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Shih T, Park S, Thorlacius LR, Daveluy S, Garg A, Goegji SD, Kirby JS, McGrath BM, Riis PT, Villumsen B, Zalik K, Jemec GBE, Hsiao JL. Wound drainage measurements: a narrative review. Arch Dermatol Res 2023; 315:1863-1874. [PMID: 36680593 PMCID: PMC10366279 DOI: 10.1007/s00403-023-02525-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 12/07/2022] [Accepted: 01/06/2023] [Indexed: 01/22/2023]
Abstract
Drainage from chronic wounds can significantly negatively impact a patient's quality of life. Change in severity of wound drainage is an important measure of treatment efficacy for wounds. This study reviews existing tools used to assess wound drainage. Qualitative drainage tools are overall less burdensome, and however, differences in user interpretation may reduce inter-rater reliability. Quantitative drainage tools enable more reliable comparisons of drainage severity and treatment response between patients but sometimes require equipment to administer, increasing responder burden. Gaps in the current wound drainage measurement landscape are highlighted. Many of the existing scales have not been validated in robust studies. There is also a lack of validated global drainage measurement tools for patients with chronic inflammatory skin disorders with drainage, such as hidradenitis suppurativa or pyoderma gangrenosum. Development of a succinct drainage measurement tool for inflammatory skin diseases where drainage is a prominent symptom will improve monitoring of meaningful treatment response.
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Affiliation(s)
- Terri Shih
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Sarah Park
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Linnea R Thorlacius
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark
- Department of Dermato-Venereology & Wound Healing Centre, Bispebjerg Hospital, Copenhagen, Denmark
| | - Steven Daveluy
- Department of Dermatology, Wayne State University, Detroit, MI, USA
| | - Amit Garg
- Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | | | - Joslyn S Kirby
- Department of Dermatology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | | | - Peter T Riis
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark
| | | | | | - Gregor B E Jemec
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark
- Health Sciences Faculty, University of Copenhagen, Copenhagen, Denmark
| | - Jennifer L Hsiao
- Department of Dermatology, University of Southern California, 1441 Eastlake Ave, Ezralow Tower, Suite 5301, Los Angeles, CA, 90033-9174, USA.
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Glasbey J. Adaptation of the Wound Healing Questionnaire universal-reporter outcome measure for use in global surgery trials (TALON-1 study): mixed-methods study and Rasch analysis. Br J Surg 2023; 110:685-700. [PMID: 37005373 PMCID: PMC10364512 DOI: 10.1093/bjs/znad058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 12/21/2022] [Accepted: 02/05/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND The Bluebelle Wound Healing Questionnaire (WHQ) is a universal-reporter outcome measure developed in the UK for remote detection of surgical-site infection after abdominal surgery. This study aimed to explore cross-cultural equivalence, acceptability, and content validity of the WHQ for use across low- and middle-income countries, and to make recommendations for its adaptation. METHODS This was a mixed-methods study within a trial (SWAT) embedded in an international randomized trial, conducted according to best practice guidelines, and co-produced with community and patient partners (TALON-1). Structured interviews and focus groups were used to gather data regarding cross-cultural, cross-contextual equivalence of the individual items and scale, and conduct a translatability assessment. Translation was completed into five languages in accordance with Mapi recommendations. Next, data from a prospective cohort (SWAT) were interpreted using Rasch analysis to explore scaling and measurement properties of the WHQ. Finally, qualitative and quantitative data were triangulated using a modified, exploratory, instrumental design model. RESULTS In the qualitative phase, 10 structured interviews and six focus groups took place with a total of 47 investigators across six countries. Themes related to comprehension, response mapping, retrieval, and judgement were identified with rich cross-cultural insights. In the quantitative phase, an exploratory Rasch model was fitted to data from 537 patients (369 excluding extremes). Owing to the number of extreme (floor) values, the overall level of power was low. The single WHQ scale satisfied tests of unidimensionality, indicating validity of the ordinal total WHQ score. There was significant overall model misfit of five items (5, 9, 14, 15, 16) and local dependency in 11 item pairs. The person separation index was estimated as 0.48 suggesting weak discrimination between classes, whereas Cronbach's α was high at 0.86. Triangulation of qualitative data with the Rasch analysis supported recommendations for cross-cultural adaptation of the WHQ items 1 (redness), 3 (clear fluid), 7 (deep wound opening), 10 (pain), 11 (fever), 15 (antibiotics), 16 (debridement), 18 (drainage), and 19 (reoperation). Changes to three item response categories (1, not at all; 2, a little; 3, a lot) were adopted for symptom items 1 to 10, and two categories (0, no; 1, yes) for item 11 (fever). CONCLUSION This study made recommendations for cross-cultural adaptation of the WHQ for use in global surgical research and practice, using co-produced mixed-methods data from three continents. Translations are now available for implementation into remote wound assessment pathways.
