J Wound Ostomy Continence Nurs. 2016;43(2):140-147.
Published by Lippincott Williams & Wilkins
WOUND CARE
Tap Water Versus Sterile Normal Saline
in Wound Swabbing
A Double-Blind Randomized Controlled Trial
Mun Che Chan  Kin Cheung  Polly Leung
■ ABSTRACT
PURPOSE: The use of tap water as a wound-cleansing
agent is becoming more common in clinical practice, es-
pecially 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 significant dif-
ference between the experimental and control groups in
the proportions of wound infection and wound healing.
CONCLUSIONS: Study findings 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
■ Introduction
Wound cleansing plays a vital role in wound manage-
ment.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 in-
tracellular fluid,1,3 as well as its sterile and noncytotoxic
140 J WOCN ■ March/April 2016 Copyright © 2016 by the Wound, Ostomy and Continence Nurses Society™
Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-14-00058_LR 140
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 colleagues1 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 con-
trolled 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 com-
munity settings (Australia); the other 5 were set in acci-
dent and emergency departments in Sweden and the
United States.5,8-12 The demand for wound care manage-
ment 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
 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 de-
sign. 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 man-
uscript. KC and PL supervised the study.
The authors declare no conflict of interest.
Correspondence: Kin Cheung, PhD, School of Nursing, The Hong
Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
(kin.cheung@polyu.edu.hk).
DOI: 10.1097/WON.0000000000000213
20/02/16 8:30 AM
 J WOCN ■ Volume 43/Number 2
water has been suggested as an effective cleansing agent
for lacerations, postoperative, and chronic wounds16; 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 ad-
dition, 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 individ-
uals. Use of tap water for wound cleansing in the commu-
nity setting is anticipated to augment self-management of
wounds at home. Hence, more evidence is needed to sup-
port 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 ad-
vocated in several recent nursing skills textbooks,18,19 and
it is commonly used in clinical practice. Swabbing in-
volves the use of a swab or gauze moistened with a cleans-
ing agent such as sterile saline or tap water. This technique
differs from wound irrigation where sterile saline or an-
other agent is used to flush the wound via application
under pressure.18,19 As there is currently no study to sup-
port or refute use of the swabbing technique to cleanse
wounds,16 there is a need to find 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 nor-
mal saline using a swabbing method.
■ Methods
In order to test this hypothesis, we conducted a double-
blind, 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 re-
ceive 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
Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-14-00058_LR 141
Chan et al 141
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 specific
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 (con-
trol 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 assign-
ment. 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 defined as an inva-
sion of bacteria into healthy tissues, followed by contin-
ued proliferation and a host reaction including erythema,
pain, swelling, persistent high-volume exudate, odor, and
delayed healing.22 We operationally defined a wound in-
fection as clinical signs and symptoms like erythema, pres-
ence of high volume of exudates and odor, and sensation
of increased pain by subjects. Wound healing was meas-
ured by the change in wound size and the presence of
epithelial tissues on the wound bed.5 Wounds were meas-
ured using a 1-cm flexible wound grid (Coloplast
Proprietary, Hong Kong), which is considered a standard-
ized 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 perpen-
dicular to the first 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 de-
termined after each home visit by the CNS nurses. Most
wounds were cleansed once daily. The CNS nurses fol-
lowed 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
20/02/16 8:30 AM
 142 Chan et al
cleansed by the CNS nurse. Wound size was measured
weekly.
Baseline data were extracted through the community-
based nursing system, which included sex, age, medica-
tion use, medical history, living arrangement, personal
hygiene, mental status, hydration status, attitude of care-
givers 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 system24), 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 heal-
ing.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 solu-
tions. One hundred milliliters of tap water from the CNS
water tap was aseptically collected into 100-mL sterile bot-
tles a day before wound cleansing. The hospital water tanks
are routinely washed and cleaned every 3 months accord-
ing 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 bacte-
rial counts for the tap water collected from the CNS were
performed 1 month before the study commenced, and ran-
domly (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 mi-
crobiological tests on the tap water used in wound cleans-
ing, 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 in-
side 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 collec-
tion relied on 2 forms, a wound documentation form and
a wound-cleansing form. Three wound care specialists
Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-14-00058_LR 142
J WOCN ■ March/April 2016
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 photo-
graphs of wounds in order to test the nurses’ understand-
ing of wound classifications, identification of amount of
wound exudates, granulating status, infection status, and
wound documentation techniques. The scale-level con-
tent validity index was 0.93.
After content validation procedures were completed,
the modified 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 modified forms.
Intraclass correlation coefficients 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 (indicat-
ing study variables were not normally distributed), non-
parametric 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 vari-
ables such as sex, medication use, comorbid conditions,
living environment, personal hygiene, mental status, at-
titude of the caregiver toward patients, wound type, stage,
location, wound infection, presence of epithelialization
and granulation, presence of inflamed periwound skin,
exudate volume (dichotomized as high vs low), and pres-
ence of severe wound pain.
■ Results
Seventy-one persons were identified as potential subjects,
and 30 were excluded based on a priori exclusion criteria.
Forty-one subjects were approached about study participa-
tion, and 27 agreed to participate. One patient was with-
drawn 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 in-
cluded in the study. Random allocation resulted in 11 sub-
jects (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 (con-
trol) group (Figure 1).
20/02/16 8:30 AM
 J WOCN ■ Volume 43/Number 2
FIGURE 1. Flowchart of sampling procedure.
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 aver-
age 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 influ-
ence wound healing such as recent acquired infections,
anemia, cardiovascular diseases, diabetes mellitus, or pe-
ripheral vascular disease. However, none received antibi-
otics or chemotherapy agents during data collection. No
significant differences between the experimental and con-
trol groups were found when analyzed based on demo-
graphic characteristics or living environment (Table 1).
Table 2 summarizes and compares wound characteris-
tics (type, location, stage, frequency dressing changes, ini-
tial 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
Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-14-00058_LR 143
Chan et al 143
located on the limbs, and 54.55% (n = 12) required cleans-
ing 2 to 3 times per week. Analysis revealed no significant
differences in baseline wound characteristics between the
experimental and control groups.
Table 3 compares wound infection and healing out-
comes of the experimental and control groups; no statisti-
cally significant 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 inflamed,
neither exhibited severe pain, high-volume exudate, or
malodor. In addition, 3 wounds (18.75%) within the ex-
perimental 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
20/02/16 8:30 AM
 144 Chan et al J WOCN ■ March/April 2016

