Surgical Dressings (Wound Care Supplies)

Number: 0526

Policy

Notes: Aetna’s standard traditional plans (Managed Choice POS, PPO, and indemnity) cover medically necessary surgical dressings only when prescribed by a physician and supplied by a home care agency in conjunction with covered home health care services or when dispensed and used by a participating health care provider in conjunction with treatment of the member.  Under Aetna traditional plans, supplies are not covered when they do not require a prescription and can be purchased by the member over-the counter or when they are given to the member as take-home supplies.  Please check benefit plan descriptions.

Aetna’s standard HMO plans cover surgical dressings when they are medically necessary for wound debridement or for the treatment of a wound caused by, or treated by, a surgical procedure.  Please check benefit plan descriptions.

Covered surgical dressings include both medically necessary primary dressings (i.e., therapeutic or protective coverings applied directly to wounds or lesions either on the skin or caused by an opening to the skin) and medically necessary secondary dressings (i.e., materials that serve a therapeutic or protective function and that are needed to secure a primary dressing).  Items such as adhesive tape, roll gauze, or elastic bandages are examples of secondary dressings.  Elastic stockings, support hose, foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for the arms and hands are examples of items that are not ordinarily covered as surgical dressings.

Debridement

Note: Debridement of a wound may be any type of debridement, including surgical (e.g., sharp instrument or laser), mechanical (e.g., irrigation or wet-to-dry dressings), chemical (e.g., topical application of enzymes), or autolytic (e.g., application of occlusive dressings to an open wound).  Medically necessary dressings used for mechanical debridement, to cover chemical debriding agents, or to cover wounds to allow for autolytic debridement are covered under both HMO and traditional plans under the surgical dressings benefit, although the chemical debriding agents themselves, if self-administered, are covered under the pharmacy benefit.

Dressings over a Percutaneous Catheter or Tube

Note: Under all plans, medically necessary dressings over a percutaneous catheter or tube (e.g., intravascular, epidural, nephrotomy, etc.) are covered as long as the catheter or tube remains in place and after removal until the wound heals.

Non-Covered Dressings

Examples of situations in which dressings are of no proven benefit because of insufficient evidence in the peer-reviewed literature include the following:

1. A first degree burn;
2. A stage I pressure ulcer;
3. A venipuncture or arterial puncture site (e.g., blood sample) other than the site of an indwelling catheter or needle;
4. Drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure;
5. Wounds caused by trauma that do not require surgical closure or debridement (e.g., skin tear or abrasion).

Wound Covers

Wound covers are flat dressing pads.  A wound cover with adhesive border is one that has an integrated cover and distinct adhesive border designed to adhere tightly to the skin.  When a wound cover with an adhesive border is being used, no other dressing would be used on top of it and additional tape is usually not considered medically necessary.  Reasons for use of additional tape should be documented.  An adhesive border is usually more binding than that obtained with separate taping and is therefore considered medically necessary for use with wounds requiring less frequent dressing changes.

Note on Wound Care Items not Covered under the Surgical Dressings Benefit

The following are examples of wound care items which would not be covered under the surgical dressings benefit:

• Enzymatic debriding agents,
• Gauze or other dressings used to cleanse or debride a wound but not left on the wound,
• Skin sealants or barriers,
• Solutions used to moisten gauze (e.g., saline),
• Topical antibiotics,
• Topical antiseptics,
• Wound cleansers or irrigating solutions.

If medically necessary and available by prescription, some of these items may be covered under the pharmacy benefit if ordered by a physician.

Quantity of Surgical Dressings

The medically necessary quantity and type of dressings dispensed at any one time must take into account the current status of the wound(s), the likelihood of change, and the recent use of dressings.  Dressing needs may change frequently (e.g., weekly) in the early phases of wound treatment and/or with heavily draining wounds.  Suppliers are also expected to have a mechanism for determining the quantity of dressings that the person is actually using and to adjust their provision of dressings accordingly.  No more than a 1-month's supply of dressings is considered medically necessary at one time, unless there is documentation to support the medical necessity of greater quantities in the home setting in an individual case.  An even smaller quantity may be appropriate in the situations described above.

Surgical Dressing Kits

A surgical dressing kit is defined as non-individualized, standardized packaging containing repetitive quantities of dressings not related to the individual medical needs of a member, or whose contents have not each been prescribed for the care of the specific wounds of that member, or that contain materials in addition to surgical dressings.  Surgical dressings must be tailored to the specific needs of an individual member.  This can not be accomplished when dressings are provided as kits or trays containing fixed quantities and/or multiple types of dressings.  When surgical dressing kits are used for the provision of surgical dressings, all components of the kit will be considered not medically necessary.

Wound Fillers

Wound fillers are dressing materials that are placed into open wounds to eliminate dead space, absorb exudate, or maintain a moist wound surface.

Wound fillers come in hydrated forms (e.g., pastes, gels), dry forms (e.g., powder, granules, beads), or other forms (e.g., rope, spiral, pillows, etc).

Products containing multiple materials are categorized according to the clinically predominant component (e.g., alginate, foam, gauze, hydrocolloid, hydrogel).  Other multi-component wound dressings not containing these specified components may be classified as composite or specialty absorptive dressings if the definition of these categories has been met.  Gauze or gauze-like products are typically manufactured as a single piece of material folded into a several ply gauze pad.  Use of more than one type of wound filler or more than one type of wound cover in a single wound is rarely considered medically necessary.  It may not be considered medically necessary to use some combinations of a hydrating dressing on the same wound at the same time as an absorptive dressing (e.g., hydrogel and alginate).

Because composite dressings, foam and hydrocolloid wound covers, and transparent film, when used as secondary dressings, are meant to be changed at frequencies less than daily, appropriate clinical judgment should be used to avoid their use with primary dressings which would require more frequent dressing changes.  For these dressings, changes greater than once every other day are not considered medically necessary.  While a highly exudative wound might require such a combination initially, with continued proper management the wound should progress to a point where the appropriate selection of these products should result in the less frequent dressing changes which they are designed to allow.  An example of a combination that would be considered not medically necessary is the use of a specialty absorptive dressing on top of non-impregnated gauze being used as a primary dressing.

Dressing size should be based on and appropriate to the size of the wound.  For wound covers, the medically necessary pad size should usually be about 2 inches greater than the dimensions of the wound.  For example, a 5 cm X 5 cm (2 in. X 2 in.) wound would require a 4 in. X 4 in. pad size.

The following are some specific medical necessity guidelines for individual products when the products themselves are considered medically necessary in the individual member.  The medical necessity for more frequent change of dressing should be documented in the member's medical record.

Alginate or other Fiber Gelling Dressing

Alginate or other fiber gelling dressing covers are considered medically necessary for moderately to highly exudative full thickness wounds (e.g., stage III or IV ulcers); and alginate or other fiber gelling dressing fillers for moderately to highly exudative full thickness wound cavities (e.g., stage III or IV ulcers).  They are of no proven benefit on dry wounds or wounds covered with eschar.  Up to 1 dressing change per day is considered medically necessary, unless the medical necessity of more frequent changes is documented.  One wound cover sheet of the approximate size of the wound or up to 2 units of wound filler (1 unit = 6 inches of alginate or other fiber gelling dressing rope) would be considered medically necessary for each dressing change, unless the medical necessity for more wound cover or filler is documented.  It is usually not considered medically necessary to use alginates or other fiber gelling  dressings in combination with hydrogels.

Composite Dressing

Amino Acid Dressings

Amino acid dressings are considered experimental and investigational for the management of chronic wounds because of insufficient evidence in the peer-reviewed literature.

Contact Layer

Contact layers are thin non-adherent sheets placed directly on an open wound bed to protect the wound tissue from direct contact with other agents or dressings applied to the wound.  They are porous to allow wound fluid to pass through for absorption by an overlying dressing.  Contact layer dressings are used to line the entire wound; they are not intended to be changed with each dressing change.  Up to 1 contact layer dressing change per week is considered medically necessary, unless it is documented that more frequent changes are medically necessary.