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Affiliation(s)
- James Glasbey
- NIHR Global Health Research Unit on Global Surgery, University of Birmingham, Institute of Translational Medicine, Birmingham, UK
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Patient-Derived Framework for Quality in Hand Surgery: A Qualitative Analysis. J Hand Surg Am 2022; 47:1045-1056. [PMID: 35963794 DOI: 10.1016/j.jhsa.2022.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/27/2022] [Accepted: 06/13/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE Despite the growing attention to evaluating care from the patient perspective, the most common definitions and measurements of quality are currently defined by physicians and health systems. Studies have demonstrated how a lack of patient input can lead to discrepancies between patients' and physicians' assessments of quality and, subsequently, worse patient outcomes. Although quality measures are increasingly used in hand surgery, insufficient work has examined whether these quality measures align with what matters to patients. We completed a qualitative study to assess how patients define high-quality care through the pre-, peri-, and postoperative phases of care in hand surgery. METHODS Based on our prior work, we created an open-ended interview guide and conducted semistructured interviews with 43 hand surgery patients at 5 tertiary-care institutions during various phases of care. We completed a thematic analysis to generate subcodes and open codes, to identify themes in high-quality care from the patient perspective. RESULTS Patients defined high-quality care as a process of (1) setting and meeting clear expectations; (2) achieving functional goals after surgery; and (3) feeling comfortable with and cared for by the care team. We identified the following 4 patient-centered themes that contributed to high-quality care: (1) communication between the patient and care team through all phases of care; (2) efficient and accurate diagnosis and treatment; (3) satisfactory treatment outcomes and postsurgical experience; and (4) acceptable systemic aspects of care. CONCLUSIONS Efforts to improve health care delivery should include areas of care that are important to patients. Our results suggest that measuring aspects of care that often go without assessments, such as communication, can maximize care quality as defined by patients. CLINICAL RELEVANCE The themes identified in this study can inform efforts towards patient-centered quality measure development.
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Feasibility and diagnostic accuracy of Telephone Administration of an adapted wound heaLing QuestiONnaire for assessment for surgical site infection following abdominal surgery in low and middle-income countries (TALON): protocol for a study within a trial (SWAT). Trials 2021; 22:471. [PMID: 34289893 PMCID: PMC8293583 DOI: 10.1186/s13063-021-05398-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/25/2021] [Indexed: 12/02/2022] Open
Abstract
Background Surgical site infection is the most common complication of abdominal surgery, with a global impact on patients and health systems. There are no tools to identify wound infection that are validated for use in the global setting. The overall aim of the study described in this protocol is to evaluate the feasibility and validity of a remote, digital pathway for wound assessment after hospital discharge for patients in low- and middle-income countries (LMICs). Methods A multi-centre, international, mixed-methods study within a trial, conducted in two stages (TALON-1 and TALON-2). TALON-1 will adapt and translate a universal reporter outcome measurement tool (Bluebelle Wound Healing Questionnaire, WHQ) for use in global surgical research (SWAT store registration: 126) that can be delivered over the telephone. TALON-2 will evaluate a remote wound assessment pathway (including trial retention) and validate the diagnostic accuracy of this adapted WHQ through a prospective cohort study embedded within two global surgery trials. Embedded community engagement and involvement activities will be used to optimise delivery and ensure culturally attuned conduct. TALON-1 and TALON-2 are designed and will be reported in accordance with best practice guidelines for adaptation and validation of outcome measures, and diagnostic test accuracy studies. Discussion Methods to identify surgical site infection after surgery for patients after hospital discharge have the potential to improve patient safety, trial retention, and research efficiency. TALON represents a large, pragmatic, international study co-designed and delivered with LMIC researchers and patients to address an important research gap in global surgery trial methodology. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05398-z.
