Surgical Wound Healing Not Mines

Managing surgica Managing surgicall wound care: review of Leukomed Control dressings ABSTRACT Optimal management of surgical wounds is an important part of postoperative recovery. recovery. The aim of postoperative wound care is to facilitate rapid wound closure, while preventing complications complications and promoting minimal disturbance, to achieve the best functional and aesthetic results. Health professionals should seek to optimise the process of acute wound healing, observe progress, and prevent wound complications. Dressings that permit extended wear time, and are transparent and so allow early recognition without the need for unnecessary changes, have the potential to minimise the effect on patients and the wider health economy. economy. This ar ticle reviews recommendations for surgical wound care, and introduces the recently launched Leukomed Control dressing that is entirely transparent and allows greater flexibility, breathability, and visualisation of the wound. Key words: Surgical wound infection � Quality of life � Wound healing

Cost-effectiveness � Dressings

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nnovation has led to an increasing number of medical conditions being treated with surgery. The Health & Social Care Information Centre (HSCIC) (2015) states that surgical procedures accounted for 4.7 million episodes of care in England in 2013-2014. The majority of surgical procedures lead to a break in the protective barrier to the skin. Surgical site infection (SSI) surveillance programmes report a decreasing incidence in the recorded categories (Public Health England (PHE), 2014). An SSI is defined as a superficial incisional infection that occurs within 30 days of surgery (National Collaborating Centre for Women’s and Children’s Health, 2008). However, in spite of being rare, SSIs account for 16% of all healthcare associated infections in England (National Institute for Health and Care Excellence (NICE), 2013a)—that is, the third most common type of infection. It is thought that this figure may be underestimated, as reporting is voluntary volunta ry with the exception of mandatory orthopaedic data. Moreover, discharged patients can remain in the community for treatment, and the episode may therefore not be disclosed. Postoperative wound sepsis carries the possibility of high morbidity and potential mortality, and leads to unpredictable additional costs (NICE, 2013a). The Under the Knife report report (CareFusion, 2011) estimates the annual cost Jeanette Milne, Tissue Viability Nurse Specialist, Community Community Health Services Clarendon, South Tyneside Foundation Trust Accepted for publication: November 2015

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to be £700 million per annum, and calls for zero tolerance. It has been accepted that not all operative complications are escapable; escapabl e; howev however, er, surveillanc surveillancee has shown s hown that their th eir incidence can be reduced by taking appropriate measures (PHE, 2013). This article examines surgical wound healing, and discusses preventive approaches that can be employed to diminish postoperative complications. It also introduces evidence in support of a novel postoperative dressing.

Surgical wound healing Surgical wounds are categorised as acute wounds; healing is initiated spontaneously and resolution, in most cases, occurs in a predictable time frame. The healing of an acute wound requiress coordinated cellular and molecular responses require (Martin and Nunan, 2015). Wound healing heal ing is generall generally y divided into three phases: inflammation, proliferation, and maturation (Dealey, 2005). The priority of the inflammatory phase is to prevent further damage and prepare the site of injury for repair. Platelets are released from injured blood vessels, and vasoconstriction and coagulation occur to initiate haemostasis (Schultz et al, 2005). Concurrently, the early neutrophils that ar rive signal the generation of macrophages to expedite efficient cleansing of any devitalised tissue, as well as facilitate the removal of any bacteria that has been introduced during wounding (Dealey, 2005; Martin and Nunan, 2015). Following injury, histamine and prostaglandins are released to reverse initial vasoconstriction and increase blood vessel permeability to allow the escape of larger neutrophils and improv imp rovee blood flow to the t he wound. This, in turn, improves oxygen delivery that is required by the cells to enable escalation in metabolism (Schultz et al, 2005). Erythema and oedema occur as a result of the blood vessels expanding and increasing blood supply (Silver, 1994; Collier, 1996), and this is accompanied by heat and pain (Tortora (T ortora and Grabowski, Gr abowski, 1996; Dieglemann and Evans, 2004). Cells continue to release growth factors and cytokines to enable tight regulation and coordination of events, and the wound moves into the proliferative stage of wound healing (Hopkinson, 1992; Martin and Nunan, 2015). Angiogenesi Angiogenesiss (the growth of new blood vessels) occurs to restore blood flow, and granulation tissue is generated in the form of an extracellular matrix to fill the defect (Dealey, 2005; Martin and Nunan, Nuna n, 2015). Simultaneousl Simultaneously y, the edges of the wound contract, epithelial tissue forms, and it restores the bacterial barrier function of the skin. This proliferative British Journal of Nursing 2016, Vol 25, No 6: TISSUE VIABILITY SUPPLEMENT

