Post-Op Healing Strategies

Post-Op Healing Strategies

By Kathy Dix

The nature of minimally invasive surgery (MIS) is both a blessing and a curse; while patients have faster recovery and less scarring, they are not available to nursing staff 24/7 for follow-up. The fact they aren't convalescing in the hospital means there may be little follow-up to assess the damage and healing or lack thereof.

Wound care is not a glamorous branch of medicine. Open sores and dead tissue don't lend themselves to romanticism. But they are a fact of life, so much so that hospitals and other healthcare facilities have specific departments for wound care. And the traffic is enormous -- the wound care clinic at Good Samaritan Hospital in Phoenix sees 700 patients a month.

"In 2002, we saw 7,200 patients just on the wound side alone; that does not count hyperbaric," affirms Pat Gill, MSN, clinical nurse specialist and the assistant director of Good Samaritan's wound program.

The wound care center is often the last ray of hope for patients with chronic wounds. Their gratitude for the services they receive makes the job uniquely rewarding. "They're just so grateful for the hope that they get and for the support that they get, being in a wound center where that's all that we deal with," Gill says.

There is a difference in the acuity of outpatient cases compared to inpatient, but Gill says sometimes it's hard to tell a difference between the two, as inpatients are now being discharged so quickly. Gill's clinic sees outpatients only, but many times a patient who presents at the clinic is admitted to the hospital. For the most part, though, these wounds are a "chronic, low-tech, very expensive commodity."

The wounds span the entire physiological spectrum, from arterial, venous, diabetic and pressure ulcers to burns, immunological disorders with skin lesions and surgical incisions that have never healed. Any chronic wound is fair game.

Wounds from minimally invasive surgery are not common at the Good Samaritan clinic. But when they do appear, Gill says that the wounds are usually due to an underlying cause.

"Maybe there's a stitch left in there, or -- if they put mesh in -- the mesh got infected. Most surgical wounds heal; (if they don't) there's usually a cause," she adds.

The most rewarding aspect of Gill's job is making a difference in the lives of patients who have sometimes had their wounds for years. "When we can influence their wound healing just by good wound care alone ..." Gill muses. "(That involves) stopping the use of Betadine, peroxide, vinegar, bleach, all the stuff that people and physicians put in (wounds); stopping gauze wet-to-dry dressing -- that is really traumatic to a wound bed. So the wound just starts to put the right kind of cells in, then somebody comes along and rips them all out again when they take the gauze dressing out."

Strategies

Some post-operative strategies are universal, regardless of the surgical setting. The Association for Professionals in Infection Control (APIC) and the Wound Ostomy Continence Nurses Society (WOCN) offer several clear-cut recommendations. Their position statement on the management of chronic wounds is unique in that it addresses several controversies, including the definitions of "clean" vs. "sterile" technique and when each technique is required in managing chronic wounds.

Clean technique is intended "to reduce the overall number of microorganisms or to prevent or reduce the risk of transmission of microorganisms from one person to another or from one place to another." Elements of clean technique include scrupulous handwashing, preparing a clean field to maintain a clean environment, and using clean gloves, sterile instruments and avoiding direct contamination of materials and supplies.²

Sterile technique is intended "to reduce and maintain objects and areas as free from microorganisms as possible. Sterile technique involves meticulous handwashing, use of a sterile field, sterile gloves for application of a sterile dressing and sterile instruments. 'Sterile to sterile' involves the use of only sterile instruments and materials in dressing change procedures; contact between sterile instruments or materials and any nonsterile surface or product must be avoided."

So should a different technique be used in an outpatient than in an inpatient setting? The position statement says that a more sensible approach is to base the technique on the wound and how it will be managed. Specific contributing factors include:

• Status/acuity of the patient
• Type and extent of wound care procedure, and how invasive the procedure is
• Whether debridement is necessary
• Wound depth and location
• Types of supplies and/or instruments being utilized
• Cleansing/treatment solutions being used
• Care setting
• Type of caregiver
• Healthcare setting

Donna Werner provided a general overview on cost-effective wound care treatments in an article for Orthopedic Technology Review. These treatments involve three main steps in caring for wounds, according to one source, Robert J. Goldman, MD, assistant professor of rehabilitation at the University of Pennsylvania Health System.³

Chronic wounds should be treated by the removal of necrotic tissue (debridement), relief of pressure and dressing of the wound, Goldman says. If wounds are not neuropathic (so sensation is thus diminished), anesthetic is applied (five percent lidocaine). Wet-to-dry dressings are used until the wound is red and granulating; at this point, Goldman applies gel dressing in combination with gauze pads, non-adhesive gauze and antibiotic ointments.

