From ancient times valuable consideration has been paid to wound care (Shah, 2011) and according to Gonzales (2018), practically most of us will have to deal with an open wound sometime in our professional lives, many of them requiring hospital attendance.
In England statistics between 2014-2015 shows that 114,698 patients attended A&E for wound care, 163,926 patients for wound closure (exclude suture) and 76,624 for wound suture Baker (2017). According to Guest and Vawden (2017) these numbers are increasing every year. Wound care is coming to £5.3 billion as expense for the National Health Service (NHS) (Guest et al. 2015) and between 12-15% represents wound care expenses (Guest et al. 2016).
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Purcell (2016) describes a wound as a discontinuity of the skin, the skin being the physiological barrier between us and the outside. According to Cornish and Douglas (2016) all wounds becomes infected immediately after occurrence. British Columbia Provincial Nursing Skin & Wound Committee (2018) describes wound cleansing as a use of a solution with the purpose to eliminate any discharge or debridement’s, any foreign bodies from the inside of the wound, without further damaging the already fragile area, and Allen (2017) added that irrigation will hydrate the wound and will help the healthcare provider to examine and explore the wound.
Often wound cleansing is a conventional method and still associated with `old fashion` habits (Magson-Roberts, 2006). It is anticipating that the discrepancy in methods will be reduced, as more evidence-based information and protocols are accessible to teach the professional (Dealey, 2012). Bonham (2016) suggests nurses should be mindful of current investigations in the medical area and start using the most accurate methods within the working place. Being able to do so, appropriate assessment and management of wounds will be carried out by professionals as part of their responsibility. Wound sanitizing has been a disputed argument over the years (Sasson et al 2005), being an essential stage in caring for wounds (Jones, 2012). Once the skin integrity is interrupted, infection process occur and if the cause that produced it is not timely and efficiently removed, this will lead to infection (Everts, 2016). Moscati et al., (1998) noted that when a wound becomes infected this will delay wound healing and complications might occur leading to patient staying longer in hospital. All these will affect the patient quality of life, also increase in NHS expenses.
Although there is an unanimity that appropriate wound cleansing diminishes infection rate, various opinions and practices are between the best solution used for wound cleansing (Huang, Choong and Li, 2013). According to the same British Columbia Provincial Nursing Skin & Wound Committee (2018) the product used in wound cleansing should not be harmful to humans, generally accessible and cost-effective.
This assignment is a critical analysis of literature review whether tap water can safely replace normal saline in wound care. The review method is a literature exploration of statistics, randomized control trials (RCT), peered, and confirmed healthcare articles using keywords such as WOUND, CLEANSING, TAP WATER, NORMAL SALINE, IRRIGATION, INFECTION, AND, OR, found on CINAHL (2009-2019), MEDLINE (2009-2019), PubMed(2009-2019), Cochrane (2009-2019) and Wiley online library database limited to English only. The evidence found is looking to determine as well whether there is an impact on the wound healing, the infection rates and care settings regardless the solution used for wound cleansing.
Normal saline has been commonly used as a first choice solution for wound irrigation, due to isotonic nature, and therefore suitable for natural healing action (Flanagan, 2013). Tap water has a hypotonic character and therapists use tap water for wound cleansing due to being available at a hand reach’ without limitation, low cost and chlorinated (Ljubic, 2012). Nonetheless, a methodical analysis established no discrepancy in infection rates on acute, surgical or chronic wounds irrigated using potable tap water correlated to wounds cleansed using normal saline (Fernandez and Griffiths, 2012). The selection criteria was arbitrary and to a certain extent controlled trial that used water in comparison with different options for wound irrigation. The process of healing was a further added factor to this analysis. From the 11 experiments conducted, only 7 of them analysed the rates of infection and healing in wounds where tap water and normal saline were used as cleansing agents. Exposure to infection between tap water and normal saline in chronic wounds was 0.16. This is available for acute wounds, for adults and children (adults: RR 0.66, 95% CI 0.42 to 1.04; children: RR 1.07, 95% CI 0.43 to 2.64), therefore, no confirmation was found to demonstrate that using tap water in cleansing wounds affects wound infection in any way. The inconvenience in this trial is that there is no information in assessing wound infection method, the members were hidden from the solution used for wound cleansing, not sufficiently described inclusion and exclusion method, not mentioned if volume and irrigation method has any effect in the process of wound cleansing, which gives a narrow competence for this evidence.