Foam Dressing

Foam dressings are considered medically necessary when used on full thickness wounds (e.g., stage III or IV ulcers) with moderate to heavy exudate.  Usual dressing change for a foam wound cover used as a primary dressing is up to 3 times per week.  When a foam wound cover is used as a secondary dressing for wounds with very heavy exudate, dressing changes may be medically necessary up to 3 times per week.  Up to 1 dressing change for foam wound fillers per day is considered medically necessary, unless it is documented that more frequent changes are medically necessary.  Ibuprofen foam dressings for painful venous leg ulcers are considered experimental and investigational because they have not been shown to be more effective than standard foam dressings.

Gauze, Non-Impregnated

For a dressing without a border, up to 3 non-impregnated gauze dressing changes per day are considered medically necessary, unless there is documentation that more frequent changes are medically necessary.  For dressing changes with a border, 1 change per day is considered medically necessary, unless more frequent changes are medically necessary.  It is usually not considered medically necessary to stack more than 2 gauze pads on top of each other in any one area.

Gauze, Impregnated, other than Water or Normal Saline, Hydrogel, or Zinc Paste

Note: Impregnated gauze dressings are woven or non-woven materials in which substances such as iodinated agents, petrolatum, zinc compounds, crystalline sodium chloride, chlorhexadine gluconate (CHG), bismuth tribromophenate (BTP), water, aqueous saline, or other agents have been incorporated into the dressing material by the manufacturer.  However, when the dressing and the substance with which it is impregnated are listed in combination in the Food and Drug Administration (FDA) Orange Book (e.g., an antibiotic impregnated dressing which requires a prescription), then the entire item is considered a drug which would be covered under the pharmacy benefit if self-administered, ordered by a physician and available by prescription. 

Up to 1 dressing change per day is considered medically necessary for gauze dressings impregnated with other than water, normal saline, hydrogel, or zinc paste, unless there is documentation that more frequent changes are medically necessary.

Gauze, Impregnated, Water or Normal Saline

There is no medical necessity for these dressings compared to non-impregnated gauze, which is moistened with bulk saline or sterile water.  Note: Bulk saline or sterile water is not covered.

Hydrocolloid Dressing

Hydrocolloid dressings are considered medically necessary for use on wounds with light to moderate exudate. Up to 3 dressing changes per week are considered medically necessary for hydrocolloid wound covers or hydrocolloid wound fillers, unless it is documented that more frequent changes are medically necessary.

Hydrogel Dressing

Hydrogel dressings are considered medically necessary when used on full thickness wounds with minimal or no exudate (e.g., stage III or IV ulcers).  Hydrogel dressings are typically of no proven benefit for stage II ulcers.  Documentation must substantiate the medical necessity for use of hydrogel dressings for stage II ulcers (e.g., location of ulcer is sacro-coccygeal area).  For hydrogel wound covers without adhesive borders or hydrogel wound fillers, up to 1 dressing change per day is considered medically necessary, unless it is documented that more frequent dressing changes are medically necessary.  For hydrogel wound covers with adhesive borders, up to 3 dressing changes per week are considered medically necessary, unless it is documented that more frequent changes are medically necessary.

The medically necessary quantity of hydrogel filler used for each wound should not exceed the amount needed to line the surface of the wound.  Additional amounts used to fill a cavity are not considered medically necessary.  Documentation must substantiate the medical necessity for hydrogel filler billed in excess of 3 units (fluid ounces) per wound in 30 days.

Use of both a hydrogel filler and a hydrogel cover on the same wound at the same time is of no proven benefit.

Specialty Absorptive Dressing

Transparent Film

Transparent film dressings are considered medically necessary when used on open partial thickness wounds with minimal exudate or closed wounds.  Up to 3 transparent film dressing changes per week are considered medically necessary, unless it is documented that more frequent dressing changes are medically necessary.

Wound Filler, not Elsewhere Classified

Up to 1 dressing change per day is considered medically necessary, unless it is documented that more frequent changes are needed.

Wound Pouch

A wound pouch is a waterproof collection device with a drainable port that adheres to the skin around a wound.  Up to 3 dressing changes per week are considered medically necessary, unless the medical necessity of more frequent changes is documented.

Tape

Tape is considered medically necessary to hold on a wound cover, elastic roll gauze or non-elastic roll gauze.  Additional tape is usually not considered medically necessary when a wound cover with an adhesive border is used.  The medical necessity for tape in these situations should be documented.  The medically necessary frequency of tape change is determined by the frequency of change of the wound cover.  Quantities of tape submitted should reasonably reflect the size of the wound cover being secured.  The following amounts of tape are considered medically necessary, unless the medical necessity of additional tape is documented: for wound covers measuring 16 square inches or less, up to 2 units per dressing change is considered medically necessary; for wound covers measuring 16 to 48 square inches, up to 3 units per dressing change is considered medically necessary; for wound covers measuring greater than 48 square inches, up to 4 units per dressing change is considered medically necessary.

Elastic Bandage

Elastic bandages are considered medically necessary when used as a secondary dressing to hold wound cover dressings in place.  When an elastic bandage is used over a wound cover with adhesive border or over a wound cover which is held in place by tape, elastic roll gauze or non-elastic roll gauze, or transparent film, the elastic bandage is of no proven benefit.  Elastic bandages have also not been proven useful for strains, sprains, edema, or situations other than as a secondary surgical dressing.

Most elastic bandages are reusable.  No more than 1 replacement per week is considered medically necessary, unless the medical necessity of more frequent replacements is documented.

Gauze, Elastic

The medically necessary frequency of elastic gauze dressing changes is determined by the frequency of changes of the selected primary dressing.  Overlying elastic gauze is of no proven benefit when a dressing is secured with tape or has an adhesive border.

Gauze, Non-Elastic

The medically necessary frequency of non-elastic gauze dressing changes is determined by the frequency of change of the selected primary dressing.  Overlying non-elastic gauze is of no proven benefit when a dressing is secured with tape or has adhesive border.

Tissue Adhesives, Tissue Sealants, Hemostatic Agents

The use of tissue adhesives, tissue sealants or hemostatic agents as an alternative to sutures in wound closure is considered integral to the surgical procedure and not separately reimbursed.

Light Compession Bandage, Moderate/High Compression Bandage, Self-Adherent Bandage, Conforming Bandage, Padding Bandage

Most compression bandages are reusable. Usual medically necessary frequency of replacement would be no more than one per week unless they are part of a multi-layer compression bandage system.

The medical necessity of conforming bandage dressing change is determined by the frequency of change of the selected underlying dressing.

Gradient Compression Wrap

A gradient compression stocking or a non-elastic gradient compression wrap is considered medically necessary when it is used in the treatment of an open venous stasis ulcer. The medically necessary frequency of a non-elastic gradient compression wrap is limited to one per 6 months per leg. Quantities exceeding this amount will be denied as not medically necessary.

Dialkylcarbomoyl Chloride (DACC)-Coated Ddressing

Aetna considers dialkylcarbomoyl chloride (DACC)-coated dressing experimental and investigational for surgical site infection because its effectiveness has not been established.

Negative Pressure Dressings

Aetna considers negative pressure dressings not medically necessary for open fractures because they are no better than standard dressings for open fractures. (See CPB 0344 - Negative Pressure Wound Therapy).

OxyBand Wound Dressing

Aetna considers OxyBand wound dressing experimental and investigational because its effectiveness has not been established.

Notes on Relationship with Other Policies

Under both HMO and traditional plans, charges for disposable supplies and accessories may also be covered when required to operate durable medical equipment or prosthetic devices (e.g., tracheostomy supplies, urologic supplies, ostomy supplies, dialysis supplies, etc.).

Background

This policy is based in part upon Medicare DMERC criteria.

In a prospective, observational study, Cassino and Ricci (2010) examined if the topical application of an amino acid dressing, Vulnamin, aids the management of chronic wounds.  A total of 160 patients with non-infected cutaneous chronic wounds were recruited.  Before treatment, wound size was assessed using digital planimetry.  Treatment lasted for a maximum of 6 weeks.  Wound area measurements were repeated 2 and 6 weeks after starting treatment.  There was a significant reduction in the mean wound area after 2 weeks (7.4 +/- 8.7 cm2) and 6 weeks (4.6 +/- 6.3 cm2) of treatment, when compared with baseline (11.2 +/- 12.1 cm2, p < 0.01).  At the final follow-up, 23 % of patients (n = 36) healed and 34 % (n = 54) achieved a greater than 60 % reduction in wound size.  A total of 76 % (n = 120) of subjects achieved positive outcomes (defined as a greater than 40 % reduction in the ulcer size).  The authors concluded that although further investigations on the potential effects of this product on chronic wound healing are needed, these findings suggest amino acid dressings may promote healing in venous, pressure and diabetic ulcers.

