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140 J WOCN ■ March/April 2016 Copyright © 2016 by the Wound, Ostomy and Continence Nurses Society™ WOUND CARE J Wound Ostomy Continence Nurs. 2016;43(2):140-147. Published by Lippincott Williams & Wilkins ■ Introduction Wound cleansing plays a vital role in wound management. 1,2 In most situations, sterile normal saline is used in both western and eastern countries because of its isotonic properties, its osmotic pressures, which are similar to intracellular fl uid, 1,3 as well as its sterile and noncytotoxic Mun Che Chan, MSc, Community Nursing Services, Kwong Wah Hospital, Hong Kong. Kin Cheung, PhD, School of Nursing, The Hong Kong Polytechnic University, Hong Kong. Polly Leung, PhD, Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong. This study was funded by The Hong Kong Polytechnic University and Kwong Wah Hospital. MCC, KC, and PL were responsible for the study conception and design. KC and PL performed laboratory testing. MCC performed the data collection and data analysis. MCC and KC were responsible for the drafting of the manuscript. MCC, KC, and PL reviewed the manuscript. KC and PL supervised the study. The authors declare no confl ict of interest. Correspondence: Kin Cheung, PhD, School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong ( kin.cheung@polyu.edu.hk ). ■ ABSTRACT PURPOSE: The use of tap water as a wound-cleansing agent is becoming more common in clinical practice, especially in community settings. The aim of this study was to test whether there are differences in wound infection and wound healing rates when wounds are cleansed with tap water or sterile normal saline. DESIGN: Double-blinded randomized controlled trial. SUBJECTS AND SETTING: Subjects were recruited from the community nursing service of a local hospital in Hong Kong. The target sample included subjects who were aged 18 years or more, and receiving chronic or acute wound care treatment. METHODS: Subjects were randomly assigned to wound cleansing with tap water (experimental group) or sterile normal saline (control group). Wound assessment was conducted at each home visit, and an assessment of wound size was conducted once a week. The main outcome measures, occurrence of a wound infection and wound healing, were assessed over a period of 6 weeks. RESULTS: Twenty-two subjects (11 subjects in each group) with 30 wounds participated in the study; 16 wounds were managed with tap water cleansing and 14 were randomly allocated to management with the sterile normal saline group. Analysis revealed no signifi cant difference between the experimental and control groups in the proportions of wound infection and wound healing. CONCLUSIONS: Study fi ndings indicate that tap water is a safe alternative to sterile normal saline for wound cleansing in a community setting. KEY WORDS: Cleansing agents , Home care , Randomized control trials , Wound care , Wound swabbing Tap Water Versus Sterile Normal Saline in Wound Swabbing A Double-Blind Randomized Controlled Trial Mun Che Chan Kin Cheung Polly Leung DOI: 10.1097/WON.0000000000000213 properties. 4 Recently, the use of tap water as a cleansing agent has been reported in western countries, such as Australia, 5 Germany, 6,7 Sweden, 8 and the United States, 9-12 but it is not normally used in eastern countries. In their systematic review, Fernandez and colleagues 1 concluded “there is no evidence that using tap water to cleanse acute wounds in adults increases infection” (p. 2), rather in some cases, tap water can reduce wound infection. However, the reviewers found only 6 randomized controlled trials (RCTs) 1 conducted in western countries that evaluated the effectiveness of tap water as compared with sterile normal saline in wound cleansing. Hence, there is a need to evaluate whether it is safe to use of tap water in wound cleansing in eastern countries. Among the 6 RCTs, only one was conducted in community settings (Australia); the other 5 were set in accident and emergency departments in Sweden and the United States. 5,8-12 The demand for wound care management in the community setting is increasing, as acute care facilities attempt to reduce length of hospital stays and rely more on community services. 13 In the United States, 31% to 36% of patients in community settings have wounds. 14 Similarly, 51% of community nursing services in Hong Kong involve wound care management. 15 Tap Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. JWOCN-D-14-00058_LR 140 WOCN-D-14-00058_LR 140 20/02/16 8:30 AM 0/02/16 8:30 AM J WOCN ■ Volume 43/Number 2 Chan et al 141 water has been suggested as an effective cleansing agent for lacerations, postoperative, and chronic wounds 16; it is an acceptable alternative to cleanse wounds in the home environment, as showering and bathing are becoming common practices for the care of chronic wounds. 17 In addition, tap water costs less than sterile normal saline, and it is both readily available in the community setting and relatively affordable to most. 1 Nevertheless, sterile normal saline is usually used for wound cleansing in most Asian countries, and in Hong Kong. The cost of sterile saline, combined with manufacturer recommendations that the contents of the bottle be discarded 24 hours after opening, results in higher costs than those associated with tap water. 4 Community nursing aims at maximizing existing resources to achieve optimal health outcomes for individuals. Use of tap water for wound cleansing in the community setting is anticipated to augment self-management of wounds at home. Hence, more evidence is needed to support its safe use in the community setting. Additional research is also needed because the 6 RCTs discussed previously used irrigation rather than swabbing for wound cleansing. 5,8-12 However, wound swabbing is advocated in several recent nursing skills textbooks, 18,19 and it is commonly used in clinical practice. Swabbing involves the use of a swab or gauze moistened with a cleansing agent such as sterile saline or tap water. This technique differs from wound irrigation where sterile saline or another agent is used to fl ush the wound via application under pressure. 18,19 As there is currently no study to support or refute use of the swabbing technique to cleanse wounds, 16 there is a need to fi nd out the effectiveness of wound swabbing with either tap water or sterile normal saline, especially in community settings. We therefore tested the following hypothesis: there is no difference in the proportions of wound infection and wound healing when wounds are cleansed with tap water or sterile normal saline using a swabbing method. ■ Methods In order to test this hypothesis, we conducted a doubleblind, randomized controlled trial. Data were collected over 2 time periods: from August 30 to October 9, 2010 (6 weeks), and November 22, 2010, to January 2, 2011 (6 weeks). Subjects were recruited from the community nursing service (CNS) of a local hospital in Hong Kong. Patients who live at home or in a nursing home can receive nursing services from the CNS. 20 Inclusion criteria for the study were: age 18 years or more and receiving either chronic or acute wound care treatment from our CNS. Exclusion criteria were women receiving postnatal care, immunosuppressed persons, patients with acute or chronic leukemia, malignant lymphoma, solid tumors, long-term corticosteroid therapy, autologous stem cell transplantation, solid organ transplantation, 21 an infected wound or receiving antibiotics, 5 stage I or IV pressure ulcers, or leg ulcers or leg wounds involving tendon or bone. Subjects with wound cleansing under specifi c wound-cleansing protocols, such as using silver dressing material, were also excluded from participation. Subjects were randomly assigned to cleansing with tap water (experimental group) or sterile normal saline (control group) by computer-generated random numbers. Since this was a double-blinded study, 100 mL of tap water and 100 mL of sterile normal saline were
