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Wound Care Patient Case Lauren  Bussian , AJ Cushman, Maria King, Sarah Wound Care Patient Case Lauren  Bussian , AJ Cushman, Maria King, Sarah

Wound Care Patient Case Lauren Bussian , AJ Cushman, Maria King, Sarah - PowerPoint Presentation

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Wound Care Patient Case Lauren Bussian , AJ Cushman, Maria King, Sarah - PPT Presentation

Wound Care Patient Case Lauren Bussian AJ Cushman Maria King Sarah Nockengost Bryce Shank The Patient 59 yearold female History of LE ischemia Lives with immediate family within 25 miles of hospital ID: 762207

dressing wound patient healing wound dressing healing patient study hydrofiber cessation dressings wounds acute removal surgical mills msc phd

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Wound Care Patient Case Lauren Bussian , AJ Cushman, Maria King, Sarah Nockengost , Bryce Shank

The Patient 59 year-old female History of LE ischemia Lives with immediate family within 25 miles of hospitalPatient and patient’s mother both drive Currently disabledInsured with Medicaid and MedicareCity/county water at home

Database Past Medical History: HTN Hepatitis C PVDHistory of DVTNeuropathyCurrent 3 pack per day smoker Surgical History:2013: Bilateral ilio -femoral bypass 2 months prior to ER admission: Aorta endarterectomyR common iliac and L femoral bypass with Decron Graft

Database

Timeline of Current Hospital Visit

PT Evaluation Vital Signs : AfebrileBP: 110/70 mmHgWeight: 114 lbs Lab Values:WBC: 7.4Hgb : 7.8 INR : 1.1 Pulses:L femoral palpable (yet femoral artery not visible ) L dorsalis pedis palpable Left LE motor and sensory intact

PT Evaluation L groin wound with 100% pink muscle in wound bed3.5 cm long x 0.8 cm wide x 1.6 cm deep Copious serous drainage (>250 ml per shift ) Periwound intact No erythema or maceration No odor Bedrest orders

PT Evaluation Chief complaint:Left groin wound presenting with copious drainagePain not assessed during evaluation Patient goals:To have wound closed To function without any medical equipment

Physical Therapy Diagnosis Patient is a 59 year old female with signs and symptoms consistent with an acute surgical wound secondary to femoral bypass infection or complication that was corrected with Sartorius muscle flap.

ICF Model Copious Drainage Low Hgb/FatigueSkin Integrity Left Groin Wound Patient and mother drive City/County water Lives w/family Lives close to hospitalHx of smokingMotivated to move w/o ADDisabled Ambulation Participation w/family and community

Understanding the Surgery Sartorius Muscle Flap Proximal end dissected from ASIS Sartorius is rotated along long axis Then sutured medially to inguinal ligament

Prognostic Question In an acute lower extremity surgical wound, does recent cessation from smoking improve wound healing rate?

Smoking Cessation Reduces Postoperative Complications: A Systematic Review and Meta-analysis Edward Mills, PhD, MSc et al. The American Journal of Medicine. 2011.

Edward Mills, PhD, MSc et al “Tobacco remains the leading cause of preventable death in the world.” PURPOSE:To determine the role of smoking cessation and the duration of cessation required in preventing postoperative complications.

Smoking Cessation Reduces Postoperative Complications: A Systematic Review and Meta-analysisEdward Mills, PhD, MSc et al. The American Journal of Medicine. 2011. MATERIALS AND METHODS : Randomized controlled trials (RCTs) and observational studiesData Analysis Phi statisticRelative Risk (RR)Short and long term effects (</> 4 weeks) Impact of time (weeks) Edward Mills, PhD, MSc et al

STUDY SELECTION/QUALITY: Reviewed 847 abstracts Included 6 RCTs and 15 observational studies Exclusion (search was sensitive, not specific)Non-humanNon-EnglishNot address the review topicReview articles Risk of biasRCTs: modified Cochrane risk-of-bias toolNon-RCT: Newcastle-Ottawa Scale Edward Mills, PhD, MSc et al