stage ends when the wound is fully closed. The final stage of healing is called maturation, during which time the wound regains its tensile strength, collagen fibres reorganise, the network of new blood vessel growth rationalises, and the scar loses some of its red pigmentation (Schultz, 2005). Reorganisation of tissue can take up to 18 months to be completed (Dealey (Dealey,, 2005). Surgical wound healing is augmented by the surgical technique—larger vessels damaged during the procedure will be ligated or cauterised to reduce blood loss. The majority of surgical wounds will have the wound edges approximated with sutures, clips, or glue in an attempt to minimise the defect (Aindow and Butcher, 2005). Approximation facilitates clotting, mimics the natural process of contraction, and supports epithelial migration from the edges to effect rapid closure, thereby providing a barrier against bacterial penetration (Roberts et al, 2011). Some surgical wounds, for example the excision and drainage of an abscess or pilonidal sinus, are commonly left open and heal by secondary intention. The process of wound healing is the same. Further information in relation to managing wounds healing by secondary intention is discussed by Schultz (2003) and Burton (2006).

Common complications of surgical wounds A common complication of surgery is the risk of patients developing an SSI. Undetected superficial wound infection can lead to wound dehiscence (Oldfield and Burton, 2009). The latter can also occur as a result of haematoma, poor nutrition, nutrit ion, impaired blood flow flow,, and mechanical f ailure, which can be due to inappropriate closure technique technique or patient-related patient-rela ted factors, f actors, such as obesity, excess mobility, mob ility, shear, and friction (van Ramshorst et al, 2010). Increased pain, exudate, prolonged er ythema, unresolved oedema, and odour accompanied by pyrexia, are cardinal signs and symptoms of acute wound infection (European Wound Management Association (EWMA), 2005). It is important to bear in mind that the normal inflammatory phase of wound healing leads to t o redness, swelling, heat, and pain, and that this is part of the physiological process of healing. As such, these symptoms alone do not equate to a wound complication. Initial assessment may indicate the need for microbiological analysis, blood tests, or imaging investigations to confirm the diagnosis (World Union of Wound Healing Societies (WUWHS), 2008).Yao et al (2013) ( 2013) recommend recomme nd that t hat local signs of inflammatio inflammation n do not warrant immediate action but should be closely monitored if these progress; if wound infection is suspected, active management must be commenced (Keast and Swanston, 2014). Blistering of the peri-wound area is another common complication described by Bhattacharyya et al (2005) and Cosker et al (2005). Lifestyle and patient comorbidities can also affect outcomes, and while these are not easy to address, consideration must be given to the management of factors such as minimising the effect of concomitant disease, for example, optimising glucose control in diabetes, pre- and postoperative nutrition, smoking, and vascular disease, as well as the effect on perfusion, to name but a few (Yao (Yao et al, al , 2013). 2013).

