Rapid growth in products makes communication critical and difficult
Two experts push for changes in terminology
What clinicians put in, on, and around chronic wounds has profound effects on healing processes. As wound care moves closer to mainstream medicine, medical product manufacturers have cranked out scores of new dressings, some novel, some simply copycats of products already on the market. It would be a full-time job just keeping track of all of the dressing variations that manufacturers develop - not just those from different companies, but also within an individual manufacturer's product line. At least 30 dressing categories now exist, and about the same number of hydrocolloid dressings alone. One product guide lists nearly 400 wound-dressing products.
But do the commonly used dressing categories help clinicians decide which dressing would work best in a given situation? Not anymore, say a couple of researchers who believe the current system has outlived its usefulness and has become a source of confusion and consternation. "The way dressings are currently categorized is good for dealing with reimbursement, but clinically they're useless," says Lia van Rijswijk, RN, ET, a nurse consultant in Newtown, PA.
What's in a name?
Current dressing categorizations break down products by ingredients (e.g., hydrocolloid, calcium alginate) and features (e.g., occlusive, semiocclusive). Neither type of description helps clinicians distinguish precisely among the choices. For example, the category of hyrdogel dressings can be misleading because it includes not only pure hydrogel products, but also combination products that contain ingredients other than hydrogels, such as calcium alginate, says Janice Beitz, PhD, RN, CS, CNOR, CETN, associate professor and graduate program director at La Salle University School of Nursing in Philadelphia.
"That makes it difficult to compare different hydrogel products because their constituent components vary so much," Beitz notes. Dressings listed as hydrocolloids can vary and may also come as combination dressings, she adds.
Using features to describe dressings is fraught with another type of problem, explains van Rijswijk: Even terms that are tossed about without much thought may be defined very differently by seasoned health care professionals.
Van Rijswijk and colleague Beitz began a serious consideration of wound dressing categories while working on a validation study of wound algorithms. Over the course of the project, they noticed that many of the health care professionals they questioned did not agree on the meanings of some commonly used wound care terms, such as occlusive, semiocclusive, moist wound environment, and absorption.
Providers disagree on fundamentals
For instance, when they asked wound care professionals what constitutes an absorptive dressing, van Rijswijk and Beitz received widely divergent answers. Even the term "absorbent" did not gain a consensus opinion. Beitz notes that that calcium alginate dressings are considered highly absorptive, and some hydrogels are also considered absorbent, while others are minimally absorbent. "If the product is a combination of those types of dressings, then a lot of confusion can result," she says.
They found disagreement on wound care fundamentals, such as how to assess the wound bed and how to diagnose tunneling and undermining. They also found that phrases such as "moist wound healing environment," "warm environment," "cool environment," "unnecessary loss of body fluid," and "mildly deodorizing" were all interpreted differently depending on whom they asked. Even the common dressing appellations "occlusive" and "semiocclusive" are used interchangeably in the wound care community, yet their meanings should be distinctly separate.
The researchers don't fault clinicians; none of the terms referring to dressings (and many other aspects of wound care) have been standardized or clinically validated. For example, if occlusive means 100% moisture retention, does semiocclusive mean 50% moisture retention?
"The absence of valid definitions hampers the entire process of providing optimal care and communicating to others exactly what you're doing," says van Rijswijk. "When we say 'moist environment' or 'moisture-retentive dressing,' what do we mean? What is exudate absorption and how is it quantified? There's no valid definition of exudate absorption."
"Terminology issues have a real impact on how we prescribe products for patients," says Beitz. "When I talk to another wound care nurse, there can be confusion because what I understand may not be what she understands. With wound dressings, the categories are based on dressing contents, not what they do or their clinical efficacy."
Without consensus, usage and definition will depend on individual interpretation. Dressing categorization, as it stands, is not a source of clarification, but of confusion - a place where communication can break down.
Using dressing categories to divide wound dressings is a natural and useful method for helping clinicians decide which dressing to choose, and for teaching. Van Rijswijk and Beitz recently wrote: "As a teaching strategy, the strength of placing dressings into categories is particularly helpful when novices are faced with learning the wide variety of available products. Unfortunately, 'matching' products to actual wound interventions on the basis of dressing category remains a difficult task for the inexperienced. Wound care treatment decisions should be based on an assessment of the patient and the wound, the goal of care, the care environment, caregiver expertise, reimbursement, and cost-effectiveness of the plan of care. However, in a survey of nursing homes, dressing selection by category for stages III and IV pressure ulcers was based on many variables except critical aspects of wound assessment such as exudate and depth."1
Unfortunately, says Beitz, dressing choices are often influenced more by product availability and reimbursement than the goal of care or the characteristic of the wound. The time has come, van Rijswijk and Beitz suggest, to describe dressings not by what they contain, but by their functions and what they accomplish. Beitz points out that medications are not prescribed based on their contents, but on each one's specific action in a given situation.
"Maybe it's time, because of the explosion of wound care products, to categorize dressings according to what they do and their purpose. This issue does cause problems," says Beitz.
Time for a new system
Beitz and van Rijswijk propose a new wound dressing classification system that emphasizes dressing functions over dressing features. Features are usually described with vague or invalidated terminology such as "highly absorbent," "conformable," "protects the wound," and "mildly deodorizing." Functional descriptions include phrases such as "stays in place for X number of days," "reduces pain," and "provides a bacterial barrier." To make them meaningful, such functional claims should be quantified through clinical trials that provide solid evidence of a product's safety and efficacy.
For example, products that are categorized as occlusive or semiocclusive are available by the score, yet the term does not tell clinicians in any substantial way how moist they will keep a wound. "Because, by definition, most of these dressings are supposed to prevent desiccation of the wound bed, the most practical and objective operational definition of occlusion can be based on a dressing's ability to retain moisture," they write.1
Moisture retention can be quantified by the moisture vapor transmission rate (MVTR) measured in g/m2/hr. Dressings with an MVTR of less than 35 g/m2/hr appear to facilitate healing of exuding partial-thickness wounds. Dressings with a high MVTR (over 50, for example) will not adequately maintain a moist environment for these wounds.
Using such a specific measure to describe a dressing's actions would greatly aid clinicians in choosing the best product to apply. Beitz says additional research into applying the MVTR is needed, but adds that it is so far the only wound dressing variable that is clearly defined and shown to correlate with healing times. Therefore, it could serve as a starting point for clinicians and manufacturers to develop functional product categories.
Functional product criteria that could be used in lieu of vague dressing categories could include:1
· incidence of irritation and sensitization of intact skin and wounds;
· incidence of complications such as infection;
· ability to absorb wound exudate and the effect of such capabilities on healing;
· ability to dissolve necrotic tissue or fibrinous slough;
· effect on pain;
· effect on patient quality of life;
· effect on scarring and range of motion.
There's a clear need for a common language that does not yet exist when discussing wound care, says Beitz. The words themselves may be the same, but people's interpretations of them vary a great deal. "If something as straightforward as this causes confusion, then we have a serious issue," she adds.
Beitz points to the definitions of pressure ulcers formulated by the National Pressure Ulcer Advisory Panel as an example of how consensus serves to clarify what might otherwise have remained a muddled issue. Is it time to call a conference to hammer out definitions? Not yet, says Beitz. "People first need to recognize it as a problem. Then we'll see more of them saying we need a shift in thinking."
Reference
1. van Rijswijk L, Beitz J. The traditions and terminology of wound dressings: Food for thought. JWOCN 1998; 25:116-121.
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