Nurses' and surgeons' views and experiences of surgical wounds healing by secondary intention: A qualitative study

Acute care nurses' experience in providing evidence-based care for patients with laparotomy wounds: A scoping review

To systematically search and synthesise available literature on barriers and enablers to evidence-based care for patients with laparotomy wounds reported by acute care nurses. Specifically, we focused on wound assessment, infection control techniques, wound products used, escalation of care, dressing application, documentation and holistic care. The Preferred Reporting Items for Systematic review and Meta-Analyses extension for Scoping Reviews Checklist and explanation documents directed the review. The methodology framework created by Arksey and O'Malley, updated by Levac et al., and the Joanna Briggs Institute were utilised to assist the scoping review process. Data synthesis was guided by the Theoretical Domains Framework. Six qualitative and mixed methods studies were selected for the review. Most reported barriers and enablers were mapped to knowledge, skills, beliefs about consequences, environmental context and resources and beliefs about capability domains. The main barriers were limited access to and utilisation of wound assessment tools and clinical practice guidelines for wound management and suboptimal time management skills. Inconsistent management of laparotomy wounds was related to ward culture and nurses' lack of knowledge and skills in surgical wound assessment and aseptic technique during wound encounters. The reported enablers were knowledge of multi-factorial risk factors for surgical wound recovery, valuing education and reflective practice and believing that protocols should be utilised alongside comprehensive wound assessments. Holistic wound care included patient education on the role of mobilisation and nutrition in wound healing. Acute care nurses do not routinely incorporate comprehensive, evidence-based care recommendations for laparotomy wound management. Further research on evidence-based care behaviours in managing laparotomy wounds is required. The results indicate a need for standardising the practice of laparotomy wound management while acknowledging the current challenges faced in the ward environment.

Design, preparation, and characterization of CS/PVA/SA hydrogels modified with mesoporous Ag2O/SiO2 and curcumin nanoparticles for green, biocompatible, and antibacterial biopolymer film

One of the most significant factors affecting the rapid and effective healing of wounds is the application of appropriate wound dressings. In the present study, novel antibacterial wound dressings are fabricated that consist of Chitosan (CS)/Polyvinyl alcohol (PVA)/Sodium Alginate (SA), which are all biocompatible, functionalized with mesoporous Ag₂O/SiO₂ and curcumin nanoparticles as reinforcements. In this research nanocomposites are fabricated (0 wt%, 5 wt%, 10 wt%, 15 wt%, and 20 wt% of Ag₂O/SiO₂). After the composition of nanocomposites using the cross-linked technique, Fourier Transform Infrared (FT-IR) spectroscopy is performed to confirm the functional groups that are added to the polymer at each step. X-ray diffraction (XRD) is done to show the crystallinity of Ag₂O/SiO₂. Field emission scanning electron microscopy (FE-SEM) studies are performed to demonstrate the morphology of the structure, Energy-dispersive X-ray spectroscopy (EDS) is done to examine the elements in the wound dressing and atomic force microscopy (AFM) study is performed to show surface roughness and pores. Then the nanocomposites with different weight percentages are cultured in three bacteria called Acinetobacter baumannii, Staphylococcus epidermidis, and Proteus mirabilis, all three of which cause skin infections. Finally, by performing the tensile test, the results related to the tensile strength of the wound dressings are examined. The results show that with the increase of Ag₂O/SiO₂, the mechanical properties, as well as the healing properties of the wound dressing, have increased significantly. Fabricating these nanocomposites helps a lot in treating skin infections.

CS/PVA/SA hydrogels modified with mesoporous Ag₂O/SiO₂ and curcumin nanoparticles for antibacterial biopolymer film.

Patient decision-making and regret in pilonidal sinus surgery: a mixed-methods study

AIM

Little is known about optimal management strategies for pilonidal sinus disease (PSD). We conducted a mixed-methods study to understand why patients make, and sometimes regret, treatment decisions.

METHOD

We conducted longitudinal semi-structured interviews at the time of surgery and 6 months later with 20 patients from 13 UK hospitals. Framework analysis was performed, and themes were mapped to (1) the coping in deliberation framework and (2) an acceptability framework. Results were triangulated with those from structured survey instruments evaluating shared decision-making (SDM, best = 9) at baseline and decision regret (DR, most regret = 100) at 6 months.

