Attachment 1 - NHS Airedale, Wharfedale and Craven Clinical

Wound Management Guidance and Formulary The 5 key messages the reader should note about this document are: 1. Wound care is estimated to cost the NHS around £3.1 billion per year (based on 2006 costs) and is rising year on year. 2. By selecting treatment that is appropriate to the cause and condition of the wound within a framework of holistic care, healthcare professionals will improve performance. 3. This guidance has been developed to maintain and enhance a standardised approach to wound care practice 4. Wound care practice needs to be clinically effective, cost effective and safe for the management of patients who have acute and chronic wounds. 5. All Bradford District Care Trust (BDCT) staff and those contracted to work within the Trust who manage wounds will work in accordance with the Wound Care Policy and Wound Management Guidelines and Formulary
1 Wound Management Guidelines and Formulary V7.2 This guidance has been approved. Circumstances may arise where staff become aware that changes in national policy or statutory guidance (e.g. National Institute for Clinical Excellence (NICE) guidance, Employment Law) may affect this guidance. It is the duty of the staff member concerned to ensure that the guidance author is made aware of this change so that the matter can be dealt with through the document review process. NOTE: All guidance remains extant until notification of an amended document via Global e­mail and posting on the intranet. Document details: Wound Management Guidance and Formulary Version: 7.1 Persons / committees consulted: Nursing Council Approved by: Professions Council Date approved: 21 December 2011 Ratified by: NA Date ratified: NA Title of originator / author: Lorraine Oxborough, Tissue Viability Service Manager Title of responsible committee / group (or Trust Board): Clinical Risk and Governance sub­committee Title of responsible Director: Cheryl Kirby Head of Adult Services (community) Date issued: 16 Jan 2012 Review date: 31 December 2013 Frequency of review: 2 years Target audience: All Bradford District Care Trust (BDCT) staff and those contracted to work within the Trust who manage wounds Responsible for dissemination: Lorraine Oxborough Copies available from: Where is previous copy archived (if applicable) Amendment Summary: BDCT Intranet NA Amendment detail: Amendment Page number Subject
2 Wound Management Guidelines and Formulary V7.2 CONTENTS C Section 1 Introduction Topic Page Number 4 2 Aims 4 3 Holistic Assessment 5 4 Wound Assessment 6 5 Wound Cleansing 6 6 Conservative Sharp Debridement 7 7 Wound Management/Dressing Selection Rationale 7 8 Single Use 7 9 Recording Information 8 10 Wound Continuums 8 11 Wound Dressing Quick Guide 9 12 How To Use Wound Continuums for Wound Assessment 10 13 Pressure Ulcer Damage 11 14 EPUAP Pressure Ulcer Classification System 12 15 Dressing Selection Flow Chart 13 16 Formulary – User Guide 14 17 Formulary Options 15 Dressing Packs; Tape; Skin Protective 15 Wound Contact Layer; Non/Low Adherent; Hydrogels; Films 16 Hydrocolloids; Hydrofiber; Alginates 17 Foams; Absorbent; Super Absorbent; Odour Control 18 Antimicrobials 19 18 Bandage Options; Emollients 21 19 Compression Hosiery Options 24 20 Appliances and Other Medical devises 25 21 Formulary High Cost Items 26 22 Formulary Specialist Product Only 27 23 1 st Dressing Pack for District Nurses 28 24 Drug Protocol for Skin Infections 30 25 References 31
3 Wound Management Guidelines and Formulary V7.2 Wound Management Guidelines and Formulary 1. Introduction This Wound Management Guidelines and Formulary supports the Wound Management Policy and has been devised by the Tissue Viability Team in consultation with community nurses, podiatrists and pharmacists. The contents are based on the best practice evidence at the time of publication. There are a wide range of products included in the formulary that will assist clinicians in making informed clinical management decisions appropriate for specific stages of wound healing. In exceptional circumstances where a suitable dressing cannot be found in the formulary further information and advice must be sought from the Tissue Viability Service. WOUND MANAGEMENT GUIDELINES 2. Aims The aims of these guidelines are to ensure that all patients with a wound have the following:
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Patient centred holistic assessment in relation to wound care
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Comprehensive and accurate wound assessment
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Rationale for wound management and treatment selection
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Documented evidence of patient advocacy
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Contemporaneous record of all interventions
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Review dates
4 Wound Management Guidelines and Formulary V7.2 3. Holistic assessment The healing process is complex and is affected by numerous general and local factors. It is essential to treat the whole person and not just the wound in isolation. Assessment should include; Full clinical history and physical examination detecting factors that may delay healing Medication, prescribed and over the counter e.g. Anti­inflammatory drugs (can suppress the preliminary inflammatory response), topical or systemic corticosteroids (can repress the immune system and decrease the multiplication of fibroblasts) Age, the skin’s resistance to injury reduces with the ageing process and cell replication is slower (Guo & DiPietro, 2010) Nutritional status, poor nutrition will have an adverse affect on wound healing Immune response, e.g. allergies to topical applications can delay healing Detailed visual examination, e.g. for signs of venous or arterial disease, skin damage from localised pressure Psychological status, stress and worry increases the production of hormones such as Glucocorticoids which can stem the inflammatory phase and slow down healing (Guo & DiPietro, 2010) Pain, a detailed pain history is integral to alleviating stress and anxiety and improving quality of life. This includes the patient’s perception of pain such as specificity, frequency, immediate or post dressing change, severity etc. Pain assessment should identify Nociceptive or Neuropathic pain or a combination of both
· Nociceptive pain is typically well localized, constant, and often with an aching or throbbing quality. It is often found in patients who have chronic wounds
