date on the stickers before placing them on surgical wound dressings. "The stickers serve as on-the-spot reminders for tempted patients to keep dressings in place until wounds begin to close," says Dr. Davis.
Less invasive wound closure alternatives intrigue surgeons and patients alike.
The fundamentals of wound closure are changing for the better. Many surgeons still use time-honored sutures, which do a good job of approximating wound edges. The suturing process, however, takes a while, and turnaround times can make all the difference for a busy outpatient facility. Fortunately, there are numerous alternative technologies for wound closure that markedly reduce the time surgeons need to close wounds.
We recently asked Asit K. Shah, MD, PhD, an orthopedic surgeon with Englewood (N.J.) Hospital, why he's embraced alternatives to suturing. He gave four compelling reasons:
- Patient satisfaction. When Dr. Shah surveyed his patients on wound closure, he discovered many had a strong fear about having staples removed. He says the use of non- or less-invasive adhesive wound closure alternatives can not only allay those fears but can lead to positive reviews of the care your team provides. "If a patient sees the surgeon is on the cutting edge and using these staple-free devices, he's likely to tell his friends and family about your facility," explains Dr. Shah.
- Increased safety. This is about both patients and staff. Accidental sticks that occur during suturing are notoriously common OR injuries; alternative solutions remove this sharps safety hazard. On the patient safety side, says Dr. Shah, "With staples, you're leaving little holes in the body. That's a possible source of infection. It hasn't been clinically proven, but it's always a concern for surgeons."
- Time savings. Alternative wound closure methods may appear more expensive than sutures, but look past the upfront price tags. "You may be paying $20 for staples versus maybe $80 for some type of alternative closure device," says Dr. Shah. "That shouldn't be a prohibitive cost, especially if you're looking at the big picture." That big picture is the time you'll save not removing staples from patients. Staple removal essentially is like a minor procedure that keeps surgeons from seeing other patients, notes Dr. Shah.
- Ease of use. Not only can these products save time, but because many of the closure products available are so simple and intuitive to use, surgeons can potentially delegate closures to surgical assistants, another invaluable result in high-volume facilities looking to close as many cases in a day as possible.