The Use of Wet to Dry Dressings

THE USE OF WET-TO-DRY DRESSINGS

LINDA JOYCE COWAN

A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING

UNIVERSITY OF FLORIDA

2004

Linda Joyce Cowan

ACKNOWLEDGMENTS

Many thanks go to my husband Bill for many dinners out and dinners at home with the one dish he knows how to cook (spaghetti). Many thanks go to my son Josh, who said he did not mind me starting back to college the same year he started college (as long as I was not in any of his classes). Many thanks go to my daughter Debbie for helping me study, reading words that she didn’t know how to pronounce, much less what they meant

(most of which she said she’d rather not know what they meant). Many thanks go to my parents, sister, extended family and church family for their prayers, support and constant encouragement of my going back to school after 20 years. Many thanks go to my friends Ruthie Jo, Elaine, Pricilla, Katherine, Kathy, Shari, Marion, Liz, Karen, Seleeta,

Sylvia, Bonnie, Cindy, Veta, Judy, Candice, Bev, and Tara, who never seemed to doubt me, even when I doubted myself.

Special thanks go to my thesis advisor, Dr. Joyce Stechmiller, who was an endless source of wisdom, encouragement, mentoring, advice and guidance. She has opened so many opportunities outside of the classroom to learn an enormous amount about research and helped me to grow a real enthusiasm and love for research. She has also been one of my biggest cheerleaders.

I have been very blessed by each member of my advisory committee and have been fortunate indeed to have such wonderful researchers on my thesis committee. I would like to sincerely thank Dr. Susan Schaffer, who is one of the most meticulous editors I have ever met. She has been very encouraging to me and was the first to spark my interest into

iii the possibilities of continuing with the Ph.D. program. I would also earnestly like to thank

Dr. Meredith Rowe, who was the best and most valuable research professor I ever had.

She made research methods come alive and made me realize that I really could do

research that may make a difference in clinical practice. Each of their contributions to my

thesis supervisory committee has been beyond measure.

I could not end my acknowledgments without recognizing that ultimately it has

been by the grace of God that I have successfully completed my studies. I most gratefully

submit my thanks and praise to Him alone for any good that comes out of my life. May I

keep my main goals in life as my motivation for all that I do (to serve God by helping my

fellow man, and to please and honor my Savior, Jesus Christ, by utilizing the gifts He has given me to the fullest extent possible). May I always trust that through His strength and help, I can do more than I think I can.

TABLE OF CONTENTS

page

ACKNOWLEDGMENTS ...... iii

LIST OF TABLES...... vii

LIST OF FIGURES ...... viii

ABSTRACT...... ix

CHAPTER

1 INTRODUCTION ...... 1

Statement of the Problem...... 1 Scope of the Problem...... 5 Purpose of the Study...... 8 Research Questions...... 8 Significance of the Study to Nursing...... 8 Description of Terms ...... 10

2 REVIEW OF THE LITERATURE ...... 11

A History of Wound Care...... 11 Moist Wound Healing...... 16 Wet-to-Dry dressings...... 17 The Physiology of Wound Healing ...... 19 Wound Healing Considerations...... 22

3 METHODOLOGY ...... 27

Purpose ...... 27 Setting and Sample ...... 27 Design of Study ...... 27

4 RESULTS...... 32

Sample Characteristics...... 33 Research Questions...... 34 What Is the Incidence of Wet-to-Dry Dressings?...... 34

v What Types of Wounds Are Wet-to-Dry Dressings Being Used for? ...... 36 What Specialties of Health Care Providers Are Most Frequently Ordering Wet-to-Dry Dressings? ...... 38 When Wet-to-Dry Dressings Are Being Ordered, Do Clinical Data Suggest the Need for Mechanical Debridement? ...... 39

5 DISCUSSION AND CONCLUSIONS...... 41

Discussion of Findings ...... 41 Data Review...... 41 Dry Gauze...... 42 Surgical Wounds...... 43 Cytotoxic Solutions ...... 44 Mechanical Debridement...... 45 Limitations of the Study...... 46 Conclusions...... 47 Implications for Future Research...... 49 Implications for Practice and Education...... 50 Summary...... 53

LIST OF REFERENCES...... 54

BIOGRAPHICAL SKETCH ...... 63

LIST OF TABLES

Table page

4-1 Sample Characteristics and Wound Characteristics...... 33

4-2 Types of Dressings and Amounts of Granulation Tissue ...... 34

4-3 Amounts of Granulating Tissue Noted in the Wound Beds...... 39

4-4 All Dressings by Wound Type ...... 40

vii

LIST OF FIGURES

Figure page

1-1 Cost Comparison of Wet-to-dry vs. Collagen Gel Dressings (HHRN = Home Health Registered Nurse, BID = twice a day, QD = once daily) ...... 4

3-1 Wound Data Collection Form ...... 31

4-1 Incidence of Wet-to-dry Dressings in a Sample of 202 Wound Care Patients ...... 35

4-2 Dressings by Wound Type by Number of Subjects ...... 36

4-3 All Wet-to-dry Dressings by Wound Type ...... 37

4-4 Wet-to-dry Dressings by Type of Healthcare Specialist...... 38

4-5 Breakout Data for Dry Gauze Dressings, Wet-to dry Dressings and all others...... 39

viii

Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science in Nursing

THE USE OF WET-TO-DRY DRESSINGS

Linda Joyce Cowan

December 2004

Chair: Joyce Stechmiller Major Department: Nursing

Wounds represent a major health problem, as well as a significant social and economic dilemma in the world. A health technology assessment of wound management in the United Kingdom estimates a worldwide prevalence of 62 to 78 million leg ulcers, pressure sores, surgical wounds healing by secondary intention, and burn wounds. It is vital to examine current primary treatment modalities of wounds, namely wound dressings. Health care providers need to assure that wound treatment practices are based

on scientific evidence. It is possible that the inappropriate selection or application of

wound dressings may be contributing to the growing number of chronic, complex,

recalcitrant or non-healing wounds. The use of wet-to-dry dressings may be one example

of a wound modality used with inappropriate frequency in today’s health care arena.

This study describes a retrospective review of 202 patients with open wounds

(healing by secondary intention) in Florida. This study suggests that wet-to-dry dressings

are the most frequently ordered wound care modality. The incidence of wet-to-dry

ix dressings in the study population was over 41% of all principal wound care modalities,

followed next by enzymatic (7.43%) and, thirdly, dry gauze (6.93%). The majority of

wounds with wet-to-dry ordered in the study population are surgical. Out of the 84 wet-

to-dry dressings ordered in this population, 58 (69%) were ordered for surgical wounds.

Of these 58 surgical wounds with wet-to-dry dressings, 51 (88%) were ordered by a surgical specialty (general surgeon, GYN surgeon, GI surgeon, orthopedic surgeon, cardiac surgeon, trauma surgeon, etc). Interestingly, 7 (12%) of the 58 wet-to-dry surgical wound dressings ordered were ordered by non-surgical specialists (rehabilitation medicine, DPM, urology, internal medicine). The next most frequent type of wound where wet-to-dry dressings were ordered was neuropathic ulcers (10%) and thirdly pressure ulcers (5.9%).As suggested above, this study implies that general surgeons are the health care specialists most likely to order wet-to-dry dressings. Out of the 84 wet-to- dry dressings ordered for wound treatment in this study, 32 (38%) were ordered by general surgeons. The next highest frequency of health care provider to order wet-to-dry dressings in the study population was internal medicine, with 12 (14.2%) out of 84.

Data also indicated that in over 78.6% of wounds with wet-to-dry dressings ordered, mechanical debridement was not indicated (the percent of granulating tissue in the wound bed was > 75%). Finally, Chi-squared test of significance was utilized to determine if there were significant differences in the wet-to-dry group. Physician specialty (general surgeon, p <0.0001), amount of exudates (small or moderate, p =

0.0017), wound location (abdominal, p = 0.0003), wound type (surgical, p = 0.0002), and wound thickness (full thickness, p = 0.0001) were all statistically significant.

x CHAPTER 1 INTRODUCTION

Statement of the Problem

Currently there are over 350 well-tested wound care products on the market in the

United States (Levin, 2002; Ovington, 2001). Most modern day wound care products

have been developed within the past 50 years and have been based on the principles of

moist wound healing described by George Winters’ pivotal wound research in 1962.

Wet-to-dry dressings have apparently been used in various forms and with various

solutions since at least the mid 1800’s when Joseph Lister used clean cotton batting (until sterile gauze was available in 1867) soaked in carbolic acid to pack wounds (Halsall,

1998). Though not referred to as “wet-to-dry” dressings until after the early 1960’s, the use of dry gauze packed with salt (and left in the wound up to 10 days) was a common wound care practice in certain parts of the world around 1909 – 1918, prior to and during parts of World War 1 (WWI). This practice was then changed to use a saline solution instead of solid salt as part of a “tanning” procedure of wounds (yes, similar to tanning hides with tannic acid) until wound “tanning” was discontinued by the medical community after WWI due to frequent wound complications.

Later in WWI, the Carrel-Dakin method of using a continuous infusion of hypochlorite solution (now known as Dakin’s solution) directly into gauze packed into the wound became a standard method of treatment throughout the British Army. It is important to note that neither of these methods intended the gauze to dry out. In World

War II, wounds were typically dressed with gauze dressings “so as to keep the wound

1 2

open without plugging” (Stout, 1954). At first, Vaseline gauze or “tulle gras” was used

to ensure an “atraumatic” dressing, which would minimize pain and trauma with dressing

changes. In Italy, when delayed primary suture became the routine, plain gauze was

substituted for the Vaseline gauze as it was found that this dressing left “a healthier

surface for suture.” This could have been the first documented observation of the

mechanical debridement possibilities of wet-to-dry gauze dressings. As the gauze was

removed under anesthetic, the question of pain did not arise. In addition, cotton wool,

gamgee, etc., were used as outer dressings (Stout, 1954).