· Neuropathic pain is the result of an injury or malfunction in the peripheral or central nervous system. Nerves can be infiltrated or compressed by scar tissue or inflamed by infection. The pain frequently has burning, lancing, or electric shock qualities. It is frequently of a chronic nature
· Combination of Nociceptive and Neuropathic pain is a nervous system dysfunction that triggers the neural release of inflammatory mediators and subsequent neurogenic inflammation Social factors, for example;
· Smoking as the effects of nicotine and carbon monoxide in cigarette smoke causes tissue hypoxia (Guo & DiPietro, 2010)
· Alcohol missuse can lead to delayed wound healing by impairing the early inflammatory response, inhibiting wound closure, angiogenesis, collagen production, and altering the protease balance at the wound site (Guo & DiPietro, 2010)
· Illicit drug abusers may become compromised by repeated intravenous vascular access and injection of toxic drug substances. This has devastating effects on the veins, skin, muscles, and joints of the lower extremities, thus increasing the risk of chronic venous disease and venous ulcers that tend to be multiple and large by the time wound care is sought (Williams & Southern 2005)
5 Wound Management Guidelines and Formulary V7.2 4. Wound Assessment To ensure optimum wound management and patient comfort is achieved, a holistic wound assessment should include; Aetiology (type), e.g. leg ulceration, diabetic foot ulcer, pressure ulcer, fungating, burn, laceration, post surgical Location, including number of wounds Size, including length, width, depth, position/extent of sinuses, undermining of surrounding skin. A photographic record and/or wound tracing must be undertaken. Exudate, including type, colour, approximate amount / extent of strike through on current wound management product, odour Wound bed, e.g. healthy granulation tissue, epithelialisation, slough, brown/black eschar Wound margins, e.g. increasing, decreasing, static, colour Surrounding skin, e.g. dry, eczematous, fragile, maceration oedema, colour, erythema, maceration Signs of Infection, e.g. suspected, confirmed and details of any swab results Pain, wound related, at dressing or post dressing change, Neuropathic or Nociceptive or combination of both 5. Wound Cleansing The aim of wound cleansing is to remove gross contamination with minimal pain and tissue trauma. NICE guidelines for the prevention and treatment of surgical site infection state that sterile saline should be used for wound cleansing up to 48 hours after surgery, after which tap water should be used (NICE 2008) Tap water is therefore mostly used in the community for cleansing wounds. It is easily accessible, efficient and cost effective. Where tap water is of high quality (drinkable), it is as good as other methods such as sterile water or saline and more cost­effective (Fernandez & Griffiths 2008). The fluid should be close to body temperature. The use of liners in bowls or buckets reduces the risk of cross infection. Wounds should only be cleansed to;
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Remove excess exudate
Remove slough and / or necrotic tissue
Remove remnants of previous dressing products
Facilitate accurate assessment of the wound
Promote patient comfort
6 Wound Management Guidelines and Formulary V7.2 6. Conservative Sharp Debridement Conservative sharp debridement is defined as the removal of dead tissue with a scalpel above the level of viable tissue and is identified as a high risk clinical procedure. This procedure will only be undertaken by skilled and competent Tissue Viability Nurses (TVN) or Podiatrist. TVN or Podiatrist carrying out sharp debridement will have completed a validated educational programme in the subject. Dead tissue in the form of slough and necrosis can, if present in a wound, delay healing and promote infection. Debridement describes any method by which such materials are removed and as a consequence the potential to achieve wound healing enhanced. Debridement can be achieved either through the use of wound care products (including Larvae) or by conservative sharp debridement. If conservative sharp debridement is necessary referral must be made to the relevant professional (Haycocks & Chadwick, 2008). 7. Wound management / dressing selection To optimise healing a moist wound environment is desirable. This encourages the breakdown of fibrin and dead tissue, promotes the interaction of growth factors that stimulates healing and prevents tissue dehydration. However, where ischaemic or thrombolytic aetiology is suspected it is essential that the area is kept dry. Dressing selection should include the following characteristics;
· Maintenance of a moist environment (where appropriate)
· Controlled exudate management
· Allow gaseous exchange
· Provide thermal insulation
· Non adherent to wound bed
· Be non­allergic and non­sensitising
· Impermeable to micro­organisms
· Comfortable and conforming
· Acceptable to the patient
· Cost effective 8. Single – Use A device (dressing products, bandages, scissors, forceps etc) designated for ‘single­ use’ must not, under any circumstances be reused. It should only be used on an individual patient during a single procedure and then discarded. It is not intended to be reprocessed and used again, even on the same patient. The symbol below is used on medical device packaging indicating ‘do not reuse’ and may replace any wording (MHRA 2006).
7 Wound Management Guidelines and Formulary V7.2 9. Recording Information It is a legal requirement that all interventions are fully documented in the patient’s treatment record. The organisations Wound Management Chart hard copy and/or electronic patient clinical system should be used to record all information. 10. Wound Continuums Clinicians are encouraged to use the wound continuums to assess, document and evaluate the treatment in a common language. The Wound Healing Continuum The wound healing continuum is an aid to understanding the type of tissue present in the wound and how it should progress. The continuum helps to identify colour changes of the wound from black to pink; it correlates with the healing stages. The Wound Infection Continuum This wound infection continuum is a simple sliding scale to aid clinical decision­making regarding the level of bacterial colonisation of a wound. The Protocol for the selection of systemic antimicrobials for the treatment of common infections in adults can be found on page 24 of this document.