prepared using the same kind of sterile bottles by the main researcher who was the only person to know the result of group assignment. Therefore, the randomization procedure was blinded to subjects and CNS nurses who performed wound cleansing. ■ Outcome Measures The main outcome measures were wound infection and wound healing. Wound infection was defi ned as an invasion of bacteria into healthy tissues, followed by continued proliferation and a host reaction including erythema, pain, swelling, persistent high-volume exudate, odor, and delayed healing. 22 We operationally defi ned a wound infection as clinical signs and symptoms like erythema, presence of high volume of exudates and odor, and sensation of increased pain by subjects. Wound healing was measured by the change in wound size and the presence of epithelial tissues on the wound bed. 5 Wounds were measured using a 1-cm fl exible wound grid (Coloplast Proprietary, Hong Kong), which is considered a standardized measurement for wound size. 5,23 Two-dimensional measurements in the form of surface area were done by measuring its linear dimension, for example, a rectangle (length × width), a circle (diameter × diameter), or an oval (maximum diameter × maximum diameter perpendicular to the fi rst measurement). 23 Study Procedures Study procedures were reviewed and approved by the Human Subjects Committee of the Hong Kong Polytechnic University, and the Clinical Research Ethics Committee of the Kowloon West Cluster of the Hospital Authority. Informed consent was obtained from subjects if they were cognitively alert, or proxy consent was obtained from the subject’s guardian if the subject was unable to sign the consent form. The frequency of wound cleansing was determined after each home visit by the CNS nurses. Most wounds were cleansed once daily. The CNS nurses followed the same standard protocol to perform wound cleansing using a swabbing method for each patient; only the agent used to cleanse the wound (tap water or sterile saline) varied between the groups. Wound infection and healing were assessed each time when the wound was Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. JWOCN-D-14-00058_LR 141 WOCN-D-14-00058_LR 141 20/02/16 8:30 AM 0/02/16 8:30 AM 142 Chan et al J WOCN ■ March/April 2016 cleansed by the CNS nurse. Wound size was measured weekly. Baseline data were extracted through the communitybased nursing system, which included sex, age, medication use, medical history, living arrangement, personal hygiene, mental status, hydration status, attitude of caregivers toward patients, Barthel Index together with the wound type (acute or chronic), stage (pressure ulcers were staged based on the National Pressure Ulcer Advisory Panel staging system 24), size, location, and frequency of wound dressing. Baseline data were collected by CNS nurses as a part of an initial assessment on newly admitted patients. The Barthel Index is a tool to measure a person’s activity of daily living on feeding, bathing, grooming, dressing, bowel, bladder, toilet use, transfer, mobility, and stairs, with a maximum score of 100. 25 Decreased activity level impedes vascular blood supply and exerts pressure to body skin, which would affect the progress of wound healing. 26 This baseline information was extracted to see whether there were any baseline differences between the experimental and control groups. Preparation of Cleansing Agents Because this was a double-blind study, 100 mL of tap water and 100 mL of sterile normal saline were prepared by one researcher using the same type of container for both solutions. One hundred milliliters of tap water from the CNS water tap was aseptically collected into 100-mL sterile bottles a day before wound cleansing. The hospital water tanks are routinely washed and cleaned every 3 months according to hospital policy. To ensure consistency, tap water from the CNS water tap was used for the study instead of water from the subjects’ homes. Furthermore, total bacterial counts for the tap water collected from the CNS were performed 1 month before the study commenced, and randomly (once a week) during the 6-week study interval. Tap water from the CNS tap was pilot-tested using the conventional plate count method in late March 2010. The quality of the CNS tap water was found to be acceptable. On average, there were 0.08 units of bacteria per milliliter of tap water. Only 2 RCTs had previously performed microbiological tests on the tap water used in wound cleansing, and they reported a total bacterial count of less than 5 and 1 units per milliliter, respectively. 8,12 Sterile normal saline used in the study was supplied by the hospital. Either sterile normal saline or tap water was placed inside 100-mL sterile bottles by the main researcher the day before wound cleansing. The bottles were then collected and sterilized after each use. Interrater Reliability Wound cleansing and assessments were performed by 18 CNS nurses who cared for the study subjects. Data collection relied on 2 forms, a wound documentation form and a wound-cleansing form. Three wound care specialists from different public hospitals were invited to form a panel of experts; they evaluated content validity of the wound documentation form. Fifteen multiple-choice questions were posed after CNS nurses viewed 6 photographs of wounds in order to test the nurses’ understanding of wound classifi cations, identifi cation of amount of wound exudates, granulating status, infection status, and wound documentation techniques. The scale-level content validity index was 0.93. After content validation procedures were completed, the modifi ed wound documentation and wound-cleansing technique forms used by the local hospital for internal nurse auditing were distributed to the 18 CNS nurses who collected study data to establish interrater reliability. Each nurse was instructed on completion of the modifi ed forms. Intraclass correlation coeffi cients were 0.996 (95% CI, 0.993-0.999) and 0.991 (95% CI, 0.982-0.997) respectively. Data Analysis Statistical analysis was performed using the Statistical Package for the Social Science Program version 19 (SPSS Chicago, IL). Descriptive statistics