OBJECTIVE: This retrospective descriptive study explored the prevalence of wet-to-dry dressings ordered for wound care of open wounds healing by secondary intention. Research questions included the following: How frequently are healthcare providers ordering wet-to-dry dressings for wound care? Which specialties of healthcare providers are most frequently ordering wet-to-dry dressings? Are wet-to-dry dressings being ordered appropriately?
METHODS: A retrospective chart review examined admission orders for 202 randomly selected Florida home care and health maintenance organization patients from 2002 to 2004. All subjects in the study had open wounds healing by secondary intention (42 partial-thickness and 160 full-thickness wounds). Frequencies are reported as the main outcome measure.
RESULTS: Wet-to-dry dressings accounted for 42% of wound care orders, followed by enzymatic (7.43%) and dry gauze (6.93%). Most wounds treated with wet-to-dry dressings were surgical (69%), followed by neuropathic ulcers (10%) and pressure ulcers (5.9%). Surgical specialists preferred wet-to-dry dressings (73%). Mechanical debridement was not clinically indicated in more than 78% of wounds treated with wet-to-dry dressings. Therefore, wet-to-dry dressings were inappropriately ordered in these cases.
CONCLUSIONS: These findings suggest that wet-to-dry dressings (or dry gauze) are prescribed inappropriately in situations where there is little evidence to support their use. To achieve evidence-based practice in wound care, clinical decision making should be scientifically based. Future research should focus on which wound dressings are most effective in optimizing wound healing, as well as on investigating the reasons for the continued use of wet-to-dry dressings.
The scientific literature regarding wound care of open wounds describes many advanced wound care modalities developed over the past 40 years.1 Many of these wound care modalities have been well tested in repeated scientific studies.1-8 Modern or "advanced" wound care products and modalities are designed to provide a variety of functions. Most researchers agree these functions should address the following: debridement of nonviable tissue, infection control, moisture regulation, and attention to the wound edges (TIME).9-11 Carville12 suggests adding "S" to the acronym (TIMES) to address the periwound skin. National and international wound research organizations, such as the Wound Healing Society; European Tissue Repair Society; International Wound Bed Preparation Advisory Board; American Academy of Wound Management; National Pressure Ulcer Advisory Panel; World Union of Wound Healing Societies; American Professional Wound Care Association; Wound Ostomy, Continence Nurses Society; and others have provided evidence-based wound care or "best practice" guidelines for the treatment of many types of chronic wounds. Unanimously, these organizations recommend moist dressings for open wounds healing by secondary intention. Many of these treatment guidelines are available on the National Guideline Clearinghouse Web site sponsored by the Agency for Healthcare Research and Quality (formerly AHCPR [http://www.guideline.gov ]).
MOIST WOUND HEALING VERSUS DRY WOUND BEDS
Moist wound healing has been accepted as the prominent and most advantageous principle of wound treatment modalities since George Winter's pivotal work in 1962 demonstrating that moist wounds heal 2 to 3 times faster than dry wounds.6,9,13 Research has demonstrated that moist wound environments promote granulation and epithelial cell migration in wounds, whereas dry wounds impair fibroblast proliferation and prevent cell migration.9,10,14,15 The primary purpose of wet-to-dry dressings is the mechanical debridement of necrotic tissue. However, it has been suggested that the use of wet-to-dry dressings over the past 50 years has become more or less a "default" dressing used for every type of wound regardless of the amount of necrotic tissue present in the wound bed or the amount of exudates present.3,16-21 Modern wet-to-dry dressings are typically accomplished by moistening 8- or 12-ply cotton gauze with a solution (usually 0.9% normal saline) and placing it in the wound, allowing it to dry, then removing it dry from the wound bed, thus performing mechanical debridement. There are several reasons why this form of debridement is detrimental to the wound bed and unnecessary, with so many other forms of wound debridement available today. Increased pain, lack of procedural compliance, increased risk of infection, reinjury to healthy granulating tissue, and increased cost are several key reasons wet-to-dry dressings are inappropriate for wound care in most cases.1,18-26
Bolton14 aptly stated, "There is ample evidence on how to give wounds the opportunity to heal by providing a moist physiological environment for the cells that do the work of healing. Yet practitioners thoughtlessly expose wounded tissue to desert environments that desiccate and kill healing cells. This dried tissue, often with gauze remnants acting as foreign bodies, is more prone to infection and pain and heals more slowly than if it were kept physiologically moist, placing patients at risk of amputation or longer hospital stays. The medical profession eradicated polio and smallpox, but often ignores the most basic evidence on how to heal wounds."14
This was a descriptive study. A retrospective chart review of 202 subjects with open wounds healing by secondary intention was performed during 2003-2004 (Table 1).
