Dear Doc, No more wet-to-dry wound dressing orders. How a home health agency improved wound related outcomes while maintaining patient census by saying “no” to the inappropriate use of wet-to-dry wound care dressings

Problem
After a continued lack of improvement in two Medicare home health quality indicators 1) improvement in surgical wounds and 2) urgent care related to wounds, a rural home health agency performed a root cause analysis that demonstrated the indicator results were partially attributed to the use of wet-to-dry dressings.  Wet-to-dry dressings have been a topic of debate for several decades leading to frustration among healthcare professionals, while causing delayed or impaired wound healing (Ovington, 2001). Physicians continue to write orders for wet-to-dry dressings and nurses continue to follow these orders more than twenty years after the literature has shown us that wounds kept moist will epithelialize faster (Armstrong & Price, 2004) . Patients, nurses, and facilities alike have facilitated the continued provision of this outdated practice.

Methodology
Much to the dismay and disapproval of local physicians, a rural home health agency implemented a comprehensive program to improve the quality indicators that included a policy banning the use of wet-to-dry dressings.  The program included: basic wound and skin education for all clinicians, specific Outcome Assessment Information Set (OASIS) wound item education, promoting the use of evidenced based wound and skin protocols, physician and referral source education, and implementing a policy banning the use of wet-to-dry dressings.  Physician satisfaction was not considered as a deterrent or incentive in the program.

Goals
The goals of the new program were to improve the OASIS quality indicators and maintain patient census.

Outcomes
Nine months after implementing the program, a retrospective study was completed to determine if implementation of the policy had reduced the number of patients in the two quality indicators while maintaining patient census.  OASIS data sets, OASIS outcomes data, and agency wound and census logs were utilized to determine if the goals of the program were met. Study results showed that patient census initially declined from 1613 to 1490 in the first three months. Census then rose dramatically ending with 1604 for an overall decrease of less than 1%. Outcome data for improvements in surgical wounds rose an encouraging 4% from 76 to 80%. Urgent care for wound related issues remained at less than 1%. Surprisingly, the number of wound patients as a percentage of total patients actually increased from (163)10% to (262)16% over the time frame. The increase in wound patients was attributed to extensive physician education regarding the wound management program and aggressive marketing of the wound care protocols.

Conclusion
The agency considers the program to be a success and plans to continue all aspects of the program. It is hoped that this effort will grow regionally(two other local agencies now refuse to accept orders for wet-to-dry dressings) and ultimately nationally and that wet-to-dry dressings will be used less and perceived by physicians and the patients as substandard care. Maybe, in our lifetime, we will see wet-to-dry become a thing of the past.