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Fat Grafting Improves Fibrosis and Scarring in Vulvar Lichen Sclerosus: Results From a Prospective Cohort Study. J Low Genit Tract Dis 2021; 24:305-310. [PMID: 32205767 DOI: 10.1097/lgt.0000000000000520] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aim of the study was to evaluate the effect of lipotransfer in women presenting with fibrosis and scarring due to lichen sclerosus. MATERIALS AND METHODS This prospective cohort study included 33 women attending the vulvar clinic of a public hospital. Patients received one lipotransfer treatment. Validated measures were used prospectively to assess the sexual function (Female Sexual Function Index, Female Sexual Distress Scale); symptoms (visual analog scale for itching, burning, soreness), pain (Pain Anxiety Symptoms Scale 20); psychological status and quality of life (Hospital Anxiety and Depression Scale, Relationship Assessment Scale, Wound Management Questionnaire Revised); physician-based disease signs (Vulvar Architecture Severity Scale). Data were analyzed using paired t test with nonparametric Wilcoxon matched-pairs signed rank test and unpaired t test with nonparametric Mann-Whitney test (Prism6 Software). RESULTS The mean (SD) follow-up was 12.9 (3.5) months. Sexual function improved after treatment (p < .001), as well as the distress associated with sexuality (p < .0001). A significant improvement was reported in itching (p < .001), burning (p < .05), soreness (p < .001), and pain (p < .0001). Patients reported a significant improvement in romantic relationship (p < .05), anxiety (p < .0001), and depression (p < .0001). Improvement was not significant in the self-care associated with self-disgust assessment (p = .42). The clinical physician-based score showed an overall improvement in all the treated areas to lesser or greater extent. CONCLUSIONS The use of fat grafting in lichen sclerosus is promising. Further studies are required to rule out a potential placebo effect and to better understand the underlying molecular mechanism of action.
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Reeves BC, Rooshenas L, Macefield RC, Woodward M, Welton NJ, Waterhouse BR, Torrance AD, Strong S, Siassakos D, Seligman W, Rogers CA, Rickard L, Pullyblank A, Pope C, Pinkney TD, Pathak S, Owais A, O'Callaghan J, O'Brien S, Nepogodiev D, Nadi K, Murkin CE, Munder T, Milne T, Messenger D, McMullan CM, Mathers JM, Mason M, Marshall M, Lovegrove R, Longman RJ, Lloyd J, Lim J, Lee K, Korwar V, Hughes D, Hill G, Harris R, Hamdan M, Brown HG, Gooberman-Hill R, Glasbey J, Fryer C, Ellis L, Elliott D, Dumville JC, Draycott T, Donovan JL, Cotton D, Coast J, Clout M, Calvert MJ, Byrne BE, Brown OD, Blencowe NS, Bera KD, Bennett J, Bamford R, Bakhbakhi D, Atif M, Ashton K, Armstrong E, Andronis L, Ananthavarathan P, Blazeby JM. Three wound-dressing strategies to reduce surgical site infection after abdominal surgery: the Bluebelle feasibility study and pilot RCT. Health Technol Assess 2020; 23:1-166. [PMID: 31392958 DOI: 10.3310/hta23390] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Surgical site infection (SSI) affects up to 20% of people with a primary closed wound after surgery. Wound dressings may reduce SSI. OBJECTIVE To assess the feasibility of a multicentre randomised controlled trial (RCT) to evaluate the effectiveness and cost-effectiveness of dressing types or no dressing to reduce SSI in primary surgical wounds. DESIGN Phase A - semistructured interviews, outcome measure development, practice