||Table 1. SAMPLE CHARACTERISTICS AND WOUND CHARACTERISTICS
One hundred two subjects were randomly selected from a health maintenance organization (HMO) wound care management database covering the state of Florida; 193 additional subjects were randomly selected from a home healthcare organization in north Florida by their patient entry number in the database using a random-digits table. Clinical documentation and claims data were reviewed using a data collection sheet. The data collection sheet surveyed patient demographics in addition to wound size, wound bed description (amount of viable and nonviable tissue present), color and amount of drainage, infection present, type of initial dressing ordered by the healthcare provider, and specialty of the ordering healthcare provider. Patient charts were excluded from the analysis if the patient did not have an open wound (such as a closed surgical incision, ostomy, drain site, or chest tube). Patient charts were also excluded if they were missing 6 or more required items from the data collection sheet. A total of 202 eligible subjects were included in the study from the HMO (n = 74) and home health organization (n = 128). The data questionnaire was designed to collect data to answer the following questions: (1) Which wound dressings were most preferred? (2) What was the prevalence of wet-to-dry dressings versus other modalities? (3) What healthcare specialties ordered wet-to-dry dressings with the greatest frequency? (4) For what types of wounds were wet-to-dry dressings most frequently ordered? (5) What was the average amount of viable and nonviable tissue present in these wounds? (6) Was mechanical debridement indicated by the amount of nonviable tissue described in the wound bed? The data were collected on the Wound Data Collection Form and entered on a spreadsheet, double-checked, then copied into SAS for data analysis.
Statistical analysis was performed with SAS statistical analysis software. Descriptive statistics were determined, and frequencies of dressings, physician specialties, types of wounds, and amounts of viable tissue described in the wound beds were recorded. Further analysis was done to determine if there were significant differences in the wet-to-dry-dressing group versus all other types of wound dressings and analyzed with the chi-squared test of significance. The level of significance was set at .05 for all analyses.
Table 1 displays the sample characteristics and wound characteristics. There were slightly more women (n = 114) in the sample than men (n = 88). More than 66% of the sample was white (n = 135), 16.34% African American (n = 33), and 3.96% Hispanic (n = 8). Most study subjects were older than 41 years (83.17%) and nondiabetic (>59%).
Wet-to-dry dressings were the most frequently ordered wound care modality for open wounds healing by secondary intention. Wet-to-dry dressings accounted for nearly 42% of all wound care (n = 84) (Figure 1) for both full-thickness and partial-thickness wounds, followed by enzymatic dressings (7.43%, n = 15) and dry gauze (6.93%, n = 14). Surgical wounds (69%, n = 58) represented the majority of wounds treated with wet-to-dry dressings (Figure 2). The location of the open surgical wounds treated with wet-to-dry dressings varied, but "abdominal" was the most frequent location cited (38 abdominal, 7 lower extremity, 4 chest, 3 perirectal, 2 groin, 2 neck, 1 upper extremity, and 1 buttocks). Neuropathic foot ulcers (11%, n = 9), pressure ulcers (PrUs) (6%, n = 5), and venous (4%, n = 3) and arterial ulcers (2%, n = 2) were also treated with wet-to-dry dressings (Table 2). In addition, dry gauze alone was the wound dressing ordered for 12 open surgical wounds (1 chest, 3 lower extremity, 5 abdominal, and 3 perirectal), 2 injury-related wounds, and 1 venous ulcer. Of the 58 surgical wounds for which wet-to-dry dressings were ordered, general surgeons accounted for most orders (55%, n = 32); other surgical specialties (eg, gynecology, gastrointestinal, orthopedic, cardiac, trauma, urology, and podiatry) accounted for only 13 of these surgical wounds (22%). In addition, nonsurgical specialists (rehabilitation medicine, family practice, internal medicine) ordered 5 of the 58 wet-to-dry surgical wound dressings (9%). These results imply that general surgeons were the healthcare providers most likely to order wet-to-dry dressings in this sample population (Figure 3).