Materials

Certain materials lend themselves to post-operative care away from the healthcare facility. According to Werner, moist dressings are the most cost-effective overall, even though they may be more expensive up-front. Because they can be changed daily or every two to three days, they are less time-intensive than wet-to-dry dressings, which require changing as much as every six hours. Moist dressings, however, should be changed more often if the wound is infected.

In general, moist dressings reduce the amount of pain for patients and reduce the chances of re-injury and trauma during dressing changes; they also have the benefit of autolytic debridement.

"The key to optimizing wound healing is to maintain an environment that balances the amount of moisture," writes Werner. "The wound should be neither too wet nor too dry."

Silver dressings are another option; because silver controls a broad spectrum of pathogens, it helps prevent infection in the wound and reduces time and costs associated with wound care.

More homeopathic remedies are sometimes incorporated to promote wound healing. "Alginate, like Kaltostat, (is) a moisture absorber; it's a dressing for the highly exudating," says Gill. "(In addition, you're using) any kind of secondary -- it depends on what the goal of the dressing is and what type of wound it is. We are more and more looking to do less frequent wound care with higher tech products. A lot of times we'll often put alginate on highly exuding wounds but put them into a dressing we won't change for a week."

Other than ultimate healing of a wound -- which is not always possible -- the goal is to keep the wound healthy. "In the short term, the goal is to keep the wound infection-free, to protect it from injury, to keep it insulated, to keep a moist wound environment. Keep it warm because wounds tend to be too cold, especially arterial wounds," Gill affirms.

The materials depend on the goal and the type of wound. "Do you need a dressing that will help the wound to autolytically debride? If you have a moist wound environment where the drainage is controlled but the wound is not dried out, the body will put the correct kind of cells in it to clean it up itself; it's the slowest type of debridement but oftentimes it's the most effective. (That's) because it's the body's natural cells ... We're not really aggressive with sharper surgical debridement of arterial wounds, because there's not enough blood to it already. Sometimes if you cut that tissue back it just continues to die," explains Gill.

There are many remedies patients and their physicians will try that directly counter the wound's ability to heal. Some patients who can't obtain normal saline over the counter (because their insurance doesn't provide for it) and who aren't comfortable using tap water (which is what Gill's clinic recommends) will purchase saline solution for contact lenses. But, Gill says, "those solutions have a preservative in them [that] is actually cytotoxic. It's not okay for your chronic wound, because it's going to kill off the cells that your body's trying to put in; [or] maybe not kill them off but change their character so they can't function in the way they were made to."

Higher-tech dressings that can increase the time between dressing changes are another component of the wound care program. Lower-end dressings, like gauze, are not necessarily the best. "Many times we'll find that gauze is the least cost-effective dressing because it has to be changed too often," says Gill. "So we're looking at composite dressings that can absorb drainage and provide odor control and keep an ideal wound environment with less frequent dressing changes."

An occlusive dressing will not allow anything into the wound but does not absorb very well either, so that dressing would be used over a wound without much exudate. An absorption dressing can be a foam, collagen-type dressing or a cellulose dressing.

Cost Differences

In the long run, is wound care less expensive for outpatients than inpatients? Outpatients don't have to worry about nosocomial infections once they've checked out of the ambulatory surgery center (ASC) -- sometimes within an hour or two after the procedure. So the duration of their exposure to nosocomial pathogens is very limited compared to inpatients. And patients of MIS certainly have smaller wounds, thus requiring less bandaging/suture material.

On the other hand, because the patient isn't available for daily follow-up as he would be in-hospital, is infection more common due to the quality of wound care the patient provides for himself? If infection does rear its ugly head, is more spent overall on follow-up visits and cleaning/debriding? Answer: it depends on the wound. And chronic wounds can be costly.

Follow-up care depends on the wound and the patient. "Typically they're seen weekly for the first three or four weeks ... it kind of depends on the wound type;" Gill reiterates. "If it's a venous wound, we're going to see them very often to get the edema under control, and to get them into a long-term dressing that's compression, and to get the whole disease process in control. If it's an arterial wound, we may see them less frequently, because the goal is going to be to keep that wound healthy and let the body heal it to the best of its ability. We'll do a diagnostic workup. Many times they're here for pain control or palliative control; they're not looking for a cure."

