Methods: : The project was a face to face provider to patient clinic visit held between the researcher and the patient across a total of three visits over approximately two weeks per patient. The researcher communicated with the patient verbally, teaching through demonstration, at regular clinic visits in a wound care office with the patients and caregiver about wound care. Intervention included researcher use of the PCCCI tool which advocates use of (a) patient-centered communication (b) reflective listening, (c) active listening, (d) relationship building, and (e) PEARLS (partnership, empathy, apology, respect, legitimization, and support) to improve patient-provider communication. Implementation of these communication techniques were objectively measured through researcher use of a Provider Communication Checklist across all three visits. Evaluation of patient-provider communication was evaluated through researcher use of a researcher evaluation form. The wound length, width, depth, and amount of exudate was monitored to assess wound improvement and response to treatment. Data collected was analyzed at the completion of the three office visits. The demographics form and researcher evaluation form were analyzed using SPSS. The demographics and modifying factors were analyzed using SPSS descriptive statistics, frequency distributions to describe and summarize the data. The data was used to assess patient recall of wound care instructions with assessment of how demographics affect patient understanding of the instructions. Outcome measures were patient understanding of wound care and compliance with wound care instructions and home dressing changes. Independent-samples t test and chi-square test of independence were used to analyze relationships between demographics and wound healing. Chi-square test of independence tested whether the variables were independent of each other. Independent-samples t test were used to compare the means of two different groups.
Results:
Thirty-five wound patients were assessed in this project. The age range was from 20 to 94 years old with a mean age of 57 years. Fifty-one percent of the patients were male and over 80 percent were college graduates. Eighty-three percent were non-smokers and seventy-one percent of patients were on oral antibiotics. Eighty-six percent had assistance with wound care. Only one out of the thirty-five patients did not have English as a primary language.
Fifty-one percent had no significant past medical history to effect wound healing such as diabetes, PVD, cancer, or other conditions. The other conditions listed that may affect wound healing were obesity, lymphedema, and autoimmune disorders such as Crohns and Ankylosing spondylitis. Eighty percent of the patients had acute wounds from surgery or injury, and twenty percent were from chronic conditions such as diabetes, PVD, or radiation therapy. One hundred percent of the patients or caregivers were able to verbalize the wound care plan correctly on the first visit. On the second visit, 96 percent were able to and four percent were unable to correctly explain the plan of care. Fourteen percent did not answer the question due to no second visit due to healed status, no show, or the follow visit is pending. One hundred percent of the patients or caregivers correctly explained the plan of care for the third office visit. Wound improvement was evaluated as met/not met (with one point assigned for the presence of improvement on each of the following 6 criteria: decreased wound size, improved granulation and wound edges, and no infection, tunneling or undermining. The mean wound improvement for visit number two was 4.92 out of 6 and for visit three 5.45 out of 6. In summary, the patients in this project were primarily status post-acute surgery without significant past medical history to affect wound healing, well educated, English speaking non-smokers.
Independent-samples t test comparing mean scores of the group with wound care assistance and the group without assistance found a significant difference between the means of the two groups (t(24) = t = 3.944, p < .001). The mean of the group without assistance was significantly lower (m = 2.33, sd = .577) than the mean of the group with assistance (m = 5.26, sd = 1.251). Independent samples t-test determined gender in this cohort did not affect wound healing. No significant difference was found (t(24) = .273, p > .05). The mean score for men (m = 5, sd = 1.468) was not significantly different from the mean of women (m = 4.83, sd = 1.642). No significant difference was found in wound healing scores when considering use of tobacco products (t(22) = -1.583, p > .05). The mean of the non-tobacco users (m = 5.1, sd = 1.500) was not significantly different from the mean of tobacco users (m = 3.6, sd = .289).
A comparison of wound healing scores between chronic and acute type of wounds required use of Chi-square test of independence. A significant interaction was found (x2(4) = 10.87, p < .05). Sixty percent of the patients having chronic wounds had a wound improvement score of 5-6/6 and 76 percent of those having acute wounds had the same wound improvement score of 5-6/6. No significance was determined for the relationship between past medical history, education level, wound medications, and English as a primary language with wound healing.
Diabetes patients scored 5.25, PVD 3, cancer 2, no PMH 5.29, and other 5.5 out of a possible 6 points. The post-graduate patients scored the highest mean at 5.5 on wound healing, followed by college graduates at 5 point and high school graduates at 4.6. Despite the results not being statistically significant, the higher educated and healthy patients scored higher on wound improvement. A large majority of the patients were English speakers and on antibiotics.
Conclusion:
The patients were able to verbalize their wound regimen correctly and list signs and symptoms of wound infection. The two who were not able to at visit number two were on the ends of the age spectrum. One was in the age range of twenties with a new acute wound and the other elderly with a newly diagnosed chronic disease. Every patient across all three visits was able to state the signs of infection except for two on visit number two. There was data for all three patient visits except for five on visit two and seven on visit three because the wound healed, the patient no-showed, or the patient was referred to a higher level of care. The lowest scores for wound improvement were a two out of six points from four patients found on opposite ends of the age spectrum and primarily associated with chronicity of the wound. The low scores all improved on the third visit except for the wound with wound dehiscence. There was no correlation between tobacco past and current use with poor wound healing scores except for a young active duty patient. Diabetes had a delayed affect on wound healing, but the patients all eventually healed. The patients with cancer and PVD had lowest scores for wound improvement. However, the patients with obesity and autoimmune disease scored high on wound improvement. Patients who had assistance with dressing changes scored higher on wound healing scores than the group without assistance. The healing scores for chronic wounds were lower than acute wounds since chronic wounds have an underlying condition that needs to be addressed. The use of PCCCI gave the researcher the confidence and skills to communicate effectively with the patient as evidenced by the patient verbalizing the plan of care correctly and improved wound healing. Evidence supports that effective communication leads to good health outcomes, and this project shows promise being able to support that finding. However, the healthy and well educated military cohort cannot be dismissed as contributors to the high wound healing scores.
The PCCCI assisted the researcher with staying on track with the patient-centered interview. Instead of asking the exhausting list of provider questions, she asked the patients what brought them to the FBCH. She provided open ended questions and let them answer without interrupting. This helped her elicit all the information related to the visit and prevent steering the conversation. In the end, the tools allowed for her to get even more details in a shorter amount of time.
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