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:
- Clinical best practice(s)
- Proven result or outcomes data about moist wound healing
- Educational requirements—agency staff and referral sources
- 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 email@example.com or a CWOCN in your area. Please join me in this endeavor to become a "no more wet-to-dry" agency!
Agency for Healthcare Research and Quality. (2005, March 8). Usual care in the management of chronic wounds: A review of the recent literature
(Technology Assessment). Retrieved from Center for Medicaid and Medicare Services
Armstrong, M. H., & Price, P. (2004). Wet-to-dry dressings. Fact and fiction. WOUNDS, 16
Ayello, E. A., Dowsett, C., Schultz, G. S., Falango, R. G., Harding, K. G., & Romanelli, M. D. (2004). TIME Heals all wounds. Nursing2004, 34
Ayello, E., Ciddigan, J., & Kerstein, M. (2002). Skip the knife: Debriding without surgery. Nursing2002, 32
Baldwin, K. M. (2005). How to treat and prevent pressure ulcers. LPN2005, 1
Bergstrom, N., Bennell, M. A., & Carlson, C. E. (1994). Treatment of pressure ulcers
[Clinical practice guideline No. 15]. Rockville, MD: US Department of Health and Human Service, Public Health Service. Agency for Healthcare Policy and Research. Publication NO 95–0652.
Bolton, L. (2007). Evidence based report card. Operational definition of moist wound healing. Journal of Wound Ostomy Continence Nursing, 34
Centers for Medicare and Medicaid Services. (2005). Medicare Coverage Advisory Committee: Usual care of chronic wounds. March 29, 2005
. Retrieved from Centers for Medicare and Medicaid Web site.
from Centers for Medicare and Medicaid Services Web site. (2010). OASIS Background
. Modified December 20, 2010. Retrieved
from Centers for Medicare and Medicaid Services (2010a). Process-Based quality improvement manual
(Guidance Manual). Retrieved
from Centers for Medicare and Medicaid Services. (2010b). Process-based Quality Improvement (PBQI) Manual
from Centers for Medicare and Medicaid Services. (2011). State operations manual, appendix PP- guidance for surveyors for long term care facilities. (Rev 70, 01-07-11)
Cowan, L. J., & Stechmiller, J. (2009). Prevalence of wet-to-dry dressings in wound care. Advances in Skin and Wound Care, 22
Eisenbud, D., Hunter, H., & Zulkowski, K. (2003). Hydrogel wound dressings: Where do we stand in 2003? WOUNDS, 49
Fleck, C. (2009). Why "wet to dry"? Journal of the American College of Certified Wound Specialists, 1
, 109–113. doi: 10.1016/j.jcws.2009.09.003
Fonder, M. A. (2008, February 1). Treating the chronic wound: A practical approach to the care of non-healing wounds and wound care dressings. Journal of the American Academy of Dermatology, 58
(2), 185–206. Retrieved from Medline database.
Highmark Medical Services, Inc. (2010, September 7). Local coverage determination (LCD) L27547: Wound care
[Medicare Medical Policy Coverage Document]. Camp Hill, PA: Highmark Medicare Services, Inc.
Lee, J. C., Kandula, S., & Sherber, N. S. (2009). Beyond wet-to-dry: A rationale approach to treating chronic wounds. Journal of Plastic Surgery, 9
, 131–137. doi: PMCID: PMC2680240.
National Center for Health Statistics. (2005). Health, United States, 2005 with chartbook on trends in the health of Americans
(76–641496). Centers for Disease Control (CDC). Washington, DC: U.S. Government Printing Office.
from National Institute of Health and Clinical Excellence. (2008). Surgical site infection: Prevention and treatment of surgical site infection
Ovington, L. (2001). Hanging wet-to-dry out to dry. Home Healthcare Nurse, 19
Ovington, L. (2002, March/April). Hanging wet-to-dry dressings out to dry. Advances in Skin and Wound Care, 15
from Park-Lee, E. Y., & Decker, F. H. (2007). Compare of home health and hospice agencies by organizational characteristics and services provided: United States 2007
(National Health Statistics Report; No 30). Retrieved
Schwien, T., Gilbert, J., & Lang, C. (2005). Pressure ulcer prevalence and the role of negative pressure wound therapy in home health quality outcomes. Ostomy Wound Management, 51
Spear, M. (2008, April–June). Wet-to-dry dressings: Evaluating the evidence. Plastic Surgical Nursing, 28
© 2011 Lippincott Williams & Wilkins, Inc.
Winter, G. D. (1962). Formation of the scab and the rate of epithelialization of superficial wound in the skin of the young domestic pig. Nature, 193