Analysis of results of Community Outlook wound quiz: Part 2 Dr S Thomas July 1993 In October 1992, Community Outlook published a quiz designed to review the knowledge of nursing staff working in the com- munity on various aspects of wound management. Part 1 of the quiz dealt with scientific aspects of the subject and an analysis of these results has been published previously.[1] In the second part of the quiz, participants were asked to examine photographs of ten different wounds and, based upon their experience with the products concerned, decide which dressings they would apply to each from a list of examples provided. Additional dressings, not included in the list, could be identified if required and up to three products could be selected for each indication. The wound types selected were as follows: +-------+------------------------------------------+ |Figure | Wound Type | | No. | | +-------+------------------------------------------+ | 1 | Dry necrotic areas on a foot | +-------+------------------------------------------+ | 2 | A large, dry sloughy wound | +-------+------------------------------------------+ | 3 | A moist infected wound | +-------+------------------------------------------+ | 4 | A smooth sided surgical cavity | +-------+------------------------------------------+ | 5 | A cavity with overhangs and sinuses | +-------+------------------------------------------+ | 6 | A smelly heavily exuding infected wound | +-------+------------------------------------------+ | 7 | An epithelialising wound | +-------+------------------------------------------+ | 8 | An overgranulating wound | +-------+------------------------------------------+ | 9 | A superficial area with some broken skin | +-------+------------------------------------------+ | 10 | A deep narrow sinus | +-------+------------------------------------------+ A total of 106 usable completed forms were received. The dressings most commonly selected for each wound type are summarised in the tables which follow. Only products which were identified by 10 or more individuals as their first choice for the treatment of each condition are shown in de- tail in these tables although examples of other recommended products are also provided in some instances. TABLE 1. Dressings selected for dry necrotic areas on foot +----+---------------+-----+---------------+-----+----------------+ |No. | 1st Choice | No. | 2nd Choice | No. | 3rd Choice | +----+---------------+-----+---------------+-----+----------------+ |33 | Intrasite gel | 21 | Varidase | 20 | Intrasite gel | |20 | Varidase | 21 | Intrasite gel | 13 | Granuflex | |16 | Granuflex | 20 | Granuflex | 10 | Varidase | |11 | Comfeel | 7 | Comfeel | 8 | Debrisan Paste | +----+---------------+-----+---------------+-----+----------------+ Comment Other products suggested for this application included Io- dosorb ointment, Aserbine and hydrogen peroxide. Although approximately 20% of all respondants stated that they would use the enzymatic debriding agent, Varidase, for this indication, this is a possible cause for concern. Un- less the black eschar is first scarified, to allow penetra- tion of the enzyme, or the solution is injected directly be- neath the dead tissue, the dressing is likely to be totally ineffective; both these procedures are considered to be of very limited acceptability and potentially fraught with problems. Much greater success is likely to result from the use of the hydrogel and hydrocolloid dressings preferred by the majori- ty of nurses. TABLE 2. Dressings selected for dry sloughy wound +----+---------------+-----+---------------+-----+----------------+ |No. | 1st choice | No. | 2nd choice | No. | 3rd choice | +----+---------------+-----+---------------+-----+----------------+ |46 | Intrasite gel | 26 | Granuflex | 11 | Intrasite gel | |19 | Granuflex | 18 | Intrasite gel | 10 | Varidase | |12 | Comfeel | 12 | Varidase | 9 | Debrisan Paste | +----+---------------+-----+---------------+-----+----------------+ TABLE 3. Dressings selected for infected sloughy wound +----+-------------------+-----+-------------------+-----+---------------+ |No. | 1st choice | No. | 2nd choice | No. | 3rd choice | +----+-------------------+-----+-------------------+-----+---------------+ |17 | Iodosorb ointment | 17 | Inadine | 8 | Inadine | |16 | Inadine | 12 | Iodosorb ointment | 7 | Intrasite gel | |14 | Intrasite gel | 10 | Granuflex | 7 | Sorbsan Sheet | |12 | Kaltostat sheet | 7 | Intrasite gel | 6 | Lyofoam | +----+-------------------+-----+-------------------+-----+---------------+ Comment Other products suggested for this application included Iod- oflex, Iodosorb Powder, Debrisan Beads and Flammazine. It is interesting to note that Varidase was not highly favoured for the treatment of either of the sloughy wounds, despite the fact that it may have some value for these indications. Clearly there is a need for a major educational initiative to provide medical and nursing staff with unambiguous infor- mation and advice on the appropriate use of enzymatic de- briding agents if these expensive materials are to be used in a cost effective manner. TABLE 4. Dressings selected for open cavity wound +----+----------------------+-----+--------------------+-----+-----------------+ |No. | 1st choice | No. | 2nd choice | No. | 3rd choice | +----+----------------------+-----+--------------------+-----+-----------------+ |21 | Kaltostat Packing | 15 | Silastic Foam | 10 | Allevyn Cavity | |19 | Silastic Foam | 15 | Sorbsan Packing | 8 | Silastic Foam | |14 | Sorbsan Packing | 10 | Kaltostat Packing | 7 | Sorbsan Packing | |11 | Kaltostat sheet | 7 | Lyofoam | 6 | Intrasite gel | |10 | Allevyn Cavity Wound | 7 | Kaltostat sheet | 4 | Granuflex | +----+----------------------+-----+--------------------+-----+-----------------+ Comment Other products suggested for this application included Sorb- san Sheet and Granuflex Paste. Only 1 individual indicated a preference for Eusol. Also, 29 nurses stated that they would use Silastic foam or Allevyn, despite the fact that these are not available on FP 10. This suggests that many community nursing staff have developed effective if highly unorthodox methods of obtain- ing products that they consider to be essential for the care of their patients. TABLE 5. Dressings selected for cavity wound with overhangs +----+-------------------+-----+-------------------+-----+-----------------+ |No. | 1st choice | No. | 2nd choice | No. | 3rd choice | +----+-------------------+-----+-------------------+-----+-----------------+ |33 | Sorbsan Packing | 25 | Sorbsan Packing | 7 | Allevyn Cavity | |28 | Kaltostat Packing | 17 | Kaltostat Packing | 6 | Silastic Foam | |12 | Intrasite gel | 11 | Intrasite gel | 6 | Sorbsan Packing | +----+-------------------+-----+-------------------+-----+-----------------+ Comment The use of Silastic foam for wounds with overhangs and si- nuses is probably contra-indicated because of problems of removal. It should therefore not be used for the wounds shown. TABLE 6. Dressings selected for a smelly, heavily exuding, infected wound +----+---------------+-----+---------------+-----+--------------------+ |No. | 1st choice | No. | 2nd choice | No. | 3rd choice | +----+---------------+-----+---------------+-----+--------------------+ |17 | Kaltocarb | 14 | Actisorb Plus | 10 | Lyofoam C | |17 | Actisorb Plus | 12 | Kaltocarb | 10 | Iodosorb ointment | |16 | Intrasite gel | 12 | Intrasite gel | 8 | Kaltocarb | +----+---------------+-----+---------------+-----+--------------------+ Comment Other products suggested for this application included De- brisan Beads, Sorbsan Packing and Varidase. Once again, there is considerable reliance placed upon products such as the activated charcoal dressings which are not available on FP 10 because of the refusal of the Drug Tariff authorities to recognise the need for these materials in the community. This despite the fact that more and more patients with chronic malodorous wounds are being discharged from hospital and cared by the primary care services. TABLE 7. Dressings selected for an epithelialising wound +----+------------+-----+------------+-----+-------------+ |No. | 1st choice | No. | 2nd choice | No. | 3rd choice | +----+------------+-----+------------+-----+-------------+ |28 | Granuflex | 19 | Comfeel | 7 | NA Dressing | |16 | Comfeel | 14 | Granuflex | 6 | Tegaderm | |13 | Tegaderm | 11 | Opsite | 6 | Lyofoam | +----+------------+-----+------------+-----+-------------+ Other products suggested for this application included Ly- ofoam, Kaltostat Sheet and NA Dressing. TABLE 8. Dressings selected for an overgranulating wound +----+----------------+-----+-------------+-----+-------------+ |No. | 1st choice | No. | 2nd choice | No. | 3rd choice | +----+----------------+-----+-------------+-----+-------------+ |14 | NA Dressing | 10 | NA Dressing | 6 | Comfeel | |11 | Lyofoam | 9 | Tricotex | 5 | NA Dressing | |11 | Silver Nitrate | 8 | Comfeel | 4 | Inadine | +----+----------------+-----+-------------+-----+-------------+ Other products suggested for this application included Granuflex, and various Tulle dressings. In fact the use of hydrocolloid dressings for the treatment of overgranulating wounds must be questionned as there is some evidence to sug- gest that hydrocolloids can actually precipitate this prob- lem. Simple low-adherent products are generally to be pre- ferred. The application of a mild corticosteroid (under med- ical supervision) will often cause the situation to resolve rapidly. TABLE 9. Dressings selected for a superficial wound +----+------------+-----+------------+-----+-----------------------+ |No. | 1st choice | No. | 2nd choice | No. | 3rd choice | +----+------------+-----+------------+-----+-----------------------+ |33 | Tegaderm | 23 | Tegaderm | 11 | Opsite | |20 | Comfeel | 18 | Comfeel | 10 | Bioclusive | |17 | Granuflex | 14 | Opsite | 7 | Granuflex | |16 | Opsite | 14 | Granuflex | 4 | Granuflex Extra Thin | +----+------------+-----+------------+-----+-----------------------+ Other products suggested for this application included Sofratulle and Melolin but the use of Sofratulle, which con- tains an antibiotic, should be avoided because it can cause skin sensitivity reactions. There is also a possibility, that if it is used inappropriately, it may lead to the emer- gence of antibiotic-resistant strains of pathogenic bacte- ria. TABLE 10. Dressings selected for a deep narrow sinus +----+-------------------+-----+-------------------+-----+----------------------+ |No. | 1st choice | No. | 2nd choice | No. | 3rd choice | +----+-------------------+-----+-------------------+-----+----------------------+ |48 | Sorbsan Packing | 21 | Kaltostat Packing | 10 | Intrasite gel | |31 | Kaltostat Packing | 20 | Sorbsan Packing | 6 | Allevyn Cavity Wound | +----+-------------------+-----+-------------------+-----+----------------------+ Other products suggested for this application included Rib- bon Gauze and Silastic foam but once again Silastic is prob- ably contra-indicated for the reason outlined previously. Respondents were asked, if for financial reasons, the range of dressings available to them was to be limited to three products, which ones they would select. The responses to this question are summarised in the table below. TABLE 11. Principal requirements +----+-----------------+-----+-----------------+-----+-------------------+ |No. | 1st choice | No. | 2nd choice | No. | 3rd choice | +----+-----------------+-----+-----------------+-----+-------------------+ |33 | Granuflex | 15 | Comfeel | 13 | Tegaderm | |16 | Comfeel | 15 | Kaltostat sheet | 12 | Intrasite gel | |12 | Intrasite gel | 12 | Granuflex | 10 | Kaltostat sheet | |12 | Kaltostat sheet | 11 | Intrasite gel | 9 | Opsite | +----+-----------------+-----+-----------------+-----+-------------------+ Comment These results indicate that most nurses consider that armed with a hydrocolloid, an alginate and an amorphous hydrogel they can cope with most wounds that they are likely to en- counter, although semi-permeable film dressings were also considered to be a useful weapon in the nurse's armamenteri- um. This faith in the value of `modern' dressings is at variance with the views of some clinicians who have less `hands on' experience in wound management, and who appear to believe that these materials are unnecessary, expensive, and rela- tively ineffective. Finally, respondents were asked if there were any dressings, currently not included in the Drug Tariff, that they felt should be included to enable them to provide optimum care of their patients. TABLE 12. Additional dressings that should be included in the Drug Tariff +----+-------------------+ |No. | Dressing | +----+-------------------+ |26 | Sorbsan Packing | |23 | Silastic foam | |21 | Actisorb C | |18 | Kaltocarb | |18 | Allevyn Cavity | |17 | Kaltostat Packing | |12 | Granuflex E | |11 | Allevyn | |10 | Lyofoam C | +----+-------------------+ These comments clearly demonstrate that in the view of those nurses who participated in the study, there is a major re- quirement for at least one cavity wound dressing and one odour absorbing dressing, DOH please take note! Of those who took part in the survey, 81 (76.4%) were dis- trict nurses, and 24 (22.6 %) were Practice nurses. One re- spondent was not identified. REFERENCES 1. Wound management quiz results analysis, Community Out- look 1993, 3 (5) 33-36.