According to a recent literature review and descriptive study conducted by

Armstrong and Price (2004), “Wet-to-dry and gauze dressings are the most widely used

primary dressing material in the United States.” Armstrong and Price sent a three-part

questionnaire to a convenience sample of 127 general surgeons in the New Hampshire

and Vermont area. The response rate was 65 (51.2%). The study was designed to

discover how many physicians would prescribe four types of gauze dressings (including

wet-to-dry), rather than 4 alternatives (alginates, foams, gels, and hydrocolloids) for each

of eight types of hypothetical wounds. All of the eight hypothetical wounds were wounds

healing by secondary intention and included open surgical wounds, abscesses, donor sites

for skin grafts, skin grafts, venous leg ulcers, second degree burns, necrotic pressure ulcers and necrotic wounds needing debridement. Armstrong and Price’s results demonstrated that “gauze dressings were prescribed much more than alternatives for all the wounds described except venous leg ulcers.” Of 65 physicians responding, 30 (46%) chose wet-to-dry for “open surgical wounds healing by secondary intention.” More than

55 of the 65 respondents selected some form of gauze dressing for surgical wounds as

well as abscesses. The researchers concluded that wet-to-dry dressings “are being

prescribed inappropriately.” The second part of Armstrong and Price’s questionnaire

asked participants to select 1 of 7 choices for performing a wet-to-dry procedure. Twenty

respondents selected the following three choices: “A wet-to-dry dressing should not be moistened before removal” + “the type of gauze is important” + “must be allowed to dry before dressing replaced.” Eleven respondents selected this other combination of choices:

“A wet-to-dry dressing should be moistened before removal” + “the type of gauze is not important” + “should not be allowed to dry before dressing replaced.” The remaining respondents selected from other options, yet there were no more than 9 who chose any other wet-to-dry procedure groups. The researchers concluded that wet-to-dry dressings are not only being ordered inappropriately, but are being performed inconsistently. The third part of the Armstrong and Price questionnaire examined the participant’s reasons

not to use modern wound care products. Cost appeared to be the barrier listed most

predominantly by the physicians, with only 7 general surgeons believing alternatives to

gauze were cost effective. However, as Armstrong and Price point out in the

interpretation of their results, “cost effectiveness and unit cost are not the same.” If a

hypothetical cost comparison is prepared for wet-to-dry dressings used twice a day--the

literature suggests wet-to-dry dressings should be done two or three times a day to be

effective--versus a comparison of collagen wound gel (Nu Gel by Johnson and Johnson,

for instance) used once daily, then resulting dollar amounts may average $1,356.69

versus $689.66. The use of the wound gel would represent a savings of almost 50% less

(see Figure 1-1). The hypothetical cost of both types of dressing supplies was based on

retail prices listed in the Edgepark Surgical Supply, Inc. 2003 catalog. The savings when

using gels versus wet-to-dry dressings would potentially be even greater than those listed

in this Figure, when you consider that granulating wounds are likely to heal faster with

the daily wound gel-moistened gauze than the wet-to-dry gauze disrupting the wound bed

twice a day.

Wet-to-dry BID Gauze + Collagen gel QD Gauze 4x4 x 12 x 7 = $12.50 Gauze 4x4 x 6 x 7 = $6.25 Saline fishes 4 x 7 = $ 4.19 Saline fishes 1 x 7 = $1.05 HHRN BID x 7 = $1330.00 30g collagen wd gel = $12.36 Tape 2 rolls = $10.00 HHRN QD x 7 = $665.00 Tape 1 roll = $5.00 Total x 1 week = $1,356.69 Total x 6 weeks = $ 8,140.14 Total x 1 week = $ 689.66 Total x 8 weeks= $10,853.52 Total x 6 weeks = $ 4137.96 Total x 8 weeks = $ 5517.28 = $$$$ Savings

Figure 1-1. Cost Comparison of Wet-to-dry vs. Collagen Gel Dressings (HHRN = Home Health Registered Nurse, BID = twice a day, QD = once daily)

Wet-to-dry dressings have been a standard, traditional or ‘default’ dressing for decades (Bryant, 2000; see also Mulder, 1995; Turner, 1997). Modern wet-to-dry dressings are accomplished by moistening sterile cotton gauze with a solution (usually

0.9% normal saline) and placing it in the wound, allowing it to dry, then removing it dry from the wound bed, thus performing mechanical debridement. There are several reasons why this form of debridement may be detrimental to the wound bed, and unnecessary with so many other forms of wound debridement available today. Cost, compliance, pain, increased risk of infection and re-injury to healthy granulating tissue are several of these reasons.

Laura Bolton (2004), Director of Scientific Affairs for Conva Tec and Adjunct

Associate Professor, Department of Surgery, University of Medicine and Dentistry of

New Jersey states,

There is ample evidence on how to give wounds the opportunity to heal by providing a moist physiological environment for the cells that do the work of healing. Yet practitioners thoughtlessly expose wounded tissue to desert environments that desiccate and kill healing cells. This dried tissue, often with gauze remnants acting as foreign bodies, is more prone to infection and pain, and heals more slowly than if it were kept physiologically moist, placing patients at risk of amputation or longer hospital stays. The medical profession eradicated polio and smallpox, but often ignores the most basic evidence on how to heal wounds. (p. 89)

It is the author’s belief that most health care providers have continued with wet-to-dry dressings more out of misunderstood tradition rather than evidence-based wound care practices. Furthermore, the use of wet-to-dry dressings as a wound care modality may be outdated and used with inappropriate frequency in today’s health care arena.

Scope of the Problem

Currently there are over 40 million inpatient surgical procedures performed each year (CDC, 1996). Healey et al. (2002) reported, “37%-60% of all major surgical complications observed in a multicenter study were avoidable.” In addition to inpatient surgeries, the Centers for Disease Control and Prevention (CDC) report that 31.5 million ambulatory surgeries were performed in 1996. It has been estimated that 75% of all operations in the United States will be performed in an ambulatory or “same-day” outpatient setting, with recovery occurring in the patient’s home. From 1986 to 1996, hospitals conducting surgical site infection (SSI) surveillance in the CDC’s National

Nosocomial Infections Surveillance (NNIS) system reported 15,523 SSI’s following

593,344 operations (Mangram et al., 1999). Among surgical patients, surgical site

infections (SSIs) are the most common reported nosocomial infection, accounting for

38% of all such infections. These infections account for most post-operative non-healing

wounds and many hospital readmissions in the United States (Mangram et al., 1999).

Commonly these infected, non-healing postoperative wounds attempt to heal by

secondary intention. If the 2.6% infection rate in the surveillance population was

extrapolated to hospitals that did not participate in the surveillance, it may represent over

one million non-healing infected wounds annually among inpatient post-operative

wounds alone.

It is estimated that up to 2.5 million Americans each year suffer with chronic leg

ulcers related to vascular insufficiencies. Approximately 45-70% of all chronic leg

ulcerations may be attributed to venous insufficiency, 10-20% arterial insufficiency, and

15-25% due to diabetic neuropathy or a mixed etiology (Mekkes et al., 2003). In 1996 there were over 88,530 non-traumatic amputations in diabetic patients in the US.

Neuropathic foot ulcers are the most common cause attributed to these amputations.

More than 85% of diabetes-related amputations are “precipitated by a foot ulcer deteriorating to deep infection or gangrene” (Apelqvist & Larsson, 2000; Levin, 2002).

Over 13 million Americans have been diagnosed with diabetes and it is estimated that at least 15% of those individuals will have foot ulcers in their lifetime (CDC, 2003). Results published by the Diabetes Control and Complications Trial (DCCT) conducted by the

American Diabetes Association suggests that diabetic complications such as foot amputations are preventable (Wang, Lau & Chalmers, 1993). Disease prevention is currently a major concern in the US. One of the national goals of Healthy People 2010 is to prevent or reduce diabetic foot amputation by at least 50%.

A Health Technology Assessment Systemic Review of wound care management in

the United Kingdom (Bradley et al., 1999) estimates the worldwide prevalence of wounds as represented by the following statistics: surgical--40-50 million; leg ulcers--8-10

million; pressure sores--7-8 million (all chronic); and burns--7-10 million (acute). These

numbers reflect that more people throughout the world have chronic, complex or non-

healing wounds than the total US population with cardiovascular disease (15 million),

asthma (18 million), or diabetes (10 million) (CDC, 2002). However, the US National

Center for Health Statistics (NCHS) at the CDC currently does not track incidence or

prevalence rates of chronic or non-healing wounds. It is obvious by these statistics that

chronic, complex or non-healing wounds represent a major health problem, as well as

significant social and economic concern in the US, and that this dilemma appears to be

growing. Health care providers need to look at current wound prevention and wound

treatment practices, particularly with regard to improving healing rates and preventing

wound infections. Health care providers can step up to the plate and improve these

statistics, perhaps with very simple strategies. Standardized evidence-based wound care

practices may be one vital step. To begin the process, it is of major importance to

examine the current primary treatment modalities of wounds, namely wound dressings.

Are wound dressings being selected appropriately according to evidence-based practices

and current knowledge of acute and chronic wound healing models?

This descriptive study involves a retrospective review of 202 patients, specifically

patients with wounds healing by secondary intention. This study is designed to observe

the incidence of health care providers ordering wet-to-dry dressings as the principal

wound care modality, note the specialty of health care providers most often ordering

these dressings, determine the type of wounds for which wet-to-dry dressings are ordered,

and to investigate associated data that would indicate whether or not the clinical condition of these wounds at the time of the wet-to-dry dressing indicated a need for mechanical debridement.

Purpose of the Study

The purpose of this descriptive study is to observe the incidence of health care providers ordering wet-to-dry dressings as the principal wound care modality, note the specialty of health care providers most often ordering these dressings, determine the type of wounds for which wet-to-dry dressings are ordered, and to investigate associated data that would indicate whether or not the clinical condition of these wounds at the time of the wet-to-dry dressing indicated a need for mechanical debridement.

Research Questions

The following questions are explored in this study:

1. What is the current incidence of the use of wet-to-dry dressings?

2. What types of wounds are wet-to-dry dressings currently being used for?

3. What type/specialty of health care provider are most often ordering wet-to-dry dressings?

4. When wet-to-dry dressings are being ordered, does clinical data (the amount of viable, granulating tissue in the wound bed) suggest that the use of a wet-to-dry dressing is appropriate for mechanical debridement of that particular wound at the time?

Significance of the Study to Nursing

Florence Nightingale (1860) in her pivotal work Notes on Nursing, reprinted by

Buccaneer Books, Inc. (1976) stated,

It is often thought that medicine is the curative process. It is no such thing; medicine is the surgery of functions, as surgery proper is that of limbs and organs. Neither can do anything but remove obstructions; neither can cure; nature alone

cures. Surgery removes the bullet out of the limb, which is an obstruction to cure, but nature heals the wound. So it is with medicine; the function of an organ becomes obstructed; medicine so far as we know, assists nature to remove the obstruction, but does nothing more. And what nursing has to do in either case is to put the patient in the best condition for nature to act upon him. (p. 133)

Nursing continues in this high calling. All health care providers involved in wound care,

especially nurses, need to query current wound care practices with the additional

scientific knowledge we have at our disposal today. Like the question above posed by

Nightingale over 150 years ago, we may ask a similar question, “Are we putting the patient in the best condition for the natural wound reparative processes to act upon him or her?”

