Wound Care: What's Really Cost-Effective?

Nursing Homes, April, 2001 by S. Kwon Lee, Gwen B. Turnbull

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 with traditional methods; discuss debridement techniques; and address the role some products play in promoting or preventing infection.

Wet-to-Dry Dressings

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. [1] 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 [4] 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, [5] 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 [9] showed that hydrocolloids cost less to use than gauze dressings. Gorse and Messner [10] 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 [11] 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]