The Effectiveness of a Health Education Intervention

on Care of Traumatic Wounds

Abstract

Objective. The purpose of this study is to explore the effectiveness of wound care program for emergency traumatic patient in Taiwan.

Background. Wound care is one of the most major issues for trauma patients at home. Wound infection has been alerted mostly on medical treatment. Little is known about how health care education impact patient care of traumatic wound after discharged from emergency department.

Design. A quasi-experimental design was used by using two groups posttest.

Method. Random sampling was used to recruited participants, 89 participants in each group in emergency department at a medical center in Taiwan. A 25 minuets wound care program was given to patients in the intervention group. A questionnaire was used to evaluate the effectiveness of the program after 72 hours as patient followed up in out-patient department. The data of wound infection was collected from patient’s medical record by followed two weeks after injured.

Results. After wound care program, the knowledge, skills of wounds care, the satisfaction of health education in experimental group are better than the control group (p < .05). Wound infection rate in experimental group (9%) is lower than control group (20.2%), and statistically significant (p < .05).

Conclusion. The wound care program could increase the knowledge, skills of wound care of emergency patient, and reduce the wound infection rate.

Relevance to clinical practice. Wound care requites technical knowledge, thus, practical demonstration of teaching and self-practice is more effectiveness for patients in learning their wound care. An appropriated health program can improve the patients’ wound care and care quality.

Key word: Trauma wound care program, patient in emergency department, patient education, wound infection, knowledge and skill of wound care.

INTRODUCTION

Traumatic wounds are the most common problem for people presenting to the emergency department (ED) seeking health care. Research indicates that approximately 12 million people go to emergency department for traumatic wounds care each year in the United States (Singer & Dagum 2008). Statistics also indicate that over 450 thousand people visit emergency department for trauma wounds; and people with lacerations were the most frequently seeking treatment for external wounds in 2008 in Taiwan (Department of Health Executive Yuan in Taiwan 2006). At least 7.3 million lacerations are treated annually in the US (Singer et al. 2006). In Japan, lacerations account for 14% of the daily clinical practice of those performing medical treatments (Kuwabara et al. 2006). Research suggests that approximately 20% of patients recuperating at home need wound care (Sturkey et al. 2005); therefore, wound care is one of the most significant issues for trauma patients who return home.

BACKGROUND

The primary goal in the management of traumatic wounds is to achieve healing with optimal functional results. The best accomplished result depends on the prevention of wound infection during healing (Abubaker 2009). Wound infection is the most frequent wound complication, as well as having an important influence on wound healing (Drew et al. 2007, Singer et al. 2000, Sturkey et al. 2005). The incidence of wound infection is from 12% to 20% of the time (Kuwabara et al. 2006, Kumar & Leaper 2007, Vowden & Vowden 2009). There are many factors that influence the rate of wound infections, including the environment where the injury was caused, the seriousness of the wound, presence of bacteria, toxicity, patient factors such as nutrition, obesity, disease management, socioeconomic status, and wound care methods (Singer & Dagum 2008, Hollander et al. 2001, Yu 2008, London 2007, Flarity & Hoyt 2011). These factors, compounded by the patients’ lack of wound care knowledge and skills, exacerbate the difficulty that patients often experience in managing wounds at home. Recommendations from research state that good execution of wound care would reduce the wound infection rate, decrease the frequency of home visits by medical personnel, and reduce medical costs (Sturkey et al. 2005, London 2007). This highlights the importance of teaching patients how to care for their wounds.

With the short treatment times in the emergency department and lack of the knowledge about caring for wounds, patient often have difficulty understating their care and discharge instructions. Research has shown that 78% of patients who discharged from ED do not understand at least one, and 34% do not understand three of the following categories: the diagnosis and pathogenesis of patient’s condition, emergency care, self-care, and follow-up visits (Engel et al. 2009). Another study by Peng et al. (2008) revealed that approximately 81% of trauma patients hoped that medical staff could provide wound care information, including wound self-care precautions and dressing procedures. Effective information about wound care after discharge from the ED to home is critically important to wound healing. However, related research on wound infections has been focused mainly on medical treatment (Dire et al. 1995, Pfaff & Moore 2007, Hoyt et al. 2011) and chronic wound care (Rijswijk Gray 2011). There are currently no studies that provide comprehensive health education especially for emergency trauma, lacerations and abrasions. This study aims to address these issues.

