Evidence-Based Practice on Wound Packing

Evidence-Based Practice on Wound Packing Following Incision and Drainage

• Arlena Davis

The first article was related to MD’s not using any packing when it comes to treating I & D’s. Many times packing is used to debride the wound and keep fluids from pooling under the skin as well as keep area free of infection. In order to understand the outcome we need to fully understand what is involved.An abscess is a collection of pus, surrounded by inflamed tissue and usually localized (Pfenninger & Fowler, 2010).The reason we need the packing is related to having an abscess and we need to keep the area clean. Leinwand 2013states packing is thought to aid hemostasis, and prevent reorganization of the abscess, we sought to determine whether packing could be omitted with equal efficacy.

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The second article I chose was Alimov, V., Lovecchio, F., Sinha, M., Foster, K. N., & Drachman, D. (2013)to the use ofa silver-containing hydrofiber dressing for filling abscess cavity following incision and drainage in the emergency department. Is using packing always effective? Can we have equal efficacy when there is no packing used? These are questions that were sought after and answered in this particular article. At the end of the trial the patients reported faster heling and les pain as it relates to traditional packing.

In the research that was conducted in the first article entitled Use of Silver-containing hydro fiber dressing in filling the cavity related after incision and drainage at the emergency department: a randomized controlled trial. Advances in skin & wound care, (Alimov, Lovecchio, Sinha, Foster, & Drachman, 2013), clinical study design was used. This study design took the form of prospective randomized control trial. The sample size in this case was ninety-two patients (Alimov, Lovecchio, Sinha, Foster, & Drachman, 2013). These patients were more than 18 years of age and were suffering from cutaneous abscess. The ninety-two study participants had been randomly assigned into two groups. These are the intervention group (Skillman, Aquacel, New Jersey, and Convatec) and the iodoform group (Alimov, Lovecchio, Sinha, Foster, & Drachman, 2013). The iodoform group is the control group in this case. Of these two groups, it was noted that there were no differences in terms of demography as well as their clinical characteristics.

The weaknesses that are evident in data collection are that the researchers should have randomly selected the patients in two equal groups that is 46 persons per each group. The follow-up period is also not consistent. Inconsistency comes in whereby the study claims that patients were followed up in a span of the first two weeks (Alimov, Lovecchio, Sinha, Foster, & Drachman, 2013), though the follow-up was not continuous. However, the strength of this study is that it had both the intervention group and the control group. The intervention group comprised of four subgroups depending on the intended intervention. These four groups were based on interventions such as Convatec, New Jersey, Aquacel, and Skillman) (Alimov, Lovecchio, Sinha, Foster, & Drachman, 2013).The other strength of the study is that it was able to provide a comparison on the level of pain between the patients initial visit and the first follow-up.

In relation to the second article that dealt with the incision and the drainage of the subcutaneous abscess without packing, (Leinwand, Downing, Slater, Beck, Burton, & Moyer, 2013) clinical study design was also used. In this regard, the clinical study took the form of retrogressive randomized control trial. The sample size in this study was a hundred patients, who were reported to be suffering from subcutaneous abscesses back in between May 2008 and December 2010. These 100 patients were assigned into two groups namely, the packing and the non-packing groups (Leinwand, Downing, Slater, Beck, Burton, & Moyer, 2013). In this case, there were some exceptions in that some patients portraying some given conditions could not be considered. Such conditions include; patients who are immunosuppressed, or rather those suffering from diabetes. The other exception was in case the patient had a perineal or a pilonidal abscess. Last but not least, the other exception was on whether the abscess is secondary to the previous operation. These exceptions can be used as a basis for comparison among the sample, to the patients who will be seeking treatment.