survey, literature reviews and value-of-information analysis. Phase B - pilot RCT with qualitative research and questionnaire validation. Patients and the public were involved. SETTING Usual NHS care. PARTICIPANTS Patients undergoing elective/non-elective abdominal surgery, including caesarean section. INTERVENTIONS Phase A - none. Phase B - simple dressing, glue-as-a-dressing (tissue adhesive) or 'no dressing'. MAIN OUTCOME MEASURES Phase A - pilot RCT design; SSI, patient experience and wound management questionnaires; dressing practices; and value-of-information of a RCT. Phase B - participants screened, proportions consented/randomised; acceptability of interventions; adherence; retention; validity and reliability of SSI measure; and cost drivers. DATA SOURCES Phase A - interviews with patients and health-care professionals (HCPs), narrative data from published RCTs and data about dressing practices. Phase B - participants and HCPs in five hospitals. RESULTS Phase A - we interviewed 102 participants. HCPs interpreted 'dressing' variably and reported using available products. HCPs suggested practical/clinical reasons for dressing use, acknowledged the weak evidence base and felt that a RCT including a 'no dressing' group was acceptable. A survey showed that 68% of 1769 wounds (727 participants) had simple dressings and 27% had glue-as-a-dressing. Dressings were used similarly in elective and non-elective surgery. The SSI questionnaire was developed from a content analysis of existing SSI tools and interviews, yielding 19 domains and 16 items. A main RCT would be valuable to the NHS at a willingness to pay of £20,000 per quality-adjusted life-year. Phase B - from 4 March 2016 to 30 November 2016, we approached 862 patients for the pilot RCT; 81.1% were eligible, 59.4% consented and 394 were randomised (simple, n = 133; glue, n = 129; no dressing, n = 132); non-adherence was 3 out of 133, 8 out of 129 and 20 out of 132, respectively. SSI occurred in 51 out of 281 participants. We interviewed 55 participants. All dressing strategies were acceptable to stakeholders, with no indication that adherence was problematic. Adherence aids and patients' understanding of their allocated dressing appeared to be key. The SSI questionnaire response rate overall was 67.2%. Items in the SSI questionnaire fitted a single scale, which had good reliability (test-retest and Cronbach's alpha of > 0.7) and diagnostic accuracy (c-statistic = 0.906). The key cost drivers were hospital appointments, dressings and redressings, use of new medicines and primary care appointments. LIMITATIONS Multiple activities, often in parallel, were challenging to co-ordinate. An amendment took 4 months, restricting recruitment to the pilot RCT. Only 67% of participants completed the SSI questionnaire. We could not implement photography in theatres. CONCLUSIONS A main RCT of dressing strategies is feasible and would be valuable to the NHS. The SSI questionnaire is sufficiently accurate to be used as the primary outcome. A main trial with three groups (as in the pilot) would be valuable to the NHS, using a primary outcome of SSI at discharge and patient-reported SSI symptoms at 4-8 weeks. TRIAL REGISTRATION Phase A - Current Controlled Trials ISRCTN06792113; Phase B - Current Controlled Trials ISRCTN49328913. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 39. See the NIHR Journals Library website for further project information. Funding was also provided by the Medical Research Council ConDuCT-II Hub (reference number MR/K025643/1).
