Article originally featured on WoundSource

In a recent survey, we asked our WoundSource Editorial Advisory Board members what outdated wound care practices they continue to see in the field. Depending on what health care setting clinicians work in, there are specific guidelines, policies, and procedures that may impact standard of care. Our board members come from a variety of backgrounds, so their answers varied based on their areas of expertise, but there were a few practices that they could all agree should be left in the past. Do you still use any of these?

Wet-to-Dry Dressings

Six of the 15 board members mentioned wet-to-dry dressings as something that should be discontinued. Wet-to-dry dressings are a method of mechanical debridement where a moistened gauze dressing is placed on a wound and left in place to dry. When the dry dressing is removed, the new cells and wound tissue that have adhered to the dressing as it dried are removed with it. This is a non-selective method of debridement, meaning viable tissues are just as likely to be removed as non-viable tissues, and there is very little the clinician can do to control how much of either tissue type is removed.

This method of debridement has come under fire in recent years both for being unselective in tissue removal and for being painful for patients. Some providers continue to use this practice, however, either because they are unaware of research that recommends other methods of debridement or because wet-to-dry dressings are relatively inexpensive and easy to use.

Selecting an alternative debridement method will depend on many factors, including patient’s pain tolerance, wound etiology and location, and any underlying conditions the patient may have that would be contraindications to certain types of debridement, such as autoimmune disorders in patients who would otherwise undergo autolytic debridement.1 Mechanical debridement is still a viable option for some wounds, so long as methods other than wet-to-dry dressings are employed. Use of a monofilament pad to remove devitalized tissue has proven effective,2 for example, or pulse lavage.

Whirlpool Debridement

On the topic of out-of-date debridement methods, some WoundSource Board members brought up whirlpool debridement. Whirlpool debridement involves submerging the wounded limb in a pool of 92° to 96 °F water, which is then circulated at high speeds to remove devitalized tissue.3 There is a high risk of infection with this method of debridement because adequately disinfecting the equipment between therapies has proven difficult, thus potentially leading to infection in the patients who undergo the therapy.3 It is hypothesized that the rise of antimicrobial-resistant organisms may be the cause of inadequate disinfection of the equipment.3

Misuse of Antibiotics

Antibiotic-resistant organisms are among the largest health threats we face. With a current associated death toll of 700,000 persons per year,4 antimicrobial-resistant infections are on the rise. The misuse and overuse of antibiotics are leading causes of antimicrobial-resistant organisms, and the WoundSource Board indicated that these practices should be left behind. Clinicians should take the time to educate themselves on the dangers of antimicrobial-resistant organisms, antimicrobial stewardship programs, and the proper administration of antibiotics. Click here to view the resources made available in the January Practice Accelerator Program on Infection Control and Wound Management.

ACE Bandages and Other Mistreatment of Edema

Edema is the swelling of tissues secondary to interstitial fluid retention, usually occurring in the extremities. Although compression is a treatment for edema, and a well-known one, it should be prescribed only once the underlying cause of the edema has been resolved and once the swelling has gone down. ACE elastic bandages should generally not be used as a compression method for edema because they are a long-stretch bandage, which will not apply enough compression.5

There are multiple treatments for edema, and their effectiveness will vary depending on the severity and cause of the edema. Exercise and elevation of the affected limb may help to resolve edema by causing the excess fluid to move back toward the heart.6 If compression garments are necessary, short-stretch bandages may be used, but they will need to be frequently reapplied as the edema reduces and the leg shape changes.7,8

Cytotoxic Cleansers

As the conversation around antimicrobial cleansing solutions continues to evolve, there have been more and more calls to abandon cytotoxic cleansers. Cytotoxic cleansers damage healthy cells while destroying bacteria, thereby impeding wound healing. With non-cytotoxic agents available (check out WoundSource’s product directory for examples), clinicians should consider exploring the use of non-cytotoxic products.

What to Add: Patient Education

One WoundSource Board member noted occasions of patients using items such as crushed papaya to treat wounds. Off label wound care treatments are not evidence based and may cause more harm than good. Taking the time to educate your patients on proper wound cleansing and treatment can save time, money, and energy further into the treatment journey. Explain how to cleanse a wound properly, how to change the dressing, and what signs and symptoms should alert your patient that the wound has become infected.

References

1. Manna B, Morrison C. Wound debridement. StatPearls. 2020. https://www.ncbi.nlm.nih.gov/books/NBK507882/ Accessed August 18, 2020.

2. Schultz GS, Woo K, Weir D, Yang Q. Effectiveness of a monofilament wound debridement pad at removing biofilms and slough: ex vivo and clinical performance. J Wound Care. 2018;27(2):80-90. https://pubmed.ncbi.nlm.nih.gov/29424644/ Accessed August 18, 2020.

3. Tao H, Butler JP, Luttrell T. The role of whirlpool in wound care. J Am Coll Clin Wound Spec. 2012;4(1):7-12.

4. McLeod M, Ahmad R, Shebl NA, Micallef C, Sim F, Holmes A. A whole-health-economy approach to antimicrobial stewardship: analysis of current models and future direction. PLoS Med. 2019;16(3):e1002774.

5. Slone-Rivera N, Wu SC. A guide to compression dressings for venous ulcers. Podiatry Today. 2012;25(2). https://www.podiatrytoday.com/guide-compression-dressings-venous-ulcers Accessed August 18, 2020.

6. Mayo Clinic Staff. Edema. Mayo Clinic. 2017. https://www.mayoclinic.org/diseases-conditions/edema/diagnosis-treatment... Accessed August 18, 2020.

7. Marston W, Vowden K. Compression therapy: a guide to safe practice. In: Understanding Compression Therapy. European Wound Management Association (EWMA) position document. London, United Kingdom: MEP Ltd.; 2003:2-4.

8. Jones JE, Nelson EA. Compression hosiery in the management of venous leg ulcers. J Wound Care. 1998;7(6):293-296.