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Strategies for postoperative wound management The aim of postoperative wound care is to facilitate rapid wound closure while preventing complications and promoting minimal disturbance to achieve the best functional and aesthetic results (Baxter, 2003). Oldfield and Burton (2009) suggest that patients often feel more comfortable with their wound covered, as it prevents closure materials from catching on to clothing that may in turn lead to trauma. Baxter (2003) points out that during initial repair in the early hours after surgery, the edges of the wound have little tensile strength and require support from the chosen closure material until full epithelialisation takes place. Optimising wound healing in the surgical patient requires a multidisciplinary approach, involving the patient, the surgical team, immediate theatre recovery staff, and postoperative caregivers, irrespective of whether they work on a ward or in the community setting (NICE, 2008; 2013a; Milne et al, 2012). Guidance and care bundles are aimed at promoting structured, timely, evidence-based interventions in the pre-, intra-, and postoperative management (Department of Health (DH), 2011). This has recently been supplemented with SSI quality standards (NICE, 2013a) that can be used to monitor organisations. In addition, in some areas, these have been linked to commissioning for quality and innovation targets. These enable commissioners to reward excellence by linking a proportion of income to desired measurable outcomes (NICE, 2013b). It is hoped that promoting adherence to the standards will improve equity and encourage enhanced outcomes. The SSI evidence review (NICE, 2013a) includes care bundles (DH, 2011) and the World Health Organization (WHO) surgery surge ry safety s afety checklist che cklist (WHO (WHO,, 2009).The NICE (2013a) review continues the three phases of clinical actions in the pre, intra, and postoperative postoper ative phases of o f care, reviews reviews the evidence for each recommendation, and gives clarity in relation to unanswered questions, suggesting areas for research. For example, showering or bathing preoperatively continues to be supported; however, the review suggests that the use/benefit of doing so with an antimicrobial agent is uncertain in terms of efficacy. Interestingly,, and perhaps most relevant to this article, Interestingly the evidence review document (NICE, 2013a) supports recommendations from the recently published article in the Cochrane Database of Systematic Reviews on dressings used in surgical surg ical wound care (Dumville et al, 2011).This review evaluated evidence from randomised control trials that studied the incidence of SSI. It concludes that there was not enough evidence to determine if the use of wound dressings helped to prevent SSIs in wound healing by primary intention versus leaving the wound exposed, and that no particular dressing appeared to be better. NICE (2013a) acknowledges limitations, stating that most studies had inappropriate control dressings, such as gauze or pads. The studies were small, and most were either assessed as poor quality or could not be assessed because of incomplete reporting, and only four studies were published within the last l ast decade. As a result, comparison between two modern dressings is not clear. Dumville et al (2011) conclude British Journal of Nursing 2016, Vol 25, No 6: TISSUE VIABILITY SUPPLEMENT

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that wound dressings should be chosen on the basis of cost and specific qualities/management properties of the product itself. NICE (2008) recommends covering a wound at the end of the procedure with an interactive dressing, but does not specify which dressing. An interactive dressing can be described as one that supports and maintains an optimum environment for healing (Schultz et al, 2003). It is difficult to determine how many postoperative dressings exist. A recent search of the Wound Care Handbook 2015– 2016 (Cowan, (Cowan, 2015) reveals that most wound products are recommended for use on postoperative wounds. Limiting the search to those specifically designed for use postoperatively is not easy, as they are not grouped in this way. A lack of definitive evidence to support specific choice (Dumville et al, 2014) and the number of products available today can make product selection difficult. Oldfield and Burton (2009) suggest that clinicians could leave postoperative wounds covered and undisturbed for 48 hours. Yao et al (2013) suggest that a dressing should be removed earlier if there is excessive inflammation, which may suggest complications or an increase in wound pain/ pressure reported by the patient that is difficult to control with analgesia. Baxter (2003) suggests that the initial function of a postoperativee dressing is to absorb blood or haemoserous postoperativ fluid and provide protection. The choice of dressing can also be determined by the type of surgery, the closure technique, anatomical location, and size of the wound (Milne et al, 2012). Clinicians should also look for a dressing that, on removal, remo val, will minimise trauma and the degree of sensory stimulus to the wounded area in order to reduce patientreported pain (Briggs and Torra i Bou, 2002). In addition, careful consideration should be given to dressing or ientation and tension, as well as how patient movement postoperatively may affect this (Milne et al, 2012). Leal and Kirby (2008) report skin damage and blister ing over over joints as a result of joint articulation postoperatively with some products.

Box 1. Benefits of vapour-permeable film dressings Barrier function prevents contamination Allows postoperative inspection of the peri-wound area and the wound itself without removal Allows easy removal as a result of low adhesion to the wound Maintains a moist wound environment and prevents excessive moisture (breathable) Can be left in place for up to 7 days Enables the patient to shower after 48 hours without removal (waterproof) Is conformable to body contours and tends to be more stretchy, allowing for postoperative movement/wearer comfort with reduced incidence of blistering Source: Roberts et al, 2011

Film and pad dressings have also been reported to reduce blistering in some instances (Gupta et al, 2002; 2002; Bhattacharyya Bhattacharyya et al, 2005; Cosker et al, 2005). In more recent years, it has been suggested that vapour-permeable film dressings could offer a number of advantages over non-woven dressings (Roberts et al, 2011) (Box 1).