Education

Awareness and education are paramount. "You cannot believe the number of people in the community with a chronic wound that nobody's treating. It's unbelievable," Gill says. "Most of the primary care physicians are not equipped, both in terms of knowledge of chronic wounds and particularly in time ... There's a lack of community knowledge on dealing with them and a lack of community resources, which is why so many wound care centers sprung up."

Awareness, which may have been limited in the past, is increasing as baby boomers age. "You're going to see a lot more venous disease in the future," Gill predicts. "Probably nothing has really changed in terms of what the conditions are behind it, except we live so much longer now. We live with cancer now where before people just died, or you live with peripheral vascular disease or heart disease where before people just died. So we're going to see these problems more and more as we age."

Patient education is critical. "You have to get the patient to buy into their plan of treatment; they are part of developing it. If we cannot fix the source, like a venous ulcer that can't be surgically repaired (or even if it can be repaired), these patients have to stay in a compression garment for the rest of their lives, so patient education and ongoing education is a very important factor."

Quick diagnosis and patient education are hallmarks of good wound care. The final element is the use of caregivers who are specifically trained in wound care. "We really encourage community people to come in and spend a half a day with us, in the clinic, taking a look at what the goals are," Gill says. "There's a lot more wound care education available now, too -- for the general public and for the community caregivers."

This Just In

The world's first antibacterial suture has been cleared by the Food and Drug Administration (FDA). Vicryl Plus is offered by Ethicon Products, a division of Johnson & Johnson-owned Ethicon, Inc. Vicryl Plus is the first and only suture designed with an antibacterial agent known to be effective against Staphylococcus aureus, Staphylococcus epidermidis and methicillin-resistant strains of staphylococcus, the leading surgical site bacteria.

The suture is absorbable and therefore should not be used if extended approximation of tissue under stress is necessary. It also should not be used in patients allergic to IRGACARE MP (triclosan).

Advances in Wound Care Technology

CardioTech
CardioTech International, Inc. has received FDA approval for marketing of an antibiotic hydrogel wound and burn dressing, indicated for venous stasis ulcers, diabetic ulcers, pressure sores, blisters, superficial wounds, abrasions, lacerations and donor sites.

The CardioTech hydrogel dressing is a unitary construction that is absorbent, with reduced tendency to adhere to skin lesions. The dressing is designed to be placed directly on the wound, and will absorb five times its own weight of exudate by hydrophilic action. With hydration, the hydrogel forms intimate contact with the wound, minimizing dead space, and because it does not adhere to tissue, the removal is atraumatic and painless.

(781) 933-4772 or www.cardiotech-inc.com

Closure Medical
Closure Medical Corp. has received approval from the FDA to market its high viscosity Dermabond Topical Skin Adhesive. The new, thicker formulation of Dermabond adhesive provides greater precision and control of application especially when used on curved areas of the body, such as around the eyes and nose. The product will be distributed by Ethicon Products, a division of Ethicon Inc., a Johnson & Johnson company. This new approval is based in part on the findings of an 84-patient multicenter clinical study conducted at the Orlando Regional Medical Center and Stony Brook University Hospital in New York. Dermabond is used extensively by health professionals in the fields of trauma, plastic and other surgeries, emergency medicine and pediatrics.

(919) 876.7800 or www.closuremed.com

3M
3M Foam Dressings, designed to address fluid management, are available in adhesive and non-adhesive styles and have a non-swelling polyurethane foam pad designed to prevent exudates from pooling. The padding is also breathable and helps moisture evaporate from the dressing. "We believe clinicians will see remarkable results when using 3M Foam Dressings," says Gary Ackert, marketing manager. "Traditionally, heavily draining wounds have required frequent dressing changes, resulting in higher material expenses and discomfort for patients. But the combination of fast wicking, high absorbency and breathability in 3M Foam Dressings can extend the time between dressing changes and promote the health of periwound skin."

www.3m.com or (800) 228-3957

Healthpoint
Healthpoint, Ltd., a market leader in skin asepsis, tissue management and dermatology products, has formed Healthpoint Surgical, a new division that will expand infection prevention research, development and product availability and launch Oasis Wound Matrix to the surgical market.

Oasis, an innovative biomaterial providing a supportive environment to allow a patient's body to heal itself, is a natural, extracellular matrix that can manage a variety of wounds by helping the body rebuild and repair damaged tissue. Oasis can be used in the management of partial and full-thickness skin loss injuries from surgical and trauma wounds, autograft donor sites, second-degree burns, pressure, venous and chronic vascular ulcers, diabetic ulcers and abrasions.

(800) 441-8227 or www.healthpoint.com