Guidance for the use of Wound Care Products

Transcription

1 Mid Cheshire Hospitals NHS Trust Central and Eastern Cheshire Primary Care Trust East Cheshire NHS Trust Cheshire East Community Health Guidance for the use of Wound Care Products Issued: September 2010 Review: September 2012

2 Examples of dressing choice according to tissue type Wound type Necrotic Sloughy Granulating Epithelialising Treatment aim Debride Remove slough. Promote or protect Promote Provide clean granulation. epithelialisation and base for Provide healthy base wound maturation granulation tissue for epithelialisation Primary dressings Actiform Cool or Actiform Cool, Protect - Tegaderm Tegaderm hydrocolloid low to medium Tegaderm Activon Tulle Foam, or Allevyn, thin or C View or exudate hydrocolloid or Larvae or Atrauman Atrauman or N A Ultra Promote granulation - Tegaderm hydrocolloid or Urgotul Primary dressings, Not applicable Aquacel or larvae Sorbsan Plus Not applicable heavy exudate or Algivon or Sorbsan Plus Secondary Pad and retaining Pad and retaining Pad and retaining Pad and retaining dressings bandage e.g. bandage e.g. bandage e.g. Clinifast bandage e.g. Clinifast may be all Clinifast may be all may be all that is Clinifast may be all that is required that is required required over Urgutol that is required over Moderate exudate: or Sorbsan Plus Atrauman or N A Ultra Allevyn Allevyn or Tegaderm Heavy exudate: Foam (if required) Sorbsan Plus or contact TV for further management. For larvae therapy follow policy This table represents guidance only and should be used in conjunction with clinical assessment. It is expected that the majority of wounds can be managed according to this guidance. Any that cannot, refer to Tissue Viability Nurse.

3 Infected Fungating Diabetic Foot Venous Leg Ulcer Manage infection Palliation e.g. Preserve tissue Promote venous return and absorb exudate manage odour, viability to achieve healing bleeding, exudate Consult GP or Atrauman or NA Ultra Atrauman or Inadine Atrauman or NA Ultra Microbiologist and Fast-track to 2* regarding need for Specialist Podiatrist. systemic antibiotics. Consult TV Nurse regarding choice of dressings as silver products could be used. Aquacel. Sorbsan Plus Aquacel or Sorbsan plus Consult TV if 2* Follow wound management is difficult assessment pathway Allevyn or pad and Use selected compression retaining bandage system. e.g. Clinifast may be all that is required. See leg ulcer guidance. Clinisorb to help manage odour.

4 Wound Care Products Product Sizes Units Price per Dressing Comments on use available per single changes outer item (FP10) 1* Actiform Cool 10cm x 10cm days Hydrogel sheet that will de-bride necrotic 5cm x 6.5cm tissue. Personal experience suggests a very 10cm x 15cm useful product for debriding haematomas. 20cm x 20cm Cut to the size of the wound. Allevyn 5cm x 5cm days Highly absorbent. For moderately to heavily Non adhesive 10cm x 10cm exuding wounds only. Not to be used for 20cm x 20cm pressure relief. 10cm x 20cm Allevyn 7.5cm x 7.5cm days The sizes given include the wound contact pad Adhesive 10cm x 10cm plus the adhesive border (e.g. for the smallest 12.5cm x 12.5cm square dressing the wound contact pad 17.5cm x 17.5cm is 5cm x 5cm). 22.5cm x 22.5cm cm x 22.5cm cm x 17cm (anatomically shaped sacral dressing) 22cm x 22cm days (anatomically shaped sacral dressing) Aquacel 4cm x 10cm days Heavily exuding wounds only. 4cm x 20cm cm x 30cm Has desloughing action. 5cm x 5cm cm x 10cm cm x 15cm cm x 45cm ribbon days Atrauman 5cm x 5cm 50 25p Up to Non adherent greasy dressing. Tulle dressing 7.5cm x 10cm 50 26p 5 days 10cm x 20cm 30 58p 20cm x 30cm Comfeel Plus 10cm x 10cm Up to Thin, self adhesive, hydrocolloid. Not to be Transparent 15cm x 15cm days applied to infected or heavily exuding wounds Duoderm 5cm x 10cm 10 71p 7 days Minimally exuding wounds only Extra Thin 9cm x 15cm Occlusive. 9cm x 25cm Can be used for protecting surrounding 9cm x 35cm skin during VAC or larval therapy. 7.5cm x 7.5cm 5 75p 10cm x 10cm cm x 15cm