were used to examine all the variables under study. Since all the study variables had P values larger than .05 in the normality tests (indicating study variables were not normally distributed), nonparametric inferential tests were used to detect differences between groups. The Mann-Whitney U test was used to test differences between the experimental and control groups based on age, initial wound size, frequency of dressing changes, and Barthel Index scores. The Fisher exact test was used to test for differences in nominal variables such as sex, medication use, comorbid conditions, living environment, personal hygiene, mental status, attitude of the caregiver toward patients, wound type, stage, location, wound infection, presence of epithelialization and granulation, presence of infl amed periwound skin, exudate volume (dichotomized as high vs low), and presence of severe wound pain. ■ Results Seventy-one persons were identifi ed as potential subjects, and 30 were excluded based on a priori exclusion criteria. Forty-one subjects were approached about study participation, and 27 agreed to participate. One patient was withdrawn from each group because of hospital admissions for reasons not related to wound infection. One subject from the control group was excluded because of extreme wound size when compared with the others. Consequently, 22 subjects (9 female and 13 male) with 30 wounds were included in the study. Random allocation resulted in 11 subjects (6 female and 5 male) with 16 wounds in the tap water (experimental) group, and 11 subjects (3 female and 8 male) with 14 wounds in the sterile normal saline (control) group ( Figure 1 ). Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. JWOCN-D-14-00058_LR 142 WOCN-D-14-00058_LR 142 20/02/16 8:30 AM 0/02/16 8:30 AM J WOCN ■ Vol
ume 43/Number 2 Chan et al 143 Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. The average age of the 22 subjects was 76.77 ± 12.23 years (mean ± standard deviation). More than half (n = 14, 63.64%) lived in a nursing home, 90.91% (n = 20) were judged to have good personal hygiene, and 77.27% (n = 17) received good support from caregivers. The average Barthel Index score was 38.93 ± 35.95. Nearly two thirds had normal mental status. Each subject had nearly one (median = 0.82) comorbid condition likely to infl uence wound healing such as recent acquired infections, anemia, cardiovascular diseases, diabetes mellitus, or peripheral vascular disease. However, none received antibiotics or chemotherapy agents during data collection. No signifi cant differences between the experimental and control groups were found when analyzed based on demographic characteristics or living environment ( Table 1 ). Table 2summarizes and compares wound characteristics (type, location, stage, frequency dressing changes, initial wound size) between the sterile saline and tap water groups. The largest portion of subjects (n = 10, 45.45%) had Stage II pressure ulcers; 14 wounds (63.64%) were located on the limbs, and 54.55% (n = 12) required cleansing 2 to 3 times per week. Analysis revealed no signifi cant differences in baseline wound characteristics between the experimental and control groups. Table 3compares wound infection and healing outcomes of the experimental and control groups; no statistically signifi cant differences were found for either variable. Two wounds (12.50%) in the experimental group versus no wound in the control group were found to be infl amed, neither exhibited severe pain, high-volume exudate, or malodor. In addition, 3 wounds (18.75%) within the experimental group and none (0.00%) in the control group had newly developed epithelialization and granulation. During the study period, no wound from either group healed completely. ■ Discussion We found no differences in wound infection and wound healing outcomes in subjects managed by a community-based FIGURE 1. Flowchart of sampling procedure. JWOCN-D-14-00058_LR 143 WOCN-D-14-00058_LR 143 20/02/16 8:30 AM 0/02/16 8:30 AM 144 Chan et al J WOCN ■ March/April 2016 Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. nursing service when wounds were cleansed with sterile saline versus tap water. The results of our study support fi ndings from a single community-based study set in Australia, 5 as well as fi ndings from 5 studies based in the acute care facilities in Sweden and the United States. 8-12 Considered cumulatively, fi ndings from these studies provide evidence that tap water may be used for cleansing chronic wounds in both acute and community settings. Further studies with larger sample sizes, multicenter involvement, and longer data collection durations are recommended. To our knowledge, this is the fi rst study to compare sterile saline with tap water in an Asian country, and our fi ndings serve as a foundation for future study in this area. Water Quality and Infection Risk The incidence of hospital-acquired infections has increased over the past decades, 27 and tap water has been recognized as a source of hospital-acquired infections. 28 For example, bacterial contamination from tap water has been identifi ed in several intensive care units with critically ill and often immunosuppressed patients, which was attributed to various hospital-acquired infections. 29,30 As a result, researchers TABLE 1. Demographic and Living Environment of Study Sample Variables Groups Total Mann- Whitney U P Value Experimental Control (n = 16) n (%) (n = 14) n (%) (n = 30) n (%) Sex Male 10 (62.50) 11 (78.57) 21 (70) .44 a Female 6 (37.50) 3 (21.43) 9 (30) Comorbid condition b No 13 (81.25) 9 (64.29) 22 (73.33) .42 a Yes 3 c (18.75) 5 d (35.71) 8 (26.67) Living arrangement Home 8 (50.00) 2 (14.29) 10 (33.33) .06 a Home for the elderly 8 (5.000) 12 (85.71) 20 (66.67) Personal hygiene Good 15 (93.75) 13 (92.86) 28 (93.33) 1.00 a Smelly 1 (6.25) 1 (7.14) 2 (6.67) Mental status Normal 11 (68.75) 8 (57.14) 19 (63.33) .71 a Abnormal (disorientated, confused, stuporous) 5 (31.25) 6 (42.86) 11 (36.67) Hydration status Satisfactory 9 (56.25) 10 (71.43) 19 (63.33) .47 a Unsatisfactory 7 (43.75) 4 (28.57) 11 (36.67) Attitude of the caregiver toward patients Good 13 (81.25) 11 (78.57) 24 (80.00) 1.00 a Fair 3 (18.75) 3 (21.43) 6 (20.00) Mean ± SD Mean ± SD Mean ± SD Age, y 75.69 ± 12.01 78.00 ± 8.10 76.77 ± 10.26 91.00 .38 Barthel Index e 33.06 ± 30.54 45.64 ± 41.43 38.93 ± 35.95 88.50 .32 Abbreviation: SD, standard deviation. a Fisher exact test. b Comorbid condition likely to infl uence wound healing. c Acquired infection, anemia, cardiovascular disease, diabetes mellitus, peripheral vascular disease. d Acquired infection, anemia, diabetes mellitus, and peripheral vascular disease. e An index to measure activities of daily living in regard to feeding, bathing, grooming, dressing, bowel, bladder, toilet use, transfer, mobility, and stairs. Maximum score: 100. JWOCN-D-14-00058_LR 144 WOCN-D-14-00058_LR 144 20/02/16 8:30 AM 0/02/16 8:30 AM J WOCN ■ Volume 43/Number 2 Chan et al 145 Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. who conducted these studies advised against using tap water to cleanse wounds in high-risk areas such as critical care units, oncology, and hematology units. As hospital faucet taps with aerators may easily contaminate the water with bacteria, 31 tap water outside the hospital environment is considered to be relatively safer. In addition, some bacterial pathogens such as methicillinresistant Staphylococcus aureus are less likely to survive outside the hospital environment. 