DALE, BARBARA A. RN, BSN, CWOCN, CHHN; WRIGHT, DENISE H. RN, BSN, CCM, COS-C
A home health agency (HHA) receives a new referral for a patient with an open wound. The physician has ordered twice daily wet-to-dry wound dressing changes. The intake coordinator at the HHA requests from the referral source to use the agency's topical wound care protocols instead of wet to dry. The referral source then asks, what are these wound care protocols? The intake coordinator reads from the protocol that is entitled "alternatives to wet-to-dry" dressings for wound management.
According to the Centers for Disease Control (CDC), in 2005 there were 9,814 home health agencies and 3.1 million users/patients (National Center for Health Statistics, 2005). The most recent National Home Care and Hospice Survey sampled 1,904 home health agencies in 2004 and found there were 1.3 million patients in a home health episode and of that 1.3 million, more than 121,000 (or 9.3%) had a current diagnosis of disease of the skin and subcutaneous tissue, which includes pressure ulcers (Park-Lee & Decker, 2007). These data do not include any patients with other wounds such as surgical, stasis, diabetic, or traumatic. These data show that wound care and wound care management is an important component of home care.
Wet-to-dry dressings consist of moistened gauze placed in or on a wound, left until dry and then removed. This procedure is usually done one to four times daily. True wet-to-dry dressings help to serve the goal of mechanical debridement. However, practitioners in the United States order this wound care for all types of wounds in all types of settings even when mechanical debridement is not the goal (Baldwin, 2005).
How and Why to Use the Research
What is wet to dry? Do all healthcare practitioners define wet to dry the same? Do all physicians and practitioners consider the same technique when ordering wet to dry? Why do we still use wet-to-dry dressings? Tradition from the medical schools? Nursing preference? Do we perform the wet-to-dry procedure appropriately? How many clinicians moisten the gauze prior to removal? Research over the past 50 years repeatedly shows that wounds heal faster and stronger when moist wound healing principles are utilized. Is it a lack of consistency in basic wound care principles? Why are there no widely accepted standards? There are no widely accepted interdisciplinary basic wound care guidelines and there are no widely accepted verbiage or operational definitions for some aspects of wound care.
In 2005, the Centers for Medicare and Medicaid Services (CMS) held a Medicare coverage advisory committee meeting discussing the evidence of what encompasses usual care for chronic wounds. Although the panel was full of renowned wound care experts, no agreement could be reached because within the research there was "not only a lack of standardized usual care practices but also a lack of a standardization in the documentation process itself" referring to common verbiage and definitions (Agency for Healthcare Research and Quality [AHRQ], 2005; CMS, 2005, para. 282:21–22). In 2008, the National Institute for Health and Clinical Exellence (United Kingdom) released the guideline "Surgical site infection: prevention and treatment of surgical site infections" (National Institute of Health and Clinical Excellence [NICE], 2008). The guideline specifically states "do not use ... gauze, or moist cotton gauze ... to manage surgical wounds that are healing by secondary intention" (NICE, 2008, p. 15). Is the lack of common verbiage and standardized usual care part of the reason that wet to dry continues to be the most common topical wound care ordered? Or does it just fall upon tradition and what continues to be taught in medical schools? Fonder (2008) reported "until the message of moist care becomes taught as a standard of care in medical school, gauze will often be the treatment recommended by doctors... Gauze is still used probably 50% of the time...The gauze market is larger than the moist market" (p. 188).
In the past two decades, randomized controlled trials have repeatedly demonstrated that wet-to-dry dressings are not the most appropriate in all healthcare settings or wound care situations emphasizing the previously documented historical research (Ovington, 2001; Lee et al., 2009). In fact, the first research-based recommendation for moist wound healing as opposed to allowing the wound to dry out was published nearly 50 years ago (Winter, 1963). Research-based evidence published by the U.S. government as clincial practice guidelines has shown that a moist wound environment is a primary factor for the wound healing process to occur (Bergstrom, 1994). Wet-to-dry dressings allow the wound base to dry and healing cells to desiccate within the wound. These dressings can also be very painful for the patient, they physiologically impede wound healing, and the labor and supplies involved can add up to unnecessarily spent dollars (Armstrong & Price, 2004; Spear, 2008).
