NPUAP Mission - National Pressure Ulcer Advisory Panel · PDF file6/29/2016 2 International...

6/29/2016

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Clinical Practice Guidelines:

Wound Dressings for the

Management of Pressure

Injuries

Margaret Goldberg, MSN, RN, CWOCN

June 29, 2016

npuap.org

NPUAP MissionThe National Pressure Ulcer

Advisory Panel (NPUAP)

serves as the authoritative

voice for improved patient

outcomes in pressure injury

prevention and treatment

through public policy,

education and research.

©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

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International Guideline

NPUAP – in collaboration with the

European Pressure Ulcer Advisory

Panel (EPUAP) and the Pan Pacific

Pressure Injury Alliance (PPPIA) –

has worked to develop a NEW

pressure ulcer prevention and

treatment Clinical Practice

Guideline and a companion Quick

Reference Guide.

Purchase your copy today at

www.npuap.org

npuap.org©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

NPUAP Monograph

Released in November 2012, the 254-page,

24 chapter monograph, Pressure Ulcers:

Prevalence, Incidence and Implications for the

Future was authored by 27 experts from NPUAP

and invited authorities and edited by NPUAP

Alumna Dr. Barbara Pieper.

The monograph focuses on pressure ulcer rates

from all clinical settings and populations; rates in

special populations; a review of pressure ulcer

prevention programs; and a discussion of the

state of pressure ulcers in America over the last

decade.

Purchase the monograph today at www.npuap.org

• E-version $49

• Individual Chapters $19npuap.org


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Save the date


Save the date


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25 – 29 September

www.wuwhs2016.com

THANK YOU to the following companies that have provided support for this webinar!

American Medical Technologies

ArjoHuntleigh

Augustana Care

ConvaTec

EHOB, Inc.

First Quality Healthcare

Hill-Rom

Joerns Healthcare

Leaf Healthcare

Medline Industries

Mölnlycke Health Care

Span America

Tamarack Habilitation Technologies

WellsenseThe NPUAP webinar commercial supporters did not

have any input regarding the content of this

presentation.

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Faculty Disclosure

The following faculty member has listed a financial

interest/arrangement with one or more of the corporate

organizations listed below, however no conflict of

interests exists for this webinar.

• Margaret Goldberg, MSN, RN, CWOCN

Member of the Nursing Advisory Panel for Acelity.


Planning Committee Disclosures

• Sharon Baranoski, MSN, RN, CWCN, APN-CCNS, FAAN

• Joyce Black, PhD, RN, CWCN, FAAN

• Jeffrey Levine, MD

• Mary Litchford, PhD, RD, LDN

• Sally O’Neill, PhD

• Mary Sieggreen, MSN, CNS, NP, CVN

The planning committee members have listed no financial interest/arrangements that would be considered a conflict of interest.


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Objective

Describe criteria for wound dressing

selection from the clinical practice

guidelines


Strengths of Evidence - The body of evidence supporting each recommendation was given a level of evidence

A. The recommendation supported by direct scientific evidence controlled trials on pressure ulcers in humans (level 1 studies)

B. Supported by direct scientific evidence from clinical series on pressure ulcers in humans

(level 2, 3, 4, 5 studies)

C. Supported by indirect evidence (e.g. studies in healthy humans, humans with other types of chronic wounds, animal models) and/or expert opinion


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Introduction to wound dressings for treatment of pressure ulcers

Wound dressings are a central

component of pressure ulcer care


Since the 1960’s, it has been accepted that wound

healing is optimized when the wound is kept in

a moist environment rather than

– air-dried (OTA)

– dried with heat lamps

– treating with topically applied drying agents

Dressings for Pressure Ulcers


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Dressings

Occlusive or semi-occlusive

wound dressings that maintain

wound bed moisture promote

re-epithelialization and wound

closure

Wound dressings for pressure

ulcers are designed to:

• Improve wound healing time

• Absorb blood and tissue exudate

• Minimize pain associated with

application and removal

• Absorb and control malodour

• Reduce injury to periwound skin


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General Recommendations

Wound dressing selection is based on the:

– Ability to keep the wound bed moist

– Need to address bacterial bioburden

– Nature/volume of wound drainage

– Condition of the tissue in the ulcer bed

– Condition of peri-ulcer skin

– Ulcer size, depth and location

– Presence of tunneling and/or undermining

– Goals of the individual with the ulcer

SOE = C©2016 National Pressure Ulcer Advisory Panel | www.npuap.org


A clean granulating pressure ulcer requires a dressing that

remains in contact with the wound bed or a skin barrier that

keeps the periwound dry and prevents maceration.

As the ulcer either heals or deteriorates over time, the type of

wound dressing most appropriate for promotion of healing may

change.

For example wound exudate usually decreases as the pressure

ulcer heals.

This statement is based on expert opinion


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Protect peri-ulcer skin

(SOE = C)




Assess pressure ulcers at

every wound dressing

change and confirm the

appropriateness of the

current dressing regimen.