There are several weaknesses of the study in terms of data collection, with one of them being that it was not age specific. Apart from that, the other weakness is that; the patients were only clinically evaluated, in case there was suspicion of recurrence in the follow-up calls on the day seven and thirty (Leinwand, Downing, Slater, Beck, Burton, & Moyer, 2013). These two days were referred to as postoperative. The other weakness is that, of the 100 patients, only 85 patients managed to complete the study. The study does not indicate the whereabouts of the 15 patients. On the other hand, the strength of this study is that it omitted other patients who had some other conditions that could interfere with the results. Such exceptional cases were the diabetic, immunosuppressed (Leinwand, Downing, Slater, Beck, Burton, & Moyer, 2013), among others.

Identification, critical appraisal, and synthesis of evidence from research articles is an essential skill in evidence-based practice (EBP) (Titler, 2008). This paper will critique two primary research articles related to the issue of wound packing following incision and drainage. The first article is authored by Leinwand et al. (2013) and is entitled “Incision and drainage of subcutaneous abscesses without the use of packing”. The second article is authored by Alimov et al. (2013) and is entitled “Use of a silver-containing hydrofiber dressing for filling abscess cavity following incision and drainage in the emergency department: A randomized controlled trial”.

The study by Leinwand et al. (2013) sought to determine whether omission of the wound packing component in the management of subcutaneous abscess has similar efficacy to wound packing. The study employed a prospective randomized controlled trial design whereby 100 participants were randomized to either the wound packing group or to the non-packing group. The study enrolled pediatric participants aged less than 18 years with subcutaneous abscesses. The sample size for the study was small (100). Consequently, the study did not have significant statistical power as a sample size of 4000 was required to gain power of 80%. The researchers, however, accepted the small sample size as it was practical for the purposes of the study. The selected sample is appropriate to the population of interest because the participants were experiencing the phenomenon of interest that is abscesses requiring incision and drainage.

Regarding data collection, similar pre-intervention data was collected on the operative day for all participants. These data included age, gender, and location and size of the abscess. Post-intervention data was collected through follow-up telephone calls by a pediatric surgery nurse specialist. These calls were made on the 7^th and 30^th post-operative days and included information on general wound appearance, adherence with warm soaks and antibiotic therapy, presence of fever, and timing of pack removal. The reliance on self-reported information may have introduced information bias due socially desirable responding and problems with recall (Fadnes, Taube, & Tylleskar, 2008).

Of the 100 participants who enrolled for the study, only 85 completed the study. The study found that the packing group and non-packing groups did not vary statistically with respect to abscess recurrence rates, initial parameters, and incidence of methicillin-resistant staphylococcus aureus (MRSA). Only two abscess recurrences were reported, one for each group. In their discussion, the authors contextualize these findings in light of pre-existing evidence. They note that the findings of their study are identical to those of similar previous studies on both adults and children. The authors also compare the strengths and weaknesses and merits and demerits of their study and intervention with those of previous studies. They also discuss the two cases of treatment failure. Lastly, they provide recommendations for future studies.

On the incorporation of evidence into treatment protocols, integration of research findings into treatment protocols/procedures occurs through the process of evidence-based practice. Research articles relevant to a clinical issue of concern are identified, appraised critically, and their findings used to make specific recommendations for practice on incision and drainage (Dontje, 2007).

The Purpose of the Alimov et al. (2013) study was to investigate whether packing of abscess cavity with a silver-containing hydrofiber dressing instead of the standard iodoform dressing leads to less pain and faster wound healing. The study employed a prospective randomized controlled trial design whereby participants were randomized to the silver-containing hydrofiber or standard care groups. The study population consisted of adults aged more than 18 years who visited the emergency department of a teaching hospital with cutaneous abscesses >2cm in diameter that required incision and drainage. The selected sample consisted of 92 patients. The sample for the study is appropriate to the selected topic as it focuses on the issue of incision and drainage protocols.