||Figure 1. PREVALENCE OF WET-TO-DRY DRESSINGS IN 202 WOUND CARE SUBJECTS
||Figure 2. WET-TO-DRY VERSUS OTHER TYPES OF DRESSINGS BY WOUND TYPE BY NUMBER OF SUBJECTS
||Figure 3. WET-TO-DRY DRESSINGS ORDERED BY HEALTHCARE PROVIDER SPECIALTY TYPE
||Table 2. ALL DRESSINGS LISTED BY WOUND TYPE AND PERCENTAGES (ALL OPEN WOUNDS)
Including all wounds (surgical and nonsurgical), family practice physicians accounted for 23 of the total wound care orders (11%) in the sample (5 wet-to-dry orders, 18 "other dressing" orders). Internal medicine physicians accounted for 25 wound orders (12%; 12 wet-to-dry and 13 other dressings). Vascular surgeons wrote 6 wound care orders (3%; 4 wet-to-dry and 2 other dressings). General surgeons accounted for 48 total wound care orders (24%; 32 wet-to-dry and 16 other dressings). Physicians at wound care centers accounted for 18 of wound care orders (9%) for open wounds. Interestingly, none of these physicians ordered wet-to-dry dressings. Unfortunately, the number of separate physicians in each specialty was not collected. This is a limitation of the study, although study subjects included physician locations scattered over the entire state of Florida, so more than just a few different physicians in one area were represented.
Furthermore, it is important to note that most of the wounds (78%) where wet-to-dry dressings were ordered had greater than 75% granulating tissue noted in the wound bed (Table 3) at the time of the initial wet-to-dry order. More than 42% of the wet-to-dry-dressing group had 76% to 99% granulating wound bed, and an additional 36% of the wet-to-dry-dressing group had 100% granulating tissue documented in the wound bed at the time of the initial wet-to-dry orders. Only 3 wounds in the wet-to-dry dressing group had 25% to 50% granulation tissue documented; 3 others were documented with 50% to 75% granulation tissue. The scientific literature supports mechanical debridement by wet-to-dry dressings only when the benefit of removing nonviable tissue from the wound bed outweighs the risks of detrimental disruption of healthy granulating tissue in the wound bed (such as when >50% nonviable tissue is present in the wound bed).1,3,21,23,26-28 Therefore, even excluding wounds without granulation tissue documented, 82% of all wounds (n = 69) with wet-to-dry dressings ordered in the study had greater than 50% granulation tissue documented in the wound bed and were not appropriate for this method of mechanical debridement.
||Table 3. AMOUNTS OF GRANULATING TISSUE NOTED IN THE WOUND BEDS
Finally, to determine if there were significant differences in the wet-to-dry dressing group and the group composed of all other dressings, the chi-squared test of significance was used. General surgeons, more than any other healthcare provider in the study, ordered wet-to-dry dressings for wound care (P < .01). Wounds with wet-to-dry dressings ordered versus all other types of dressings were more likely to be abdominal wounds (P < .01). Surgical wounds versus all other types of wounds were more likely to have wet-to-dry dressings ordered (P < .01). Wet-to-dry dressings were more likely to be ordered for full-thickness wounds than partial-thickness wounds (P < .01). High amounts of granulating tissue (76%-99%) in the wound bed of the wet-to-dry-dressing group versus all other types of dressings were a meaningful finding (P = .11), indicating that mechanical debridement was not clinically indicated in most wounds where wet-to-dry dressing was ordered. However, statistical significance was not achieved because wounds with 76% to 99% granulating tissue in the wound bed or 100% granulating wound beds were analyzed in 2 separate groups. This also is a limitation in the study.
Healthcare provider preferences for choosing dressing materials should be evidence based, matching specific needs of the wound bed with the most appropriate wound care products. Although numerous products maintain a moist wound environment and have reported successful wound healing results in clinical trials, it is evident that healthcare providers continue to order wet-to-dry dressings for wound care despite scientific data against the practice.17,29 As the name implies, wet-to-dry dressings ultimately result in dry wound beds (even if for limited amounts of time), and the practice of using them is no longer evidence based.2-4,9,10,13,14,18,19,22,23,30-34 The scientific literature reports that dry gauze dressings in open wounds (whether used dry or used as wet-to-dry) disrupt granulating tissue,3 impair epithelial cell migration and histological activity, 9,14,23 leave foreign bodies in the wound bed,14 increase the risk of infection, aerosolize bacteria,14,22,35 cause severe pain upon removal,24,36 and are less effective and more costly than other forms of debridement such as collagenase, fibrinolysin, and autolysis.25,26,37 To reiterate, wet-to-dry dressings are used primarily for mechanical debridement, and they are not described in any current scientific literature as having another purpose. The use of wet-to-dry dressings is usually reserved for "heavily necrotic wounds"1,16,21,28 (suggesting those with >50% nonviable tissue present in the wound bed). Wet-to-dry dressings (and dry gauze) were ordered with disturbing frequency (>48%) by physicians for a variety of open wounds recorded by this study. Furthermore, wet-to-dry dressings were used most often in wounds with more than 75% granulating wound beds where mechanical debridement was not indicated.
