Is there a normal healing rate for wounds in ICUs?
Set aside special time to re-assess interventions
Intensive care nurses should set aside a special period of time each day for assessing wound management strategies with other members of the clinical team. Discussions with physicians, nutritionists, and respiratory therapists should be appropriately timed to avoid interfering with daily patient assessments or other business, according to a surgeon who authored a study on ICU wound management.
The additional time will be worth the effort, says Douglas M. Geehan, MD, assistant professor of surgery at the University of Missouri School of Medicine in Kansas City.
Time for discussion
By setting aside more time, nurses will have the freedom to fully assess prescribed interventions, make necessary alterations to care plans, and discuss particular factors about a patient’s progress, Geehan explains.
The notion that patients will respond to therapies according to predictive timetables can be misleading, Geehan adds. It assumes that wound management techniques can be subordinated on a list of other "more important" patient-care considerations.
In fact, the progress of wound healing affects other morbidities and therefore requires special attention, Geehan states. One study indicates that wound infection increases hospital stays by nearly 10 days.1
Although there is a "normal" healing rate for wounds, "there is enough variability to make it difficult for us to say that any wound is healing normally," Geehan states.
However, there may be systems for predicting infection rates. A joint study conducted by the University of North Carolina in Charlotte and Baylor University Medical Center in Dallas attempted to establish predictive measures in the development of sternal wound infections.
Researchers identified 19 risk factors most often associated with sternal wound infections (SWIs) in the ICU including gender, obesity, impaired immune responses, preoperative ICU stays, and hypotension or hypoperfusion in the ICU.
The scale produced more than 62% correct predictions of infection and non-infection. A more advanced version of the scale (with 21 factors) produced 72.8% correct predictions. According to the research, making proper patient diagnoses for risk can lead to higher predictability.2
Nurses in step-down or telemetry units can quickly complete the predictive infection scale by reviewing the patient’s chart and identifying which risk factors apply to the patient, states the study.
In the SWI project, assigned scores were given to each risk factor. If a score was higher than 27 (numerical value is arbitrary) — which is the cut score on the SWI scale — the patient was at risk of developing infection, researchers state.
No one healing protocol effective with wounds
However, the scale is only relevant to sternal wounds and not to other wound infection types, says Barbara Leeper, RN, MN, CCRN, an ICU nurse at Baylor and study investigator. It also predicts the infection rate, not necessarily the healing rate for wounds, she points out.
Interventions can vary dramatically, so nurses should be vigilant about varying degrees of healing, Geehan states. A wound that is left open rather than immediately closed doesn’t necessarily mean a setback in healing time, he adds.
Geehan identifies three forms of wound healing strategies (see chart on p. 66):
• primary intention;
• secondary intention;
• delayed primary closure.
Some wounds require immediate approximation (closure) while others may be left open. Differences in dressing changes and antiseptic use in cleaning can also alter the degree of "normal" healing, Geehan says.
For this reason, a strict adherence to a multidisciplinary team in carefully assessing wounds is highly recommended, he adds.
"The management of a patient in the ICU who has a significant wound or a wound infection requires the synthesis of multiple areas of knowledge and skill" to return the patient to a normal state of function in the least amount of time, Geehan says.3
References
1. Cruse PJE, Foord R. A five-year prospective study of 23,649 surgical wounds. Arch Surg 1973; 107:206-210.
2. Hussey LC, Leeper B, Hynan LS. Development of the sternal wound infection prediction scale. Heart Lung 1998; 27:326-336.
3. Geehan DM, Pemberton LB. Management of wounds and wound infections in the intensive care unit. Crit Care Nur Q 1997; 20:69-78.
ICU Wound Management Terminology
Terminology Definition
Primary intention Cut edges of the wound are closed (directly approximated). Wound is not left open.
Secondary intention Cut edges of the wound are left open. Wound develops granular tissue, re-epithelialization, and contraction prior to closure.
Delayed primary closure Wound is initially left open. Debris is eliminated, infection cleared, granulation initiated prior to closure. Timing of closure is variable but can be accomplished within five days.
Clean An operative classification describing absence of inflammation; may call for surgical entry into gastrointestinal, respiratory, or genitourinary tract if urine is infected.
Refined clean Clean case considered elective and closed primarily without drainage.
Clean contaminated Minor entry/try into genitourinary tract if urine is infected.
Contaminated Major entry required. Acute bacterial inflammation without pus; spillage from gastrointestinal tract, fresh traumatic wound.
Dirty Presence of pus; perforated viscus; old traumatic wound.
Source: Geehan DM, Pemberton LB. Management of wounds and wound infections in the intensive care unit. Crit Care Nurs Q 1997; 20:69-78.
Compliance Guidelines for Physical Restraints
• Explain to the patient and/or family use of restraint as a safety measure.
• Apply restraint over the patient’s gown.
• Ensure that restraints have not been applied too tightly or too loosely and can be released with one pull.
• Secure the restraint to the bed frame, not the railings.
• Document the patient’s condition every two hours on a standardized protective care plan of car.
• Release restraints for 10 minutes every two hours.
• Provide educational materials to patient and family.
• Obtain a physician’s order when initiating restraints and when they are renewed every 24 hours.
Source: Vanessa Alvarado-Greer, Veterans Affairs Hospital, Fresno, CA.
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