Wounds have been under much study in the past 30 years. Many advances have been made in understanding optimal environments for cellular regeneration and tissue repair. Micro cellular systems and biological models are described in more detail in the

last 20 years than ever before (Bryant, 2000; Chen et al., 1999; Clark, 1988; Parks, 1999;

Pilcher et al., 1999; Schultz et al., 2003; Trengrove et al., 1999; Wysocki et al., 1990,

1992, 1993, 1996, 1999), yet we continue to see great variation in approaches to common

wounds. Wounds are indiscriminant, inflicting every ethnic group, young and old, rich

and poor, male and female alike. Wounds are a worldwide pandemic. Perhaps nurses can

lead the way for health care providers to standardize wound care practices and utilize

evidence-based protocols to take us beyond the dark ages of wound care. If standard

wound care practices (using existing cost-effective treatment modalities) were utilized,

resulting in even a mere 10% reduction in the incidence of diabetic foot ulcer infection,

this could prevent over 6000 lower extremity amputations annually in the US.

Description of Terms

• CWOCN – Certified Wound, Ostomy and Continence Nurse – A national board certification usually obtained through the WOCN (Wound, Ostomy and Continence Nurses) organization. Available only to Registered Nurses or Advanced Practice Nurses that have a bachelor’s degree or higher.

• CWS – Certified Wound Specialist – A national board certification obtained through the American Academy of Wound Management. Available to Nurses, Physical Therapists, and Physicians.

• Debridement: Sharp, selective, non-selective, mechanical, enzymatic, autolytic, larval. Debridement is defined as the removal of nonviable material, foreign bodies, and poorly healing tissue from a wound (Steed, 2004).

• Evidence based medicine (or practice)- A Term first coined by Sackett et al. in the 1990’s to imply medical management of patient care based on a process of question forming, searching for (scientific) evidence, critical appraisal of that evidence and evaluation of potential application to current (medical) practices (Sackett, 1995, 1996).

• Fibroblast – Cells that secrete the protein collagen and other protein fibers found in connective tissue. Fibroblasts are responsible for collagen formation in a scaffolding-like matrix in the wound bed also referred to as granulation tissue.

• HMO – Health Maintenance Organization. A typically not for profit health insurance available to patients usually through their employer.

• Outcomes – Typically the measured ‘end result’ of medical and/or nursing interventions in respect to a disease process or condition or cost of care.

• Wound care – The treatment modality ordered by a health care provider for wound healing.

CHAPTER 2 REVIEW OF THE LITERATURE

A thorough search of scientific literature published through September 2004 was

made through MEDLINE and CINAHL regarding wound healing in general and more

specifically, the use of wet-to-dry and other types of wound dressings. There was no

referenced work discovered that described either the person or the era in which the term

‘wet-to-dry’ dressing was first coined.

A History of Wound Care

Guido Majno, M.D. invested ten years of his life researching this worldwide history of wound care. In his book The Healing Hand – Man and Wound in the Ancient

World (Harvard University Press, 1975), he relates wound history as far back as the oldest known infected wound: estimated at 200 million years ago (a Permian reptile broke one of its dorsal spines and there is fossil evidence that suggests this bone became infected as a result). Dr. Majno’s book has been highly referenced for his accurate history of wound care. It seems that some of the earliest fossil remains of man indicate that he has been plagued with wounds from the start. Some were accidental wounds (broken bones), some animal attacks, and others that were obviously man-made (trauma to the head by blows to the skull, and trepanation – early skull surgery or the practice of drilling holes in the skull while the patient was still alive). The study of the history of wound care can give us insight into our own humanity and perhaps re-focus our rationale towards wound healing.

11 12

Several ancient Egyptian documents obtained by Dr. Smith in 1862 gives modern scholars a glimpse of ancient wound care. These documents known collectively as “The

Smith Papyrus” were translated in the 1920s. They described some of the earliest recorded medical practices common to the Egyptians such as plant fibers (willow or sycamore leaves) used to secure various poultices in place to deliver medicinal substances while keeping wounds moist at the same time (Majno, 1975).

Claudius Galen (131-201 AD) was born at Pergamum and studied medicine at

Alexandria. He went to Rome about 162 AD to be a surgeon appointed to the gladiator games. With ample gladiator wounds, he was given the opportunity to experiment with a variety of wound care treatments and examine human anatomy of living patients. He is reported to have perfected the suturing of tendon and muscle. Galen dissected a myriad of animals, and by dissecting live animals such as apes, pigs or goats, worked out the function of the nerves and spinal cord. Though a surgeon, his prime interests were science and internal medicine, not surgery. He wrote extensively on anatomy, physiology

and practical medicine. 1800 years before George Winter’s pivotal recognized research

on moist wound healing, Galen first documented that wounds heal best in a continually

moist environment (Majno, 1975).

Galen wrote, “As I have previously explained, it is necessary to keep the wound continually moist, because if the dressings dry out, the ulcer becomes inflamed. This is true especially in the summer, at which time when the pontifices of Pergamum were celebrating the appointed gladiatorial games, I cured the most seriously injured by covering the wounds by a cloth wet with astringent wine kept moist both day and night by a superimposed sponge.” (p. 400)

One of the most popular wound dressings in Rome was made from wool and

honey, which would also effectively provide a moist environment not hospitable to

bacterial growth (Majno, 1975; see also Davies, 1999; Pearcy, 1983). Ancient Egyptian

medical practices that have been improving and moving toward a scientific approach to

wound care were all but forgotten as superstition and quackery replaced health care from

a medical perspective with unfounded spiritual beliefs regarding illness and healing

throughout the next several centuries. Fortunately, the “Ebers Papyrus” suggests that a

few Egyptian wound practices survived, such as the use of resins, like frankincense or

myrrh, which were apparently used through 1500 BC. These resins “have been shown to

have occlusive properties” (Bolton, 2004; Majno, 1975). Many forms of wound

dressings have been used through the centuries, from unsuccessful practices such as

applying animal dung, boiling water, harsh resins and raw meat to open wounds; to more

successful wound applications such as honey (current research has demonstrated natural

broad-spectrum antibiotic properties of honey). However, it appears that very few wound

applications until the 1900’s have been based on scientific evidence. In the 200 years

prior to the 1950’s, the majority of wound practices were based on trial and error, accidentally discovering an effective application, or simply tradition (Majno, 1975).

While an ancient text from India (1000 BC and 800) describes an early occlusive dressing for leg ulcers using “honey and clarified butter” held in place with leaves, the first recorded “strapping” of venous leg ulcers is attributed to Thomas Baynton, who applied occlusive adhesive strips to venous ulcers in 1797. His original intention was to

“draw the edges of the ulcer closed.” One may surmise that this provided a source of compression as well. He tightly wrapped the leg with overlapping layers of adhesive strips two inches wide. If the ulcer was inflamed, he would apply a layer of soft fabric moistened with cool water to the outside of the adhesive strips. The ulcers healed despite the wound failing to contract. Baynton discovered that the ulcers remaining covered with

tape healed more rapidly than when dressed with conventional gauze dressings. Oscar

Gilje, a Norwegian dermatologist that published his thesis one hundred and fifty years

later in 1948, replicated this finding. His studies confirmed, “The ulcers covered with adhesive tape healed faster than those covered with gauze.” Under cynical supervision at the Rigs hospital in Copenhagen, Dr. Gilje repeated studies similar to Baynton’s. He applied tight adhesive strips (2.5 cm wide, separated by 2 to 3mm) over venous ulcers in

23 patients. Over these he placed a pad of dry gauze to absorb exudate, and then covered the gauze with an elastic compression bandage. Fifteen patients (65%) healed in 12 weeks. His dissertation involved more than 268 patients. These were probably the first scientifically controlled studies of wound healing. These experiences helped lead the way for the scientific exploration of wound dressings (Bolton, 2004; Danbolt, 1967).

Building on Gilje’s work, a British surgeon named George Winter conducted scientific studies using pig models in 1962, which showed that “swine partial-thickness excision wounds kept moist with polyethylene film epithelized more rapidly than similar adjacent air exposed excisions.” Although Galen first observed in 162 AD that wounds kept moist healed better than dry wounds and Gilje was really the first scientific pioneer of the twentieth century in the field of wound dressings, George Winter is probably more widely known and credited as having completed a “pivotal work,” defining the principles of moist wound healing. Winter’s work has been duplicated in many studies but Hinman and Maibach made the next ‘human’ step less than a year after Winter’s studies were published. These two dermatologists from the University of California confirmed,

“human shave biopsies healed twice as fast when dressed with polyethylene film than if exposed to air.” Hundreds of scientific studies have since been performed on acute and

15 chronic full-thickness and partial-thickness wounds. The overwhelming majority of these studies “have confirmed faster healing rates, decreased pain and scarring and reduced likelihood of infection in wounds dressed with moisture-retentive dressings.” It is disappointing to note that despite this growing accumulation of scientific evidence supporting moist wound healing, it appears that current wound care management has

NOT put into practice the science of wound dressing. It has been observed that most wounds continue to be dressed today much as they were 3000 years ago, when most practitioners were compelled by tradition rather than scientific evidence (Bolton, 2004).

Many age-old remedies have persisted throughout thousands of years of medical practice. Some, such as honey, propolis, extract of marigold, sugar and papaya have been demonstrated to be helpful (O’Meara et al., 2000; Pieper & Caliri, 2003). Others such as

Betadine, alcohol (Damour et al., 1992), sodium hypochlorite/Dakin’s solution (Cooper et al., 1990; Hidalgo, Bartolome & Dominguez, 2002), hydrogen peroxide, acetic acid

(Doughty, 1994), Sulfamylon (mafenide acetate)(Boyce et al., 1999; Cooper et al., 1990), undiluted lavender oil (Prashar, Locke & Evans, 2004), capsaicin (Ko et.al., 1998), etc. have been demonstrated to be cytotoxic to human fibroblasts, keratinocytes, osteoblasts, and/or epithelial tissue. Furthermore, over 350 well-tested non-cytotoxic wound care products have evolved in the past 30 years. (Ovington, 2001). Florence Nightingale

(1860/1976) remarked on the results of scientific studies or observations:

In dwelling upon the vital importance of sound observation, it must never be lost sight of what observation is for. It is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort. (p. 125)

Scientific studies regarding medical treatments are done repeatedly to improve

health, comfort and effectiveness. When repeated studies demonstrate a treatment is

harmful, change is accomplished in practice. Carbolic acid, which Lister used over 100

years ago, is no longer commonly used in practice, yet other cytotoxic solutions as well

as outdated treatment modalities are slow to be removed from clinical practice. Although

Florence Nightingale was not a cellular microbiologist, she recognized that treatments

should at least not cause harm to the patient, but rather put the patient in the best possible

condition for the subsystems of his own body to do the job of healing that they were

designed for. Wet-to-Dry dressings may not be putting the patient in the best condition

for nature to act upon him. We no longer use products such as carbolic acid or tannic acid

in wounds because they were found to be detrimental to the wound bed. Are wet-to-dry

dressings also detrimental to the wound bed? Many studies over the past forty years seem

to suggest that they are.