Importance of choosing the most suitable dressing In a time of austerity, reduced funding is compounded by an ageing population and a corresponding increased demand for healthcare resources. Surgical wound care is not immune to scrutiny (Dumville et al, 2011). Proposed healthcare reforms in England and across the UK recommend addressing patients’ expressed needs as a priority. Any treatment plan would need to address all identified risk factors (NICE, 2013a). 2013a). Interventions for the management of acute wounds should centre on reducing potential wound-related complications such as SSI. Part of this process is the selection of a dressing to cover the wound; most are designed to address local factors, for example, absorb Red strips for easier application in line with the Leukomed range

Hydropolymer islands for reliable absorption and atraumatic removal

Very thin and flexible polyurethane (PU) film; the same film used in Cutimed Siltec and new film range

Hydropolymerfree zones for extra flexibility and additional breathability

Soft, acrylic adhesive to secure adhesion

Figure 1. Description of the Leukomed Control dressing

British Journal of Nursing 2016, Vol 25, No 6: TISSUE VIABILITY SUPPLEMENT

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free zones (Figure (Figure 1) 1) that allow greater flexibility, breathability, and visualisation of the wound. The dressings have a soft acrylic adhesive at the margins that allow secure adhesion, while the hydropolymer islands that cover the incision are non-adhesive. This facilitates moist wound healing while absorbing excess exudate and minimising pain and trauma to the incision on removal. The entire hydropolymer pad is transparent, which allows the clinician to easily inspect the wound without the need to remove the dressing. Consequently, this helps to lengthen the wear time and prevent external contamination and trauma associated with early removal.

Figure 2. Case study 1

a) Wound closure

c) One week post closure, dressing removed

b) Postoperative dressing

d) Two weeks post closure

exudate, donate fluid, and/or reduce bioburden. Dressings help to manage the symptoms of the wound and manipulate the environment in which healing takes place. Optimisation of the wound environment can improve patient outcomes, accompanied with transparency, which allows inspection without removal, will help to alleviate and address patient-related concerns. Cost-effectiveness in surgical care relates to overall treatment costs and is balanced with an ability to maintain or improve patient outcomes. In surgery, the resultant injury to the skin is a necessary by-product of the intervention. The relative cost associated with the treatment of the wound is minimal when compared to that of the procedure itself. This of course assumes that none of the above-mentioned complications occur, because costs escalate with complications such as SSIs. These complications commonly commonly lead to increased length of stay and the need for more interventions, such as an increased frequency of dressing changes, debridement, or further surgery. As such, the cost of the dressing should be assessed in relation to evidence of efficacy in its chosen application and its ability to meet the goal of care.

Leukomed Control dressings Leukomed Control dressings (BSN medical) are made of a very thin, flexible, polyurethane film that is used in the new Leukomed range of film and postoperative dressings. The backing of the dressing provides stability for application and has red strips on the edges that enable easier visualisation and application with aids. The dressing has been designed with hydropolymer islands that allow reliable absorption and facilitate atraumatic removal. There are hydropolymer-

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Case study 1 Steve Jeffrey, Professor, Wound Study, Birmingham City University, and consultant plastic surgeon A 36-year-old man sustained a fractured tibia while parachuting abroad. The fracture was plated abroad and, unfortunately, it did not heal and the patient developed osteomyelitis of the tibia. He also developed complex regional pain syndrome, and after much discussion an elective above-knee amputation was performed. About 6 weeks following the amputation, he developed an abscess in the end of the stump. The stump was very painful and ‘throbbing’. The patient was admitted and underwent opening up of the stump. A wound irrigation system using the KCI VAC-Ulta device was placed in theatre, theat re, using octenilin Wound Irrigation Solution. Every 3 hours the sponge wound wound filler was filled with 45 ml of the irrigation solution and held hel d for 15 minutes. Postoperatively, Postoperatively, the patient immediately reported a complete reduction in his pain. The dressings were changed at day 3 on the ward and at day 6 the patient was taken back to theatre where the wound was closed (Figure (Figure 2a). 2a). Leukomed Control was applied post-operatively (Figure (Figure 2b). 2b). This wound was particularly at r isk of developing further infection and the ability to see any redness in the postoperative wound was the reason that this dressing was chosen. The patient was reviewed at 1 week when the dressing was removed (Figure ( Figure 2c ). ). A further Leukomed control dressing was applied. At 2 weeks the wound was completely healed (Figure (Figure 2d ). ). The use of the Leukomed Control dressing allowed for inspection of this at-risk wound without removal of the dressing. The patient found the dressing to be comfortable.

