A multinational survey of the assessment of pain when removing ...

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Clinical RESEARCH/AUDITPercentage of survey population≤ 60 61–70 71–80 81–90 ≥ 90 No answerAge group (years)Figure 1. Age demographics of survey population.7%31%14%1%25%13%4%5%Figure 2. Wound types included in the survey.Adhesive foams0Venous leg ulcer (or mixed)BurnArterial leg ulcerSkin tearPressure ulcerDiabetic foot ulcerOtherNo answerNumber of patients200 400 600 800 1000 1200 1400 16001445no trauma associated with the dressingsutilising Safetac technology.Evaluation of painData relating to pain (before, during andafter dressing removal) associated with thetraditional adhesive-based dressings at visit1 compared with that associated with thedressings utilising Safetac technology at visit2 are presented in Figure 5.The results from this study show thatat visit 1 the ranges of VAS pain scoresreported with the traditional adhesivebaseddressings were:8 Before removal of the dressings:2.4–3.28 At the time of the dressing changes:4.6–5.28 After dressing changes: 2.9–3.9.It was evident that there was aconsistent trend associated with all ofthe traditional adhesive-based dressingsevaluated where pain levels increasedduring their removal.In comparison, signifi cantly lowerpain scores (p=0.01) were reportedat visit 2 after the patients had beentreated with the dressings utilisingSafetac technology compared with thosereported at visit 1 after the patients hadbeen treated with traditional adhesivebaseddressings (Table 3).HydrocolloidsOther dressings4951095The ranges of VAS pain scores at visit2 were:8 Before removal of the dressings:1.7–1.88 At the time of the dressing changes:2.1–2.28 After dressing changes: 1.6–1.7.Figure 3. Advanced dressings with traditional adhesives used at baseline.and other dressings (n=495) such as fi lms,surgical dressings and alginates.Evaluation of traumaData relating to trauma associated withthe traditional adhesive-based dressingsat visit 1 compared with that associatedwith the dressings utilising Safetactechnology at visit 2 are presented inFigure 4. The results at visit 1 demonstratethat about 10% of responses indicatedhigh levels of trauma; 28–39% of theresponses indicated moderate levels;31–35% indicated very slight trauma;and 18–29% indicated no traumaassociated with the traditional adhesivebaseddressings. In comparison, theresults at visit 2 demonstrate that only1% of responses indicated high levels oftrauma; 11% of the responses indicatedmoderate levels; 35–37% indicated veryslight trauma, and about 50% indicatedUnlike the traditional adhesive-baseddressings, the dressings with Safetactechnology were not associated withincreased pain at dressing changes. Thepain scores at visit 2 remained low andconsistent throughout the dressingchanges.When asked about dressingpreference, more than 90% of patientssurveyed indicated that they preferred thedressings with Safetac technology to theirprevious dressing regimen (Figure 6).16 Wounds UK , 2008, Vol 4, No 1

Clinical RESEARCH/AUDITProportion of patientsAdhesive foams Hydrocolloids Other dressings Mepilex (Lite) Mepilex Border (Lite)18 172950 4935 35 37 393633312812 11 11 11 9No Very slight Moderate HighDressingsFigure 4. Trauma scores at visit 1 (wounds treated with advanced dressings with traditional adhesives)compared with those obtained at visit 2 (wounds treated with foam dressings with Safetac soft siliconeadhesive technology).Pain scores (VAS)3.25.23.93.15.13.6Adhesive foams Hydrocolloids Other dressings Mepilex (Lite) Mepilex Border (Lite)DressingsFigure 5. Pain scores at visit 1 (wounds treated with advanced dressings with traditional adhesives)compared with those obtained at visit 2 (wounds treated with foam dressings with Safetac soft siliconeadhesive technology) before, during and after dressing removal.TotalMepilex Lite0%43Mepilex Border Lite 4Prefer previous dressingFigure 6. Preferred dressing use after completion of survey.2.44.62.91.8 2.1 1.61.71 1Before During AfterPrefer a Mepilex dressing2.21.720% 40% 60% 80% 100%93 394 393 3No answerand sometimes aggressive adhesiveson dressings has been shown to causedamage to the newly forming wound bedand/or adjacent peri-wound skin, and thedamage caused by repeated applicationand removal of adhesive dressings is themain cause of trauma to wounds andperi-wound skin (Dykes et al, 2001; Dykesand Heggie, 2003; Dykes, 2007).This trauma can give rise to variablelevels of