8 Wound Management Guidelines and Formulary V7.2 11 . W WO OU UN ND D D DR RE ES SS SI IN NG G G GU UI ID DE EL LI IN NE ES S 1 1. HEALING INFECTION EXUDATE Hi Moisture/exudate descriptors Necrotic Sloughy Granular Epithelial *Spreading Local Critically Colonised Infection Infection Colonised SI AIM Attain 100% ‘Epithelial’ tissue OBJECTIVE Remove Necrotic and/or Sloughy Tissue * Promote Granulation and Epithelial tissue TREATMENT Autolysis or re­ hydration Use dressing to promote a moist wound healing. NECROTIC (Dry)* FOAMS HYDROGEL HYDROCOLLOID ALGINATE HYDROCOLLOID FILM SLOUGHY (Moist/wet) LOW ADHERENT (Leg ulcers) HONEY CC Attain a healthy bacterial wound bed Treat infection Treat infection Reduce bacterial levels Attain moist wound environment Maintain bacterial levels Manage exudate Highly absorptive products Use systemic antibiotic on Spreading Infection (see page 28) ANTIMICROBIAL ­ Silver Dressings ­ Iodine Dressings ­ Honey 0 – 8) Col SUPER ABSORBANT ALGINATE No antimicrobial required HONEY LI Leaking:Exudate not contained by dressing Wet: Exudate contained but dressing saturated Moist: Exudate at optimum levels Dry: Insufficient moisture at wound bed HYDROFIBRE Moderately exudate absorption FOAM Low exudate absorption LOW ADHERENT ALGINATE HYDROCOLLOID HYDROFIBRE FOAM NON ADHERENT (if required) HYDROCOLLOID ALGINATE CADEXOMER IODINE Skin protecting creams/ lotions to surrounding skin may be required to prevent maceration * Please note in some cases it may not be appropriate to re­hydrate necrosis. In such cases Inadine may be the most appropriate product
9 Wound Management Guidelines and Formulary V7.2 12 . H HO OW W T TO O U US SE E T TH HE E C CO ON NT TI IN NU UU UM MS S F FO OR R W WO OU UN ND D A AS SS SE ES SS SM ME EN NT T 1 2. STEP ONE – The Wound Healing Continuum
This is an aid to understanding the type of tissue present in the wound and how it
should progress. Thought of as a continuum of colour changes (See diagram 1) from black to pink, it correlates with the healing stages of the wound. Not all wounds progress across the whole spectrum e.g. not all wounds will have a black stage.
Di ag gr ra am m 1 1 ­ ­ T Th he e W Wo ou un nd d H He ea al li in ng g C Co on nt ti in nu uu um m D ia BL AC CK K B LA BL AC CK K /Y EL LL LO OW W B LA / YE YE LL LO OW W Y EL YE LL LO OW W / /R RE ED D Y EL RE D R ED RE D /P IN NK K R ED / PI PI NK K P IN Di ag gr ra am m 2 2 ­ ­ T Th he e W Wo ou un nd d I In nf fe ec ct ti io on n C Co on nt ti in nu uu um m D ia USING THE WOUND HEALING CONTINUUM Identify the colour of the wound that is furthest to the left of the continuum. For example, if the wound contains yellow slough and red granulating tissue it would be defined as a yellow/red wound. The management plan would focus on the removal of the yellow, sloughy tissue and promotion of red granulation tissue. As this objective is achieved, the patient can progress along the wound healing continuum towards the right and therefore a pink / healing status.
STEP TWO – The Wound Infection Continuum There are four criteria which work from left to right with the most severe, “Spreading Wound Infection” on the left (Diagram 2). The continuum moves right, through “Local Infection”, “Critical Colonisation”, to “Colonisation.”
USING THE WOUND INFECTION CONTINUUM
Spreading Infection Local Infection Critically Colonised 3 2 1 Colonised 0
This Wound Infection Continuum is a simple sliding scale to aid clinical decision­making regarding the level of bacterial colonisation of a wound. A patient may never move to the furthest point on the right (Colonised) on the continuum during their entire treatment. However, lower bacterial levels found in colonised wounds generally lead to better healing. The status of a wound, which has Spreading Infection, Localised Infection or is Critically Colonised, should be considered when developing a treatment plan.
Spreading infection can be a life threatening condition. Local signs & symptoms associated with a spreading soft tissue infection includes; spreading redness (>2cm around wound margin), very high exudate levels, pain, malodour, heat in the surrounding tissues & blistering.
Localised infection is characterised by <2cm of redness around the wound margin, symptoms similar to spreading infection may also be present but to a lesser degree.
Critical colonisation is characterised by delayed healing, malodour & raised exudate levels, (slough may also be present). However, the wound will not present as if locally infected.
