Wound Care: What's Really Cost-Effective?
Heeding outcomes--not just dressing costs--makes for the best care and the best use of wound care dollars
Pressures to provide care for our growing aging population, along with increased constraints on payment mechanisms, have created tremendous demands and stress on long-term care facilities in all areas of patient care, but particularly in wound care. Treating wounds can be both confusing and costly, considering the 2,000-plus wound care products available and the diversity of treatment techniques. Clinicians waver between using less-costly, "traditional" wet-to-dry dressings or "expensive" state-of-the-art dressings and growth factors, often without considering outcomes data.
There is a growing body of evidence defining just what cost-effective wound care really is and how to provide it. This article will review the current literature, comparing moist wound healing wound healing Physiology The repair of a wound Steps Inflammation, repair and closure, remodeling, final healing; repair of incisions may be either simple–'clean' wounds with little loss of tissue heal by 'primary intention', or 'dirty' wounds heal by with traditional methods; discuss debridement Debridement Definition
Debridement is the process of removing nonliving tissue from pressure ulcers, burns, and other wounds.
Debridement speeds the healing of pressure ulcers, burns, and other wounds. techniques; and address the role some products play in promoting or preventing infection.
Unfortunately, wet-to-dry dressings are frequently relied upon beyond their intended use. A common misconception is that wet-to-dry dressing facilitates healing, when in reality it is a debridement technique. This method is acceptable when the wound contains necrotic tissue-if you don't mind damaging clean or delicate, new granulating tissue and causing reinjury to the wound bed. Furthermore, epithelial cells Epithelial cells
Cells that form a thin surface coating on the outside of a body structure.
Mentioned in: Corneal Transplantation can actually grow into the gauze fibers, and gauze dressings can leave cotton fibers embedded in the wound.  This can create a foreign body reaction, which in turn might cause chronic inflammation chronic inflammation
Inflammation that may have a rapid or slow onset but is characterized primarily by its persistence and lack of clear resolution; it occurs when the tissues are unable to overcome the effects of the injuring agent. . Such circumstances can also lead to bacterial growth and infection.
Another problem with wet-to-dry dressings relates to the solutions commonly used to moisten them. Reviews by Lineweaver [2,3] and Kozol  have demonstrated that the four most commonly employed solutions are actually toxic to living cells. These include: (1) sodium hypochlorite sodium hypochlorite
An unstable salt usually stored in solution and used as a fungicide and an oxidizing bleach. (Dakin's solution Da·kin's solution
Buffered sodium hypochlorite solution, used as a bactericidal irrigant of open wounds.
Dakin's solution ), which is dilute bleach; (2) betadine; (3) hydrogen peroxide hydrogen peroxide, chemical compound, H2O2, a colorless, syrupy liquid that is a strong oxidizing agent and, in water solution, a weak acid. It is miscible with cold water and is soluble in alcohol and ether. ; and (4) acetic acid acetic acid (əsē`tĭk), CH3CO2H, colorless liquid that has a characteristic pungent odor, boils at 118°C;, and is miscible with water in all proportions; it is a weak organic carboxylic acid (see carboxyl group). . If these solutions can kill bacteria, they are perfectly capable of killing healthy cells--and they might not even be killing bacteria. In fact, two reports have shown stock betadine solutions actually growing Pseudomonas Pseudomonas
A genus of gram-negative, nonsporeforming, rod-shaped bacteria. Motile species possess polar flagella. They are strictly aerobic, but some members do respire anaerobically in the presence of nitrate. species,  which means clinicians could be swabbing bacteria into the wound rather than protecting it against infection.
From a cost-effectiveness perspective, we could surmise that delayed healing and increased costs would result from using solutions that kill new cells and dressings that damage tissue. Obviously, this is not acceptable. Today, more than ever before, wound care means being liable, responsible and accountable. Clinicians will no longer be permitted to just "do" dressing changes without attempting to heal wounds, and using the cheapest product is not always the least costly approach.
Moist Wound Healing
The destruction of tissues or cells of an organism by the action of substances, such as enzymes, that are produced within the organism. Also called self-digestion. debridement with moist wound healing is one of the most studied and documented wound management techniques today. Unfortunately, most clinicians believe that the "new" products used in this technique are costly and, therefore, not the most cost-efficient way to heal wounds. As a result, moist wound healing is one of the least used wound care methods practiced in long-term care long-term care (LTC),
n the provision of medical, social, and personal care services on a recurring or continuing basis to persons with chronic physical or mental disorders. , even though there are now more than 500 studies demonstrating its efficacy.
