Clinicians often find it difficult to prescribe a wound dressing because they are unaware of the dressing functions and are not up to date on current reimbursement guidelines if patients are going to be using the dressings at home. It is difficult for the clinician to be knowledgeable on all the dressings currently on the market and new ones are arriving on a regular basis. Understanding the purpose of a dressing, the dressing categories and what makes up a dressing prescription can be helpful in taking away the mystery of prescribing dressings.
A wound dressing serves several purposes. Obviously, one of the main purposes of a dressing is to absorb drainage. Excess drainage can macerate a wound, create a foul odor and increase the risk of infection. Some dressings wick moisture away from the wound vertically and others vertically and horizontally. The amount of drainage is one of the main factors in choosing an appropriate dressing and also affects eligibility for insurance coverage. Achieving moisture balance in the wound is one of the essential concepts of wound care.
A dressing protects the wound and prevents infection statically by acting as a barrier or actively by inhibiting bacteria with various ingredients like silver. It also prevents contamination of the environment by containing bacteria in the wound. A dressing reduces pain and provides physical and psychological comfort. Dressings immobilize and splint the wound area. They may also apply topical medications or cover biologic dressings.
A Closer Look At The Wound Dressing Categories
It can make a prescriber’s life much easier by prescribing dressings by category (generic) instead of by brand name. Whether a clinician is ordering a dressing on the inpatient floor, through an outpatient clinic, skilled nursing facility or home health, or for home use, the formularies differ. If clinicians prescribe a generic category, like “collagen” instead of a branded name collagen, it will avoid multiple calls or faxes for permission to substitute if the brand isn’t on the formulary. This also minimizes any delay the patient has in getting the dressing prescribed.
In reality, the clinical differences between the same dressings in a class are minuscule. Manufacturers tout benchtop studies with fancy graphs and pseudoscience, but I’m unaware of randomized controlled trials comparing dressings in the same class. It would take a large number of patients to prove that one collagen is more effective than another. The main categories of dressings and their usage are listed in the table “A Closer Look At Dressing Categories And Descriptions” at right.
What Goes Into The Anatomy Of A Wound Dressing Prescription
Prescribing a dressing doesn’t have to be confusing. A good prescription has a primary, secondary and tertiary dressing, dressing adjuncts (i.e. tape and saline), and includes the frequency of dressing change. The table “Examples Of Dressing Prescriptions By Wound Etiology” at left lists wounds by etiology and drainage level, and provides common examples of dressing prescriptions.
The primary dressing is in contact with the wound. In healthy looking wounds, which are mostly granular and have minimal drainage, using collagen as a primary dressing is a reasonable choice. In wounds that are infected or have significant bioburden, one can use a silver-impregnated dressing (collagen, alginate or foam). To cover a biologic or a skin graft, a non-adherent dressing is usually an option. Hydrocolloids are best on pressure injuries with intact dermis. Since hydrocolloids are occlusive, they can macerate wounds that have any drainage. For necrotic wounds in which debridement is contraindicated or delayed, a dry, sterile dressing is appropriate. Fibrotic wounds that are well perfused do best with sharp debridement but enzymatic agents are sometimes necessary.
The secondary dressing covers the primary dressing. With no drainage or mild drainage, gauze pads may be sufficient and inexpensive. For wounds that have moderate or heavy drainage, a foam is appropriate. Some foams are supplied with non-adherent contact layers. Abdominal (ABD) pads are useful as a secondary layer in situations of heavy drainage.
The tertiary dressing usually affixes the primary and secondary dressings to the patient. These are roll gauze (Kling or Kerlix) or dressings bordered with adhesive. Roll gauze can cover non-bordered foams and gauze. Some bordered foams have a silicone contact layer and are gentle on the skin.
Several dressing adjuncts are available. Physicians can order tapes with the dressing and insurance usually covers them. Several types of tape exist. When the tape will only contact the dressing, use a cloth or plastic tape, but when the tape is to contact the skin, by bordering or otherwise, paper tape is most appropriate. Order saline to clean the wound or moisten the primary dressing. Other wound cleansers are also available. Consider recommending a cast protector to keep the dressing dry when the patient is bathing. Skin preps can keep the periwound skin from becoming macerated when there is moderate or heavy drainage.
How Often Should Dressing Changes Happen?
There is no science driving the decision on dressing change frequency. Determine this by the amount of drainage. In wounds without any drainage, one can change some dressings weekly if they remain clean, dry and intact. Patients would change most dressings every other day or two times a week.
If the wound is macerated, it is an indication that the dressing may need changing more frequently. Conversely, if the dressing is dry after two days, one can extend the frequency. Dressing change frequency is not static and patients should feel comfortable changing a dressing if it becomes saturated.
Wound dressings do not heal wounds independent of good clinical wound treatment. Wounds still need to be well perfused, free from infection, offloaded (diabetic foot ulcers) and compressed (venous leg ulcers). The dressing should support these best practices, not replace them. With these pearls, clinicians can feel more comfortable their patients are receiving the dressings they need and are entitled to have.
Dr. Rogers is the Medical Director of Advanced Tissue, a company that supplies dressings from any manufacturer to patients’ homes. He is also the Medical Director of the Amputation Prevention Centers of America, a RestorixHealth company, which manages 215 wound centers in 35 states.