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By Stacie McIe, RN, BSN, Trisha Petitte, RN, BSN, Lori Pride, RN, BSN, Donna Leeper, RN, BSN, and C. Lynne Ostrow, RN, EdD

Background Pressure dressings have been used as the standard following sheath removal after percutaneous transluminal angioplasty in many institutions. Patients complain about dis- comfort while the dressing is in place, pain when the dressing is removed after discharge, and skin complications afterward. Many patients have experienced skin irritation where tape has been applied. Nurses have also described difficulty assessing the sheath insertion site in the groin when a pressure dressing is in place. Objectives To compare 3 different dressings with respect to effect on bleeding, discomfort voiced by patients, and ease of groin assessment in patients after percutaneous transluminal coronary angiography. Methods A total of 100 patients were randomly assigned to 1 of 3 groups: pressure dressing, transparent film dressing, or adhesive bandage. Outcome variables were bleeding, patient discomfort, and nurse-reported ease of observation of the groin site. Results No bleeding occurred in patients with transparent film dressings or adhesive bandages. Patients rated these dressings significantly higher than they rated the pressure dressing. Because two-thirds of the sample had previously undergone percutaneous transluminal coronary angiography, they could compare their experience with the new dressing with previous experiences with pressure dressings. Nurses rated the ease of assessing the groin significantly higher for the transparent film and adhesive bandage dressings than for pressure dressings. Conclusions As a result of this study, a practice change was made hospital-wide: rather than a standard opaque pressure dressing, a transparent film dressing is used for all patients after removal of a femoral sheath. (American Journal of Critical Care. 2009;18:14-20)

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TRANSPARENT FILM DRESSING VS PRESSURE DRESSING AFTER PERCU- TANEOUS TRANSLUMINAL CORONARY ANGIOGRAPHY

C E 1.5 Hours Notice to CE enrollees:

A closed-book, multiple-choice examination following this article tests your under standing of the following objectives: 1. Examine how the researchers determined

the best practice for dressing comfort and ease of percutaneous transluminal coronary angiography site assessment.

2. Describe how changes in practice were insti- tuted through research.

3. Determine how this research process is important to your practice.

To read this article and take the CE test online, visit www.ajcconline.org and click “CE Articles in This Issue.” No CE test fee for AACN members.

Evidence-Based Practice in Critical Care

Many patients have memories of discomfort and skin irritation during and after dressing removal. Specifically, patients’ complaints include skin irritation, pain, pulling, rash, blisters, and skin burns after the dressing is removed (see Figure).

The adult cardiac care units, the cardiac catheterization laboratory, and the interventional radiology department at West Virginia University Hospital all used pressure dressings as the standard after sheath removals. Nurses were concerned about their inability to visualize the sheath removal site to check for hematoma, bleeding, or groin complica- tions at an early stage when the pressure dressing was in place. They also were concerned for patients who experienced discomfort, especially during and after dressing removal.

Review of the Literature A literature search of PubMed and CINAHL was

done by using the search terms dressings, bandages, and catheterization and/or angioplasty. We found only 2 studies3,4 that addressed the issue of dressing type after cardiac catheterization. In the first study,3

researchers compared traditional pressure dressing by means of an elastic adhesive bandage (Tensoplast) with use of a light transparent tape (Tegaderm). No significant differences in bleeding were found between the 2 groups, but the group that used the light trans- parent tape reported significantly less pain and dis- comfort. In the second study,4 a total of 739 patients undergoing diagnostic catheterization or interven- tional procedures were randomly assigned to receive

either a pressure dressing or an adhesive bandage. The groups did not differ significantly in either inci- dence or size of bruising or hematoma, or in the frequency of complications such as pseudoa- neurysm, embolism, or bleeding. The authors4 concluded that the rou- tine use of a pressure dressing was unnecessary, and, as a result, the institution where that study origi- nated (in Edinburgh, Scotland) dis- continued the use of pressure dressings for all cardiac catheteriza- tion patients.