In a Cochrane review, Briggs and Nelson (2010) evaluated the effectiveness of dressings, local anesthetics or topical analgesia for pain relief in venous leg ulceration.  For this update, the search strings were revised and the following databases were searched: The Cochrane Wounds Group Specialised Register (searched 16/12/09) The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library Issue 4 2009; Ovid MEDLINE - 1950 to November Week 3 2009; Ovid EMBASE - 1980 to 2009 Week 50; EBSCO CINAHL - 1982 to December 16 2009.  No date or language restrictions were applied.  Randomized controlled trials (RCTs) that evaluated local interventions used to relieve venous leg ulcer pain were considered.  Pain was defined as either persistent pain or pain at dressing changes or debridement.  Ulcer healing and reported adverse events were also considered as further outcomes.  Eligibility for inclusion was confirmed by 2 review authors who independently assessed the potential trials.  Two trials evaluating interventions for persistent venous leg ulcer pain were identified for this review update.  Both studies evaluated ibuprofen slow release foam dressings; one comparing it with local best practice and the other with an identical foam comparator.  The primary end point for both studies was "pain relief achieved".  When compared with a foam dressing alone, there was no evidence of a statistically significant effect of the ibuprofen foam dressing in terms of achieving some pain relief the first evening after treatment: 74 % in the ibuprofen group (46/62) had pain relief compared with 58 % (35/60) in the foam group (no significant difference: relative risk [RR] 1.27, 95 % confidence interval (CI): 0.98 to 1.65).  In the second study 100 % (32/32) of people with venous ulcers achieved some pain relief with the ibuprofen dressing on the first evening of treatment compared with 93 % (26/28) in the local best practice group (no significant difference: RR 1.08, 95 % CI: 0.96 to 1.21).  Pooling these studies in a meta-analysis (using a random effects model as significant heterogeneity present (p = 0.1), I(2) = 64 %) there is no evidence that ibuprofen dressings increase the pain relief experienced by the first evening of use (RR 1.15, 95 % CI: 0.91 to 1.44).  These investigators were unable to extract sufficient data to combine other pain outcomes from these trials.  There was no difference in healing rates but slightly more adverse events with ibuprofen dressings than with a similar foam dressing without ibuprofen.  Six trials evaluated interventions for the pain associated with debridement and were considered sufficiently similar to pool.  There was a statistically significant reduction in debridement pain scores with 5 % eutectic mixture of local anesthetics (EMLA): lidocaine-prilocaine cream; the difference in means (measured on a 100-mm scale) was 20.6 mm (95 % CI: 12.19 to 29.11).  Of these 6 trials, only 1 small trial measured healing as an outcome and found no difference in the numbers of ulcers healed at the end of the study.  The authors concluded that there is no evidence that ibuprofen dressings offer pain relief, as measured at the first evening of use, to people with painful venous leg ulcers compared with foam dressings or best practice.  Eutectic mixture of local anesthetics appears to provide effective pain relief for venous leg ulcer debridement but the effect (if any) of EMLA on ulcer healing remains unknown.

In a Cochrane review, Coulthard et al (2010) examined the relative effects of various tissue adhesives and conventional skin closure techniques on the healing of surgical wounds.  These investigators searched the Cochrane Wounds Group Specialised Register (searched 17/11/09); the Cochrane Central Register of Controlled Trials (CENTRAL) - the Cochrane Library Issue 4 2009; Ovid MEDLINE - 1950 to November Week 1 2009; Ovid EMBASE - 1980 to 2009 Week 46; EBSCO CINAHL - 1982 to 17 November 2009.  No date or language restrictions were applied.  Only RCTs were eligible for inclusion.  Screening of eligible studies and data extraction were conducted independently and in triplicate while assessment of the methodological quality of the trials was conducted independently and in duplicate.  Results were expressed as random effects models using mean difference for continuous outcomes and relative risks with 95 % CI for dichotomous outcomes.  Heterogeneity was investigated including both clinical and methodological factors.  This update identified an additional 6 trials resulting in a total of 14 RCTs (1,152 patients) which met the inclusion criteria.  Sutures were significantly better than tissue adhesives for minimising dehiscence (10 trials).  Sutures were also found to be significantly faster to use.  For all other analyses of infection, patient and operator satisfaction and cost there was no significant difference between sutures and tissue adhesives.  No differences were found between tissue adhesives and tapes (2 trials) for minimising dehiscence, infection, patients assessment of cosmetic appearance, patient satisfaction or surgeon satisfaction.  However a statistically significant difference in favor of using tape was found for surgeons' assessment of cosmetic appearance (mean difference 13, 95 % CI: 5 to 21).  Tapes were also demonstrated to be significantly faster to use than tissue adhesives as were staples (1 trial).  No other outcome measures were analysed in this group.  One trial compared tissue adhesives with a variety of methods of wound closure and found both patients and clinicians were significantly more satisfied with the alternative closure methods than the adhesives.  In this same trial, tissue adhesives were significantly less time consuming to use.  For the remaining outcomes of dehiscence and infection no difference was observed between groups.  This trial also compared high viscosity with low viscosity adhesives and found that high viscosity adhesives were less time consuming to use than low viscosity tissue adhesives.  For all other outcomes of dehiscence, infection, patient satisfaction and operator satisfaction there was no statistically significant difference between high and low viscosity adhesives.  The authors concluded that sutures were significantly better than tissue adhesives for minimizing dehiscence and were found to be significantly faster to use.  Although surgeons may consider the use of tissue adhesives as an alternative to other methods of surgical site closure in the operating theater, they must be aware that adhesives may take more time to apply and that if higher tension is needed upon an incision, sutures may minimize dehiscence.  The authors stated that there is a need for more well-designed RCTs comparing tissue adhesives and alternative methods of closure.  These trials should include people whose health may interfere with wound healing and surgical sites of high tension.

Lund-Nielsen et al (2011) stated that between 5 % and 10 % of cancer patients develop malignant wounds.  In-vitro and some clinical studies suggest that silver- or honey-coated dressings may have an anti-bacterial effect in non-malignant wounds, but their possible anti-bacterial effect in malignant wounds remains unknown.  A prospective, randomized, single-blind, controlled clinical study was conducted to evaluate the bacteriology of malignant wounds and compare the effect of a honey-coated (Group A) to a silver-coated (Group B) dressing on the qualitative bacteriology of malignant wounds.  All wound interventions were performed by the same healthcare professional.  Swab cultures were obtained at baseline and following a 4-week intervention and were evaluated without information about the patient treatment group.  Of the 75 patients with advanced cancer and malignant wounds identified, 67 (34 in group A, 33 in group B; median age of 64 years, range of 47 to 92) consented to participate and completed the 4-week study.  The majority were women (88 %) with breast cancer (79 %).  No statistically significant differences were found between the type and number of different wound pathogens in the wounds during the course of the study or between Group A and Group B.  Neither anti-neoplastic nor antibiotic treatment influenced the presence of wound pathogens.  Staphylococci were found in 42 %, enteric bacteria in 34 %, anaerobic bacteria in 16 %, Pseudomonas in 10 %, and hemolytic streptococci in 6 % of wounds at baseline; in total, 25 different bacterial species were identified.  Sixty-one percent (61 %) of wounds decreased in size following treatment, but no significant differences were observed between the type and variety of wound pathogens and whether wound size decreased.  Although quantitative bacteriological changes may have occurred, the possible anti-bacterial effect of the honey or silver dressing could not be confirmed in these malignant wounds.  Routine wound swabbing of malignant wounds is of little value and should be restricted to cases where signs of infection requiring antibiotic intervention are observed or where resistant organisms require special infection control measures.