SOE = C


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(SOE = C)

Follow manufacturer

recommendations,

especially related to

frequency of dressing

change


Change dressing if feces seep

beneath the dressing

(SOE = C)


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The plan of care should

guide usual dressing wear

times and contain

provisionary plans for

dressings changes if needed

(for family, individual and

staff) due to soiling,

loosening, etc. (SOC = C)



Ensure dressing material

completely removed with each

dressing change

(SOE = C)


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Hydrocolloid Dressings

• Use for clean Stage 2 pressure ulcers in

body areas where they will not roll or

melt. (SOE = B)

• Consider use for noninfected, shallow

Stage 3 pressure ulcers.

(SOE = B)

• Consider using filler dressings beneath

hydrocolloid dressings in deep ulcers to

fill in dead space.

(SOE = B)


Hydrocolloid Dressings

HCPC Codes A6234 –A6241

For use on wounds with light to moderate exudate.

Usual dressing change for covers or fillers, is up to 3

times per week.

Remove carefully on fragile skin to reduce

skin trauma

(SOE = B)


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Transparent Film Dressings

• Consider using for autolytic debridement

when the individual is not

immunocompromised. (SOE = C)

• Consider using as a secondary dressing for

pressure ulcers treated with alginates or

other wound filler that will likely remain in

the ulcer bed for an extended period of time

(e.g., 3-5 days).

(SOE = C)

• Carefully remove film dressings on fragile

skin to reduce skin trauma. (SOE = C)


Transparent Film Dressings (cont.)

Do not use as the tissue interface layer over moderately to heavily exudating ulcers. (SOE = C)

Do not use as the cover dressing over enzymatic debriding agents, gels or ointments. (SOE = C)

HCPC A6257-A6259

Covered when used on open partial thickness wounds

with minimal exudate or closed wounds.

Usual dressing change is up to 3 times per week.

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Hydrogel Dressings

Consider use on shallow, minimally

exudating pressure ulcers.

(SOE = B)

Consider the use of amorphous hydrogel for

pressure ulcers that are not clinically infected

and are granulating. (SOE = B)

Consider use for treatment of dry ulcer beds

(SOE = C)

Consider use for painful pressure ulcers.

(SOE = C)©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

Hydrogel Dressings (Cont.)

Consider the use of hydrogel sheet dressings for

pressure ulcers without depth and contours and/or

on body areas that are at risk for dressing

migration. (SOE = C)

Consider the use of amorphous hydrogel for

pressure ulcers with depth and contours and/or on

body areas that are not at risk for dressing

migration. (SOE = C)

HCPC A6231-A6233 – A6242-A6248 Pads, Ribbons

Used on full thickness wounds with minimal or no exudate (e.g.,

stage 3 or 4 ulcers).Usual dressing change for hydrogel wound cover

without adhesive border or hydrogel wound fillers is up to once per

day.©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

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Alginate Dressings

Consider for the treatment of moderately and heavily exudating ulcers. (SOE = B)

Consider in clinically infected ulcers when there is appropriate concurrent treatment of infection. (SOE = C)

Gently remove the alginate dressing, irrigating it first to ease removal if necessary.

(SOE = C)

Consider lengthening the interval or changing the type of dressing if the alginate dressing is still dry at the scheduled time for dressing change. SOE = C)©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

Alginate Dressings

HCPC A6196-A6199 - Alginate or other fiber

gelling dressing

For moderately to highly exudative full

thickness (e.g., stage 3 or 4 ulcers): and

alginate or other fiber gelling dressing

fillers for moderately exudative full

thickness wound cavities (e.g., stage 3 or

4 ulcers).

Not medically necessary for dry wounds or

covered with eschar. Change once per day.


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Foam Dressings

Consider using on exudative Stage 2 and shallow stage 3 pressure ulcers. (SOE = B)

Avoid using single small pieces of foam in exudating cavity ulcers. (SOE = C)

Consider using gelling foam in highly exuding pressure ulcers. (SOE = C)

HCPC A6209-A6215 Foam Dressings

Used on full thickness wounds (e.g., stage 3 or 4

ulcers) with moderate to heavy exudate.

Dressing change up to 3 times week. Foam wound

fillers up to once per day.©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

Silver-Impregnated Dressings

Consider use for pressure ulcers that are

clinically infected or heavily colonized.

(SOE =B)

Use for ulcers at high risk of infection.

(SOE =B)

Avoid prolonged use, discontinue when

wound infection is controlled.

(SOE = C)

HCPC 4649 – Surgical Supply Misc.©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

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Honey-Impregnated Dressings

Consider use of dressings impregnated with medical-grade honey for the treatment of Stage 2 and 3 pressure ulcers. (SOE = C)


Cadexomer Iodine Dressings

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HCPC A6261-Gel HCPC A6262-Pad

Reduces bacterial load. Once daily dressing change.