Moist Wound Healing

Moist wound healing has been accepted as a prominent and advantageous principle of wound treatment modalities since George Winter’s pivotal work in 1962, when he demonstrated that moist wounds heal several times faster than dry wounds. Research has confirmed in multiple repeated studies that moist wound environments promote granulation and epithelial cell migration in wounds, whereas dry wounds impair

fibroblast proliferation and prevent cell migration (Bryant, 2000; Rovee & Maibach,

2004; Vogt et al., 1995). Despite the hundreds of scientific studies which have been

performed on acute and chronic full- and partial-thickness wounds and “have confirmed

the faster healing rates, decreased pain and scarring and reduced likelihood of infection in wounds dressed with moisture-retentive dressings”, most wounds continue to be dressed

today much as they were thousands of years ago, allowing the wound bed to dry out

(Bolton, 2004). Why?

Moist wound healing may be accomplished by a myriad of modalities presently on the market. Wound gels (glycerine or silicone based are common), gas-permeable transparent dressing or a hydrocolloid (moisture retentive without being completely occlusive) is probably the simplest approach for a shallow wound with little or no exudate. A shallow wound with greater amounts of exudates may be approached with a hydrofiber, alginate, or a foam dressing to name a few. Deep but dry wounds may be loosely packed with a single length of Kerlix (cut to the size needed) moistened with a wound gel, and a secondary absorbent dressing may be placed over this, if desired. Deep but exudative wounds may benefit from an alginate, foam, specialty or ‘super- absorptive’, a combination of products, or negative pressure wound therapy such as a vacuum assisted wound closure device (Ovington, 2000; see also Bale, 1997; Bryant,

2000; Mulder, 1995; Thomas et al., 1998; Turner, 1997).

Wet-to-Dry dressings

Wet to dry dressings do not maintain a moist wound environment, but rather as the

name implies, ultimately results in a dry wound environment (whether or not they are re-

wetted with liquid prior to removal). The use of gauze alone (typically a 12-ply cotton

gauze measuring 4” x 4”) or moistened with an isotonic 0.9% saline (normal saline)

solution and allowed to dry in the wound, and then removed dry from the wound bed

along with necrotic tissue which has adhered to the gauze has been known as a ‘wet-to-

dry’ dressing. As described, it has been the “conventional or traditional method of

mechanical debridement for decades” (Bryant, 2000; Mulder, 1995; Turner, 1997).

Disconcertingly, wet-to-dry dressings are frequently performed incorrectly or

18 inconsistently (Armstrong & Price, 2004; Bryant, 2000; Goode and Thomas, 1997).

Often the dry dressing is re-moistened before removal. (Armstrong & Price, 2004). Wet- to-dry dressings leave fibers from the gauze behind in the wound, which act as foreign bodies, increasing inflammatory responses and harboring bacteria (Hoekstra, Hermans,

Richters & Dutrieux, 2002; Mulder, 1995). Wet-to dry dressings may promote wound infection; disturb fibroblast proliferation, collagen deposition and impair granulating tissue formation, as well as prevent epithelial cell migration. Wet-to-dry dressings are prone to cause maceration of the surrounding peri-wound skin. Not to mention, they are

NOT the most economical wound dressing, contrary to popular belief.

Wet-to-dry dressings have been demonstrated to be less cost effective than other wound dressings available (Capasso & Munro, 2003; Mosher, et. al., 1999; Mulder,

1995). Capasso & Munro (2003) reported in their comparison study of wet-to-dry saline dressings versus hydrogel dressings:

Repeated measures of analysis of covariance revealed a similar rate of wound healing in the two groups. The overall cost of wound care was significantly higher (P = .006) for patients in the normal saline group, with a higher number and cost of home nursing visits. The cost of supplies was not significantly different between groups, although amorphous hydrogel dressings cost an average ($1.50) more than wet-to-dry normal saline gauze dressings. The two treatments are equally efficacious in promoting wound healing, but amorphous hydrogel dressings are significantly more cost effective and, thus, a better value for the home care dollar (p. 984).

Wet-to-dry dressings and dry gauze dressings have been identified as the most painful of wound dressings (Bethell, 2003; Collier & Hollinworth, 2000; Vermeulen et al., 2004). Vermeulen et al. (2004) reported in a Cochrane Database Review of dressings that in four trials gauze dressings were associated with “significantly more pain for patients during dressing changes than other dressings”. In addition, wet-to-dry dressings may be responsible for cross contamination of other patients and nurses from

aerosolization of bacteria upon removal of the dry gauze dressing from the wound.

Several studies have demonstrated + MRSA (methicillin-resistant Staphylococcus aureus)

strains cultured from nares of nurses and their gowns as well as inanimate objects in rooms of patients who were infected or colonized with MRSA (Lawrence et al., 1992 –

1994; see also Boyce et al., 1997; Horikawa, Murakami & Kawano, 2001). Ameen et al.

(2000) suggest that gauze dressings have the least ability to resist penetration of MRSA

than other contemporary wound dressings available today.

According to the literature, the primary purpose of a wet-to-dry dressing is

“mechanical debridement” of necrotic tissue (Mulder, 1995; see also Brown, 2000;

Bryant, 2000; Dowsett, 2002). However, as a debridement alternative, when they are

used on wounds with non-viable tissue, they have been demonstrated to be far less

effective at debridement than other common debridement products such as collagenase,

fibrinolysin, autolysis or larval therapy (Mosher, Cuddigan, Thomas & Boudreau, 1999;

see also Capasso & Munro, 2003; Harding, Morris & Patel, 2002; Ovington, 2001). It

appears that the use of wet-to-dry dressings over the past 50 or more years has become

more or less a ‘default’ dressing which has been used for every type of wound regardless

of the amount of necrotic tissue, exudates, or need for debridement (Armstrong & Price,

2004; Ovington, 2002).

The Physiology of Wound Healing

In order to fully appreciate the wound healing process, it is necessary to have a

basic understanding of human physiology related to skin anatomy, human tissue repair

and healing in general. The skin is the largest organ of the human body, covering

approximately 3000 square inches on the average adult. Its primary functions are

“protection, immunity, thermoregulation, sensation, metabolism and communication.”

The skin forms a protective barrier from the external environment while maintaining a

homeostatic internal environment. The layers of the skin consists of the epidermis, or outermost layer; the basement membrane, which separates the epidermis from the dermis; the dermis, which is the thickest tissue layer of the skin; and the hypodermis, or the superficial fascia (Bryant, 2000; Huether & McCance, 2000; Schultz et al., 2003;

Wysocki, 1999).

An alteration in the skin’s integrity may be caused by an injury, disease, surgery, or environmental assault on the human body (Bryant, 2000). These alterations in skin integrity may be considered wounds. Chronic, recalcitrant or non-healing wounds represent a significant health, economic and quality of life burden to individuals as well as to society in general. Some chronic diabetic foot ulcers may persist for over a year.

Despite the prevalence of recalcitrant or chronic wounds such as those resulting from post-operative infections, diabetic foot ulcers, or venous insufficiency, it has been observed that they are “often neglected or managed inadequately” (Zimmet, 1999; see also Healey et al., 2002; Goldman & Fronek, 1989).

To review how wounds typically heal, one must examine basic wound and tissue physiology. Partial thickness wounds are shallow wounds involving epidermal loss and partial loss of the dermal layer. Full thickness wounds involve total loss of the epidermal and dermal layers, “extending to at least the subcutaneous tissue layer and possibly as deep as the fascia, muscle layer and the bone” (Kloth & McCulloch, 2002).

It is widely accepted that wound healing occurs by primary, secondary or tertiary

(dermal primary) intention. Primary intention or closure is commonly a surgical closure accomplished by sutures, staples or tape. Secondary intention is the term given to wound

21 healing accomplished by leaving a wound open and letting it heal by tissue remodeling or scar formation. Tertiary or delayed primary healing is managed by allowing the wound to stay open for several days (or longer), and then after the center of the wound has started granulation tissue formation, approximating the superficial edges of the wound with sutures, staples or tape (Bryant, 2000). Most chronic open wounds heal by secondary intention or granulation, rather than primary or delayed primary intention (Bradley et al.,

1999). Therefore, this paper will focus on wounds healing by secondary intention.

Wound healing or tissue repair has been well documented to occur in a sequence of specific events. Inflammation, reconstruction or granulation, epithelialization and remodeling or scar maturation are the four generally accepted phases of wound healing

(Dowsett, 2002). The following algorithm may define these phases further. Injury is when wounding initially occurs. This leads to the body’s attempts to restore immediate homeostasis by instant platelet aggregation and the initiation of the coagulation cascade.

Homeostasis is usually achieved very quickly (within minutes) unless large blood vessels are damaged or the patient’s clotting is impaired, such as with anticoagulants or bleeding disorders. This results in the stimulation of the inflammatory response, which releases neutrophils, macrophages, prostaglandins, lymphocytes, cytokines and histamines to the local area as well as systemically (Bryant, 2000; Huether & McCance). This phase lasts about four to five days but may be prolonged due to infection, foreign bodies or inappropriate wound dressings, causing additional trauma to the wound (Dealey, 1998;

Ovington, 2001). The inflammation phase leads to reconstruction, where fibroblast formation, angiogenesis (growing new capillaries) and the development of granulation tissue occur. This phase also included wound contraction, where the volume of the

wound (wound size in length, width and depth) decreases. Epithelialization occurs when

surface epithelial cells cover the wound to close it. Macrophages release epidermal growth factors, which stimulate proliferation and migration of epithelial cells. These cells move into place across the wound surface by a “leapfrog” fashion. Remodeling or maturation is the final stage of wound healing during which “collagen fibril cross- linking and scar tissue tensile strength is maximized”. This may start after 21 days of wounding and may take up to a year to reach a maximum potential tensile strength of

80% of normal tissue (Bryant, 2000; Dealey, 1999; Dowsett, 2002; Huether & McCance,

2000).

Waldorf and Fewkes (1995) described only three phases of tissue repair, the inflammatory phase, proliferative phase, and the remodeling phase. These phases consist of the same components named above, but combine the events of injury, homeostasis and inflammation in the inflammatory phase; fibroblast formation, collagen synthesis and deposition, angiogenesis, wound contraction and epethialization in the

proliferative phase; and scar maturation with increasing tensile strength in the final

remodeling phase.

