Standard Operating Procedure Template

Transcription

1 Standard Operating Procedure Template Title of Standard Operation Procedure: Topical Negative Pressure (TNP) Reference Number: Version No: 1 Issue Date: May 2012 Review Date: August 2015 Purpose and Background Scope (i.e. organisational responsibility) Vital functions affected by this procedure: Monitoring Compliance The purpose of this document is to provide guidance for the clinician on the safe use of Topical Negative Pressure for the management of complex wounds. This is one of the treatments that is referenced in the Wound management guidance. TNP has been provided previously but not in a co-ordinated way (previously having two different pumps in use). This is the first document that provides guidance for both community and Hospital use. The organisation has a responsibility to ensure procedures are carried out in a safe and consistent way following best practice. A consistent training programme following a competency framework for all staff using TNP be used to ensure safe working practices are followed. Pathways for assessment will ensure consistency of assessment and evidence of documentation will provide a monitoring process for this. A patient pathway for discharge from MGDH to community will enhance patient flow and reduce hospital bed days. Requirement to be monitored. Must include all requirements within NHS LA Standards Process to be used for monitoring e.g. audit Responsible individual/ committee for carrying out monitoring Frequency of monitoring Responsible individual/ committee for reviewing the results Responsible individual/ committee for developing action plan Responsible individual / committee for monitoring action plan Assessment of patient against standard Details of all cases on Community using TNP, clinical outcomes, TNP Assessment documentation Report produced by TV Tissue Viability/Matro n PCT contract monitoring days Escalations (if you require any further clarification regarding this procedure please contact): annually Quarterly Sue Cooke Sally Walsh Tissue Viability Lead Nurse Consultation: Committees / Group Mr Khan (surgical consultant) Surgical ward managers Surgical matron Tissue Viability team Infection control Date April 2012 March 2012

2 Approval Committee Community Business unit SQS Corporate SQS Ratified by Committee: Community Business Unit SQS July 2012 Received for information: Operating Procedure Definition Topical negative pressure (TNP) is a therapy, which applies a topical negative pressure to the wound. (This is also sometimes referred to as VAC therapy). A foam or gauze based dressing is applied to the wound and sealed using a transparent adhesive drape. A negative pressure is then applied across the wound via a drainage tube secured in the drape. Wound exudate is collected in a canister at the end of the tube fitted into the pump. The aims of negative pressure are to; Improve the blood flow Draw the edges together to assist closure Promote moist healing and fast granulation Reduce bacterial colonisation The application of TNP therapy is sometimes also suitable for a small number of patients where standard treatments fail. However, it must be confirmed that a logical and competent treatment pathway has been undertaken prior to any request for TNP. Further it must be confirmed that prior treatments failed for clinical reasons and not lack of treatment competency. Indications for Use a) To provide an occlusive protective covering to reduce bacterial contamination and the risk of wound infection. b) To improve tissue perfusion, to remove wound drainage and to facilitate mechanical desloughing / debridement. c) To promote moist wound healing N.B particularly useful where; there is extensive tissue loss, risks of infection are high, or to promote healing where the wound has become static. (original policy Author s observations). Clinical Assessment for Use The use of TNP therapy is normally considered in cases where a patient has a) A large wound, too large for conventional dressings b) A reduced immune system where conventional dressings are not proving effective e.g. diabetics. Clinical Assessment will follow a set Performa and the assessment should completed and placed in the patients notes Appendix 3