32 Best practice guidelines from the Joanna Briggs Institute 16 recommends that tap water be potable (suitable for drinking) when used as a wound-cleansing agent, the quality of such water should be addressed before it is used for wound cleansing. 33 Variability in tap water quality can be affected by water treatment works, service reservoirs, trunk mains, connection points, and domestic taps. 34 More studies are needed to ensure the safety of tap water in the community setting in a variety of eastern and western countries. Perceptions of Using Tap Water We further acknowledge that perceptions of tap water cleanliness may infl uence patients’ and families’ willingness to use it for wound cleansing. Nevertheless, studies based in the United States and Germany found that patients preferred their wounds to be showered with tap water rather than cleansed with sterile normal saline. 6,35 In Germany, patients who were encouraged to shower their wounds postoperatively reported a sense of well-being. 6,7 However, our experience strongly suggests that perceptions of using tap water to cleanse a wound may be different in the Chinese culture. In Chinese culture, “Qi” is “the root of a human being.” 36 External environmental factors such as cold, heat, damp, and other factors may damage the “Qi.” 37 Water, considered as one of the 5 basic elements in the physical universe, belongs to Yin, which represents cold. 36 China has a long history of boiling water prior to drinking based on hygienic considerations. 38,39 Therefore, we hypothesize that Chinese patients and their families may perceive tap water as being “cold,” weakening or blocking this energy fl ow “Qi” and promoting illness. In addition, showering to cleanse wounds is not a common practice in Asian countries, such as Hong Kong. We observed that only 27 (66%) of the 41 eligible persons agreed to participate. The anticipated risk associated with use of tap water to cleanse an open wound was cited by many of those who declined participation. Understanding patients’ own cultural interpretation of health and negotiating over health outcomes between healthcare professionals and patients are the key to narrowing the gap and
achieving a satisfactory therapeutic outcome. 40 We searched the literature but found no studies focusing on Chinese patients’ level of satisfaction and their attitude toward tap water use or showering in the presence of an open wound. We therefore recommend qualitative TABLE 2. Comparison of Wound Characteristics Between Experimental and Control Groups Variables Groups Total Mann-Whitney U P Experimental Control (n = 16) n (%) (n = 14) n (%) (n = 30) n (%) Wound type Chronic a 12 (75.00) 7 (50.00) 19 (63.33) .26 b Acute c 4 (25.00) 7 (50.00) 11 (36.67) Pressure ulcer stage Stage II 4 (33.33) 6 (85.71) 10 (52.63) .06 b Stage III 8 (66.67) 1 (14.29) 9 (47.37) Location of wound 1/Head and main body 7 (43.75) 4 (28.57) 11 (36.67) .47 b 2/Upper and lower limbs 9 (56.25) 10 (71.43) 19 (63.33) Mean ± SD Mean ± SD Mean ± SD Frequency of wound dressing 2.5 ± 1.37 2.36 ± 1.50 2.43 ± 1.41 109.00 .90 Initial wound size, cm 2 3.18 ± 4.83 1.89 ± 2.46 2.58 ± 3.90 109.00 .90 Abbreviation: SD, standard deviation. a Chronic wounds: pressure sores, leg ulcers. b Fisher exact test. c Acute wounds: surgical wounds, trauma, and skin abscesses. JWOCN-D-14-00058_LR 145 WOCN-D-14-00058_LR 145 20/02/16 8:30 AM 0/02/16 8:30 AM 146 Chan et al J WOCN ■ March/April 2016 Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. studies examining patients’ perceptions toward and experience with the use of tap water when caring for a wound. Limitations Limitations of the study include the use of hospital tap water and relatively low power to determine the group size. We recommend further research to address the use of tap water from patient’s homes in various settings and various countries. ■ Conclusions We found no signifi cant difference in wound infection and healing outcomes when comparing wounds cleansed with tap water to those cleansed with sterile saline. We recommend additional research comparing the effectiveness of tap water versus sterile saline for wound cleansing in a variety of community settings in both western and eastern countries. In addition, we advocate research into patients’ perceptions regarding the use of tap water for wound care. Finally, we recommend research establishing safety parameters for tap water prior to its use as a wound-cleansing agent on a local level. ■ ACKNOWLEDGMENTS The authors gratefully acknowledge statistical support from Dr. Anthony Wong. Special thanks to nurses of the Community Nursing Service, Kwong Wah Hospital, for their support and collecting data for the study. ■ References 1. Fernandez R , Griffi ths R , Ussia C . Water for wound cleansing (review) . Cochrane Database Syst Rev. 2010 ;( 2 ): CD003861 . doi: 10.1002/14651858.CD003861.pub2. 2. Lindholm C , Bergsten A, , Berglund E . Chronic wounds and nursing care . J Wound Care. 1999 ; 8 : 5-10 . TABLE 3. Comparison of Outcome Variables (Wound Infection and Wound Healing) Between Experimental and Control Groups Variables Groups Total P Experimental Control (n = 16) n (%) (n = 14) n (%) (n = 30) n (%) Wound infection Wound infection Yes 2 (12.50) 0 (0.00) 2 (6.67) .49 a No 14 (87.50) 14 (100.00) 28 (93.33) Infl amed surrounding skin Yes 2 (12.50) 0 (0.00) 2 (6.67) .49 a No 14 (87.50) 14 (100.00) 28 (93.33) Presence of severe pain Yes 0 (0.00) 0 (0.00) 0 (0.00) NA No 16 (100.00) 14 (100.00) 30 (100.00) Presence of high-volume exudate Yes 0 (0.00) 0 (0.00) 0 (0.00) NA No 16 (100.00) 14 (100.00) 30 (100.00) Wound healing Decrease in wound size Yes 10 (62.50) 9 (64.29) 19 (63.33) 1.00 a No 6 (37.50) 5 (35.71) 11 (36.67) Newly developed epithelialization and granulation Yes 3 (18.75) 0 (0.00) 3 (10.00) .23 a No 13 (81.25) 14 (100.00) 27 (90.00) Abbreviation: NA, not applicable. a Fisher exact test. 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Cheung K , Leung P , Wong YC , et al. Water versus antiseptic periurethral cleansing before catheterization among home care patients: a randomized controlled trial . Am J Infect Control. 2008 ; 36 ( 5 ): 375-380 . 21. Engelhart S , Glasmacher A , Kaufmann F , Exner M . Protecting vulnerable groups in the home: the interface between institutions and the domestic setting . J Infect. 2001 ; 43 : 57-59 . 22. Rolstad BS , Ovington LG , Harris A . Principles of wound management . In: Bryant RA , ed. Acute and Chronic Wounds: Nursing Management. 2nd ed. St. Louis : Mosby ; 2000:93 . 23. Vieweswar B , Nilesh KA , Siddhartha B . Measurement of wound healing and tissue repair . In: Mani R , Romanelli M , Shukla V , eds. Measurements in Wound Healing: Science and Practice. London : Springer-Verlag London Limited ; 2013 . 24. National Pressure Ulcer Advisory Panel . Updated Staging System: Pressure Ulcer Stages Revised by NPUAP. USA : National Pressure Ulcer Advisory Panel ; 2007 . http://www.npuap.org/pr2.htm . Accessed July 11, 2010. 25. Collin C , Wade DT , Davies S , Horne V . The Barthel ADL Index: a reliability study . Int Disabil Stud. 1988 ; 10 : 61-63 . 26. Jones KR . Wound healing in older adults . Aging Health. 2009 ; 5 : 851-866 . 27. Hassan M , Tuckman HP , Patrick RH , Kountz DS , Kohn JL . Cost of hospital-acquired Infection . Hosp Top. 2010 ; 88 ( 3 ): 82-89 . 28. Cervia JS , Ortolano GA , Canonica FP . Hospital tap water. A reservo