Studies analyzing wound fluid show it to be rich in growth factors, collagenase collagenase /col·la·ge·nase/ (kah-laj´e-nas) an enzyme that catalyzes the hydrolysis of peptide bonds in triple helical regions of collagen.
n. , enzymes and other cells crucial to healing. [6-8] Everything required to debride de·bride·ment
Surgical excision of dead, devitalized, or contaminated tissue and removal of foreign matter from a wound.
[French débridement, from débrider, and heal a wound is already present in the wound itself. If the wound is prevented from drying out, the body can "self-debride" necrotic tissue naturally, or autolytically, without destroying new cell growth. This is an advantage over the solutions used in wet-to-dry dressings, which create a virtual "Molotov cocktail," killing the pivotal cells that produce these essential factors.
Is Cheaper Really Cost-Effective?
Using the least expensive wound care product is not always cost-effective--especially in today's outcome-driven healthcare environment (see Table). Gauze has always been considered cost-effective because of its low price, but because it requires more frequent changes, gauze is very labor intensive Labor Intensive
A process or industry that requires large amounts of human effort to produce goods.
A good example is the hospitality industry (hotels, restaurants, etc), they are considered to be very people-oriented.
See also: Capital Intensive, Trading Dollars , and a large quantity of it must be used.
Gauze Versus Hydrocolloids
Studies as far back as 1984 document the true cost of gauze dressings compared to those of hydrocolloids. In a crossover, prospective study of daily costs for pressure ulcer Pressure ulcer
Also known as a decubitus ulcer, pressure ulcers are open wounds that form whenever prolonged pressure is applied to skin covering bony outcrops of the body. Patients who are bedridden are at risk of developing pressure ulcers. management, Fellin  showed that hydrocolloids cost less to use than gauze dressings. Gorse gorse: see furze.
Any of several related plants of the genera Ulex and Genista. Common gorse (U. europaeus) is a spiny, yellow-flowered leguminous shrub native to Europe and naturalized in the Middle Atlantic states and on Vancouver Island. and Messner  conducted a randomized ran·dom·ize
tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es
To make random in arrangement, especially in order to control the variables in an experiment. , prospective study of weekly costs and healing of Stage II and III pressure ulcers. More of the ulcers dressed with a hydrocolloid hydrocolloid /hy·dro·col·loid/ (-kol´oid) a colloid system in which water is the dispersion medium.
1. A substance that forms a gel with water.
2. healed (87% versus 69% for gauze), resulting in lower weekly supply costs ($6.20 versus $52.50). Shannon and Miller  looked at the treatment of pressure ulcers in patients with spinal cord injury Spinal Cord Injury Definition
Spinal cord injury is damage to the spinal cord that causes loss of sensation and motor control.
Approximately 10,000 new spinal cord injuries (SCIs) occur each year in the United States. and found lower costs and fewer recurrences of ulcers dressed with a hydrocolloid than with gauze. Similar results have been demonstrated for venous leg ulcers, [12-14]
Labor costs. The amount of time required for dressing changes must also be considered when comparing gauze dressings to hydrocolloids. In a study conducted by Xakellis and Chrischilles,  healing rates were only slightly better for hydrocolloid dressings (9 days) than for wet saline gauze dressings (11 days), but there was a significant difference in median total cost: $25.31 for gauze versus $15.90 for the hydrocolloid. The higher purchase price of the hydrocolloid (3.3 times higher than for gauze) was offset by the fact that labor costs for its use were one-eighth of those associated with gauze dressing changes. This is an important difference, since nursing and physician time are the most costly aspects of wound care.
In another study comparing gauze and hydrocolloids in patients with Stage II and III pressure ulcers, conducted by Colwell et al,  the average number of dressing changes per week for the saline gauze group was 28.8, compared with 2.94 for the hydrocolloid dressing group. The difference in average daily cost was dramatically different: $12.26 for the gauze group and $3.55 for the hydrocolloid group.
Bolton and colleagues  developed a clinical model that illustrates the powerful effect of outcomes on the total costs of wound care. Regardless of wound type or the cost of supplies, dressings that facilitate healing are less expensive than dressings that do not.
For example, if there are 10 chronic wounds ma facility and wet-to-dry dressings are ordered two or three times a day, 140 to 210 dressing changes must be performed each week. On the other hand, if hydrocolloid dressings are ordered for the same 10 wounds, only 20 to 30 dressing changes a week will be needed. This represents a 7- to 10-fold reduction in the number of dressings, a tremendous savings in nursing time and costs.