Teaching in the emergency department is especially challenging because of highly variable, unpredictable learning needs and little time for teaching. Laidley & Braddock (2000) suggested that the adult learning theory can be applied to evaluate the effectiveness of strategies for teaching patient in ambulatory setting. According to Adult Learning Theory, effective learning is based on the educational needs identified by the learners themselves (Knowles 1980). Since adults learn better through real-life problem and self-directed means, they become involved in the learning process when they come across problems (Bastable 2005). For trauma patients, wounds influence their daily life and thus require immediate attention. Patients can thus be expected to participate in wound care education voluntarily. Educational interventions that incorporate these features are more likely to positively affect learning outcomes (Allabaugh et al. 2008). However, there is little evidence related to the health education for patients in their wound care at emergency department. Thus, a Trauma Wound Care Program (TWCP) was developed to address the gaps in knowledge and abilities to care for wounds at home. This program was empirically evaluated for its effectiveness in improving outcomes.

Aim

The purpose of this study was to explore the effectiveness of a Trauma Wound Care Program (TWCP) on wound care and wound infection rates in patients with trauma-related wounds.

Research Hypotheses

1. Patient will exhibit increased in knowledge and skills of wounds care after Trauma Wound Care Program as compared to those in the routine care.

2. Patient will exhibit decreased in wound infection rates after Trauma Wound Care Program as compared to those in the routine care.

METHODS

Design

A quasi-experimental design was used to investigate the effectiveness of Trauma Wound Care Program (TWCP) in subjects with trauma wounds. A two-group posttest design was implemented. Subjects were assigned to either the experimental group or control group by using a block randomization method. Those in the treatment group received the TWCP while those assigned to the control group received routine care. Outcome measures of knowledge and skills related to wound care and wound infection rate were measured for subjects in both groups.

Subjects

Subjects were recruited by convenience sampling of patients admitted to an emergency department at a hospital in the central district of Taiwan. Patients were 18 years old above and received emergency care for a traumatic wound and were allowed to go home following wound care but required to follow up in the hospital’s outpatient department after two or three days. Patients were excluded from this study if they had other complications such as diabetes mellitus, suicidal ideation or intent, psychiatric diagnosis, and wounds caused by domestic violence. An effect size was calculated to determine sample size. To detect a 10 percentage point difference in the wound infection rate between the groups at á = 0.05, a total of 80 subjects were needed in each group to achieve a power of 90% to detect a statistically significant result.

This study first enrolled 322 patients who had lacerations and abrasions and were admitted to the emergency department; however, only 178 of these returned for out-patient follow-up and 89 in each group completed the survey, a 55.3% completion rate in total.

Intervention: Trauma Wound Care Program (TWCP)

The development of TWCP for the emergency patient with traumatic wounds was based on adult learning theory, synthesized literature, and clinical experts’ experience. The program was conducted using health education, skill demonstration, actual practice, and discussion. The Trauma Wound Care Program (TWCP) was a 25 minute program that included the following components: 1. Nurses’ instruction on wound care with a poster (care procedures were presented in realistic pictures with pithy formulaic form); 2. nurses’ demonstration on the skills of wound care; 3. patients’ practicing on the skill of wound care by using a prosthetic model; and 4. a guideline booklet, a paper flyer in same content of poster’s instruction and a list of supplies for wound (laceration and abrasion) care to bring home. Three instructors were trained for the intervention to maintain consistency throughout the study. Instructor competency in the intervention and consistency in delivering it were evaluated by the researchers.

Patients were randomized into treatment group, in blocks of size 2. Patients were assigned to different groups by allocating random permutations of treatments within each block. Those randomized to the control group received routine care, approximately 10 minutes, which included provision of methods of wound care by verbal communication only, original flyers with information of wound care, and poster with wound care. The content of wound care is the same in both groups. But, the way of delivery the wound care management is different. There is no any demonstration and practicing, and information of supplies of wound care in the control group.