Wound Healing Considerations

It is now widely accepted that a moist wound environment is desired in most partial

or full thickness wounds left to heal by secondary intention for the following reasons:

Granulation tissue formation occurs faster. Cellular migration cannot occur in a dry

environment. There is an increase in available nutrients to the wound bed. There is

typically less necrotic tissue formation and less scarring.

Epithelialization and wound contraction occurs more rapidly in a moist

environment. However, studies have documented that chronic wounds exhibit distinct

23 differences from acute wounds at the molecular level that should be well thought-out when considering a primary wound treatment modality. These differences include increased levels of inflammatory cell proteases such as matrix metalloproteinases

(MMPs) in chronic wound fluid, which can inhibit fibroblast and endothelial cell proliferation and function (Wysocki et al., 1993, 1996; see also Trengove et al., 1999).

Therefore, wound products for chronic wounds may do well to absorb chronic wound fluid, which is high in the inhibitory factors, yet still maintain a moist environment at the wound bed and deter (or at least not encourage) bacterial growth. Saline moistened gauze dressings may be ineffective at meeting this criteria due to the decreased absorbency of already moistened gauze, “inhospitable dry wound bed environment” when no longer moist, and “propensity for cotton fiber gauze to support bacterial growth” (whether dry or in an isotonic solution) (Trengove et al., 1999; see also Bryant, 2000; Ovington, 2001).

The purpose of wound dressings are typically to provide a moist healing environment,

“protect the wound from environmental contaminants or re-injury”, provide bactericidal action, and also may include mechanical debridement of non-viable tissue (Dowsett,

2002; Wiechula, 2003).

Much research has been conducted in the area of occlusive or moist wound healing since the early 1960’s when G.D. Winter “first published his influential text on the effect of occlusion on wound healing” (Bradley et al., 1999). The efficacy of wet or moist wound healing has been documented by multiple experimental studies. Many of these studies reveal the detrimental effects of allowing a wound bed to dry out completely, such as decreased fibroblast formation and impaired epithelial cell migration (Bolton,

2000; Capasso & Munro, 2003; Harding, Morris & Patel, 2002; Svensjo et al., 2000;

Wiechula, 2003). The use of gauze alone (typically a 12-ply cotton gauze measuring 4” x

4”) or moistened with an isotonic 0.9% saline (normal saline) solution and allowed to dry in the wound, and then removed dry from the wound bed along with necrotic tissue which

has adhered to the gauze has been known as a ‘wet-to-dry’ dressing.

As described, it has been the conventional or “traditional method of mechanical

debridement for decades” (Mulder, 1995; see also Bryant, 2000; Turner, 1997). Wet-to-

dry dressings are meant for the primary purpose of mechanical debridement (Bryant,

2000; Kloth & McCulloch, 2002; Ovington, 2001). However, exposed epithelial and granulation tissue in the wound are “likely to be removed or damaged during these dressing changes.” In addition, gauze fibers may be left in the wound bed essentially as foreign objects, which may impair healing. It has been suggested that the untreated cotton gauze and isotonic saline environment of wet-to dry dressings provide a “beneficial media for bacterial growth” as well (Mulder, 1995; Hoekstra, Hermans, Richters &

Dutrieux, 2002).

It is important to note that wet-to-dry dressings have been associated with an increased report of patient pain related to the dressing change procedure, and the debridement effect is non-selective (Wiechula, 2003; see also Bethell, 2003; Ovington,

2001). There are far less painful debridement modalities available in most cases, such as autolytic debridement, sharp or surgical debridement, enzymatic debridement, moist wound therapy or even maggot therapy (Courtenay, Church & Ryan, 2000).

Wet-to-dry dressings are primarily to be applied more than once a day (typically three times a day) and are not to be re-moistened before removal from the wound bed, which reduces the debridement effect (Ovington, 2001). Several studies have been

documented, which indicate that many health care providers are not performing wet-to-

dry dressing changes correctly. Indeed, many health care providers admit that if the cotton dressing material adheres to the wound bed while removing a wet-to-dry dressing,

they will moisten it with saline to facilitate removal (Goode and Thomas, 1997; see also

Armstrong & Price, 2004; Bryant, 2000). This then, would not technically be considered

a wet-to-dry dressing. It has been suggested that wet-to-dry dressings may be

substandard in today’s wound care technology for several reasons: they may add to the

patient’s discomfort, they are more labor intensive, they may incur more costs for the

healthcare system, and they may impede healing and increase the risk of infection

(Ovington, 2001).

Many internal and external factors have been demonstrated to influence the wound healing process. The major factors that have a significant impact on wound healing are:

The patient’s general health (co-morbidities) and immunological status; medication; the aging process; nutritional status; environmental threats (including smoking); tissue perfusion and oxygenation; infection (local or systemic); the presence of necrotic tissue, and the presence of continued trauma (Bryant, 2000; Dowsett, 2002; Schultz et al., 2003).

The presence of continued trauma occurs primarily when pressure is not relieved (as with pressure ulcers or not offloading a diabetic foot ulcer), foreign objects are left in the wound, the wound bed dries out, or when mechanical debridement is attempted but there is inadequate necrotic tissue present in the wound bed to prevent healthy, granulating tissue from being traumatized. The presence of continued trauma is known to impair wound healing, whereas the absence or reduction of continued trauma (and its causative factors) will improve wound healing (Bolton, 2004; Bryant, 2000; Ovington, 2001).

The average cost and effectiveness of wet-to-dry dressings as compared to other forms of wound care dressings (alginates, gels or hydrocolloids) have been explored in

several experimental as well as descriptive studies. These studies support the fact that

wet-to-dry dressings have generally been found to be more costly, more painful, more

labor intensive, and less effective than other available wound care modalities (Mosher,

Cuddigan, Thomas & Boudreau, 1999; see also Capasso & Munro, 2003; Harding,

Cutting & Price, 2000; Ovington, 2001).

The UK has documented several Health Technology Assessments and research reviews which detail comparisons of various wound products and therapies (Bradley et al., 1999). However, a detailed search of Pub Med, Medline, CINHAL and various e- journals did not result in any Health Technology Assessments or Meta-analysis of experimental studies done specifically on the effectiveness of wet-to-dry dressings, the appropriate procedure for application of wet-to-dry dressings or the primary purpose of wet-to-dry dressings (mechanical debridement versus autolytic, enzymatic or sharp debridement). The bulk of the research done involving effects of wet-to-dry dressings appears to have involved them only as a control or ‘standard’ of care compared to another treatment type such as hydrocolloid, alginate or hydrogel dressings (Harding, Cutting &

Price, 2000). This is disconcerting, because there is no accounting in these studies to say whether the wet-to-dry dressing could have actually impaired wound healing, while the treatment dressing possibly did not impair healing as much. More research is needed in the use of gauze dressings, both as wet-to-dry and moist saline dressings to determine their effectiveness and appropriate use, if any, in current wound care therapeutic environments.

CHAPTER 3 METHODOLOGY

Purpose

Setting and Sample

The setting for this study was a home care agency in north central Florida and a health maintenance organization (HMO) member database located in north central

Florida. The sample size was 202 subjects for retrospective review.

Design of Study

The design of this study was descriptive correlational. A retrospective chart review was performed (of 202 patients with open wounds healing by secondary intention in

2003). Subjects were randomly selected at the HMO by reviewing a wound member database. Using a random digits table - every 3 digits were selected; those random digits over 932 (the number of members in the database) and duplicates were skipped. Members were selected by their patient entry number in the database that corresponds to the random digit selected. Wound and claims data were reviewed using a data collection sheet which surveyed age range of the patient, sex, ethnicity, co-morbid conditions,

27 28 smoking status, wound size, wound bed description (amount of viable and non-viable tissue present), color and amount of drainage, infection present, type of initial dressing ordered by the health care provider and specialty of the ordering health care provider

(Figure 3.1). Subject identifying information was not collected on the data collection sheet or any log. The member’s information was returned to the agency records and the collection form was assigned a number from 1 to 100 based entirely on order of completion of the review. Identifying data was not recorded. Patient charts/files were not removed from any facility. Once charts were reviewed, they were returned to the agency files and subject anonymity was maintained. The total number of member files reviewed from the HMO database was 102, thirty-eight were unusable due to incomplete information (more than six pieces of data from the data collection sheet were not documented in the member’s record). Therefore, 74 HMO members were used as study subjects.

The home care agency medical records department provided charts from discharged patients from 2003 with an admitting diagnosis with a wound related ICD-9 diagnosis code. Charts were reviewed using a wound care data collection sheet (figure 3.1) which surveyed age range of the patient, sex, ethnicity, co-morbid conditions, smoking status, wound size, wound bed description (amount of viable and non-viable tissue present), color and amount of drainage, infection present, type of initial dressing ordered by the health care provider and specialty of the ordering health care provider. Patient identifying information was not collected on the data collection sheet or any log. The chart was returned to the agency records and the collection form was assigned a number from 1 to

100 based entirely on order of completion of the review. There was no necessity for

destruction of identifying data because none was recorded. The patient chart was not

removed from the health care facility. Once charts were reviewed, they were placed back

in the agency file and it was not possible to distinguish which patients had been reviewed

or not after the study was completed. There is no danger of duplicate review of data,

because the investigator kept a temporary log of the last 3 digits of the chart number until

the data collection was completed and the medical records department sent the charts to

their long-term storage facility at a different location after the chart review was

completed.

All of these 193 home care charts were reviewed by the investigator, and those charts that had closed incisions, ostomies, drain sites, chest tubes or no open wounds were returned without data collection. All charts in both home care and the HMO that had incomplete data or missing documentation of more than 6 items on the data collection sheet were not used in the study. The total completed study subjects from home care were

128. The total number of subjects for the study with both the HMO and home care was

202. The non-identifiable wound data was recorded on an excel spreadsheet and inferential statistics done on selected categorical data, primarily to see if the incidence of wet to dry dressings is significant. Also examined were: What percent of dressings ordered were wet to dry versus other modalities? What was the specialty of health care provider which ordered wet-to-dry dressings with greatest frequency? What were the types of wounds for which wet-to-dry dressings are ordered most frequently? What was the average amount of viable and non-viable tissue present in these wounds? Was mechanical debridement indicated by the clinical picture in the majority of these wounds?

The data entered on the Wound Data Collection Form (figure 3.1) was assigned a

30 different number for each possible answer (purple color). After data was collected, if any answers were written in the “other” fields, they were also assigned a different numerical value (red), for data entry on the excel spreadsheet and statistical analysis with SAS statistical analysis software.

WOUND DATA COLLECTION FORM

Please DO NOT include any private information on the patient, such as name or identification number.