Rates of healing. The findings of one study showed that hydrocolloids appear to improve the rate of wound healing. Mulder et al  studied fibrinolysis fibrinolysis /fi·bri·nol·y·sis/ (fi?brin-ol´i-sis) dissolution of fibrin by enzymatic action.fibrinolyt´ic
n. pl. and the level of fibrin fibrin: see blood clotting. in wound margins (the byproducts of fibrin breakdown stimulate the production of collagen). The patients in this study had venous leg ulcers managed either with compression therapy plus a hydrocolloid or compression therapy alone. They found a significantly higher level of fibrin being broken down in the fluid under a hydrocolloid dressing than in wounds treated only with compression. Better and faster healing was observed--a result of increased fibrinolysis and collagen production in the moist environment under the hydrocolloid.
Choosing a Hydrocolloid
To say "all hydrocolloids are the same, so buy the cheapest one" is not only inaccurate, but it can also be a costly mistake. Dressings vary in composition, percentage of hydrocolloid, thickness of the hydrocolloid layer and indications for use. As with any category of wound dressings, it is important to read labels to differentiate between individual products. Although few studies have been done to compare various wound care products within categories, two studies do demonstrate significant differences in how certain hydrocolloids perform--because of varying thickness, ability to stay in place and incidence of leakage. There is also a product-to-product difference in the ability to stimulate the proliferation of human keratinocytes Keratinocytes
Cells found in the epidermis. The keratinocytes at the outer surface of the epidermis are dead and form a tough protective layer. The cells underneath divide to replenish the supply. because of a natural growth factor effect.[19,20] The bottom line is that all products are not created equal.
Enzymatic debridement. Over the past few decades, enzymatic debriding agents have been developed and used to assist in dissolving and removing necrotic tissue and thus accelerate healing. Although these agents can achieve debridement, several have been removed from the market because of lack of proven efficacy. Furthermore, some clinicians are confused about how they should be used.
The findings in Rodeheavor's review of debriding agents  are noteworthy. He states, "If the enzymatic preparation is not effective, one may still observe debridement due to the simultaneous autolytic process that is occurring."  This essentially means that debridement could be achieved with a less expensive hydrogel hy·dro·gel
A colloidal gel in which the particles are dispersed in water.
a gel that contains water.
hydrogel Wound care A polymer absorptive wound dressing. See Dressing. since it is the moisture in the wound that is responsible for facilitating debridement--especially since collagenases often cost between $70 and 100 per tube.
Enzymatic agents versus hydrogels. Hydrogels might be the most cost-effective alternative to enzymatic debriding agents.  Romanelli et al  compared the debriding action of a hydrogel used with a transparent dressing transparent dressing Transparent film Wound Care A waterproof dressing that is permeable to O2 and moisture. See Wound care. to that of an enzymatic debriding agent used alone. This study demonstrated that the combination of the hydrogel and the transparent dressing developed more consistent granulation tissue Granulation tissue
A kind of tissue formed during wound healing, with a rough or irregular surface and a rich supply of blood capillaries.
Mentioned in: Granuloma Inguinale
n , more rapidly, than the enzymatic agent. In fact, the hydrogel actually debrided better and stimulated granulation granulation /gran·u·la·tion/ (-shun)
1. the division of a hard substance into small particles.
2. the formation in wounds of small, rounded masses of tissue during healing; also the mass so formed. faster.
Martin and colleagues  compared a hydrogel to a streptodornase/streptokinase enzymatic formula and reached the same conclusion: that the hydrogels alone might be more cost-effective than enzymatic debriding agents. In this study, the average time to debride a Stage IV ulcer was 8 days with the hydrogel and 12 days with the enzymatic formula.
Sharp debridement. Even with all the modern wound care products and technologies available, sharp debridement remains the quickest, easiest way to debride. Care must be taken, however, to avoid damaging healthy tissue when using this method. It is impossible to determine with the naked eye how deeply necrotic tissue extends into the wound bed, so most practitioners debride sharply until they reach healthy tissue--causing pain, bleeding and damage. This is especially hazardous if there are only a few millimeters of healthy tissue present to begin with. When sharp debridement is performed in this fashion, a wound that would have healed is converted into a wound that will not heal and might require further surgery or limb loss, obviously compromising the patient's status and raising treatment costs.
A more selective technique of sharp debridement can be achieved by using the moist wound healing process first, to soften necrotic tissue. In addition to making sharp debridement easier to perform, this method also decreases associated pain, bleeding and trauma to the wound.