5 Wound Care Products Product Sizes Units Price per Dressing Comments on use available per single changes outer item FP10 Kerramax 10cm x 22cm Change Highly absorbent primary or 20cm x 22cm according secondary dressing. to level of Does not have a plastic backing. exudate Mepore 7cm x 8cm 55 10p Up to Useful as a primary dressing for wounds Dressing 10cm x 11cm 40 21p 7 days healing by primary intention or as a 11cm x 15cm 40 34p secondary dressing. 9cm x 20cm 30 42p 9cm x 25cm 30 58p Absorbent, perforated dressing 9cm x 30cm 30 66p with adhesive border. 9cm x 35cm 30 72p NA Ultra 9.5cm x 9.5cm 9.5cm x 19cm p 63p Up to 7 days Silicone coated, non-adherent dressing. Opsite IV cm x 7cm p Up to For Intravenous/Sub-Cutaneous therapy Non-winged 7 days peripheral. The vapour permeability is higher than 7cm x 9cm p Opsite flexigrid and C View. Ported peripheral. This helps prevent infections. 10cm x 12cm Central line. Opsite Post-Op 6.5 x 5cm Up tp Vapour permeable adhesive film dressing available in 7 days with absorbent pad. Low to moderate exudate. hospital only Can be used following canula removal. Sorbsan Plus 7.5cm x 10cm Change Highly absorbent dressing for medium to 10cm x 15cm days heavily exuding wounds. 10cm x 20cm Has an additional absorbent pad for excess 15cm x 20cm exudates. Tegaderm 14.3cm x 14.3cm Up to Highly absorbent foam with breathable film, Foam Adhesive square (Contact 7 days results in good fluid management to Pad 10 x 10 + highly exuding wounds. Border 2cm) 10cm x 11cm Highly absorbent and comfortable oval (CP 6 x 7.6 +B 1.7cm) Used for management of moderate 14.3cm x 15.6cm exudating wounds. oval (CP 10 x 11 + B 2cm) 19cm x 22.2cm oval (CP 14 x 17 + B 2.5cm) 13.9cm x 13.9cm circular (CP 7.6 x B 3.2cm) Tegaderm 10cm x 12cm days Absorbent and comfortable. Hydrocolloid (oval) (CP 7 x 9cm Used to promote granutation for the + B 1.5cm ) management of moderate exuding wounds. 13cm x 15cm (oval) (CP 10 x 12cm + B 1.5cm) 17.1cm x 16cm (sacral) (CP 13.9 x 12.3cm + irregular border)

6 Wound Care Products Product Sizes Units Price per Dressing Comments on use available per single changes outer item FP10 Tegaderm 10cm x 10cm days For low to moderate exudating wounds. Hydrocolloid (oval) (CP 7 x 9cm Thin + B1.5cm) Tegaderm Plus 5cm x 7cm 1 25p Up to Transparent film dressing with non Pad 9cm x 10cm 1 62p 7 days adherent pad. 9cm x 15cm 1 92p Useful for wounds healing by 9cm x 20cm primary intention. 9cm x 25cm cm x 35cm Zetuvit E- 10cm x 10cm 25 20p Up to Absorbent dressing with fluid STERILE 10cm x 20cm 25 23p 7 days repellent backing. 20cm x 20cm 15 37p 20cm x 40cm Only use as secondary dressing. Wound Cleansing / Irrigation Product Size Price per pack of 25 Comments Tap water - - Suitable for chronic wounds Normasol sachet 25 x 25ml 24P Low pressure. Single use. Irripod 25 x 20ml 22P Will not remove slough Wound Cleansing - SWABS etc. Product Size Price Comments per item Premier Polyfield Nitrile Patient Pack (dressing pack) 52p Consider whether dressing pack is needed 1xpr powder-free nitrile AF gloves, 1 sterile laminate sheet, 7 non-woven swabs, 1 towel, 1 white polythene disposable bag, 1 apron. Dressit (dressing pack) 60p Use as second choice if Polyfield Nitrile 1x Vitrex gloves, large apron, disposable bag, paper pack is not available. towel, softswabs, adsorbent pad, sterile field. Non-woven fabric swab 7.5cm sq 25p - sterile. (Spec 28) (5 pad pack) Cotton wool balls should not be used near to open wounds due to the risk of shed fibres.