Gender (circle one) Male 1 / Female 2 0 = not listed Ethnicity (circle one) Caucasian 3 / African decent 4 / Asian decent 5 / Hispanic 6 / Other 7 Age Group (circle one) Under 20 8 / 21-40 9 / 41-60 10 / over 60 11 Smoking (circle one) Never 12 / smoked in the past 13 / currently smokes 14 / None listed 0 Diabetes (circle one) No history 15 / Type I (IDDM) 16 / Type 2 (NIDDM) 17 Age/duration of wound (in weeks): ____ weeks 0-4 18 / 5-8 19 / 9-12 20 / 13-20 21/ >20 wks 22 Wound Size: ______L x ______W x ______D (note: all depths of 0 will be marked as 0.01cm) Amount of Exudate (circle): None 23 Small 24 Moderate 25 Large 26 Copious 27 Color of Exudate (circle): Clear 28 Yellow 29 Tan 30 Pink 31 Red 32 Green 33 Other 7 :______Purulent = 105 Wound Location (circle one) Lower extremity 34 / Upper extremity 35 / Abdomen 36 / Chest 108 Posterior body (sacral 37/buttocks 38/back 39/ hip 40) Neck = 87 /Groin = 86 Perirectal 88 Wound Thickness (circle one) Partial 41 / Full thickness 42 Wound Type (circle one) Arterial 43 / Venous 44 / Pressure 45 / Neuropathic 46 / Surgical 47 / Burn 48 / Cellulitis=91 / Injury/trauma other than burn 90 / Insect Bite 104 / Pilonidal cyst 113 Any signs of infection present or wound culture done prior to admission to program? YES 49 / NO 50 Signs of infection …………… YES 51 / NO 52 Wound Culture Initial wound dressing patient advised to use prior to admission to program (circle one): Wet to Dry 53 / Alginate 54 / Foam 55 / Wound Gel 56 / Hydrocolloid 57 / Profore 81 / Acticoat or Aquacel AG 58 / Silvadene 59 / Enzymatic 60 / PDGF (Regranex, etc) 61/ / Unna Boot 82 / Vac 80 Transparent 85 / Dry Gauze =96 / Iodoform= 95 / No admission orders specified 99 Ordered HHRN/WOCN to eval/make recom. 98/ NS wet to moist w/Vaseline gauze overlay 83 Hydrofiber 100/ Antibiotic powder, cream, oint or antifungal (bactroban, polysporin etc) 84 What is the specialty of the physician ordering dressing: FP 62/IM 63 / VS 64 / GS 65 / PS 66 / ER 89 GI 92/ DPM 67 / GYN 68 / Ortho 69 / Rehab MD106 /Hem 94 / Oral surg 93/Cardiac surg 107 (PT or CWOCN & orders signed by MD 97) / Trauma Surg 112 / WCC MD 109 / Inf. Dz 110 Urology 111 Wound Bed description: Granulation tissue (circle one): <25% 70 / 25-50% 71 / 51-75% 72 / 76-99% 73 /100%74 Non-viable tissue (circle one): <25% 75 / 25-50% 76 / 51-75% 77 / 76-99% 78 / 100%79

Figure 3-1. Wound Data Collection Form

CHAPTER 4 RESULTS

32 33

Sample Characteristics

Table 4-1. Sample Characteristics and Wound Characteristics Number Demographics Wound of Percentage Sample size = 202 Number Percent Characteristics subjects of subjects

Male 88 43.56% Location Female 114 56.44% Lower Extremity 92 45.54% Upper Extremity 7 3.47% Caucasian 135 66.83% Abdomen 58 28.71% African American 33 16.34% Sacral 11 5.45% Hispanic 8 3.96% Buttocks 10 4.95% Other 1 0.50% Peri-rectal 7 3.47% Not Documented 25 12.38% Groin 5 2.48% Chest 6 2.97% < 20 years old 1 0.50% Neck 2 0.99% 21 – 40 years old 32 15.84% 41 – 60 years old 67 33.17% Thickness > 60 years old 101 50% Full Thickness 162 80.20% Not Documented 1 0.50% Partial Thickness 39 19.31%

Current Smoker 20 9.90% Type / etiology Smoked in Past 27 13.37% Surgical 99 49.01% Never Smoked 69 34.16% Pressure 30 14.85% Not Documented 86 42.57% Neuropathic 23 11.39% Venous 21 10.40% Type I Diabetes 22 10.89% Injury - not burn 18 8.91% Type II Diabetes 54 26.73% Insect bites 4 1.98% No History of DM 120 59.41% Arterial 3 1.49% Not Documented 5 2.48% Cellulitis 2 0.99% Pilonidal Cyst 1 0.50%

Duration 0 – 4 weeks 118 58.42% 5 – 8 weeks 39 19.31% 9 - 12 weeks 14 6.93% 13 - 20 weeks 10 4.95% > 20 weeks 17 8.42%

Exudates None 17 8.42% Small 90 44.55% Moderate 63 31.19% Large 25 12.38% Copious 4 1.98%

Table 4-2. Types of Dressings and Amounts of Granulation Tissue Type of dressing N=202 Wet-to-dry 84 41.58% Dry Gauze 14 6.93% Enzymatic 15 7.43% Iodoform 10 4.95% Vac 10 4.95% Silvadene 9 4.46% Wound Gel 7 3.47% Hydrocolloid 7 3.47% Antibiotic oint, etc 7 3.47% Alginate 7 3.47% Profore 3 1.49% Unna Boot 3 1.49% Silver Dsg. 3 1.49% Foam 2 0.99% Hydrofiber 2 0.99% Vaseline Gauze 2 0.99% Transparent 1 0.50% PDGF 1 0.50% No orders specified 6 2.97%

Amount Granulation N=202 100% 62 30.69% 76 – 99 % 98 48.51% 51 – 75% 7 3.47% 25 – 50% 10 4.95% < 25% 5 2.48% Not documented 20 9.90%

Research Questions

What is the Incidence of Wet-to-dry Dressings?

The chart (chart 4.1) below illustrates the incidence of wet-to-dry dressings in the study population of 202 wound care patients. It reveals that wet-to-dry dressings were by far the most frequently ordered dressing (42% of the time) compared to the next highest frequency for enzymatic dressings or dry gauze (a frequency of approximately 7% each).

Wound Dressings Wet-to-dry

Dr y Gauze

En z ym at ic

Iodoform Cwocn to make Wound Gel recom 3% 4% Vac Hydrocolloid 3% Silvadene Silvadene Cwocn to make 4% Antibiotic oint, etc 3% recom Wound Gel Vac 5% Alginate Hydrocolloid 3% No orders specified 3% Iodoform Antibiotic oint, etc 5% Profore Alginate En z ym at ic 1% 7% Unna Boot No orders specified 1% Dr y Gauz e Othe r Silver Dsg. 7% 11% Profore 1% Foam Unna Boot 1% Hydrofiber Silver Dsg. 1% Vaseline Gauze Foam 1% Wet-to-dry PDGF Hydrofiber 42% 0% Transparent Vaseline Gauze 0% Transparent

PDGF

Figure 4-1. Incidence of Wet-to-dry Dressings in a Sample of 202 Wound Care Patients.

What Types of Wounds are Wet-to-dry Dressings Being Used For?

The chart below (Chart 4.2) illustrates wet-to-dry dressings are ordered for all types of wounds (arterial, venous, pressure, neuropathic, surgical, injuries other than burns, cellulites, pilonidal cysts, and insect bites) but with surprising frequency in surgical wounds.

120 99 100

80 All dressings 58 60 Wet-to-dry 41 40 30 Not wet-to-dry 21 25 23 18 14 18 14 20 9 8 7 3 2 1 3 5 4 1 0 In ju ry Arterial Venous Insect, Surgical pilonidal Pressure Cellulitis, Neuropathic

Figure 4-2. Dressings by Wound Type by Number of Subjects.

Wet to Dry Dressings

Arterial Insect Bite 2% 2% Cellulitis Venous 1% 4% Pressure Arterial Injury other 6% than burn Venous 5% Neuropathic Pressure 11% Neuropathic Surgical Injury other than burn Cellulitis Surgical 69% Insect Bite

Figure 4-3. All Wet-to-dry Dressings by Wound Type

What Specialties of Health Care Providers Are Most Frequently Ordering Wet-to-Dry Dressings?

This research suggests that general surgeons are the health care providers most

frequently ordering wet-to-dry dressings. 32 out of 48 general surgeons in the study

ordered wet-to dry dressings (67%). See Chart 4.4 for a better description of these

results.

Wet-to-dry dressings ordered for all wounds by specialist

not listed Card Surg RM Oral Surg PT w/md Urology Hem/onc Trauma S GI Ortho GYN DPM PS GS VS IM FP

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 Number of subjects

Figure 4-4. Wet-to-dry Dressings by Type of Healthcare Specialist

When Wet-to-Dry Dressings Are Being Ordered, Do Clinical Data Suggest the Need for Mechanical Debridement?

Table 4-3. Amounts of Granulating Tissue Noted in the Wound Beds Wet-to-dry (n=84) All other dressings (n=118)

76-99% Gran 100% % Not 76-99% Gran 100% % Not Tissue Granulating documented Tissue Granulating documented n=36 n=30 n=12 n=61 n=32 n=8 43% 36% 14% 52% 27% 7%

If the numbers from the dry gauze dressings group are added to the wet-to-dry

group, then the significance of types of wound dressing is increased. See Chart 4.5 below

for breakout data including dry gauze.

120 99 All dressings

80 58 Wet-to-dry

40 30 29 21 25 23 Dry Gauze 17 14 18 9 12 12 8 3 2 0 1 3 1 5 00 4 2 3 0 5 0 Not wet-to-dry or dry gauze Injury Arterial Venous Insect, Surgical pilonidal Pressure Cellulitis, Neuropathic

Figure 4-5. Breakout Data for Dry Gauze Dressings, Wet-to dry Dressings and all others.

Table 4-4. All Dressings by Wound Type. Number of Subjects Cellulitis, Dressing Type Arterial Venous Pressure Neuropathic Surgical Injury Insect, pilonidal All dressings 3 21 30 23 99 18 8 Wet-to-dry 2 3 5 9 58 4 3 Dry Gauze 0 1 0 0 12 2 0 Not wet-to-dry or dry gauze 1 17 25 14 29 12 5

Percentages Cellulitis, arterial venous pressure neuropathic surgical injury Insect, pilonidal wet-to-dry 67% 14% 17% 39% 59% 22% 38% dry gauze 0% 5% 0% 0% 12% 11% 0% other dsg 33% 81% 83% 61% 29% 67% 62%

Finally, in an analysis of the data obtained in this study to determine if there were significant differences in the wet-to-dry group, the Chi-squared test of significance was utilized. This revealed that physician specialty (general surgeon, p <.0001), amount of exudates (small or moderate, p = 0.0017), wound location (abdominal, p = 0.0003), wound type (surgical, p = 0.0002), wound thickness (full thickness, p = 0.0001) were all statistically significant. Also significant was the amount of granulating tissue in the

wound bed (>75%, p = 0.1075) but this is more difficult to realize since 100%

granulation and > 75% were not in the same category.