The findings of this study are consistent with those found by Helberg et al29 and Armstrong and Price,17 who found that wet-to-dry dressings (or dry gauze) are used most frequently in situations where there is little evidence to support their use. In the study of Helberg et al29 comparing scientific evidence and actual wound care practice for PrUs in 51 hospitals and 15 nursing homes in Germany (11,584 patients with PrUs), they revealed that the treatment of PrUs was consistent with current evidence in less than 50% of the time. In addition, according to a literature review and descriptive study conducted by Armstrong and Price, "Wet-to-dry and gauze dressings are the most widely used primary dressing material in the United States." Armstrong and Price17 sent a 3-part questionnaire to a convenience sample of 127 general surgeons in New Hampshire and Vermont. The response rate was 65 (51.2%). The study was designed to discover how many physicians would prescribe 4 types of gauze dressings (including wet-to-dry) rather than 4 alternatives (alginates, foams, gels, and hydrocolloids) for each of 8 types of hypothetical wounds. All 8 were wounds healing by secondary intention and included open surgical wounds, abscesses, donor sites for skin grafts, skin grafts, venous leg ulcers, partial-thickness burns, necrotic PrUs, and necrotic wounds needing debridement. The results described by Armstrong and Price17 demonstrated that gauze dressings were prescribed far more than modern alternatives for all wounds except venous leg ulcers. Of 65 physicians responding, 30 (46%) chose wet-to-dry for open surgical wounds healing by secondary intention. More than 55 of the 65 respondents selected some form of gauze dressing for surgical wounds as well as abscesses. The second part of Armstrong and Price's17 questionnaire asked participants to select 1 of 7 choices for performing a wet-to-dry procedure. Twenty respondents selected "A wet-to-dry dressing should not be moistened before removal" + "the type of gauze is important" + "must be allowed to dry before dressing is replaced."17 Eleven respondents selected "A wet-to-dry dressing should be moistened before removal" + "the type of gauze is not important" + "should not be allowed to dry before dressing is replaced."17 Other respondents selected other options, yet there were less than 9 respondents in any other wet-to-dry procedure option. Armstrong and Price concluded that wet-to-dry dressings are not only being prescribed inappropriately, but also being used inconsistently. The third part of the Armstrong and Price17 questionnaire looked at participants' reasons for not using modern wound care products. Cost appeared to be the predominantly cited barrier, with only 7 general surgeons believing that alternatives to gauze were cost-effective. However, as Armstrong and Price17 noted, unit cost and cost-effectiveness are not necessarily the same thing. If a hypothetical cost comparison (using prices from a common medical supply catalogue) is prepared for wet-to-dry dressings used twice a day (dosage suggested by the literature) versus a wound gel used daily, or other modern alternatives such as hydrocolloids, alginates, foams, and so on, then costs for performing wet-to-dry dressings are greater than costs for these alternative wound modalities.
In addition to the above findings suggesting an inappropriate use of wet-to-dry dressings, it is remarkable to note how frequently cytotoxic solutions38 (Dakin solution, hydrogen peroxide, povidone-iodine, acetic acid, alcohol, or mafenide acetate) were ordered as wound cleansers or as part of the wet-to-dry dressings in this sample. Five subjects had Dakin solution prescribed as the "wet" solution in their wet-to-dry dressings. One subject had wet-to-dry dressings ordered with 25% acetic acid-this order was probably written in error but certainly should have been clarified with the physician, because household vinegar is only a 6% acetic acid solution, and acetic acid is cytotoxic to fibroblasts and keratinocytes at even a 0.25% solution.38 Gentamicin-clindamycin-polymyxin B solution, diluted povidone-iodine, and mafenide acetate were ordered in other wet-to-dry dressings in this study. In addition, hydrogen peroxide was ordered as a daily cleansing agent for 5 subjects with various primary dressings. All of these listed solutions are known to be cytotoxic. Interestingly, only 3 of the subjects described above had any signs or symptoms of infection documented (erythema, edema, warmth, purulent exudates, increasing pain, hypergranulation tissue, or necrosis) before or after any antimicrobial solution was ordered.
