Wound Care: What's Really Cost-Effective?
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 with traditional methods; discuss debridement 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 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. 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 (Dakin's solution), which is dilute bleach; (2) betadine; (3) hydrogen peroxide; and (4) acetic acid. 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 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
Autolytic 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, 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, enzymes and other cells crucial to healing. [6-8] Everything required to debride 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, 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 management, Fellin  showed that hydrocolloids cost less to use than gauze dressings. Gorse and Messner  conducted a randomized, prospective study of weekly costs and healing of Stage II and III pressure ulcers. More of the ulcers dressed with a hydrocolloid 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 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 and the level of fibrin 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 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 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 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, more rapidly, than the enzymatic agent. In fact, the hydrogel actually debrided better and stimulated granulation 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 (HIV).  In a small study, Wilson and collegues  demonstrated that when hydrocolloid dressings were used to cover leg ulcers containing methicillin-resistant S aureus (MRSA), 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 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, 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, is an international consultant on reimbursement and skin and wound care.
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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