CHAPTER 5 DISCUSSION AND CONCLUSIONS

Discussion of Findings

The purpose of this descriptive study was to observe the incidence of health care providers ordering wet-to-dry dressings as the principal wound care modality, note the specialty of health care providers most often ordering these dressings, determine the type of wounds for which wet-to-dry dressings are ordered, and to investigate associated data that would indicate whether or not the clinical condition of these wounds at the time of the wet-to-dry dressing indicated a need for mechanical debridement. This chapter will review the data obtained in the study, remark on the use of dry gauze as well as wet-to- dry dressings, comment on surgical wounds, examine the use of cytotoxic solutions in wound care, and review the principles of mechanical debridement. A summary will be presented at the end of this chapter after limitations of the study and conclusions are discussed as well as implications for future research, practice and education.

Data Review

This study describes a retrospective review of 202 patient patients with open wounds (healing by secondary intention) from a large home health agency and wound care case management program at a health maintenance organization (HMO) in Florida.

This study suggests the current incidence of wet-to-dry dressings is over 41% of all principal wound care modalities, followed next by enzymatic (7.43%) and thirdly, dry gauze (6.93%). The majority of wounds with wet-to-dry ordered are surgical. Out of the

84 wet-to-dry dressings ordered in this population, 58 were ordered on surgical wounds

41 42

(69%). Of these 58 surgical wounds, 51 (88%) were ordered by a surgical specialty

(general surgeon, GYN surgeon, GI surgeon, orthopedic surgeon, cardiac surgeon, trauma surgeon, etc). Interestingly, 7 (12%) of the 58 wet-to-dry surgical wound dressings ordered were ordered by non-surgical specialists (rehabilitation medicine,

DPM, urology, internal medicine). The next most frequent type of wound where wet-to- dry dressings were ordered was neuropathic ulcers (10%) and thirdly pressure ulcers

(5.9%).As suggested above, this study implies that general surgeons are the health care specialists most likely to order wet-to-dry dressings. Out of the 84 wet-to-dry dressings ordered for wound treatment in this study, 32 (38%) were ordered by general surgeons.

The next highest frequency of health care provider to order wet-to-dry dressings in the study population was internal medicine, with 12 (14.2%) out of 84.

0.0017), wound location (abdominal, p = 0.0003), wound type (surgical, p = 0.0002), and wound thickness (full thickness, p = 0.0001) were all statistically significant.

Dry Gauze

This study revealed 84 out of 202 dressings ordered were wet-to-dry (41.58 %). An additional 14 were dry gauze (6.93% of all dressings). This means that wet-to-dry or dry gauze dressings made up > 48% of all the wound dressings ordered. No admission orders for wound dressings were written on six patients. One chart had no dressing orders listed on the chart. On eight patient charts the physician wrote orders asking for HHRN or

CWOCN recommendations. 23 providers ordering wound care were family practice

physicians, 25 were internal medicine, 6 were vascular surgeons, 48 were general

surgeons (32 of these 48 ordered wet-to-dry). Most of the surgical wounds in the study

were abdominal wounds and most of the wounds that wet-to-dry dressings were ordered

for (78%) had > 75% granulating tissue noted in the wound bed.

Surgical Wounds

As was stated above, the majority of wet-to-dry dressings were ordered for surgical

wounds. 58 of the 84 wet-to-dry dressings were on surgical wounds – this represents 69%

of all wet-to-dry dressings ordered in the study (Chart 4.3). It is important to note that

these are not closed incisions; these numbers represent open wounds (dehisced abdominal

wounds such as hysterectomies, caesarean-sections, gastric bypass or GI surgeries,

incision and drainage of abscesses, etc.), a great deal of which have mostly granulating

wound beds (see table 4.3). In addition, 78 out of 84 (93%) of the wounds that wet-to-dry

dressings were used on were full-thickness wounds. Only 6 of the 84 wet to dry dressings

ordered were for partial thickness wounds. It is important to be aware of what needs to

occur for partial thickness and full thickness wounds to heal. Partial thickness wound

healing includes resolution of the inflammatory response, followed by epithelial

resurfacing. Dermal repair occurs concurrently with epithelial cell migration. A moist

wound bed is desired to optimize this (Bryant, 2000; Doughty, 2004; Winter, 1962).

Healing of full thickness wounds, on the other hand, is far more involved. Repair of a full

thickness wound includes resolution of the inflammatory process, followed by a

proliferative phase where fibroblasts increase in number (proliferate) and produce protein fibers (mostly collagen) to lay down a delicate scaffolding or fiber matrix (granulation tissue) which is needed to fill in the wound defect. Also involved in this process is the

formation of delicate new blood vessels (angiogenesis). This entire process requires

adequate amounts of oxygen, nutritional protein, ascorbic acid and zinc as well as a moist

wound bed and protection from trauma, infection, foreign bodies and drying out (Bryant,

2000; Doughty, 2004).

A review of the literature concerning wet-to-dry dressings indicates a significant lack of research base for the practice of utilizing wet-to-dry or gauze dressings in general.

Many studies have used wet-to-dry dressings as a control dressing, but do not explain if

the difference they find in the tested product’s improved healing rates versus gauze

dressings is really due to the positive effects of the tested product or possibly negative

effects from the wet-to-dry or gauze dressings (Whitney & Wickline, 2003; see also

Banks et al., 1997; Cohn et al., 2004; Eginton et al., 2003; Xakellis & Chrischilles, 1992).

Other studies have demonstrated that even when wet-to-dry dressings are performed, they

are commonly done incorrectly or inconsistently (some once a day, twice a day, and

others three times a day; some caregivers moisten the adherent gauze before removal)

(Armstrong & Price, 2004; Ovington, 2001). Apparently, the principle of moist wound

healing is frequently misunderstood.

Cytotoxic Solutions

The results of this descriptive study indicate that wet-to-dry dressings are ordered

with disquieting frequency (>41% of the time) by general surgeons, plastic surgeons,

vascular surgeons, GYN, internal medicine and other specialties for a variety of wounds,

many with 100% granulating wound beds. In addition, it is remarkable to note that in

current practice, cytotixic solutions are sometimes also used as wound cleansers or in

conjunction with wet-to-dry dressings (Dakin’s, H2O2, Betadine, acetic acid, alcohol or

sulfamylon). 5 subjects in this study with wet-to-dry dressings ordered had Dakins

solution ordered as the ‘wet’ solution. In 1 subject wet-to-dry was ordered with 25%

acetic acid - this order most probably represented an error in the written order, but

certainly should have been clarified with the physician (household vinegar is only a 6% acetic acid solution and is known to be cytotoxic to fibroblasts). Gentamycin-

Clindamycin-Polymixon B (GCP) solution used in yet another wet-to-dry dressing.

‘Diluted betadine’ was ordered in 1 wet-to-dry, Sulfamylon was noted in 2 wet-to-dry dressings in this study. In addition, hydrogen peroxide ordered as a daily cleansing agent in 5 subjects with various primary dressings ordered.

Dakin’s solution was developed during World War I by English chemist, Henry

Drysdale Dakin, and a French surgeon and Alexis Carrel. It is a highly diluted, supposedly ‘neutral’ antiseptic solution used frequently for cleansing wounds, but it consists of sodium hypochlorite (0.45 % to 0.5 %) and boric acid (4 %). Studies have demonstrated that “concentrations of NaOCl (sodium hypochlorite as in Dakin’s solution) greater that 0.01% are lethal to fibroblasts” (Heling et al., 2001). In addition Dakin’s solution is unstable and cannot be stored more than a few days. Furthermore, multiple studies have demonstrated the cytotoxic effects of products used as wound cleansers such as acetic acid, sulfamylon, hydrogen peroxide, Betadine, alcohol and Dakin’s solutions

(Cooper, 1990; see also Boyce, 1999; Damour, 1992; Hidalgo, Bartolome & Dominguez,

2002). One must ask, “Why are these solutions still being used as a daily wound cleansing or packing solution?”

Mechanical Debridement

Mechanical debridement may be achieved with whirlpool, pulsed lavage/irrigation, or wet-to-dry dressings (Bryant, 2002). Larval or maggot therapy may or may not also be considered in this category (Thomas, 2002). The literature states that wet-to-dry dressings

are used primarily for mechanical debridement. They are not described in any of the

current scientific literature as having any other purpose. The use of wet-to-dry is usually

indicated when the wound is a “heavily necrotic wound” (Bryant, 2000), this suggests

greater than 50% or 75% of the tissue in the wound bed is non-viable. However, since

this percentage was not exact in the literature, it was felt that greater than 75% healthy,

viable tissue is present in the wound bed would most certainly be an appropriate measure

of a wound where mechanical debridement was NOT indicated (especially since the

amount of healthy tissue exposed to the potential trauma by removal of adherent gauze

would far outweigh any potential benefit by debridement of non-viable tissue). It was

therefore quite disturbing to note that in 79% of the subjects where wet-to-dry dressings

were ordered, there was greater than 75% granulating tissue noted in the wound bed. In

addition in 36% of all of the wet-to-dry dressings, NO debridement of any kind was

indicated – the wound bed was documented to have 100% granulation tissue present! It is

felt by the author that there was no clinical support for the use of wet-to-dry dressings in

most of the cases where it was ordered in this study.

Limitations of the Study

One limitation of this study may be that it was a retrospective study versus a prospective study, although with this type of descriptive data, it was not felt to weaken

the results. However, a prospective study in a larger population including wound healing

outcomes would potentially be a stronger study. Another limitation of the study could be

regional. The study site locations were both in north central Florida, so this may pose

regional bias. While the sample size was moderate (n=202), the population characteristics

being predominately white, over 60 years old, non-diabetic and having such a high

number of surgical wounds, could limit the generalizability of this study. A comparison

was not done looking at the frequency of these characteristics in the general population.

Overall, a larger study in more than one location (and tracking wound healing outcomes) with reproducible results would potentially make a stronger study.