Many clinicians incorrectly believe that covering a Wound for a prolonged period causes infection, but in fact, the opposite is true. In their review, which examined both retrospective and prospective studies, Hutchinson and McGuckin  found reported wound infection rates of 2.6% with hydrocolloid dressings and 7.1% for gauze-type dressings. One explanation for these findings is that gauze is very permeable, permitting bacteria such as Staphylococcus aureus and Pseudomonas aeruginosa to travel through 64 layers of gauze. By contrast, some hydrocolloid dressings have been clinically proven to provide a 100% barrier to external contamination and bacteria.  More recent studies have shown them to be an effective barrier against both hepatitis B and human immunodeficiency virus human immunodeficiency virus
Human immunodeficiency virus (HIV)
A transmissible retrovirus that causes AIDS in humans. (HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. ).  In a small study, Wilson and collegues  demonstrated that when hydrocolloid dressings were used to cover leg ulcers containing methicillin-resistant S aureus The aureus (pl. aurei) was a gold coin of ancient Rome valued at 25 silver denarii. The aureus was regularly issued from the 1st century BC to the beginning of the 4th century AD, when it was replaced by the solidus. (MRSA MRSA Methicillin-resistant Staphylococcus aureus. See MARSA. ), five of the six wounds were cleared of the bacteri a within two weeks, effectively isolating the bacteria and preventing transmission.
Wound management will continue to be a challenging issue for long-term care. Too much of what we do is based upon tradition rather than fact. Facilities' inhouse policies must reflect current proven methods and lessen the potential for litigation An action brought in court to enforce a particular right. The act or process of bringing a lawsuit in and of itself; a judicial contest; any dispute.
When a person begins a civil lawsuit, the person enters into a process called litigation. inherent in archaic and unproven techniques.
Obviously, more comparison studies need to be conducted that contrast advanced wound debriding techniques, including those employing collagenase, because most studies to date have merely compared the newer products with gauze alone. The data available to date appear to demonstrate that debriding agents work, but at a very high cost. Long-term care providers must ask themselves if the cost is worth the outcome when simpler products might achieve the same result at a much lower cost.
5. Kwon Lee, MD, FACS FACS Fellow of the American College of Surgeons.
Fellow of the American College of Surgeons
fluorescence-activated cell sorter. , a general surgeon, is wound care coordinator for several Northeast Ohio nursing homes and director of the wound care program for University Hospitals Home Care. Gwen B. Turnbull, RN, CETN CETN Coastal Engineering Technical Notes , is an international consultant on reimbursement and skin and wound care.
(1.) Hughes M. Basic Wound Healing Science Now and in the Future. 4th Annual Oxford European Wound Healing Summer School. Oxford, UK, June 1999.
(2.) Lineweaver W. Cellular and bacterial toxicities of topical antimicrobials. Plast Reconstr Surg 1985a;75:394-6.
(3.) Lineweaver W. Topical antimicrobial toxicity. Arch Surg 1985b;120:267-70
(4.) Kozol RA. Effects of sodium hypochiorite (Dakin's solution) on cells of the wound module. Arch Surg 1998;123:420-3.
(5.) Burks RI. Povidone-iodine solution in wound treatment. Phys Ther 1998;78:212-8.
(6.) Bolton L, Johnson C, van Rijswijk L. Occlusive dressings: Therapeutic agents and effects on drug delivery. Clinics in Dermatology 1991;9:573-83.
(7.) Chen WYI, Rogers AA, Lydon MJ. Characterization of biologic properties of wound fluid collected during early stages of wound healing. Invest dermatol 1992;99:559-64.
(8.) Lydon M. Dissolution of wound coagulation coagulation (kōăg'ylā`shən), the collecting into a mass of minute particles of a solid dispersed throughout a liquid (a sol), usually followed by the precipitation or and promotion of granulation tissue under DuoDERM. Wounds: Compendium Clin Res Pract 1989;1:95-106.
(9.) Fellin R. Managing decubitus ulcers. Nurs Manage 1984;15:29-30.
(10.) Gorse GJ, Messner RL. Improved pressure sore healing with hydrocolloid dressings. Arch Dermatol 1987;123:766-711.
(11.) Shannon ML, Miller B. Evaluation of hydrocolloid dressings on healing of pressure ulcers in spinal cord injury patients. Decubitus decubitus /de·cu·bi·tus/ (de-ku´bi-tus) pl. decu´bitus [L.]
1. an act of lying down; the position assumed in lying down.
2. decubitus ulcer. 1988;1:42-6.
(12.) Arnold TE, Stanley JC, Fellows EP, et al. Prospective, multicenter study of managing lower extremity venous ulcers. Ann Vasc Surg 1994;8:356-62.
