NHS Fife Woundcare Guidelines

Wound Formulary and Wound Management Guidelines

2016/7

Developed by the NHS Fife Wound and Skin Care Forum (WSCF) Group

Approved: February 2016 Amended: July 2016 & December 2016 For review: February 2017 Approved by NHS Fife ADTC August 2016

Area Drug and Therapeutics Committee

Contents

Introduction 2-3

Wound definition 4

Comprehensive wound assessment 4

Factors to consider when planning holistic wound care 5

Characteristics of ideal dressings 6

Guide to selection of wound dressings 7 Overgranulation 8

Bacterial burden and management of infection 9-10

Wound cleansing guidelines 11-13

Monographs for dressings Barrier film 14

Vapour-permeable film 15 Non adherent dressings 16 Low adherence dressings 16 Hydrocolloid dressings 17 Foam dressings 18 Hydrofibre dressings 19 Hydrogel dressings 20 Alginate dressings 21 Deodorising dressings 22 Silicone dressings 23 Super Absorbent Dressings 24 Guidance for use of Specialised dressings and therapies 25-26 Antimicrobial Dressings 27 Silver containing Dressings 27 Honey Preparations 28 Iodine containing Dressings 28-29

Antimicrobial Alginate Gel 29 Pain Management Dressings 29 Debridement product 30

Tulle Dressings 30 Larvae Therapy 30 Negative Pressure Wound Therapy 31 Wound Drainage Bags 31

Glossary of wound terms 32 Reading list / Resources 33-34 Appendix 1 - Woundcare Products Conversion Chart 35 Appendix 2 - Wound Assessment Chart 36-38

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Introduction Wound care consumes a significant amount of resources in terms of wound management products and professional time. The range of wound care products currently available can be bewildering and choosing the most appropriate dressing difficult. There is no such thing as the perfect dressing, so the choice is usually a compromise, trying to achieve the optimum environment to encourage the best outcomes in the shortest time. The dressing selected will invariably change as the wound healing proceeds, adding to the number of decisions necessary. The introduction of non-medical prescribing has increased both responsibility and accountability in wound management. Prescribers must therefore ensure that the choice of dressing is based on a full and accurate assessment of all the factors which may influence healing, and not just the wound itself. These guidelines aim to assist practitioners in the assessment and management of wounds. They encourage rational, cost-effective prescribing of dressings and other materials used in wound care. Demonstrating the use of evidence based treatments, and allowing practitioners to disseminate and share best practice, will promote seamless care across all sectors. On most of the pages containing information on dressings, a 1st and 2nd choice is given. Where possible, the 1st choice dressing should be used, however there may be reasons that this is not appropriate, therefore the 2nd choice dressing may be used. Staff must be able to give a rationale for choosing a dressing out with the main pages of the guidelines and this should be documented in the patients’ notes. Other dressings / treatment choices are within the specialised dressing pages. Dressing prices (Scottish Drug Tariff, February 2016/7) have been added to make practitioners aware of cost. More expensive dressings may still be cost effective if used in the correct manner. Practitioners’ are advised to contact their local Tissue Viability nurse for further advice, if they have a good rationale for not using the choice of dressing given. These guidelines are based on a selection of up to date research and clinical expertise of group members. We do accept that opinions vary and point out that these guidelines are not intended to be a definitive textbook, therefore a further reading list is included.

Disclaimer Guideline users should be mindful that, as with any clinical guideline, recommendations may not be appropriate for use in all circumstances. Clearly, a limitation of any guideline is that it simplifies clinical decision making processes and recommendations. Decisions to adopt any particular recommendations must be made by the practitioner in the light of available resources, local services, policies and protocols. The particular patient’s circumstances and wishes, available personnel and equipment, clinical experience of the practitioner and knowledge of more recent research findings must all be considered and decisions must be clearly documented in the patient’s notes.

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Acknowledgements The NHS Fife Wound and Skin Care Forum would like to thank the Glasgow Wound Guidelines Group, for allowing us to use some of their work, particularly in the teaching area of the Fife Guidelines. We would also like to thank Ruth Ropper, Tissue Viability Nurse in Lothian for her permission to use the Ropper Lothian Ladder for wound infection. We would also acknowledge the contribution of both NHS Fife Community Health Partnerships and NHS Fife Acute Services Division staff in the development of these Guidelines. Wound Definition For the purposes of these guidelines, the following definitions apply - > A simple wound is one where there is damage to the epidermal layer of the skin, including

discolouration due to pressure damage.

> A complex /chronic wound is one which heals by granulating from the base up and requires contraction and scar tissue to close. Debridement of slough and necrotic tissue may be necessary.

> It is important to note that the term chronic suggests longevity; however, many wounds e.g. diabetic

foot or rheumatoid lesions may be termed chronic at the onset. A more accurate term for a chronic /complex wound would be a compromised wound. It is the underlying host response to the wound, which will determine to a great extent its ability to heal.

Comprehensive Wound Assessment > Recognised good practice is to assess a wound using a validated wound assessment chart > Compromised wound healing is usually a result of the patients underlying disease processes, ability to

initiate an inflammatory response and fight infection. Intrinsic factors must therefore be taken into account whilst planning wound care.

> Extrinsic factors at the wound bed (slough, necrotic tissue, biochemical and bacterial burden or damage

to underlying structures, e.g tendon) may inhibit the healing process and wound bed preparation must be carried out to promote proliferation and epithelialisation. (See web site below).

> The condition of the surrounding skin must be considered when recognising if there are signs of

infection, tracking or undermining of the wound. Consideration must be made as to whether adhesive or non-adhesive dressings should be used dependent on the vulnerability of the surrounding skin.

> Address patient issues to establish if the patient/carer can be empowered to assist in their own wound

care. It is important to determine if they have the ability to cope psychologically with the presence of a wound. It is important to recognise the need for adequate pain control / analgesia and this must be reviewed regularly.

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> It is not always possible to heal wounds due to the patients underlying aetiology (e.g. in fungating tumours or advanced disease). In this instance palliative care may be the aim, with management of symptoms in a way that is acceptable to the patient.

> There should be an awareness in the non-healing compromised wound that further referral to the appropriate specialty may be required, e.g. vascular, dermatology, diabetic or tissue viability.

Assessment tools have been developed by the National Association of Tissue Viability Nurses (Scotland) and the Scottish Wound Assessment and Action Guide can be accessed on-line at http://www.healthcareimprovementscotland.org/our_work/patient_safety/tissue_viability_resources/wound_assessment_action_guide.aspx

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Factors to Consider when Planning Holistic Wound Care Patient Issues (Relating to wound and personal) Pain Odour

Exudate Anxiety

Low Self Esteem Poor Mobility

Social Isolation Loss of employment/income

Feeling vulnerable Need to be included with their management

Intrinsic factors that delay healing Compromised blood flow Oedema

Diabetes Poor nutrition

Connective tissue disorders Smoking

Malignancy Alcohol misuse

Drug treatment /radiotherapy Systemic infection

Surrounding Skin Redness Maceration

Dry / Flaky Oedematous

Nodular Fragile

Undermining Tracking

Condition of margins Suppleness

Wound Bed Healthy granulation Exposed tendon or bone

Epithelialisation Bacterial Burden

Wet / Dry Slough Biochemical imbalance

Type & Colour of exudate Depth, presence of sinus or fistulae

Necrosis Precise anatomical position

Nutritional Factors which may compromise wound healing Inability to access food Poor economic status Reduced mobility Inability to communicate preference Socially isolated

Poor appetite Underlying disease process Medication Depression

Difficulty in swallowing Stroke Neuromuscular disorders Underlying malignancy

Inability to absorb adequate nutrients Gastro-intestinal disorders Malabsorption syndrome Paralytic ileus Vomiting and diarrhoea Small or large bowel resection

Increase metabolic demand Trauma Sepsis Recent surgery

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Characteristics of Ideal Dressings

1. Provide the optimum environment for wound healing - a moist environment - at the wound/dressing interface.

2. Allow gaseous exchange of oxygen, carbon dioxide and water vapour.

3. Provide thermal insulation - wound healing is temperature dependent.

4. Impermeable to micro-organisms (in both directions).

5. Free from particulate contaminants.

6. Non-adherent (many products are described as non-adherent but are low adherent).

7. Safe to use (non-toxic, non-sensitising, non-allergenic).

8. Acceptable to the patient.

9. High absorption characteristics (for exuding wounds).

10. Cost effective.

11. Carrier for medicaments, e.g. antiseptics.

12. Capable of standardisation and evaluation.

13. Provide mechanical protection.

14. Conformable and mouldable (especially over sacrum, heels and elbows).

It is generally recognised that modern wound dressings are capable of being left on the wound bed for up to seven days, however this is dependent on exudate levels and whether there is infection present within the wound, therefore check with the instructions given within the box of dressings for further information. Ordering Dressings All dressings listed on the general pages of the Wound Management Guidelines are available on Drug Tariff in suitable sizes and forms with the exceptions of 365® Film (at time of printing). Community practitioners should order dressings on prescription (GP10/GP10N) or via stock order (GP10A) as appropriate. Hospital and Primary Care managed services e.g. NHS Fife treatment rooms, should obtain supplies of wound management products from the Area Distribution Centre, as this is the most cost-effective route of supply.