7 Wound Care Products Bandages Function Product Size Outer size Price per Comments single item Wadding K-Soft 10cm x 3.5m 5 42p Absorbs exudate, pads 10cm x 4.5m 5 53p bony prominences Clinifast: (Red Line) All available May be useful as a 3.5cm x 1m as singles 56p retaining secondary (Green Line) dressing as an alternative 5cm x 1m 58p to bandaging. 5cm x 3m cm x 5m 2.81 (Blue Line) 7.5cm x 1m 77p 7.5cm x 3m cm x 5m cm x 1m 1.20 (Yellow Line) 10.75cm x 3m cm x 5m 6.04 (Beige Line) 17.5cm x 1m 1.83 Support K-lite 5cm x 4.5m 16 55p Use instead of crepe 7cm x 4.5m 16 72p 10cm x 4.5m 16 94p 15cm x 4.5m cm x 5.2m Compression K-plus 10cm x 8.7m Class 3a ( part of the 4-layer Combination K-plus long 10cm x 10.25m compression system) depends on ankle Ko-flex 10cm x 6m Class 3a cohesive ( part of circumference Ko-flex long 10cm x 7m the 4-layer compression system) K Three C 10cm x 3m Class 3c (always apply as a spiral) Used in 4-layer compression system for larger circumference legs. Short Stretch Actico 4cm x 6m All available 2.19 Short stretch with some compression: 6cm x 6m as singles 2.57 elastomeric fibres. gives high 8cm x 6m 2.95 working 10cm x 6m 3.07 pressures 12cm x 6m 3.91 and low resting Comprilan 6cm x 5m Only for use in mobile pressure. cotton short 8cm x 5m patients. stretch 10cm x 5m bandage. 12cm x 5m

8 Wound Care Products Bandages Function Product Size Outer size Price per Comments single item 2 layer K Two Multi-layer Ankle Gives 40mmHg pressure. compression * NB:it is now compression circumference: Can only be used for pure kit (Urgo) necessary to add bandaging kit. venous leg ulcers. the required ankle 18-25cm (8cm) 7.32 circumference to 18-25cm (10cm) 7.70 Cannot be used as a ensure that you 18-25cm (12cm) 9.78 reduced compression are supplied with system. Need to order the correct size cm (8cm) 7.96 dependent on ankle 25-32cm (10cm) 8.41 circumference and 25-32cm (12cm) bandage width. Adhesive Tape Product Size Price per item Outer size Comments Clinipore 1.25cm x 5m 35p Singles Cheaper than Scanpor, Leukopor 2.5cm x 5m 59p and Micropore 2.5cm x 10m 73p 5cm x 5m 99p Mefix 5cm x 5m 1.71 Singles Cheaper than Hypafix 10cm x 5m 2.74 Skin Sealant Product Size Price Outer size Comments Cavilon 28ml pump spray 6.54 each 1 To help prevent or treat maceration 1ml foam applicator Re-apply every 2-3 days 3ml foam applicator Please consider whether Cavilon needs to be used. 1* Maximum length of time that the dressing can be left in place. The frequency of dressing changes will vary depending on the level of exudate and the condition of the wound. See manufacturer s information or consult Tissue Viability. 2* Refer to leg ulcer guidelines for advice on using products under compression for venous leg ulcers. WARNING: Paraffin based products do present as a potential fire hazard, as they will easily ignite with a naked flame or cigarette. All patients using these products must be warned of this potential hazard.