Conclusions

The author recently read about a risk management case involving a woman with a

large abdominal surgical wound dehiscence status post abdominal hysterectomy, wet-to-

dry dressings were performed in the hospital, and in the home upon discharge from the

hospital. Her wound never completely closed, and two months later she presented to the hospital with constipation. While she was there the gynecological (GYN) surgeon visited her and noted that her abdominal surgical wound was not healed. The surgeon explored the wound and removed a retained 4”x4” gauze. She was sent home but was readmitted to the hospital two months later for continued ‘non healing’ of her abdominal wound. She was taken back to surgery and additional retained 4” x 4” gauze was removed from the abscess (Brenner & Johns, 2002). This is just one possible example of the inappropriate use of wet-to-dry dressings and perhaps poor technique as well. It may be unwise to pack large, deep wounds with separate gauze pads unless a count is recorded when they are placed in the wound and again when they are removed from the wound. One continuous

Kling or Kerlex gauze cut to the appropriate size and moistened with a wound gel may be

far more effective and less dangerous both to the wound bed and to the patient, as well as

less painful to the patient and more cost effective (Mosher, Cuddigan, Thomas &

Boudreau, 1999; see also Capasso & Munro, 2003; Harding, Cutting & Price, 2000;

Ovington, 2001).

A descriptive study was recently conducted by Armstrong and Price (2004) to evaluate “what actually constitutes a wet-to-dry dressing, explain why it is used, and

48 describe how specialist nurses interpret this technique.” Their research suggests that wet- to-dry dressings (or dry gauze) are prescribed commonly for situations where there is little evidence to support their use, such as with open surgical wounds healing by secondary intention. It demonstrated that there is inconsistency among surgeons and specialist nurses on how the technique should be performed - particularly relating to whether the gauze should be dry or moist when removed. Although 75 percent of respondents had access to more sophisticated dressings, reasons for not using these dressings included “conflict with traditional approaches to wound care, lack of education, and cost issues” (Armstrong & Price, 2004).

Wet-to-dry dressings may only be indicated for mechanical debridement of necrotic tissue, but preliminary studies point out that they are done far more frequently than medically indicated and for many wounds that have 100% granulating tissue in the wound bed. This thesis data suggests that this is indeed the case. This is a very disturbing consideration. Further, this data suggests that a more professional multidisciplinary approach to wound care, which is firmly evidence based, needs to be developed.

Several problems or concerns regarding current wound care practices arise from this thesis study and others similar to it (Armstrong and Price, 2004). In this age of scientific advancement, wound care needs standardization and consistency. It has been said, “no one owns wound care.” Wound care is provided at inpatient, outpatient, and wound clinic facilities, in MD offices, home care and nursing homes. Wound care is ordered and performed by primary care physicians, specialist physicians such as general surgeons, plastic surgeons, orthopedic physicians, rehabilitation medicine, internal medicine, GYN, DPM; physical therapists, PA’s, NP’s, etc. There seems to be

tremendous knowledge deficit or educational insufficiency in the area of appropriate

wound care practices and the use of dressings for open wounds healing by secondary

intention. Medicine presently has no wound care specialty education or board

certification, although in a recent issue of Wound Repair and Regeneration is appears that

this is on the horizon (Ennis, 2004). Physicians, therapists and nurses may obtain CWS

(certified wound specialist) certification through meeting wound care experience criteria

and passing a national board certification through the American Academy of Wound

Management, but this is not recognized by the American Medical Association or board of

medicine as a physician board specialty. Nursing has several national board certifications

for wound care (WCN, WOCN, CWOCN, CWS, etc.) mostly obtainable through

specialty programs in the United States like Emory University’s Wound Ostomy

Continence Education Program Center (Atlanta, GA), but wound care education using

advanced modalities is not at present a part of most nursing education programs – either

at the undergraduate or the graduate level. Health care professionals and educators

nationwide must address these didactic deficits in health care education.

Implications for Future Research

More data in needed to examine ‘how’ wet-to-dry dressings are being utilized locally, nationally, and internationally. Questions could be answered through scientific study such as: “Is the present use of wet-to-dry dressings for wound care a local problem?” “How big is the scope of the problem?” or “Should this thesis research study be expanded to a national level?” It may be beneficial to measure outcomes of wound dressings with randomized controlled trials (RCT) including large samples, done longitudinally, over time to track final healing outcomes and wound recurrence rates.

Other research questions to explore include: “What solutions are being used with gauze

50 in dressings (Betadine, Dakins, Sulfamylon, GCP, H2O2, acetic acid)?” “Should this practice be changed, and if so, how?” “Regarding wet-to-dry dressings – should they be extensively tested as a wound modality not just as a control (i.e. study the effects of wet- to-dry on the micro cellular environment of the wound bed and track healing outcomes and infection rates in patients with these dressings versus other well-tested dressings)?”

Or “Should wet-to-dry dressings not be used at all?”

Implications for Practice and Education

‘Why’ are wet-to-dry dressings still being used? What influences healthcare providers to continue to use wet-to-dry dressings (and/or cytotoxic solutions)? Is it tradition, culture, age of provider, lack of wound care knowledge, lack of standardized wound care education in medical (particularly surgical rotations?), therapy and nursing programs, or possibly confusion over multitude of wound products?

A closer look is definitely warranted. What is the present state of wound care education in health sciences: Nursing (undergraduate, graduate, advanced practice, doctoral levels), Medicine (every specialty rotation – and particularly surgery), Physician

Assistant programs, and Physical therapy programs? Is there a need for, and can wound care education be standardized throughout these multidisciplinary programs?

Implications for Practice and Education

The progress of the Internet has made available an enormous mass of research information not readily available to practitioners in the past. This has resulted in the development of evidence based medical practice. Evidence based medical practice is a term first coined in the 1990’s. Historically, evidence based medicine (EBM) was developed in Canada to teach medical students but was later applied to solving clinical

problems. Prof. David Sackett and his colleagues at Oxford are now encouraging its

application in the UK.

Sackett stated, "Evidence based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. This practice means integrating individual clinical experience with the best available external clinical evidence from systematic research"(Sackett et al., 1996).

There are several national guidelines for wound care available from the WOCN or listed on www.guidelines.gov (such as for lower extremity arterial ulcers and for pressure ulcers). There is an urgent need for health care providers to utilize standard treatment guidelines and for researchers to develop additional evidence based guidelines in the future that are more specific when it comes to recommending a type of dressing (besides saying ‘choose a dressing that will provide a moist wound environment’). Nurses need to be involved in research that will lead us to question traditions in wound care that are not supported with scientific evidence as well as research which will guide our current clinical practice and help to standardize care with well-tested effective products that are available, less painful and most cost effective.

A. John Popp, M.D. (1995), author of Crossroads at Salerno: A biographical sketch of Eldridge Campbell and the writings of Teodorico Borgognoni on wound healing reflected on Eldridge Campbell’s work in the 1940’s. Theodoric was an Italian surgeon circa 1205-1296 that first described surgical debridement of wounds, rinsing them with wine, re-approximating the edges of the wound and covering them with clean lint soaked in wine (most likely acting as an antimicrobial) for 3 to 4 days. His practices were all but lost and forgotten until WWII, when neurosurgeon Eldridge Campbell learned of them

when older Italian army surgeons in Italy described them to him and Campbell began to

use them with great success instead of the current practice of the time, which was to use a

“closed plaster method to treat wounds”. Campbell then sought to translate the methods

and wound healing principles of Theodoric and modernize them, using antibiotics in the wound instead of wine. He attempted to bring these principles to the US, where he met with some resistance by the medical community. Popp remarked about Campbell,

In persevering in his translation of Theodoric’s works, Campbell has offered us what is often sadly lacking in medicine today: perspective. Through his research, he has taken us to the crossroads at Salerno and allowed us to look down two roads: one firmly rooted in medical tradition and one reflecting a willingness to question those traditions and the authorities behind them. Today, as in the past, the medical community stands at a similar crossroads. We must strike a balance between accepting the teaching of the “authorities” in medicine and questioning those authorities, while keeping in mind that the patients we treat are not well served by physicians who fail to examine the validity of commonly accepted medical practices or who dismiss summarily new and innovative approaches that are proposed. Finally, as we examine the tenets established by the authorities, we must strive to judge the facts on which they are based, not the people who present them (p. 176).

Perhaps wet-to-dry dressings do not have a place in modern wound care. It may be that

wound gel-moistened gauze should have replaced wet-to-dry 20 years ago. It has been

demonstrated that there are far more efficacious options available now to accomplish

moist wound healing as well as debridement. These include: hydrocolloids, gels, silver

dressings, alginates, foams, hydrofibers, specialized compression wraps, transparent

dressings, platelet derived growth factors, enzymatics, bioactives, collagen matrixes,

composites, pastes, non-cytotoxic antimicrobials, larval therapy, pulsed lavage, sharp

debridement, autolytic debridement, etc. Many of these products and procedures are very

well-tested, yet should continue to receive on-going testing and retesting to determine

their efficacy and optimum use. Health care providers should familiarize themselves with

wound healing products and principles, get recommendations or refer to someone who is

certified in wound care (such as: CWOCN, ET, CWS, WOCN etc.) rather than blindly

following tradition. •

Wound care is evolving into much more than just dressing the wound. Currently

there are many advanced wound treatment modalities available such as: Negative

Pressure Wound Therapy (wound vac), Warm up therapy, Anodyne (infrared light

therapy for treatment of diabetic neuropathy), Provant (radiofrequency signals), bio-

engineered collagen matrix taken from the submucosa of bovine intestine (Oasis) and tissue-engineered skin substitutes (Apligraf), to name a few. Many more are on the horizon. Wound care research is booming with new ideas like topical application of oxygen in a foam transport, more cost effective tissue engineering of skin, cartilage and

bone, and gene therapy. Where does the use of wet-to-dry dressings fit into this modern

age of wound care?

Summary

In summary, the author believes the literature to present does not support the use of wet-to-dry dressings for wound care of granulating wounds. Furthermore, it is suggested by the results of this retrospective review of wound care patients that wound care is frequently being done with inappropriate frequency and methods. This implies an urgent need for standardized wound treatments, as well as wound care education for all healthcare providers involved in ordering wound care treatments.

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BIOGRAPHICAL SKETCH

Linda Cowan was born and raised most of her life in Miami, Florida. She attended

Jackson Memorial Hospital School of Nursing as well as Miami-Dade Community

College in the late 1970’s and early 1980’s. She was employed as a registered nurse for over 20 years before going back to graduate school in 2001. She currently resides in

Gainesville, Florida, with her husband and children. She is a member of the Florida

Nurses Association, Southern Nursing Research Society (SNRS), the Wound, Ostomy and Continence Nurses Society (WOCN), and the Wound Healing Society (WHS), where she serves on the education committee. She is also board certified as a wound specialist and has participated in several research studies involving wound care over the past two years. She graduates from the University of Florida with her Master of Science in

Nursing degree in December 2004, and will be licensed as an Advanced Registered Nurse

Practitioner with a board certification in family practice. Her career goals include pursuing a doctorate degree in nursing and contributing to education and research, particularly in the area of wound care.