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Guide to Selection of Wound Dressings Further examples of complex wounds are available on-line as part of the Scottish Wound Assessment and Action Guide (SWAAG). http://www.healthcareimprovementscotland.org/programmes/patient_safety/tissue_viability_resources/wound_assessment_action_guide.aspx Epithelialising

Objectives: Thermal insulation, low adherence, moisture retention. To protect and promote new tissue growth. Choice of dressing > Extra thin hydrocolloid for low exudate levels (page 17) > Non adherent dressing with absorbent pad or foam dressing for

moderate to high exudate levels (page 16, 18)

Granulating

Objectives: Fluid absorption, thermal insulation, moisture control. To encourage angiogenesis and promote wound healing. Choice of dressing > Superficial or low exudate wound, thin hydrocolloid or

non-adherent dressing. (page 16,17 ) > Deeper wound or moderate to high exudate levels - hydrofibre

dressing or alginate dressing. (page 19,21 ) > Secondary dressing non-adherent with pad or foam dressing (page

16,18 ) Sloughy

Objectives : To remove all debris and promote autolysis. Dry slough – rehydration and moisture retention. Wet slough – fluid absorption Choice of dressing > Low exudate / dry slough - hydrogel (page 20) > Secondary dressing non-adherent with pad or foam dressing (page

16,18) > Moderate to high exudate / wet slough, hydrofibre or alginate

dressing with secondary dressing as above (page 19) Necrotic

Objectives: To rehydrate eschar and promote autolysis (debridement) to facilitate healing. Please note that depending on overall aims, it may not be appropriate to break necrosis down, e.g. palliative or vascular wounds. Choice of dressing > Hydrogel and non-adherent dressing with pad or foam (page 16, 20) > Thin hydrocolloid (page 17)

Infected

Objectives: To reduce bacterial load in wound. Manage exudate levels, contain odour Choice of dressing > Superficial / low exudate levels - antimicrobial impregnated

dressing (page 27) > Secondary dressing of non-adherent plus pad (page 16) deeper

wound / high exudate levels - silver alginate / hydrofibre with absorbent pad (page 27, 19)

> CarboFlex or Clinisorb if odour present (Page 22)

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Area Drug and Therapeutics Committee N.B. Always assess the condition of the surrounding skin before using adhesive secondary dressings. Overgranulation An essential aspect of secondary intention wound healing is the proliferation of granulation tissue, (McGrath, 2011). Granulation incorporates a dense network of blood vessels and newly growing capillaries with an irregular upper layer created by the capillaries looping together on the wound surface. This is what gives the appearance of red lumps or granules on the wound surface. When granulation ‘over grows’ beyond the surface of the wound, this is known as overgranulation, or hypergranulation. It is clinically recognised by a soft, fleshy, friable, often shiny appearance which is raised above the level of the surrounding skin. The wound will not continue to heal as the presence of this tissue will prevent the migration of epithelial tissue across the wound bed. The exact cause of overgranulation is unknown, (Russell 2000). It is thought to be the consequence of a reaction to foreign bodies, infection/bio burden, mechanical trauma or allergies and hypersensitivities. The research to date to support treatment options for overgranulation is limited, (McGrath, 2011). Reported treatments attempt to treat the causative factor, and focus on reducing bacteria present, applying pressure, using non occlusive dressings and the use of steroid therapies. It is essential that the clinician can identify the causative factor of the overgranulation, in order to make informed clinical decisions on an effective treatment. A number of treatment options exist, and for this reason, the advice of an appropriate specialist should be sought, e.g. local Tissue Viability Nurse or Plastics Nurse.

References McGrath A (2011) Overcoming the challenge of overgranulation. Wounds UK 7(1): 42-49 Russell L (2000) Understanding physiology of wound healing and how dressings help. British Journal of Nursing 9(1): 10-21

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Bacterial Burden and Management of Infection Bacterial burden and virulence are important factors in assessing the wound for infection. Host resistance is a major determinant in the body’s ability to fight infection and initiate an inflammatory response. This may be illustrated in the following equation: Infection = dose x virulence host resistance

Bacterial Burden Continuum Bacterial Load Definition Wound Dressing Contaminated Presence of non replicating

bacteria in the wound Topical antimicrobial and antibiotics not recommended.

Colonised Replicating bacteria adhering to the wound, with no detrimental effect to wound healing

As above.

Critically colonised Presence of bacteria at the wound bed, which compromises healing but does not result in infection

Topical antimicrobial dressings can be used. In general, a two week treatment is advised. If no improvement in wound after this time, seek advice from local wound care specialist

Infection Invasion and multiplication of micro-organisms in body tissues with overt host response

If there is clinical evidence of invasive infection systemic antibiotics are required. Prescribe systemic antibiotic therapy in conjunction with appropriate dressing.

Wound Swabs for Microbiology > Wound infection is recognised by the presence of clinical signs of infection rather than the isolation of

bacteria from a wound swab. A wound swab should only be taken when there is concern regarding infection. They should not be taken as part of “routine practice”. Taking a wound swab will give a qualitative picture of bacteria present on the wound surface. These are most commonly colonising bacteria and not responsible for infection. (Refer to Wound Assessment Chart for signs of infection). N.B. Do not confuse signs of inflammation with infection

> Organisms most commonly associated with soft tissue infections are S.aureus, and Group A, B, C, and G

Streptococcus. The clinical presentation should be reviewed alongside the swab result to ensure the most appropriate treatment is prescribed.

> Swabbing for culture and sensitivity is only recommended before antibiotics are commenced or to

confirm that the antibiotics commenced are appropriate. If a patient fails to respond to antibiotics within 72hours, then consider re-swabbing or seek further Medical advice.

> The cost incurred for each Wound Swab is in excess of £15.

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> The wound bed must be cleansed prior to swabbing so as to avoid sampling slough or necrotic tissue that may only reveal surface organisms which are not causing underlying infection. Critically colonised or infected wounds can be treated with antimicrobial dressings but when significant infection is present systemic antibiotics should be commenced.

Procedure for taking a Wound Swab

> Irrigate the wound with Sodium Chloride 0.9% solution. > Swab the edge of the wound adjacent to the good tissue which is inflamed. It is the organism

infecting the good tissue which will be the major pathogen. This would normally tend to be nearer the edge of the wound as the tissue in the centre is more often necrotic.

> The swab should be rotated between the fingers to ensure that all sides of the swab make contact

with the wound.

Infected wound below, swab area as directed by arrows

Example of most Suitable areas to swab

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Area Drug and Therapeutics Committee Wound Cleansing Guidelines

To Clean or Not To Clean?

> There is no single correct way to clean a wound or the surrounding skin, although there are a number of important considerations

> Does the wound really need cleansing? > What is the safest method that causes no ill effect and maintains the wound temperature? > What is acceptable to the patient?

Simple wound cleansing procedure (e.g. suture lines, superficial breaks)

> Gentle skin washing with warm tap water (e.g. showering). > A minimalist approach is recommended to reduce interference at the wound bed. > Dry surrounding skin with non woven gauze to allow adherence of wound dressing.

Compromised / complex wound cleansing procedure

Aims: > Remove excess exudate, debris or old dressing materials. > Minimize pain and trauma. > Prevent infection.

Procedure

1 Explain procedure and rationale to patient.

2 Wash hands thoroughly as per hand hygiene policy prior to and following procedure.

3 Dressing packs are not always necessary.

4 Requirements: non woven swabs, clean surface, non-sterile gloves.

5 Remove dressing as per manufacturer’s instructions.

6 Assess wound type and carry out appropriate irrigation procedure (see pages 11 and 12).

7 Dry surrounding area with non woven swabs.

8 Do not touch surface of wound with swabs.

9 Apply new dressing.

See also Fife Wound Care Policy W7 accessed via http://intranet.fife.scot.nhs.uk/Publications/index.cfm?fuseaction=publication.display&objectID=0E0A717D-5056-8C6F-C07ADBCEF2FC4663

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Wound Cleansing Guidelines Preparation Procedure Rationale

With tap water Gentle showering of wound area during routine social hygiene

Run shower for three minutes. Ensures free flowing warm clean water. Gently irrigate wound with warm water using shower head. Ensures safe removal of exudate, loose

slough and wound dressing residue. In healthcare premises, shower should be cleaned with general purpose neutral detergent/cream cleanser before and after use.

Maintains clean working environment.

In the home care setting patients own household cleaner should be used to clean the shower and/or bath before and after the procedure. Refer to Infection Control Manual.