TABLE 1.
Demographic and Living Environment of Study Sample
Groups
Experimental Control Total
(n = 16) (n = 14) (n = 30)
Variables n (%) n (%) n (%) Mann- Whitney U P Value
Sex
Male 10 (62.50) 11 (78.57) 21 (70) .44a
Female 6 (37.50) 3 (21.43) 9 (30)
Comorbid condition b

No 13 (81.25) 9 (64.29) 22 (73.33) .42a

Yes 3 (18.75)
c
5 (35.71)
d
8 (26.67)
Living arrangement
Home 8 (50.00) 2 (14.29) 10 (33.33) .06a
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) 1.00a
Smelly 1 (6.25) 1 (7.14) 2 (6.67)
Mental status
Normal 11 (68.75) 8 (57.14) 19 (63.33) .71a
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) .47a
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) 1.00a
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 Indexe 33.06 ± 30.54 45.64 ± 41.43 38.93 ± 35.95 88.50 .32
Abbreviation: SD, standard deviation.
aFisher exact test.
bComorbid condition likely to influence wound healing.
cAcquired infection, anemia, cardiovascular disease, diabetes mellitus, peripheral vascular disease.
dAcquired infection, anemia, diabetes mellitus, and peripheral vascular disease.
eAn 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.

nursing service when wounds were cleansed with sterile sa-
line versus tap water. The results of our study support find-
ings from a single community-based study set in Australia,5
as well as findings from 5 studies based in the acute care fa-
cilities in Sweden and the United States.8-12 Considered cu-
mulatively, findings 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 knowl-
edge, this is the first study to compare sterile saline with tap
water in an Asian country, and our findings serve as a foun-
dation 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 identified
in several intensive care units with critically ill and often
immunosuppressed patients, which was attributed to vari-
ous hospital-acquired infections.29,30 As a result, researchers

Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.

JWOCN-D-14-00058_LR 144 20/02/16 8:30 AM

 J WOCN ■ Volume 43/Number 2 Chan et al 145

TABLE 2.
Comparison of Wound Characteristics Between Experimental and Control Groups
Groups
Experimental Control Total
(n = 16) (n = 14) (n = 30)
Variables n (%) n (%) n (%) Mann-Whitney U P
Wound type
Chronica 12 (75.00) 7 (50.00) 19 (63.33) .26b
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) .06b
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) .47b
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, cm2 3.18 ± 4.83 1.89 ± 2.46 2.58 ± 3.90 109.00 .90
Abbreviation: SD, standard deviation.
aChronic wounds: pressure sores, leg ulcers.
bFisher exact test.
cAcute wounds: surgical wounds, trauma, and skin abscesses.

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 con-
taminate the water with bacteria,31 tap water outside the
hospital environment is considered to be relatively safer.
In addition, some bacterial pathogens such as methicillin-
resistant Staphylococcus aureus are less likely to survive out-
side the hospital environment.32
Best practice guidelines from the Joanna Briggs
Institute16 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 clean-
liness may influence patients’ and families’ willingness to
use it for wound cleansing. Nevertheless, studies based in
the United States and Germany found that patients pre-
ferred their wounds to be showered with tap water rather
than cleansed with sterile normal saline.6,35 In Germany, pa-
tients who were encouraged to shower their wounds post-
operatively 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, con-
sidered as one of the 5 basic elements in the physical uni-
verse, belongs to Yin, which represents cold.36 China has a
long history of boiling water prior to drinking based on hy-
gienic considerations.38,39 Therefore, we hypothesize that
Chinese patients and their families may perceive tap water
as being “cold,” weakening or blocking this energy flow
“Qi” and promoting illness. In addition, showering to
cleanse wounds is not a common practice in Asian coun-
tries, such as Hong Kong. We observed that only 27 (66%)
of the 41 eligible persons agreed to participate. The antici-
pated risk associated with use of tap water to cleanse an
open wound was cited by many of those who declined par-
ticipation. Understanding patients’ own cultural interpreta-
tion 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

Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.

