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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 that 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."
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. Its 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, 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:
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.
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.
If infection occurs in a wound, Werner says, its polymicrobial quality necessitates a regimen of broad-spectrum oral antibiotics. Goldman utilizes an anti-aerobic agent and an anti-anaerobic agent as well, to best eliminate gram-positive, gram-negative and anaerobic pathogens.
Generally speaking, antibiotics are not part of the wound care regimen at Gill's clinic. Although all of the wounds are colonized, just by virtue of being chronic, Gill says that few of them are actually infected. Thus, "unless they have some kind of systemic signs and symptoms, or have demonstrated osteomyelitis from X-ray or bone scan or MRI, they do not get treated with antibiotics and we use very little antibiotic ointment."
Even if topical antibiotics are included in the therapy, they will be Bacitracin or Neosporin, which are both offered over the counter. "Review of the literature feels that all it does is set the patient up for MRSA because you're treating a broad spectrum of bugs that are sitting on the wound," Gill says. "But unless they're there in sufficient quantities to actually cause infection, you're just giving antibiotics for no good reason. The other thing is, patients oftentimes develop an allergy to long-term use with Neosporin or Bacitracin because of the vehicle they're mixed in--(like) petroleum jelly."
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."
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 have 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."