Bucket lined with polythene bag for lower limbs

Gently wash limb. Dry skin surrounding wound prior to application of new dressing. Avoid direct contact with wound bed.

Ensures safe removal of exudate, loose slough and wound dressing residue. It incorporates social hygiene into wound management procedure.

In healthcare premises, bucket should be cleaned with general purpose neutral detergent and warm water, rinsed and dried. Buckets should be stored dry and inverted. Patients own household cleaner should be used in home care setting. Refer to Infection Control Manual.

Maintains clean working environment.

Infection Control Manual can be accessed via: Intranet / Subjects / Infection Control / Infection Control Manual http://intranet.fife.scot.nhs.uk/subjects/index.cfm?fuseaction=service.display&pageid=7A5F5BB2-5056-8C6F-C03F5A9FA592A31A&subjectid=6C965E0A-DB7D-B17A-04E54EAC6A42E839&objectid=6BE801F1-5056-8C6F-C0E12BB07758F462

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http://intranet.fife.scot.nhs.uk/subjects/index.cfm?fuseaction=service.display&pageid=7A5F5BB2-5056-8C6F-C03F5A9FA592A31A&subjectid=6C965E0A-DB7D-B17A-04E54EAC6A42E839&objectid=6BE801F1-5056-8C6F-C0E12BB07758F462

http://intranet.fife.scot.nhs.uk/subjects/index.cfm?fuseaction=service.display&pageid=7A5F5BB2-5056-8C6F-C03F5A9FA592A31A&subjectid=6C965E0A-DB7D-B17A-04E54EAC6A42E839&objectid=6BE801F1-5056-8C6F-C0E12BB07758F462

Area Drug and Therapeutics Committee With Sodium Chloride 0.9% Solution - Hospital = Miniversol® 45ml / Primary Care = Irripod®

Warm Sodium Chloride 0.9% solution pods by running under hot water Does not require alcohol swab to wipe pod prior to use Available on prescription

Irrigate wound area with Sodium Chloride 0.9% solution to remove surface exudate and loose slough or dressing residue.

To maintain optimum temperature for healing.

If slough is not easily removed by irrigation, further hydration with wound dressing products will be necessary.

With Prontosan® 40ml / 350ml FOR COMPROMISED WOUNDS ONLY Use soak of Prontosan® Solution with gauze swabs for 10

minutes at dressing change, then discard. Deeper cleansing of wound and biofilm removal

Dressing Size (Pack Size) Drug Tariff Cost - Feb 2016/7 (Each) Irripod®

20ml (25) 23p

Prontosan® Prontosan Wound Gel X

40ml (24) 350ml 30ml

35p £4.78 £6.38

N.B. Prontosan is for use in chronic or infected wounds only.

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Monographs for Dressings

Barrier Film Sureprep® No Sting Barrier Film Sorbaderm® Cream Description Sureprep® No Sting Barrier Film provides long lasting skin protection for up to 72 hours. Sorbaderm® Cream provides long lasting protection from bodily fluids whilst moisturising the skin

Indications Intended to be used as a primary barrier against irritation from bodily fluids e.g. from urine and/or faeces. The no sting film acts as a protective barrier against adhesive wound dressings and surgical tapes, provides peri-wound protection from exudate damage and provides protection from damage caused by friction and shear. It is suitable for use in neonates. The barrier cream acts as a moisturiser for severely dry skin and as a protection for skin damage associated with incontinence.

Method of Use Both film and cream should be applied to clean, dry skin. Sureprep® No Sting Barrier film should be applied in a uniform coating over the entire treatment area when using the foam applicator. If using the spray, hold the nozzle 10 - 15cm from the treatment area and apply a smooth, even coat. Allow to dry for 60 seconds before applying any adhesive dressings or surgical tapes. Reapply at least every 48 - 72 hrs (or more frequently if required) Sorbaderm® Cream should be applied in small amounts, gently smoothing into the skin over the affected area and allowed to dry for 30 seconds before applying any dressing N.B. If the after feel of the skin is oily, then too much has been applied. Dressing Size (Pack Size) Drug Tariff Cost – Feb 2016/7 (Each) Sureprep® No Sting Barrier Film

1ml foam applicator (25) 3ml foam applicator (25) 28ml spray bottle (1)

£0.77 £1.32 £5.00

Sorbaderm® Cream

2g sachet (20) 28g (20) 92g tube (1)

£0.33 £2.20 £3.20

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Non-adherent Dressings N-A® Ultra Description A primary wound contact layer consisting of a knitted viscose rayon sheet with a silicone coating. Indications Provides moisture retention or rehydration, thermal insulation and low-adherence. A secondary dressing is required to dress more heavily exuding wounds. Method Of Use

Apply directly to the wound surface. Secondary dressings are required to retain dressing in position. Frequency of changing the dressings depends on exudate/ strike through

Dressing Size (Pack Size) Drug Tariff Price – Dec 2016/7

(Each) N-A® Ultra 9.5cm x 9.5cm (40)

9.5cm x 19cm (25) £0.33 £0.63

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Hydrocolloid Dressings

First choice : Comfeel® Plus Transparent Second choice : Duoderm® Extra Thin

Description A hydrocolloid dressing is a micro granular suspension of various natural or synthetic polymers, e.g. gelatin or pectin, in an adhesive matrix. The dressings are interactive with wound exudate - by slowly absorbing fluid. They physically change to form a gel, which may be cohesive, and/or hydrophilic. Indications Aids debridement in wounds covered with black necrotic tissue, suitable for softening eschar and promoting granulation. Suitable for low to moderately exuding wounds. May also be used prophylactically on areas prone to breakdown and as a secondary dressing. Method Of Use Apply dressing of sufficient size to provide at least 2cm overlap onto intact skin. Smooth dressing into place - warmth of the hand improves initial adhesion. For best results aim to leave dressing in place for at least 3 days. Dressings may be left in place for up to 7 days in low exuding wounds. N.B. Owing to the occlusive nature of their backing hydrocolloids are not considered suitable for the treatment of clinically infected or very heavily exuding wounds. Dressing Size (Pack Size) Drug Tariff Price– Feb 2016/7

(Each) Comfeel® Plus Transparent

5cm x 7cm (10) 5cm x 25cm (5) 9cm x 14cm (10) 10cm x 10cm (10) 15cm x 15cm (10) 20cm x 20cm (5)

£0.66 £2.53 £2.39 £1.25 £3.27 £3.34

Duoderm® Extra Thin 5cm x 10cm (10) 7.5cm x 7.5cm (5) 9cm x 15cm (10) 9cm x 25cm (10) 9cm x 35cm (10) 10cm x 10cm (10) 15cm x 15cm (10)

£0.75 £0.79 £1.74 £2.78 £3.89 £1.30 £2.81

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Foam Dressings

Tegaderm® Foam / Tegaderm® Foam Adhesive Tegaderm® Foam Adhesive - Heel only

Description Highly absorbent polyurethane foam dressing with semipermeable film backing layer. Foam dressings in general provide thermal insulation, do not shed fibres or particles and can be cut or shaped to fit the wound (non-adhesive). They help to maintain a moist environment at the surface of the wound and are gas permeable and non adherent. Should be used on moderate to highly exuding wounds. Tegaderm® Foam / Tegaderm® Foam Adhesive Tegaderm Foam is suitable for use in moderate to highly exuding wounds. Tegaderm Foam Adhesive is suitable for low to highly exuding wounds. Can be used on clean granulating wounds or as a secondary dressing in sloughy or necrotic wounds, can be used under compression. Adhesive version is beneficial for patients wishing to bathe or shower. Dressing should be renewed when exudate has reached within 1cm of the edges of the dressing. The dressing may be left in place for 3 - 7 days depending on the level of exudate. Tegaderm® Foam Adhesive – Heel only A highly absorbent polyurethane foam dressing with semipermeable film backing layer and adhesive border. Comprises of four layers for high fluid absorption. Contraindications None Listed Dressing Size (Pack Size) Drug Tariff Price – Feb 2016/7

(Each) Tegaderm® Foam 8.8cm x 8.8cm (10)

10cm x 10cm (10) 20cm x 20cm (5) 10cm x 20cm (5) 10cm x 60cm (5) (Roll)

£2.23 £2.19 £5.92 £3.71 £12.54

Tegaderm® Foam Adhesive

6.9cm 7.6cm (10) 8.8cm x 8.8cm (10) 10cm x 11cm (10) 14.3cm x 14.3cm (10) 14.3cm x 15.6cm (5)

