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Background


1. Objectives

2. Background

  1. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Canadian Association of Wound Care (CAWC)
  2. Clinical Best Practice Guidelines Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients
  3. Canadian Association of Wound Care (CAWC) Best Practice Enabler and Quick Reference Guide
  4. Wound Bed Preparation Paradigm

3. Address Patient Centered-Concerns

  1. Assess Psychosocial Needs /Pain and Quality of Life (QOL)
  2. Socioeconomic Determinates of Health
  3. Self-management

4. Identify and Treat the Cause

4.1 Assessment of surgical site infection

4.2 Factors that can affect healing

  1. Risk Factors for surgical dehiscence, infection or stalled healing
  2. Odds Ratio of surgical wound NOT Healing in 24 weeks

4.3 Complete a Holistic Assessment

  1. Obtain a comprehensive patient history
  2. Complete a comprehensive physical examination
  3. Lower Leg Assessment
  4. Assess Wound and Peri-wound
  5. Wound Measurement
  6. Determine if the wound is "Healable, Maintenance or Non-Healable"
  7. Nutritional Assessment

4.4 Optimize Medical Therapy

4.5 Surgical and Medical Intervention Strategies

4.6 Presence of Superficial Bacteria

  1. Surgical wound infection

5. Provide Local Wound Care

  1. Post-surgical wound care
  2. Signs and symptoms of Cellulitis
  3. Determining Goals for Local Treatment for Surgical Wounds
  4. Utilize Product Picker from Canadian Association of Wound Care (CAWC)
  5. Patient Education on Skin Care
  6. Adjunctive Therapies

6. Provide Organizational Support

  1. Multi-disciplinary Referral Criteria
  2. Patient/Patient Teaching and Learning Resources
  3. Discharge or Transfer Planning and Communications
  4. Waterloo Wellington Integrated Wound Care Program Evidence-Based Wound Care Surgical Wounds Clinical Pathway

Levels of Evidence

The best practice recommendations provide clinicians with the best available evidence. The tables below show the levels of evidence from the Registered Nurses Association of Ontario Guidelines (RNAO):

RNAO's
Interpretation of Evidence1

Levels of Evidence

A Evidence obtained from at least one randomized controlled trial or meta-analysis of randomized controlled trials
B Evidence from well-designed clinical studies but no randomized controlled trials
C Evidence from expert committee reports or opinion and/or clinical experience or respected authorities. Indicates absence of directly applicable studies of good quality
 

RNAO’s
Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients2

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trial
Ib Evidence obtained from at least one randomized controlled trial
IIa Evidence obtained from at least one well-designed controlled study without randomization
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies
IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities
 

RNAO’s
Integrating Smoking Cessation into Daily Nursing Practice3

Levels of Evidence

A Requires at least two randomized controlled trials as part of the body of literature of overall quality
and consistency addressing the specific recommendations.
B Requires availability of well conducted clinical studies, but no randomized controlled trials on the
topic of recommendations.
C Requires evidence from expert committee reports or opinions and/or clinical experience of
respected authorities. Indicates absence of directly applicable studies of good quality.
 

NICE and Scottish Intercollegiate Guidelines
Surgical Site Infection – Prevention and Treatment of Surgical Site Infection4 5

Levels of Evidence

1++ High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1 - Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++ High-quality systematic reviews of case–control or cohort studies; high-quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal
2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal
2 - Case–control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal
3 Non-analytical studies (for example, case reports, case series)
4 Expert opinion, formal consensus
 

Background

From April 2013 until March 2014, surgical wound care costs in Waterloo Wellington region doubled from the previous year costing the Community Care Access Centre 1.5 million dollars. A significant number of nursing visits were required for over 1544 patients with surgical wounds at an average cost per client of almost $1000. The average length of stay requiring community wound care for patients with surgical wounds in Waterloo Wellington was 53 days.6
 
It is estimated that 75% of all surgical procedures are performed on an outpatient basis. With shorter lengths of stay, increased acuity, patients with multiple comorbidities, higher body mass indexes and people living to advanced age, the community resources are being strained.
 
“Surgical site infections are the third leading cause of hospital-acquired infections in Canada.”7“Wound infections increase hospital-related nursing costs by up to 50 percent and inpatient hospital costs directly related to the wound by almost $4000 per infection.”8 The ability to treat wounds using evidence-based best practices and to identify signs of infection in the community is paramount.9
  

Best Practices for Assessment and Treatment of Surgical Wounds

In 2010, Orsted et al developed Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds in Wound Care Canada. Woundpedia has developed evidence-informed recommendations for surgical wounds using evidence-based research findings.10 In 2008, the National Institute of Health and Clinical Excellence (NICE) in the United Kingdom commissioned Surgical Site Infection – Prevention and treatment of surgical site infection clinical guideline to be developed. The following guidelines utilize these best practice recommendations as well as those recommended by the Waterloo Wellington Community of Practice Collaborative.

All clinicians are expected to use best practices to assess and treat surgical wounds to improve patient outcomes. The framework used in this guideline was applied from the Registered Nurses Association of Ontario (RNAO). The RNAO Clinical Best Practice Guidelines “Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients” (2010)11 was also used for self-management section. A complete list of references used can be found in the appendices.
 
 

a. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Canadian Association of Wound Care (CAWC)

 

b. Clinical Best Practice Guidelines Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients

 

c. CAWC Best Practice Enabler and Quick Reference Guide

 

d. Wound Bed Preparation Paradigm

The wound bed preparation (WBP) paradigm is used to assess, diagnosis, and treat wounds while considering patient concerns.12 It links evidence-based literature, expert opinion, and clinical experiences of respected wound care specialists.  The framework is beneficial because the components are interrelated and can be re-evaluated if the wound deviates from the care plan. Furthermore, the interprofessional team is able to collaborate together through shared discussion to classify a healable, maintenance, and non-healable wound.
 
Figure 1 Adapted from:
Orsted, et al, Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds, Wound Care Canada, Volume 8 Number 1, 2010

Address Patient-Centred Concerns

 

  1. Ontario, Registered Nurses Association of. Assessment and Management of Venous Leg Ulcers. Toronto : s.n., 2004.
  2. Ontario, Registered Nurses Association of. Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients. 2010.
  3. Ontario, Registered Nurses Association of. Nursing Best Practice Guideline: Integrating Smoking Cessation into Daily Nursing Practice. 2007.
  4. Excellence, National Institute for Health and Clinical. Surgical Site Infection - Prevention and treatment of surgical site infection. London, U.K. : Royal College of Obstetricians and Gynaecologists, 2008.
  5. Network, Scottish Intercollegiate Guidelines. Postoperative Management of Adults. 2004.
  6. SBR, Optimus. Current-State Assessment. s.l. : Waterloo Wellington Community Care Access Centre (CCAC), 2015.
  7. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.
  8. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.
  9. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.
  10. Surgical Wounds. Woundpedia. [Online] [Cited: June 1, 2016.] http://woundpedia.com/evidence-informed-topics/surgical-wounds/.
  11. Ontario, Registered Nurses Association of. Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients. 2010.
  12. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.

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