Wet to Dry: A Method of Debridement
The wet-to-dry dressing process is one of the methods of mechanical debridement. Logically thinking about this method tells the clinician that this may be painful, similar to pulling off a scab. This method removes healthy tissue attached to the gauze in the drying process. As this method is painful for the patient, most clinicians moisten or wet the gauze prior to removal, which defeats the intended purpose of mechanical debridement. Wet-to-dry dressings must also be performed several times per day and while gauze is seemingly a less expensive product than advanced wound care dressings, the labor costs actually make the dressing exponentially more expensive (Table 1).
Particularly in the HHA setting, wet-to-dry dressings can prove to be a costly venture. In one retrospective study, Cowan and Stechmiller (2009) reviewed 202 wound-specific charts and found that 42% (58) of all home health wound care orders were wet-to-dry dressings and that 78% of those were inappropriate because mechanical debridement was not clinically indicated. The only accepted indication for wet to dry is mechanical debridement (Bergstrom et al., 1994). This is because wet-to-dry dressings (1) are a form of nonselective debridement, removing healthy tissue as well as necrotic tissue; (2) are painful to the patient; (3) impede healing through local tissue cooling; (4) prolong the inflammatory process; and (5) increase the risk for wound infection (Ayello et al., 2002; Fleck, 2009; Spear, 2008).
With the advent of the HHA prospective payment system in 1997, HHAs are required to furnish all medically necessary routine wound care supplies in the bundled payment system. Although some may see wet-to-dry dressings as low cost gauze and saline, the supply costs are just the beginning. Add in the daily nursing visits and increased length of stay and the costs jump exponentially. Furthermore, quality initiatives increase the focus of home healthcare on outcomes and not just costs. Some studies have shown that more advanced therapies decrease healing times and thereby reduce length of stay for home health patients (Schwien et al., 2005). With pay for performance (P4P) on the horizon, agencies must devise a method to decrease costs and improve outcomes to stay fiscally viable in the changing times. P4P bases reimbursement not only on the Outcomes and Assessment Information Set (OASIS) data, but on patient outcomes. OASIS-C is a group of data elements that represent core items of a comprehensive assessment for an adult home care patient and is mandated by Medicare. The OASIS-C assessment is not used solely as a comprehensive assessment tool but produces data items necessary to measure patient outcomes. OASIS-C items have utility for outcome monitoring, clinical asessment, care planning, and other internal agency-level applications (Centers for Medicare and Medicaid Services Web site, 2010). Under the P4P system, agencies that rank in the top 10% for outcomes will receive higher reimbursements while those agencies in the bottom 10% will receive lower payments. For example, use of best practices is not mandated at this time, but the new process based outcomes manual states that certain best practice process measures "may be incorporated in future quality-based purchasing (pay for performance) system for home health care" (CMS, 2010a, Ch 1, p. 7). Examples of best practice process measures include OASIS-C M2250 Plan of care synopsis items: M2250f-the use of risk assessment tools for pressure ulcers and M2250g-pressure ulcer treatment based on principles of moist wound healing (CMS, 2010b). These best practice process measures were developed to evaluate the HHAs use of specific evidence-based processes of care.
One Agency's Performance Improvement Project
One method to establish your agency in the top 10% for P4P is to optimize best practices for wound care while eliminating wet-to-dry dressings. Our agency found that eliminating wet-to-dry dressings may increase patient healing rates, decreased emergent care for wound infections, decreased complications and potential adverse events, increased patient and physician satisfaction, and reduced supply costs. Implementing a "no more wet-to-dry" protocol at your agency may seem to be a cumbersome prospect but is worth the effort. Establishment of science based topical wound care protocols, staff and referral source education, and administrative buy-in are three critical components to a successful "no more wet-to-dry" program and agency. This is one agency's experience.
Starting a No More Wet-to-Dry Program
A proprietary rural freestanding HHA, the agency noticed their quality indicators were not as good as they thought they should be. Improvement in surgical wound status was 76.8% while the national average was 79.5%. Emergent care for wound infection was also up at 0.95% with the National average at 1.22%. Using a modified fish bone diagram, a root cause analysis was performed to help develop a plan for improvement (Figure 1). It was determined through the root cause analysis and through chart reviews that the use of wet-to-dry dressings were linked to these less than optimal outcomes.