£1.46 £2.23 £2.39

£3.54 £4.24

Tegaderm® Foam Adhesive – Heel dressing only

13.9cm x 13.9cm (5) £4.22

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Hydrofibre Dressings Aquacel® Extra/ Aquacel® Description A soft, non woven pad composed of hydrocolloid fibres. This interacts with wound exudate and forms a soft gel which is easy to remove with little or no damage to healing tissue. Indications Used in the management of moderate to heavily exuding wounds. Can be used in acute and chronic wounds, e.g. abrasions, lacerations, leg ulcers, pressure sores. Infection is not a contraindication to use. Method Of Use Apply directly to the wound surface. Irrigation facilitates removal. Secondary dressing is required. May be left in place for up to seven days - depending on the level of exudate. NB If “packing” a wound with Aquacel® Extra, always leave a small piece outside of the wound to facilitate removal. Also record the number of pieces of used. (See wound chart). Dressing Size (Pack Size) Drug Tariff Cost – Feb 2016/7

(Each) Aquacel® Extra

5cm x 5cm (10) 10cm x 10cm (10) 15cm x 15cm (5)

£1.00 £2.38 £4.48

Aquacel®

1cm x 45cm Ribbon (5) 2cm x 45cm Ribbon (5)

£1.86 £2.48

Hydrofibre Foam Dressing Aquacel® Foam Aquacel® foam dressings have a soft absorbent pad, an aquacel contact layer, a gentle silicone adhesive and a waterproof/ bacteria barrier. It can be used on a variety of moderate to heavily exuding wounds. Dressing Size (Pack Size) Drug Tariff Cost Feb 2016/7 (Each) Aquacel® Foam Non Adhesive

5cm x 5cm (10) 10cm x 10cm (10) 15cm x 15cm (5) 15cm x 20cm (5) 20cm x 20cm (5)

£1.35 £2.51 £4.30 £5.88 £7.01

Aquacel® Foam Adhesive

8cm x 8 cm (10) 10cm x 10cm (10) 12.5cm x 12.5cm (10) 17.5cm x 17.5cm (10) 21cm x 21cm (5) 25cm x 30cm (5)

£1.39 £2.16 £2.68 £5.36 £7.84

£10.05

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Hydrogel Dressings

First choice : Purilon®Gel Description An amorphous gel with high water content, containing Calcium Alginate (Purilon®) Indications Hydrogels facilitate autolysis by rehydrating necrotic tissue and effecting debridement. They provide a moist environment which promotes healing. They are non-adherent and do not harm viable tissue or surrounding skin. Bacterial colonisation of the wound is not a contraindication to the use of a hydrogel. Method Of Use Apply the gel directly into the wound. A secondary moisture - retentive dressing is required e.g. Hydrogel should be changed when the cover dressing leaks. Intervals should not exceed 3 days when used on sloughy or necrotic wounds or 7 days if used on clean granulating wounds. N.B. When using in cavity wounds only half fill the cavity. Due to the effective debridement of necrotic tissue, a wound being treated with gel may appear larger at first dressing change, however, this is a natural step in the healing process. Dressing Size (Pack Size) Drug Tariff Price- Feb 2016/7 (Each) Purilon® Sterile 8g tube (10)

Sterile 15g tube (10) £1.76 £2.30

Alginate Dressings

Kaltostat® Description The basic elements of alginates are extracted from brown seaweed (Phaeophyceae). Their clinical composition means that they are highly absorbent and biodegradeable. Alginates vary in composition (calcium/sodium salts of alginic acid) and in the arrangement of fibres. Indications Alginate dressings are suitable for moderate to heavily exuding wounds. They form a gel on contact with the wound exudate, and are effective at absorbing exudate, debriding slough and encouraging granulation tissue. Where bleeding is involved, Kaltostat® may be considered as a haemostatic agent. Method Of Use Apply to the wound surface/cavity, secondary dressing required to secure. Frequency of change will depend on level of exudate. Dressing Size (Pack Size) Drug Tariff Price – Feb 2016/7

(Each)

20


Kaltostat®

5cm x 5cm (10) 7.5cm x 12cm (10) 10cm x 20cm (10) 15cm x 25cm (10)

£0.96 £2.10 £4.12 £7.08

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Deodourising Dressings

First choice : Clinisorb® Second choice : CarboFlex®

Clinisorb® Description Clinisorb® is an activated charcoal cloth dressing, produced by carbonising and activating woven viscose rayon that is sandwiched between two layers of a nylon and viscose rayon blend. Clinisorb® has the optimum combination of microporous activity and activated charcoal cloth weight, for significantly reducing odour by attracting and permanently trapping bacteria. It is non-adhesive and contained in a sterile peel pack. Indications Clinisorb® can be used to manage malodourous wounds such as fungating breast lesions, pressure ulcers, leg ulcers and diabetic foot ulcers. Method Of Use Clinisorb® can be used as a primary or secondary dressing and its soft, flexible construction can be cut to fit practically any wound. Even unusually shaped fungating wounds on curved body sites can be easily dressed. Clinisorb® is highly effective wet or dry, can be used either side down, and can be left in place for up to one week. CarboFlex® Description A sterile non-adhesive dressing consisting of five layers - film layer, absorbent padding, activated charcoal cloth, film layer and absorbent wound contact layer containing Kaltostat® and Aquacel®. Indications For use in the management of malodourous acute and chronic wounds. May be used as a primary dressing for shallow wounds or as a secondary dressing over wound fillers with deeper wounds. Method Of Use This dressing must not be cut to size or shape. The fibrous surface is placed directly on to the wound. This may be left undisturbed for up to three days depending on the level of exudate. Dressing Size (Pack Size) Drug Tariff Price – Feb 2016/7

(Each) Clinisorb® 10cm x 10cm (10)

10cm x 20cm (10) 15cm x 25cm (10)

£1.91 £2.54 £4.09

CarboFlex® 8cm x 15cm Oval (5) 10cm x 10cm (10) 15cm x 20cm (5)

£3.89 £3.24 £7.38

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Silicone Dressings Mepitel® One Description A sterile transparent soft silicone wound contact layer, which is non adherent to a moist wound bed. Indications For use in a wide range of painful, chronic and traumatic wounds and wounds with compromised or fragile surrounding skin. The soft silicone adheres gently to the surrounding skin and ensures removal with minimal trauma and pain. Mepitel®One prevents the outer dressing sticking to the wound. The porous structure of Mepitel® One allows exudate to pass to an outer absorbent dressing. Method Of Use Apply directly to the wound or wound bed. It can be cut to size or shape of wound if desired. Requires a secondary dressing which can be changed independently as the Mepitel® One can remain in place for up to 10 days. Mepitel® One may offer advantages when primary dressings are required to stay in place for longer periods, since it is adhesive on one surface only. Dressing Size (Pack Size) Drug Tariff Price – Feb 2016/7

(Each) Mepitel® One 6cm x 7cm (5)

9cm x 10cm (5) 13cm x 15cm (5) 24cm x 27.5cm (5)

£1.22 £2.41 £4.95

£14.25 Mepilex® Lite Description A thin absorbent foam dressing with soft silicone contatc layer and film backing Indications For use on non to low exuding woumds. May also be used as a protective dressing on compromised or fragile skin. Method of Use Apply directly to wound or wound bed. Mepilex® Lite can be easily cut to fit an individual wound and makes it ideal for difficult to dress wounds, such as armpits, breast etc. Dressing Size (Pack Size) Drug Tariff Price – Feb 2016/7

(Each) Mepilex® Lite 6cm x 8.5cm (5)


£1.82 £2.17 £4.22

£26.60

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Silicone Foam Dressings Allevyn® Gentle / Alleyvn ®Gentle Border Description An absorbent hydrocelluar pad sandwhiched between a perforated soft gel adhesive wound contact layer and highly permeable waterproof outer film. Alleyvn ®Gentle Border benefits from an easy application and removal of the dressing with the ability to reposition through an adhesive technology based on the soft silicone gel in the dressing. Indications Designed for a wide range of moderate to highly exuding wounds e.g. leg, foot and pressure ulcers, traumatic wounds and secondary healing wounds. Method of Use During the early stages of wound management, Allevyn Gentle Border dressings should be inspected frequently. Where the product is used on infected wounds, the infection should be inspected and treated as per local clinical protocol.

Dressings can be left in place for up to 7 days depending on the condition of the wound and the surrounding skin or until exudate is visible and approaches to within 1.5cm of the edge of the dressing pad, whichever is sooner. If required, Allevyn®Gentle can be cut.