Swan et al (2011) stated that excessive post-operative drainage following groin and axillary lymphadenectomy may be associated with a prolonged hospital stay and an increased complication rate.  The use of fibrin sealant before wound closure may reduce post-operative wound drainage.  Consecutive patients undergoing elective groin or axillary lymphadenectomy were randomized to standard wound closure or to having fibrin sealant sprayed on to the wound bed before closure.  Post-operative wound drainage, duration of drainage and complications were recorded, as were loco-regional recurrence, distant metastasis and mortality.  A total of 74 patients requiring 38 groin and 36 axillary dissections were randomized.  The median post-operative wound drainage volume for the groin dissection cohort was 762 (range of 25 to 3,255) ml in the control group and 892 (265 to 2,895) ml in the treatment group (p = 0·704).  Drainage volumes in the axillary cohort were 590 (230 to 9,605) and 565 (30 to 1,835) ml in the control and treatment groups respectively (p = 0·217).  There was no difference in the duration of drainage or post-operative complication rate between the treatment groups in both the axillary and groin cohorts.  Local recurrence, distant metastasis and mortality rates did not differ between the treatment groups.  The authors concluded that there was no advantage in using fibrin sealant during elective lymphadenectomy in terms of reducing drainage output or post-operative complication rate.

In a Cochrane review, Dumville et al (2013) compared the effects of hydrocolloid wound dressings with no dressing or alternative dressings on the healing of foot ulcers in people with diabetes.  For this first update, in April 2013, these investigators searched the following databases the Cochrane Wounds Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (in-process & other non-indexed citations); Ovid EMBASE; and EBSCO CINAHL.  There were no restrictions based on language or date of publication.  Published or unpublished RCTs that have compared the effects on ulcer healing of hydrocolloid with alternative wound treatments in the treatment of foot ulcers in people with diabetes were selected for analysis.  Two review authors independently performed study selection, risk of bias assessment and data extraction.  They included 5 studies (535 participants) in the review: these compared hydrocolloids with basic wound contact dressings, foam dressings, alginate dressings and a topical treatment.  Meta-analysis of 2 studies indicated no statistically significant difference in ulcer healing between fibrous-hydrocolloids and basic wound contact dressings: RR 1.01 (95 % CI: 0.74 to 1.38).  One of these studies found that a basic wound contact dressing was more cost-effective than a fibrous-hydrocolloid dressing.  One study compared a hydrocolloid-matrix dressing with a foam dressing and found no statistically significant difference in the number of ulcers healed.  There was no statistically significant difference in healing between an antimicrobial (silver) fibrous-hydrocolloid dressing and standard alginate dressing; an anti-microbial dressing (iodine-impregnated) and a standard fibrous hydrocolloid dressing or a standard fibrous hydrocolloid dressing and a topical cream containing plant extracts.  The authors concluded that currently there is no evidence to suggest that any type of hydrocolloid wound dressing is more effective in healing diabetic foot ulcers than other types of dressing or a topical cream containing plant extracts.  Decision makers may wish to consider aspects such as dressing cost and the wound management properties offered by each dressing type (e.g., exudate management).

In a Cochrane review, Toon and colleagues (2013) evaluated the risk and benefits of removing a dressing covering a closed surgical incision site within 48 hours permanently (early dressing removal) or beyond 48 hours of surgery permanently with interim dressing changes allowed (delayed dressing removal), on surgical site infection.  In July 2013, these investigators searched the following electronic databases: The Cochrane Wounds Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library); Database of Abstracts of Reviews of Effects (DARE) (the Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (in-process & other non-indexed citations); Ovid EMBASE; and EBSCO CINAHL.  They also searched the references of included trials to identify further potentially-relevant trials.  Two review authors independently identified studies for inclusion.  They included all RCTs conducted with people of any age and sex, undergoing a surgical procedure, and who had their wound closed and a dressing applied.  They included only trials that compared early versus delayed dressing removal; and excluded trials that included people with contaminated or dirty wounds.  These researchers also excluded quasi-randomized studies, and other study designs.  Two review authors independently extracted data on the characteristics of the trial participants, risk of bias in the trials and outcomes for each trial.  They calculated RR with 95 % CI for binary outcomes and mean difference (MD) with 95 % CI for continuous outcomes.  They used RevMan 5 software to perform these calculations.  A total of 4 trials were identified for inclusion in this review.  All the trials were at high risk of bias; 3 trials provided information for this review.  Overall, this review included 280 people undergoing planned surgery.  Participants were randomized to early dressing removal (removal of the wound dressing within the 48 hours following surgery) (n = 140) or delayed dressing removal (continued dressing of the wound beyond 48 hours) (n = 140) in the 3 trials.  There were no statistically significant differences between the early dressing removal group and delayed dressing removal group in the proportion of people who developed superficial surgical site infection within 30 days (RR 0.64; 95 % CI: 0.32 to 1.28), superficial wound dehiscence within 30 days (RR 2.00; 95 % CI: 0.19 to 21.16) or serious adverse events within 30 days (RR 0.83; 95 % CI: 0.28 to 2.51).  No deep wound infection or deep wound dehiscence occurred in any of the participants in the trials that reported this outcome.  None of the trials reported quality of life.  The hospital stay was significantly shorter (MD -2.00 days; 95 % CI: -2.82 to -1.18) and the total cost of treatment significantly less (MD EUR -36.00; 95 % CI: -59.81 to -12.19) in the early dressing removal group than in the delayed dressing removal group in the only trial that reported these outcomes.  The authors concluded that early removal of dressings from clean or clean contaminated surgical wounds appears to have no detrimental effect on outcomes.  However, it should be noted that the point estimate supporting this statement was based on very low quality evidence from 3 small RCTs, and the CI around this estimate were wide.  Early dressing removal may result in a significantly shorter hospital stay, and significantly reduced costs, than covering the surgical wound with wound dressings beyond the first 48 hours after surgery, according to very low quality evidence from 1 small RCT.  The authors stated that further RCTs of low risk of bias are needed to examine if dressings are necessary after 48 hours in different types of surgery and levels of contamination and investigate whether antibiotic therapy influences the outcome.

In a Cochrane review, Dumville et al (2014) examined the effects of various tissue adhesives compared with conventional skin closure techniques for the closure of surgical wounds.  In March 2014 for this second update, these investigators searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL.  They did not restrict the search and study selection with respect to language, date of publication or study setting.  Only RCTs were eligible for inclusion.  These researchers conducted screening of eligible studies, data extraction and risk of bias assessment independently and in duplicate.  They expressed results as random-effects models using mean difference for continuous outcomes and RR with 95 % CI for dichotomous outcomes.  They investigated heterogeneity, including both clinical and methodological factors.  This second update of the review identified 19 additional eligible trials resulting in a total of 33 studies (2,793 participants) that met the inclusion criteria.  There was low quality evidence that sutures were significantly better than tissue adhesives for reducing the risk of wound breakdown (dehiscence; RR 3.35; 95 % CI: 1.53 to 7.33; 10 trials, 736 participants that contributed data to the meta-analysis).  The number needed-to-treat for an additional harmful outcome was calculated as 43.  For all other outcomes – infection, patient and operator satisfaction and cost – there was no evidence of a difference for either sutures or tissue adhesives.  No evidence of differences was found between tissue adhesives and tapes for minimizing dehiscence, infection, patients' assessment of cosmetic appearance, patient satisfaction or surgeon satisfaction.  However there was evidence in favor of using tape for surgeons' assessment of cosmetic appearance (mean difference (visual analog scale [VAS] 0 to 100) 9.56 (95 % CI: 4.74 to 14.37; 2 trials, 139 participants).  One trial compared tissue adhesives with a variety of methods of wound closure and found both patients and clinicians were significantly more satisfied with the alternative closure methods than the adhesives.  There appeared to be little difference in outcome for different types of tissue adhesives.  One study that compared high viscosity with low viscosity adhesives found that high viscosity adhesives were less time-consuming to use than low viscosity tissue adhesives, but the time difference was small.  The authors concluded that sutures are significantly better than tissue adhesives for minimizing dehiscence.  In some cases tissue adhesives may be quicker to apply than sutures.  Although surgeons may consider the use of tissue adhesives as an alternative to other methods of surgical site closure in the operating room, they need to be aware that sutures minimize dehiscence.  They stated that there is a need for more well designed RCTs comparing tissue adhesives with alternative methods of closure.  These trials should include people whose health may interfere with wound healing and surgical sites of high tension.