ir of risk for health care associated infection . Infect Dis Clin Pract. 2008 ; 16 ( 6 ). 29. Aumeran C , Paillard C , Robin F , Kanold J , Baud O , Bonnet R , Souweine B , Traore O . Pseudomonas aeruginosa and Pseudomonas putida outbreak associated with Pseudomonas aeruginosa in a medical intensive care unit . J Hosp Infect. 2007 ; 67 ( 1 ): 72-78 . 30. Rogues A , Boulestreau H , Lashéras A , et al. Contribution of tap water to patient colonisation with contaminated water outlets in an oncohaematology paediatric unit . J Hosp Infect. 2007 ; 65 ( 1 ): 47-53 . 31. Christina ML , Spagnolo AM , Casini B , et al. The impact of aerators on water contamination by emerging gram-negative opportunists in at-risk hospital departments . Infect Control Hosp Epidemiol. 2014 ; 35 ( 2 ); 122-129 . 32. Dancer SJ . Importance of the environment in meticillinresistant Staphylococcus aureus acquisition: the case for hospital cleaning . Lancet Infect Dis. 2008 ; 8 : 101-113 . 33. Fernandez R , Griffi ths R . Water for wound cleansing . Cochrane Database Syst Rev. 2012 ;( 2 ): CD003861 . doi: 10.1002/14651858. CD003861.pub3. 34. Hong Kong Water Supplies Department . Fresh Water Plumbing Maintenance Guide [Internet]. Hong Kong: Hong Kong Water Supplies Department ; 2008 . http://www.wsd.gov.hk/ fi lemanager/en/share/pdf/FWPMGe.pdf . Accessed on January 12, 2015. 35. Goldberg H , Rosenthal S , Nemetz J . Effect of washing closed head and neck wounds on wound healing and infection . Am J Surg. 1981 ; 141 : 358-359 . 36. Xuen W. Traditional Chinese medicine: an overview . In: Yuen CS , Bieber EJ, Bauer BA, eds . Traditional Chinese Medicine. London : Informa Healthcare ; 2011 . 37. William T. Chinese Medicine: Acupuncture, Herbal Remedies, Nutrition, Qigong and Meditation for Total Health. Dorset : Element Books Ltd ; 1995 . 38. Custer C. Why Do Chinese People Drink Hot Water? The World of Chinese, December 6 ; 2010 . http://www.theworldofchinese. com/blog/culture/988-why-do-chinese-people-drink-hotwater.html . Accessed on October 21, 2011. 39. McFadden DD. Green tea . In: Yuen CS, Bieber EJ, Bauer BA, eds . Traditional Chinese Medicine. London : Informa Healthcare ; 2011 . 40. Kleinman AM . Explanatory Models in Health Care Relationships, in Health of the Family (National Council for International Health Symposium). Washington : NCIH ; 1975 : 159 – 172 . JWOCN-D-14-00058_LR 147 WOCN-D-14-00058_LR 147 20/02/16 8:30 AM 0/02/16 8:30 AM

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140 J WOCN ■ March/April 2016 Copyright © 2016 by the Wound, Ostomy and Continence Nurses Society™
WOUND CARE
J Wound Ostomy Continence Nurs. 2016;43(2):140-147.
Published by Lippincott Williams & Wilkins
■ Introduction
Wound cleansing plays a vital role in wound management.
1,2 In most situations, sterile normal saline is used in
both western and eastern countries because of its isotonic
properties, its osmotic pressures, which are similar to intracellular
fl uid, 1,3 as well as its sterile and noncytotoxic
Mun Che Chan, MSc, Community Nursing Services, Kwong Wah
Hospital, Hong Kong.
Kin Cheung, PhD, School of Nursing, The Hong Kong Polytechnic
University, Hong Kong.
Polly Leung, PhD, Department of Health Technology and
Informatics, The Hong Kong Polytechnic University, Hong Kong.
This study was funded by The Hong Kong Polytechnic University
and Kwong Wah Hospital.
MCC, KC, and PL were responsible for the study conception and design.
KC and PL performed laboratory testing. MCC performed the
data collection and data analysis. MCC and KC were responsible for
the drafting of the manuscript. MCC, KC, and PL reviewed the manuscript.
KC and PL supervised the study.
The authors declare no confl ict of interest.
Correspondence: Kin Cheung, PhD, School of Nursing, The Hong
Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
( kin.cheung@polyu.edu.hk ).
■ ABSTRACT
PURPOSE: The use of tap water as a wound-cleansing
agent is becoming more common in clinical practice, especially
in community settings. The aim of this study was
to test whether there are differences in wound infection
and wound healing rates when wounds are cleansed
with tap water or sterile normal saline.
DESIGN: Double-blinded randomized controlled trial.
SUBJECTS AND SETTING: Subjects were recruited from the
community nursing service of a local hospital in Hong
Kong. The target sample included subjects who were
aged 18 years or more, and receiving chronic or acute
wound care treatment.
METHODS: Subjects were randomly assigned to wound
cleansing with tap water (experimental group) or sterile
normal saline (control group). Wound assessment was
conducted at each home visit, and an assessment of
wound size was conducted once a week. The main
outcome measures, occurrence of a wound infection and
wound healing, were assessed over a period of 6 weeks.
RESULTS: Twenty-two subjects (11 subjects in each group)
with 30 wounds participated in the study; 16 wounds
were managed with tap water cleansing and 14 were
randomly allocated to management with the sterile
normal saline group. Analysis revealed no signifi cant difference
between the experimental and control groups in
the proportions of wound infection and wound healing.
CONCLUSIONS: Study fi ndings indicate that tap water is
a safe alternative to sterile normal saline for wound
cleansing in a community setting.
KEY WORDS: Cleansing agents , Home care , Randomized
control trials , Wound care , Wound swabbing
Tap Water Versus Sterile Normal Saline
in Wound Swabbing
A Double-Blind Randomized Controlled Trial
Mun Che Chan Kin Cheung Polly Leung
DOI: 10.1097/WON.0000000000000213
properties. 4 Recently, the use of tap water as a cleansing
agent has been reported in western countries, such as
Australia, 5 Germany, 6,7 Sweden, 8 and the United States, 9-12
but it is not normally used in eastern countries. In their
systematic review, Fernandez and colleagues 1 concluded
“there is no evidence that using tap water to cleanse acute
wounds in adults increases infection” (p. 2), rather in
some cases, tap water can reduce wound infection.
However, the reviewers found only 6 randomized controlled
trials (RCTs) 1 conducted in western countries that
evaluated the effectiveness of tap water as compared with
sterile normal saline in wound cleansing. Hence, there is a
need to evaluate whether it is safe to use of tap water in
wound cleansing in eastern countries.
