Implementing Advanced Wound Dressing Protocol

Critical Appraisal Wet-to-Dry Wound Care
There is a need for surgeons and nurses to understand the impact of using a wet-to-dry dressing of wounds. Research on the usage of this method is over 50 years old and this was carried out by Dr. Winters. Although the research was pivotal and it demonstrated that wounds healed faster than those that were allowed to dry out. It is time for a change in practice. Nursing care is no longer about healing and treating, there is an aspect of care that is attached to it. There have also been major advancements, especially in wound care products. However, even with the advancements and development of superior products wet-to-dry dressing are still been used to date. According to Wodash (2012) wet-to-dry dressings are still the most commonly used primary dressing in most hospitals. The main reason has nothing to do with the appropriateness of them but rather on the lack of knowledge. Numerous nurses have reported the adverse effects that patients face when their wounds are dressed using this method. Patient care is reduced as the dressing has to be performed every 4 to 6 hours, which causes unbearable pain to the patient (Fleck, 2009). It is also assumed that the advanced products are expensive when compared to the wet-to-dry dressing products and this is not correct. The most common reason is the understanding by most physicians that gauze is a one size fits all and it is readily available.
Wet-to-dry dressings are meant to be used as a method of mechanical debridement (Wodash, 2012). Debridement is the mainstay of wound bed preparation because devitalized materials do harbor bacteria that delays healing and increases the risk of infection. While this is true, it does not mean that wet-to-dry dressing or moist gauze constitutes advanced wound care (Fleck, 2009). A wet-to-dry dressing is a nonselective debridement and it is painful for patients who are sensate and has the potential to result in numerous negative outcomes. Mechanical debridement is a non-selective form of debridement that not only removes necrotic tissue, but also healthy granulating tissue. A wet-to-dry dressing is not ideal as it impedes healing by local tissue cooling, increases risks of infection, and is labor intensive. This method has been discouraged by several clinical guidelines. It has been established that gauze dressings are not the best for wound care. Gauze dressings have been found to not support optimal granulation and healing and they are more labor intensive when compared to advanced dressings like polyacrylates, hydrocolloids, foams, hydrogels, transparent films, and alginates (Wodash, 2012). It is for this reason that this old method of wound dressing should be abandoned as it not considered to be a standard of care.
Evidence
There is an increased chance of external infection and contamination when a wound is dressed using the wet-to-dry protocol. It has also been established that gauze dressings do not present any physical barrier to bacterial entry. Research has shown that bacteria can travel through 64 layers of gauze (Dale & Wright, 2011). The frequent dressing changes result in the temperature of the wound dropping, which causes vasoconstriction and decreases blood perfusion. This will result in the impairment of oxygen to clear bacteria from the wound that leads to an increase in the infectability of tissue. Every time the wound dressing is changed, there is cooling and destruction of the wound microenvironment that leads to hypoxia, which in turn impairs leukocyte mobility and phagocytic efficiency. There is a little impediment of fluid evaporation when a wound is dressed with a wet-to-dry dressing. The dressing does not provide moist wound healing not unless it is kept continuously wet. The inflammatory phase of wound healing is prolonged and this is counterproductive to all efforts of wound closure (Dale & Wright, 2011). As saline evaporates it becomes hypertonic and the fluid from the wound is pulled into the dressing promoting desiccation. As the wound dries there are cell migration and impediment of proliferation. Then as the dried dressing is being removed there is a dispersion of significant amounts of bacteria into the air.