Fungating wounds arise from primary, secondary or recurrent malignant disease and are associated with advanced cancer.  A small proportion of patients may achieve healing following surgical excision, but treatment is usually palliative.  Fungating wound management usually aims to slow disease progression and optimize quality of life by alleviating physical symptoms, such as copious exudate, malodor, pain and the risk of hemorrhage, through selection of appropriate dressings and topical agents.  In a Cochrane review, Adderley and Holt (2014) evaluated the evidence of the effects of dressings and topical agents on quality of life, and symptoms that impact on quality of life, in people with fungating malignant wounds.  For this third update, these investigators searched the Wounds Group Specialised Register in August 2013; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL.  Eligible studies comprised RCTs or, in their absence, controlled clinical trials (CCTs) with a concurrent control group.  Data extraction and risk of bias assessment was undertaken by one review author and checked for accuracy by a second.  A total of 4 trials involving 164 people were included.  One RCT in women with superficial breast lesions compared 6 % miltefosine solution with placebo and found that miltefosine delayed tumor progression.  The study reported that the time to treatment failure was significantly longer in the miltefosine group (median of 56 days) than in the placebo group (median of 21 days) (p value 0.007, log-rank test).  A second trial compared topical metronidazole with placebo but the results up to the point of cross-over were not statistically significant.  A third trial compared the effect of foam dressings containing silver to foam dressings without silver and found that more patients experienced decreased malodor in the foam with silver group than in the foam alone group (p value=0.049).  The fourth trial compared the effect of manuka honey-coated dressings with nano-crystalline silver-coated dressings and found no statistically significant difference with regard to exudate, malodor and wound pain.  All trials, however, had methodological limitations.  The authors concluded that there is weak evidence from 1 small trial that 6 % miltefosine solution applied topically to people with superficial fungating breast lesions (smaller than 1cm) who have received either previous radiotherapy, surgery, hormonal therapy or chemotherapy for their breast cancer, may slow disease progression.  They noted that there is also weak evidence to suggest that foam dressings containing silver may be effective in reducing malodor; and there is insufficient evidence to give a clear direction for practice with regard to improving quality of life or managing wound symptoms associated with fungating wounds.  They stated that more research is needed.

Andrew and colleagues (2015) reviewed published RCTs and non-RCTs examining the effect of drains and dressings on wound healing rates and complications in posterior spine surgery.  The use of post-operative drains and the type of post-operative dressing is at the discretion of the treating surgeon with no available clinical guidelines.  Drains will theoretically decrease incidence of post-operative hematoma and therefore, potentially decrease the risk of neurologic compromise when the neural elements have been exposed.  Occlusive dressings have more recently been advocated, potentially maintaining a sterile barrier for longer time periods post-operatively.  A systematic review of databases from 1969 to 2013 was undertaken.  All papers examining drains in spine surgery and dressings in primary healing of surgical wounds were included.  Revman (version 5.2; The Nordic Cochrane Centre, The Cochrane Collaboration, Oxford, UK) was used to test for overall treatment effect, clinical heterogeneity and risk of bias.  Of the papers identified, 1,348 examined post-operative drains in spine surgery and 979 wound dressings for primary wound healing of all surgical wounds.  A total of 7 studies were included for analysis for post-operative drains and 10 studies were analyzed for primary wound healing.  The use of a post-operative drain did not influence healing rates and had no effect secondarily on infection (odds ratio [OR] 1.33; 95 % CI: 0.76 to 2.30).  These researchers were not able to establish whether surgical drains prevent hematomas causing neurologic compromise.  There was a slight advantage to using occlusive dressings versus non-occlusive dressings in wound healing (OR 2.09; 95 % CI: 1.44 to 3.02).  Incisional vacuum dressings as both an occlusive barrier and superficial drainage system have shown promise for wounds at risk of dehiscence.  There is a relatively high risk of bias in the methodology of many of the studies reviewed.  The authors recommended favoring of occlusive dressings based on heterogeneous and potentially biased evidence.  They stated that drain use does not affect wound healing based on similar evidence; and incisional vacuum dressings have shown promise in managing potentially vulnerable wounds.

Dialkylcarbamoyl Chloride (DACC)-Coated Dressings for Surgical Site Infection

Totty and associates (2017) noted that dialkylcarbomoyl chloride (DACC)-coated dressings (Leukomed Sorbact and Cutimed Sorbact) irreversibly bind bacteria at the wound surface that are then removed when the dressing is changed.  They are a recent addition to the wound care professional's armamentarium and have been used in a variety of acute and chronic wounds.  These researchers evaluated the evidence supporting the use of DACC-coated dressings in the clinical environment.  They included all reports of the clinical use of DACC-coated dressings in relation to wound infection.  Medline, Embase, CENTRAL and CINAHL databases were searched to September 2016 for studies evaluating the role of DACC-coated dressings in preventing or managing wound infections.  These investigators identified 17 studies with a total of 3,408 patients that were included in this review.  The DACC-coating was suggested to reduce post-operative surgical site infection (SSI) rates and resulted in chronic wounds that subjectively looked cleaner and had less bacterial load on microbiological assessments.  The authors concluded that existing evidence for DACC-coated dressings in managing chronic wounds or as a SSI prophylaxis was limited but encouraging with evidence in support of DACC-coated dressings preventing and treating infection without adverse effects.

Silver-Containing Dressing for Surgical Site Infection

Dumville and colleagues (2016) stated that surgical wounds (incisions) heal by primary intention when the wound edges are brought together and secured, often with sutures, staples, or clips. Wound dressings applied after wound closure may provide physical support, protection and absorb exudate.  There are many different types of wound dressings available and wounds can also be left uncovered (exposed); SSI is a common complication of wounds and this may be associated with using (or not using) dressings, or different types of dressing.  In a Cochrane review, these investigators examined the effects of wound dressings compared with no wound dressings, and the effects of alternative wound dressings, in preventing SSIs in surgical wounds healing by primary intention.  They searched the following databases: the Cochrane Wounds Specialised Register (searched September 19, 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library 2016, Issue 8); Ovid Medline (including In-Process & Other Non-Indexed Citations, MedlineE Daily and Epub Ahead of Print; 1946 to September 19, 2016); Ovid Embase (1974 to September 19, 2016); EBSCO CINAHL Plus (1937 to September 19, 2016).  There were no restrictions based on language, date of publication or study setting; RCTs comparing wound dressings with wound exposure (no dressing) or alternative wound dressings for the post-operative management of surgical wounds healing by primary intention.  Two review authors performed study selection, “risk of bias” assessment and data extraction independently.  These researchers included 29 trials (5,718 participants).  All studies except 1 were at an unclear or high risk of bias.  Studies were small, reported low numbers of SSI events and were often not clearly reported.  There were 16 trials that included people with wounds resulting from surgical procedures with a “clean” classification, 5 trials that included people undergoing what was considered “clean/contaminated” surgery, with the remaining studies including people undergoing a variety of surgical procedures with different contamination classifications; 4 trials compared wound dressings with no wound dressing (wound exposure); the remaining 25 studies compared alternative dressing types, with the majority comparing a basic wound contact dressing with film dressings, silver dressings or hydrocolloid dressings.  The review contained 11 comparisons in total.  It was uncertain whether wound exposure or any dressing reduced or increased the risk of SSI compared with alternative options investigated: these researchers assessed the certainty of evidence as very low for most comparisons (and low for others), with down-grading (according to GRADE criteria) largely due to risk of bias and imprecision.  They summarized the results of comparisons with meta-analyzed data below: film dressings compared with basic wound contact dressings following clean surgery (RR 1.34, 95  % CI: 0.70 to 2.55), very low certainty evidence down-graded once for risk of bias and twice for imprecision.  Hydrocolloid dressings compared with basic wound contact dressings following clean surgery (RR 0.91, 95 % CI: 0.30 to 2.78), very low certainty evidence down-graded once for risk of bias and twice for imprecision.  Hydrocolloid dressings compared with basic wound contact dressings following potentially contaminated surgery (RR 0.57, 95 % CI: 0.22 to 1.51), very low certainty evidence down-graded twice for risk of bias and twice for imprecision.  Silver-containing dressings compared with basic wound contact dressings following clean surgery (RR 1.11, 95 % CI: 0.47 to 2.62), very low certainty evidence down-graded once for risk of bias and twice for imprecision.  Silver-containing dressings compared with basic wound contact dressings following potentially contaminated surgery (RR 0.83, 95 % CI: 0.51 to 1.37), very low certainty evidence down-graded twice for risk of bias and twice for imprecision.  There was limited and low or very low certainty evidence on secondary outcomes such as scarring, acceptability of dressing and ease of removal, and uncertainty whether wound dressings influenced these outcomes.  The authors concluded that it was uncertain whether covering surgical wounds healing by primary intention with wound dressings reduced the risk of SSI, or whether any particular wound dressing was more effective than others in reducing the risk of SSI, improving scarring, reducing pain, improving acceptability to patients, or was easier to remove.  They stated that most studies in this review were small and at a high or unclear risk of bias.  They noted that based on the current evidence, decision makers may wish to base decisions about how to dress a wound following surgery on dressing costs as well as patient preference.