Case studies 2–6 Sharon Hunt, advanced nurse practitioner, South Tees Hospital NHS Foundation Trust The following case studies were made up of five postsurgical wounds that attended follow-up at their reg istered GP centre, which deals with minor injuries/walk-ins and has a resident wound care specialist/nurse practitioner (the author) on rota. The patients all attended for their first postoperative dressing change and follow-up care. Three patients attended postoperatively from the acute sector and two from the walk-in centre (in-house intervention). All five patients gave verbal consent for product application following British Journal of Nursing 2016, Vol 25, No 6: TISSUE VIABILITY SUPPLEMENT

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Table 1. Case study 2: Presenting date 25/1/2016 – classed as day 0

Dressing size=7x10 cm

Date

L eng t h

Width

Depth

Exudate

Infected

25/1/2016

2.0

1.8

1.0

Low

No

28/1/2016

1.5

1.5

0.5

Low

No

31/1/2016

1.0

0.8

0.2

None

No

3/2/2016

0

0

0

None

No No

7/2/2016

0

0

0

None

No

Date

Pain score 0/10 peri (on application and removal)

Pain score 0/10 post (in between dressing changes)

Dressing satisfaction (nurse N) (patient P) 0/3

Self-application satisfaction (nurse N) (patient P) 0/3

Adverse events

25/1/16

8 /10

3/10

P=2, N=2

P=3, N=3

None

28/1/16

2 /10

0/10

P=2, N=2

P=3, N=3

None

31/1/16

0 /10

0/10

P=2, N=2

P=3, N=3

None

3/2/16

0/1 0

0/10

P=2, N=2

P=3, N=3

None

7/2/16

0/1 0

0/10

P=2, N=2

P=3, N=3

None

Dressing satisfaction = 1, poor; 2, good; 3, excellent. Self-application satisfaction = 1, poor; 2, manageable; 3, excellent

Table 2. Case study 3: presentin g date 25/1/2016 – classed as day 0

Dressing size 10x35 cm

Date

L eng t h

Width

Depth

Exudate

Infected

25/1/2016

35

2

8

Low

No

28/1/2016

33

2

8

Low

No

31/1/2016

28

1.8

6

Low

No

3/2/2016

28

1.8

6

Low

No

7/2/2016

25

1.5

5

Low

No

Date





Adverse events

25/1/2016

4/10

4/10

P=2, N=2

P=2, N=3

None

28/1/2016

2/10

2/10

P=2, N=2

P=2, N=3

None

31/1/2016

0/10

0/10

P=2, N=2

P=2, N=3

None

3/2/2016

0/10

0 /1 0

P=2, N=2

P=2 (patient needed help to apply due to dressing size), N=3

None

7/2/2016

0/10

0 /1 0

P=2, N=2

P=2, N=3

None


verbal information from the author who applied the initial products, collected the relevant data twice per week from the patients’ electronic electronic records and compiled the background case study information. Those that gav gavee per mission for photos have been used in this article. Following Following the first fir st application by the author, all five patients then car ried out their own dressing application as part of their care plan with twice-weekly visits for wound assessment, measurement and verbal support and reassurance. Pain score was obtained at dressing change and between visits. All wounds had low to moderate exudate levels.The evaluation process was carr ied out in accordance with current trust policy and therefore British Journal of Nursing 2016, Vol 25, No 6: TISSUE VIABILITY SUPPLEMENT

did not warrant ethical approv approval. al. All data were collected and stored in the patients’ electronic medical file as per normal practice. pr actice. Summaries of the patients’ medical histories and surgery are detailed below, and results of the use of Leukomed Control dressings are detailed in Tables 1–6 . Case study 2 (Figure 3) This patient is a 45-year old male who works as a manager for a large UK firm dealing with computer and service provision. He is normally fit and well with no allergies, medical history or illnesses. He had not taken any medication when he presented to surgery with recurrence

