Globally, the reported prevalence of Childhood-onset Heart Disease varies between 4 and 10 per 1,000 live births. 1–Reference Ferencz, Rubin and McCarter3 Half of these babies will require surgical intervention in their lifetime, and almost a quarter will develop an infection related to their hospital stay, sometimes in the sternal or thoracotomy surgical wound. Reference Bratzler, Dellinger and Olsen4–Reference Sahu, Siddharth and Devagouru6 Surgical site infections increase morbidity and mortality, quadruple the risk of death, and double the length of hospital admission and/or intensive care stay. Reference Braxton, Marrin and McGrath7,Reference Demmy, Park and Liebler8
Paediatric surgical site infection management strategies are largely drawn from data extrapolated from adult guidelines. Reference Huang, Sunstrom and Munar9–Reference Sochet, Cartron and Nyhan11 Because of the quality of evidence available, the clinical practice guidelines are often principle-based, rather than direct, pragmatic instruction required for a diverse population with varying anatomy, physiology, and associated risk for complications such as surgical site infections and wound dehiscence. No national or international guidelines currently exist for the management of cardiac surgery wounds in children. Further, there are little high-quality research trials on this topic to inform the development of these guidelines.
The prevention of surgical site infections in this population crosses many health disciplines and departmental siloes. As the children pass through pre-operative units, operating theatres, ICUs, infant/cardiac surgical wards, and into the home care environment, their wound is managed by interdisciplinary clinicians with a range of expertise and training. Each interaction with this vulnerable cohort and surgical wound is an opportunity to promote wound healing, or conversely, cause surgical site infections. Studies focusing on reducing infection in delayed sternal closure and examining optimal antibiotic regimes suggest the need for coordinated wound assessments. Reference Woodward, Taylor, Son, Taeed and Husain12,Reference Woodward, Son, Calhoon, Michalek and Husain13,Reference Jha, Shafique, Thomas, Pangilinan Cruz, Tariq and Kiraly18 However, there is a paucity of evidence examining nursing and interdisciplinary practices regarding acute surgical wound management in this population. Reference Woodward, Taylor, Son, Taeed and Husain12–Reference Woodward, Son, Calhoon, Michalek and Husain13 In particular, nurses are a vital workforce to ensure the effective management of post-surgical wounds in paediatrics, Reference Bannigan and Watson14 but their current practice and training are relatively unexplored.
This study aimed to explore wound management practices by health care professionals caring for children undergoing cardiac surgery in Australia and New Zealand. The results of this study will then be used to design high-quality interventional studies and local education and quality improvement projects to improve the use of evidence in cardiothoracic wound care practice, and thereby prevent surgical site infections.
Materials and method
Design
A bi-national cross-sectional study, using an online survey, was used to explore current practices surrounding paediatric cardiac surgery wounds across Australia and New Zealand.
Data collection methods
The online survey was structured using local wound management guidelines unspecific to paediatric/cardiac services. In addition to collection of basic survey respondent characteristics, it included 24 items across the domains of pre-operative (i.e., skin assessment, skin preparation), intra-operative (i.e., skin decontamination, dressings), post-operative (i.e., wound surveillance), and wound management (i.e., topical agents, wound documentation, systemic antibiotic indications, education). The survey included multi-choice and free text responses (see Supplementary file). The survey was iteratively developed by the investigator team (10 nurses, >100 combined years of paediatric, wounds, and/or cardiac care practice), and internally piloted for face and content validity, Reference Bannigan and Watson14,Reference DeVon, Block and Moyle-Wright15 prior to distribution.
Sample characteristics
An Exponential Non-Discriminative Snowball Sampling approach was used. At least one nurse from each Australian or New Zealand healthcare facility known to provide paediatric cardiac surgical care (n = 5) was contacted and recruited to complete the survey. They then provided multiple referrals to varying clinical departments within their own institute. Each new referral provided more data for referral and so on until there were enough subjects for the sample. All clinicians in an Australia or New Zealand institution who actively provide cardiac surgical management of children were eligible to participate.