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Affiliation(s)
- Barnaby C Reeves
- Clinical Trials and Evaluation Unit, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Leila Rooshenas
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rhiannon C Macefield
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mark Woodward
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Nicky J Welton
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Andrew D Torrance
- Department of Surgery, Sandwell and West Birmingham NHS Trust, West Bromwich, UK
| | - Sean Strong
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,North Bristol NHS Trust, Bristol, UK
| | - Dimitrios Siassakos
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,North Bristol NHS Trust, Bristol, UK
| | | | - Chris A Rogers
- Clinical Trials and Evaluation Unit, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Lloyd Rickard
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Caroline Pope
- Clinical Trials and Evaluation Unit, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Thomas D Pinkney
- Academic Department of Surgery, Queen Elizabeth Hospital, University of Birmingham, Birmingham, UK
| | - Samir Pathak
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Anwar Owais
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | | - Dmitri Nepogodiev
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Academic Department of Surgery, Queen Elizabeth Hospital, University of Birmingham, Birmingham, UK
| | | | - Charlotte E Murkin
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Tonia Munder
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Tom Milne
- North Bristol NHS Trust, Bristol, UK
| | - David Messenger
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Christel M McMullan
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jonathan M Mathers
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Matthew Mason
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | | | | | | - Jeffrey Lim
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Kathryn Lee
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - Daniel Hughes
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - Rosie Harris
- Clinical Trials and Evaluation Unit, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mohammed Hamdan
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK.,North Bristol NHS Trust, Bristol, UK
| | | | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - James Glasbey
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Caroline Fryer
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Lucy Ellis
- Clinical Trials and Evaluation Unit, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Daisy Elliott
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jo C Dumville
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | | | - Jenny L Donovan
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West at University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - David Cotton
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Joanna Coast
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Madeleine Clout
- Clinical Trials and Evaluation Unit, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Melanie J Calvert
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, UK
| | - Benjamin E Byrne
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Oliver D Brown
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Natalie S Blencowe
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Katarzyna D Bera
- Clinical Academic Graduate School, University of Oxford, Oxford, UK
| | | | - Richard Bamford
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - Muhammad Atif
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Kate Ashton
- Clinical Trials and Evaluation Unit, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Lazaros Andronis
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Jane M Blazeby
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Squitieri L, Tsangaris E, Klassen AF, van Haren ELWG, Poulsen L, Longmire NM, van Alphen TC, Hoogbergen MM, Sorensen JA, Cross K, Pusic AL. Patient-reported experience measures are essential to improving quality of care for chronic wounds: An international qualitative study. Int Wound J 2020; 17:1052-1061. [PMID: 32320141 PMCID: PMC7949344 DOI: 10.1111/iwj.13374] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/29/2020] [Accepted: 04/02/2020] [Indexed: 02/03/2023] Open
Abstract
Traditional quality measures for chronic wounds have focused on objective outcomes that are challenging to risk adjust, lack patient input, and have limited ability to inform quality improvement interventions. Patient-reported experience measures (PREMs) provide information from the patient perspective regarding health care quality and have potential to improve patient-centredness, increase care efficiency, and generate actionable data for quality improvement. The purpose of this study was to understand patient experiences and health care processes that impact quality of care among patients with chronic wounds. Sixty patients at least 18 years of age with various wound aetiologies were recruited from Canada, Denmark, The Netherlands, and the United States as part of a larger phase 1 qualitative study to develop a patient-reported outcome measure for chronic wounds (WOUND-Q). All patients had a chronic wound for at least 3 months, were fluent in their native speaking language, and able to participate in a one-on-one semi-structured interview. Interviews were digitally recorded and transcribed verbatim. Interpretive description was used to identify recurrent themes relating to patient experience and quality of care. We identified five domains (care coordination, establishing/obtaining care, information delivery, patient-provider interaction, and treatment delivery) and 21 sub-domains (access to patient information, interdisciplinary communication, encounter efficiency, provider availability, specialist referral, staff professionalism, travel/convenience, modality, reciprocity, understandability/consistency, accountability, continuity, credentials, rapport, appropriateness, complication management, continuity, environment/setting, equipment and supply needs, expectation, and patient-centred) as potential opportunities to measure and improve quality of care in the chronic wound population. PREMs for chronic wounds represent an important opportunity to engage patients and longitudinally assess quality across clinical settings and providers. Future research should focus on developing PREMs to complement traditional objective and patient-reported outcome measures for chronic wounds.