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Figure 3. Case study 2

b) Post-intervention with product applied

a) Peri-inter vention

c) Day 10: healed



Date

L eng t h

Width

Dept h

Exudate

Infected

26/1/2016

3

0.8

2.5

Low

No

29/1/2016

2.8

0.5

2.5

Low

No

1/2/2016

2.5

0.3

2.0

Low

No

4/2/2016

1.5

0.2

1.0

Low

No

8/2/2016

1.0

0.2

0.3

Low

No

Date





Adverse events

26/1/2016

2/10

0/10

P=3, N=3

P=3, N=3

None

29/1/2016

0/10

0/10

P=3, N=3

P=3, N=3

None

1/2/2016

0/10

0/10

P=3, N=3

P=3, N=3

None

4/2/2016

0/10

0/10

P=3, N=3

P=3, N=3

None

8/2/2016

0/10

0/10

P=3, N=3

P=3, N=3

None




Date

L eng t h

Width

De p t h

Exudate

Infected

27/1/2016

1

3.2

0.8

Low

No

30/1/2016

1

3.2

0.8

Low

No

2/2/2016

1

3.0

0.5

None

No

5/2/2016

1

3.0

0.5

None

No

9/2/2016

1

2.5

0.4

None

No

Date





Adverse events

27/1/2016

0/10

0 /10

P=3, N=3

P=3, N=3

None

30/1/2016

0/10

0 /10

P=3, N=3

P=3, N=3

None

2/2/2016

0/10

0/1 0

P=3, N=3

P=3, N=3

None

5/2/2016

0/10

0/1 0

P=3, N=3

P=3, N=3

None

9/2/2016

0/10

0/1 0

P=3, N=3

P=3, N=3

None


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PRODUCT FOCUS

PRODUCT FOCUS



Date

L eng t h

Width

Depth

Exudate

Infected

27/1/2016

1.5

29

3

Med

No

30/1/2016

1.5

27

3

Low

No

2/2/2016

1

22

2.8

Low

No

5/2/2016

1

22

2.5

Low

No

9/2/2016

1

20

2

Low

No

Date





Adverse events

27/1/2016

4/10

0/10

P=2, N=2

P=2, N=3

None

30/1/2016

2/10

0/10

P=2, N=2

P=2, N=3

None

2/2/2016

0/10

0 /1 0

P=2, N=2

P=2, N=3

None

5/2/2016

0/10

0 /1 0

P=2 (pulled a little when bending knee), N=2

P=2, N=3

None

9/2/2016

0/10

0 /1 0

P=3, N=3

P=2, N=3

None


of a raised subcutaneous cyst to his left radial region of the wrist. This was affecting his working role (using computers), due to its position and resulting pressure and pain. The patient consented to debridement of the mass. Leukomed Control was applied by the author and details of the dressing’s use are in Table 1. 1. Case study 3 This patient is an 82-year-old female who is a retired teacher, independent and lives alone. Her medical history includes hypercholesterolemia for which she is on medication, no allergies and fully mobile. She is prescribed simvastatin 20 mg once per day. She presented to surgery for first dressing change following a right hip replacement. Before this, she had lost her balance in the garden and f allen on to a concrete path fracturing her neck of femur. A Softpore (Richardsons) adhesive surgical dressing (10 cm x 30 cm) was in situ on attendance. Leukomed Control was applied by the author and details of the dressing’s use are in Table 2. 2. Case study 4 (Figure 4) This patient is a 23-year-old male who works as a healthcare worker with older people in the NHS. He suffers from frequent abscess formation, folliculitis and depressive illness, and feels well with no allergies. He is taking sertraline 20 mg once per day and flucloxacillin 500 mg four times a day for one week. This patient presented to surgery with a postoperative surgically debrided abscess on the r ight midaxillary for his first wound review and dressing application. A Softpore adhesive surgical dressing (6 cm x 7 cm) was in situ on attendance. Leukomed Control was applied by the author and details of the dressing’s use are in Table 3. British Journal of Nursing 2016, Vol 25, No 6: TISSUE VIABILITY SUPPLEMENT

Case study 5 This patient was an unemployed 48-year-old father of two, who cares at home for his young children alone. His medical history includes diabetes mellitus, for which he takes medication, HBA1c 8%, SINBAD (diabetic foot classification) level 3, diagnosed neuropathy and peripheral vascular disease, hypertension, hypercholesterolemia, obesity and heavy smoker (30 cigarettes a day). He is currently taking metformin 500 mg in the mor ning; metformin 1000 mg in the evening, and ramipril 10 mg; simvastatin 20 mg once a day; and flucloxacillin 500 mg four times a day for a 10-day period. He wears an offloading diabetic shoe (Procare) as directed. This patient presented to surgery for first dressing change following a left great toe amputation. Before this, he had chronic and recurrent Staphyloco Staphylococcus ccus aureus aureus infection infection with resulting necrosis and cellulitis of the foot. A Mepilex Border adhesivee dressing (Mölnlycke Health Care) (7 cm x 7.5 cm) adhesiv Figure 4. Case study 4

a) Day 0

b) Day 10

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KEY POINTS �

Surgical site infections account for 16% of all healthcare-associated infections in England