A Colonised wound is the normal healing state of a wound. A reduction in wound size over a two­week period would suggest an acceptable level of colonisation. 10 Wound Management Guidelines and Formulary V7.2 13. Pressure Ulcer Damage European Pressure Ulcer Advisory Panel (EPUAP) 2009 Pressure Ulcer Definition is; A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Assessment and Treatment includes
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Removing the cause i.e. pressure and shear
Assessing the extent of the tissue damage, the state of the wound bed, the level of bacterial load, the condition of the surrounding skin and the perfusion of the wound area
Deciding on treatment objectives for the wound
Where appropriate create a healing environment at the wound surface by: o Debriding dead tissue/slough o Reducing undermining o Identifying and treating infection o Reducing contamination by faeces or urine o Supporting healthy granulation tissue
Improve the patients general condition including their nutritional status
Managing pain and psychological stress The following EPUAP pressure ulcer classification system should be used in conjunction with the Maelor risk assessment tool as part of a holistic assessment, as described in the pressure ulcer prevention & management policy (Vowden 2010) Please note, grading only applies to Pressure Damage and should not be used to describe other types of wounds
Wound Management Guidelines and Formulary V7.2 11 14. (2009) EPUAP Pressure Ulcer Classification System (Vowden K (2010) Pressure Ulcer Prevention & Management Policy, Bradford Teaching Hospital; Bradford & Airedale NHS; Bradford & Airedale Community Health Services)
Wound Management Guidelines and Formulary V7.2 12 15. DRESSING SELECTION FLOW CHART The following dressing selection flow chart can be used as a guide to help clinicians select a type of dressing. The list of formulary products will then guide the clinician to specific brands of product. Dressing Selection Flow Chart Assessment Necrotic Tissue Black wounds Goal Yes Action Plan Hydrocolloid Hydrogel Cadexomer Iodine Sharp Debridement (TVN or Podiatry only) Debride (If unsure of arterial status keep dry as below) No Mummify/ Keep dry Sloughy Tissue Green & yellow wounds Yes No Deslough Granulation Tissue Red & pink wounds No Yes Promote healing Healing Wound Pink Epithelialisation No Non healing Wound •Look for possible cause of non healing e.g. patient or wound factors •Refer to Tissue Viability Service for advice and/or assessment Low exudate; Povidone Iodine High exudate Cadexomer Iodine (Avoid foams if aim is to keep dry) Low exudate; Hydrocolloid Hydrogel Maggots High exudate; Hydrofiber Alginate Foam Maggots Low exudate; Hydrocolloid Hydrogel Film Low Adherent Wound contact High exudate; Hydrofiber Alginate Foam No Infection resolved/wound healing Infection – attain a healthy bacterial wound bed Antimicrobial Products (use for 14 days & reassess); Silver, Honey, Cadexomer Iodine (use beyond 14 days to be discussed with TVN) Systemic antibiotics for spreading infection (see page 28)
FORMULARY PRODUCTS Wound Management Guidelines and Formulary V7.2 Yes Stop antimicrobial – review 13 16. FORMULARY USER GUIDE All products listed are available on Prescription unless indicated. * indicates items only available from NHS Supplies or direct from manufacturers. The following rating is a cost code system for products within the recommended product groupings; Green, is for ‘go’ and are products that should be considered first Amber, is for ‘caution’ and are products that can be considered but are more costly than green Red, is for ‘stop and think’ and are high cost items compared to the amber or green group G Green indicates items that are comparable in cost within their product group A Amber indicates items that are more costly than the comparisons in the green product group R
Red indicates items that are more costly than the comparisons in the green or amber product group Wound Management Guidelines and Formulary V7.2 14 17. FORMULARY OPTIONS Recommended Product Group Dressing Packs Polyfield Nitrile Patient Pack Small gloves Medium gloves Large gloves State size of gloves required Softdrape Small, Medium or Large gloves State size of gloves required *Only available through NHS supplies Gauze Swabs Sterile pack 5 x 4ply swabs To be used to cleanse wounds or as alternative to dressing pack Wound Measurement Grids Wound Care Grid (Coloplast) Box of 50 *Only available through NHS Supplies Tape Clinipore Range Paper based – suitable for sensitive skin & long term use Cost code Alternative Product Cost code G Dress­it Small/med gloves Med/large gloves State size of gloves required G Mefix Range Fabric based – suitable for securing dressings, catheters, cannulae A G G G G Skin Protective Cavilon No sting barrier Film A Range To be used as barrier against body fluids (e.g. urine, faeces) or adhesives. Protects for up to 72 hours. Can be used on broken skin. Use for 2 weeks & reassess. Cavilon Durable Barrier Cream A Range To be used as barrier against irritation from body fluids & prevention of skin damage. Daily or every 3 rd wash. Not for use on broken skin. Use for 2 weeks & reassess. Medihoney Barrier Cream Range A