9 Extended Formulary Products These products are not to be used as everyday items, but have a specific use within an identified area of practice. Product Sizes available Units Price per Dressing Comments on use per single Changes outer item 1* Activon Tulle 5cm x 5cm days A non-adherent dressing with (impregnated 10cm x 10cm manuka honey. Useful for with manuka de-sloughing wounds, but can honey) be painful for some patients. Advadraw Spiral 0.5cm x 40cm 10 81p Up to 7 days, Capillary dressing. Use to wick may be needed exudates away from the daily initially wound bed. Contraindicated for heavily bleeding wounds. Algivon 5cm x 5cm days An alginate containing manuka 10cm x 10cm honey. Useful for de-sloughing wounds with moderate exudates. May need to protect surrounding skin if heavy exudate. May be painful for some patients. Clinisorb 10cm x 10cm Dependent A secondary dressing to aid 10cm x 20cm upon exudate odour absorption. Charcoal 15cm x 25cm becomes inactivated when wet. Flaminal Forte 15g days Alginate with glucose oxidase and gel 50g lactoperoxidase, for moderately to heavily exuding wounds. Flaminal Hydro 15g days Alginate with glucose oxidase gel 50g and lactoperoxidase, for lightly to moderately exuding wounds. Inadine 5cm x 5cm 25 32p Up to 7 days To reduce the bacterial load, 9.5cm x 9.5cm 10 48p specifically useful in diabetic foot ulcers. Mepilex 10cm x11cm Max 5 days Foam dressing with silicone, only 11cm x 20cm to be used on fragile skin or 15cm x 16cm children, otherwise use Allevyn 20cm x 21cm or Tegaderm foam. Mepilex Border 7cm x 7.5cm Max 5 days Foam dressing with silicone (with silicone 10cm x 12.5cm adhesive, only to be used on adhesive border) 10cm x 20cm fragile skin or children, 10cm x 30cm otherwise use Allevyn 15cm x 17.5cm or Tegaderm foam. 17cm x 20cm Urgotul 11cm x 11cm Up to 14 days Hydrocolloid and paraffin 16cm x 21cm impregnated. 10cm x 40cm Non adherent dressing All paste bandages only to be used following specialist advice

10 Larvae Both the new Larvae Pak and the Larvae Bio FOAM dressing are available in a range of sizes. Ordering code Product Price STD1 Standard Pack 1 Kit STD2 Standard Pack 2 Kit STD3 Standard Pack 3 Kit STD4 Standard pack 4 Kit STD5 Standard Pack 5 Kit HB1 Half Boot Pack 1 Kit HB2 Half Boot Pack 2 Kit HB3 Half Boot Pack 3 Kit HB4 Half Boot Pack 4 Kit HB5 Half Boot Pack 5 Kit Ordering code Product Price BT2 Boot Pack 2 Kit BT3 Boot Pack 3 Kit BT4 Boot Pack 4 Kit BT5 Boot Pack 5 Kit SLE3 Sleeve Pack 3 Kit SLE4 Sleeve Pack 4 Kit SLE5 Sleeve Pack 5 Kit Each container of maggots will continue to be supplied with a piece of LarvE Net, according to the size and shape of the wound being treated specify size required on prescription. N.B. Sleek, hydrocolloid sheet and 1 pod of water are provided with the maggots. Ordering code Product Price BFD20C Biofoam Dressing 2cm x 2cm Kit BFD25C Biofoam Dressing 2.5cm x 4cm Kit BFD50C Biofoam Dressing 5cm x 5cm Kit BFD70C Biofoam Dressing 7cm x 7cm Kit BFD120C Biofoam Dressing 7cm x 12cm Kit BFD150C Biofoam Dressing 2.5cm x 15cm Kit BFD100C Biofoam Dressing 10cm x 10cm Kit N.B. 1 pot of Sudocrem and 1 pod of water is provided with the maggots. Despite the obvious practical and aesthetic advantages of the BioFOAM dressing, free-range maggots should still be regarded as the treatment of choice where cavities or areas of undermining are present. The benefits of free-range maggots in the treatment of MRSA infected wounds have yet to be confirmed with the BioFOAM dressing. Products available from: Zoobiotic (tel ). As LarvE must be applied to the wound on the day that they are delivered, it is essential that you inform your Pharmacist when you require them to be delivered. All LarvE packs are delivered on the date required by a next day courier service (by 12 noon). Orders placed before 2.30pm, Monday - Friday, can be despatched for delivery the following day. Ordering larvae for hospital must be completed before 12 noon, as this is processed through the Integra system. The following may be needed for Larvae therapy dressings Cavilon T.N.P. (Topical Negative Pressure) Information Ensure all pathways and procedures are followed for T.N.P. Use of the above for all patients in community must be agreed on an individual basis by Tissue Viability prior to commencement. All dressings and canisters for MCHT to be ordered through Integra. For MDGH, pumps should be ordered through SBS and canisters and dressings through supplies. If therapy is discontinued for any reason, Tissue Viability MUST be informed on the day of discontinuation.

