Stream Overview

Recommendations

Identify and Treat the Cause
1 Monitor patients’ physical status post-operatively to identify and treat potential infections or other complications. Level of Evidence
5
2 If an acute confusional state is present, exclude treatable causes by appropriate history, physical examination and investigations. Level of Evidence
5


Address Patient-Centered Concerns
3 Provide ongoing support and education to patient and family regarding incision care. Level of Evidence
5
4 Maintain optimal strategies for caring for patients postoperatively. Level of Evidence
5
5 Consult appropriate Professionals, including Dieticians to ensure appropriate nutrition. Level of Evidence
5


Provide Local Wound Care
6 Review the results from microbiological specimens regularly and change antibiotics as necessary. Level of Evidence
5
7 Perform hand washing with soap and water or with alcoholic cleansing agents before and after patient contact. Use gloves for hand-contaminating activities. Level of Evidence
5
8 Consider adjunction therapy, including hyperbaric oxygen to assist healing, as appropriate. Level of Evidence
4


Provide Organizational Support
9 Empower an interprofessional surgery team ensuring involvement of appropriate professionals, e.g., dietician, and provide education and support. Level of Evidence
5


Background

Surgical wounds are . Local surgical factors such as infection, edema, seroma and hematoma formation, wound tension, wound trauma, wound drainage, the presence of drainage devices, muscle spasticity, and wound dressings all affect postoperative wound healing. Considerations to optimize healing should be given to reduce tension across the surgical site and to improve perfusion, nutrition, and free radical destruction. Surgical reconstructive options should be considered for selected patients whose length of healing would be extraordinarily long and whose health status is appropriate for rapid healing.

A systematic literature search for clinical practice guidelines on surgical wounds was completed using the Medline, CINAHL, and Embase databases and 46 guideline clearinghouses. A librarian was involved in identifying the appropriate keywords and search strategies to ensure that all guidelines on the topic were found.

112 surgical wounds treatment clinical practice guidelines were found in the English literature from 2002 until May 2007. Many of these published articles were excluded due to a variety of reasons. They were: not specifically addressing surgical wounds, articles, review papers, not CPGs, supplemental documents of a guideline and quick reference guides.

Of the identified papers, 14 guidelines were appraised by a minimum of three reviewers using the AGREE instrument (http://www.agreecollaboration.org/instrument/). The AGREE instrument has six domains: scope and purpose, stakeholder involvement, rigour of development, clarity and presentation, applicability, and editorial independence. It is not recommended that the scores obtained for the domains be aggregated. Instead the guidelines that received the highest scores for most of the domains and particularly for rigour of development were ranked highest and their recommendations will be reported throughout this Acute Wounds – Surgery stream.

The most highly ranked guidelines were developed by the Scottish Intercollegiate Guidelines Network (SIGN) on Postoperative Management in Adults: A Practical Guide to Postoperative Care for Clinical Staff (2004); Holmes’ Skeletal Pin Site Care: National Association of Orthopaedic Nurses guidelines for Orthopaedic Nursing (2005); McKibben’s Guidance on Public Reporting of Healthcare-associated Infections: Recommendations of the Healthcare Infection Control Practices Advisory Committee (2005); Johnson’s Consensus Recommendations for the Diagnosis, Treatment and Control of Myobacterium Ulcerans Infection (Bainsdale or Buruli Ulcer) in Victoria, Australia (2007).

The following figure indicates the AGREE domain scores for these surgical wounds treatment guidelines.


The following general recommendations are intended to help busy clinicians provide excellent care. They are based on the high ranking guidelines that are referenced. Only the SIGN guideline provides guidance for general post-surgical care. The other guidelines are directed toward specific topics that are not discussed in our recommendations. Practitioners are advised to review guidelines that address their surgical specialty.

References

High Ranking Guidelines
1 Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Scottish Intercollegiate Guidelines Network. (2004). Postoperative Management in Adults: A Practical Guide to Postoperative Care for Clinical Staff.
This guideline emphasizes the importance of pre-emptive management in postoperative care. Regular assessment, selective monitoring and timely documentation are key to postoperative care. The method of recommendations is by consensus statement, developed from structured discussion, informed by any existing evidence and the group’s clinical experience, and validated using a formal scoring system.
2 Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Holmes SB and Brown SJ. Pin Site Care Expert Panel, (2005). Skeletal pin site care: National Association of Orthopaedic Nurses guidelines for orthopaedic nursing. Orthop.Nurs. 24 (2), 99-107.
This guideline provided evidence-based recommendations for the care of the skin immediately surrounding the skeletal pin. The recommendations provided are very specific. The levels of evidence are supported by RCTs, case series, and expert opinion.
3 Quality Indicator
 Type: CPG (Clinical Practice Guideline)
McKibben L, Horan T, Tokars JI, Fowler G, Cardo DM, Pearson ML, Brennan PJ. Healthcare Infection Control Practices Advisory Committee, (2005). Guidance on public reporting of healthcare-associated infections: recommendations of the healthcare infection control practices advisory committee. Am.J.Infect.Control, 33 (4), 217-226.
This guideline is intended to assist policymakers, program planners, consumer advocacy organizations, and others tasked with designing and implementing public reporting systems for Healthcare Associated Infections. The recommendations are provided by the Healthcare Infection Control Practices Advisory Committee based on expert opinion.
4 Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Johnson P, Hayman JA, Quek TY, Fyfe J, Jenkin GA, Buntine JA, Athan E, Birrell M, Graham J, Lavender CJ. (2007). Consensus recommendations for the diagnosis, treatment and control of Mycobacterium ulcerans infection (Bairnsdale or Buruli ulcer) in Victoria, Australia. The Medical Journal of Australia. 186 (2): 64-68.
This guideline presents recommendations for the treatment of Bairnsdale ulcer by using oral antibiotics and intravenous amikacin. The recommendations are very specific and they are based on consensus statements from plastic surgeons, general practitioners, laboratory scientists, pathologists, infectious disease physicians and public health experts. The level of evidence is 4/5 (0bservational case series/expert opinion), except where specific references are cited.
5 Quality Indicator
 Type: Concensus Statement
Fleck T, Gustafsson R, Harding K, Ingemansson R, Lirtzman MD, Meites HL, Moidl R, Price P, Ritchie A, Salazar J, Sjogren J, Song DH, Sumpio BE, Toursarkissian B, Waldenberger F, Wetzel-Roth W. (2006). The management of deep sternal wound infections using vacuum assisted closureTM (V.A.C.) therapy. Int.Wound.J. 3 (4), 273-280.
This guideline presents the VAC Therapy to assist wound closure. VAC Therapy is favoured because the standard approach to management of deep sternal wound infections was labour intensive and had implications for health care costs and staffing. The effects of the VAC Therapy include increased wound perfusion, reduction in inhibitory substances and lowering of bacterial load, oedema and increased granulation tissue formation. The recommendations are based on current evidence or the majority consensus of the international group of experts.


Enablers for practice

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