The results of this descriptive study indicate wet-to-dry dressings were used with inappropriate frequency in the treatment of open wounds healing by secondary intention, especially open surgical wounds. Armstrong and Price's17 research evaluating physician intentions in the use of wet-to-dry dressings supports these findings. Their results also suggest that "wet-to-dry dressings and gauze are commonly prescribed for situations where there is little evidence to support their use[horizontal ellipsis]" and "inconsistency [horizontal ellipsis] on how the technique should be performed."17 Furthermore, a wound care knowledge survey of 692 nurses from 48 states, 5 Canadian provinces, and 7 countries39 indicated that 26% of respondents did not know that moist wound healing is the criterion standard1,9,14,40 for chronic wound management, and 38% of nurse respondents incorrectly stated that wet-to-dry dressings are best used to treat clean granulating chronic wounds. In addition, 70% of nurse respondents indicated they believed they had not received sufficient education on chronic wound care in their basic nursing educational background.
A great knowledge deficit exists among healthcare professionals related to the use of wet-to-dry dressings versus modern wound modalities for the care of open wounds healing by secondary intention. Further research, as well as improvements in the standardizing of interdisciplinary wound care education curricula, is needed.
1. Bolton L. Wound Dressings. In: Rovee D, Maibach H, eds. The Epidermis in Wound Healing. Boca Raton, FL: CRC Press; 2004:217-31. [Context Link]
2. Thomas DR, Goode PS, LaMaster K, Tennyson T. Acemannan hydrogel dressing versus saline dressing for pressure ulcers. A randomized, controlled trial. Adv Wound Care 1998;11:273-6. [Context Link]
3. Ovington LG. Hanging wet-to-dry dressings out to dry. Home Healthc Nurse. 2001;19:477-83. [Context Link]
4. Levin ME. Management of the diabetic foot: preventing amputation. South Med J 2002;95(1):10-20. [Context Link]
5. Bradley M, Cullum N, Nelson EA, Petticrew M, Sheldon T, Torgerson D. Systematic reviews of wound care management: (2). Dressings and topical agents used in the healing of chronic wounds. Health Technol Assess. 1999;3(17 Pt 2):1-75. [Context Link]
6. Eaglstein W. Moist wound healing with occlusive dressings: a clinical focus. Dermatol Surg 2001;27:175-81. [Context Link]
7. Bolton L. Compression in venous ulcer management. J Wound Ostomy Continence Nurs 2008;35:40-9. [Context Link]
8. Ennis WJ, Foremann P, Mozen N, Massey J, Conner-Kerr T, Meneses P. Ultrasound therapy for recalcitrant diabetic foot ulcers: results of a randomized, double-blind, controlled, multicenter study. Ostomy Wound Manage 2005;51(8):24-39. [Context Link]
9. Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation: a systematic approach to wound management. Wound Repair Regen 2003;11 Suppl 1:S1-S28. [Context Link]
10. Schultz GS, Barillo DJ, Mozingo DW, Chin GA; Wound Bed Advisory Board Members. Wound bed preparation and a brief history of TIME. Int Wound J 2004;1(1):19-32. [Context Link]
11. Dowsett C. The role of the nurse in wound bed preparation. Nurs Stand 2002;16(44):69-72, 74, 76. [Context Link]
12. Carville K. Which dressing should I use? It all depends on the 'TIMEING'. Aust Fam Physician 2006;35:486-9. [Context Link]
13. Winter GD. Formation of the scab and the rate of epithelization of superficial wound in the skin of the young domestic pig. Nature 1962;193:293-4. [Context Link]
14. Bolton LL. Moist Wound Healing from Past to Present. In: Rovee DT, Maibach H, eds. The Epidermis in Wound Healing. Boca Raton, FL: CRC Press; 2004:90-101. [Context Link]
15. Geronemus R, Robins P. The effect of two new dressings on epidermal wound healing. J Dermatol Surg Oncol 1982;8:850-2. [Context Link]
16. Ayello EA, Baranoski S, eds. Wound Care Essentials: Practice Principles. Philadelphia, PA: Lippincott Williams & Wilkins: 2004. [Context Link]
