More on Incontinence……..

I could find no publications that reported a statistically significant causal link between incontinence and pressure injury (PI) development. An examination of the literature and the risk factors for incontinence, included in many tools reveals the potential  difficulty screening poses for healthcare workers. Most PI risk screening tools, as well as the studies that have reported on  incontinence as a potential risk factor for PU development, [1] do not differentiate between ‘urinary incontinence’ (UI) and ‘faecal incontinence’ (FI), nor between the different types of UI, stress or functional incontinence.[2]

Many assessment tools have combined urinary incontinence and faecal incontinence, into one risk factor, ‘incontinence.’  It is therefore, difficult to objectively assess ‘incontinence’ as a causal risk factor, or an intervening variable coming after a predictive factor, prior to PI development. However bivariate analysis has shown UI to be associated with a significantly higher rate of PI development.[3] Berlowitz (2001) reported continent residents had a higher rate of PI 90 days after the initial screening than those coded as ‘usually continent’ or ‘incontinent’. This prospective study was carried out on 14,607 nursing home residents who were without a Stage 2 PI, or larger, although these Stages were not defined.

[1] Allman RM, Goode PS, Patrick MM, Burst N. & Bartolucci AA.  Pressure ulcer risk factors among hospitalized patients with activity limitation. JAMA 1995; 273(11): 865- 70; Fisher AR, Wells G. & Harrison MB. Factors Associated with Pressure Ulcers in Adults in Acute Care Hospitals. Advances in Skin & Wound Care 2004; 17(2): 80-90; Papanikolaou P. Lyne PA. & Lycett EJ. Pressure ulcer risk screening: application of logistic analysis. J Adv Nurs 2003; 44(2):128-36; Pase MN. Pressure relief devices, risk factors, and development of pressure ulcers in elderly patients with limited mobility. Adv Wound Care 1994; 7: 38–43;  Maklebust J, Siggreen MY. Pressure Ulcers. Guidelines for Prevention and Nursing Management. Springhouse PA: Springhouse Corporation, 1996, 24; Versluysen M. Pressure sores in elderly patients. The epidemiology related to hip operations. J Bone Joint Surg Br 1985; 67(1): 10-3; Brandeis GH, Morris JN, Nash DJ et al. The epidemiology and natural history of pressure ulcers in elderly nursing home residents. JAMA 1990; 264:2905–2909.

Incontinence causes pressure ulcers…but does it??

Are you going to change your practice? I’m not!

No doubt many of you will be questioning the findings of the Cochrane Review ‘Dressings for the Prevention of Surgical Site Infection’ in my last post but there is no need to get rid of the wonderful dressings on the market to revert to dry gauze dressings or to leave the surgical site exposed. I certainly will not be recommending gauze or exposure of the surgical site.

You don’t need to be critical of the methodology of its findings – just remember the Cochrane Review and the recommendations are based on RCTs only and did not take into account all the other papers that are not RCTs.

We already know that hydrocolloids, for example, prevent bacteria & water from entering the surgical site and they prevent self-contamination of the surgical site from the patient’s own fingers or staff hands; great Infection Control measures.

We know that tape used to secure gauze dressings may be contaminated. And bloody gauze dressings pose huge OH&S issues for nurses handling and removing them, ‘flick’ & ‘splash’ injuries for example. So despite spending forever researching this subject & co-authoring the Cochrane Review I will NOT put gauze on a surgical site nor will I leave the surgical site exposed. I won’t be persuaded by [perceived] cost savings either.

I look forward to your comments. What are your favourite dressings for surgical sites? Did any of you contemplate leaving a surgical site exposed after reading the Review?

Kate

Dressings for the prevention of surgical site infection

Plain Language Summary
No recommendations regarding type of wound dressing for the prevention of surgical site infection
Millions of surgical procedures are conducted globally each year. The majority of procedures result in wounds in which the edges are brought together to heal using stitches, staples, clips or glue – this is called ‘healing by primary intention’. Afterwards, wounds are often covered with a dressing that acts as a barrier between them and the outside environment.

One advantage of this may be to protect the wound from micro-organisms, and thus infection. Many different dressing types are available for use on surgical wounds, however, it is not clear whether one type of dressing is better than any other at preventing surgical site infection, or, indeed, whether it is better not to use a dressing at all. We conducted a review of all available, relevant, evidence regarding the impact of dressings on the prevention of surgical site infections in surgical wounds healing by primary intention.

The review examined data from 16 randomised controlled trials and found no evidence to suggest either that one dressing type was better than any other, or that covering these wounds with dressings at all was better, at preventing surgical site infection, or that any dressing type improves scarring, pain control, patient acceptability or ease of removal.

It is important to note that many trials in this review were small and of poor quality, at high or unclear risk of bias. Decisions on wound dressing should be based on dressing costs and the need for management of specific symptoms e.g., absorption of exudate.