Contraindications Do not use Allevyn® Gentle Border dressings with oxidising agents such as hypochlorite solutions (e.g. Eusol or Hydrogen peroxide, as these can break down the absorbent polyurethane component of the dressing. If reddening or sensitisation occurs discontinue use. Dressing Size (Pack Size) Drug Tariff Price – Feb 2016/7

(Each) Allevyn® Gentle Border 7.5cm x 7.5cm (10)

10cm x 10cm (10) 12.5cm x 12.5cm (10) 15cm x 15cm (10) 17.5cm x 17.5cm (10) 10cm x 20cm (10)

£1.51 £2.21 £2.71 £4.04 £5.34 £3.56

Allevyn® Gentle

5cm x 5cm (10) 10cm x 10cm (10) 10 x 12cm (10) 15cm x 15cm (10) 10cm x 20cm (10) 20cm x 20cm (10)

£1.27 £2.53

£4.25 £4.07 £6.78

Allevyn® Gentle Border Sacrum 16.8cm x 17.1cm (10) 21.6cm x 23cm (10)

£4.00 £5.66

Allevyn Gentle Border Lite 5 x 5cm 7.5 x 7.5 cm 10 x10cm 15 x 15cm

£.90 £1.39 £2.16 £3.81

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Area Drug and Therapeutics Committee 5.5 x 12cm 8 x 15cm 10 x 20cm

£1.85 £3.43 £3.43

Technology Lipidocolloid (TLC) Urgo Dressings Urgo® Clean Pad & Rope Description A TLC Healing Matrix dressing which allows a pain free desloughing action, trapping and binding slough with its polyabsorbent fibres. It is also available as a rope which has similar absorption properties to Aquacel Indications For use in moderate to heavily exuding wounds. Change Urgo® Clean 1-2 days during the desloughing phase, then as often as required (up to 7 days)depending on levels of exudate. Contraindications Do not use Urgo®Clean in combination with hydrogen peroxide organomercuric antiseptics or heocamidine. Dressing Size (Pack Size) Drug Tariff Price – Feb 2016/7

(Each) Urgo® Clean Pad 6cm x 6cm (10)

10cm x 10cm (10) 20cm x 15cm (10)

£0.96 £2.14 £4.02

Urgo® Clean Rope/Probe 5cm x 50cm (5) £3.18 2.5cm x 50cm (5) £2.41 Urgo® Start/Urgo® Start Contact Description Urgo® Start is a soft adherent TLC foam dressing which stimulates fibroblast proliferation. The dressing neutralises excess proteases and re –establishes wound equilibrium. The semi-permeable backing prevents maceration. Urgo ®Start Contact is a contact layer which should be used with a pad or absorbent dressing for heavily exuding wounds. Indications For use on low to moderately exuding chronic wounds, leg ulcers, pressure and diabetic foot ulcers, Can be used under compression and may be left in place for 7 days. Urgo ®Start Contact can also be used in cavity wounds.

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Area Drug and Therapeutics Committee Contraindications Urgo® Start/Urgo® Start Contact should not be used on infected or critically colonised wounds. Not to be used in cancerous or fistula wounds which may reveal a deep abcess. It is also not recommended to use as first line treatment in acute wounds or in the treatment of Epidermolysis Bullosa (EB). Dressing Size (Pack Size) Drug Tariff Price – Feb 2016/7

(Each) Urgo® Start 6cm x 6cm (10)

10cm x 10cm (10) 20cm x 15cm (10)

£4.45 £6.16

£11.08 Urgo® Start Contact 5cm x 7cm (10) £3.00 10cm x 10cm (10) £4.24 15cm x 20cm (10) £10.12 16cm x 21cm (10) £9.95 Urgo SSD – refer to specialised dressings section Urgotul – refer to Tulle dressings section 26


Super Absorbent Dressings Kliniderm® Description Super absorbent secondary dressing compromising of four layers: a hydrophillic wound contact layer, a distribution layer, a super absorbent inner core and a fluid repellent wound conact layer Indications Moderate to heavily exuding wounds. May be used under compression Indications Not to be used on dry wounds, heavy bleeding wounds and surgical implantation. The dressing must not be cut. Eclypse® Description Super sbsorbent secondary dressing Indications Moderate to heavily exuding wounds Indications Not to be used on arterial bleeds or heavily bleeding wounds. If a wound has a potential to dry out, a non adherent wound contact layer should be applied beforehand. Do not cut dressing. Dressing Size (Pack Size) Drug Tariff Cost – Feb 2016/7

(Each) Kliniderm®

10cm x 10cm (50) 10cm x 15cm (10) 10 x 20cm (50) 20cm x 20cm (15) 20cm x 30cm (10) 20xm x 40cm (10)

£0.49 £0.69

£0.99 £1.49 £1.99

Eclypse®

15 x 15 cm 20 x 30 cm 60cm x 40cm (10)

£0.97 £2.14 £8.15

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Specialised Dressings & Therapies

Antimicrobial Dressings Antimicrobials are agents which kill or inhibit the growth and division of micro-organisms. Commonly used in wound management are honey, iodine and silver. There is no robust clinical evidence that dressings containing antimicrobials (e.g. silver, iodine or honey) are more effective than unmedicated dressings for the prevention of wound infections. Indiscriminate use of topical antimicrobial dressings should also be discouraged because of concerns over bacterial resistance and toxicity. You may be asked by your local pharmacist, GP Practice or Wound Specialist Nurse to give a rationale for using these products. Please use the following tips to aid your selection. 10 top tips when using Antimicrobial Dressings General points > Is the wound clinically infected

o Check for signs of infection o Don’t confuse normal signs of

inflammation with infection > Systemic antibiotics are indicated in cases of overt

wound infection where classical signs are evident > Check the correct antimicrobial is chosen according to

the wound exudate levels > If no improvement in wound after two weeks, review

wound and antimicrobial choice > Check cautions as stated in manufacturer instructions,

and BNF when using antimicrobial preparations.

Silver dressings > Some silver products oxidise in contact with air and

this may be displayed as a brown/black discolouration on the wound bed and/or surrounding skin

Honey products > Patients may experience pain due to osmotic effects of

dressing on wound (e.g. “drawing sensation”). Monitor pain levels, consider simple analgesia and only remove if the dressing is not tolerated.

> Wound exudate may increase when using honey ointments and therefore use an appropriate absorbent secondary dressing.

Iodine preparations > These products are rapidly deactivated by wound

exudate therefore consider other antimicrobials for moderate – highly exudating wounds

> All iodine products change from orange/brown to white when iodine is inactive/”used up”.

Please see Ropper Lothian Ladder on next page for further guidance

The Adapted Ropper Lothian Ladder

Guidelines for identifying infected wounds and when to start & stop using topical antimicrobial dressings

Initiation of these products should be on the advice of the local Tissue Viability service or relevant specialist nurse and follow local policies for use.

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Area Drug and Therapeutics Committee Each stage builds on the previous signs noted

Stage 4: Overt signs of local infection and signs of systemic infection: may lead to sepsis if not treated • Spreading cellulitis • Pus/abscess • Patient systemically unwell

e.g. confusion • Pyrexia • Raised white cell count/CRP • Malodour of wound

Stage 4 – Treatment • If systemic signs only, consider other source of infection • Swab wound using standardised method • Consider taking blood cultures prior to starting antibiotics • Start broad spectrum systemic antibiotics* while awaiting culture

results • Consider combination therapy with topical antimicrobials** e.g. in

PVD, diabetes • Monitor wound progress, review wound at 2 weeks and stop

topical antimicrobials when signs of infection cease • Once topical antimicrobial stopped continue with correct dressing

regime for wound/tissue type

Stage 3: Overt signs of local infection: evidence of surrounding tissue involvement, wound deteriorating • Localised cellulitis • Discoloured or bleeding granulation tissue • Pain in or around wound • Exudate: thick, haemopurulent or purulent

and/or high volumes • Localised oedema • Malodour

Stage 3 – Treatment • Swab wound using standardized method • Drain any local collections of pus/fluid • Consider combination therapy with broad spectrum systemic

antibiotics* and topical antimicrobials** • Monitor wound progress, review wound at 2 weeks and stop

topical antimicrobials when signs of infection cease • Once topical antimicrobial stopped continue with correct dressing

regime for wound/tissue type • If no progress after two weeks and/or signs of systemic infection

move to Stage 4

Stage 2: Increasing signs of infection (Critical colonisation): healing not progressing normally • Exudate – high volumes • Malodour • Pain in or around wound • Discolouration of granulation tissue • Slough/Necrosis

Stage 2 – Treatment • Select topical antimicrobial** • Monitor wound progress, review wound 1-2 weeks • If no improvement:

i. Consider swabbing wound using standardised method ii. Consider alternative topical antimicrobial**

• If improved stop topical antimicrobials when signs of infection cease

• Once topical antimicrobial stopped continue with correct dressing regime for wound/tissue type

• If no progress after two weeks and/or increasing signs of systemic infection move to Stage 3

Stage 1: Few subtle signs: healing progressing normally

• Exudate – low to moderate volume • Pain – minimal • Odour – minimal • Slough/necrosis – minimal

Stage 1 – Treatment • Promote moist wound healing using correct dressing regime for

wound/tissue type & exudate level • Monitor wound progress, if no improvement in 1-2 weeks

reassess wound and dressing choice • Check underlying aetiology of wound, if required refer to

appropriate specialist e.g. vascular, diabetic podiatry, tissue viability, lymphoedema etc.