11 Oxyzyme and Iodozyme Must only be used when directly requested by Tissue Viability Product Size Pack Cost per Dressing Comments on use Contrasize single Changes indications item 1* Oxyzyme 10 x 10cm Every For use on non-infected chronic Oxyzyme and 6.5 x 5cm days and acute wounds, dry or lightly Iodozyme exuding. Promotes debridement contain a low and facilitates healing. It is a level of iodine: hydrogel dressing that should not incorporates a biochemical be used on system. This consists of two patients with separate components which must known or be applied together in order to suspected activate the biochemical process. sensitivity or allergy to Iodozyme 10 x 10cm Every iodine or on 6.5 x 5cm days For use on infected chronic and patients with acute wounds, low to moderately a thyroid exuding. Promotes debridement. disorder. It comprises of a two component hydrogel dressing that incorporates a more advanced biochemical system than the oxyzyme. Both layers to be applied together in order to activate the biochemical process. All prescribing of these products will be monitored regularly

12 Silver Information Sheet Silver dressings are only to be used when there are clinical signs of infection in the wound, usually in conjunction with systemic antibiotics. British National Formulary, Edition 59 March 2010 Silver dressings must discontinue at the same time as systemic antibiotics. The only exception to the above is following assessment and advice from Tissue Viability or Wound Care Specialist Podiatry. Product Sizes available Units Price per Dressing Comments on use per single Changes outer item 1* Aquacel Ag 5cm x 5cm Up to For use on heavily 10cm x 10cm days exuding wounds 15cm x 15cm cm x 10cm cm x 20cm cm x 30cm cm x 30cm Aquacel Ag 2cm x 45cm Ribbon Urgotul SSD 11cm x 11cm days Slow release silver up to 72 hours. 16cm x 21cm None to low exuding wounds. Atrauman AG 5cm x 5cm 10 48p 3-4 days A non-adherent silver dressing. 10cm x 10cm cm x 20cm

13 Wound Assessment Pathway Is the wound clinically infected? Yes Swab and treat with antibiotics and antimicrobial dressings e.g. Silver or Inadine (following formulary) Measure and trace wound at least weekly Adjust antibiotic dependant on swab Results - complete treatment. Discontinue use of silver dressing once antibiotics stop Identify different tissues in wound bed and %? % Epithelilised % Granulation % Slough % Necrotic Identify levels of exudate? Min Moderate Large What is your short term aim? For the dressing and the wound! Dressing - to absorb, donate fluid Wound - Deslough Debride Protect Document all of above on wound assessment form Follow wound care formulary to determine dressing to meet aims. (this should not be a silver dressing) Avoid any known sensitivities Is the dressing meeting the aims? No Yes Continue with present dressing and re-evaluate as wound changes until healed Reassess If not responding after 2 weeks or wound deteriorates rapidly refer to Tissue Viability Holistic assessment still needs to be undertaken to determine any general factors that may delay healing. Once healed protect fragile skin