Li and colleagues (2017) noted that silver-containing dressings for the prevention of surgical site infections (SSIs) remained controversial, and accumulating evidence was lacking, so a meta-analysis was conducted to systematically assess the safety and effectiveness of silver-containing dressings for clean and clean-contaminated surgical incisions.  PubMed, Embase, and the Cochrane Library were searched from the inception to February 2016 for RCTs, which explored silver-containing dressings for the prevention of SSIs in clean and clean-contaminated operations; RR with 95 % CI was pooled using random effects model.  Pre-defined subgroup analyses, sensitivity analyses, and influence analyses were further undertaken.  A total of 9 RCTs totaling 2,196 patients (1,141 in silver-containing group and 1,055 in control group) were included.  Silver-containing dressings did not effectively prevent the incidence of SSIs (9 RCTs; RR: 0.92; 95 % CI: 0.66 to 1.29; I2 = 40 %), superficial SSIs (5 RCTs; RR: 0.67; 95 % CI: 0.36 to 1.24; I2 = 36 %), and deep SSIs (5 RCTs; RR: 0.78; 95 % CI: 0.41 to 1.49; I2 = 0).  Subgroup analyses, sensitivity analyses, and influence analyses confirmed the robustness of the pooled estimate.  The authors concluded that the current available evidence indicated that silver-containing dressing as compared with silver-free dressing was not associated with lower incidence of SSIs.  Moreover, they stated that considering the quality of evidence ranking very low, further studies with higher quality are needed.

Negative Pressure Dressings for Open Fractures

Costa and colleagues (2018) stated that open fractures of the lower limb occur when a broken bone penetrates the skin.  There can be major complications from these fractures, which can be life-changing.  In a multi-center, randomized study, these investigators examined the disability, rate of deep infection, and quality of life (QOL) in patients with severe open fracture of the lower limb treated with negative pressure wound therapy (NPWT) versus standard wound management after the first surgical debridement of the wound.  Thus trial was performed in the United Kingdom (UK) Major Trauma Network, recruiting 460 patients aged 16 years or older with a severe open fracture of the lower limb from July 2012 through December 2015.  Final outcome data were collected through November 2016.  Exclusions were presentation more than 72 hours following injury and inability to complete questionnaires.  Interventions were NPWT (n = 226) in which an open-cell solid foam or gauze was placed over the surface of the wound and connected to a suction pump, creating a partial vacuum over the dressing, versus standard dressings not involving application of negative pressure (n = 234).  Disability Rating Index score (range of 0 [no disability] to 100 [completely disabled]) at 12 months was the primary outcome measure, with a minimal clinically important difference of 8 points.  Secondary outcomes were complications including deep infection and QOL (score ranged from 1 [best possible] to -0.59 [worst possible]; minimal clinically important difference, 0.08) collected at 3, 6, 9, and 12 months.  Among 460 patients who were randomized (mean age of 45.3 years; 74 % men), 88 % (374/427) of available study subjects completed the trial.  There were no statistically significant differences in the patients' Disability Rating Index score at 12 months (mean score of 45.5 in the NPWT group versus 42.4 in the standard dressing group; mean difference, -3.9 [95 % CI: -8.9 to 1.2]; p = 0.13), in the number of deep surgical site infections (16 [7.1 %] in the NPWT group versus 19 [8.1 %] in the standard dressing group; difference, 1.0 % [95 % CI: -4.2 % to 6.3 %]; p = 0.64), or in QOL between groups (difference in EuroQol 5-dimensions questionnaire, 0.02 [95 % CI: -0.05 to 0.08]; Short Form-12 Physical Component Score, 0.5 [95 % CI: -3.1 to 4.1] and Mental Health Component Score, -0.4 [95 % CI: -2.2 to 1.4]).  The authors concluded that among patients with severe open fracture of the lower limb, the use of NPWT compared with standard wound dressing did not improve self-rated disability at 12 months; these findings did not support negative pressure dressings for the treatment of severe open fractures.

National Institute for Health Research (NIRH) Signal’s technology assessment on “Negative pressure dressings are no better than standard dressings for open fractures” (2018) stated that open fractures of the leg, where the broken bone is exposed by the original injury or has burst through the skin, are prone to infection.  Usually, the wound is thoroughly cleaned, damaged tissue debrided, the bone stabilized and a standard dressing applied; NPWT requires a special dressing and an additional vacuum pump.  This removes surplus blood and fluid from the wound, which was expected to improve the chances of healing and reduce deep tissue infections.  The NIHR assessment stated that negative pressure wound dressings are neither more nor less effective than standard wound dressings for severe open fractures of the lower leg.  Any difference between groups was neither clinically important nor statistically significant.  The outcomes included self-rated disability at 1 year, QOL and deep surgical site infections at 1 month that occurred in around 7 to 8 % in each group.  The results of this NIHR-funded trial suggested that this more expensive option offered no significant gains for patients.

Tamponade Dressings Following Open Hemorrhoidectomy

Langenbach and colleagues (2014) stated that bleeding following hemorrhoidectomy is common.  Many surgical textbooks recommend insertion of an anal tampon in order to reduce post-operative bleeding.  This practice, however, is bothersome and probably painful for patients.  The effect of using a tamponade has not been validated in RCTs.  In a pilot study with 100 patients who were scheduled for Milligan-Morgan hemorrhoidectomy, these investigators examined whether the insertion of an anal tamponade would reduce post-operative bleeding.  During surgery, patients were randomly assigned to receive or not to receive an anal tampon at the end of the procedure.  Data on pain, complications and wound care were collected.  There were 48 patients in the group with tamponade, and 52 patients were left without tamponade.  The trial's primary outcome and maximum pain intensity, averaged 6.1 and 4.2 in the 2 groups (p = 0.001).  In the group with tamponade, a complication was recorded in 7 patients (15 %), which was similar to the group without tamponade (21 %).  Severe anal bleeding occurred in 2 and 5 patients, respectively.  Bandage changes were less necessary often in the group treated without tamponade (p = 0.013); hospital stay was 4 days in both groups.  The authors concluded that the findings of this study indicated that insertion of an anal tampon following hemorrhoidectomy did not reduce post-operative bleeding; but caused significantly more pain.  These investigator stated that following hemorrhoidectomy, anal tampons should not be used routinely but may be considered when specific indications justify its use.

Langenbach and Seidel (2019) noted that symptomatic hemorrhoids are one of the most common anorectal disorders.  Many surgeons use tamponades following open hemorrhoidectomy to manage post-operative bleeding.  The question of whether a tamponade is necessary and beneficial following hemorrhoidectomy has not yet been conclusively answered.  A previously conducted single-center, pilot trial (Langenbach et al, 2014) included 100 patients following Milligan-Morgan hemorrhoidectomy.  The data indicated that insertion of an anal tamponade following hemorrhoidectomy did not reduce post-operative bleeding but caused significantly more pain. The findings of this pilot trial are now to be verified by means of a multi-center randomized clinical study called NoTamp.  These researchers plan to include 953 patients following Milligan-Morgan or Parks hemorrhoidectomy in the NoTamp study.  The aim is to demonstrate that using no tamponade dressing after open hemorrhoidectomy is not inferior to using tamponades with respect to post-operative bleeding, and that the patients report less pain.  Primary end-points of the trial are the maximum post-operative pain within 48 hours and the incidence of severe post-operative bleeding that requires surgical revision within 7 days after the surgical procedure.  Secondary end-points of the study are the use of analgesics in the post-operative course, the lowest hemoglobin (Hb) documented within 7 days, QOL and patient satisfaction.  Safety analysis includes all adverse and serious adverse events (AEs) in relation to the study treatment.  The authors concluded that this study received full ethics committee approval; the first patient was enrolled on May 3, 2017.  This trial will finally answer the question whether the insertion of a tamponade following open hemorrhoidectomy is necessary and beneficial.

