AMANDA PALMER discusses how to prevent and manage infection in wound care.
Preventing and managing infection in wound care can often be challenging. In particular, chronic wounds are almost inevitably going to acquire a collection of various bacteria, likely to include staphylococcus aureus and pseudomonas, along with a mixture of gram-positive and gram-negative bacteria.
To imagine that we can stop this from occurring will only lead to disappointment; the key here is to reduce the impact and significance, and importantly, reduce the risk of spreading these bacteria to other clients and patients.
Keeping hands clean
The most fundamental element to any infection control policy is effective hand washing, both before and after dealing with any patient or client. We hear this time and time again, and yet, if we take the time to quietly observe our – and our colleagues’ – hand washing frequency and technique, it is usually apparent that it leaves a lot to be desired!
During the SARS outbreak in Toronto, Canada a few years ago, every ward, department, patient, visitor, and staff member were encouraged to clean their hands with hand sanitiser gel at regular intervals. The risk of contracting SARS was at the forefront of people’s minds, and so everyone became far more diligent. Interestingly, this resulted in a significant reduction in cases of infection within the hospital. A coincidence? Or proof that generally we don’t wash our hands as well as we should?
Every infection control manual and policy will have guidelines on effective hand washing, and however busy we are, this should be a priority in our everyday practice. This is so important in aged care facilities and where vulnerable people are bought together and the risk of cross-contamination is high.
Importance of cleansing
When it comes to wound care, good cleansing is also important to help reduce the bacterial loading and contamination of the surrounding skin. All too often, dressings are removed, a little saline is wiped over the wound bed, and the dressings are reapplied. This lack of attention towards the surrounding skin can increase the likelihood of infection. Outbreaks of rash-like pustules on the skin can be caused by staph infection, which can be easily reduced and managed through regular effective cleaning of the whole limb or area.
Showering or soaking in a bowl of warm water and the use of mild soaps, or in cases of contamination, washing with Chlorhexidine™ wash, can control the opportunistic bacteria. Several studies have been undertaken looking at the benefits of wound hygiene using saline versus warm tap water (where the supply is safe), and there is no evidence of any detrimental effects from tap water. It is high time we gave up the idea of keeping the wound dry and away from water!
However, in facilities where patients share baths or showers, cleaning down these areas thoroughly with bleach cleaning agents is essential to prevent cross-contamination.
A simpler idea, where practical, is to line a big bucket with a clean bin sack, which can then be discarded after the patient has had their arm or leg washed. In particular, cavities and sinuses and areas of undermining are excellent places for infection to collect and cleaning should pay particular attention to these areas.
Effective wound treatment
It is also important to apply a moisturiser such as aqueous cream or 50 per cent soft white paraffin and 50 per cent liquid paraffin to the limb/surrounding skin to prevent this becoming dry from washing and being dressed. A build-up of dry skin can harbour bacteria and be itchy. However, it is important to ensure the limb is thoroughly washed to prevent the moisturiser building up on the skin, which will in itself cause problems.
Slough and necrotic tissue on the wound bed provide an ideal environment for bacteria. Where it is possible to gently remove slough and necrotic tissue, this should be done regularly. Keeping the wound warm and moist will assist in the process known as autolytic debridement, where the action of the body’s macrophages works to break down debris and dead tissue. Where this is not effective enough, sharp debridement should be considered but only undertaken by a skilled and trained member of staff and should not cause pain.
There are many versions of silver dressings available. Unfortunately, the research does not back its use in most cases, and the evidence of its effectiveness is questionable. The inappropriate overuse of these products is likely to lead to the development of resistant bacteria. Effective hand washing, wound and skin cleansing, dressings that manage exudate, and redressing once these have reached their limit are more effective ways of controlling infection.
Cross-contamination also comes from strike-through. If a dressing is unable to contain the exudate from a wound, there is a risk of contamination of the environment. If the dressing leaks or if the dressing padding becomes saturated, then every surface the patient comes into contact with will become contaminated: this is a significant risk to other patients. Dressings should have a semi-permeable film outer layer to prevent this and also to prevent bacteria travelling from the wet outer layer into the wound bed.
Some patients are unable to tolerate adhesives on their skin due to sensitivities or frequency of redressing, but the outer layer of the dressing can be covered with a semi-permeable film dressing such as Smith and Nephew Opsite™, 3M Tegaderm™, or Hartmann Hydrofilm™. This does not necessarily have to overlap onto the skin, though if possible, this is preferable, as it will reduce the risk of leaking exudate. Where there are high amounts of exudates, it is important to use barrier creams such as 3M Cavilon™ or Smith and Nephew Extra Protection Cream™ to prevent breakdown of the surrounding skin under the exudate.
Where the issue of contamination is due to patients who remove dressings inappropriately, a bandage such as Smith and Nephew Handigauze™ or 3M Coban™ can be helpful, as it sticks to itself but not the skin, and once in place, it can be difficult to pull off and will not slacken and pull apart like bandages do. An important point to remember when applying dressings that go right around a limb is not to create a tourniquet effect. The risks here are that oedema can build beyond the bandaging and the edges of the dressing can then cause pressure damage, rubbing, friction, and pain and damage to the area of the limb where the oedema collects. Where dressings slip or are fiddled with, there is a tendency to want to apply the securing layer firmly to prevent this. If this is the case, the securing bandage/tubigrip/tubifast should go the length of the limb – for example, toes to knee or wrist to elbow, not just a band around the middle.
There are no easy quick-fix answers to dealing with dressings where patients fiddle and remove them, and there is no easy answer on how to reduce contamination, but thorough cleansing of the wound, limb, and of the staff member’s hands at every dressing change can reduce the risk.
References (web-based): Waitemata DHB Wound Guidelines, European Wound Management Association protocols, World Union of Wound Healing Societies protocols, Australian Wound Management Association guidelines, New Zealand Wound Management Association guidelines, Dermnetnz.org, Woundsinternational.com, Global Wound Academy, Cochranelibrary.co.uk
Amanda Palmer is a nurse specialist for Wound Management Consultancy Ltd. She will be speaking at the Care Advisory Services training programme, ‘Pain Management and Wound Care’, to be held on 20 November in Mt. Wellington, Auckland.
Key points to remember:
- Effective hand washing before and after every patient contact is essential.
- Reduce risk of cross contamination.
- Look after the whole (limb or patient), not just the hole.
- Antibacterial dressings should be used with caution and rarely.