The goal of our study was to determine whether a change in the type of dressing used after PTCA reduced patients’ complaints and improved nurses’ abilities to assess the sheath insertion site after the procedure while maintaining patients’ safety. Three different types of dressings—transparent film,

A ngioplasty, which was first performed in 1997 for treatment of occluded coronary arteries, is now used in more than 1 million patients a year in the United States alone.1 In 2005, a total of 1265000 percutaneous transluminal coronary angio- plasties (PTCAs) were performed.2 Nurses at West Virginia University Hospitals, Ruby Memorial, Morgantown, West Virginia, noted that the type of dressing

used after PTCA sheath removal was a cause for concern, especially for patients who had pre- viously undergone PTCA and anticipated pain and discomfort with the dressing because of that experience.

About the Authors Stacie McIe, Trisha Petitte, Lori Pride, and Donna Leeper are nurses at West Virginia University Hospitals, Ruby Memorial Hospital, Morgantown, West Virginia. C. Lynne Ostrow is an associate professor at West Virginia Uni- versity School of Nursing in Morgantown.

Corresponding author: C. Lynne Ostrow, RN, EdD, PO Box 9260, West Virginia University School of Nursing, Mor- gantown, WV 26506 (e-mail: [email protected]).

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Patients have discomfort and skin irritation during and after pressure dressing removal.

Figure Skin breakdown across the posterior part of the thigh where tape had been placed.

time was less than 150 seconds (eptifibatide) or less than 200 seconds (bivalirudin). Mechanical pressure was maintained with the FemoStop device for 60 minutes or manually for 30 minutes in each patient. The sheath removal site was then dressed with 1 of the 3 dressings as described earlier.

All 60 nurses employed on the unit where patients were admitted after PTCA were trained to par- ticipate in the study. The nurses assessed the patients every 4 hours for complaints of discomfort in addition to the routine checking of vital signs and assessment of the groin site after sheath removal. The first assess- ment of the groin site was made when the dressing was applied, and additional assessments were done at 4-hour intervals after that. This frequency yielded a mean of 4.7 (SD, 0.06) assessments per patient. The nurses also recorded whether they were able to observe the groin site directly and rated the ease of assessment of the site for bleeding or hematoma for- mation on a scale of 1 (difficult to assess) to 5 (easy to assess). Patients’ complaints about the groin site were noted during these assessments.

Patients were discharged 24 hours after admis- sion and removed the dressing at home. A follow- up telephone call was made within 48 to 72 hours after discharge by a nurse investigator (T.P.). Patients were asked to rate how comfortable it was to remove the dressing and to rate the condition of the groin site when the dressing was removed. In order to rate the pain, patients were asked, “On a scale of 1 (very comfortable) to 10 (painful), how comfortable was it for you to remove the dressing?” The scale used was based on the Numeric Pain Scale5 rating of 1 through 10 used in clinical nursing practice. Patients also were asked if they had ever had a catheterization with a pressure dressing before and, if so, how this experience compared with the previous one. Patients were given the opportunity to provide additional comments about the experience. The nurse surveyor recorded the comments verbatim.

Data Analysis A power analysis was conducted on the basis

of previous work3 that showed a 40% difference between the 2 groups (pressure dressing vs light transparent tape) on the variable of discomfort. Thus, in order to test for that same difference among 3 groups, 26 patients per group would yield 80% power. The actual sample sizes of 32, 33, and 35 patients in each group yielded approximately 90% power. Descriptive statistics, χ2 tests, and Kruskal- Wallis tests were used to analyze the data from the patients and nurses.

adhesive bandage, and pressure dressings—were compared with respect to 3 outcomes: bleeding after PTCA, satisfaction of patients, and ease of nursing assessment of the sheath insertion site in

the groin. The study was conducted at a tertiary care center (West Virginia University Hospital, a level I trauma center) that provides care for patients undergoing elective and emergent per- cutaneous coronary interventional pro- cedures. The hypotheses for this study were as follows:

• Bleeding complications will not differ among the 3 dressing groups.

• Satisfaction will be higher among patients with a transparent film dressing and/or an adhesive bandage than in patients with a pressure dressing.

• Nurses will rate ease of assessment of the groin site higher in patients with a transparent film dress- ing and/or an adhesive bandage than in patients with a pressure dressing.

The study was approved by the institutional review board at West Virginia University.