JWOCN-D-14-00058_LR 145 20/02/16 8:30 AM

 146 Chan et al J WOCN ■ March/April 2016

TABLE 3.
Comparison of Outcome Variables (Wound Infection and Wound Healing) Between Experimental and Control
Groups
Groups
Experimental Control Total
(n = 16) (n = 14) (n = 30)
Variables n (%) n (%) n (%) P
Wound infection
Wound infection
Yes 2 (12.50) 0 (0.00) 2 (6.67) .49a
No 14 (87.50) 14 (100.00) 28 (93.33)
Inflamed surrounding skin
Yes 2 (12.50) 0 (0.00) 2 (6.67) .49a
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) 1.00a
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) .23a
No 13 (81.25) 14 (100.00) 27 (90.00)
Abbreviation: NA, not applicable.
a
Fisher exact test.

studies examining patients’ perceptions toward and experi-
ence 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 set-
tings and various countries.
■ Conclusions
We found no significant 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 ad-
vocate 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, Griffiths 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.

Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.

JWOCN-D-14-00058_LR 146 20/02/16 8:30 AM

 J WOCN ■ Volume 43/Number 2
3. Magson-Roberts S. Is tap water a safe alternative to normal sa-
line for wound cleansing? J Community Nurs. 2006;20(8):19-24.
4. Crestodina L, Fellows J. Home-prepared saline. A safe, cost-
effective alternative for wound cleansing in home care. J
WOCN. 2006;33(6):606-609.
5. Griffiths RD, Fernandez RS, Ussia CA. Is tap water a safe alter-
native to normal saline for wound irrigation in the community
setting? J Wound Care. 2001;10(10):407-411.
6. Neues C, Haas E. Modification of postoperative wound healing
by showering. Der Chir. 2000;71(2):234-236.
7. Riederer S, Inderbitzi R. Does a shower put postoperative
wound healing at risk? Der Chir. 1997;68(1):715-717.
8. Angeras MH, Brandberg A, Falk A, Seeman T. Comparison be-
tween sterile saline and tap water for the cleansing of acute
traumatic soft tissue wounds. Eur J Surg. 1992;158(6-7):
347-350.
9. Bansal BC, Wiebe RA, Perkins SD, Abramo TJ. Tap water for ir-
rigation of lacerations. Am J Emerg Med. 2002;20(5):
469-472.
10. Godinez FS, Grant-Levy TR, McGuirk TD, Letterle S, Eich M,
O’Malley GF. Comparison of normal saline vs tap water for ir-
rigation of minor lacerations in the emergency department.
Acad Emerg Med. 2002;19(5):396-397.
11. Moscati RM, Mayrose J, Reardon RE, Janicke DM, Jehle DV. A
multicentre comparison of tap water versus sterile saline for
wound irrigation. Acad Emerg Med. 2007;14:404-410.
12. Valente JH, Forti RJ, Freundlich LF, Zandieh SO, Crain EF.
Wound irrigation in children: saline solution or tap water? Ann
Emerg Med. 2003;41(5):609-616.
13. Hurd T, Posnett J, Zuiliani N. Evaluation of the impact of re-
structuring wound management practices in a community
care provider in Niagara, Canada. Int Wound J. 2008;5(2):
296-304.
14. Dobal M, Jacox A, Pieper B, Templin T. Home care nurses’ rat-
ings of the appropriateness of wound treatments and wound
healing. J WOCN. 2002;29:20-28.
15. Wong I. Measuring the incidence of lower limb ulceration in
the Chinese population in Hong Kong. J Wound Care.
2002;11(10):377-379.
16. The Joanna Briggs Institute. Solutions, techniques and pressure
in wound cleansing. Best Practice. 2006;10(2):1-4.
17. Milne CT, Corbett LQ, Dubuc DL. Wound, Ostomy and
Continence Nursing Secrets. Philadelphia, PA: Hanley & Belfus;
2003.
18. Berman A, Snyder S. Kozier & Erb’s Fundamentals of Nursing:
Concepts, Process and Practice. 9th ed. Boston: Pearson;
2012.
19. Lam WC, Shree DG, eds. Ngee Ann Nursing Series: Nursing Skills
(book 1). Singapore: McGraw Hill; 2008.
20. 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 institu-
tions and the domestic setting. J Infect. 2001;43:57-59.
22. Rolstad BS, Ovington LG, Harris A. Principles of wound man-
agement. In: Bryant RA, ed. Acute and Chronic Wounds: Nursing
Management. 2nd ed. St. Louis: Mosby; 2000:93.
Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-14-00058_LR 147
Chan et al 147
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 res-
ervoir 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 meticillin-
resistant Staphylococcus aureus acquisition: the case for hospital
cleaning. Lancet Infect Dis. 2008;8:101-113.
33. Fernandez R, Griffiths 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/
filemanager/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-hot-
water.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.
20/02/16 8:30 AM