• If no progress after a further 1-2 weeks and/or increasing signs of infection/critical colonisation move to Stage 2

START

This guidance should be used along with clinical judgement in complex patients; in particular patients with diabetic wounds, vascular problems and immuno compromised patients may require topical antimicrobials for prophylaxis as well as treatment. *Systemic Antibiotics – Follow NHS Fife Antibiotic Guidance for the Treatment of Community Managed Infections Sept 2010. **Topical Antimicrobial – NHS Fife Joint Wound Formulary 2010. Topical antimicrobials can include honey, iodine, silver, PHMB, DACC and enzymatic products. Contact TVN team for more info if required.

References: European Wound Management Association (2005) Position Document: Identifying criteria for wound infection, MEP, London European Wound Management Association (2006) Position Document: Management of wound infection, MEP, London Best Practice Statement: Use of topical antiseptic/antimicrobial agents in wound management, Wounds UK, Aberdeen (2010) Good Practice Recommendation for Antimicrobial Use in Frail Elderly 2013

Adapted and reproduced with permission of R. Ropper, TVN CNS NHS Lothian

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Specialised Dressings & Therapies

Silver Containing Dressings

Aquacel® Ag+ Alginate Urgo®SSD

Aquacel® Ag+ Alginate Description Aquacel®Ag+ Alginate is a versatile primary dressing The combination of Hydrofiber® Technology with ionic silver (Ag+) produces a dressing that is highly absorbent and has favourable gelling characteristics with the aid of broad-spectrum antimicrobial activity Indications For use in moderate to highly exuding chronic and acute wounds where there is infection or an increased risk of infection. Also suitable for cavity wounds Contraindications Should not be used on patients who are sensitive to, or have had an allergic reaction to silver or sodium carboxymethycellulose. Urgo®SSD Description A non adherent, non occlusive, antibacterial contact layer. The contact layer is a polyester mesh impregnated with hydrocolloid petroleum jelly and silver sulphadiazine particles. Indications For use on non to lightly exuding wounds with signs of infection. Can be combined with an absorbent layer for heavily exuding wounds. Can also be used in cavity wounds. Contraindications Do not use on patients with a known sensitivity to any components of the dressing. Caution: Do not use on patients undergoing MRI scans. Avoid contact with electrodes or conductive gels during electronic measurement procedures Dressing Size (Pack Size) Drug Tariff Cost – Feb 14 (Each) Aquacel® Ag+ Alginate 1cm x 45cm (5)

2cm x 45cm (5) £3.12 £4.76

Urgo® SSD

10cm x 12cm (10) 15cm x 20cm (10)

£3.17 £8.99

Initiation of these products should be on the advice of the local Tissue Viability service (Acute Division only) or relevant specialist nurse and follow local policies for use.

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Antimicrobial Dressings Cutimed® Sorbact Cutimed® Sorbact dressings are coated with a fatty acid derivative (DACC) which give them highly hydrophobic properties. In the moist environment of an infected wound, bacteria are attracted to the dressing and become bound to it. The bacteria cannot multiply and are removed with the dressing. Cutimed®Sorbact Hydroactive is a Semipermeable polyurethane film which contains Bacteria-binding Sorbact® acetate mesh N.B. Using the dressing in combination with cream/ointments impairs the effect of the DACC. Dressing Size (Pack Size) Drug Tariff Cost – Feb 2016/7

(Each) Cutimed® Sorbact Ribbon Cutimed® Sorbact Swab Cutimed®Sorbact Hydroactive

2cm x 50cm (20) 5cm x 200cm (10) 4cm x 6cm (unfolded 11cm x 16cm) (5) 7cm x 9cm (unfolded 17cm x 27cm (5) 7cm x 8.5cm 14cm x 14cm 19cm x 19cm 14cm x 24cm 24cm x 24cm

£3.96 £7.81 £1.62

£2.70

£3.68 £5.37

£10.10 £8.60

£15.31

Honey Preparations Honey provides a moist healing environment with antibacterial and deodorizing properties as well as autolytic and osmotic debriding actions. It can be used on a variety of acute and chronic wounds. Medihoney® Products

For use in acute and chronic wounds: leg/foot ulcers, pressure ulcers, sloughy wounds, necrotic wounds, infected wounds, malodorous wounds, donor and recipient graft sites, and burns, diabetic wounds and surgical wounds.

Activon® Products

Activon®(ointment) is ideal for debriding necrotic tissue. Ideal for topping up dressings where the honey has washed away or for using directly into cavities. Can be washed out using normal saline solution.

Initiation of these products should be on the advice of the local Tissue Viability service (Acute Division only) or relevant specialist nurse and follow local policies for use.

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Area Drug and Therapeutics Committee Actilite® Actilite® is a light viscose net dressing coated with antibacterial Manuka honey & Manuka oil. The dressing is designed to protect a wound, promote healing and allow the passage of exudate. The antibacterial effect of Actilite has been enhanced by combining high grade antibacterial Manuka oil with Manuka honey. The combination of Manuka honey and Manuka oil has been demonstrated in-vitro to be effective against a number of major wound infecting organisms including MRSA and VRE. Dressing Size (Pack Size) Drug Tariff Cost - Feb 2016/7

(Each) Medihoney® Antibacterial Honey Apinate Medihoney® Tulle

5cm x 5cm (10) 10cm x 10cm (5) 5cm x 5cm (5) 10cm x 10cm (5)

£2.00 £3.40 £1.70 £2.98

Medihoney medical honey 20g tube £3.96

Actilite®

5cm x 5cm 10cm x 10cm (10) 10cm x 20cm (10)

£0.57 £0.98 £1.90

Iodine Dressings CAUTION : Care must be taken when these dressings are used with Thyroid and Renal Inadine® A sterile low-adherent fabric dressing impregnated with 10% povidone iodine in a water soluble slow release base. Povidone iodine is a potent antibacterial agent with a broad spectrum of activity It is used as a primary wound dressing providing prophylactic treatment against infections in superficial wounds and minor skin injuries. The dressing should be changed daily or when the orange/ brown colour turns to white. lodoflex® Iodoflex is a sterile Cadexomer Iodine paste containing Iodine in an inert base. The sachet consists of the paste sandwiched in protective gauze. Used for the topical treatment of a variety of chronic and acute wounds. When applied to the wound lodoflex® cleans and reduces' bacteria at the wound surface and is particularly useful in highly exuding wounds. Remove the protective gauze on both sides of the paste, lodoflex® can then be moulded into shape and applied to the wound surface. An appropriate secondary dressing can then be applied. The dressing should be changed every 72 hours. N.B. Maximum single application is 50g; weekly maximum must not exceed 150g; treatment duration should not exceed three months. Dressing Size (Pack Size) Drug Tariff Cost – Feb 2016/7

(Each) Inadine® 5cm x 5cm (25)

9.5cm x 9.5cm (10) 33p 49p

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Area Drug and Therapeutics Committee Iodoflex® 5g (5)

10g (3) 17g (2)

£4.13 £8.25

£13.06 Antimicrobial Alginate Gel Flaminal® Flaminal® is an antimicrobial alginate gel, indicated for a variety of wounds. It maintains a moist wound environment, helps debride and restore bacterial balance. It comes in two preparations, Flaminal® Forte for medium to heavily exuding wounds, and Flaminal® Hydro for low to moderately exuding wounds. Dressing Size (Pack Size) Drug Tariff Cost – Feb 14 (Each) Flaminal® Forte 15g (5)

50g (5) £7.61

£25.18 Flaminal® Hydro 15g (5)

50g (5) £7.61

£25.18

N.B. Flaminal® preparations are intended for single patient use, but can be used for multiple applications on the same patient, as this will make the product more cost effective.

Pain Management Dressing ActiFormCool® A transparent, non-adhesive high water content hydrogel, formed around a supporting blue polyethylene matrix. It can be particularly useful for painful wounds, e.g. leg ulcers and diabetic ulcers. Dressing Size (Pack Size) Drug Tariff Cost – Feb 2016/7

(Each) ActiFormCool® 5cm x 6.5cm (5)


£1.81 £2.66 £3.83 £8.01

FOAM DRESSING FOR HEAVILY EXUDING WOUNDS Allevyn® Life A dressing which is a multi-layered design incorporating hydrocellular foam with a hyper-absorber lock away core. It has a highly waterproof outer film and incorporates a mesh screen on the pad which allows the levels of exudate to be visible. This indicates when the dressing should be changed. Dressing Size (Pack Size)

Drug Tariff Cost – Feb 2016/7 (Each)

Alleyvn® LIfe 10cm x 10.3cm

12.9cm x 12.9cm 15.4cm x 15.4cm 21cm x 21cm

£1.71 £2.51 £3.06 £6.04

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Sorbion Sachet S A versatile fibre dressing with high wearing comfort for highly exuding wounds. The dressing absorbs wound exudate and locks it in, creating a moist wound environment by gel formation. It provides a large capacity for wound exudate and ensures high retention of absorbed fluids Dressing Size (Pack Size) Drug Tariff Cost – Feb 2016/7

(Each) Sorbion®Sachet S

7.5cm x7.5cm 10cm x 10cm (5) 20cm x 10cm 20cm x 20cm

£1.78 £2.25 £3.73 £7.00

Debridement Product Kerraprep® pad

A Soft, polyester-fibre pad with finger pouch which are conformable and controllable for effective preparation of the wound bed and surrounding skin. The mitts gently remove non-viable tissue, hyperkeratotic skin, and debris in a manner that increases patient tolerance and acceptance with wound preparation. It can be used on sloughy leg ulcers and surrounding skin to remove debris. Debrisoft ® Lolly Comprises of monofilament polyester fibres with a blue X-ray detectable polypropylene thread. The Debrisoft ® Lolly is intended for the debridement of deep – including surgically invasive – to superficial wounds for wound bed preparation. It is used to absorb exudates, debris and keratoses during debridement.