The agency's certified wound ostomy continence nurse's (CWOCN) findings from a comprehensive literature review detailed that wet-to-dry dressings should not be routinely performed on all patients with wounds. A team was formed at the HHA which included the assistant administrator who is also an RN, the outcome-based quality improvement (OBQI) director who is an LPN, and the agency's CWOCN. A proposal to initiate a no more wet-to-dry policy in the agency was developed and submitted to administration for approval. Demonstrations of cost models were included in the proposal.
Luckily, education and clinical best practice is and always has been the driving force behind clinical decision and policy making at this HHA. After much discussion and careful consideration of the above factors, the decision was made to implement a "no more wet-to-dry" protocol within the agency. The plan was approved and began.
The first step was to develop alternatives to wet-to-dry protocol to go along with the agency's other wound care protocols (Figure 2). The team believed this would also help educate referral sources when the HHA initially started refusing to perform wet to dry. Providing the referral source with some options instead of just saying no was the initial goal towards permanent change. The "alternatives to wet-to-dry" protocol was then developed (Figure 3). The protocol included three choices for physician to initiate depending on specific patient wound care goals. HHA staff, marketing, and referral sources were also educated on the new initiative. This education included approximately 30 internal medicine or family practice physicians, surgeons, podiatrists, and wound clinic's staff. The education was completed over a 60-day period. Referral sources were educated about the concept of the program with goals being (1) improved patient outcomes and (2) less patient complications. Other goals of the new program were to improve the OASIS-C quality indicators related to wounds and wound care and maintain patient census.
Information from the long-term care surveyor guidelines, specifically F-tag 314, was used to show referral sources that agencies were being found deficient in care when providing wet-to-dry wound care inappropriately in that setting for care. F-tag 314 specifically states that "facilities may use wet-to-dry dressings in limited situations... may remove healthy tissue and increase resident pain" (CMS, 2011, p. 215). Peer-reviewed journal articles as well as product literature from the alternatives to wet-to-dry products were used as additional educational information for referral sources and left at the organization when/where the education occured. HHA intake staff, who are nurses, were educated about the new initiative using a "script" to model so that all referral sources heard the same consistent information (Figure 4).
At the beginning there was resistance at all levels. The most significant being clinical staff, who were comfortable with the tradition of wet-to-dry dressings and also did not want to upset the physicians. After all external and internal education was provided, the "no more wet-to-dry" program was in implementation mode. Several physicians initially refused to use the agency for their patients. In fact, one referral source stated such things as "I am the doctor" and "I won't be dictated to by a bunch of nurses...if you can't do wet to dry when I ask then you won't get any of my patients."
Staff education was mandatory to all clinicians that perform wound care including registered and practical nurses and physical therapists and physical therapy assistants. The education focused on the fundamentals of wound care and moist wound healing principles and was taught by the CWOCN (Figure 5).
To implement a "no more wet-to-dry" policy in your HHA, a better and more thorough understanding of moist wound healing and wet-to-dry wound care is necessary. Maintaining an arsenal of nationally accepted guidelines and peer reviewed journal articles will also facilitate staff in requesting moist wound healing wound care orders from referral sources instead of wet-to-dry dressings.
Providing the Science
Although the literature shows that research has generated a deeper knowledge and understanding of wound care and that wet-to-dry dressing are not therapeutic, wet to dry has remained in the forefront and is reported as the most commonly ordered topical therapy (Armstrong & Price, 2004; Cowan & Stechmiller, 2009). A great number of physicians continue to order wet-to-dry daily wound care for home health patients (Armstrong & Price, 2004; Ayello et al., 2004). Medicare's local and regional intermediaries explicitly state in their provisions of coverage that wet-to-dry dressing are only approved as medically necessary for mechanical debridement (Highmark Medical Services, 2010). HHAs should enable best practice by understanding the science and armoring themselves with scholarly articles for referral source education. The following are some articles that encompass the basic information needed to support best practice requests and recommendations for no more wet-to-dry dressings.