infl ammatory skin damage— oedema, soreness and adverse effectson skin barrier function (Gerritsen et al,1994; Dykes and Heggie, 2003; Dykes,2007). In a series of studies, Dykes hasshown that some traditional adhesivebaseddressings which use acrylic-basedadhesives can be more aggressive thanothers using Safetac soft silicone adhesivetechnology. When applied to the skin ofvolunteers with healthy skin it has beenshown that traditional adhesive-baseddressings demonstrate a greater degree ofdamage to the stratum corneum (Dykeset al, 2001), higher levels of discomfort(Dykes and Heggie, 2003) and skindamage as measured by transepidermalwater loss (TEWL) with greaterdiscomfort measured using a cumulativeirritancy score (Dykes, 2007). With thephysical trauma caused to the wound andskin, it has been suggested that patientssuffer stress as a result of pain relatedto dressings and dressing changes whichmay in turn be detrimental to the healingprocess (Soon and Acton, 2006; Coulling,2007; Vileikyte, 2007).A further problem associated withtraditional adhesive-based dressings is painresulting from the damage that they cancause to wounds and peri-wound skin.Pain is a major problem and is most oftenrelated to inappropriate dressing selection.The selection of a suitable, non-adherentdressing which will result in greater patientacceptability is a very important partof the holistic approach to treatment(Meaume et al, 2004).DiscussionThere are a number of criteria that havebeen listed as necessary to create anoptimum wound dressing (Dale, 1997;Morgan, 1998) but essentially a dressingshould provide protection for thewound and an optimum environment18 Wounds UK , 2008, Vol 4, No 1for healing, but above all it must notcause any further damage or sufferingto the patient. Unfortunately, whilemany dressings go some way to fulfi llingthese criteria, many of them can causefurther trauma and subsequent pain forthe patient. The use of inappropriateA number of studies have lookedat the impact of pain in patients with avariety of different wounds. In a largestudy undertaken to evaluate theincidence of pain in 5,850 patients withacute (n=2,914) or chronic wounds(n=2,936) of various causes during

Clinical RESEARCH/AUDITTable 3Statistical analysis of pain scores: traditional adhesive-based dressings versus dressingswith Safetac technology’ParameterAverage pain scores(VAS) (n=3,034)Before removal: first visit (advanced dressings utilising traditional adhesives) 3.0Before removal: second visit (dressing with Safetac technology) 1.8Difference -1.2SignificanceP=0.01At removal: first visit (advanced dressings utilising traditional adhesives) 5.1At removal: second visit (dressing with Safetac technology) 2.2Difference -2.9Significance P = 0.01After removal: first visit (advanced dressings utilising traditional adhesives) 3.6After removal: second visit (dressing with Safetac technology) 1.7Difference -1.9SignificanceP=0.01dressing removal, and to evaluate theeffect of switching to a non-adherentdressing, patients with both types ofwounds reported ‘moderate to severe’pain during the medical screening visit(79.9% and 79.7%) and ‘very severe’pain in their self-evaluation questionnairecompleted at home (47% and 59%respectively) (Meaume et al, 2004).Dressing removal was found to be mostpainful when there was adherence tothe wound bed. Switching to a new, nonadherentdressing reduced pain duringdressing changes in 88% of patients withchronic wounds and 95% of patients withacute wounds.A recent one-day survey wasundertaken at a university hospital inParis, France. The purpose of the studywas to evaluate the prevalence, clinicalaspects and management of wounds in thehospital by undertaking a ‘snapshot’ surveyof all hospitalised patients to ascertain theprevalence of wounds and the provisionof wound care on one specific day inApril 2005. The results demonstrated that,out of a total of 624 patients examined,327 (52%) had 933 wounds (an averageof 2.8 per patient). Importantly, pain atwound dressing changes was treatedin 89% of cases (Mahé et al, 2006). Thefindings of Mahé et al highlight that painat wound dressing change is endemic and,furthermore, often requires a treatmentintervention, thus emphasising the need forappropriate dressing usage and dressingchange procedures.A recently published article hashighlighted the fact that a high percentage(60%) of patients with venous leg ulcersand other types of chronic wounds exhibitpain, the result of which is detrimentalto