Silicone based containing Medihoney Antibacterial Honey. Helps prevent maceration & excoriation around wounds, skin folds, and pressure areas. Apply as required. Protects against body fluid (incontinence) & maintain skin pH. Use for 2 weeks & reassess Wound Management Guidelines and Formulary V7.2 15 Recommended Product Group Wound Contact Layers Softpore Range Self­adhesive absorbent perforated plastic film faced dressing for low to moderately exuding wounds Non to Low Adherent Atrauman Range Non­Adherent polyester mesh wound contact layer impregnated with neutral triglycerides. Effective for up to 7 days Adaptic Touch Range Non­adhering silicone dressing, flexible open mesh wound contact layer. Cost code Alternative Product Cost code G Mepore Range Self­adhesive dressing for low to moderately exuding wounds A G A Mepitel Range Mepitel – soft silicone wound contact layer May be considered as long as the intention is not to remove within 7 days Urgotul Range Urgotul – Polyester mesh impregnated with hydrocolloid and petroleum jelly particles R R Hydrogels Intrasite Gel Range G Amorphous Hydrogel partially hydrated to donate moisture. For low to moderately exuding wounds shallow, deep and excoriated skin Intrasite Conformable Range G Non woven dressing impregnated with Amorphous Hydrogel partially hydrated to donate moisture. For low to moderately exuding wounds shallow, deep and excoriated skin Actiform Cool Range A Ionic Hydrogel sheet that will donate or absorb fluid. For low to high exuding wounds and to help manage Nociceptive wound pain Films C­View Range G Transparent vapour permeable dressing for non or lightly exuding superficial epithelialising and minor wounds Wound Management Guidelines and Formulary V7.2 Tegaderm Film Range A
Transparent vapour permeable dressing for non or lightly exuding superficial epithelialising and minor wounds 16 Recommended Product Group Tegaderm with Absorbent Pad Range Vapour­permeable adhesive film with absorbent pad IV3000 Range Film dressing for IV/subcutaneous therapy sites Hydrocolloids Hydrocoll Thin Range Thin, transparent gelatine­free hydrocolloid sheet with vapour permeable film backing Cost code G Cost code G G Tegaderm Thin Range Very thin adhesive Hydrocolloid with film backing layer. For low to moderately exuding wounds A Comfeel Plus Range Hydrocolloid with vapour permeable film backing. Gelatine­ free. Shaped for use on difficult areas. For low exudating wounds G Hydrofiber Aquacel Range G Non­woven pad or ribbon dressing composed of sodium carboxymethylcellulose. Has extra absorbent properties and transforms to a soft gel Alginates Sorbsan Range G Calcium alginate fibre non woven highly absorbent for moderate to heavy exuding wounds. Not suitable for dry or necrotic wounds. Urgosorb Range Highly absorbent dressing composed of G type calcium alginate fires and hydrocolloid particles. Gels and swells in contact with exudate. Promotes haemostasis Alternative Product Granuflex Range A Adhesive Hydrocolloid with an outer polyurethane foam layer. For low to moderately exuding wounds DuoDerm Extra Thin A Range Thin adhesive Hydrocolloid dressing. For dry to low exuding wounds Tegaderm A Hydrocolloid Range Adhesive Hydrocolloid with film backing layer. Highly absorbent for moderate to heavily exuding wounds Kaltostat Range A Calcium sodium alginate fibre dressing for moderate to heavily exuding wounds. Promotes haemostasis. A
Wound Management Guidelines and Formulary V7.2 17 Recommended Product Group Cost code Foams Adhesive and Non­adhesive Tegaderm Foam Range G Polyurethane foam dressing with semi­permeable film backing layer for low to moderate exuding wounds Biatain Range G Absorbent foam dressing, vapour­ permeable film backing. Allevyn Gentle Range G Hydrocellular foam pad between a perforated soft silicone adhesive wound contact layer Absorbent Dressings Zetuvit E Range G Absorbent cellulose dressing with fluid repellent backing. For moderate to heavily exuding wounds. Can be used under compression. Super Absorbent Dressings Zetuvit Plus range G Super absorbent wound dressing pad for the treatment of superficial, heavily exuding wounds. Can be used under compression. Kerramax range Super absorbent polyacrylate primary dressing for management of heavily exuding leg ulcers. A Alternative Product Cost code Tielle Range G Hydropolymer foam island dressing with vapour­permeable film backing. Mepilex Range A Absorbent foam with soft silicone contact layer and film backing Lyofoam Range G Polyurethane foam dressing Sorbion sachet range R Highly absorbent hydro active dressing with hypoallergenic polypropylene outer sheath and internal cellulose mat. Can be used under compression Flivasorb Range A Super absorbent wound dressing with non­ adherent contact layer. Suitable for heavily exuding wounds e.g. lymphorrhea. Can be used under compression Odour Control Clinisorb Range G Activate charcoal cloth between layers of nylon/viscose rayon. Use as secondary dressing. Exudate will reduce dressing effectiveness. Suitable for malodorous wounds. Carboflex Range A
Non­adhesive primary dressing with absorbent wound contact layer, activated charcoal central pad and a water resistant top layer Suitable for malodorous wounds Wound Management Guidelines and Formulary V7.2 18 Recommended Product Group Antimicrobials Aquacel Ag Range Non­woven pad or ribbon dressing composed of sodium carboxymethylcellulose containing 1.2% ionic silver. Has extra absorbent properties and transforms to a soft gel. Use as primary dressing for moderate to highly exuding wounds where there is infection or increased risk of infection. Use for 2 weeks and reassess. Silvercel non­adherent range Silver alginate inner layer which releases silver ions into wound fluid and a non­adherent outer layer. Use as primary dressing for moderate to heavily exuding wounds where there is infection or increased risk of infection. Use for limited period of time. Use for 2 weeks and reassess. Inadine Range Non­adherent dressing impregnated with 10% povidone iodine. Only use for management of minor traumatic skin injuries and mummification of wounds such as diabetic foot wounds. Medihoney Range Standardised antibacterial honey dressing Cost code Alternative Product Cost code G G G G
Medihoney tube; standardised medical grade honey ­ single patient use tube Medihoney Wound Gel; standardised medical grade honey with combined waxes and oils – single patient use tube Tube and wound gel products are for sloughy, infected, malodorous wounds, leg/foot ulcers. Wound Management Guidelines and Formulary V7.2 19 Recommended Product Group Medihoney Apinate; contains calcium alginate Medihoney Gel Sheet; contains sodium alginate Medihoney Tulle Dressing; non­ adherent impregnated dressing. Cost code A Alternative Product Cost code Above products for acute and chronic wounds, sloughy, infected, malodorous wounds, leg/foot ulcer Cutimed Sorbact Swab Range G