17. Armstrong MH, Price P. Wet-to-dry gauze dressings: fact and fiction. Published 3/03/2004. http://www.medscape.com/viewarticle/470257. Last accessed October 12, 2009. [Context Link]
18. Mulder GD. Cost-effective managed care: gel versus wet-to-dry for debridement. Ostomy Wound Manage 1995;41(2):68-76. [Context Link]
19. Mulder GD. Evaluation of three nonwoven sponges in the debridement of chronic wounds. Ostomy Wound Manage 1995;41(3):62-7. [Context Link]
20. Turner TD. The development of wound management products. In: Krasner D, Kane D, eds. Chronic Wound Care. 2nd ed. Wayne, PA: Healthcare Management Publications; 1997. [Context Link]
21. Bryant RA. Acute and Chronic Wounds. St. Louis, MO: Mosby; 2000. [Context Link]
22. Lawrence JC, Lilly HA, Kidson A. Wound dressings and airborne dispersal of bacteria. Lancet 1992;339(8796):807. [Context Link]
23. Hoekstra MJ, Hermans MH, Richters CD, Dutrieux RP. A histological comparison of acute inflammatory responses with a hydrofibre or tulle gauze dressing. J Wound Care 2002;11:113-7. [Context Link]
24. Collier M, Hollinworth H. Pain and tissue trauma during dressing change. Nurs Stand 2000;14(40):71-3. [Context Link]
25. Harding K, Cutting K, Price P. The cost-effectiveness of wound management protocols of care. Br J Nurs 2000;9(Suppl 19):S6, S8, S10 passim. [Context Link]
26. Lewis R, Whiting P, ter Riet G, O'Meara S, Glanville J. A rapid and systematic review of the clinical effectiveness and cost-effectiveness of debriding agents in treating surgical wounds healing by secondary intention. Health Technol Assess. 2001;5(14):1-131. [Context Link]
27. Bethell E. Why gauze dressings should not be the first choice to manage most acute surgical cavity wounds. J Wound Care. 2003;12(6):237-9. [Context Link]
28. Bryant R, Nix D. Acute and Chronic Wounds: Current Management Concepts. St. Louis, MO: Mosby; 2006. [Context Link]
29. Helberg D, Mertens E, Halfens RJ, Dassen T. Treatment of pressure ulcers: results of a study comparing evidence and practice. Ostomy Wound Manage 2006;52(8):60-72. [Context Link]
30. Vogt PM, Andree C, Breuing K, et al. Dry, moist, and wet skin wound repair. Ann Plast Surg 1995;34:493-9. [Context Link]
31. Ameen H, Moore K, Lawrence JC, Harding KG. Investigating the bacterial barrier properties of four contemporary wound dressings. J Wound Care 2000;9:385-8. [Context Link]
32. O'Meara S, Cullum N, Majid M, Sheldon T. Systematic reviews of wound care management: (3) antimicrobial agents for chronic wounds; (4) diabetic foot ulceration. Health Technol Assess 2000;4(21):1-237. [Context Link]
33. Cohn SM, Lopez PP, Brown M, et al. Open surgical wounds: how does Aquacel compare with wet-to-dry gauze? J Wound Care 2004;13(1):10-12. [Context Link]
34. Vermeulen H, Ubbink D, Goossens A, de Vos R, Legemate D. Dressings and topical agents for surgical wounds healing by secondary intention. Cochrane Database Syst Rev 2004;(2):CD003554.
35. Lawrence JC. Dressings and wound infection. Am J Surg 1994;167(1A):21S-24S. [Context Link]
36. Beldon P. Comparison of four different dressings on donor site wounds. Br J Nurs. 2004;13(6 Suppl):S38-45. [Context Link]
37. Mosher BA, Cuddigan J, Thomas DR, Boudreau DM. Outcomes of 4 methods of debridement using a decision analysis methodology. Adv Wound Care 1999;12:81-8. [Context Link]
38. Wilson JR, Mills JG, Prather ID, Dimitrijevich SD. A toxicity index of skin and wound cleansers used on in vitro fibroblasts and keratinocytes. Adv Wound Care 2005;18(7):373-8. [Context Link]
39. Ayello EA, Baranoski S, Salati DS. A survey of nurses' wound care knowledge. Adv Skin Wound Care 2005;18(5 Pt 1):268-75. [Context Link]
40. Sibbald RG, Orstead HL, Coutts PM, Keast DH. Best practice recommendations for preparing the wound bed: update 2006. Adv Skin Wound Care 2007;20:390-405. [Context Link]