Among the 6 RCTs, only one was conducted in community
settings (Australia); the other 5 were set in accident
and emergency departments in Sweden and the
United States. 5,8-12 The demand for wound care management
in the community setting is increasing, as acute care
facilities attempt to reduce length of hospital stays and
rely more on community services. 13 In the United States,
31% to 36% of patients in community settings have
wounds. 14 Similarly, 51% of community nursing services
in Hong Kong involve wound care management. 15 Tap
Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
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J WOCN ■ Volume 43/Number 2 Chan et al 141
water has been suggested as an effective cleansing agent
for lacerations, postoperative, and chronic wounds 16; it is
an acceptable alternative to cleanse wounds in the home
environment, as showering and bathing are becoming
common practices for the care of chronic wounds. 17 In addition,
tap water costs less than sterile normal saline, and
it is both readily available in the community setting and
relatively affordable to most. 1 Nevertheless, sterile normal
saline is usually used for wound cleansing in most Asian
countries, and in Hong Kong. The cost of sterile saline,
combined with manufacturer recommendations that the
contents of the bottle be discarded 24 hours after opening,
results in higher costs than those associated with tap
water. 4 Community nursing aims at maximizing existing
resources to achieve optimal health outcomes for individuals.
Use of tap water for wound cleansing in the community
setting is anticipated to augment self-management of
wounds at home. Hence, more evidence is needed to support
its safe use in the community setting.
Additional research is also needed because the 6 RCTs
discussed previously used irrigation rather than swabbing
for wound cleansing. 5,8-12 However, wound swabbing is advocated
in several recent nursing skills textbooks, 18,19 and
it is commonly used in clinical practice. Swabbing involves
the use of a swab or gauze moistened with a cleansing
agent such as sterile saline or tap water. This technique
differs from wound irrigation where sterile saline or another
agent is used to fl ush the wound via application
under pressure. 18,19 As there is currently no study to support
or refute use of the swabbing technique to cleanse
wounds, 16 there is a need to fi nd out the effectiveness of
wound swabbing with either tap water or sterile normal
saline, especially in community settings. We therefore
tested the following hypothesis: there is no difference in
the proportions of wound infection and wound healing
when wounds are cleansed with tap water or sterile normal
saline using a swabbing method.
■ Methods
In order to test this hypothesis, we conducted a doubleblind,
randomized controlled trial. Data were collected
over 2 time periods: from August 30 to October 9, 2010
(6 weeks), and November 22, 2010, to January 2, 2011
(6 weeks). Subjects were recruited from the community
nursing service (CNS) of a local hospital in Hong Kong.
Patients who live at home or in a nursing home can receive
nursing services from the CNS. 20 Inclusion criteria
for the study were: age 18 years or more and receiving
either chronic or acute wound care treatment from our
CNS. Exclusion criteria were women receiving postnatal
care, immunosuppressed persons, patients with acute or
chronic leukemia, malignant lymphoma, solid tumors,
long-term corticosteroid therapy, autologous stem cell
transplantation, solid organ transplantation, 21 an infected
wound or receiving antibiotics, 5 stage I or IV pressure
ulcers, or leg ulcers or leg wounds involving tendon or
bone. Subjects with wound cleansing under specifi c
wound-cleansing protocols, such as using silver dressing
material, were also excluded from participation.
Subjects were randomly assigned to cleansing with tap
water (experimental group) or sterile normal saline (control
group) by computer-generated random numbers.
Since this was a double-blinded study, 100 mL of tap water
and 100 mL of sterile normal saline were prepared using
the same kind of sterile bottles by the main researcher who
was the only person to know the result of group assignment.
Therefore, the randomization procedure was
blinded to subjects and CNS nurses who performed wound
cleansing.
■ Outcome Measures
The main outcome measures were wound infection and
wound healing. Wound infection was defi ned as an invasion
of bacteria into healthy tissues, followed by continued
proliferation and a host reaction including erythema,
pain, swelling, persistent high-volume exudate, odor, and
delayed healing. 22 We operationally defi ned a wound infection
as clinical signs and symptoms like erythema, presence
of high volume of exudates and odor, and sensation
of increased pain by subjects. Wound healing was measured
by the change in wound size and the presence of
epithelial tissues on the wound bed. 5 Wounds were measured
using a 1-cm fl exible wound grid (Coloplast
Proprietary, Hong Kong), which is considered a standardized
measurement for wound size. 5,23 Two-dimensional
measurements in the form of surface area were done by
measuring its linear dimension, for example, a rectangle
(length × width), a circle (diameter × diameter), or an
oval (maximum diameter × maximum diameter perpendicular
to the fi rst measurement). 23
Study Procedures
Study procedures were reviewed and approved by the
Human Subjects Committee of the Hong Kong Polytechnic
University, and the Clinical Research Ethics Committee of
the Kowloon West Cluster of the Hospital Authority.
Informed consent was obtained from subjects if they were
cognitively alert, or proxy consent was obtained from the
subject’s guardian if the subject was unable to sign the
consent form. The frequency of wound cleansing was determined
after each home visit by the CNS nurses. Most
wounds were cleansed once daily. The CNS nurses followed
the same standard protocol to perform wound
cleansing using a swabbing method for each patient; only
the agent used to cleanse the wound (tap water or sterile
saline) varied between the groups. Wound infection and
healing were assessed each time when the wound was
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142 Chan et al J WOCN ■ March/April 2016
cleansed by the CNS nurse. Wound size was measured
weekly.
Baseline data were extracted through the communitybased
nursing system, which included sex, age, medication
use, medical history, living arrangement, personal
hygiene, mental status, hydration status, attitude of caregivers
toward patients, Barthel Index together with the
wound type (acute or chronic), stage (pressure ulcers were
staged based on the National Pressure Ulcer Advisory
Panel staging system 24), size, location, and frequency of
wound dressing. Baseline data were collected by CNS
nurses as a part of an initial assessment on newly admitted
patients. The Barthel Index is a tool to measure a person’s
activity of daily living on feeding, bathing, grooming,
dressing, bowel, bladder, toilet use, transfer, mobility, and
stairs, with a maximum score of 100. 25 Decreased activity
level impedes vascular blood supply and exerts pressure to
body skin, which would affect the progress of wound healing.
26 This baseline information was extracted to see
whether there were any baseline differences between the
experimental and control groups.
Preparation of Cleansing Agents
Because this was a double-blind study, 100 mL of tap water
and 100 mL of sterile normal saline were prepared by one
researcher using the same type of container for both solutions.
One hundred milliliters of tap water from the CNS
water tap was aseptically collected into 100-mL sterile bottles
a day before wound cleansing. The hospital water tanks
are routinely washed and cleaned every 3 months according
to hospital policy. To ensure consistency, tap water
from the CNS water tap was used for the study instead of
water from the subjects’ homes. Furthermore, total bacterial
counts for the tap water collected from the CNS were
performed 1 month before the study commenced, and randomly
(once a week) during the 6-week study interval.
Tap water from the CNS tap was pilot-tested using the
conventional plate count method in late March 2010. The
quality of the CNS tap water was found to be acceptable.