Methods In this 3-arm experimental design, participants

were randomly assigned to 1 of 3 dressing conditions: 1. Pressure dressing: 4-in (10-cm) Elastikon

(Johnson & Johnson, New Brunswick, New Jersey) elastic tape (3 pieces, each about 10-12 in [25-30 cm]

long) secured over 1 box of 4 x 4-in (10 x 10-cm) gauze sponges

2. Transparent film dressing: Opsite IV3000 Standard (Smith & Nephew, London, England), a 4 x 5½- in (10 x 14-cm) transparent dressing applied over one 2 x 2-in (5 x 5-cm) gauze sponge

3. Adhesive bandage: Flexible adhesive bandage (Kendall, Covidien, Mansville, Massachusetts), 4 x 2-in (10 x 5-cm) opaque dressing applied directly to the puncture site

Patients who underwent PTCA with eptifibatide or bivalirudin and sheath sizes ranging from 6F to 8F

were included in this study. Depending on the med- ication used, patients’ sheaths were removed by using either the manual technique or the FemoStop device (RADI Medical Systems, Uppsala, Sweden). Activated clotting times were measured hourly, and sheaths were removed when the activated clotting

16 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2009, Volume 18, No. 1 www.ajcconline.org

No bleeding was noted when

either transpar- ent film dressings or adhesive band- ages were used.

Ease of groin assessment was

greater with both the transparent

film dressing and adhesive band- age compared

with the pressure dressing.

Results A total of 213 patients gave consent to be in the

study. Of these, 100 had catheterizations that showed stenosis and underwent angioplasty and stent place- ment. The study sample was 68% men and 32% women, with a mean age of 62 years (SD, 13.3). The majority (67%) of the sample had previously undergone catheterization. The mean number of previous catheterizations per patient was 2.06 (SD, 2.83). The type of drugs received during catheteriza- tions, type of pressure applied after sheath removal, and activated clotting times are described in Table 1. None of the demographic variables differed signifi- cantly among the 3 dressing groups.

Patient Data The 100 patients were each hospitalized for a

mean of approximately 24 hours if they had no complications. After sheath removal, the mean num- ber of hours until discharge was 14.8 (SD, 2.3).

Only 2 of the 100 patients, both in the pressure dressing group, had bleeding after sheath removal. One of these patients had a pseudoaneurysm. None of the patients in the transparent film dressing or adhesive bandage groups had any bleeding.

All but 4 patients were contacted via phone 48 to 72 hours after discharge. One patient had no memory of the event, so the final telephone sample was 95. A Kruskal-Wallis test was done to analyze for any differences in scores on the pain rating scale among the 3 dressing groups. Patients in the pressure dressing group rated the experience of removing the dressing as significantly more painful than did patients in either of the other 2 groups (Table 2). Patients in the transparent film group and patients in the adhesive bandage group did not differ signifi- cantly on this variable.

At each assessment from when the sheath was removed to when the patient was discharged from the hospital, the nurses recorded what complaints (if any) the patients had about the groin site. A total of 26 patients (79%) with a pressure dressing had 1 or several complaints about the groin site (Table 3). Only 1 patient (3%) in the transparent dressing group had a complaint (skin irritation), and 3 patients (9%) in the adhesive bandage group had complaints.

Patients were also asked how this experience compared with their last catheterization (67% of the sample had experienced at least 1 catheteriza- tion before this study, some at other institutions). Table 4 shows patients’ assessments of the transpar- ent film dressing and adhesive bandage compared with prior pressure dressings.

The patients’ qualitative comments were coded

as either positive or negative depending on the words they used to describe removal of the dressing. Almost half (48%) of the patients in the pressure dressing group had negative comments about the dressing. Conversely, 71% of the transparent film dressing group and 58% of the adhesive bandage group had positive comments. Many negative comments about previous pressure dressings were contained within

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Table 1 Demographic data about the sample (N = 100)

Age, mean (SD), y

No. of previous catheterizations, mean (SD)

Activated clotting time, mean (SD), s

Sex, % of patients Male Female

First catheterization, % of patients Yes No

Drug during angioplasty, % of patients Bivalirudin Eptifibatide Abciximab

Clopidogrel, % of patients Yes No

Aspirin, % of patients Yes No

Abciximab, % of patients Yes No

Tirofiban, % of patients Yes No

Eptifibatide, % of patients Yes No

Type of pressure applied, % of patients Manual FemStop device

62 (13.3)

2.06 (2.83)

163 (20.5)

68 32

30 67

51 31 11

78 18

74 24

13 81

1 95

30 66

60 40

a Percentages for some characteristics do not total 100 because of missing data.