the well-being of patients (Price etal, 2007) and can delay healing (Soonand Acton, 2006). Price et al underlinethe message that pain and its causeshould be handled as one of the mainpriorities in chronic wound management,that assessment should be undertakenroutinely, and if this is not done then itwill lead to patient suffering and increasedcosts to healthcare service providers (Priceet al, 2007).Pain associated with trauma can, insome instances, be considerable, notablywhen dressings are changed, and is aconcern in patients with chronic wounds(e.g. venous leg ulcers) and friable periwoundskin. As a consequence, painmanagement has become a major partof wound care with many organisationsand care providers incorporating themanagement of wound pain into standardsand guidelines. The European WoundManagement Association (EWMA)has developed a position documentthat provides clinical recommendationson how to assess and manage woundpain (European Wound ManagementAssociation, 2002).The results from this largemultinational clinical survey demonstratethat foam dressings with Safetac softsilicone adhesive, when used in the placeof some types of adhesive foams andhydrocolloids, reduce traumatic injuriesto the wound or adjacent tissue. Theintroduction of dressings with Safetactechnology resulted in a reduction in thelevels of trauma compared with thosereported with the advanced dressingsutilising traditional adhesive systems. Forexample, the percentage of responsesindicating no trauma with the dressingsutilising Safetac technology was almostdouble that recorded for the advanceddressings with traditional adhesives.The findings also demonstrate that thedressings are associated with clinicallysignificant reductions in levels of woundassociatedpain at dressing changes. Thelow pain scores recorded immediatelybefore dressing change reflect the lowlevels of pain associated with foamdressings using Safetac soft siliconetechnology during wear, even though thescores could have been influenced bypatients anticipating possible effects of theimminent dressing removals.The pain scores in this multinationalsurvey seem relatively low when comparedwith pain scores from patients with woundsreported in the published literature. Forexample, in a study that was undertaken toevaluate the application of a topical collagenmatrix to patients with venous leg ulcers(Wollina et al, 2005), one of the objectiveswas to measure pain associated with thewound. The mean VAS pain scores beforetreatment were reported to be 8.72 and7.88, for the treatment and non-treatmentgroups respectively. After one week oftreatment, the scores dropped to 5.76 and6.66, although the treated group did showa reduction in pain scores to 3.84 in thesecond week of treatment. Overall thescores were notably higher than seen inthe multinational survey presented in thisarticle. Another study investigated pain as20 Wounds UK , 2008, Vol 4, No 1

Clinical RESEARCH/AUDITmeasured by VAS in patients with skin graftsites treated with three different dressings(Poonyakariyagorn et al, 2002). The painscores associated with two film dressingswere comparable to those obtainedin this survey, whereas the pain scoresassociated with a tulle gauze dressing weremuch higher. The low pain scores may beexplained, at least in part, by the fact thatthe patients reported their pain scores tothe investigators who actually undertookthe dressing changes, although this practiceis in line with the recommendations of theWorld Union of Wound Healing Societiesin relation to pain assessment (WUWHS,2004).Pain scores are also related to thewound type: some wounds are morepainful than others, and some woundsmay present with little or no pain. It mighttherefore be appropriate to group thisdata according to wound type in order toobtain a more detailed view of the abilityof foam dressings with Safetac soft siliconeadhesive technology to reduce pain.ConclusionTrauma to wounds or peri-wound skinmay exacerbate the condition leadingto delayed healing or further woundcomplications. Pain leading to increasedstress in patients has also been implicatedin contributing to a delayed healingresponse. In view of this, the use ofdressings that do not cause trauma andpain present obvious benefits to patientsas well as clinical benefits by having thepotential to shorten healing times whichultimately makes better use of the limitedresources available to health workerstreating chronic wounds.The results of this survey demonstratethat