Hydrophobic antimicrobial wound contact swabs. Impregnated with dialkylcarbamoyl chloride. Designed to bind bacterial under moist wound conditions. Caution: Do not use in combination with ointments and creams as action is impaired. For chronic and acute wounds that are critically colonised or infected. Wound Management Guidelines and Formulary V7.2 20 18. BANDAGE OPTIONS Compression bandage classification and use All bandages must be applied in accordance with manufactures instructions e.g. spiral, figure of eight etc Long Stretch multi­layer bandaging is a compression bandaging system (sub­ bandage pressure 35­40mmHg at the ankle) that incorporates elastic layers to achieve a sustained level of compression over time and not suitable for patients with chronic oedema (sustained pressure significantly reduces lymphatic refill). Long Stretch Multi­layer generally consists of:­
· 3a Light compression provide up to 20 mmHg at the ankle
· 3c High compression provide up to 40 mmHg at the ankle. Useful for bigger limbs and more active patients E.g. Layer 1. Wadding or Undercast padding Layer 2. Retention bandage Layer 3. Compression bandage class 3a or 3c depending on ankle size Layer 4. Cohesive compression bandage class 3a Short stretch Have limited extendibility and must be applied over wadding or undercast padding Two layer systems Comprising of an inner layer and outer compressive layer (SIGN 2010) Short stretch multi­layer bandage for Chronic Oedema exerts high pressure peaks intermittently during walking and a low resting pressure. These pressure variations allow the lymph vessels to fill and thus facilitate lymph flow. (Foldi, Junger, Partsch 2005) Short stretch multi­layer generally consists of:­
· 8cm cohesive cotton bandage toe to ankle – multi­layer to achieve the desired pressure
· 10cm cohesive cotton bandage ankle to knee­ multi­layer to achieve the desired pressure
· 12cm cohesive cotton bandage knee to mid or high thigh (as required) ­ multi­layer to achieve the desired pressure E.g. Toe bandages if toes are swollen (conforming bandage) Layer 1. Wadding or Undercast padding as many as required to equalise the pressure, reshape the limb, fill hollows etc over the entire bandage area Layer 2. Cohesive short stretch bandages 8cm and10cm, plus 12cm if thigh length is required. All applied multi­layered to achieve the desired pressure. N.B It is recommended that stockinette is applied to the limb prior to application of any wadding or undercast padding to promote comfort and help prevent skin irritation
Wound Management Guidelines and Formulary V7.2 21 Recommended Product Group Tubular bandages Comfifast range Elasticated viscose stockinette for dressing retention Cost code Alternative Product Cost code G Clinifast range Elasticated viscose stockinette for dressing retention G Mölnlycke ribbed stockinette G 100% unbleached cotton, natural rubber latex free. Suitable for use as an undercast or under bandage stockinette. Bandage Wadding & Undercast Padding Cellona Range G K­Soft Range Padding layer for under Compression sub compression bandage wadding Light Weight conforming bandage Mollelast Range G e.g. 4cm x 4m size for chronic oedema toe bandaging K­Band Range Viscose/nylon retention bandage Retention bandages K­Lite Type 2 light support 10cm x 4.5m, 10cm x 5.25m G Actiwrap Range e.g. 6cm x 4m size for chronic oedema toe bandaging A Profore #2 Type 2 light support A G G Elastic compression bandages and kit components K­Plus 10cm x 8.7m Profore A K­Plus long 10cm x 10.25 G #1 ­ Sub compression 3a compression bandage wadding Ko­Flex 10cm x 6m #2 ­ Type 2 light support #3 ­ 3a compression 3a cohesive compression K­Three C #4 ­ 3a cohesive 3c high compression bandage for compression ankles greater than 25cm Latex free elastic compression bandages and kit components Ultra Four G Profore Latex Free #1 Ultra Soft ­ Sub compression #1, #2, #3, #4 bandage wadding (as for Profore above) #2 Ultra lite ­ Type 2 light support #3 Ultra Plus ­ 3a compression #4 Ultra Fast ­ 3a cohesive compression Short Stretch Inelastic compression bandages Actico Cohesive short stretch cotton bandages suitable for venous leg ulceration and chronic oedema 8cm x 6m 10cm x 6m 12cm x 6m A G
Wound Management Guidelines and Formulary V7.2 22 Recommended Cost code Alternative Cost code Product Group Product 2 layer compression Systems K Two system Range G Coban system A Composite 1 st layer compressive Latex free foam padding fabric & 2 nd layer cohesive elastic layer & cohesive bandage (approx 40mmHg at compression bandage ankle) Emollients (All can be used as soap substitutes) Emulsifying Ointment 500g G Hydromol Ointment A Epaderm Cream A Hydromol Cream R Double base Gel A Epaderm Ointment A Diprobase Ointment A Diprobase Cream A
Wound Management Guidelines and Formulary V7.2 23 19. COMPRESSION HOSIERY OPTIONS Compression hosiery classification and use Compression hosiery is available in different sizes, lengths and compression classifications. Legs must be measured in accordance with each manufacturers own guide. Ready made and made to measure is available in all classifications. It should be noted that there is a difference of compression between:
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Circular knit (2 way stretch) are suitable for patients with no or minimal oedema and limb shape distortion
Flat knit made to measure (1 way stretch) are suitable for patients with minimal to gross chronic limb oedema / distortion and/or rebound oedema as the hosiery does not curl, twist or tourniquet (Doherty Morgan & Moffatt 2006)
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British standards – circular knit only for patients without limb oedema (garment life span 12 weeks)
European standards – circular knit and flat knit for patients with limb oedema (garment life span 24 weeks) (Johnson 2002)