3 Suitable wounds include: Cavity wounds Pressure Ulceration Traumatic Tissue Loss Diabetic Wounds Dehisced Surgical Wounds Surface wounds Trauma Burns Skin Grafts Skin/muscle flaps Leg ulcers To improve healing rate of a chronic wound that is not responding to traditional treatment or preparing site for surgical intervention. To improve micro-vascular supply of deep acute wounds and prevent bacterial contamination whilst awaiting possible surgical intervention To reduce the risk of osteomyelitis and improve healing rates To control exudate, improve healing rates and reduce the bacterial contamination To improve the micro-vascular supply to degloving injuries and so increase the healing rates or aid the take of a subsequent skin graft. To reduce burn oedema, control exudates and reduce bacterial contamination. To aid the take of skin grafts post operatively To aid the take of the flaps post operatively To debride and reduce bacterial infection and to improve healing rates Contraindications a) Non-enteric or unexplored Fistulae b) Malignancy in the wound c) Untreated osteomyelitis d) Necrotic tissue and eschar e) Do not use directly over exposed blood vessels or organs Precautions An actively bleeding wound b) Patients on anticoagulants c) In presence of bone fragments or sharp edges d) With respect to weakened, irradiated or sutured blood vessels or organs e) With enteric fistulae f) Patients with difficult wound healing Application This is done following the protocol in Appendix 1. A care plan for application will be placed in the patients nursing Notes. Consent for treatment must be agreed by the patient and documented on the assessment form. Reasons for discontinuation 1. Wound not responding to treatment after 1-2 consecutive weeks of treatment, or wound deteriorates 2. Frank pus in dressing / canister 3. Excessive bleeding / haematoma under dressing 4. Patient not happy with Treatment or self discontinuation Community discontinuation Once the TNP is discontinued return the TNP pump to Tissue Viability service. Patient Monitoring Tissue Viability will review the patient every 2 weeks whilst on TNP therapy if on the community. District nurses will undertake dressing s in-between. Whilst the patient is in MGDH the wound can be reassessed by the consultant/ Tissue Viability or any competent clinician (in TNP) depending on who initiated treatment. Timescales for reassessment to be

4 decided by the initiating clinician. This process of review continues until the therapy is no longer assessed as clinically appropriate and the therapy stops. The wound will be reassessed using a standard wound assessment form at each dressing change Competency of staff using the system TNP Therapy must only be applied by a Registered Nurse that has been assessed as competent with TNP therapy. Evidence of competence to be confirmed within each individual KSF. They must be, and feel, competent to apply and remove the therapy. Appropriate application of therapy Community Central and Eastern Cheshire PCT will support TNP Therapy for patients in the community essentially to prevent hospital admission, or allow patients to be discharged from acute settings, where TNP therapy has been previously applied and continues to be clinically appropriate. No patient discharged from hospital or within the community will have TNP therapy provided unless they have been assessed as suitable by the Tissue Viability Team. The Tissue Viability team must confirm that the patient falls within the treatment protocols and in addition that the community district nursing staff responsible for providing the treatment, are assessed as competent. If the nursing staff are not assessed as competent the tissue viability team must work with them to achieve competency in TNP before any therapy can commence. A patient who is requiring TNP on Discharge must normally have had 2 dressing changes with TNP on the ward prior to discharge to ensure no immediate complications are evident. The process flowchart for acceptance of patients in the community for TNP provided in appendix 5. If a case is confirmed as meeting the criteria for appropriate use, the patient can be considered for TNP therapy by the TV team and the PCT has funded a number of TNP therapy machines for use by the service. MGDH Patients commenced with TNP in Macclesfield District General Hospital (MGDH) must be assessed as falling within the treatment protocols. This assessment must be undertaken by a clinician who has the necessary competence and training to undertake this assessment. If TNP is requested but there is no fully competent clinician (within TNP) to undertake this assessment referral should be made to Tissue Viability to undertake this assessment. No patient will have TNP therapy provided unless they have been assessed as suitable by a competent clinician having received appropriate training in TNP. An individual must not initiate TNP if they do not feel competent to do so. The assessing clinician must confirm that the patient falls within the treatment protocols and that clinicians subsequently undertaking dressing changes for TNP are assessed as competent. If the nursing staff are not assessed as competent the tissue viability team must work with them to achieve competency in TNP before any therapy can commence. Access to machines Community The use of these machines is managed by the Tissue Viability service in line with the criteria outlined within this specification. It is understood that each case accepted for TNP requires support from the Tissue Viability team, in addition to the required district nursing input. This limits the number of cases that can therefore be supported for TNP. This has been accepted to be 4 cases by the Tissue Viability team and this is the number of machines that has been supplied to the Tissue Viability service.. However, it is accepted that there may be EXCEPTIONAL CIRCUMSTANCES where an additional machine is required above the number held by the team. In these rare cases, rental of an additional machine may be necessary. If the tissue viability lead nurse, or her designated deputy, conclude that exceptional circumstances apply, and that there is a need for a rental machine, an application to the PCT Bespoke Care Panel (BCP) must be made, with the details of the case, on the current BCP panel paperwork. By making any