Characteristic Valuea

Table 2 Discomfort score by dressing

Pressure (n = 33)

Transparent film (n = 35)

Adhesive bandage (n = 32)

6.0 (0.67)a

2.5 (0.44)

2.0 (0.43)

a Kruskal-Wallis test, χ2 = 22.7, P < .001.

Type of dressing Mean score (SD)

the praise for the transparent film dressing or adhe- sive bandage. Examples of actual statements by the patients are presented in Table 5.

Nurse Data Each patient had a minimum of 2 nurses (range,

2-4 nurses) who made the assessments every 4 hours. The nurses were asked to respond to 2 questions at each of these assessments. The first question was, “Were you able to directly observe the groin site?” Percentages of yes and no responses were averaged for all nurses over all observation points. For the transparent film dressing, 97% of the nurses answered yes, as did 59% for the adhesive bandage group (Table 6). Only 15% of the nurses in the pressure dressing group said that they were able to observe the groin site directly. These percentages are significantly different from one another (χ2 = 47.2, P < .001).

The nurses also were asked to rate the ease of assessment of the groin for bleeding or hematoma once the dressing was in place. The scores were again averaged for all nurses across all observation points to determine a mean score for ease of observation. Because the data were ordinal, a Kruskal-Wallis test was done to assess for any differences in ease of observation among the 3 types of dressings. A sig- nificant χ2 of 67.1 (P < .001) was found (Table 7). Mann-Whitney tests were used to determine which pairs differed; differences were significant (P < .001) between the pressure dressing and the transparent film and between the pressure dressing and the adhesive bandage, but not between the transparent film and the adhesive bandage. Ease of observation of the groin was rated significantly lower for the pressure dressing group than for either the transpar- ent film or adhesive bandage groups.

Discussion No bleeding complications occurred in patients

in the transparent film or adhesive bandage dress- ing groups, but 2 complications occurred in the pressure dressing group. Patients rated the transpar- ent film and adhesive bandage dressings as more comfortable while the dressings were in place, easier to remove at home, and better than their last expe- rience with cardiac catheterization when they had had a pressure dressing. Patients gave graphic com- ments about the discomfort felt while the pressure dressing was in place and after it was removed. In contrast, patients in the transparent film and adhe- sive bandage groups had positive comments about the dressings and viewed them much more favor- ably than pressure dressings. Although ratings for the transparent film dressing were slightly higher

18 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2009, Volume 18, No. 1 www.ajcconline.org

Table 4 Comparison of present dressing with pressure dressing used in prior catheterization (n = 63)a,b

Pressure (n = 17)

Transparent film (n = 25)

Adhesive bandage (n = 21)

2 (12)

24 (96)

18 (86)

7 (41)

1 (4)

1 (5)

6 (35) 2 (12)

2 (9)

Type of dressing Better Same Worse No memory

No. (%) of responses

Table 5 Examples of statements by patients

Pressure

Transparent film

Adhesive bandage

Rated as an 8 (10 being most painful) because of pain associated with pulling hair off back of leg when removing dressing.

Red welts all over his leg when tape came off.

Adhesive turned to glue in shower and became part of my body.

Liked transparent dressing much better than pressure dressing in past.

Dressing came off so easily.

Dressing this time was much better than pressure dressing. Pressure dressing pulled skin off with last catheterization. Lots better than when they used all tape in the hospital!

Much better than pressure dressing by far.

Dressing was a godsend. This dressing so much better. It was much easier to walk around. Would recommend to anyone having a catheterization.

More than better. “Fantastic.” Comes off easily.

You don’t have to pull, tug, scream, and yell.

Recommend the adhesive bandage to anyone. If he has another catheterization, will not have that “big” dressing again.