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Two layer hosiery kits comprising of a liner and outer stocking when combined give 40mmHg compression or worn as separate components are available in British and European classifications (SIGN 2010) Compression Class Class 1 Class 2 Class 3 Class 4 British Classification European Classification For Patients without oedema For Patients with oedema 14 – 17 mmHg 18 – 24 mmHg 25 – 35 mmHg Not available 18 – 21 mmHg 23 – 32 mmHg 34 – 46 mmHg 49 – 70 mmHg When considering the type of compression to use, practitioners should take into account:
· Practitioner level of expertise and knowledge of products available
· Hosiery that meets clinical needs that is, patients should be offered the strongest compression that maintains concordance (SIGN 2010)
· Patient preference, lifestyle and likely concordance
· Required frequency of application e.g. ability to don on and off
· Size and shape of leg (if ready made or made to measure is required)
· Chronic Oedema, defined as long standing oedema of greater than 3 months duration must be treated with European circular or flat knit hosiey dependant on limb distortion
· Latex allergy (Latex free hosiery is available)
· Quality of product and cost comparisons
Wound Management Guidelines and Formulary V7.2 24 20. APPLIANCES AND OTHER MEDICAL DEVICES Exudate Management Eakin wound pouch Range Wound drainage system consisting of hydrocolloid adhesive and drainage bag. Available with fold and tuck closure, or tubing outlet with bung for connection to remote drainage. Available in different sizes, small medium and large fold & tuck (10), small, medium and large bung (10) All purpose boot Kerraped All purpose boot that keeps dressings and toes clean and dry. Available in a range of sizes to accommodate bulky dressings and bandages. Dressing protection Limbo Range Transparent limb­shaped plastic cover with flexible seal at the opening. Used to keep leg or foot dressings dry during bathing or showering. Seal­Tight Range Waterproof dressing protector, latex free, can be fully submerged. Used to keep leg or foot dressings dry during bathing or showering. Redistribution pressure product Aderma dermal pad range Polymer gel material that redistributes pressure whilst protecting and padding bony prominences. Formulated to the constituency of fatty tissue, available in squares, strips, heel shape and sacrum shape. Washable and single patient multi­use. For use over intact skin only. Active debridement pad Debrisoft Soft and flexible fleecy pad that binds to debris, locking it into the fibres. It removes wound debris, necrotic material, slough, exudate and long standing hyperkeratotic tissue from surrounding skin. Dermasilk Undersocks Silk garment for use in the management of contact dermatitis.
Wound Management Guidelines and Formulary V7.2 25 21. HIGH COST ITEMS The following items should only be used following discussion with a Tissue Viability Nurse. Use of these products is intensely monitored Flamazine Broad spectrum white hydrophilic antibacterial cream containing Silver Sulfadiazine 1% in an oil and water base. Effective topical antimicrobial active against most strains of gram positive and gram negative bacteria. Prontosan Solution Wound irrigation solution containing Betaine which is a gentle effective surfactant which penetrates disturbs and removes bio­film and wound debris, and Polyhexamethylene Biguanide (PHMB) to help control bacterial levels on the wound. Suprasorb X + PHMB Biocellulose dressing pad impregnated with broad spectrum antimicrobial (PHMB) designed to regulate absorption and re­hydration of moisture. For use on light to moderately exuding critically colonised and infected wounds. Acticoat, Acticoat Flex and Acticoat Absorbent range Acticoat; Antimicrobial dressing with absorbent rayon/polyester core between 2 layers of nanocrystalline sliver­coated, low adherent polyethylene net. Acticoat Flex Antimicrobial barrier with flexible, low adherent polyester layer coated with nanocrystalline silver. Acticoat Absorbent; Calcium alginate fibre coated on other surfaces with nanocrystalline silver. Combines the absorbency of alginates with the antimicrobial properties of silver. Polymem Range Polyurethane foam containing a non­ionic surfactant which is activated by moisture and claimed to facilitate wound cleansing, a humectant (glycerol) which prevents the dressing drying out and adhering to the wound bed, and a starch copolymer to enhance the fluid handling properties of the foam. Also available with silver. Promogram Range Promogram; Composite of oxidised regenerated cellulose and collagen. Inactivates proteases and protects grow factors. Can be used under compression. Promogram Prisma; Composite of oxidised regenerated cellulose, collagen and silver. Inactivates proteases and protects grow factors. Can be used under compression. Urgo Start Range; Non­adherent non­occlusive contact layer derived from LipidoColliod technology. Composed of polyester mesh impregnated with hydrocolloid and petroleum jelly and Nano­Oligosaccharides Factor particles to promote faster healing in chronic wounds. Use for minimum of 4 weeks to see benefits. Advadraw Capillary­action dressing. Absorbent non­adherent dressing with rapid wicking effect. Fluid from the wound bed is rapidly absorbed into the dressing and retained within the absorbent central layer Iodoflex Cadexomer iodine dressing with iodine for the treatment of chronic exuding wounds. Contains 0.9% povidone iodine. N.B Discussion with TVN is only necessary for this product where use extends beyond 2 weeks
Wound Management Guidelines and Formulary V7.2 26 22. SPECIALIST PRODUCTS The following products can ONLY be commenced by Podiatry or following referral to a Tissue Viability Nurse. Negative Pressure Wound Therapy Negative Pressure Wound Therapy (NPWT) is a mechanical wound care treatment that uses controlled negative pressure to assist and accelerate wound healing. Wounds that may benefit from NPWT include; partial / full thickness pressure ulcers, dehisced surgical wounds, diabetic / Neuropathic ulcers, venous leg ulcers, post­surgical wounds. Larvae (LarvE) Sterile larvae of ‘Lucilia Sericata’ suitable for debridement of sloughy and wet necrotic wounds. (Biomonde Clinical Helpline 08452306806)
