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Hemostatic Dressing:Comparing the Effects of Two Types of Hemostatic Dressing Securements on Skin Integrity

2016-01-07 / Categories:hemostasis, hemostatic, bandage, dressing,
  
All of these procedures involve percutaneous access to the femoral artery. Promoting hemostasis after femoral artery sheath removal is an essential element of patient care. Manual and mechanical compression devices along with collagen plugs are the initial methods to achieve hemostasis. Subsequent care generally includes a combination of visual monitoring, bed rest, sandbags and pressure hemostatic dressing. Complications most commonly identified after removal of a femoral sheath include bleeding, hematoma formation, pseudoaneurysm and impaired perfusion to the extremity distal to the site of sheath removal.

The frequency of groin complications, including hematoma formation and bleeding, are difficult to track and are highly variable depending upon procedure, population and measurement tool. Published rates range from .5 to 15% (Silkman, Kim, & Baim, 1988; Simon, Bumgarner, Clark, & Israel, 1998). Loss of skin integrity under the groin dressing was often considered a minor complication or not mentioned in studies; however, one study noted a 7.9% rate of skin injury related to the post-procedural dressing secural (Blankenship, Clegg, & Powell, 1991). Guidelines for practice must be validated through scientifically based studies. Differences in dressing protocols require investigation of their impact on skin integrity, hematoma formation and bleeding. Although lacking in control and randomization, Quality Improvement projects in clinical practice provide a setting in which interventions may be evaluated for their impact on patient outcomes.

The Problem

When nursing staff at a large Midwestern regional medical center identified significant loss of skin integrity under groin dressings as an adverse outcome after cardiac catheterization, dressing application protocols were changed and a quality improvement project instituted. Forty percent of the patients (n = 4/10) had erythema and/or epithelial stripping after removal of the pressure dressing. The dressing protocol was revised by discontinuing use of the benzoin spray and adding a skin prep before the dressing was applied. Elastikon tape, with bi-directional stretch, remained the securement device, but smaller pieces of tape were applied with less stretch of the tape during application and adhesive remover was used during removal. (See Dressing Protocols, Tables 1 & 2.) This change in practice resulted in an immediate reduction in incidents of patients’ impaired skin integrity. During a follow-up, no patients exhibited stripping or blisters, and only one (n = 1/10) had erythema which was minimal. The committee noted that use of the skin prep and adhesive remover were inconsistent and removed them from the dressing protocol. In the following year and a half, intermittent complaints of skin irritation and anecdotal reports of increased hematomas and bleeding were received by the cardiac catheterization lab staff. This project was developed in response to staff requests for assistance in determining optimal care guidelines for patients after removal of femoral arterial sheaths. The staff of the cardiac catheterization lab selected an alternate adhesive tape, Medipore H tape, a non-woven, polyester “soft cloth” tape with cross and diagonal stretch, (See Dressing Protocols, Table 3) while the nursing care areas continued to use the standard tape (Elastikon tape) to secure the pressure dressings. This project evaluated the two clinical groups post-femoral artery sheath removal for the outcomes of skin integrity, hematoma formation and bleeding.

Methodology

This prospective, repeated measure study compared the effects of two types of adhesive tape used to secure postfemoral artery sheath removal dressings on skin integrity, hematoma formation and bleeding in a convenience sample. The use of Medipore H tape or Elastikon tape was based on the standard protocol in the patient care area where the arterial sheath was removed. If the sheath was removed in the Cardiac Catheterization Lab, Medipore H tape was used to secure the groin dressing. If the sheath was removed on a nursing unit, Elastikon tape was used to secure the groin dressing. The dressing protocols were very similar and the post-procedural care was identical except that patients in the Elastikon tape group returned to the nursing unit with the arterial sheath secured by Medipore H tape. The Medipore H tape was replaced with Elastikon tape when the sheath was pulled, so this group had one more “dressing” change. To help control for this effect, patients with impaired skin integrity at baseline (after hemostasis has been obtained) were not included in the project. Skin integrity, hematoma formation and bleeding were measured at three points in time: (a) immediately after hemostasis had been obtained but before application of the groin dressing, (b) 6–8 hours and (c) 12–16 hours post-hemostasis.

Instruments

The outcome variables (skin integrity, hematoma formation and bleeding) were measured by physical assessment of the groin site. Patients with impaired skin integrity or injury at baseline were excluded from the project.

Skin Integrity Scale. Skin integrity was measured by visual inspection of the skin where the dressing was applied using the Skin Integrity Scale (Patrick & Maibach, 1991). The groin site was graded on an ordinal scale, 0 to 4, based on the following categories:

Hematoma Formation and Bleeding Scale.

The hemostasis scale for evaluating hematoma formation and bleeding was originally developed by Christenson, Staab, Burko, & Foster (1976). In 1995, it was modified by Hogan-Miller, Rustad, Sendelbach, & Goldenberg by adding measurement of the hematoma in centimeters. Variations of this instrument have been used in several studies (Barkman & Lunse, 1994; Christenson et al., 1976; Eisenberg & Mani, 1977) although these researchers did not discuss the validity or reliability of the tool. Hematomas and bleeding were graded on an ordinal scale, 0 to 4, based on the following categories:

Loss of blood was defined as application of additional manual pressure on the puncture site for > 15 minutes to alleviate bleeding. Hematoma was defined as the presence ˆ of a localized mass of blood under the skin. Hematoma formation and bleeding were assessed by palpation, visual inspection and chart review. The RN palpated the femoral arterial puncture site for a hard accumulation of blood.

Methodology (continued)

under the skin. The edges of the hematoma were outlined with a marking pen and the widest dimension measured to the nearest centimeter. The chart was also reviewed for documentation of bleeding from the site.

Sample Groups

The target population was adult patients undergoing diagnostic or interventional cardiac procedures performed via percutaneous transfemoral arterial approach at an urban Midwestern regional medical center. Following current practice, patients having sheaths removed immediately in the Cardiac Catheterization Recovery Room (following diagnostic procedures) had 3M™ Medipore™ H Soft Cloth Surgical Tape used to secure the groin dressing. Patients having sheaths removed either in the Interventional Cardiology Unit or Coronary Intensive Care Unit (following diagnostic or interventional procedures) had Elastikon tape used to secure the groin dressings. A convenience sample of 30 patients was in each group. Exclusion criteria included thrombolytic therapy within 48 hours of the time of procedure, known bleeding disorders, intra-aortic balloon placement, injury to the groin from prior invasive procedures, and tape allergy or hypersensitivity.

Procedure

An initial assessment provided a baseline measurement for all participants and was documented on the data collection tool. The edges of the dressing were elevated to make the assessment at 6–8 hours. If no problems were identified, the edges of the dressing were resealed. At 12–16 hours, the dressing was completely removed and the area reassessed. A “small adhesive bandage” was then applied to the puncture site.