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Development and Validation of a Surgical Wound Assessment Tool for Use in Vietnam

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Development and Validation of a Surgical Wound Assessment Tool for Use in Vietnam DEVELOPMENT AND VALIDATION OF A SURGICAL WOUND ASSESSMENT TOOL FOR USE IN VIETNAM DO THI THU HIEN RN, BN, MN Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy School of Nursing Faculty of Health Queensland University of Technology 2019 Keywords Evaluation, reliability, surgical site infection, surgical wounds, surgical wound assessment tool, validity. Development and validation of a surgical wound assessment tool for use in vietnam i Abstract Background: Wounds are a major source of morbidity for patients and a financial burden for healthcare providers (Fletcher, 2010). Recovery from these wounds costs billions of dollars and the cost increases when wound complications occur (Franz, Steed, & Robson, 2007). There are a number of complications associated with surgical wounds, such as surgical site infection (SSI) seroma, haematoma, ischaemic, and dehiscence (World Union of Wound Healing Societies, 2016a). SSI is one of the most common complications of surgical wounds (Allegranzi et al., 2011; European Wound Management Association, 2005). It is estimated that at least 5% of patients who experience a surgical procedure will go on to develop a SSI (National Institute for Clinical Excellence, 2008). The impact of a SSI is a significant economic burden in terms of the extra postoperative length of stay in hospital, increased costs of treatment, reduced patient quality of life, and higher mortality rates compared to patients without a SSI (Andersson, Bergh, Karlsson, & Nilsson, 2010; de Lissovoy et al., 2009; Tovar & Badia, 2014; World Health Organization, 2016a) Prevention, detection, and management of surgical wound complications are important (National Institute for Clinical Excellence, 2008). Evidence-based wound assessment is essential to facilitate early detection of complications and guide management to promote early healing. Inappropriate management may result in delayed healing and an increased risk of complications (Fletcher, 2010). However, in Vietnam, no standard tool currently exists to assist nurses with assessing and recording surgical wound information to guide appropriate surgical wound management. Aim: This project aimed to develop and validate a surgical wound assessment tool for use in Vietnam. Method: The research was undertaken in Vietnam and involved three studies. The first study included a retrospective chart audit and a think aloud interview technique to determine current surgical wound assessment and documentation in Vietnam. The development of a surgical wound assessment tool (SWAT) was then undertaken in the second study, which included two phases. In Phase One an initial SWAT was developed based on international evidence-based guidelines and a ii Development and validation of a surgical wound assessment tool for use in vietnam comprehensive literature review. Vietnamese surgeons then evaluated the initial SWAT. In Phase Two, Vietnamese wound care nurse experts used an interactive Delphi process to develop and refine a final version of the SWAT. The final study involved a prospective evaluation of the SWAT. Exploratory factor analysis was used to examine construct validity. Intraclass correlation coefficient and Cohen’s kappa were used to evaluate reliability. General linear regression was applied to identify which risk factors in the SWAT predicted surgical wound complications at post- operative day five. Results: The first study indicated that the current practice approach to surgical wound assessment was inadequate. Nurses evaluated surgical wounds based on their experience and observation, without using a standard guideline for their assessments, leading to only a few wound components, such as wound edge, peri-wound skin, volume of exudate, and signs of infection being assessed. Other wound characteristics and risk factors associated with wound healing were less frequently assessed by nurses. Regarding surgical wound assessment documentation, among the 200 records that were audited, less than 10% of pre-operative risk factors related to delayed wound healing were documented. Furthermore, there was no documentation about incision location, wound dimension, wound bed (in wounds healing by secondary intention), or odour during the first five days post-operation. Pain and wound appearance (swelling, or erythema) were documented in less than 40% of charts. The SWAT was developed in the second study. In Phase One, 22 items were developed and included. The initial SWAT was evaluated by 10 surgeons and had item-content validity index (I-CVI) scores of 1.00 in 17 out of 22 items. The remaining items had an I-CVI ranking of 0.8 to 0.9. The overall scale-content validity index was 0.97. Surgeons recommended eight more items to be included in the SWAT, increasing the total to 30 items. In Phase Two (Delphi process), 21 Vietnamese nurse wound care experts completed all three rounds of the Delphi process. After three rounds, 24 out of 30 items reached full consensus, and six items did not reach consensus. In the evaluation study (Study Three), the results of the exploratory factor analysis supported a three-component structure of the SWAT. The intraclass correlation coefficient value of the overall scale was 0.81 (95% CI 0.68-0.89, p< 0.001), confirming excellent inter-rater reliability. Cohen’s kappa value ranged from 0.5-1, demonstrating moderate to an almost perfect level of agreement for individual Development and validation of a surgical wound assessment tool for use in vietnam iii items, with the exception of the wound pain item. Five items made a unique and statistically significant contribution to surgical wound complications at post-operative day five, including body mass index, diabetes, surgical duration, surgical wound contamination classification, and type of surgery. Conclusion: The SWAT was deemed a valid tool for monitoring the status of surgical wound healing and detecting early factors that may increase the risk of surgical wound complications. Furthermore, the tool demonstrated excellent inter- rater reliability. Application of the SWAT will improve the assessment of surgical wounds in daily nursing practice in Vietnam, which will promote improved postoperative wound management. It is an easy and practical tool for enhancing inter- disciplinary communication and care outcomes for all patients with surgical wounds. However, further modification and testing is required to strengthen the tool. iv Development and validation of a surgical wound assessment tool for use in vietnam Table of Contents Keywords .................................................................................................................................. i Abstract .................................................................................................................................... ii Table of Contents ......................................................................................................................v List of Figures ......................................................................................................................... ix List of Tables ............................................................................................................................x List of Abbreviations .............................................................................................................. xi Statement of Original Authorship .......................................................................................... xii Acknowledgements ............................................................................................................... xiii Chapter 1: Introduction ............................................................................................ 1 1.1 Background .....................................................................................................................1 1.2 Vietnamese Context ........................................................................................................2 1.2.1 Inadequate nursing educational preparation .........................................................4 1.2.2 Overcrowded hospitals .........................................................................................6 1.2.3 Few career development opportunities .................................................................7 1.3 Aims and Research Questions ........................................................................................8 1.3.1 Specific objectives ................................................................................................9 1.3.2 Research questions ...............................................................................................9 1.4 Overview of Methdology ..............................................................................................10 1.5 Significance of the Study ..............................................................................................11 1.6 Thesis Outline ...............................................................................................................12 Chapter 2: Literature Review of Surgical Wounds .............................................. 14 2.1 Introduction ..................................................................................................................14 2.2 Prevalence of Surgical Wounds ....................................................................................14 2.3 Surgical Wound Healing ...............................................................................................16
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