Edward Mills, PhD, MSc et al RCT RESULTS :6 RCTsPooled RR of 0.59

Author, Year Intensity of Program Definition of Perioperative ComplicationsRelative Risk (95% CI) Lindstrom, 2008Intensive-Events causing additional tx prolonged hospital stay-Any wound complication0.51 (0.27-0.97)0.49 (0.20-1.16) Moller, 2002 Intensive -Death/post-op morbidity - Wound healing complications 0.34 (0.19-0.64) 0.17 (0.05-0.56) Myles, 2004 Less Intensive -Post-op wound infections 0.82 (0.06-11.33) Sorensen, 2003 Intensive -Adverse events w/in 30d requiring med/ sx tx 0.94 (0.51-1.73) Sorensen, 2007 Less Intensive -Post-op wound infection 0.71 (0.21-2.41) Warner, 2005 Less Intensive -Serious post-op events 0.86 (0.24-3.03) Edward Mills, PhD, MSc et al SMOKING CESSATION PROGRAM: More intense RR 0.55 Less intense RR 0.78

EACH WEEK OF CESSATION RR - 0.191< 4 WEEKSRR 0.92> 4 WEEKSRR 0.45 Edward Mills, PhD, MSc et al

Complication Studies Reporting RR (95%) P ValueOtherTotal 120.76 (0.69-0.84)<0.0001 significant reduction Pulmonary 7 0.81 (0.70-0.93)0.003no diff b/w early/late quitters* Wound-healing 5 0.73 (0.61-0.87) 0.0006 significant reduction Hospital LOS 2 n/a Other study found identical duration Mortality 2 1.00 (0.64-1.55) 0.98 no difference Duration of cessation period 7 0.80 (3-33) 0.02 Removed study- no longer significant OBSERVATIONAL STUDIES: Edward Mills, PhD, MSc et al

STRENGTHS: Extensive searching Data abstraction in duplicate RCTs and observationalRegression analysisLength of time from cessation associated with magnitude LIMITATIONS:Heterogeneous reporting of outcomesInconsistent definitions of past smoking statusDifferent observational study designs Low power for certain analyses Edward Mills, PhD, MSc et al

Edward Mills, PhD, MSc et al CONCLUSION: 8-10 million procedures performed on cigarette smokers If all patients were offered smoking cessation intervention (assuming 25% cessation rate)... Roughly 2 million complications avoided!Large savings for patients and health services . PATIENT RELEVANCE: Cessation period unknown, however, pt wound healing will still benefit from quitting with continued cessation during hospital stay over the next several weeks

Interventio n Question Is a Hydrofiber dressing the most appropriate treatment option to manage exudate and promote wound healing for our patient with an acute surgical wound?

Hydrofiber Dressing

Dressings for Acute and Chronic Wounds: A Systematic Review Chaby , G et al. JAMA Dermatology. 2007

Chaby, G et al STUDY DESIGN: Systematic Review of RCTs, meta-analyses and cost-effectiveness studiesPURPOSE : Critically review the literature on the efficacy of modern dressings in healing chronic and acute wounds by secondary intention

METHOD: Searched MEDLINE, EMBASE, and Cochrane Controlled Clinical Trials Register from January 1990-June 2006 19 reviewers graded articles using Sackett’s criteria checklist 99 articles met selection criteria (89 RCT, 3 meta-analyses, 7 systematic reviews, 1 cost-effectiveness study)No level A studies found, 14 level B (6 acute), and 79 level C Chaby, G et al

INCLUDED ACUTE WOUNDS:Skin graft donor sites Partial-thickness burns Posttraumatic wounds Post-surgical woundsEXCLUDED:Deep partial and full thickness burns Chaby, G et al

RESULTS of LEVEL B EVIDENCE:Hydrofiber dressing (HFD) had a mean time to complete healing of 7-10 days vs 10-14 days (p=.02) for paraffin gauze dressing(PFD) in patients with skin graft donor site (SGDS) wounds Pain during dressing change and ease of use had significant findings in favor of HFD when compared to PFD in acute SGDSChaby, G et al

RESULTS of LEVEL B EVIDENCE: Hydrofiber dressings increased wound healing rates greater than wet to dry dressings in deep, acute surgical woundsThese results approached statistical significance (p=.08) Hydrofiber(HFD) dressings received higher scores on ease of application and removal of first dressing, and re-application on the first post-op day and one week post-op when compared to alginate dressings on acute surgical wounds Patients in HFD group also reported less pain on removal of dressingsChaby, G et al

Chaby, G et al STUDY LIMITATIONS: Level of evidence found (no A, few B for acute wounds) Found benefits, but many were not statistically significant Ability to generalize to our patientSample size for studies reported was small (23, 50, and 100 respectively)