dressings that include Safetac softsilicone adhesive technology benefitpatients in terms of significantly reducingpain during wear (as indicated by thepain scores recorded immediately beforedressing change), at dressing removal, andafter dressing change, when comparedwith advanced dressings that usetraditional adhesives. WUKReferencesActon C (2007) The holistic management ofchronic wound pain. Wounds UK 3(1): 61–922 Wounds UK , 2008, Vol 4, No 1Coulling S (2007) Fundamentals of painmanagement in wound care. Br J Nurs 16(13):S4–S12Dale J (1997) Wound dressings. Prof Nurse 12(Suppl): S12–S14Dykes PJ (2007) The effect of adhesive dressingedges on cutaneous irritancy and skin barrierfunction. J Wound Care 16(3): 97–100Dykes PJ, Heggie R, Hill SA (2001) Effects ofadhesive dressings on the stratum corneum ofskin. J Wound Care 10(2): 7–10Dykes PJ, Heggie R (2003) The link betweenthe peel force of adhesive dressings andsubjective discomfort in volunteer subjects. JWound Care 12(7): 260–2European Wound Management Association(2002) Position Document: Pain at WoundDressing Changes. Medical EducationPartnership Ltd, LondonFranks PJ, Moody M, Moffatt CJ, Hiskett G,Gatto P, Davies C, Furlong WT et al (2007)Randomized trial of two foam dressings in themanagement of chronic venous ulceration.Wound Repair Regen 15(2): 197–202Freeman K, Smyth C, Dallam L, JacksonB (2001) Pain measurement scales: acomparison of the visual analogue and facesrating scales in measuring pressure ulcer pain.J Wound Ostomy Cont Nurs 28(6): 290–6Gerritsen MJ, van Erp PE, van Vlijmen-WillemsIM, et al (1994) Repeated tape stripping ofnormal skin: a histological assessment andcomparison with events seen in psoriasis. ArchDermatol Res 286(8): 455–61Harms-Ringdahl K, Carlsson AM, Ekholm J,Raustorp A, Svensson T, Toresson HG (1986)Pain assessment with different intensity scales inresponse to loading of joint structures. Pain 27:401–11Mahé E, Langlois G, Baron G, et al (2006)Results of a comprehensive hospital-basedwound survey. J Wound Care 15(9): 381–4Meaume S, Teot L, Lazareth I, Martini J, BohbotS (2004) The importance of pain reductionthrough dressing selection in routine woundmanagement: the MAPP study. J Wound Care13(10): 409–13Morgan DA (1998) The application of the ‘idealdressing’ theory to practice. Nursing ScotlandJuly: 16–8Poonyakariyagorn T, Sirimaharaj W, Pinchai O,Angspatt A (2002) Comparison among Op-site,polyvinyl chloride film and tulle gauze in thetreatment of skin graft donor site. J Med AssocThai 85(4): 455–61Price P, Fogh K, Glynn C, Krasner DL,Osterbrink J, Sibbald RG (2007) Managingpainful chronic wounds: the wound painManagement Model. Int Wound J 4(S1): 4–15Soon K, Acton C (2006) Pain-inducedstress: a barrier to wound healing. WoundsKey Points8 Repeated application and removalof many adhesive dressings canresult in trauma to wounds andperi-wound skin.8 A large, multinational survey wasundertaken to assess the impactof introducing advanced dressingswith soft silicone adhesivetechnology on levels of woundtrauma and pain associated withdressing application and removal,compared to a previous regimenof using advanced dressings withtraditional adhesives.8 Soft silicone dressings, when usedin the place of some traditionaladhesive-based dressings, reducedtraumatic injuries relating tothe wound or adjacent skin andsignificantly reduced levels of painat dressing change.8 The very low pain scoresrecorded immediately beforedressing change reflect the lowlevels of pain associated with softsilicone dressings during wear.8 The use of dressings that do notcause trauma and pain presentobvious benefits to patients.UK 2(4): 92–101Tokumura F, Umekage K, Sado M, et al (2005)Skin irritation due to repetitive applicationof adhesive tape: the influence of adhesivestrength and seasonal variability. Skin ResTechnol 11(2): 102–6Vileikyte L (2007) Stress and wound healing.Clin Dermatol 25(1): 49–55White R (2005) Evidence for atraumatic softsilicone wound dressing use. Wounds UK 1(3):104–9Wollina U, Schmidt WD, Krönert C, NelskampC, Scheibe A, Fassler D (2005) Some effectsof a topical collagen-based matrix on themicrocirculation and wound healing in patientswith chronic venous leg ulcers: preliminaryobservations. Int J Low Extrem Wounds 4(4):214–24World Union of Wound Healing Societies (2004)Principles of best practice: minimising pain atwound dressing-related procedures. A consensusdocument. http://www.wuwhs.org/pdf/consensus_eng.pdf Last accessed 20th August 2007