Pin site care project

Background

At the York RCN Society of Orthopaedic Nursing Conference Jenny Lee – Smith presented a paper on the current lack of evidence to support pin site care. This generated a significant amount of discussion and the then co-ordinator of NEBPOT suggested that it was something that NEBPOT should try and address. The first stage was a consensus conference and this has led to the publication of guidelines for pin site management and a second article discussed the lack of empirical evidence in this field and recommended areas for research.

References

Pin Site Management. Towards a Consensus: Part 1  Lee-Smith et al, Journal of Orthopaedic Nursing (2001) 5: 37-42

Pin Site Management. Towards a Consensus: Part 2  Davis et al, Journal of Orthopaedic Nursing (2001) 5: 125-130

Cochrane review

Following the work of the consensus conference Jenny Lee- Smith (now Jenny Temple) was invited to carry out a Cochrane review and she invited Julie Santy to participate in this as a second reviewer. This review has now been published in the Cochrane Library and the reference is as follows:

Pin site care for preventing infections associated with external bone fixators and pins (Cochrane Review), Temple, J, Santy, J The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons Ltd

The conclusion of this review is that there is very little evidence as to which pin site regimen best reduces infection rates and states that there is clearly a for large Randomised Controlled Trials to determine the best method of pin site management.

Pin site care research project

At the same time as the Cochrane review was taking place NEBPOT also decided to try and take forward a research project looking at one of the research questions identified at the consensus conference. This has turned out to be a very ambitious plan for a small group.

Progress to date:

  • A Steering group was formed in 2001 including several members of NEBPOT and Kate Seers from the RCN Institute, Oxford. An initial meeting was held in November 2001 and an action plan was developed:
    1. Establishing information on the scale of the problem
    2. Obtaining information on infection rates and assessment methods/scales
    3. Continue Cochrane protocol work
    4. Establish contact/support from medical/international colleagues
    5. Propose a draft protocol to explore the question: what should pin sites be cleaned with?
  • A tentative hypothesis was drafted with a research proposal. The hypothesis is as follows:
    The rate of infection of percutaneous pin sites is the same when patients shower daily and dry their external fixator with a clean towelas when the sites are cleaned using aseptic technique with either sterile water or sterile Normal Saline (0.9 per cent)
  • This hypothesis was discussed at out NEBPOT meeting in December 2001 and feedback obtained.
  • The hypothesis and research proposal were sent out for peer review and the steering group had a meeting with several Professors in the field of nursing who gave valuable advice and feedback. Changes to the protocol were made in response to this process.
  • It was proposed that a large clinical trial be undertaken and there was discussion around whether an RCT was a realistic and appropriate design, the pragmatic nature of such a study and the difficulties of maintaining control and dealing with confounders was raised.
  • At the NEBPOT spring meeting in March 2003, the lack of progress and the difficulties of moving this project forward were discussed extensively. Most of these discussions were around the day-to-day practicalities of taking responsibility, setting up and managing such a large-scale project.
  • A steering group meeting was proposed to take place later on in the year of 2003, however this did not take place for a variety of reasons.
  • At the RCN SOTN conference in Llandudno in September 2003 discussion took place about the project and the difficulties being experienced. It has been a lesson to us all that no matter how motivated/enthusiastic people are and no matter how important the problem is it can be very difficult to get a project like this off the ground. All the steering group members and NEBPOT members have demanding full time jobs and live scattered around the country. Even with e mail it is difficult at times to keep communication going.
  • It was agreed at the conference meeting that before we could move any further forward and identify funding we would need to identify the scale of the problem- yet to be addressed and we would also need to identify what current practices exist around the country. It was agreed that a survey should be carried out at the conference in Bath 2004 and that an abstract should be submitted for this.
  • A poster abstract was accepted for the RCN SOTN conference to be held in Bath in September 2004. A questionnaire has been produced and this has been peer reviewed and piloted. This will be given to nurses attending the conference and we hope that we will get a good response with a wide variety of nurses from hospitals all over the UK completing the questionnaire. Once results have been analysed these will be published on the website.

It is hoped that the results of this survey will help us to identify what problems/issues exist in practice and from that we hope to be able to  move the pin site project forward.