Data for the study was collected and documented on a standard form except for pain. The data collected included pertinent demographic and clinical variables. Pain was assessed using a self-report scale, the Wong-Baker FACES Pain Rating Scale. The use of a self-report scale for pain may have introduced social desirability bias. The findings of the study may have also been contaminated by bias due to the manual measurement of the dimensions of the abscess cavities. The primary outcome measures for the study were the proportion of patients with a reduction of 30% or > in the surface area of the abscess at the first follow up visit (between 48 and 72 hours). The other main outcome variable was proportion of patients with 30% or > decrease in the surrounding cellulites at the first visit. The secondary outcome measure was the change in self-reported pain intensity at primary and consequent visits.

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The study found that 82.6% of the patients in the silver-containing hydrofiber group had a reduction of 30% or > in the surface area of the abscess compared to the 26.1% of the subjects in the iodoform group (p<.0003). Patients in the silver-containing hydrofiber group also experienced a statistically significant change in severity of pain scores between the first and follow-up visits. The findings on reduction of surrounding cellulites were not statistically significant. The discussion section of the study discusses the findings of the current study in light of previous research. This section also describes the limitations of the study. For instance the use of self-report scales to assess pain levels as these are subject to bias. The results of the current study can be integrated into existing care protocols through the process of EBP. In this case, the article would need to be appraised together with other relevant articles and their findings synthesized. Recommendations for practice would then be made depending on the level and strength of evidence contained in the articles (Dontje, 2007).

In this article, the number of participating pediatric patients who had subcutaneous abscesses was one hundred. Patients who successfully completed the study were only 85: 43 packing group and 42 non-packing group. There existed an arithmetic variance between the two groups that concerned the initial parameters, recurring abscesses, (single in every group), or incidence of MRSA (81.4 packing groups over 85.7 non-packing group). Subcutaneous abscesses incision, as well as drainage without the utilization of packing, is an effective as well as a safe technique. This article should present the data in a more transparent way.

In this article, there was a prospective enrollment of 92 patients and these patients. There was also random assignment of these patients to the iodoform groups or Aquacel Ag. The SD was 12.0, and the average age was 38. The patients in iodoform group were 43 while those in Aquacel group were 49. There two groups lacked disparity in clinical and demographic characteristics. The domino effect of the deterioration study pointed out that the Aquacel Ag was autonomously associated with over 30% abscesses’ surface area reduction. This, however excluded first follow-up cellulitis. The pain intensity also decreased significantly as perceived by the Aquacel group patients. In cutaneous abscesses patients, there was faster wood healing as well as pain reduction while using antimicrobial-hydro fiber ribbon form of dressing than while using iodoform dressing. This article is important as it offers information on which choice is best while dressing.

It is recommended thatmore research on this subject as this will provide more information on subcutaneous abscesses treatment. These articles will help me in my career as a nurse practitioner because of the versatility of the procedures and the information provided.

In summary, this paper has critiqued two research articles related to the issue of wound packing following incision and drainage. The articles by Leinwand et al. (2013) and Alimov et al. (2013) have been critiqued in terms of their purpose, design, sample, data collection procedures, results, and discussion.

References

Alimov, V., Lovecchio, F., Sinha, M., Foster, K. N., & Drachman, D. (2013). Use of a silver- containing hydrofiber dressing for filling abscess cavity following incision and drainage in the emergency department: A randomised controlled trial. Advances in Skin and Wound Care, 26, 20-25.

Dontje, K. J. (2007). Evidence-based practice: Understanding the process. Topics in Advanced Practice Nursing, 7(4).

Fadnes, L., Taube, A., Tylleskar, T. (2008). How to identify information bias due to self-reporting in epidemiological research. The Internet Journal of Epidemiology, 7(2).

Leinwand, M., Downing, M., Slater, D., Beck, M., Burton, K., & Moyer, D. (2013). Incision and drainage of subcutaneous abscesses without the use of packing. Journal of Pediatric Surgery, 48(9), 1962-1965.

Titler, M. G. (2008). The evidence for evidence-based practice implementation. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK2659/