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Techniques for Surgical Dressing Changes

Monday July 2, 2007
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Have you ever been in a patient's room with a surgeon, surgical resident, or intern and observed him or her changing an open wound dressing using clean gloves? Wasn't the importance of sterile technique for changing surgical dressings taught in "Fundamentals of Nursing" during nursing school?

A nurse presented this question to the shared governance research council at our community hospital. The council agreed to research current best practices in the use of sterile vs. clean technique when changing the dressings on open contaminated wounds.

Open surgical wounds left to heal by secondary intention comprise approximately 10% of surgical wounds seen in major medical and trauma centers. These infections increase patients' hospital stays by 10 days and an additional $2,000. Deep wounds are associated with even greater increases in hospital stays and cost. Some clinicians contend using clean gloves and/or clean dressing materials will save money and will not adversely affect outcomes. Others identify several factors that preclude the use of clean gloves, including patient immunosuppression; wounds with visible bone, tendons, or vasculature; or wounds undergoing sharp debridement.

In an environment characterized by tight budgets and a nursing shortage, care teams must examine all practice patterns to ensure they are supported by evidence and not just done "because we have always done it this way."

When nurses make a glove choice, they must consider the type of wound. Is it a simple wound or is it complicated by possible exposed bone or tendons? If a practice change to the use of clean gloves increases the risk of delayed wound healing, then patients may experience increased length of stay and/or increased care costs.

Our review of the literature revealed a lack of any well-conducted, large, randomized studies on the care of infected wounds healing by secondary intent. Two studies directly addressed our query, but each had significant limitations. In the first study, "Sterile Versus Clean Techniques in Postoperative Wound Care of Patients with Open Surgical Wounds: A Pilot Study," conducted by Stotts and colleagues and published in 1997, patients were followed for only four days. Four days of follow-up for care of large, open wounds is not enough time to determine the effectiveness of sterile vs. clean technique. In the second study, "Does Sterile or Non-Sterile Technique Make a Difference in Wounds Healing by Secondary Intention?" conducted by Lawson and colleagues and published in 2003, not all wounds were cultured and the study group included all patients admitted to surgical units, not just all patients with open wounds healing by secondary intention.

To date, there is no compelling research to demonstrate the safety or efficacy of abandoning sterile dressing technique recommendations in acute care settings for wounds healing by secondary intention. Conversely, there is evidence to support the choice to continue using sterile gloves when changing dressings. An article by Sadowski and colleagues that was published in a 1988 issue of the Journal of Burn Care & Rehabilitation reported on research that was conducted on thermally injured pediatric patients during a two-month period in two intensive care units of Shriner's Hospitals-Cincinnati. Each patient in the semi-private rooms was assigned identifiable, patient-specific glove boxes. Twenty-six boxes were collected and analyzed; all had some type of organism present on or in the boxes, with the most common organism cultured being Staphylococcus aureus. This finding demonstrates the risk of cross contamination between patients if a box of gloves is shared, as often is the case in semi-private medical-surgical rooms. Using sterile gloves during dressing changes can decrease the cross contamination that may occur through the use of clean gloves from boxes that may have been contaminated.

After reviewing the literature, we are recommending our facility continue to use sterile technique (including sterile gloves and supplies) in dressing changes of wounds healing by secondary intention. We continue to support our present hospital initiative of frequent hand washing as the first line of prevention. As members of the research council at our hospital, we encourage and support new research initiatives to explore the risks and benefits of sterile vs. clean dressing technique.

Mary-Lou Dorman, RN, BSN, BC, is a staff nurse in an interventional catheterization/EP lab at a community hospital at which she serves on the research committee. Michelle Lincoln, RN, BSN, is a staff nurse in the IV therapy department at South Shore Hospital, Weymouth, Mass., where she serves on the shared governance research council. Deborah Oakes, RN, BS, CWCN, works in the surgical intensive care unit at South Shore Hospital.

EDITOR'S NOTE: The online version of this article features a full resource list.


• Centers for Disease Control and Prevention. (1999). Guidelines for Prevention of Surgical Site Infection. Infec Cont Hosp Epid, 20(4):247-278

• Lawson, Juliano, Raliff. (2003). Does Sterile or Non-Sterile Technique Make a Difference in Wounds Healing by Secondary Intention? Ostomy Wound Management. Vol 49, Issue(4):56-58, 60.

• Pearlman, Francis, Rutledge, Foote, Martino & Dranitsaris. (2004). Sterile vs. Nonsterile Gloves for Repair of Uncomplicated Lacerations in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med, 43(3):362-370.

• Sadowski, Pohlman, Maley, & Warden. (1988). Use of Non-Sterile Gloves for Routine Noninvasive Procedures in Thermally Injured Patients. J Burn Care Rehabil, 9:613-615.

• Stotts, Barbour, Griggs, Bouvier, Buhlman, Wipke-Travis and Williams. (1997). Sterile Versus Clean Techniques in Postoperative Wound Care of Patients with Open Surgical Wounds: A Pilot Study. JWOCN. 24:10-18.

• Wise, Hoffman, Grant, & Bostrom. (1997). Nursing Wound Care Survey: Sterile and Nonsterile Glove Choice. JWOCN, 24(3):144-150

• Wooten and Hawkins. WOCN position statement. (2005). Clean Versus Sterile: Management of Chronic Wounds. WOCN Society. January 2005.