5 BCP application, the TV team is confirming that it has the staffing resources to manage the additional case. If an urgent case, the papers can be identified as such, and an emergency panel will meet and decide the case. Payment for such rentals will then be managed thorough the BCP accounting processes. The BCP process is a mechanism by which the operational and financial process is managed and resourced by the PCT - and not by ECT. As such any exceptional cases agreed by the BCP are to be funded and arranged by the PCT, although the TV team may advise the BCP administration process as required. MGDH TNP is provided using the Renasys TNP system by Smith and Nephew. 5 Machines have been purchased by East Cheshire Trust for use in the hospital. These are kept in the store room. If all TNP systems are in use add hoc rental should be made using the Renasys System. 2 Rental pumps are kept on ICU and 2 on ward 6 Orthopaedics. Smith and Nephew must be informed when these are started for patients to commence invoicing (following pathway Appendix 4).. The treatment method for application of TNP is included as appendix 1. Transfer of patients from MGDH to Community requiring TNP Follow flow chart in Appendix 5 Patients for discharge with TNP must have a risk assessment (which is incorporated in the Discharge TNP chart) performed by the ward prior to discharge to confirm that the patient is safe to have TNP at home i.e. it does not present as a falls risk. A patient who is requiring TNP on Discharge must normally have had 2 dressing changes with TNP on the ward prior to discharge to ensure no immediate complications are evident. No patient discharged from hospital to the community will have TNP therapy provided unless they have been assessed as suitable by the Tissue Viability Team. Patients should be discharged with 2 full dressing systems and 2 canisters. Patients will be discharged on conventional dressings and if TNP has been assessed as being required by the Tissue Viability Nurse (TVN) will be applied within 2 days of agreed discharge date (with ward and TVN). If there is no TNP system available the ward will be informed of this and an agreed plan of future care made. Training The TVN is competent with setting up, monitoring and evaluation of TNP therapy. Competence has been obtained through guided observation and supervised practice by company representative and other TVN currently using this treatment in the hospital. TVN and the wards (if the patient is to be discharged requiring TNP) will ensure that the District Nurse looking after the patient is competent to undertake dressing changes, and training will be offered as required by the nursing team. Formal training will be offered periodically through the Trust. Infection Prevention and Control In order to reduce the risk of transmission this device must be cleaned appropriately. 1. All single use elements must be disposed of in the appropriate waste stream. 2. In the community the device should be bagged for transport 3. Decontaminate hands using soap and water, if non available use Alcohol hand gel as an interim measure. ( as per Infection Prevention and Control Good Practices Policy) 4. Put on gloves and aprons 5. Clean the canister with the appropriate disposable wipe as per the manufacturers instructions ensuring any gross contamination is removed 6. Remove Gloves and Aprons 7. Decontaminate hands 8. Return to equipment store labelled as clean ready for re use. Additional Information (if appropriate)

6 TREATMENT PROTOCOL For TNP therapy Appendix 1 Equipment TNP machine (state which model and which type of dressing) Foam dressing /gauze dressing and drape (dependant on size of wound) and level of exudate Hydocolloid dressing Urgotul to cover foam if using the black foam Information booklet Wound dressing pack Skin barrier Sterile scissors Procedure for Application Patient and medical consent must be obtained prior to treatment and information given Action Rationale 1. Explain to patient what is going to Information reduces anxiety happen 2. Wash hands, apply gloves and apron To prevent cross infection 3. Remove current dressing 4. If the surrounding skin is fragile, apply hydrocolloid to the intact skin surrounding the wound leaving the wound visible or alternatively apply skin barrier to surrounding skin. 5. If gauze with drain Line the wound with wet gauze dressing inserting drain wrapped with gauze. (See specific instructions for individual drains). If gauze with port Line the wound with wet gauze. Cover with transparent film. Cut a small circular hole in the centre of the film over the gauze. The hole needs to be 0.6cm in size. Remove any access trimmed film. Remove the backing from the port dressing; align the port over the hole in the film using gentle pressure to anchor. 6. If foam - Cut the foam to the size of the wound so it sits just in the wound. The wound edges need to touch the sponge. Do not pack tightly If using the black foam, cover all edges of the foam that touch the wound with Urgotul or Atrauman. Cover with transparent film. Cut a small circular hole in the centre of the film over the gauze. The hole needs to be 0.6cm in size. Remove any access trimmed film. Remove the backing from the port dressing; align the port over the hole in the film using gentle pressure to anchor. 7. Connect tubing with canister to tubing from port. Ensure both clamps are open. 8. Turn the machine on and the air is sucked out of the foam/gauze causing it to collapse. Set the suction at either continuous or intermittent and at recommended pressure settings (see manufacturers instructions). This will help protect the surrounding skin from trauma Dressing not to be larger than the wound as this can cause excoriation to the skin The film should extend 5cm beyond the wound margin to facilitate an adequate seal. This ensures granulation is pulled from all edges and no sinuses develop To prevent Granulation tissue being pulled through the black foam This ensures a single system, with no leaks This activates treatment, and is considered the optimum treatment for therapy. Pressure can be altered in agreement with the Tissue Viability Nurse if optimum not tolerated

