Wounds have been a health concern ever since the first Homo sapien sustained injury while flaking a stone blade about 40,000 years ago. Despite efforts over thousands of years, however, wound prevention and care practices that are not evidence-based are still used in all health care settings. 1 Bridging the gap between research and practice will entail careful examination of institutional and other obstacles impeding the improvement of wound care. 2 Although it would be impossible to discuss all potential obstacles in this article, it will be helpful to consider a few common ones and suggest ways of surmounting them—particularly those pertaining to choosing the best wound dressing.
Obstacles to Improving Wound Care
One such obstacle is the plethora of wound care products available, including alginates; composites; absorbent foams; transparent films; hydrocolloid dressings; and woven, nonwoven, impregnated, or nonimpregnated gauze dressings. With so many choices, determining which product to use and when to use it is not a simple matter. In addition, most nonpharmacologic wound prevention and treatment products can be marketed on the basis of limited, if any, safety and efficacy data. For example, in a meta-analysis, Kerstein and colleagues 3 conducted a search of the literature for outcomes data presented in various wound treatment studies, excluding those with sample sizes of fewer than 100 wounds. They found only 3 pressure ulcer and 3 venous ulcer dressing regimens that had sufficient data for inclusion in the study, and these represented approximately 1% of all dressings available at the time. 4 Other products surely have some safety and effectiveness data available, but it is the clinician’s responsibility to determine whether the dressings being used at his or her facility have been tested.
The common institutional obstacles to improving wound care often pertain to tradition and economic considerations. Providers accustomed to certain products may be resistant to writing orders for new ones. Hospital purchasing departments pressed to cut costs may be reluctant to pay more than a few cents per dressing, and the practice of substituting less expensive but inferior products for better ones is common. At the same time, the gap between research and practice widens further and, as a result, most wounds continue to be dressed with a product wrongly considered as the standard in health care—gauze.
What the Data Indicate
Consider this summary of what more than 40 years of research has revealed about the healing of wounds: In comparison with dressings of the gauze type, those that retain moisture not only permit acute and chronic wounds to heal faster, but they are also associated with lower levels of pain, a lesser risk of infection, fewer dressing changes, and lower cost. 5 According to the combined results of 26 studies, the proportion of pressure ulcers that were healed after 8 weeks ranged from 25% in the gauze dressing group to 42% in the hydrocolloid dressing group. 3
A Comparison of Outcomes
In theory, some might argue, ordinary gauze dressings moistened with saline would provide a moist wound environment and an outcome comparable to that of a hydrocolloid dressing. But, in practice, it is difficult to keep a gauze dressing moist without maceration of the surrounding tissue; the dressing must be moistened or changed about every 3 hours. This regimen not only encumbers the clinician, but it can also further distress the patient, especially at night when sleep may be interrupted for dressing care.
In addition, whether moist or dry, gauze dressings do not protect wounds from infection and even may be a source of infection by cross-contamination. Studies have shown that bacteria take only a few minutes to penetrate 2 or more layers of gauze and are readily dispersed into the air during gauze dressing changes. 6 Several studies have also indicated that patients whose wounds are managed with dressings designed to retain moisture are in less pain than are those whose wounds that are managed with gauze dressings 7–9 because dressing changes are less frequent.
A Comparison of Costs
Changing a dressing 2 or 3 times per week rather than 2 or 3 times a day is easier on the patient and saves time and money. 5 Incorporating outcomes as factors in the cost formula gives the true measure of a treatment’s cost effectiveness. For example, Kerstein and colleagues 3 determined that in a typical managed-care plan, 3500 of every 100,000 people covered would have a pressure ulcer. In a modeling study based on outcomes from a literature review, they estimated that wound care costs to heal 1 ulcer in 12 weeks ranged from $910 per hydrocolloid dressing regimen to $2179 per gauze dressing regimen. Those figures represent the costs of only supplies and labor, not other costs related to equipment such as specialty beds, hospitalization, complications, or continuing care of ulcers that failed to heal after 12 weeks.
Any health care facility is likely to have a great number of patients with wounds at any time. According to the most recent National Pressure Ulcer Prevalence Survey, 10 the prevalence rate of pressure ulcers in acute care facilities is 14.8%, and every surgical and burn patient has at least 1 wound. Considering this, as well as the possible impact on outcomes, labor, and costs, it is not surprising that facilities are beginning to address the gap between research and practice.
One strategy involves the creation of a multidisciplinary wound care protocol review committee, the members of which would vary by facility but should include staff nurses, nurse managers, and representatives from relevant departments, such as vascular surgery, internal medicine, podiatry, physical therapy, pharmacy, and purchasing.
Committee members would:
- identify gaps in research and practice.
- search the literature concerning wound care within their areas of expertise (burn wound care, for example).
- obtain other relevant literature, which may include review articles and guidelines of care; meta-analyses; prospective, randomized, controlled clinical studies of various treatment modalities; and preclinical and clinical studies concerning topics of special interest (for example, wound contamination).
- create a list of products and treatment methods that have been studied and summarized in the findings.
- compare safety and efficacy of products and treatment methods in all types of wounds and for all indications, deleting those that do not work as well.
- call manufacturers to request additional product information, descriptions of related services (such as staff training programs concerning the use of the product), purchasing information, and product-trial options.
- discuss how current wound care practice might be improved and consider the practical aspects and implications of doing so at the facility.
- make a list of recommended changes in wound care practices.
Armed with clinical evidence supporting their recommendations and with practical information relevant to the implementation of new wound care practices, committee members will be better able to address and surmount institutional obstacles to change.
The evidence shows that moist dressings rather than dry gauze should serve as the standard in wound care, and this knowledge must be put into practice. Not all health issues will be as easily identified and studied, but it is essential that clinicians participate in such debates concerning health care practices and in all efforts to bridge the gap between research and practice. The quality of patient care—and the quality of their lives—depends on it.
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2. Beitz JM. Overcoming barriers to quality wound care: a systems perspective. Ostomy Wound Manage 2001; 47(3):56–64.
3. Kerstein M, et al. Cost and cost effectiveness of venous and pressure ulcer protocols of care. Disease Management Health Outcomes 2001;9(11)651–63.
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6. Lawrence JC. Dressings and wound infection. Am J Surg 1994;167(1A):21S–4S.
7. Madden MR, Nolan E, Finkelstein JL, et al. Comparison of an occlusive and a semi-occlusive dressing and the effect of the wound exudate upon keratinocyte proliferation. J Trauma 1989;29:924–30.
8. Smith DJ Jr, Thomson PD, Bolton LL, Hutchinson JJ. Microbiology and healing of the occluded skin-graft donor site. Plast Reconstr Surg 1993;91:1094–7.
9. Nemeth AJ, Eaglstein WH, Taylor JR, Peerson LJ, Falanga V. Faster healing and less pain in skin biopsy sites treated with an occlusive dressing. Arch Dermatol 1991;127:1679–83.
10. Amlung SR, Miller WL, Bosley LM. The 1999 National Pressure Ulcer Prevalence Survey: a benchmarking approach. Adv Skin Wound Care 2001;14:297–301.