This is a Cochrane review abstract and plain language summary prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2011 Issue 7, Copyright © 2011 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).

This record should be cited as: Dumville JC, Walter CJ, Sharp CA, Page T. Dressings for the prevention of surgical site infection. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD003091. DOI: 10.1002/14651858.CD003091.pub2
Editorial Group: Wounds Group
This version first published online: July 6. 2011
Last assessed as up-to-date: May 10. 2011

Abstract
Background
Surgical wounds (incisions) heal by primary intention when the wound edges are brought together and secured – often with sutures, staples, clips or glue. Wound dressings, usually applied after wound closure, provide physical support, protection from bacterial contamination and absorb exudate. Surgical site infection (SSI) is a common complication of surgical wounds that may delay healing.

Objectives
To evaluate the effects of wound dressings for preventing SSI in people with surgical wounds healing by primary intention.

Search strategy
We searched the Cochrane Wounds Group Specialised Register (searched 10 May 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011 Issue 2); Ovid MEDLINE (1950 to April Week 4 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, May 9, 2011); Ovid EMBASE (1980 to 2011 Week 18); EBSCO CINAHL (1982 to 6 May 2011). There were no restrictions based on language or date of publication.

Selection criteria
Randomised controlled trials (RCTs) comparing alternative wound dressings or wound dressings with leaving wounds exposed for postoperative management of surgical wounds healing by primary intention.

Data collection and analysis
Two review authors performed study selection, risk of bias assessment and data extraction independently.

Main results
Sixteen RCTs were included (2578 participants). All trials were at unclear or high risk of bias. Nine trials included people with wounds resulting from surgical procedures with a contamination classification of ‘clean’, two trials included people with wounds resulting from surgical procedures with a ‘clean/contaminated’ contamination classification and the remaining trials evaluated people with wounds resulting from various surgical procedures with different contamination classifications. Two trials compared wound dressings with leaving wounds exposed. The remaining 14 trials compared two alternative dressing types. No evidence was identified to suggest that any dressing significantly reduced the risk of developing an SSI compared with leaving wounds exposed or compared with alternative dressings in people who had surgical wounds healing by secondary intention.

Authors’ conclusions
At present, there is no evidence to suggest that covering surgical wounds healing by primary intention with wound dressings reduces the risk of SSI or that any particular wound dressing is more effective than others in reducing the rates of SSI, improving scarring, pain control, patient acceptability or ease of dressing removal. Most trials in this review were small and of poor quality at high or unclear risk of bias. However, based on the current evidence, we conclude that decisions on wound dressing should be based on dressing costs and the symptom management properties offered by each dressing type e.g. exudate management.

Special Contribution on Biofilm in Wounds from Leonard Schembri

The Wound Centre^© has received another wonderful contribution from Leonard Schembri in Malta.

I would like to thank Leonard for his dedication in writing this  - a significant contribution about Biofilm.

It’s contributions like these that helps to further knowledge in Wound Care.

If you have a contribution (papers, studies, feedback, comments, tips, ideas), please forward them to…

info(at)thewoundcentre.com
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And together we’ll bring the world of Wound Care closer.

With the Wound Care newsletter going out to over 31 countries,
the information we can learn from each other is priceless.

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BIOFILM/S AND WOUNDS

Leonard Schembri S.N., R.N. (Aust.), B.Nsg. (Aust.), B.A., T.E.F.L.

Phytotherapeutical Studies (Brazil).

A biofilm is a collection of microbial cells that are attached to a surface and embedded in a self-produced extrapolymeric substance. (Davis et. al. 2008). Bacterial biofilms cause or complicate numerous medical conditions, including chronic wounds. (Wolcott & Rhoads 2008).

The biofilm has become a common occurrence in wounds and this poses a big challenge to all the Nurses and Doctors. Unfortunately, many Health Professionals still do not know how to manage a biofilmed wound.

There are different schools of thought of how and why a biofilm is formed. Be that as it may, this short article is not about the how and why. It is about different methods of “how to remove” the biofilm from wounds whether they’d be acute or chronic.

All the information below is from the author’s experience.

First method A biofilm could easily be removed with sterile plastic forceps. The procedure itself is, many a time, painless. However, with certain types of wounds, for example, an arterial leg ulcer (below the knee), this simple procedure could be painful.

The problem of pain could be overcome by either one of the following two methods explained below.

1. a. The application of Emla Cream (a local anaesthetic) on top of and around the wound. Then the Health Practioner has to wait an hour for the cream to absorbed. Waiting for two hours is better.
2. b. If the pain is excessive, in addition to the Emla Cream, the Nurse (or other Health Practioner), can apply Lignocaine 1% solution. The vial’s transparent solution is placed onto two layers of gauze and then the wet gauze is applied over the wound and its immediate and surrounding healthy tissue. This is left in place for 2 minutes or slightly longer. Soon afterwards, the Nurse can start to remove the biofilm with a sterile scoop or the edge of a sharp blade.