Type of dressing Statement

Table 3 Complaints about groin site while dressing in place

Pressure (n = 33)

Transparent film (n = 35)

Adhesive bandage (n = 32)

a Includes itching, skin irritation, burning, tightness, and pulling.

Type of dressing Complaints No. (%) of patients

Pulling

Discomfort

Anticipating pain on removal of dressing

Several complaintsa

Skin irritation

Discomfort

Anticipating pain

Skin irritation/itching

5 (15)

3 (9)

4 (12)

14 (42)

1 (3)

a Percentages may not total 100 because of rounding. b χ2 = 42.15, P < .001.

REFERENCES 1. National Heart, Lung, and Blood Institute. Diseases and

conditions index: what is coronary angioplasty? http://www .nhlbi.nih.gov/health/dci/Diseases/Angioplasty/Angioplasty_ WhatIs.html. Published July 2007. Accessed October 2, 2008.

2. American Heart Association. Angioplasty and cardiac revascularization statistics. http://www.americanheart.org/ presenter.jhtml?identifier=4439. Accessed October 5, 2008.

3. Boonbaichaiyapruck S, Hutayanon P, Chanthanamatta P, et al. Groin dressing after cardiac catheterization. Comparison among light dressing with thin transparent tape (Tega- derm) and conventional tight/pressure dressing and elastic adhesive bandage (Tensoplast). J Med Assoc Thai. 2001;84(12):1721-1728.

4. Robb C, McLean S. Using pressure dressings after femoral artery sheath removal. Prof Nurse. 2000;15(6):371-374.

5. McCaffery M, Pasero C. Pain: Clinical Manual. St Louis, MO: Elsevier Saunders; 1999.

6. American Association of Critical-Care Nurses. Procedure Manual for Critical Care. 5th ed. St Louis, MO: Elsevier Saunders; 2005.

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected].

than ratings for the adhesive bandage, those differ- ences were not statistically significant.

Nurses reported that they could directly observe the groin for bleeding in patients with transparent film or adhesive bandage dressings. Nurses also reported greater ease in assessing the groin site with both the transparent film dressing and the adhesive bandage as opposed to the pressure dressing. Our findings in relation to bleeding and increased com- fort of patients are similar to results reported for both earlier studies3,4 in which different types of dressings were examined.

As a result of this research study, a practice change has been instituted at West Virginia Univer- sity Hospital. We discussed the study results with all persons in the institution who had an interest in the issue, including interventional radiologists, car- diology physicians, and vascular surgeons, and changes in policy and procedure were reviewed and agreed on. Nursing staff were oriented to the policy change via posters and staff meetings. The new pol- icy was developed after review of the latest proce- dure guidelines from the American Association of Critical-Care Nurses6 and incorporates the changes as a result of our research.

The results of our study, which had a 3-arm experimental design, revealed significantly greater satisfaction among patients after cardiac catheteriza- tion when the sheath insertion site in the groin was dressed with either a transparent dressing or a sim- ple adhesive bandage rather than the standard pres- sure dressing. Nurses also reported improved ease of assessment of the groin site in patients with the transparent film or adhesive bandage dressings.

Our report illustrates the process of making a practice change based on research evidence. The clinical problem of dissatisfaction among patients was identified by the nurses caring for patients after PTCA and spurred a review of literature on the topic. Consultation with a faculty member in the school of nursing enabled us to plan and implement this study. The result has been an institution-wide change in practice. Not only have patients benefited from this change, but members of the nursing staff have increased their knowledge, skills, and commitment to evidence-based nursing practice.

FINANCIAL DISCLOSURES None reported.

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Table 6 Ability to directly observe the groin site

Pressure (n = 33)

Transparent film (n = 35)

Adhesive bandage (n = 32)

(15)

(97)

(59)

(85)

(3)

(41)

a χ2 = 47.2, P < .001.

Type of dressing

No. (%) of dressings

Yesa No

Table 7 Ease of assessment of groin for bleeding or hematoma

Pressure

Transparent film

Adhesive bandage

2.12

4.04

3.73

0.63

0.28

0.99

a χ2 = 67.1, P < .001. Significant difference between pressure dressing and the other 2 types of dressings.

Type of dressing Mean scorea SD

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