Instrument

The instrument to measure wound care was the developed from a synthesized literature review of wound care. The instrument contained 42 questions divided into five subscales. The first subscale consisted of demographic data including age, education, gender, marriage, occupation, experience of previous injury and wound care, and history of disease etc. The second subscales gathered the wound characteristics such as the reason of injury, time of admitted ED after injury, and wound management before admitted ED, the type of wound, location of wound, size of wound, sutured, and foreign body in the wound etc. The third subscales consisted 24 true/false items of knowledge of wound care which contained basic knowledge of wound care (6 items), knowledge of wound dressing (11 items), and knowledge of wound infection (7 items). The fourth subscales focused on skills of wound care. A 11 items with score on being fully implementation (2), partial implementation (1), no/wrong implementation (0) was built. The fifth subscales converged on patients’ satisfaction of program and self care. A seven items with five-point Likert scale, from ‘Strongly agree’ (5) to ‘Strongly disagree’ (1), was constructed. Higher scores indicated better knowledge and skills of wound care and higher level of satisfaction of program and self-care. One open question was given to know “what reasons affect to take care of your wound?” The instrument required 10 minutes to complete.

Reliability and Validity of Instrument

The instrument’s readability, accuracy and adaptability were adequate as determined by the review of expert panel and pilot study with a sample of 31 patients. The face validity of instrument was determined by an expert review with a CVI value of 0.92. Concurrent validity measures the consistency of responses of the participant by using different measurements or criteria at the same time. In the pilot test, the skill of wound care was also observed by researcher. Using the same 11 items of skill of wound care, nurses measured the patient’s skill of wound care while patient displayed his/her wound care in prosthetic model. The scoring is the same as the patient’s self-measurement from fully implementation (2), partial implementation (1), to no/wrong implementation (0). The measurement of patient’s skill of wound care by nurses served as the criterion for concurrent validity. The moderate correlation (r = 0.56, p<.001) was found between patient self–report of skill of wound care and nurse measured patient’s skill of wound care, indicating a good concurrent validity. The reliability of the instrument was determined from a pilot study. The internal consistency of the instrument was measured using a KR20 0.70 in knowledge of wound care, Cronbach’s alpha 0.87 in skill of wound care, and Cronbach’s alpha 0.90 in satisfaction of program and self-care at pilot study.

Wound infection was defined when wound appear infection sign such as redness, swell, heat, pain and have antibiotic prescription from doctors. The wound infection rate was collected from patient’s medical record by followed two weeks after injured.

Data collection and Analysis

The study was approved by the Institutional Review Board of the university hospital. Once patient meeting admission criteria was admitted to the emergency department, patients were invited to participate in the study and informed consent was obtained. All participants discharged from the hospital after treatment and were scheduled to return after two or three days for follow-up care. Outcome measures of patient’s self report of knowledge of, skills related to, and satisfaction with wound self-care were collected at patients’ follow up visits at outpatient department. Data related to wound infection were gathered from patients’ medical records two weeks after the date of injury. The data were collected from February to April, 2010.

The data were analyzed using descriptive and inferential statistics. T-test analysis was applied to compare means of knowledge and skill of wound care in two groups; and chi-square test was used to compare means of wound infection in two groups. The alpha level of 0.05 was designated as statistical significance.

RESULTS

Descriptive data

In this study, 52.8% (n = 94) of the participants were male. The age range was from 18 to 77 years with an average of 33 years old. The majority of participants were single (65.2%) and held college degrees (53.3%). The most frequent cause of trauma was accident (59.6%) and falls (14.6%). Most of the patients were admitted to the hospital by themselves (52.8%). Laceration wounds were 44.9%, abrasion wounds were 39.3% and both combined wounds were 15.8% of wound types in this study. The wounds were mostly located on upper limbs (36.3%) and lower limbs (33.4%). The chi-square test of homogeneity result showed that participants’ demographic data and wound characteristics were homogeneous between the treatment and control groups.