14 Diabetic Foot Ulcers: Initial Treatment of Infection for CECPCT A B C D E ANTIBIOTICS: Diabetic Foot (Acute) - Staphyloccoccus spp / Streploccoccus spp / Gram ve bacilli / Anaerobes Swab wound then prescribe initial empirical treatment. It is important to check subsequently that the antibiotic chosen matches the swab result. Diabetic foot infections range from simple acute cellulites to chronic osteomyelitis and always require aggressive management. In more complex patients e.g. those over 75 years old and/or history of C.difficile diarrhoea, discussion with microbiologist is recommended. If first line treatment has not worked then repeat the swab and discuss with microbiologist. Systemically well Co-amoxiclav - 500/125mgs TDS for 7 days Doxycycline - 100mg BD for 7 days plus Metronidazole - 400mg TDS for 7 days Systemically unwell / limb threatening infection Medical Emergency - Admit for assessment and treatment according to hospital antibiotic guidelines. Management of infection guidelines taken from 11th edition Infection Control guidelines - Ensure the latest guidance is followed BONE INVOLVEMENT X Ray the foot to exclude Osteomyelitis or Charcot Arthropathy. CHIROPODY / VASCULAR REFERRAL Specialist wound care and pressure relieving footwear are required. Specialist Podiatrist Bleep 2349 Voic 3033 Tissue Viability Nurse DIABETIC CONTROL Raised blood sugars may require medication review. Diabetes Specialist Nurse Bleep 2353 Voic 3599 DRESSINGS Do not use Hydrogels Antimicrobial dressings are required Inadine or Urgotul SSD for low exudate Aquacel Ag for High exudate. Tissue Viability Nurse EXAMINE Examine both feet to compare shape, swelling, colour and temperature. ELEVATION Elevation and rest are essential. Make sure the patient understands.

15 Cheshire East Community Health Mid Cheshire Hospitals NHS Trust GUIDANCE FOR THE MANAGEMENT OF LEG ULCERS IN THE COMMUNITY AIM To facilitate wound healing by ensuring an accurate assessment AIM To refer non-venous ulcers to the appropriate professional for further assessment Undertake full holistic assessment including ABPI on all leg ulcers (6 weeks or over) Undertake wound assessment including tracings or photographs. Reassess weekly Diagnosis of rheumatoid arthritis or diabetes Venous ulcer Evidence of venous disease plus ABPI Mixed Ulcer Evidence of venous disease plus arterial disease ABPI Arterial Ulcer Evidence of arterial disease ABPI under 0.6 Calcification of vessels ABPI over 1.3 Contact Dermatitis - Treat with steroid ladder Refer to Dermatology for patch testing Refer to Tissue Viability. Patients will be offered an appointment within 7 working days If ulcer responds to compression - continue Treat with compression If ulcer fails to respond within 4 weeks of compression refer to Tissue Viability Patients will be offered an appointment within 7 working days Refer to Tissue Viability. Patients will be offered an appointment within 7 working days Urgent referral to Tissue Viability or Vascular Urgent referrals will be fast-tracked Refer to Tissue Viability. Patients will be offered an appointment within 7 working days Any patient, with or without a wound, who exhibits symptomatic vascular impairment to be referred to vascular nurse or consultant

16 Summary information on products and sizes is available in the table Wound Care Products. Consult manufacturer s information (as in BNF) on indications, use, contraindications and side effects. Products have been selected for inclusion in this guidance on the basis of clinical evidence, effectiveness, personal experience and value for money. This guidance was issued in September It will be reviewed in September If you have a product which you wish to be considered for inclusion in the guidance please contact Tissue Viability Lead For advice contact: Specialist podiatry Tel: Tissue Viability Service Tel: Fax: MDGH only Tel: Please use this space to record any recent updates, such as dressing size changes which may occur during the use of this dressings guidance. The formulary is constantly being updated as new items are evaluated by the district nurses and the tissue viability team. A list of additions and deletions to the current formulary can be found recorded on the following links: CECH Share point/ tissue viability/wound care formulary/ additions wound care products