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Increased knowledge and use of guidelines, clinical standards, and care bundles will ensure early recognition of signs and symptoms of wound complications

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Leukomed Control dressings contain hydropolymer-free zones that allow greater flexibility, flexibility, breathability, breathability, and visualisation of the wound

�

Being completely transparent, Leukomed Control allows clinicians to easily inspect the wound without the need to remove the dressing

was in situ on attendance. Leukomed Control was applied by the author and details of the dressing’s dressing’s use are in Table 4. 4. Case study 6 This patient is a 51-year-old female who works as a catering assistant and stands for long periods of time (up to 8 hours a day.) She is normally fit and well with no allergies, medical history or illnesses. No medications were being taken at presentation. The patient presented to surgery for fir st dressing change following postoperative cartilage repair of her left patella. Before this, she had chronic pain and a ‘grinding’ sensation, especially at the end of the day and on long walks. A Softpore adhesive surgical dressing (10 cm x 35 cm) was in situ on attendance. Leukomed Control was applied by the author and details of the dressing’s use are in Table 5 . Summary of case studies 2-6 While using the product, the author noticed the following:  Reduced adhesion to skin that is hairy and pulls on hairy skin; suggest hair removed before application  Only applied to none, low or moderate serous/ haemoserous exudate in this evaluation  One older patient needed some assistance with longlength dressing application. The author received positive feedback from the patients, who in the main applied the dressing independently with no problems, thus promoting self-care and reducing the need for extra dressing visits. The patients found the dressing to be light, comfortable and atraumatic in application and removal. They all wished to continue use of the product and felt it was visually appealing because it was almost invisible. The author found the product easy to use and found the transparency when in situ useful; she felts it was a good alternative to dressings traditionally used.

Conclusion This article provides a general overview of surgical wound healing and potential complications, including SSI. Care bundles, NICE guidance, and quality standards are considered and should be used to direct care to minimise complications. It is hoped that increased knowledge and use of these standards will ensure early recognition of signs and symptoms that will, in turn, reduce the adverse effect on a patient’s quality of life and minimise any associated costs.