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Affiliation(s)
- Lee Squitieri
- Robert Wood Johnson Clinical Scholars Program, David Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
- Health Services Research and DevelopmentU.S. Department of Veterans Affairs Greater Los Angeles Health SystemLos AngelesCaliforniaUSA
| | - Elena Tsangaris
- Department of Surgery, Patient Reported Outcome, Value, and Experience (PROVE) Center, Harvard Medical SchoolBrigham and Women's HospitalBostonMassachusettsUSA
| | - Anne F. Klassen
- Department of PediatricsMcMaster UniversityHamiltonOntarioCanada
| | | | - Lotte Poulsen
- Department of Plastic SurgeryOdense University HospitalOdenseDenmark
| | | | - Tert C. van Alphen
- Department of Plastic and Reconstructive SurgeryCatharina ZiekenhuisEindhovenThe Netherlands
| | - Maarten M. Hoogbergen
- Department of Plastic and Reconstructive SurgeryCatharina ZiekenhuisEindhovenThe Netherlands
| | - Jens Ahm Sorensen
- Department of Plastic SurgeryOdense University HospitalOdenseDenmark
| | - Karen Cross
- Division of Plastic and Reconstructive SurgerySt. Michael's HospitalTorontoOntarioCanada
- Department of SurgeryUniversity of TorontoTorontoOntarioCanada
| | - Andrea L. Pusic
- Department of Surgery, Patient Reported Outcome, Value, and Experience (PROVE) Center, Harvard Medical SchoolBrigham and Women's HospitalBostonMassachusettsUSA
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Blazeby J. Bluebelle pilot randomised controlled trial of three wound dressing strategies to reduce surgical site infection in primary surgical wounds. BMJ Open 2020; 10:e030615. [PMID: 31932387 PMCID: PMC7045119 DOI: 10.1136/bmjopen-2019-030615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 10/23/2019] [Accepted: 11/11/2019] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Surgical site infection (SSI) affects up to 25% of primary surgical wounds. Dressing strategies may influence SSI risk. The Bluebelle study assessed the feasibility of a multicentre randomised controlled trial (RCT) to evaluate the effectiveness and cost-effectiveness of different dressing strategies to reduce SSI in primary surgical wounds. DESIGN A pilot, factorial RCT. SETTING Five UK hospitals. PARTICIPANTS Adults undergoing abdominal surgery with a primary surgical wound. INTERVENTIONS Participants were randomised to 'simple dressing', 'glue-as-a-dressing' or 'no dressing', and to the time at which the treatment allocation was disclosed to the surgeon (disclosure time, before or after wound closure). PRIMARY AND SECONDARY OUTCOME MEASURES Feasibility outcomes focused on recruitment, adherence to randomised allocations, reference assessment of SSI and response rates to participant-completed and observer-completed questionnaires to assess SSI (proposed primary outcome for main trial), wound experience and symptoms, and quality of life (EQ-5D-5L). RESULTS Between March and November 2016, 1115 patients were screened; 699 (73.4%) were eligible and approached, 415 (59.4%) consented and 394 (35.3%) were randomised (simple dressing=133, glue=129 and 'no dressing'=132). Non-adherence to dressing allocation was 2% (3/133), 6% (8/129) and 15% (20/132), respectively. Adherence to disclosure time was 99% and 86% before and after wound closure, respectively. The overall rate of SSI (reference assessment) was 18.1% (51/281). Response rates to the Wound Healing Questionnaire and other questionnaires ranged from >90% at 4 days to 68% at 4-8 weeks. CONCLUSIONS A definitive RCT of dressing strategies including 'no dressing' is feasible. Further work is needed to optimise questionnaire response rates. TRIAL REGISTRATION NUMBER 49328913; Pre-results.
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Affiliation(s)
- Jane Blazeby
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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9
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McMullan C, Blazeby J, Donovan JL, Rooshenas L, Elliott D, Mathers J. Dressing use issues in primary abdominal wounds: a qualitative study of health staff and patient views. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2019; 28:S10-S18. [PMID: 31714826 DOI: 10.12968/bjon.2019.28.20.s10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Primary surgical abdominal wounds are usually covered with a dressing. However, little is known about the practical issues and costs around these dressings. This study aimed to provide an in-depth description of patients' and health professionals' perspectives on the clinical and practical issues associated with standard and novel dressing (glue-as-a-dressing) use on primary surgical wounds, and to establish whether and how their experience compares with these perspectives. During semi-structured interviews, patients and health professionals discussed their positive experience of glue-as-a-dressing and no dressing around six themes: wound contamination and infection, wound healing, wound care, physical protection afforded by simple dressings, the potential psychological impact of an exposed wound, and ability to carry out everyday tasks. Current views on the practice of dressings for primary abdominal wounds are influenced by ingrained clinical practice. These views can be challenged when exposed to novel dressing strategies or as new evidence of the clinical effect of dressing strategies emerges.