It has been established that even with the advancement of dressing products and the products been readily available. physicians will still prescribe wet-to-dry dressing instead of the other advanced modalities (Fleck, 2009). This was research based on the responses of 127 general surgeons. The interesting fact is that although the physicians had access to the advanced therapies, they still opted to prescribe wet-to-dry dressing. A wet-to-dry dressing is erroneously considered to be a standard of care (Adkins, 2013). There have been cost analysis that has been done to determine if a wet-to-dry dressing is cost effective and it has been established that the cost of care is reduced when the advanced dressing is used. The major cost of care was found to be nursing time and this was still with some of the patient's or their family helping to care and dress the patient (Ousey, Rippon, & Stephenson, 2016). Due to the frequent dressing changes the cost of wet-to-dry dressing increases wound care cost. According to the Association for the Advancement for Wound Care, they developed a comprehensive guideline that had recommendations for debridement (Wodash, 2012). The guideline considered wet-to-dry dressing as substandard practice. It has been recommended that the use of gauze be avoided because it delays healing, increases pain, dressing change frequency, infection rates, and is not cost effective. The study by the association made a comparison to the other advanced wound dressing therapies. There have been other dressing therapies that have been shown to be less painful when compared to gauze dressings.
Hall et al. (2018) posits that wound pain may be decreased if a moist wound environment is maintained. However, this would require there to be continuous wetting of the wound and this is not possible all the time. Therefore, there is the possibility of pain occurring. While this method of wound care has been used and still continues to be used there is little evidence that supports its continued usage. This demonstrates the underlying problem when it comes to wound care. There is little evidence to support the method been used. While the main goal for wet-to-dry dressing is mechanical debridement it is used for all types of wounds even when there is no goal of mechanical debridement.
There is supporting evidence that eliminating wet-to-dry dressing increases patient healing rates, decreases emergent care for wound infections, decreases complications, increases patient and physician satisfaction, and reduces supply costs (Powers, Higham, Broussard, & Phillips, 2016). Initially it might seem that implementing a no more wet-to-dry protocol is cumbersome, however, it is worth the effort. It is expected that most clinical staff will resist the new protocol mainly because they are comfortable with the tradition of wet-to-dry dressings. Some of them would rather continue using this method in order to not offend physicians. With proper education and knowledge sharing, it is possible to fully eliminate the usage of wet-to-dry dressing.
In conclusion, nurses should question the usage of wet-to-dry dressing on patients who do not need mechanical debridement. This way they can push for advanced wound dressing protocol that has better outcomes and offers better patient care as compared to wet-to-dry dressing. There is also a need to increase knowledge amongst the physicians and nurses regarding the usage of advanced wound dressing therapies. This will increase knowledge and promote improved patient outcomes. Healthcare facilities can implement policies that discourage the use of wet-to-dry wound dressing and instead recommend the use of other methods. With this policy, it will be difficult for physicians to push for the archaic method. It should also be noted that costs are not as high as most people assume and nursing time should also be considered to be a cost.


References
Adkins, C. L. (2013). Wound care dressings and choices for care of wounds in the home. Home Healthcare Now, 31(5), 259-267.
Dale, B. A., & Wright, D. H. (2011). Say goodbye to wet-to-dry wound care dressings: changing the culture of wound care management within your agency. Home Healthcare Now, 29(7), 429-440.
Fleck, C. A. (2009). Why “wet to dry”? The Journal of the American College of Certified Wound Specialists, 1(4), 109.
Hall, C., Regner, J., Abernathy, S., Isbell, C., Isbell, T., Kurek, S., . . . Frazee, R. (2018). Surgical Site Infection after Primary Closure of High-Risk Surgical Wounds in Emergency General Surgery Laparotomy and Closed Negative-Pressure Wound Therapy. Journal of the American College of Surgeons.
Ousey, K., Rippon, M., & Stephenson, J. (2016). Barriers to wound debridement: Results of an online survey. Wounds UK, 12(4), 36-41.
Powers, J. G., Higham, C., Broussard, K., & Phillips, T. J. (2016). Wound healing and treating wounds: Chronic wound care and management. Journal of the American Academy of Dermatology, 74(4), 607-625.
Wodash, A. J. (2012). Wet-to-dry dressings do not provide moist wound healing. Journal of the American College of Clinical Wound Specialists, 4(3), 63-66.