Dressing Size (Pack Size) Drug Tariff Cost – Feb 2016/7 (Each)

Kerraprep® pad 10cm x 10cm (5) 13.5cm x 20cm

TBC

Debrisoft Lolly £5.79 Tulle Dressings Urogtul® A non adherent, non – occlusive flexible contact layer derived from Technology Lipido-Colloid (TLC Technology). It is composed of a flexible polyester mesh impregnated with hydrocolloid and petroleum jelly particles. Can be used on acute wounds, skin abrasions and may be left for up too 7 days. Dressing Size (Pack Size) Drug Tariff Cost – Feb 2016/7

(Each) Urgotul® 5cm x 5cm (10)

10cm x 10cm (10) £1.55 £3.11

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Area Drug and Therapeutics Committee 15cm x 15cm (10) 10cm x 40cm (10) 15cm x 20cm (10) 20cm x 30cm (5)

£6.60 £10.44

£8.79 £14.13

Larvae Therapy Larvae reduce or eliminate odour and combat infection by ingesting and killing bacteria. Sterile larvae of the common green-bottle Lucilia Sericata are used to treat most types of sloughy, infected or necrotic wounds. They may also reduce wound pain and stimulate the formation of granulation tissue. Larvae therapy is available on a GP10 prescription. Refer to local policy. Dressing Size (Pack Size) Drug Tariff Cost – Feb 2016/7

(Each) BioBag® Dressing 2.5cm x 4cm (1)

5cm x 6cm (1) 10cm x 10cm (1)

£195.00 £245.00 £295.00

Negative Pressure Wound Therapy (NPWT) Negative Pressure Wound Therapy (NPWT) is a treatment used across the wound through a dressing positioned in the wound cavity or over a flap or graft. Excess fluid is collected in a disposable canister. NPWT helps to reduce oedema, increase blood supply and decrease bacterial colonisation. It has proven to be effective with acute surgical wounds, pressure ulcers, chronic wounds, including diabetic feet, and skin grafts.

Patients may be discharged from the Acute Services Division into Community with NPWT in situ. Community staff should consult local policy, as permission must be granted from the Lead Nurse for hire of unit and dressings. From February 2016/7, the NPWT pumps used (Acelity) will be free of charge. Dressings and canisters are available on drug tariff. All pumps once discontinued must be returned to the original source. Within the Acute Services Division return units to Ward 33.For community rentals, return to Acelity. PICO® (Disposable NPWT system) A disposable and portable system designed to kick start wound healing. It can be used on both acute and chronic wounds, diabetic or pressure ulcers, flaps and grafts and surgically closed incision sites. The pack contains one PICO® device and two PICO® dressings. Advice should be sought from the local tissue viability nurse or specialist nurse before using. Contraindications Contraindicated in the presence of: malignancy in the wound bed or wound margins (except in palliative care to enhance quality of life). Dressing Size (Pack Size) Drug Tariff Cost – Feb 2016/7

(Each) PICO® 10cm x 20cm (1)

10cm x 30cm (1) 10cm x 40cm (1)

£123.50 £123.50 £141.61

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Area Drug and Therapeutics Committee 15cm x 15cm (1) 15cm x 20cm (1) 15cm x 30cm (1) 20cm x 20cm (1) 25cm x 25cm (1)

£123.50 £123.50

£141.61 £141.61 £141.61

Wound Drainage Bag Wound drainage bags have a central hydrocolloid island that can be cut and shaped to fit the wound. They are particularly useful in large abdominal wounds with high levels of exudate, where conventional dressings would need to be changed more than twice daily. Dressing Size (Pack Size) Drug Tariff Cost – Feb 2016/7

(Each) Biotrol® Draina S Fistula Mini (30)

Medium (20) Large (20)

£2.43 £3.64 £4.48

Eakin® Wound Pouches (various closures)

Small (10) Medium (10) Large (10) Extra Large (5)

From £4.52 From £6.58 From £8.60

From £15.17 Other sizes/styles are available, contact companies directly for sizes and prices.

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Glossary of Wound Terms Angiogenesis Generation of new blood vessels initially seen at the base of a

wound. Autolysis Breakdown of devitalised tissue by leucocytes. Biofilm A thin but robust layer of mucilage adhering to a solid surface

and containing a community of bacteria and other organisms. Cellulitis A spreading non-suppurative infection of the soft tissue. Colonisation Multiplication of micro-organisms without a corresponding

host reaction. Contraction Function of the healing process in granulating wounds

whereby the edges of the wound are drawn towards each other.

Debridement Removal of devitalised tissue and foreign matter from a wound.

Epithelialisation Final stage of the proliferative phase. Eschar Scab consisting of dried serum and devitalised dermal cells. Granulation Formulation of new tissue filling the defect which takes place

during the proliferative phase of healing. The name is derived from the fact that the buds of new tissue take on the appearance of small granules.

Healing by first intention Also called Primary Intention. Wounds are closed leaving a minimal defect.

Healing by secondary intention Wound left open and allowed to heal by granulation. Healing by third intention Also called Tertiary intention, or delayed closure. Wound left

open often to assist drainage and closed surgically at a later date.

Hypergranulation Granulation tissue is raised above the peri-wound area. Infection Micro-organisms present and multiplying, producing an

associated host reaction. Reaction may take various forms. Maceration Softening or sogginess of the tissue owing to retention of

excessive moisture. Necrosis Local death of tissue. Tissue is often black/brown in colour

and leathery in texture. Slough Devitalised tissue which has yellow/white/grey hue.

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Reading List Cooper R (2009) Biofilms: hard to detect, easy to under estimate, but most definitely here to stay. Wounds UK. 9 (1) p.12. Dow G (2003) Bacterial swabs and the chronic wound: When, how and what do they mean. Ostomy Wound Management. 49; 5A supplement: p. 8-13. Drugs and Therapeutic bulletin (2010) Silver dressings - do they work? Dtb.bmj.com. p. 38-42. European Wound Management Association (2004) Position Document Wound bed preparation in practice. London: MEP Ltd. European Wound Management Association (2005) Position Document Identifying criteria for wound infection. London: MEP Ltd. European Wound Management Association (2006) Position Document Management of wound Infection. London: MEP Ltd. European Wound Management Association (2007) Position Document Topical Negative Pressure In wound Management. London: MEP. Ltd European Wound Management Association (2008) Position Document Hard-to-heal wounds: A holistic approach. London: MEP Ltd. Gottrup F, Apelqvist J et al (2013) EWMA Document: Antimicrobials and Non-healing wounds- Evidence. Controversies and suggestions. Journal of Wound Care. 22 (5 suppl): S1-S92. Guy H (2012) The Difference Between Moisture Lesions and Pressure Ulcers. Wound Essentials. Vol. 1 p. 36-44. Available at: www.wounds-uk.com Kean J. (2010) The effects of smoking on the wound healing process Journal of Wound Care. 19 (1) p.5-8. King B (2003) A review of research investigating pain and wound care. Journal of Wound Care. 12(6) p. 219-223. Medlin S (2012) Nutrition For Wound Healing. British Journal of Nursing (Tissue Viability Supplement) Vol, 21, No 12. S11-15. NHS Quality Improvement Scotland (2009) Best Practice Statement. Prevention and Management of Pressure Ulcers. Available at www.healthcareimprovementscotland.org Phillips PL, Wolcott RD, et al. (2010) Biofilms Made Easy. Wounds International 1(3). Available at www.woundsinternational.com

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http://www.wounds-uk.com/

http://www.woundsinternational.com/

Area Drug and Therapeutics Committee Strohal R, Apelqvist J, Dissemond J et al (2013) EWMA Document: Debridement. Journal of Wound Care. 22 (suppl.1) S1-S52. Toit DF (2009) An in vitro evaluation of the cell toxicity of honey and silver dressings. Journal of Wound Care. 18 (9) p.383-399. Yates S (2012) Differentiating Between Pressure Ulcers and Moisture Lesions. Wound Essentials. Vol 2. p.16-22. Available at www.wounds-uk.com. White R, Cutting K (2008) Critical colonisation of chronic wounds: microbial mechanisms. Wounds UK. 4(1) P70-78. Wounds International (2012) Appropriate use of Silver Dressings in Wounds. An expert working group consensus. London. Available to download from www.woundsinternational.com Wounds UK (2010) PHMB and its potential contribution to wound management. Wounds UK, Aberdeen. Available at www.wounds-uk.com. Winter GD (1962) Formation of the scab and rate of epithelialisation of superficial wounds in the skin of young domestic pig. Nature 193: 293-294. RESOURCES/ LINKS

Tissue Viability Resource: www.healthimprovementscotland.org/tissueviability

Skin tear Guidelines: www.tissueviabilityscotland.org

Best practice for leg ulcer management: www.legulcerforum.org Diabetic Foot Infection Guidelines: Available on the NHS Fife Intranet Evidence based practice: www.joannabriggs.edu.au The JBI approach to evidence-based health care is unique. The JBI considers evidence-based health care to be reliant on the evidence, the context in which care is delivered, individual client preference and the professional judgement of the health professional.