The Supporting Literature
Hanging Wet-to-Dry Out to Dry
One frequently cited article in wet-to-dry dressings is Ovington's Hanging wet-to-dry dressing out to dry. This article was reviewed and published in two scholarly journals over a year apart. In fact, the first publication was in Home Healthcare Nurse. Ovington's article begins with the primary factors of wound healing then continues on to discuss topical therapies; intergrating the information together in a manner that illustrates the therapeutic benefits of moisture retentive advanced wound dressings while pointing out how gauze dressings impede healing. The article also focuses on cost issues, particular to home care, with tables of comparison (Ovington, 2001; Ovington, 2002).
Wet-to-Dry: Fact and Fiction
Wet-to-dry: Fact and Fiction (Armstrong & Price, 2004) provides a compilation of the risks and benefits associated with use of wet-to-dry dressings. The stated purpose of the article is to "bring to the attention of surgeons some of the literature on wound dressings and the concomitant lack of research base for their practice of utilizing wet-to-dry" (Armstrong & Price, 2004, p. 58). Moreover, the article points out the discrepancies in the definition of the actual procedure of wet-to-dry dressings between healthcare providers.
Skip the Knife: Debriding Without Surgery
Skip the knife: Debriding without surgery (Ayello et al., 2002) does not provide details regarding wet-to-dry in other wound care scenarios, but simply establishes when it is appropriate and the steps needed for it to be effective. The article does specifically state when debridement should be stopped, which is when the woundbed is clean and granulation tissue has formed.
Hydrogel Wound Dressings: Where Do We Stand in 2003?
Eisenbud and colleagues summarize the state of advanced wound dressings in their article Hydrogel wound dressings: Where do we stand in 2003? The article emphasizes a multitude of past research indicating a moist wound environment is necessary for optimal healing to take place (Eisenbud et al., 2003).
TIME Heals All Wounds
Ayello again reviews topical wound care treatments in correlation with the healing process with rational for each step of topical treatment in TIME heals all wounds (Ayello et al., 2004). The article explains in rationalized, referenced detail how and why wet-to-dry gauze dressings are contraindicated, how they should only be used for mechanical debridement and then stopped as soon as granulation tissue forms, and that when gauze wet-to-dry dressings are used they cause the patient a significant amount of unnecessary pain.
With the above-listed articles and/or any of the many other available conveying the same message, HHAs are better equipped to request advanced and up-to-date science-based wound care for their patients from physicians and other referral sources. However, having the research and data to back up requests and recommendations are only a portion of establishing a "no more wet-to-dry" agency. Possibly one of the most important aspects of an effective wound care program is the creation and use of detailed standardized wound care protocols. Protocols help to establish a wound program where appropriate assessment, diagnosis, and planning occurs and is the most important aspect rather than focusing on what type of material the wound dressing is made from (Bolton, 2007).
Wound Care Protocols
A protocol is described as a document with the aim of guiding decision and criteria regarding diagnosis, management, and treatment in specific areas of healthcare. The benefit of wound care protocols is that they ensure continuity of care, provide consistency through staff and caregivers, can be evidence-based and best practice, can be individualized, can be multidisciplinary, and they decrease supply and labor costs. Protocols help the clinican choose the best treatment for the patient to achieve the desired goals. This supports the standardization of care and process across the organization. An overall goal of developing a protocol set would be to improve patient outcomes and quality of life by using evidence-based wound care principles through an established set of wound management protocols.
Protocol development begins with a need assessment. What types of wounds are common to your agency? Are there great variances or does your agency usually care for the typical surgical, leg ulcers, pressure ulcers, and diabetes/neuropathic ulcers? Does your agency prefer very specific protocols or is a general format more favorable? Some manufacturers will assist HHAs in forming generalized protocols but typically the products are limited to that manufacturer. Protocols can also be purchased. Developing agency specific protocols can be a time-consuming process, but is achievable. Protocols help maintain consistency in wound care, ensure positive wound care outcomes, and reduce risk of complications. Having one good template can help you in developing the core portion of all the HHAs protocols. Consider enlisting the assistance of a CWOCN because they are an expert in the field of wound care, wound care is very complex, and the abundance of available products to sift through may be overwhelming. The clinical expertise of a CWOCN may also help educate your staff with wound assessment, documentation, and OASIS-C items.
Form a team of people who will work on this performance improvement project. This might include your HHA supply clerk, a visiting nurse, and an administrative person. You will have a few decisions to make. These include: types of protocols, number of protocols, what you will include on the protocols, and variance of products to include on the protocols. Get started first by gathering your evidence-based guidelines and resources.