On average, there were 0.08 units of bacteria per milliliter
of tap water. Only 2 RCTs had previously performed microbiological
tests on the tap water used in wound cleansing,
and they reported a total bacterial count of less than
5 and 1 units per milliliter, respectively. 8,12 Sterile normal
saline used in the study was supplied by the hospital.
Either sterile normal saline or tap water was placed inside
100-mL sterile bottles by the main researcher the day
before wound cleansing. The bottles were then collected
and sterilized after each use.
Interrater Reliability
Wound cleansing and assessments were performed by 18
CNS nurses who cared for the study subjects. Data collection
relied on 2 forms, a wound documentation form and
a wound-cleansing form. Three wound care specialists
from different public hospitals were invited to form a
panel of experts; they evaluated content validity of the
wound documentation form. Fifteen multiple-choice
questions were posed after CNS nurses viewed 6 photographs
of wounds in order to test the nurses’ understanding
of wound classifi cations, identifi cation of amount of
wound exudates, granulating status, infection status, and
wound documentation techniques. The scale-level content
validity index was 0.93.
After content validation procedures were completed,
the modifi ed wound documentation and wound-cleansing
technique forms used by the local hospital for internal
nurse auditing were distributed to the 18 CNS nurses who
collected study data to establish interrater reliability. Each
nurse was instructed on completion of the modifi ed forms.
Intraclass correlation coeffi cients were 0.996 (95% CI,
0.993-0.999) and 0.991 (95% CI, 0.982-0.997) respectively.
Data Analysis
Statistical analysis was performed using the Statistical
Package for the Social Science Program version 19 (SPSS
Chicago, IL). Descriptive statistics were used to examine
all the variables under study. Since all the study variables
had P values larger than .05 in the normality tests (indicating
study variables were not normally distributed), nonparametric
inferential tests were used to detect differences
between groups. The Mann-Whitney U test was used to
test differences between the experimental and control
groups based on age, initial wound size, frequency of
dressing changes, and Barthel Index scores. The Fisher
exact test was used to test for differences in nominal variables
such as sex, medication use, comorbid conditions,
living environment, personal hygiene, mental status, attitude
of the caregiver toward patients, wound type, stage,
location, wound infection, presence of epithelialization
and granulation, presence of infl amed periwound skin,
exudate volume (dichotomized as high vs low), and presence
of severe wound pain.
■ Results
Seventy-one persons were identifi ed as potential subjects,
and 30 were excluded based on a priori exclusion criteria.
Forty-one subjects were approached about study participation,
and 27 agreed to participate. One patient was withdrawn
from each group because of hospital admissions for
reasons not related to wound infection. One subject from
the control group was excluded because of extreme wound
size when compared with the others. Consequently, 22
subjects (9 female and 13 male) with 30 wounds were included
in the study. Random allocation resulted in 11 subjects
(6 female and 5 male) with 16 wounds in the tap
water (experimental) group, and 11 subjects (3 female and
8 male) with 14 wounds in the sterile normal saline (control)
group ( Figure 1 ).
Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
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J WOCN ■ Volume 43/Number 2 Chan et al 143
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The average age of the 22 subjects was 76.77 ± 12.23
years (mean ± standard deviation). More than half (n =
14, 63.64%) lived in a nursing home, 90.91% (n = 20)
were judged to have good personal hygiene, and 77.27%
(n = 17) received good support from caregivers. The average
Barthel Index score was 38.93 ± 35.95. Nearly two
thirds had normal mental status. Each subject had nearly
one (median = 0.82) comorbid condition likely to infl uence
wound healing such as recent acquired infections,
anemia, cardiovascular diseases, diabetes mellitus, or peripheral
vascular disease. However, none received antibiotics
or chemotherapy agents during data collection. No
signifi cant differences between the experimental and control
groups were found when analyzed based on demographic
characteristics or living environment ( Table 1 ).
Table 2summarizes and compares wound characteristics
(type, location, stage, frequency dressing changes, initial
wound size) between the sterile saline and tap water
groups. The largest portion of subjects (n = 10, 45.45%)
had Stage II pressure ulcers; 14 wounds (63.64%) were
located on the limbs, and 54.55% (n = 12) required cleansing
2 to 3 times per week. Analysis revealed no signifi cant
differences in baseline wound characteristics between the
experimental and control groups.
Table 3compares wound infection and healing outcomes
of the experimental and control groups; no statistically
signifi cant differences were found for either variable.
Two wounds (12.50%) in the experimental group versus
no wound in the control group were found to be infl amed,
neither exhibited severe pain, high-volume exudate, or
malodor. In addition, 3 wounds (18.75%) within the experimental
group and none (0.00%) in the control group
had newly developed epithelialization and granulation.
During the study period, no wound from either group
healed completely.
■ Discussion
We found no differences in wound infection and wound
healing outcomes in subjects managed by a community-based
FIGURE 1. Flowchart of sampling procedure.
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144 Chan et al J WOCN ■ March/April 2016
Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
nursing service when wounds were cleansed with sterile saline
versus tap water. The results of our study support fi ndings
from a single community-based study set in Australia, 5
as well as fi ndings from 5 studies based in the acute care facilities
in Sweden and the United States. 8-12 Considered cumulatively,
fi ndings from these studies provide evidence
that tap water may be used for cleansing chronic wounds in
both acute and community settings. Further studies with
larger sample sizes, multicenter involvement, and longer
data collection durations are recommended. To our knowledge,
this is the fi rst study to compare sterile saline with tap
water in an Asian country, and our fi ndings serve as a foundation
for future study in this area.
Water Quality and Infection Risk
The incidence of hospital-acquired infections has increased
over the past decades, 27 and tap water has been recognized
as a source of hospital-acquired infections. 28 For example,
bacterial contamination from tap water has been identifi ed
in several intensive care units with critically ill and often
immunosuppressed patients, which was attributed to various
hospital-acquired infections. 29,30 As a result, researchers
TABLE 1.