RELATED POLICIES

NHS Fife SOP for Wound Care (July 2010) NHS Fife Policy for Prevention of Pressure ulcers (Operational Division 2010) NHS Fife The use of Sterile Larvae in wound management CP-15 (January 2011) SIGN Guidelines 120. Management of Chronic Venous Leg Ulcers (August 2010)

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http://www.woundsinternational.com/


http://www.healthimprovementscotland.org/tissueviability

http://www.tissueviabilityscotland.org/

http://www.legulcerforum.org/

http://www.joannabriggs.edu.au/

Area Drug and Therapeutics Committee Appendix 1 - Woundcare Products Conversion Chart Product Group First Choice Second Choice Examples of Non Formulary Products Barrier Films Cavilon® No Sting Barrier

Film ( Community) Cavilon® Cream ( Community) Secura® (Hospital)

Brava® Clinifilm® Cutimed® Protect LBF ® No Sting Barrier Film

Medi® Derma-S Ostoguard® Pelican® Protect Peri-Prep® SkinSafe®

Sorbaderm® Sudocrem® Trio Silesse®

Vapour Permeable Adhesive Films

365® Film - Hospital Tegaderm® Adhesive Film - Community

Askina® Derm Bioclusive® C-View® ClearFilm® Hydrofilm®

Hypafix® Leukomed® T Mepitel® Film Mepore® Film Opsite® Flexigrid

Polyskin® II Protectfilm® Suprasorb® F Vacuskin®

Non Adherent Dressings

N-A® Ultra N-A® dressing Primary® Tricotex®

Low Adherence Dressings

Premierpore® Cosmopor® E Leukomed® Medipore®

Medisafe® Mepore® Primapore®

Softpore® Sterifix® Telfa® Island

Hydrocolloid Dressings Comfeel® Plus Transparent

Duoderm® Extra Thin ActivHeal® Askina® Biofilm Transparent Duoderm® Signal

Flexigran® (& Thin) Granuflex® Hydrocoll® Nu-Derm® (& Thin)

Suprasorb® H Tegaderm® Hydrocolloid Ultec® Pro

Foam Dressings Biatain®/ Biatain® Adhesive Tielle® Plus/ Tielle® Xtra (specialist use only) Tegaderm® Foam Adhesive (Heel only)

ActivHeal® Foam Allevyn® Allevyn® Adhesive Allevyn® Gentle Border

Allevyn® Plus Adhesive Permafoam® / Permafoam® Comfort

Polymem® Tegaderm® Foam Adhesive Trufoam®

Hydrofibre Dressings Aquacel® Extra Activheal Aquafibre Hydrofibre Foam Dressings

Aquacel® Foam

Hydrogel Dressings Purilon®

ActivHeal®Gel Askina® gel Aquaflo® Aquaform® Coolie® Flexigran® Gel

Gel FX® Geliperm® Granugel® Hydrosorb® Intrasite®

Mesitran® Novogel® Nu-Gel®

Alginate Dressings Tegaderm® Alginate Kaltostat ® Activheal® Alginate Algisite® M

Algosteril® Cutimed® Alginate Melgisorb®

Sorbalgon® Sorbsan® Flat

Deodorising Dressings Clinisorb® Carboflex® Askina® Carbosorb Carbopad® VC Sorbsan® Plus Carbon

Silicone Dressings Mepitel® Mepitel® One Mepilex® Mepilex® Border

Allevyn® Gentle Allevyn® Gentle Border

Allevyn® Life Askina® SilNet Cutimed® Siltec

Mepilex® Transfer Silflex® Silon -TSR®

Super Absorbent Dressings

Eclypse® - Hospital Flivasorb® - Community

Kerramax® Mesorb® Zetuvit-E®

Silver containing Dressings

Melgisorb® Ag

Askina® Calgitrol Ag Acticoat® Flex 3 Acticoat® Flex 7 Acticoat® Moisture Control Actisorb® Silver Algisite® Ag Allevyn® Ag etc

Atrauman® Ag Aquacel® Ag Biatain® Ag Mepilex® Ag Physiotulle® Ag Polymem® Silver Silvercel® & NA

Sorbsan® Silver Tegaderm® Alginate Ag Urgocell® Silver Urgosorb® Silver Urgotul® Silver

Antimicrobial Dressings Cutimed® Sorbact Honey Preparations Medihoney® Apinate

Medihoney® Tulle Activon® ointment Actilite®

Activon® Tulle

Algivon® Mesitran®

Iodine containing Dressings

Inadine® Iodoflex®

Iodosorb® Iodozyme® Oxyzyme®

Antimicrobial Alginate Gel

Flaminal® Forte Flaminal® Hydro

Pain Management Dressings

ActiFormCool®

Biatain® IBU

Debridement Product Debrisoft® pad Tulle Dressings Physiotulle® Jelonet® Paragauze® Urgotul®

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Appendix 2 – Wound Assessment Chart

Assessment Chart for Wound Management For multiple wounds complete formal wound assessment for each wound. Add Inserts as needed.

Factors which could delay healing: (Please tick relevant box)

Immobility □ Poor Nutrition □ Diabetes □ Incontinence □ Respiratory / Circulatory Disease □ Anaemia □ Medication □ Chemotherapy □ Wound Infection □ Previous History of MRSA Infection □ Inotropes □ Anti-Coagulants □ Oedema □ Steroids □ Other ………….. Allergies & Sensitivities ………………………. Body Diagram Front Back

Mark location with ‘X’ and number each wound Type of Wound Total number & duration of each type of wound

Leg Ulcer ………………………………….. Surgical Wound ………………………………. Diabetic Ulcer ………………………….… Pressure Ulcer ……………………………….. Other, specify ………………………………

Feet Diagram

Right Left

Mark location with ‘X’ and number each wound Date referred to:

TVN …………….Physiotherapist……………. Podiatrist………………Dietician……………... Other (please specify)…………………………. Assessors signature: ……………………….. Date: ………………………..…………………...

WRITE, IMPRINT OR ATTACH LABEL Surname ……………….... CHI No ….………….. Forenames ………………… Sex………………….. DoB ……………….. Location……………………………………………………

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Formal Wound Assessment Complete on initial assessment and thereafter complete at every dressing change

Date of Assessment

Number of wound

Analgesia required (Refer to local pain assessment tool)

Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No

Regular/ongoing analgesia

Pre-dressing only Wound Dimensions (enter size) Length (cm/mm) Width (cm/mm) Depth (cm/mm) Or trace wound circumference Is wound tracking/undermining Photography Tissue type on wound bed ( enter percentages) Necrotic (Black)

Sloughy (Yellow/Green)

Granulating (Red)

Epithelialising (Pink)

Hypergranulating (Red)

Haematoma

Bone/tendon

Wound exudate levels/ type (tick all relevant boxes) Low Moderate High * Serous (Straw) Haemoserous (Red/Straw) Purulent (Green/Brown/Yellow)* Peri-wound skin (tick relevant boxes) Macerated (White) Oedematous * Erythema (Red)* Excoriated (Red) Fragile Dry/scaly Healthy/intact Signs of Infection * 1 or more of these signs may indicate possible infection Heat * New slough/necrosis(deteriorating wound bed)* Increasing pain* Increasing exudate* Increasing odour* Friable granulation tissue* Treatment objectives (tick relevant box) Debridement Absorption Hydration Protection Palliative / conservative Reduce bacterial load Assessors Print Initials Dressing Renewed (planned or unplanned dressing change)

Re-assessment date

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Wound Treatment Plan and Evaluation of Care

To be completed when treatment or dressing type / regime altered NB Please write clearly

Date Wound

Number Cleansing Method, Dressing Choice & Rationale

Frequency

Evaluation & Rationale for changing dressing type

Signature

Packing Yes / No (circle) Amount …………………





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NHS Fife Woundcare Guidelines

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