Second method Another method which is liked by some Health Practioners is the application of Negative Therapy Pressure (NPT) or Vacuum Assisted Closure (VAC).

This, we have found, could be applied over a stubborn biofilm where the Nurse finds it extremely difficult to remove. After one or two applications of this therapy, the biofilm is removed.

Unfortunately, the biofilm has the tendency of returning (recalcitrance) once the therapy is stopped. Thus it is important to apply a suitable dressing or to continue with the use of NPT or VAC to prevent the biofilm from reforming.

Third method Prontosan is a new solution for biofilms. This solution is first placed on a couple of sterile gauze swabs and then applied over the wound and left in situ for 15 minutes.

This is meant to break up the biofilm or eat away, as it were, at the film and the bacteria underneath. It ought to be mentioned at this stage, that the first method (mentioned above) is first carried out and is then followed by using this method. To compliment the Prontosan solution, B. Braun has come up with Prontosan Gel.

This gel is to prevent the formation of a further biofilm or to continue the action of breaking the biofilm, that is, killing the bacteria underneath. Once the wound is free from the biofilm, the gel enhances granulating tissue.

If, on the other hand, the biofilm is thick and stubborn and  the Health Practioner can still see the biofilm present on the wound, then s/he can remove the biofilm with either a scoop or a sharp blade some 2 to 3 weeks after the application of the solution and gel. The combination of these two products seems to dislodge easier the film from the surface of the wound bed.

Fourth method A super-oxygenated environment is good for healthy tissue and bad for biofilms. (Wolcott 2008). Thus, hyperbaric oxygen is one method of combating biofilms. Even though this idea might be a good idea for diabetic ulcers with recurring biofilms, it has not as yet been accepted by our peers.

Nurses still need to promote “research marketing”, so to speak, with surgical and medical staff; research marketing which is based on anecdotal research and further up the ladder of research.

Fifth method The Cutimed Sorbact dressing – This dressing, which could be left in situ for up to one week, is applied over the biofilmed wound. However, the secondary dressing is changed regularly, that is, when there is too much discharge. The dressing captures the bacteria and inactivates their activity (sequestration).

It is an easy dressing to apply and does not require any special technique of application. It ought to be mentioned, that the first method (mentioned above) is first carried out and is then followed with the use of this dressing. It has been observed that this dressing is better used once there is no biofilm as it prevents the formation of the biofilm.

Sixth method Another simple and straightforward method is to obtain a brand new sterile toothbrush. The Health Practitioner can clean the biofilmed wound with the toothbrush under running water. S/he can refer to the guidelines of the first method, referred to above, if the patient is in pain or experiences pain during the procedure.

This method is partially successful but it aids at removing the thickness of the biofilm. To check the efficacy of the procedure, it might be a good idea to do half of the wound at first and compare this with the rest of the wound. Either one of the methods referred to above can then be applied.

Future wound dressings Presently, it is common practice not to use any other anti biofilm agents. This is because there are no specific commercial wound dressings on the market for biofilms.

However, there are potential anti biofilm agents which still need be explored and researched in the treatment for wound biofilms.

According to various authors, some of these chemical and natural agents are: Lactoferrin, Xylitol, Gallium, Dispersin B and Honey (Manuka)* (Percival et. al. 2010). In the author’s opinion, there are no anti biofilm wound dressings; at least, not in Malta.  We hope to witness, in the future, some new form of wound dressing with these agents.

This gives manufacturers the opportunity to explore and experiment with new products.

In the case of mouth biofilms, the author does not know whether there are any of the agents (mentioned above) which could be used against biofilms.

It would be interesting to find out what Dentists use when there is a biofilm in the mouth and the reason of using one agent over the other.

The methods and the chemical/natural agents used by Dentists could be adopted by Nurses and Doctors which might lead to a breakthrough in the treatment for wound biofilms.

* In some instances, Manuka Honey was used against MRSA in Mater Dei Hospital. This is not the case any longer as silver dressings have been introduced since then. There is a Honey dressing on the market but it does not specify that it is Manuka Honey. From the author’s experience, a commercial wound dressing is a sterile manufactured product where the Health Professional user opens the dressing and lays it over the wound to help/assist the wound to heal in the shortest time possible.

References: Davis S.C. et. al., Microscopic and physiologic evidence for biofilm-associated wound colonization in vivo. Wound Repair Regen. 2008 Jan-Feb; 16(1):23-9.

Percival S.L., Cutting K.F., Williams D., Biofilms: possible strategies for suppression in chronic wound. Nursing Standard Autumn 2010.

Wolcott R.D., Rhoads D.D., A study of biofilm-based wound management in subjects with critical limb ischaemia. J Wound Care. 2008 Apr;17(4):145-8, 150-2, 154-5. _______________________________________________________________________________________________

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