CONCLUSION: These results demonstrate that hydrofiber dressings may be a better choice compared to paraffin gauze, wet to dry, and alginate dressingsLess time to complete healing/ increased healing rate and ease of usePain during dressing changes can delay healing time and decrease patient compliance Further research with higher quality evidence needs to be done to validate these findingsChaby, G et al

Randomised clinical trial of Hydrofiber dressing with silver versus povidone-iodine gauze in the management of open surgical and traumatic wounds Jurczak, F. et. al. International Wound Journal. 2007

Jurczak, F. et. al STUDY DESIGN : Prospective, randomized clinical trial; Level II evidencePURPOSE: To compare the efficacy of Hydrofiber Ag versus povidone-iodine gauze dressings in reducing wound pain, improving patient comfort and exudate handling, and promoting wound healing in patients with open surgical or traumatic wounds.

Jurczak, F. et. al SUBJECT CHARACTERISTICS :67 adult patients with an open surgical wound or an open traumatic wound left to heal by secondary intent.Age range: 17-77 years 20 subjects presented with moderate-heavy wound exudate at baselineWounds areas included cervical, back, axilla, gluteal, scrotum, and groin.Median wound area: 600 mm^2Periwound normal in >65% of subjects within each treatment group Wounds open for average of 11 hours

Jurczak, F. et. al METHOD : Subjects randomly assigned to treatment with either Hydrofiber Ag dressing (n = 35) or povidone-iodine dressing (n = 32).Dressings changed as clinically indicated Average of once daily for both treatment groupsDressings could be changed at home or in the clinicDressings soaked in saline solution for ~15 min if necessary to facilitate removal.Duration of study = 2 weeks or until complete wound closure

Jurczak, F. et. al OUTCOME MEASURES : Pain severity during dressing application and removal, as well as while in placeInvestigator ratings of wound comfort, bleeding, exudate handling and trauma upon removal. Changes in wound appearance and sizeWound infectionNeed for debridement Ease of use for each treatment

Jurczak, F. et. al RESULTS : Pain (% decrease in VAS score from baseline)Comfort Rating (% rated as ‘excellent’ or ‘good’) Dressing Removal Trauma (% reporting “no trauma” at final visit) Bleeding (% reporting “no bleeding” during dressing change) Ease of Use (% reporting “very easy”) Hydrofiber Ag 62 (during removal) 33 (while in place) 97.1 (during removal) 97.1 (while in place) 94.3 88.6 78.9 (during application) 85.0 (during removal) Povidone-iodine Gauze 44 (during removal) 0 (while in place) 83.9 (during removal) 64.5 (while in place) 61.3 64.5 38.2 (during application) 52.8 (during removal)

Jurczak, F. et. al Wound Closure (% subjects with closed wounds prior to study termination) Wound Healing(% subjects with complete healing or marked improvement)Mean time to healing (# of days) Wound Size ( change from baseline in mm^2)Wound Bed Characteristics(% epithelialized tissue)Exudate Management(% reporting “excellent”) Hydrofiber Ag 23 91.2 14.1 -551 42.2 41 Povidone-iodine Gauze 9 74.2 13.9 -401 31.2 23

Jurczak, F. et. al STUDY LIMITATIONS : Small sample size without a true control groupLack of blinding to study treatmentBaseline differences in pain assessment measured by VAS Variation in analgesic use throughout study durationLack of objective outcome measuresShort duration of study

Jurczak, F. et. al CONCLUSION : Results of this study demonstrate that Hydrofiber dressings with silver is superior to povidone-iodine gauze for reducing pain and wound trauma associated with dressing removal, and for improving exudate management and overall comfort.Further research is necessary in order to compare ability of both dressing options to promote wound healing and prevent infection. Several weaknesses of this study limit its ability to determine cause of effect of intervention.