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The limited evidence for the selection of postoperative dressing products is also addressed. Guidance to choose a product on the basis of cost, features, and benefits matched to the wound type support the introduction of Leukomed Control dressings. The case studies have been used to demonstrate that appropriate dressing choice can have a positive effect on healing outcomes in patients with acute wounds. BJN Declaration of interest: this article was supported by BSN medical. Aindow D, Butcher M (2005) Films or fabrics: is it time to re-appraise postoperative dressings? Br J Nursing 14(19): S15-20 Baxter H (2003) Management of surgical wounds. Nurs Times 99 (13): 66-8 Bhattachar yya M, Bradley H, Holder S, Gerber B (2005) A prospective clinical audit of patient dressing choice for post-op arthroscopy wounds. Wounds UK 1(1): 30–4 Briggs M, Torra i Bou JE (2002) Pain at wound dressing changes: a guide to managem ent. In: EWMA Positio n Documen t Pain At Wound Dressi ng Changes.. http://tinyurl.com/z9jsw8r (accessed 17 March 2016): 12–17 Changes Burton F (2006) Best practice overview: surgical and trauma wounds. Wound Essentials 1: 98–107. http://tinyurl.com/ze9nfvv (accessed 3 March 2016) CareFusion (2011) Under the Knife: Taking a Zer o Tolerance Approach to Preventable Surgical Site Infections in UK Hospitals. Hospitals . CareFusion, Basingstoke Collier M (1996) The principles of optimum wound management. Nurs Stand 10(43): 47-52 Cosker T, Elsayed S, Gupta S, Mendonca AD, Tayton KJ (2005) Choice of dressing has a major impact on blistering and healing outcomes in orthopaedic patients. J patients. J Wound Care 14(1): 27-9 Cowan T, ed (2015) Wound Care Handbook 2015–16 . MA Healthcare Lt d, London Dealey C (2005) The Care of Wounds. Wounds. A Guide for Nu rses rses.. 3rd edn. Blackwell Publishing, Oxford Department of Health (2011) High Impact Intervention Care Bundle to Prevent Surgical Site Infection. http://bit.ly/11kifVJ (accessed 12 November 2015) Diegelmann RF RF,, Evans MC (2004) Wound Wound healing: an overview of acute, fibrotic and delayed healing. Front Biosci 9: 283–9 Dumville JC, Walter CJ, Sharp CA, Page T (2014) D ressings for the prevention of surgical site infection. Cochrane Database Syst Rev (7):CD003091. doi:10.1002/14651858.CD003091.pub2 European Wound Wound Man agement Association (2005) Position Document: Identifying Criteria for Wound Infection. Infection . http://tinyurl.com/blzjrc (accessed 16 March 2016) Gupta SK, Lee S, Moseley LG (2002) Postoperative wound bli stering : is there a link with dressing usage? J usage? J Wound Care 11(7): 271–3 Health & Social Care Information Centre (2015) Hospital Episode Statistics. Admitted Patient Care, England 2013-14. http://bit. ly/1MpS5la (accessed 12 November 2015) Hopkinson I (1992) Growth factors and extracellular matrix. J matrix. J Wound Care 1(2): 47–50 Keast D, Swanston T (2014) Ten top tips: managing surgical site infec tions. Wounds International 5(3): 13–18 Leal A, Kirby P (2008) Blister formation on primary wound closure sites: a 4(2): 31–7 comparison of two dressings. Wounds UK 4 Martin P, Nunan R (2015) Cellular and molecular mechanisms of repair in acute and chronic wound healing. Br J Dermatol 173 (2): 370-8. doi:10.1111/bjd.13954 Milne J, Vowden P, P, Fumarola S Leaper D (2012) Post-operative incisi on 8(4): 1–4 management. Wounds UK 8 National Collaborating Centre for Women’s and Children’s Health (2008) Surgical Site Infection: Prevention and Treatment of Surgical Site Infection. Infection . http://tinyurl.com/gsj5how (accessed 16 March 2016) National Institute for Health and Care Excellence (2008) NICE guidelines [CG74] Surg ical Si te Infecti ons: Prevention and Treatment. Treatment. www.nice. www.nice. org.uk/guidance/cg74 (accessed 12 November 2015) National Institute for Health and Care Excellence (2013a) Surgical Site Infection. Evidence Update June 2013. 2013. http://tinyurl.com/zm4nkbb (accessed 16 March 2016) National Institute for Health and Care Excellence (2013b) NICE Support for Commission ing for Sur gical Site In fection fection.. http://tinyurl.com/hvv3yqx (accessed 16 March 2016) Oldfield A, Burton F (2009) Surgical wounds: why do they dehisce? Wound Essentials. Essentials. http://tinyurl.com/hkepkdx (accessed 16 March 2015) Public Health England (2013) Protocol for the Surveillance of Surgical Site


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Infection Surgical Site Infection Surveillance Service . PHE, London Public Health England (2014) Surveillance of Surgical Site Infections in NHS hospitals in England, 2013/14. 2013/14 . PHE, London Roberts N, Sorrell J, Bielby A, Searle A (2011) A survey o f postop erative wound dressing practice before and after implementing national guidelines. Wounds UK 7(4): 12–21 Schultz GS, Sibbald RG, Falanga V et al (2003) Wound Wound b ed preparat ion: a systematic approach to wound management. Wound Repair Regen 11 Suppl 1: S1–28 Schultz GS, Ladwig G, Wysoki A (2005) Extracellular matrix: review of its roles in acute and chronic wounds. World Wide Wound Woundss. http://bit. ly/1kQPfPl (accessed 12 November 2015) Silver IA (1994) The physiology of wound healing. J healing. J Wound Care 3(2):

106–9 Tortora GJ, Grabowski SR (1996) Principles of Anatomy and Physiology. Physiology . Harper Collins Publications, New York van Ramshor st GH, Nieuwenhuizen J, Hop WC et al (2010) Abdomina l wound dehiscence in adults: development and validation of a risk model. World J Su rg 34(1): 20–7. doi:10.1007/s00268-009-0277-y World Health Organization (2009) Safe Surgery. http://tinyurl. com/56y97w (accessed 12 November 2015) World Un ion of Wound Wound Heal ing Societi es (2008) Principles of Best Practice: Wound Infection in Clinical Practice. An International Consensus. Consensus . http:// tinyurl.com/oglcy8c (accessed 16 March 2016) Yao Y ao K, Bae L,Yew WP (2013) Post-operative wound managemen t. Aust Aust Fam Physician 42(12): 867–70

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