Demographic and Living Environment of Study Sample
Variables
Groups
Total
Mann- Whitney U P Value
Experimental Control
(n = 16)
n (%)
(n = 14)
n (%)
(n = 30)
n (%)
Sex
Male 10 (62.50) 11 (78.57) 21 (70) .44 a
Female 6 (37.50) 3 (21.43) 9 (30)
Comorbid condition b
No 13 (81.25) 9 (64.29) 22 (73.33) .42 a
Yes 3 c
(18.75) 5 d
(35.71) 8 (26.67)
Living arrangement
Home 8 (50.00) 2 (14.29) 10 (33.33) .06 a
Home for the elderly 8 (5.000) 12 (85.71) 20 (66.67)
Personal hygiene
Good 15 (93.75) 13 (92.86) 28 (93.33) 1.00 a
Smelly 1 (6.25) 1 (7.14) 2 (6.67)
Mental status
Normal 11 (68.75) 8 (57.14) 19 (63.33) .71 a
Abnormal (disorientated, confused, stuporous) 5 (31.25) 6 (42.86) 11 (36.67)
Hydration status
Satisfactory 9 (56.25) 10 (71.43) 19 (63.33) .47 a
Unsatisfactory 7 (43.75) 4 (28.57) 11 (36.67)
Attitude of the caregiver toward patients
Good 13 (81.25) 11 (78.57) 24 (80.00) 1.00 a
Fair 3 (18.75) 3 (21.43) 6 (20.00)
Mean ± SD Mean ± SD Mean ± SD
Age, y 75.69 ± 12.01 78.00 ± 8.10 76.77 ± 10.26 91.00 .38
Barthel Index e 33.06 ± 30.54 45.64 ± 41.43 38.93 ± 35.95 88.50 .32
Abbreviation: SD, standard deviation.
a
Fisher exact test.
b
Comorbid condition likely to infl uence wound healing.
c
Acquired infection, anemia, cardiovascular disease, diabetes mellitus, peripheral vascular disease.
d
Acquired infection, anemia, diabetes mellitus, and peripheral vascular disease.
e
An index to measure activities of daily living in regard to feeding, bathing, grooming, dressing, bowel, bladder, toilet use, transfer, mobility, and stairs.
Maximum score: 100.
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J WOCN ■ Volume 43/Number 2 Chan et al 145
Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
who conducted these studies advised against using tap
water to cleanse wounds in high-risk areas such as critical
care units, oncology, and hematology units.
As hospital faucet taps with aerators may easily contaminate
the water with bacteria, 31 tap water outside the
hospital environment is considered to be relatively safer.
In addition, some bacterial pathogens such as methicillinresistant
Staphylococcus aureus are less likely to survive outside
the hospital environment. 32
Best practice guidelines from the Joanna Briggs
Institute 16 recommends that tap water be potable (suitable
for drinking) when used as a wound-cleansing agent, the
quality of such water should be addressed before it is used
for wound cleansing. 33 Variability in tap water quality can
be affected by water treatment works, service reservoirs,
trunk mains, connection points, and domestic taps. 34 More
studies are needed to ensure the safety of tap water in the
community setting in a variety of eastern and western
countries.
Perceptions of Using Tap Water
We further acknowledge that perceptions of tap water cleanliness
may infl uence patients’ and families’ willingness to
use it for wound cleansing. Nevertheless, studies based in
the United States and Germany found that patients preferred
their wounds to be showered with tap water rather
than cleansed with sterile normal saline. 6,35 In Germany, patients
who were encouraged to shower their wounds postoperatively
reported a sense of well-being. 6,7 However, our
experience strongly suggests that perceptions of using tap
water to cleanse a wound may be different in the Chinese
culture. In Chinese culture, “Qi” is “the root of a human
being.” 36 External environmental factors such as cold, heat,
damp, and other factors may damage the “Qi.” 37 Water, considered
as one of the 5 basic elements in the physical universe,
belongs to Yin, which represents cold. 36 China has a
long history of boiling water prior to drinking based on hygienic
considerations. 38,39 Therefore, we hypothesize that
Chinese patients and their families may perceive tap water
as being “cold,” weakening or blocking this energy fl ow
“Qi” and promoting illness. In addition, showering to
cleanse wounds is not a common practice in Asian countries,
such as Hong Kong. We observed that only 27 (66%)
of the 41 eligible persons agreed to participate. The anticipated
risk associated with use of tap water to cleanse an
open wound was cited by many of those who declined participation.
Understanding patients’ own cultural interpretation
of health and negotiating over health outcomes
between healthcare professionals and patients are the key to
narrowing the gap and achieving a satisfactory therapeutic
outcome. 40 We searched the literature but found no studies
focusing on Chinese patients’ level of satisfaction and their
attitude toward tap water use or showering in the presence
of an open wound. We therefore recommend qualitative
TABLE 2.
Comparison of Wound Characteristics Between Experimental and Control Groups
Variables
Groups
Total
Mann-Whitney U P
Experimental Control
(n = 16)
n (%)
(n = 14)
n (%)
(n = 30)
n (%)
Wound type
Chronic a
12 (75.00) 7 (50.00) 19 (63.33) .26 b
Acute c
4 (25.00) 7 (50.00) 11 (36.67)
Pressure ulcer stage
Stage II 4 (33.33) 6 (85.71) 10 (52.63) .06 b
Stage III 8 (66.67) 1 (14.29) 9 (47.37)
Location of wound
1/Head and main body 7 (43.75) 4 (28.57) 11 (36.67) .47 b
2/Upper and lower limbs 9 (56.25) 10 (71.43) 19 (63.33)
Mean ± SD Mean ± SD Mean ± SD
Frequency of wound dressing 2.5 ± 1.37 2.36 ± 1.50 2.43 ± 1.41 109.00 .90
Initial wound size, cm 2 3.18 ± 4.83 1.89 ± 2.46 2.58 ± 3.90 109.00 .90
Abbreviation: SD, standard deviation.
a
Chronic wounds: pressure sores, leg ulcers.
b
Fisher exact test.
c
Acute wounds: surgical wounds, trauma, and skin abscesses.
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146 Chan et al J WOCN ■ March/April 2016
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studies examining patients’ perceptions toward and experience
with the use of tap water when caring for a wound.
Limitations
Limitations of the study include the use of hospital tap
water and relatively low power to determine the group
size. We recommend further research to address the
use of tap water from patient’s homes in various settings
and various countries.
■ Conclusions
We found no signifi cant difference in wound infection
and healing outcomes when comparing wounds
cleansed with tap water to those cleansed with sterile
saline. We recommend additional research comparing
the effectiveness of tap water versus sterile saline for
wound cleansing in a variety of community settings in
both western and eastern countries. In addition, we advocate
research into patients’ perceptions regarding the
use of tap water for wound care. Finally, we recommend
research establishing safety parameters for tap water
prior to its use as a wound-cleansing agent on a local
level.
■ ACKNOWLEDGMENTS
The authors gratefully acknowledge statistical support
from Dr. Anthony Wong. Special thanks to nurses of the
Community Nursing Service, Kwong Wah Hospital, for
their support and collecting data for the study.
■ References
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Comparison of Outcome Variables (Wound Infection and Wound Healing) Between Experimental and Control
Groups
Variables
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Total
P
Experimental Control
(n = 16)
n (%)
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n (%)
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n (%)
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No 16 (100.00) 14 (100.00) 30 (100.00)
Wound healing
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No 6 (37.50) 5 (35.71) 11 (36.67)
Newly developed epithelialization and granulation
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a
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J WOCN ■ Volume 43/Number 2 Chan et al 147
Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
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