Survey administration
The survey was distributed in June and July 2022, via email to existing collaborative networks. Participants were provided with an anonymised link to the purpose-built Microsoft® Form. The survey was open for just under two months and closed on the 29th of July 2022.
Ethical considerations
Ethics approval was obtained from the Children’s Health Queensland Hospital and Health Service Human Research Ethics Committee before the study commenced. Consent was obtained by the participant agreeing to complete the survey. All data were collected anonymously and results have not been linked to individuals or health services.
Data analysis
All results were analysed descriptively according to their characteristics and distribution. Continuous variables are described as mean, median, standard deviation and interquartile range values. Categorical data are described using frequencies and percentages. Response rate calculation was not feasible, due to distribution methods (i.e., mixed paediatric/adult associations, social media). Data were analysed using PASW 22.0 (SPSS Inc., Chicago, IL). Missing data are described throughout the results tables.
Results
Respondent characteristics and descriptive results
Table and Figure 1 display the demographic and professional characteristics of the respondents. There were 68 respondents to the survey, representing all Australian states and New Zealand with paediatric cardiac surgical services (Northern Territory and Tasmania do not have dedicated services). The majority of respondents were nurses, with greater than 10 years of practice. They represented the range of practice areas managing post-cardiac surgery wounds, including the paediatric intensive care unit, general ward, and overarching service roles. Two-thirds (65%) of respondents reported using adult based cardiac post-operative wound management guidelines.
Geographical distribution of survey respondents.
Main findings
Pre-operative practices
As reported in Table 2, over 40% (n = 28) of survey participants were unsure if pre-operative skin assessments occurred at their place of practice, however, 54% (n = 37) did recognise that skin assessments were conducted during a patient’s pre-admission visit. Skin assessment tools employed included Glamorgan Tool (33%, n = 4), Risk Assessment (33%, n = 4), and Others (33%, n = 4).
Respondent characteristics (N = 68).
Pre-operative practices (N = 68).
Almost all respondents (93%; n = 63) reported using pre-operative washing plans, however, timing and washing agents differed. Pre-operative washing was carried out both the night prior to and the day of surgery amongst 57% (n = 39) of survey respondents. Chlorhexidine gluconate solution added to wash water was identified as the most common washing agent (26%, n = 18), followed by a chlorhexidine gluconate-impregnated sponge (22%, n = 15) and multiple washing agents (18%, n = 12). A total of eight agents were identified, with antibacterial wipes used alone (44%, n = 30) and in conjunction with pre-operative washes (24%, n = 16).
Prophylactic antibacterial topical ointments (i.e., mupirocin) were identified by 57% (n = 39), with 5% unsure of commencement and duration of mupirocin. While 57% (n = 39) reported use of mupirocin, wide variety of application days were reported, both pre- (3–1 days pre-op), intra- (day of surgery), and post- (1–5 days) operatively, including over eleven different schedules.
Intra-operative practices
Most respondents (65%; n = 68) were unsure of what type of skin solution was used in theatre, with the remaining using chlorhexidine gluconate in alcohol (21%; n = 14), Povidine iodine in alcohol (9%; n = 6), and Povidine iodine in water (4%; n = 3).
There was a variety of approaches to surgical wound management after direct closure in theatres. While 29% (n = 18) of respondents were unsure and 13% (n = 9) reported their dressing type varied depending on patient characteristics and/or surgeon preference, 26% (n = 18) reported that their centre uses occlusive hydrocolloid dressings, 13% (n = 9) transparent adhesive film dressings, 7% (n = 5) used surgical wound glue, and 6% (n = 4) used bordered film dressings.
Participants were primarily unsure (74%, n = 50) regarding dressing types used when the patient’s sternum is left open in the immediate post-operative period. While 10% (n = 7) sometimes used a patch, however, they were uncertain about what patch material was used.