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Affiliation(s)
- Christel McMullan
- Research Fellow, Institute of Applied Health Research, University of Birmingham
| | - Jane Blazeby
- Professor of Surgery, Population Health Sciences, Bristol Medical School, University of Bristol, and Consultant Upper GI Surgeon, University Hospitals Bristol NHS Foundation Trust
| | - Jenny L Donovan
- Professor of Social Medicine, Population Health Sciences, Bristol Medical School, University of Bristol, and NIHR Collaboration for Leadership in Applied Health Research and Care West, University Hospitals Bristol NHS Trust
| | - Leila Rooshenas
- Lecturer in Qualitative Health Science, Population Health Sciences, Bristol Medical School, University of Bristol
| | - Daisy Elliott
- Research Fellow, Population Health Sciences, Bristol Medical School, University of Bristol
| | - Jonathan Mathers
- Senior Lecturer in Qualitative and Mixed Methods Applied Research, Institute of Applied Health Research, University of Birmingham
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10
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A randomized controlled trial on the effect of a silver carboxymethylcellulose dressing on surgical site infections after breast cancer surgery. PLoS One 2018; 13:e0195715. [PMID: 29791437 PMCID: PMC5965831 DOI: 10.1371/journal.pone.0195715] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 03/27/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The incidence of surgical site infections (SSIs) after breast cancer surgery is relatively high; ranging from 3 to 19%. The role of wound dressings in the prevention of SSI after breast cancer surgery is unclear. This study compares a silver carboxymethylcellulose dressing (AQUACEL Ag Surgical (Aquacel) with standard wound dressing in SSI rate after breast cancer surgery. PATIENTS AND METHODS A single-centre randomized controlled trial among women ≥18 years, diagnosed with breast cancer, undergoing breast conserving or ablative surgery, was conducted in a combined in and outpatient setting. The intervention was the use of Aquacel, compared with standard gauze dressing. Primary outcome measure was SSI following CDC criteria. RESULTS A total of 230 patients were analysed: 106 in the Aquacel group and 124 controls. Seven patients (6.6%) developed SSI in the Aquacel group and 16 patients (12.9%) in the control group (RR 0.51 [95% Confidence Interval (CI): 0.22-1.20]; p = 0.112; adjusted OR 0.49 [0.19-1.25] p = 0.135)). Unplanned exploratory subgroup analysis of breast conserving surgery patients showed that SSI rate was 1/56 (1.8%) in the Aquacel group vs. 7/65 (10.8%) in controls; adjusted OR 0.15 [0.02-1.31] p = 0.087. The Aquacel group showed better patient satisfaction (median 8 vs. 7 on a Numerical Rating Scale, p = 0.006), fewer dressing changes within 48 hours(adjusted OR 0.12 [0.05-0.27] p<0.001), fewer re-operations (0% vs. 3.2%, p = 0.062), and lower mean wound-related treatment costs, both in a high (€265.42 (SD = 908) vs. €470.65 (SD = 1223) [p<0.001]) and low (€59.12 (SD = 129) vs. €67.55 (SD = 172) [p<0.001]) attributable costs of SSI model. CONCLUSION In this randomized controlled trial in women undergoing surgery for breast cancer, the use of AQUACEL Ag Surgical wound dressing did not significantly reduce the occurrence of SSIs compared to standard gauze dressing. The use of Aquacel resulted in significantly improved patient satisfaction, reduced dressing changes and reduced wound-related costs. TRIAL REGISTRATION www.trialregister.nl: NTR5840.