Wound Management Guidelines and Formulary V7.2 27 23. 1 st DRESSING PACK FOR DISTRICT NURSE TEAMS The pack is designed to provide District Nurses with access to a legal and safe emergency supply of wound care products for use on initial assessment of a patient. The patient would then obtain future wound care supplies on prescription, as assessed by the District Nurse with reference to the BDCT Wound Management Guidance and Formulary 2011. The first dressing pack has been reviewed against;
·
·
·
·
current best practice
Pact data of items currently prescribed by District Nurses
District Nurses opinions
The BDCT Wound Management Guidance and Formulary 2011 HOW DOES IT WORK? Each member of the District Nurse Team will have a reseal able plastic bag or wallet which will contain the items listed below: 2 x Cellona 2 x K­Lite 10 x Atrauman 5 x Biatain Silicone 10 x Softpore 1 x Clinipore
When visiting a new patient with a wound the nurse uses the most suitable items from the pack and then generates a prescription for further wound care products in accordance with the wound assessment. The pack is then replenished from stock held at the District Nurse base. Please find order codes for the 1 st dressing pack products on the following page. Note that Biatain is ordered direct from the manufacturer via online ordering system. It is stressed that the pack is intended for the first dressing only, after which the patient should be prescribed the most appropriate product in accordance with the Wound Management Guidance and Formulary. Wound Management Guidelines and Formulary V7.2 28 REQUISITION FORM From: __________________ Requisition number Date: ______________ DESCRIPTION Cellona 10cm (wadding /padding) Logistics Catalogue No. EPA 035 Cost Volume in 1 Unit of Issue Units Required 24.18 BOX OF 48 K­lite 10cm (retention bandage) ECA 100 11.53 Pack of 16 Clinipore tape 2.5 cm (paper based tape) EHU 020 3.06 Pack of 12 Atrauman 10cmx7.5cm (wound contact layer) EKA 032 8.67 Pack of 50 ** Pack of 10 **Biatain Silicone 10cm x 10cm (moist low­moderate exuding wounds) **This product is obtained via Coloplast online ordering system only Aquacel 5cm x 5cm (high exuding wounds) ELY 014 Pack of 10 9.66 Softpore 10cmx10cm covering) Pack of 50 3.80 (post­op wound EIJ013 N.B. For high exuding wounds use for example; Surgipads (from D.N. stores) or Cellona and k­lite with wound contact layer ALL DRESSING ITEMS OTHER THAN THE ABOVE MUST BE PRESCRIBED Reseal­able polythene bags MVH005 Pack of 100 3.94 Single use scissors 13cm straight blunt/sharp yellow handled FGP170 15 3.49
Requested By: ________________ Authorised By: __________________ Wound Management Guidelines and Formulary V7.2 29 24. DRUG PROTOCOL FOR SKIN INFECTIONS SELECTION of ANTIMICROBIALS for TREATMENT of COMMON SKIN INFECTIONS in ADULTS INFECTION COMMENTS DRUG DURATION OF TREATMENT Cellulitis / soft Strep pyogenes, Mild ­ 7 – 14 days tissue infection Staph aureus Flucloxacillin 500mg qds Penicillin allergy: Erythromycin 500mg qds Diabetic foot ulcers with surrounding soft tissue infection Leg ulcers Staph aureus inc MRSA, streptococci, anaerobes, Gram­ negative organisms Only use antibiotics if clinical signs of infection present Co­amoxiclav 625mg tds 7­14 days If MRSA colonised or previous history discuss with microbiology. Penicillin allergy: Discuss with microbiology As for cellulitis Add Malodorous ulcers Metronidazole 400mg qds Adapted from Bradford Teaching Hospitals NHSFT Nov 2010 document by Alistair Tinto Assistant Director of Pharmacy ­ Community and Mental Health Bradford Teaching Hospitals NHS Trust
Wound Management Guidelines and Formulary V7.2 30 25. REFERENCES Doherty Morgan & Moffatt (2006) Role of hosiery in lower limb Lymphoedema in Lymphoedema Framework, Template for Practice: compression hosiery in Lymphoedema. London: MEP Ltd, 2006. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (2009) Prevention of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel http://www.epuap.org. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (2009) Treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel http://www.epuap.org Samantha Haycocks, Paul Chadwick Fernandez R, Griffiths R. (2008), Water for wound cleansing Cochrane Database of Systematic Reviews Issue 1. Art. No.:CD003861. DOI: 10.1002/14651858.CD003861.pub2. Foldi M, Junger M, Partsch H (2005) The science of Lymphoedema bandaging In: European Wound Management Association (EWMA) Focus Document Lymphoedema Bandaging in Practice MEP Ltd, London: 1–4 Gray, D. White, R. Cooper, P, Kingsley, A (2010) Applied wound management and using the wound healing continuum in practice. Wound Essentials Vol. 5 Guo L.A. and DiPietro (2010) Factors Affecting Wound Healing JDR March 2010 vol. 89 no. 3, pp 219­229 Haycocks, S. and Chadwick, P (2008) Sharp debridement of diabetic foot ulcers and the importance of meaningful informed consent. Wounds UK, Vol. 4, No 1y Johnson S (2002), Compression hosiery in the treatment and prevention of leg ulcers, World Wide Wounds http://www.worldwidewounds.com/2002/september/Johnson/Compression­ Hosiery­Leg­Ulcers.html MHRA Device Bulletin Single­use Medical Devices: Implications and Consequences of Reuse DB2006 (04) October 2006 National Institute for Health and Clinical Excellence (2008) Prevention and Management of surgical site infection NICE clinical guideline 74 SIGN (2010) Guideline 120: Management of chronic venous leg ulcer – Annex 3 http://www.sign.ac.uk/guidelines/fulltext/120/annexes.html Vowden K (2010) Pressure Ulcer Prevention & Management Policy, Bradford Teaching Hospital; Bradford & Airedale NHS; Bradford & Airedale Community Health Services Williams, A.M and Southern S.J (2005) Conflicts in the treatment of chronic ulcers in drug addicts case series and discussion.
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