Post-operative management
As reported in Table 3, most participants identified post-operative wound surveillance as a shared responsibility at 72% (N = 49). Frequency of post-operative wound surveillance was variable; with daily (37%; N = 37) being the most common, followed by as required (24%; N = 24), with 14% (N = 14) reporting that their surveillance was conducted more frequently than daily (multiple response options available).
Post-operative wound surveillance and management (N = 68).
The post-operative day dressings are removed also varied between 3–9 days (mean: 6 days [SD2.8]). The location for dressings removal when a patient was discharged was most frequently done in either post-operative surgical review clinic at 36% (N = 23) or post-operative surgical review clinic/ GP at 28% (N = 18). Many (30%; N = 19) were unsure where patients' dressing removal took place.
Most participants reported a combination of agents 41% (N = 41) were used, followed chlorhexidine gluconate solutions 32% (N = 32) and saline 24% (N = 24). Topical agents were used commonly on the wound and surrounding skin at 81% (N = 99).
Only 21% (N = 14) of respondent’s identified that a tool/checklist was used to assess wound healing. Of those, there was not a standardised tool used either within individual centres or as a whole. Dressing changes were most commonly completed by multiple individuals with 49% (N = 72), or by bedside nurses (24%; N = 16). The date of suture removal varies between 1 and 2 weeks (mean: 11 days [SD 3]).
As reported in Table 4, wound swabs to assess for wound infections were most commonly taken by multiple individuals (physicians and nurses; 53% [N = 36]). Just under half the participants at 49% (N = 33) identified that infectious disease team were involved in wound management. Wound photography is relatively standard practice across all centres as an aid for wound surveillance with 87% (N = 59) responding that this was used within their centre. Only 51% (N = 35) of respondents reported that these photos were uploaded to patient’s medical record.
Wound complication identification and treatment (N = 68).
Only 34% (N = 23) of respondents identified they used specific definitions to describe wound infections. The instigation of antibiotic therapy was most commonly a combined approach with multiple individuals/teams (80%; N = 55). Reasons for starting antibiotics were also varied.
Education and training
Most respondents (82%; N = 56) routinely provide education and information to families, mainly via written format (65%; N = 44). Only 22% (N = 15) of clinician respondents had received any training in wound management, and of those, the training was on average 6 years ago (SD 4). Most participants (88%; N = 60) highlighted they would like training in wound management.
Discussion
Surgical site infections and wound dehiscence are serious and common problems for infants and children recovering from cardiothoracic surgery. However, the Australian and New Zealand management of paediatric cardiothoracic wounds (both sternal and thoracotomy) were shown throughout this survey to be a highly varied practice. This current state is mostly because of the absence of evidence-based, comprehensive clinical practice guidelines being available to inform practice. These guidelines are likely absent because of lack of clinical trials to inform them, and the tradition of this speciality’s research being driven by surgeons with differing priorities. However, nursing research has a strong background in the creation of high-quality evidence in wound care but has more traditionally focussed on pressure injuries and mechanical skin injuries, rather than surgically inflicted wounds. Reference August, Ullman and Coyer16 Paediatric cardiothoracic wound management to prevent infections and promote wound healing represents a strong opportunity for interprofessional collaboration, and future interventional studies of innovation effectiveness (e.g., chlorhexidine-impregnated dressings).
Identifying the wound care management needs of this patient population requires an interprofessional health care team to assist clinical leaders in decisions around wound care and understanding the available consumables and equipment to assist with wound healing. This process should involve using clinicians with expertise in evidence-based practice, as well as patient education and preventative measures to reduce the risk of wound infection and complications. Reference Prendin, Tabacco, Fazio and de Barbieri17 In order to assist future clinicians in making informed decisions around wound care, it is important that resources are easily available, clear to understand, and promote a standardised approach. This standardised approach should include specific care practices (e.g., cleaning, dressing, and prophylactic antibiotics) across the major domains of wound management (pre-, intra-, and post-operative care), Reference Jha, Shafique, Thomas, Pangilinan Cruz, Tariq and Kiraly18 which would be a good focus for future quality improvement and interventional studies.