Consider use in moderately to highly

exudating pressure ulcers. (SOE = C)


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Gauze Dressing

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Avoid using for open pressure ulcers that have

been cleansed and debrided because they are

labor-intensive, cause pain when removed if dry,

and lead to desiccation of viable tissue if they dry.

(SOE = C)

When other forms of moisture-retentive dressings

are not available, continually moist gauze is

preferable to dry gauze.

(SOE = C)

Use as a cover dressing to reduce evaporation

when the tissue interface layuer is moist.

(SOE= C)


Gauze Dressing

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Use loosely woven gauze for highly

exuding ulcers: tightly woven gauze used

for minimally exuding ulcers. SOE = C

Loosely fill (rather than tightly pack) ulcers

with large tissue defects and dead space

with saline-moistened gauze when

moisture retentive dressing are not

available SOE = C

Change gauze often enough to manage

exudate SOE = C


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Gauze Dressing

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Use a single gauze strip to fill deep ulcers;

Do not use multiple gauze dressings, because

retained gauze in the ulcer bed can serve as a

source of infection. (SOE = C)

Consider using impregnated forms of gauze to

prevent evaporation of moisture from continuously

moist gauze dressing. (SOE = C)

Gauze non-impregnated A6216-A6221, A6402-6404,A6407

Gauze, impregnated w/other than water, normal saline,

hydrogel or zinc paste A6222-A6224, A6266

Gauze impregnated water or normal saline A6228-A6230)


Silicone Dressings

Consider using as a wound contact layer to promote atraumatic dressing changes.

(SOE = B)

Consider using to prevent periwound tissue injury when periwound tissue is fragile or friable.

(SOE = B)

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HCPC A6025 Gel Sheet


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Collagen Matrix Dressings

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Consider use for non-healing Stage 3 and 4

pressure ulcers. (SOE = C)

HCPC A6010-Collagen based wound filler,

dry form

A6011 Collagen based wound filler

gel/paste

A6021-A6024 Sterile sheet may be used as

a primary or secondary dressing.


Composite Dressings

Many of the dressing types listed here are manufactured in combinations.

Various composite dressings with new components for specific purposes emerge in the wound dressing market.

42 ©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

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Biological Dressings

Biologicals function as protective wound cover and may be cellular (contain living cells) or acellular (bioglogically inert).

Due to insufficient evidence to support or refute the use of biological dressings in the treatment of pressure ulcers, biological dressings are not recommended for routine use at this time. SOE= C

43 ©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

Growth Factors: Recombinant Platelet-Derived Growth Factor

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Consider using Platelet-Derived Growth

Factors for treatment of stage 3 and 4

pressure ulcers that have delayed healing.

SOE = B


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Growth Factors: Other growth factors

45

Due to insufficient evidence to support or

refute the use of growth factors (other

than recombinant platelet-derived growth

factor) in the treatment of pressure ulcers

they are not recommended for routine use

at this time.

SOE = C


Prophylactic Dressings

Emerging evidence supports a role of

prophylactic dressing in decreasing friction

and reducing localized shear forces.

Consider applying a polyurethane foam

dressing to bony prominences (e.g., heels,

sacrum) for the prevention of pressure

ulcers in anatomical areas frequently

subjected to friction and shear. SOE = B


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When selecting a prophylactic dressing

consider:

• Ability of the dressing to manage

microclimate

• Ease of application and removal

• Ability to regularly assess the skin

• Anatomical location where the dressing

will be applied

• The correct dressing size SOE = C



Continue to use all other preventative

measure necessary when using prophylactic

dressings SOE = C

Assess the skin for signs of pressure ulcer

development at each dressing change or at

least daily, confirm appropriateness of

current regiment SOE= C

Replace the dressing if damaged, displaced

loosened or excessively moist. SOE = C©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

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Negative Pressure Wound Therapy (NPWT)

NPWT used as wound treatment modality for

decades

Used as late treatment for recalcitrant

wounds

Now being used as a first line treatment

More research is needed to identify which

participants are most likely to benefit from NPWT



NPWT has greatest efficacy in reducing wound

volume

Serves as an adjuvant therapy when combined with

debridement and other treatments that promote

wound healing such as nutritional support and

pressure redistribution.


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1. Consider as an early adjuvant for the treatment

of deep Stage 3 or 4 pressure ulcers SOE B

2. Debride Pressure Ulcer of necrotic tissue prior to

NPWT SOE = C

3. Follow a safe regimen in applying and removing

NPWT system SOE = C



4. Evaluate the pressure ulcer with each dressing

change

5. If pain is anticipated consider:

nonadherent interface dressing

lowering the level of pressure, change type of

pressure

use moist gauze filler instead of foam

6. Educate the individual and caregivers about

NPWT when used in the community setting


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Apply Evidence to Practice

Be sure to carefully read dressing

package inserts to ensure

appropriate interventions

It is every clinician’s responsibility

to educate other healthcare

providers and to provide

references for their consideration

Contemporary practice should

always incorporate evolving

evidence

Inspire change in your practice setting!

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