This conclusion has been sustained by Fernandez et al (2004) and Weiss et al (2013), in small double-blind randomized controlled clinical trials and no contrast was found in infection comparison between wounds cleaned with either tap water or normal saline solution. Randomization was carried out using a computer program allowing each subject an equal chance of getting either solution. The publishers promoted using of tap water for wound cleansing in emergency departments being convenient, adequate and ready to be used, with no cost attached. This randomized controlled trial was located in the emergency department in the USA, took place over 18 months` period, and were enrolled 631 patients. Tap water group accommodated 318 patients and 313 to the normal saline groups. Six subjects have been lost in following up. The exclusion and eligibility criteria for the trial were clear and concise, making the process of elimination quick and easy with minimum effect to patients. The reliability of this analysis is increased by having enough participants to make it conclusive, being the only study where neither participants, the treating physician and the healthcare professional checking for wound infection were not aware of the wound cleansing solution used and explicit details about control for technique of irrigation and volume of irritant were given. The disadvantage of this study was the insufficient detailed signs of infection. The conclusion is that tap water is safe to use on all wounds` cleansing with no complications in wound healing taking in account the quality of water, type of wounds and patients` comorbidities. The number of healed subjects where tap water was used supports the idea that tap water is safe enough to be used as a first line wound cleanser. Despite the study taking place in United States of America, it is considered relevant to United Kingdom taking due to the development of the country itself.
The debate by Dire and Welsh, (1990) analysed these cleansing solutions in simple, acute, traumatic sutured wounds. Two of them were eliminated as they were not conclusive for this topic: one is related to other solutions used for cleansing the wounds (Dire and Walsh, 1990) and the other one it is a study on animals (Moscati et al. 1998). Bansal et al. (2002) and Valente et al. (2003) related wound cleansing in paediatric patients with simple or complex lacerations. Patients with comorbidities including immunodeficiency system or on others therapies such antibiotics, were excluded. The analysis of Valente and his colleagues assign the infection rates of wounds irrigated with normal saline (271 patients) and tap water (259 patients), in a paediatric emergency sector. Patients were reviewed after 48-72 hours and wound cultures were obtained when the wound was attended to and then after 5 months from the beginning of the study. Almost half of the patients were followed up by phone which places this study at high risk of bias. The outcome of this analysis is that tap water can be safely used in wound irrigation in children, as no clinical discrepancy was found in infection rates. However, as it was mentioned in the study that pressure and the abundance of the tap water was measured, it is not clearly described how this influenced the final results. In the tap water group the majority of the wounds were situated at the hands level, therefore, unclear if the location of the wound can also interfere with the outcome of wound healing. Bansal at al. (2002) agreed the above conclusion by conducting a small pilot study of 46 patients, where the bitten and hands wounds and were excluded. The wounds were swabbed before and after cleansing, regardless if tap water or normal saline were used for cleansing. The wound attender and the examiner were blinded to the solution used, but unknown if patients or their companions were blinded as well. The bias consisted in the fact that patients or their companions’ has had any involvement in cleansing solution. As 44 patients returned for wound follow up, 2 of them were approached by phone. The swabs results were not significant and 2 infected wounds returned from each group. As a result tap water may safely replace normal saline in cleansing wounds, however, more corroboration is suggested.
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In a small (22 subjects) double-blinded randomized controlled trial, Chan, Cheung and Leung (2016) analysed acute and chronic wounds in the community, swabbing wounds conflicting with wound irrigation being further addition to this study. The aim of the study is to conclude if wound infection and healing is increased when tap water is used for cleansing wounds. The group was divided equally and 30 wounds were analysed. The unicity of this study is given by the fact that is addressed to an Asian country, Hong Kong. Patients were arbitrary chosen and arbitrary assigned to tap water and normal saline group. The wound was evaluated at each home visit, with a weekly wound measurement. The completion of the study was that tap water is a harmless option for wound cleansing in community. However, the efficacy of the study is uncertain due to the settings and using swabbing technique for cleansing wounds.
Wound care improved massively over the years, however not enough consideration has been given to cleansing solutions. Regardless if tap water or normal saline is used for wound cleansing, Feinstein and Miskiewicz (2009) suggested decreased wound-bed temperature leads to destroying viable cells responsible for fighting infection. Therefore using a cold wound cleansing solution, wound healing might be delayed. According with Santos et al. (2016) tap water is used in clinical practice depending on personal practice and choice, clinical settings and local protocols. Despite strong evidence that tap water can be safely used on chronic wounds, working setting is to be considered. Jefferies et al. (2012) established considerable bacteria developing in and around washbasins in hospital, confirmed by swabs cultured in laboratory. For patients with immunodeficiency system, diabetic wounds or wounds where a tendon or a bone is involved, normal saline it may be more suitable to be used as a preventive measure to decrease risk of infection (Peate and Glencross, 2015). A patient with a excised pilonidal wound or episiotomy wound, inpatient or at own home, is encouraged to shower daily or after every bowel motion (Harris et al. 2016). This is on account that the wound can be freely harmed with faecal material, but also may increase patient`s well-being.
Regardless if tap water or normal saline is used for wound cleansing, the temperature of the solution chosen should reflect a normal body temperature for preventing delay in healing. Tap water can be used for wound cleansing whether in the community or hospital setting; however, more evidence is required. If decision has been taken that tap water can be safely used for wound cleansing, the quality of the tap water, character of the wound and immune system function of the patient should be strongly considered, therefore everyone involved in wound care should be knowledgeable and mindful of the risk and therefore accountable for their actions, regardless solution used for wound cleansing.
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