However, despite a baseline focus on standardisation, this is a complex population where targeted, specialised care is often necessary. This heterogeneity includes the severity of conditions, presence of co-morbidities (i.e., genetic syndromes), age-specific structures (e.g., skin), and the developing body over the life span. Reference Prendin, Tabacco, Fazio and de Barbieri17 This is especially pertinent in paediatrics, with major physical maturation and changes between 0 and 18 years. The maturity of skin structures affects infection prevention, wound healing, and underlying skin pathologies. Reference August, Ullman and Coyer16,Reference August, van der Vis and New19 During the neonatal period, the skin is especially friable and at risk for significant complications such as infections and subcutaneous fat necrosis. Reference Stefanko and Drolet20 During adolescence, wound practices must recognise and plan for the development of breasts and chest hair, and the increased probability of acne. The developmental stage of the patient also has an effect on the compliance to wound management, including the consideration of wound care as a potentially difficult, traumatic, or painful procedure. Reference Shiferaw, Mola, Gashaw and Sintayehu21 Overall, while this means that although the principles should be standardised, specific care needs to be adaptive and personalised to the individual patient requirements.
The cross-sectional survey results signalled that there is a demand from healthcare professionals for the provision of education and training for those involved in the management of cardiac surgical wounds in the paediatric population. Given that the majority of respondents in the survey were nursing professionals, we can assume that this would be deemed particularly beneficial in this healthcare group. However, because of the multi-disciplinary team involvement with surgical wound management, it would be important to extend education and teaching to all healthcare professionals involved in the management of cardiac surgical wounds. This training needs to include the use of evidence-based practice in this field of care using the most up-to-date research for wound management as well as drawing on existing wound management programmes. Practically, centres should also partner with existing advanced wound care practitioners, including plastic surgery, and access their disciplines' clinical research.
This research has limitations. Despite the survey being multi-centred, the results cannot be generalised outside of Australia and New Zealand affecting the external validity of the outcomes discussed. Additionally, as there were multiple respondents from each centre, variability of knowledge on individual aspects of care may differ, and not reflect actual practice. However, it provides a good base to develop further research using a larger international study population. In addition, surveys do not always accurately reflect actual practice and may be impacted by response bias, ultimately affecting the internal validity of the data. The reliability of the data could also be affected by the use of a survey tool, with results not necessarily being repeatable. However, despite the limitations, this is the first study to investigate practices surrounding wound care in the paediatric cardiac surgery patient population and will contribute to designing a larger multi-centred study and a growing body of evidence.
Conclusion
This study has provided insight into the varied range of surgical wound care practices for children undergoing cardiac surgery across Australia and New Zealand. Largely linked to evidence from the adult population, the variety of wound care practices reported in this study highlights the yawning gap in research evidence for wound management and surgical site infection guidelines that specifically address the unique needs of the paediatric cardiac surgical cohort. Paediatric cardiac surgical wound care strategies continue to be informed mostly by surgical preference. The considerable burden related to morbidity and mortality risks associated with surgical site infection among vulnerable newborn infants and children undergoing cardiac surgery warrants a comprehensive nurse-led enquiry. The recent establishment of a collaborative forum for Australia and New Zealand paediatric cardiac surgical nurses provides a timely opportunity to progress research enquiry in this area. A programme of interventions and education has the potential to provide a consistent suite of cardiac surgical wound care strategies for newborn infants and children undergoing cardiac surgery that are implemented and evaluated by the paediatric cardiac surgical nurses who care for them.
Supplementary material
The supplementary material for this article can be found at https://dx.doi.org/10.1017/S1047951123003025.
Acknowledgements
We would like to acknowledge the nurses who took the time to participate in the survey and the clinical associations who supported the research through distribution.
Competing interests
The authors have no conflicts of interests to disclose. The project was unfunded.