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Reeves BC, Andronis L, Blazeby JM, Blencowe NS, Calvert M, Coast J, Draycott T, Donovan JL, Gooberman-Hill R, Longman RJ, Magill L, Mathers JM, Pinkney TD, Rogers CA, Rooshenas L, Torrance A, Welton NJ, Woodward M, Ashton K, Bera KD, Clayton GL, Culliford LA, Dumville JC, Elliott D, Ellis L, Gould-Brown H, Macefield RC, McMullan C, Pope C, Siassakos D, Strong S, Talbot H. A mixed-methods feasibility and external pilot study to inform a large pragmatic randomised controlled trial of the effects of surgical wound dressing strategies on surgical site infections (Bluebelle Phase B): study protocol for a randomised controlled trial. Trials 2017; 18:401. [PMID: 28851399 PMCID: PMC5576037 DOI: 10.1186/s13063-017-2102-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 07/12/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Surgical site infections (SSIs) are common, occurring in up to 25% of > 4 million operations performed in England each year. Previous trials of the effect of wound dressings on the risk of developing a SSI are of poor quality and underpowered. METHODS/DESIGN This study is a feasibility and pilot trial to examine the feasibility of a full trial that will compare simple dressings, no dressing and tissue-glue as a dressing. It is examining the overall acceptability of trial participation, identifying opportunities for refinement, testing the feasibility of and validating new outcome tools to assess SSI, wound management issues and patients' wound symptom experiences. It is also exploring methods for avoiding performance bias and blinding outcome assessors by testing the feasibility of collecting wound photographs taken in theatre immediately after wound closure and, at 4-8 weeks after surgery, taken by participants themselves or their carers. Finally, it is identifying the main cost drivers for an economic evaluation of dressing types. Integrated qualitative research is exploring acceptability and reasons for non-adherence to allocation. Adults undergoing primary elective or unplanned abdominal general surgery or Caesarean section are eligible. The main exclusion criteria are abdominal or other major surgery less than three months before the index operation or contraindication to dressing allocation. The trial is scheduled to recruit for nine months. The findings will be used to inform the design of a main trial. DISCUSSION This pilot trial is the first pragmatic study to randomise participants to no dressing or tissue-glue as a dressing versus a simple dressing. Early evidence from the ongoing pilot shows that recruitment is proceeding well and that the interventions are acceptable to participants. Combined with the qualitative findings, the findings will inform whether a main, large trial is feasible and, if so, how it should be designed. TRIAL REGISTRATION ISRCTN49328913 . Registered on 20 October 2015.
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Affiliation(s)
- The Bluebelle Study Group
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
- School of Social and Community Medicine, University of Bristol, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- North Bristol NHS Trust, Bristol, UK
- NIHR Collaboration for Leadership in Applied Health Research and Care West at University Hospitals Bristol NHS Trust, Bristol, UK
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
- Academic Department of Surgery, Queen Elizabeth Hospital, University of Birmingham, Birmingham, UK
- School of Clinical Sciences, University of Bristol, Bristol, UK
- Department of Surgery, Sandwell and West Birmingham NHS Trust, Birmingham, UK
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK
| | | | - Lazaros Andronis
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Jane M. Blazeby
- School of Social and Community Medicine, University of Bristol, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Natalie S. Blencowe
- School of Social and Community Medicine, University of Bristol, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Melanie Calvert
- Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Joanna Coast
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Jenny L. Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
- NIHR Collaboration for Leadership in Applied Health Research and Care West at University Hospitals Bristol NHS Trust, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | | | - Laura Magill
- Academic Department of Surgery, Queen Elizabeth Hospital, University of Birmingham, Birmingham, UK
| | - Jonathan M. Mathers
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Thomas D. Pinkney
- Academic Department of Surgery, Queen Elizabeth Hospital, University of Birmingham, Birmingham, UK
| | - Chris A. Rogers
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Leila Rooshenas
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Andrew Torrance
- Department of Surgery, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Nicky J. Welton
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Mark Woodward
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Kate Ashton
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | | | - Gemma L. Clayton
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Jo C. Dumville
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK
| | - Daisy Elliott
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Lucy Ellis
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Hannah Gould-Brown
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Christel McMullan
- Academic Department of Surgery, Queen Elizabeth Hospital, University of Birmingham, Birmingham, UK
| | - Caroline Pope
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Dimitrios Siassakos
- North Bristol NHS Trust, Bristol, UK
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Sean Strong
- School of Social and Community Medicine, University of Bristol, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Helen Talbot
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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