Intervention Question ConclusionsJurczak , et. al . Int. Wound JournalHydrofiber w/Ag more effective than gauze at managing copious drainageChaby , et al. JAMA DermatologyHydrofiber dressing more effective than paraffin gauze dressings to facilitate wound healing Hydrofiber dressing may result in increase healing rate when compared to wet-to-dry dressings

Questions & Group time

Plan of Care Frequency : 4x/weekDuration: 5 weeks Discharge Plan: Send home w/ orders for OP wound care Patient Education: Throughout course of acute intervention Three Stages of Intervention : On Bedrest : Post Op 1-7 Leg Lowering : Post Op 7-21 Non weight-bearing Off Bedrest : Post Op 21-D/C Weight-bearing

P hysical Therapy Goals In 7 days :Wound drainage will decrease from >250 mL per shift to 200 mL per shift to promote healing of wound.Patient will demonstrate understanding of bedrest orders and wound precautions to prevent graft damage and infection.Wound area will decrease by 10% in order to allow patient increased mobility in bed. Patient will demonstrate compliance with bed exercise program to increase independence with bed mobility.

Potential Long Term Goals By Discharge : Patient will demonstrate understanding of wound care principles and signs of infection to promote healing and prevent infection.Patient will ambulate 300 feet with LRAD to allow independence with ambulation at home.Wound drainage will decrease from >250 mL to <30 mL to decrease frequency of dressing changes to reduce risk for infection.Wound area will decrease by 85% in order to promote independence with ADLs and ambulation.

Patient Education Positioning Preventing contracturesBedrest OrdersWound Care WashingWater supplyDressingApplication Keep it clean! Signs of Infection Fever, swelling, redness, odor Factors that slow wound healingHydrogen peroxide (repeated use) Poor nutrition SMOKING Prevention of DVTs Ankle pumps

Stage One: Bedrest Bed mobility PositioningUE strengthening program Skin and Wound checksMonitor Vitals and Lab ValuesWound Dressing Priority : wound care and prevention of further medical complications

Stage One: Bedrest Bed Mobility Rolling ScootingGlute setsUE Strengthening Bed mini dipsT-Band flexion, abduction, ER, IR, WsI,T, and Ys while in prone Monitor Vitals and Lab Values BP, ABI INR, WBC, HgbPositioning Sidelying Bilaterally Supine Prone Skin and Wound Checks Daily by nursing and patient Wound Dressing Hydrofiber Will change as needed

Stage Two: Leg Lowering C ontinue to address: Bed mobility PositioningUE strengtheningWound dressingMonitoring vitals and lab values Wound and skin checks Priority : initiating dangling protocol and wound care

Stage Two: Leg Lowering Dangling Protocol Increase dependency of L LE Begin to work on transfersWound DressingHydrofiber Progression based on wound drainage and sizeSkin and Wound Checks Daily by nursing and patient Positioning Bed MobilityUE StrengtheningMonitor Vitals and Lab Values

Stage Three: Off Bedrest Also Address: Gait trainingTherapeutic ExerciseTransfer trainingWound and Skin Checks Monitor Vitals and Lab ValuesPriority: promoting mobility and progressing towards functional independence prior to discharge

Stage Three: Off Bedrest Therapeutic Exercise Sit → Stand MarchesBridgingHeel/toe raisesTransfer Training Bed ← → ChairBed ← → ToiletMonitor Vitals and Lab Values BP, ABI INR, WBC, Hgb Gait TrainingAmbulation with LRADSkin and Wound Checks Teach independence with wound care and skin checks Wound Dressing Progression based on wound drainage and size

References: Chaby , G. et. al. (2007). Dressings for acute and chronic wounds: a systematic review. Journal of American Medicine, Archives of Dermatology. 143 (10). 1297-1304.ConvaTec Inc., (2015). AQUACEL ® Dressing. Retrieved from: http://www.convatec.com/wound-skin/aquacel-dressing. Frescos, N. (2011). What causes wound pain? Journal of Foot and Ankle Research , 4(Suppl 1), P22. http://doi.org/10.1186/1757-1146-4-S1-P22Jurzak, F., Dugre, T., Johnstone, A., Offori , T., Vujovic , Z., Hollander, D., AQUACEL Ag Surgical/Trauma Wound Study Group. (2007). Randomised clinical trial of Hydrofiber dressing with silver versus povidone-iodine gauze in the management of open surgical and traumatic wounds. International Wound Journal. 4(1). 66-76. Mills, E., Eyawo , O., Lockart , I., Kelly, S., Wu, P., Ebbert , J.O. (2011). Smoking Cessation Reduces Postoperative Complications: A systematic review and meta-analysis. The American Journal of Medicine 124(2) . 144-154. Wei Fu-Chan MD et al. (2009) “Lower Extremity.” Flaps and Reconstructive Surgery (7). 63-70.

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