OxyBand Wound Dressing

OxyBand Wound Dressing, cleared via the 510(k) process, provides oxygen to wounds for up to 5 days.  The oxygen, pre-packaged and in a proprietary method, diffused into the patented reservoir system inside of the OxyBand Wound Dressing.  The pre-filled multi-layer, OxyBand Wound Dressing, comes pre-filled with high levels of oxygen between the layers.  OxyBand Wound Dressing incorporates a barrier layer that holds the oxygen in the vicinity of the wound, and a permeable or porous layer that allows oxygen to diffuse into the wound.  The dressing acts like an oxygen reservoir allowing the wound to utilize as much oxygen as needed, and continues to supply oxygen on demand to the wound as the wound consumes oxygen from the wound fluid.

Lairet and colleagues (2014) noted that accelerating the healing process and reducing pain during healing are beneficial for the following reasons: faster return to work, lower risk of wound infection, improved quality of life (QOL), and possibly reduced need for analgesia.  In a prospective RCT, these researchers examined the effectiveness of a new oxygen-diffusion dressing (OxyBand; Oxyband Technologies, St. Louis, MO) compared with standard Xeroform gauze dressings (Convidien, Mansfield, MA), in the care of skin-graft donor sites in burn patients.  Time to healing was the primary end-point, and pain scores and cosmetic outcome were also assessed.

This study included burn patients undergoing harvesting of 2 donor sites.  Patients were followed at pre-determined time-points for 30 to 45 days to determine the time to re-epithelialization, cosmetic appearance, and pain.  Subjects were adult burn patients with less than 30 % total body surface area (TBSA) burns admitted to the burn center, who needed excision and grafting. A total of 20 patients were enrolled, of whom 17 completed the study.  Average age was 35 years; average burn size was 9.2 % TBSA.  Patients underwent harvesting of split-thickness skin grafts with 1 donor wound dressed with OxyBand and the other dressed in Xeroform gauze.  Wounds were inspected and photographed on post-operative days 4 and 8, and then every 2 days until the donor wounds were healed.  Pain scores at each site were also collected at these visits (rated by patients on a scale from 0 to 10).  Mean time to wound healing for OxyBand was 9.3 ± 1.7 days; for Xeroform, 12.4 ± 2.7 days (p < 0.001).  Pain scores were lower (p < 0.01) at the OxyBand site compared with the Xeroform site at all time-points during post-operative days 4 to 12.  There was no difference in the cosmetic outcome of the wounds at 30 to 45 days post-operatively.  The authors concluded that the findings of this study showed a decrease in the time to healing and in pain at donor sites dressed with an oxygen-diffusion dressing.  This was a small study (n = 17 subjects who completed the study); these preliminary findings need to be validated by well-designed studies.

In a review on "Treating pain on skin graft donor sites", Sinha and associates (2017) noted that split-thickness skin grafting is the most common reconstructive procedure in managing burn injuries.  Harvesting split-thickness skin creates a new partial thickness wound referred to as the donor site.  Pain at the donor site is reported to be one of the most distressing symptoms during the early post-operative period.  These investigators identified strategies for managing donor site pain, assessed the quality of individual studies, and formulated evidence-based recommendations based on the amount and consistency of evidence.  Their analysis revealed 5 distinct approaches to minimize donor site pain.  These included: continuous subcutaneous local anesthetic infusion (3 studies), subcutaneous anesthetic injection (5 studies), topical agents (6 studies), non-pharmacological interventions (3 studies), and wound dressings (18 studies).  Available RCTs typically evaluated pain on standardized scales (i.e., VAS, numerical rating scale [NRS]), and compared the experimental group with standard care.  Recommended treatments included: subcutaneous anesthetic injection of adrenaline-lidocaine;  ice application; topical agents, such as lidocaine and bupivacaine; and hydrocolloid- and polyurethane-based wound dressings accompanied with fibrin sealant.  The authors concluded that methodologically sound RCTs examining the efficacy of modified tumescent solution, ropivacaine, plasma therapy, non-contact ultrasound, and morphine gels are lacking and should be a priority for future research.  This review did not mention the use of oxygen-diffusion dressing.

Chlorhexidine-Impregnated Wound Dressing for the Prophylaxis of Central Venous Catheter-Related Complications

Wei and colleagues (2019) noted that several RCTs examined the role of chlorhexidine-impregnated dressing for prophylaxis of central venous catheter (CVC)-related complications; however, the results remained inconsistent, updated meta-analyses on this issue are needed.  These researchers carried out a meta-analysis on the RCTs comparing chlorhexidine-impregnated dressing versus other dressing or no dressing for prophylaxis of CVC-related complications. A comprehensive search of major data-bases was conducted up to December 30, 2018 to identify related studies.  Pooled OR and MDs with 95 % CI were calculated using either a fixed-effects or random-effects model.  Subgroup analysis was performed to identify the source of heterogeneity, and funnel plot and Egger test was used to identify the publication bias.  A total of 12 RCTs with 6,028 participants were included.  The chlorhexidine-impregnated dressings provided significant benefits in reducing the risk of catheter colonization (OR = 0.46, 95 % CI: 0.36 to 0.58), decreasing the incidence of catheter-related bloodstream infection (CRBSI) (OR = 0.60, 95 % CI: 0.42 to 0.85).  Subgroup analysis indicated that the chlorhexidine-impregnated dressings were conducive to reduce the risk of catheter colonization and CRBSI within the included RCTs with sample size more than 200, but the differences weren't observed for those with sample less than 200.  No publication bias was observed in the Egger test for the risk of CRBSI.  The authors concluded that chlorhexidine-impregnated dressing was beneficial to the prevention of CVC-related complications.  Moreover, these researchers stated that future studies are needed to examine the role and cost-effectiveness of chlorhexidine-impregnated dressings.

The authors stated that this meta-analysis had several drawbacks.  First, these investigators didn’t use mesh terms in their search strategy or ask for help from a librarian developing the search strategy; thus, it was possible that some articles might have been missed in their initial search.  Second, considering the nature of intervention, it was difficult to blind the research personnel and outcome assessment, none of included RCTs was truly double-blinded design, hence the risk of bias was inevitable; and the blood culture was conducted in elected patients only among the included RCTs, this might also have introduced bias.  Third, the rates of CRBSI among included RCTs varied greatly with a range of 0 to 11.3 %, it might be related to the differences in clinical nursing practice and guidelines.  Fourth, the Egger test for the detection of publication bias was potentially under-powered given the small sample size, a non-significant Egger’s test did not necessarily suggest lack of asymmetry in the Funnel plot, therefore, these findings should be treated with cautions.  Finally, these researchers only made post-hoc subgroup analyses stratified by sample size, but not by insertion location, type of chlorhexidine-impregnated dressing, the frequency of dressing changes etc. due to the data limitation, the publication bias on the risk of catheter colonization remained unclear.  These investigators stated that f future studies addressing the role of chlorhexidine-impregnated dressing with combined consideration to those related factors are needed.

The Centers for Disease Control and Prevention (Talbot, et al., 2017) recommends chlorhexidine-impregnated dressings with an FDA-cleared label that specifies a clinical indication for reducing catheter-related bloodstream infection (CRBSI) or catheter-associated blood stream infection (CABSI) to protect the insertion site of short-term, nontunneled central venous catheters in adults.