The agency's wound management program contains 13 specific wound care protocols (Figure 2). Each protocol contains a description of the wound, etiological/systemic nursing interventions, topical care, and documentation requirements. Topical care includes more than one product so that patient individualization and staff preference can occur. Each protocol is divided up into sections: (1) Description of wound, (2) Interventions, (3) Topical care, and (4) Documentation (Figure 6). Including these four areas on each protocol allows the clinician to understand not only why they are using a specific products but to understand that wound care is not just about what product is put on the wound. All protocols are evidence based and are updated annually and as needed. Protocol X-Alternatives to wet to dry (Figure 3) also has options based on physician goals. For example, if the physician's goal is maintaining a moist wound environment then plain hydrogel is an option. To decrease bioburden, a silver hydrogel is listed. Collagen hydrogel is also an option if the physician goal is to faciliate granulation formation. Using Protocol B as a template, review the list of your current supplies, then note what a protocol at your agency might look like. Once you have a complete set of protocols, you can move on to the next phase of implementing a "no more wet-to-dry" agency.
Putting It All Together
Your agency has operationalized the change, has educated the staff, educated referral sources with guidelines and journal articles, and has a set of wound care protocols. It is time to implement your HHA's "no more wet-to-dry" program. Keep in mind that your intake staff may need some assistance on how to handle referral sources that may continue to insist on wet-to-dry dressings (Figure 4).
Administrative Buy-In Is Key—Lessons Learned
Of course, administrative buy-in is key to implementing a "no more wet-to-dry" protocol within your agency. You must have the willingness of administration to back this policy even if you lose referrals to begin with, as well as the ability to make the decision in the first place if you are attached to a corporation who administers blanket policies for multiple business license or multiple locations.
When working with administrative staff in our agency, the following areas were critical considerations:
1. Clinical best practice(s)
2. Proven result or outcomes data about moist wound healing
4. Educational requirements—agency staff and referral sources
5. Consideration of MD resistance which could equate to loss of referrals.
All staff must be educated who are currently employed as well as any new staff. This requires continuous educational planning and provision. MD education is key as is consistency. You must be consistent and firm in your decision not to accept wet-to-dry orders. Supply access must also be addressed. You must have access to purchase the correct products for moist wound protocols. Outcomes data are more important than ever with this change. You must have outcomes data to provide which supports that the program change is successful. A CWOCN is a definite positive to oversee a wound program and steer this level of performance improvement project. A fairly substantial wound population of clients is necessary to have a large impact on your patient outcomes, cost, visit reduction, and all associated factors related to continuous education.
For the agency, a gradual decline in the census of 7% was noted over the initial 6 months but by the 9th month, census was back to preprogram numbers and the percentage of wound patients had increased from 10% to 16%. The outcome data was analyzed at the end of the first year. Improvement in status of surgical wounds rose to 84.3%, which was higher than the national average at 78.5%, and emergent care for wound deterioration/infection decreased to 0.10% with the national average at 1.10%. The program was considered to be successful albeit there were still a few physicians who would not refer to the agency after this change. However, with administrative buy-in and outcomes and patient quality of life central to the program, the loss of these few physician referrals was deemed inconsequential. Overall, the change improved the caseload of patients referred to the agency with wounds.
While implementing a "no more wet-to-dry" program will increase physician and HHA staff awareness, increase patient satisfaction, and improve wound care outcomes, it is not viable to attribute 100% of the positive outcomes directly to not using wet-to-dry dressings. A host of other factors such as increased education of moist wound healing principles and topical wound care, increased face to face interaction with referral sources, fluctuating patient acuity and comorbidities, and changes in staff expectations can affect outcomes and all these and other factors must be taken into consideration. However, with P4P around the corner and new healthcare laws coming into effect, HHAs must find a way to provide evidence-based and cost effective care. Implementing a "no more wet-to-dry" program in your HHA can help to improve patient quality of life and outcomes, decrease agency costs, and move your agency into the 10% of P4P.
So, perhaps your agency should consider becoming a "no more wet-to-dry" agency. For more information about how you can develop a "no more wet-to-dry" organization, please contact firstname.lastname@example.org or a CWOCN in your area. Please join me in this endeavor to become a "no more wet-to-dry" agency!
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