(13.) Cordts PR, Hanrahan LM, Rodriguez AA, et al, A prospective, randomized trial of Unna's boot versus DuoDERM CGF CGF Commonwealth Games Federation (UK)
CGF Computer Graphics Forum
CGF Computer Generated Forces
CGF Chlorella Growth Factor
CGF Charging Gateway Function
CGF Crystal Growth Furnace
CGF College Golf Foundation hydroactive dressing plus compression in the management of venous leg ulcers. J Vasc Surg 1992;15:480-6.
(14.) Friedman SJ, Su WP. Management of leg ulcers with hydrocolloid occlusive dressing. Arch Dermatol 1984;120:1329-36.
(15.) Xakellis GC, Chrischilles EA. Hydrocolloid versus saline-gauze dressings in treating pressure ulcers: A cost-effectiveness analysis. Arch Phys Med Rehabil 1992;73:463-9.
(16.) Colwell JC, Foreman MD, Trotter JP. A comparison of the efficacy and cost-effectiveness of two methods of managing pressure ulcers. Decubitus 1993;6:28-36.
(17.) Bolton L, van Rijswijk L, Shaffer FA. Quality wound care equals cost-effective wound care: A clinical model [published erratum [Latin, Error.] The term used in the Latin formula for the assignment of mistakes made in a case.
After reviewing a case, if a judge decides that there was no error, he or she indicates so by replying, "In nollo est erratum in Nurs Manage 1996;27:10]. Nurs Manage 1996;27:30,32,33,37.
(18.) Mulder G, Jones R, Cederholm-Williams S, et al. Fibrin cuff lysis lysis /ly·sis/ (li´sis)
1. destruction or decomposition, as of a cell or other substance, under influence of a specific agent.
2. mobilization of an organ by division of restraining adhesions.
3. in chronic venous ulcers treated with a hydrocolloid dressing. Int J Dermatol 1993; 32:304-6.
(19.) Burgess B. An investigation of hydrocolloids: A comparative prospective randomised Adj. 1. randomised - set up or distributed in a deliberately random way
irregular - contrary to rule or accepted order or general practice; "irregular hiring practices" trial of the performance of three hydrocolloid dressings. Prof Nursing 1993;8:3-6.
(20.) Kreuger J. Endogenous growth factor may regulate epidermal Epidermal
Referring to the thin outermost layer of the skin, itself made up of several layers, that covers and protects the underlying dermis (skin).
Mentioned in: Antiangiogenic Therapy, Histiocytosis X
epidermal hyperplasia in chronic venous wounds: Modulation by hydrocolloid dressings. Wound Healing and Skin Physiol 1995:285-302.
(21.) Rodeheaver G. Pressure ulcer debridement and cleansing: A review of current literature. Ostomy ostomy
Surgical opening in the body, or the operation creating it, usually to allow discharge of wastes through the abdominal wall. It may be temporary, to relieve strain on damaged organs, or permanent, to replace normal channels congenitally missing or surgically removed Wound Manage 1999;45(suppl 1A):80-85S.
(22.) Romanelli M, et al. Objective measurement of venous ulcer debridement and granulation with a skin color reflectance analyzer. Wounds 1998;9:122-6.
(23.) Martin SJ, Corrado OJ, Kay EA. Enzymatic debridement for necrotic wounds. J Wound Care 1996;5:310-1.
(24.) Hutchinson JJ, McGuckin M. Occlusive dressings: A microbiologic and clinical review. Am J Infect Control 1990;18:257-68.
(25.) Lawrence JC. Are hydrocolloid dressings bacteria proof? Pharm J 1987;239:184.
(26.) Bowler PG, Delargy H, Prince D, Fondberg L. The viral barrier properties of some occlusive dressings and their role in infection control. Wounds 1993;5:1-8.
(27.) Wilson PD, Burroughs D, Dunn LJ. Methicilho-resistant Staphylococcus aureus and hydrocolloid dressings. Pharmaceutical Journal 1988;243:787-8.
Summary of clinical studies comparing costs of hydrocolloid dressings to gauze. Daily Cost: Author Wound Type Gauze Fellin  Pressure ulcers $7.89 Gorse, Messner  State II/III $7.50 Pressure ulcers Shannon, Miller  Pressure ulcers $2.64 Xakellis, Chrischilles  Pressure ulcers $25.31 Colwell et al  State II/III $12.26 pressure ulcers Daily Cost: Author Hydrocolloid Fellin  $1.09 Gorse, Messner  $0.86 Shannon, Miller  $0.92 Xakellis, Chrischilles  $15.90 Colwell et al  $3.55