RESULTS

Nine of 20 patients were not offered a choice of treatment, but this was not necessarily seen as negative (SDM median 4; range 2-4). Factors that influenced decision-making included previous experience and anticipated recovery time. Median (range) DR was 5 (0-50). Those with the highest DR (scores 40-50) were, paradoxically, also amongst the highest scores on SDM (scores 4). Burden of wound care and the disparity between anticipated and actual recovery time were the main reasons for decision regret.

CONCLUSION

To minimize regret about surgical decisions, people with PSD need better information about the burden of wound care and the risks of recurrence associated with different surgical approaches.

A mapping review of sacrococcygeal pilonidal sinus disease

BACKGROUND

Pilonidal sinus is a hole in the natal cleft which may cause severe pain and become infected. The evidence base for management of pilonidal sinus is said to be poor quality, poorly focused and rapidly proliferating. We undertook a systematic mapping review to provide a broad overview of the field and support the identification of research priorities.

METHODS

We searched MEDLINE, CINAHL, and EMBASE from inception to 22nd Nov 2020 for primary research studies focused on the management of pilonidal sinus. We extracted data on study design and categorised studies under five major headings ('non-surgical treatment', 'surgical treatment', 'aftercare' and 'other'), producing frequency counts for different study designs. Gaps in research were identified from published systematic reviews and tabulated.

RESULTS

We identified 983 eligible studies, of which 36 were systematic reviews and/or meta-analyses; 121 were randomised controlled trials), and 826 observational studies of various design. The majority of studies evaluated surgical techniques (n = 665), or adjuvant medical interventions (n = 98). The literature on wound care has developed most recently, and the evidence base includes 30% randomised controlled trials. Gaps analysis highlighted comparison of surgical techniques including flaps, laser depilation, and wound care interventions as potential areas for randomised controlled trials.

CONCLUSIONS

This mapping review summarises eight decades of research on the management of pilonidal sinus. Further research is needed to identify front-running interventions, understand variation in practice and patient values, and to prioritise future research.

The epidemiology, management and impact of surgical wounds healing by secondary intention: a research programme including the SWHSI feasibility RCT

Background

Most surgical incisions heal by primary intention (i.e. wound edges are apposed with sutures, clips or glue); however, some heal by secondary intention (i.e. the wound is left open and heals by formation of granulation tissue). There is, however, a lack of evidence regarding the epidemiology, management and impact on patients’ quality of life of these surgical wounds healing by secondary intention, resulting in uncertainty regarding effective treatments and difficulty in planning care and research.

Objectives

To derive a better understanding of the nature, extent, costs, impact and outcomes of surgical wounds healing by secondary intention, effective treatments, and the value and nature of further research.

Design

Cross-sectional survey; inception cohort; cost-effectiveness and value of implementation analyses; qualitative interviews; and pilot, feasibility randomised controlled trial.

Setting

Acute and community care settings in Leeds and Hull, Yorkshire, UK.

Participants

Adults (or for qualitative interviews, patients or practitioners) with previous experience of a surgical wound healing by secondary intention. Inclusion criteria varied between the individual workstreams.

Interventions

The pilot, feasibility randomised controlled trial compared negative-pressure wound therapy – a device applying a controlled vacuum to a wound via a dressing – with usual care (no negative-pressure wound therapy).