7 9. The dressing should be changed at least twice a week, but this will depend on the amount of granulation tissue development and individual assessment. 11. The machine will alarm when the canister is full. Change the canister when it is full, or once a week. Record amount of drainage 12. All waste, canisters and dressings to be treated as clinical waste. 13. Ensure the patient is given the instruction booklet, explain how to trouble shoot, and given the 24hr help line number if the patient is at home. 14. To follow TNP pathway for discontinuation of TNP This improves cost effectiveness and does not unduly disturb the wound. Otherwise the machine will not run In accordance with Clinical Waste Policy Helps patient feel part of the care and reduces anxiety.

8 TNP Therapy Process Flow Chart for patients in the Community Appendix 2 Assessing clinician to identify if patient is suitable/appropriate patient for TNP tnp nttnpt ttttntnpc TV Team to assess and confirm that patient suitable and fits criteria policy Patient fits criteria No Continue on conventional dressings Yes TV team to confirm DN competency in TNP Yes No TV nurses support DN s to achieve competence prior to commencement of TNP TV team agree to apply TNP and accept patient if a machine is available and wound still deemed suitable TV team to notify DN of decision If agreed If declined No further action, continue on standard treatment TV team to arrange provision of machine, manage administration and set up commencement of TNP DN to manage, treat and review patient, with close supervision by TV team, especially in first week 2 weekly review of patient carried out by TV team If improvement identified, treatment can be continued and detail included of the patient in the 3 monthly report to CECH/PCT contract monitoring meetingissioners No improvement or no longer clinically appropriate, the TV team remove the machine and the DN s advised. Patient reverts to conventional treatment if appropriate, details included on monthly report. 3 Monthly report on patients treated with TNP therapy submitted to CECH/PCT contract monitoring meeting for consideration and review Number currently in treatment Cost of dressings per patient Number of patients treated that month Clinical outcomes of each case VAC days Summary information submitted per quarter

9 Assessment form Hospital and Community Appendix 3 Patient Name/Adress/Sticker Date of assessment: Name of assessor (This should be a skilled clinician who is competent in the techniques relevant to this system) Signature of assessor: Consultant: Patient consents to treatment (following full explanation of potential complications Signature. NHS Number: Yes NO Please ensure that the patient does not have any of the following contraindications A Non-enteric or unexplored fistulae Yes No B Malignancy in the wound (check histolgy result if required) Yes No C Untreated Osteomyelitis Yes No D Necrotic tissue and eschar Yes No E Do not use directly over exposed blood vessels or organs Yes No F A 2cm area of intact skin around the wound to enable a seal to be maintained Yes No If any of the above are answered Yes Do not proceed with TNP. If unsure how to manage wound refer to Tissue viability Service Precautions A Actively bleeding wound Yes No B Patients on anticoagulants or difficult haemostasis Yes No C In presence of bone fragments or sharp edges Yes No If any of the above are answered Yes and the decision is made to use TNP monitor patient, Hb and INR closely. Aim of treatment (please indicate all that apply) Promote rapid growth of granulation tissue Manage exudate Draw edges of wound together to assist closure Prevent infection Other (please state) Expected length of time using TNP? (It is not expected to use TNP as a long-term management option) It is expected that the patient and wound will be reassessed at each dressing change If any of the above contraindications develop the TNP must be stopped If any of the precautions develop assess/ask medical advice for ability to continue using TNP. If NO progress within 2 weeks (meeting its aims) Stop TNP. Refer to Tissue Viability Nurse if required TNP commenced Yes NO Date started