Appendix

Staging of Pressure Ulcers

The staging of pressure ulcers is as follows:

Table: Stages of Pressure Ulcers

Stages	Staging of Pressure Ulcers
Stage I	Non-blanchable erythema of intact skin
Stage II	Partial thickness skin loss involving epidermis and/or dermis
Stage III	Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia
Stage IV	Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures

Table: CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
CPT codes covered if selection criteria are met:
16020	Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface are)
16025	medium (eg, whole face or whole extremity, or 5 % to 10% total body surface area)
16030	large (eg, more than one extremity, or greater than 10% total body surface area)
96574	Debridement of premalignant hyperkeratotic lesion(s) (ie, targeted curettage, abrasion) followed with photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug(s) provided by a physician or other qualified health care
97597	Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session total wound(s) surface area; first 20 sq cm or less
97598	each additional 20 sq cm, or part thereof (list separatley in addition to code for primary procedure)
97602	Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session
HCPCS codes covered if selection criteria are met [payment for these supplies may be included in payment for other services rendered]:
A4216	Sterile water, saline and/or dextrose, dilute flush, 10 ml [not covered under surgical dressings benefit]
A4217	Sterile water/saline, 500 ml [not covered under surgical dressings benefit]
A4450	Tape, non-waterproof, per 18 sq. in.
A4452	Tape, waterproof, per 18 sq. in.
A4649	Surgical supply; miscellaneous
A6025	Gel sheet for dermal or epidermal application, (e.g., silicone, hydrogel, other), each
A6154	Wound pouch, each
A6196 - A6199	Alginate or other fiber gelling dressing
A6200 - A6205	Composite dressing
A6206 - A6208	Contact layer
A6209 - A6215	Foam dressing [not covered for ibuprofen foam dressings for painful venous leg ulcers]
A6216 - A6221	Gauze, nonimpregnated, nonsterile
A6222 - A6233	Gauze, impregnated
A6234 - A6241	Hydrocolloid dressing
A6242 - A6248	Hydrogel dressing
A6250	Skin sealants, protectants, moisturizers, ointments, any type, any size [not covered under surgical dressings benefit]
A6251 - A6256	Specialty absorptive dressing
A6257 - A6259	Transparent film
A6260	Wound cleansers, any type, any size [not covered under surgical dressings benefit]
A6261	Wound filler, gel/paste, per fluid ounce, not otherwise specified
A6262	Wound filler, dry form, per gram, not otherwise specified
A6266	Gauze, impregnated, other than water, normal saline, or zinc paste, any width, per linear yard
A6402 - A6404	Gauze, non-impregnated, sterile
A6441	Padding bandage, nonelastic, nonwoven/nonknitted, width greater than or equal to 3 in. and less than 5 in., per yd.
A6442 - A6447	Conforming bandage, nonelastic
A6448 - A6452	Light, moderate, and high compression bandage, elastic
A6453 - A6455	Self-adherent bandage, elastic
A6456	Zinc paste impregnated bandage, nonelastic, knitted/woven, width greater than or equal to 3 in., and less than 5 in., per yd.
A6460 - A6461	Synthetic resorbable wound dressing, sterile, pad without adhesive border, each dressing
C1765	Adhesion barrier [not covered under surgical dressings benefit]
HCPCS Modifiers:
Modifier A1	Dressing for one wound
Modifier A2	Dressing for two wounds
Modifier A3	Dressing for three wounds
Modifier A4	Dressing for four wounds
Modifier A5	Dressing for five wounds
Modifier A6	Dressing for six wounds
Modifier A7	Dressing for seven wounds
Modifier A8	Dressing for eight wounds
Modifier A9	Dressing for nine or more wounds
HCPCS codes not covered for indications listed in the CPB:
Dialkylcarbomoyl chloride (DACC)-coated dressings, OxyBand wound dressing - no specific code:
A4364	Adhesive, liquid or equal, any type, per oz. [not covered as an alternative to sutures in wound closure]
A4550	Surgical trays [not covered for provision or surgical dressings]
A6550	Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories
A9272	Wound suction, disposable, includes dressing, all accessories and components, any type, each
E2402	Negative pressure wound therapy electrical pump, stationary or portable
K0743	Suction pump, home model, portable, for use on wounds
K0744	Absorptive wound dressing for use with suction pump, home model, portable, pad size 16 sq in or less
K0745	Absorptive wound dressing for use with suction pump, home model, portable, pad size more than 16 sq in but less than or equal to 48 sq in
K0746	Absorptive wound dressing for use with suction pump, home model, portable, pad size greater than 48 sq in
Other HCPCS codes related to the CPB:
A6010 - A6011	Collagen based wound filler
A6021 - A6024	Collagen dressing
A6457	Tubular dressing with or without elastic, any width, per linear yard
G0168	Wound closure utilizing tissue adhesive(s) only
ICD-10 codes covered if selection criteria are met (not all-inclusive):
L89.003 - L89.004, L89.013 - L89.014, L89.023 - L89.024, L89.103 - L89.104, L89.113 - L89.114, L89.123 - L89.124, L89.133 - L89.134, L89.143 - L89.144, L89.153 - L89.154, L89.203 - L89.204, L89.213 - L89.214, L89.223 - L89.224, L89.303 - L89.304, L89.313 - L89.314, L89.323 - L89.324, L89.43 - L89.44, L89.503 - L89.504, L89.513 - L89.514, L89.523 - L89.524, L89.603 - L89.604, L89.613 - L89.614, L89.623 - L89.624, L89.813 - L89.814, L89.893 - L89.894, L89.93 - L89.94	Pressure ulcer [stage III or IV]
L97.100 - L97.929	Non-pressure chronic ulcer [stage III or IV]
T20.20x+ - T20.39x+ T20.60x+ - T20.79x+	Burns and corrosion of face, head, and neck, second or third degree
T21.20x+ - T21.39x+ T21.60x+ - T21.79x+	Burns and corrosion of trunk, second or third degree
T22.20x+ - T22.399+ T22.60x+ - T22.799	Burns and corrosion of shoulder and upper limb, except wrist and hand, second or third degree
T23.201+ - T23.399+ T23.601+ - T23.799+	Burns and corrosion of wrist(s) and hand(s), second or third degree
T24.201+ - T24.399+ T24.601+ - T24.799+	Burns and corrosion of lower limb(s), except ankle and foot, second or third degree
T25.211+ - T25.399+ T25.611+ - T25.799+	Burns and corrosion of ankle and foot, second or third degree
T81.83x+	Persistent postprocedural fistula
Numerous options	Burns and corrosion of multiple and unspecified body regions, second or third degree [Codes not listed due to expanded specificity]
Numerous options	Open wounds [Codes not listed due to expanded specificity]
ICD-10 codes not covered for indications listed in the CPB:
L08.9	Local infection of the skin and subcutaneous tissue, unspecified
L89.000 - L89.002, L89.009 - L89.012, L89.019 - L89.022, L89.029 - L89.102, L89.109 - L89.112, L89.119 - L89.122, L89.129 - L89.132, L89.139 - L89.142, L89.149 - L89.152, L89.159 - L89.202, L89.209 - L89.212, L89.219 - L89.222, L89.229 - L89.302, L89.309 - L89.312, L89.319 - L89.322, L89.329 - L89.42, L89.49 - L89.502, L89.509 - L89- 512, L89.519 - L89.522, L89.529 - L89.602, L89.609 - L89.612, L89.619 - L89.622, L89.629 - L89.812, L89.819 - L89.892, L89.899 - L89.92, L89.95	Pressure ulcer [stage I, II or unspecified]
L97.100 - L97.929	Non-pressure chronic ulcer [stage I, II or unspecified]
S02.0xx+ - S02.92x+, S12.000+ - S12.691+, S22.000+ - S22.9xx+, S32.000+ - S32.9xx+, S42.001+ - S42.92x+, S52.001+ - S52.009+, S62.001+ - S62.92x+, S72.001+ - S72.466+, S72.491+ - S72.92x+, S82.001+ - S82.156+, S82.191+ - S82.309+, S82.391+ - S82.66x+, S82.831+ - S82.839+, S92.001+ - S92.919+, S99.001+ - S99.299+	Open fractures [7th character B]
T20.00x+ - T20.19x+ T20.40x+ - T20.59x+	Burns and corrosion of face, head, and neck, unspecified or first degree
T21.00x+ - T21.19x+ T21.40x+ - T21.59x+	Burns and corrosion of trunk, unspecified degree or first degree
T22.00x+ - T22.199+ T22.40x+ - T22.599+	Burns and corrosion of shoulder and upper limb, except wrist and hand, unspecified degree or first degree
T23.001+ - T23.199+ T23.401+ - T23.599+	Burns and corrosion of wrist(s) and hand(s), unspecified degree or first degree
T24.001+ - T24.199+ T24.401+ - T24.599+	Burns and corrosion of lower limb(s), except ankle and foot, unspecified degree or first degree
T25.011+ - T25.199+ T25.411+ - T25.599+	Burns and corrosion of ankle and foot, unspecified degree or first degree
Numerous options	Superficial injury [Codes not listed due to expanded specificity]
Numerous options	Burns and corrosion of multiple and unspecified body regions, second or third degree [Codes not listed due to expanded specificity]
T80.0xxA - T88.9xxS	Complications of surgical and medical care, not elsewhere classified [surgical site infection]

The above policy is based on the following references: