Evidence-Based Nursing Practice

Preoperative interview

100 patients (inclusion/exclusion)
Number of study
patients 100
Randomisation
Group B
Conventional
dressing
N=50
Group A
Hydrofibre
dressing
N=50
Group B
Conventional
dressing
N=49
Group A
Hydrofibre
dressing
N=45
- patient consent
Covering the
surgical wound
Follow-up: Day of surgery to
Day 3 postoperatively
Group A
Hydrofibre
dressing
N=29
Group B
Conventional
dressing
N=33
Follow-up forms
Group A
Hydrofibre
dressing
N=32
Group B
Conventional
dressing
N=36 (Harle,2005)

Summary of the randomised trial

This randomised controlled trial made a comparison of the clinical and economic effects of two different dressing materials in patients undergoing hip replacement surgery. The participants were randomised into group A (N = 50), where hydro fibre dressing (Aquacel) applied with adhesive polyurethane film, was used or group B (N = 50), in which the dressing was a conventional wound pad dressing with fibre tape fixation. When changing the first dressing, 59% of patients in group A had wound area reactions (blister, erythema, oedema, skin injury and haematoma) whereas in group B was 81% (P = 0.02). The average dressing material costs per patient by the third postoperative day were €14.70 in group A and €8.70 in group B (P < 0.0.) .However the material costs represented only about 0.02% of the total cost of hip replacement surgery. In conclusion, the modern hydro fibre dressing with polyurethane film fixation treats the surgical wound after hip replacement surgery better than a traditional wound pad dressing with fibre tape fixation (Harle,2005).

When dressing the wounds all precautions in orthopaedics must be observed as much as possible for example, the wounds must not contain agents that are allergenic or toxic or which cause irritation (softening) because it will be excessively moist (Eronen and Hietanen,1999;).

A too warm, moist environment provides favourable conditions for microbial proliferation..

Cost should also be calculated when choosing the wound dressing. To keep the overall cost down, the frequency with which the dressing is changed should be as low as possible (Iivanainen and Seppa¨nen, 1999).

Wound dressings can be divided into passive and active dressings. Traditionally, passive dressings, that is, absorbent tape-fixated wound pad dressings, have been used for hip replacement surgery wounds. Mechanical skin irritation (possibly blister formation and skin injury) may be prevented by using either a spray or an applicator skin protection agent underneath the adhesive (Wright,1994).

The healing of surgical wounds without infection is of key importance in postoperative care. Wound healing may be retarded for various reasons, for example because of tissue trauma and haematoma caused by a major operation and the associated oedema of the wound area. Many illnesses impair nutrition, oxygen supply to the tissues and immune resistance. Certain medicines (cortisone, insulin and cytostatics) also influence the skin’s vulnerability; retard wound healing and may make the skin prone to injury. Incision wounds made in different directions may influence muscle tension, while the fixation materials causing tension of the skin may cause skin injuries such as blistering (Milne et al., 1999). Hospital infections are the greatest infection problem in countries, with high living standards. They directly contribute to high medical attentions. The goodness is that they are better. The medical staffs are competent and efficient (Lumio, 1996).

The use of hydro fibre dressings has become common on infected, chronic wounds. Today, they are also recommended for the treatment of acute surgical wounds, for example in orthopaedics. These dressings are more expensive than conventional dressing materials and there is little study evidence of how well they function in the treatment of acute surgical wounds (Moore and Foster, 2000).

From clinical experience, the use of conventional dressing materials may be associated with skin problems in the area of the wound, for example, blister formation and skin injury around the wound underneath the fixation materials in hip replacement surgery patients. This study examines the clinical and economic effects of a hydro fibre dressing compared with a conventional wound dressing in patients following hip replacement (Sackett et al, 1996).

Methods

The study comprised both women and men, attending the ORTON Orthopaedic Hospital, Invalid Foundation, Helsinki for hip replacement surgery and who met the inclusion criterion for the study The results below were collected from the interviewed patients, such that from the two groups A and B a randomised clinical trial of two different wounds was done to investigate the evidence-base of practising nursing. The dressing materials were for hip replacement patients (Harle, 2005).

Table 1 Wound dressing materials

Group A (hydro fibre dressing) Group B (conventional dressing)

Surgical ward Hydro fibre + polyurethane film Conventional dressing

At 1st change of dressing

Observation ward/bed ward Conventional dressing Conventional dressing

After 1st change of dressing

Abundant exudation Conventional dressing Conventional dressing

Scanty exudation Adhesive wound pad Adhesive wound pad

Dry wound Wound tape Wound tape (Harle, 2005).

Result

In group A, 45% (20/45) had no need for a change of hydro fibre dressing (abundant exudation, leak at edges and drain removal) before Day 3 postoperatively, whereas in group, B the corresponding figure was 6% (3/49) (Harle,2005).

Clinically, the skin status was better in group A than in group B patients (Table 3). A smaller proportion of group A patients (5%) tended to have blisters at the first change of dressing than in group B (15%) (P = 0.16). The same trend was seen regarding skin injury (9% vs. 23%, P = 0.07) (Table 3) (Harle,2005).

Later, a change of dressing caused blisters/ skin injury in another nine patients in group A after the use of conventional dressings had been tarted (Table 4).The average cost of dressing material per patient by Day 3 postoperatively was €14.70 in group A and €8.70 in group B (P < 0.01). In cases of skin injury requiring treatment, either a silicone net or a hydrocolloid plate was used underneath he wound dressing. A single treatment of one skin injury (including clean gloves) costs €1.50–3.90. The outpatient clinic follow-up form was returned by 71% (32/45) in group A and 73% (36/49) in group B. Contrary to expectations, the replies showed that the wound had usually healed during the hospital stay or soon afterwards. Thus, no extra cost was incurred after discharge. However, one patient (group B) had to see a dermatologist because of eczema caused by the tapes (Sacket et al,1996).

Discussion

In this study, the group A patients using the hydro fibre dressing until the first change of dressing had fewer skin problems, although this dressing was more expensive than the conventional dressing used in group B. Group A patients also exhibited B, suggesting that the hydro fibre dressing absorbs postoperative bleeding better when there is no dry blood at the wound edges. This may also reduce postoperative pain and joint stiffness due to oedema. As the absorption capacity of the hydro fibre dressing is better, it can thus be expected to lower (Harle, 2005)

Table 3 Skin status at the first change of dressing in groups A and B

Group A (hydrofibre dressing) Group B (conventional dressing) P-value Blisters, %(N) 5(2) 15(7) 0.16

Erythema, %(N) 9(4) 33(16) < 0.01

Skin injury, %(N) 9(4) 23(11) 0.07

Haematoma, %(N) 25(11) 52(25) < 0.01

Oedema, %(N) 48(21) 67(32) 0.07

One of the above, %(N) 59(26) 81(39) 0.02

(Harle,2005)

Table 2 Basic data, group A (N = 45) and group B (N = 49)

Group A (hydrofibre dressing) Group B (conventional dressing)

Age, years, mean (SD) 65.0(13.5) 64.3(11.8)

Sex f/m, N/N 29/16 34/15

BMIa, mean (SD) 26.3(4.5) 26.1(4.2)

Operation, primary/revision, N/N 38/7 41/8

Osteoarthritis/rheumatoid arthritis N/N 42/1 44/2

(Harle,2005)

Table 4 Blisters/skin injuries with change of dressing

in groups A and B

Group A (hydrofibre dressing)

Group B (conventional dressing)

At first change %(N) 14(6) 38(18)

After first change %(N) 20(9) 8(6)

(Harle,2005)

A randomised clinical trial of two different wound dressing materials

The hydrofibre dressing in group A patients was changed for a conventional one at the first change of dressing. In 45% of the group A patients, the hydro fibre dressing applied in the operating theatre remained in place until Day 3 postoperatively. In both groups, if the original dressing had to be changed for a conventional dressing at an early stage and the dressing had to be changed daily or more frequently, the area around the wound was prone to repeated mechanical irritation. Skin injury occurred in some of the group A patients after change to a conventional dressing (Ruta,et al,1999).

In the wound infection follow-up, almost all patients with a superficial wound infection had a skin injury/injuries. The causes of the wound infections are related both to the patients themselves and to other causes, so the role of wound dressing alone in the aetiology of infection cannot be emphasised. During the study, it was found that the hospital had no uniform guidelines for treating skin injuries. The use of such guidelines would make it possible to assess their effectiveness and permit any necessary changes. (Teirila¨, 2000).

The general costs of treating one skin injury increase rapidly if skin injuries occur frequently are extensive, abundantly exudative and require daily care. The cost is particularly high when an infection occurs, as this delays healing and results in additional costs. Formation of blister and skin injuries related to dressing result in extra costs also .In essence, there should be no skin problems in the area of the surgical wound (Milnes,et al,1999).

According to doctors and nurses the hydro fibre dressing is better; the dressing is handy and quick to apply. The dressing ‘‘announces’’ when it needs changing and is easy to remove in one piece. It also makes monitoring of postoperative bleeding easy. When a hydro fibre dressing is used the material costs are higher than for a conventional dressing. However, the dressing represents only about 0.02% of the total cost of a hip replacement operation (Lumio, 1999).

Conclusion

The research ,on the dressings of wounds generally give a clear message that the establishments must put in consideration the costs of medical materials and apparatus for the good of everyone In addition the treatment of patients is also effective if nurses are well motivated by their employers. However hydro fibre dressing is better than the conventional dressing (Motto,et al ,1985)

References

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