10 Flow Chart for MGDH from Assessment to Accessing the Machines Appendix 4 Commencement to Topical Negative Pressure (TNP) Avenues how TNP may be commenced 1. Request for TNP by Consultant 2. Clinician thinks TNP required but unsure Refer to Tissue Viability Service for assessment 3. Wound not responding to conventional treatment Before initiating TNP; address any potential barriers to healing Patient must consent to treatment and sign on assessment form Process for Initiation Patient initial assessment to be undertaken by a competent clinician (in TNP) and clinical assessment form completed Decision not to use TNP Use conventional dressings and refer to Tissue Viability Service Decision to use TNP I If any of the problems occur during treatment eg. Bleeding, skin reaction, pain, infection, increase in size Discontinue immediately and document TNP Available Check Medical equipment Library room for Trust stock for TNP pump and log out YES Commence Care Plan and insert patient information and frequency of dressing changes No TNP available Rental TNP 2 x l TNP with ICU 2 x TNP with Orth unit Contact Smith & Nephew Tel: With pump no and commencement date Apply TNP (To be done by competent practitioner in TNP) Trouble Shooting If pump alarms: Check seal Check if canister needs changing Check clamps not on Check tube if blocked YES Reassess at each dressing and document assessment on wound care plan needs to be done at least 2 x week TNP meeting its aims and is reducing in size TNP not meeting its aims Discontinue or and use convention dressings Refer to Tissue Viability Service

11 Hospital / Ward Clinic inform Tissue Viability Nurse of proposed discharge date Ward to complete TNP referral form for Tissue Viability Fax to Patient must have had 2 dressing changes on the ward with TNP prior to discharge Tissue Viability TNP Patient Record form Flow Chart for Patient Transferring from Hospital to Community with TNP Tissue Viability Service - TNP Therapy Acceptance Pathway Tissue Viability Nurse to check a) Type of Wound suitable for TNP Contraindications Unexplored fistulae to organs/body cavity Malignancy to wound (review histology) Untreated osteomyelitis Necrotic tissue Exposed blood vessels or organs Precautions Patient on anticoagulants In presence of bone, fragments or sharp edges Actively bleeding wound b) District Nurse for patient area are contacted prior to discharge to check competency of TNP therapy TNP to be agreed by TVN senior nurses prior to commencement. Tissue Viability to meet with District Nurse on first dressing change to bring machine All D/N s to be competent in the use of TNP before undertaking unsupervised dressing changes Arrange visit for TV within 2 working days of discharge Ensure one week supply of dressing accompany patient on discharge Discharge patient on conventional dressings A) Tissue Visibility Nurse to complete TNP Patient record form with: Patient details Wound location TNP information Patient information explained Reason for introduction of TNP therapy Completed forms to be placed in the TNP review Folder. B) Tissue Viability to arrange first TNP visit review to support District Nurse regarding evaluate treatment and document reviews on record form Continue every 2 weeks until discontinuation Appendix 5 C) Tissue Viability Nurse to complete: Outcome i.e. Wound healed or reason for TNP discontinued. Frank pus in canister Excessive bleeding / haematoma under dressing Treatment after TNP which dressing used End date: DN must let TV know if TNP discontinued between TV reviews TISSUE VIABILITY LEAD TO PROVIDE COMMISSIONERS WITH TNP DATA ON A MONTHLY BASIS

12 Abbreviations BCP Bespoke Care Panel ECT East Cheshire Trust DN District Nurse MDGH Macclesfield District General Hospital PCT Primary Care Trust TNP Topical Negative Pressure TV Tissue Viability TVN Tissue Viability Nurse References Banwell PE, Teot L. Topical negative pressure (TNP): the evolution of a novel wound therapy. Journal of Wound Care. Vol Evans D, Land L. Topical negative pressure for treating chronic wounds (Cochrane Review). The Cochrane Library, Issue 2, Oxford: Updated Software. Greer SE, Duthie E, Cartolano B, Koehler KM, Maydick Youngberg D, Longaker MT. Techniques for applying sub-atmospheric pressure dressing to wounds in difficult regions of anatomy, J Wound Ostomy Continence Nurs 1999; 26(5) : Pathway for V.A.C. therapy. (Discharge from hospital) 2009 Consent Policy (2003) CECH Documentation and Record keeping. Hand Washing Policy Clinical Waste Policy CECH VAC Therapy Clinical Guidelines A reference source for clinicians Nov 2005