Wound care: the moist-dry debate: which message is getting through?

Wound care has come a long way from the days of Maalox and sunlamps.

Early in Claudia Murray's career, that was one of the ways wounds were treated. "The outcomes weren't good," she admitted.

Now the director of nursing at Senterra Nursing Center, Norfolk, Va., Murray said the advancements of employing moist dressings have improved care for residents and reduced the pain often associated with dry dressings. Yet, wet-to-dry orders are still common despite years of research showing the benefits of moist wound care.

The debate over the type of wound care that is preferable has been around for years, and while nurses seem to understand the benefits of moist, getting doctors to recognize them remains a work in progress. Murray explained that nurses tend to be more up to date on wound care than physicians "because the physicians have so many patients to see and ... don't have available to them the time to attend seminars to keep up with what's going on in wound care."

She added, "Nurses have more hands-on knowledge of what's going on with the wounds."

Doctors seeing an elderly patient with congestive heart failure and pressure ulcers is going to put higher priority on the CHF. Plus, moistened gauze is much cheaper in the short term than the hydrocolloid dressings and vacuums that suck out wound fluid.

According to Barry Wolfenson, marketing director from Derma Sciences, based in Princeton, N.J., when it comes to wound care, the industry is running in two parallel directions. "One track is still shouting the story of dry versus moist," he said, and trying to convince doctors trained to prescribe gauze that moist wound care is better care. The other track is more scientific, trying to decrease wound healing time and do anything possible to prevent the wounds, including the ongoing developments of machines that such out wound fluid.

Until the message of moist care becomes taught as a standard of care in medical schools, gauze will often be the treatment recommended by doctors, Wolfenson said. "Gauze is still used probably 50 percent of the time," he said, calling his figure an estimate, not a statistically known fact. "The gauze market is larger than the moist market."

Industry-wide figures are unknown or at least unreleased, according to Diane Johnson, spokesperson for Smith & Nephew. "Almost every company that you could work with would love to have it," she said, but the data hasn't been captured.

"It doesn't seem to me that much progress has been made in wound healing beyond the general concepts of moist wound healing," Wolfenson said.

Today I don't think anything has really proven itself for the cost," Wolfenson said. "That's the unfortunate third leg.... Long term care is so cost constrained."

Murray said a common cost estimate for a stage four decubitus is that it costs upwards of $85,000 to heal using traditional dry approaches. That's much worse than the $300-400 that could be rung up for dressings. "If we can clear it up before it advances, then it's better than not doing the very aggressive (approach) immediately," she said. "Open communication is the answer."

She said that regular in-service visits from vendors help show nurses "ways to save money by using good products up front" and offer education for the staff.

For wet-to-dry gauze dressings, used typically in debridement of wound beds, normal saline is used moisten the gauze, which is then covered with dry gauze or other dressings. When the moist gauze dries, it attaches to surface tissue, which gets removed with the dried dressing.

Not only is such debridement likely to remove healthy tissue, it's also painful.

But what's a nurse to do if the doctor's orders appear contrary to her training? "The nurse should clarify the order with the doctor, stating that wet-to-dry, when done properly, is a method of mechanical debridement and indicated if there is a significant amount of necrotic tissue in the wound," Burns said. "If the majority of the wound bed is clean, then the more appropriate order is wet-to-moist. Most doctors order wet-to-dry as a matter of habit, not necessarily a conscious decision to order mechanical debridement."

"Moist wound healing is considered the ideal environment for optimal wound healing," said Patricia Burns, RN, MSN, CWOCN, associated with Smith & Nephew, whose U.S.-based wound management division is in Largo, Fla. "The development and use of advanced wound care dressings enhances the body's natural defenses and healing processes to improve healing outcomes and contributes to improved patient comfort. Now, more than ever before, standard of practice or best practice plays an important role in the long term care industry as it relates to wound care."

Pat Oatman, marketing manager for 3M Skin Health in St. Paul, Minn., said the advantages of acrylic dressings are better for clinicians, patients and the payor. She said that the dressings are designed for patient comfort and allow wounds to be monitored without removal.

Doctors still order moist-to-dry. "That's because of their training," Oatman said.

Training can be changed. The guidelines and revisions for wound care issued last fall by Centers for Medicare and Medicaid Services (CMS) emphasize the implementation of practices that help prevent wounds from developing in long term care settings. "Detailed documentation on each resident with a pressure ulcer or residents at risk of getting a pressure ulcer can mean the difference between avoidable and unavoidable in the eyes of the surveyor," Burns said. "Facilities must be prepared to share their practices and their protocols with a focus on preventing wounds, healing wounds and treating infected wounds."

Murray was encouraged by the wound care guidelines that CMS has proposed, which are still awaiting full implementation. She said they emphasize being consistent with care, following through, and making good quality assessments. "I'm hoping that it's going to make everybody more aware that prevention is the key and that early detection is the next step."