Results

Survey data estimated that treated surgical wounds healing by secondary intention have a point prevalence of 4.1 per 10,000 population (95% confidence interval 3.5 to 4.7 per 10,000 population). Surgical wounds healing by secondary intention most frequently occurred following colorectal surgery (n = 80, 42.8% cross-sectional survey; n = 136, 39.7% inception cohort) and were often planned before surgery (n = 89, 47.6% cross-sectional survey; n = 236, 60.1% inception cohort). Wound care was frequently delivered in community settings (n = 109, 58.3%) and most patients (n = 184, 98.4%) received active wound treatment. Cohort data identified hydrofibre dressings (n = 259, 65.9%) as the most common treatment, although 29.3% (n = 115) of participants used negative-pressure wound therapy at some time during the study. Surgical wounds healing by secondary intention occurred in 81.4% (n = 320) of participants at a median of 86 days (95% confidence interval 75 to 103 days). Baseline wound area (p ≤ 0.01), surgical wound contamination (determined during surgery; p = 0.04) and wound infection at any time (p ≤ 0.01) (i.e. at baseline or postoperatively) were found to be predictors of prolonged healing. Econometric models, using observational, cohort study data, identified that, with little uncertainty, negative-pressure wound therapy treatment is more costly and less effective than standard dressing treatment for the healing of open surgical wounds. Model A (ordinary least squares with imputation) effectiveness: 73 days longer than those who did not receive negative-pressure wound therapy (95% credible interval 33.8 to 112.8 days longer). Model A cost-effectiveness (associated incremental quality-adjusted life-years): observables –0.012 (standard error 0.005) and unobservables –0.008 (standard error 0.011). Model B (two-stage model, logistic and linear regression) effectiveness: 46 days longer than those who did not receive negative-pressure wound therapy (95% credible interval 19.6 to 72.5 days longer). Model B cost-effectiveness (associated incremental quality-adjusted life-years): observables –0.007 (standard error 0.004) and unobservables –0.027 (standard error 0.017). Patient interviews (n = 20) identified initial reactions to surgical wounds healing by secondary intention of shock and disbelief. Impaired quality of life characterised the long healing process, with particular impact on daily living for patients with families or in paid employment. Patients were willing to try any treatment promising wound healing. Health professionals (n = 12) had variable knowledge of surgical wound healing by secondary intention treatments and, frequently, favoured negative-pressure wound therapy, despite the lack of robust evidence. The pilot feasibility randomised controlled trial screened 248 patients for eligibility and subsequently recruited and randomised 40 participants to receive negative-pressure wound therapy or usual care (no negative-pressure wound therapy). Data indicated that it was feasible to complete a full randomised controlled trial to provide definitive evidence for the clinical effectiveness and cost-effectiveness of negative-pressure wound therapy as a treatment for surgical wounds healing by secondary intention. Key elements and recommendations for a larger randomised controlled trial were identified.

Limitations

This research programme was conducted in a single geographical area (i.e. Yorkshire and the Humber, UK) and local guidelines and practices may have affected treatment availability, and so may not represent UK-wide treatment choices. A wide range of wound types were included; however, some wound types may be under-represented, meaning that this research may not represent the overall surgical wound healing by secondary intention population. The lack of randomised controlled trial data on the relative effects of negative-pressure wound therapy in surgical wounds healing by secondary intention resulted in much of the economic modelling being based on observational data. Observational data, even with extensive adjustment, do not negate the potential for unresolved confounding to affect the results, which can reduce confidence in conclusions drawn from observational data. Definitive evidence from a randomised controlled trial may be the only way to overcome this lack of confidence.

Conclusions

This research has provided new information regarding the nature, extent, costs, impacts and outcomes of surgical wounds healing by secondary intention, treatment effectiveness, and the value and nature of future research, while addressing previous uncertainties regarding the problem of surgical wounds healing by secondary intention. Aspects of our research indicate that negative-pressure wound therapy is more costly and less effective than standard dressing for the healing of open surgical wounds. However, because this conclusion is based solely on observational data, it may be affected by unresolved confounding. Should a future randomised controlled trial be considered necessary, its design should reflect careful consideration of the findings of this programme of research.

Future work

This research signals the importance of further research on surgical wound healing by secondary intention. Key research questions raised by this programme of research include (1) which treatments are clinically effective and cost-effective for surgical wound healing by secondary intention for all patients or for particular patient subgroups? (2) Can particular prognostic factors predict time to healing of surgical wound healing by secondary intention? And (3) do psychosocial interventions have the potential to improve quality of life in people with hard-to-heal surgical wound healing by secondary intention? Given that negative-pressure wound therapy has been widely adopted, with relatively little evidence to support its use, the design and outcomes of a randomised controlled trial would need to be carefully considered. We focused in this research on wound healing, and maintain, based on the findings of patient interviews, that this is a key outcome for future research. Impacts of negative-pressure wound therapy on outcomes such as infection and reoperation should also be considered, as should patients’ views of the treatment. The type of patient group recruited and the outcomes of interest will all influence the duration of follow-up of any planned study. The comparator in any future study will also need careful consideration.

Trial registration

Current Controlled Trials ISRCTN12761776.

Funding

This project was funded by the National Institute for Health Research Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 7. See the National Institute for Health Research Journals Library website for further project information.