Nurse Practitioner Wound Management Clinical Protocols. Clinical Protocol 1: Wound Diagnostics and Treatment

Transcription

1 Clinical Protocols Clinical Protocol 1: Wound Diagnostics and Treatment Clinical Protocol 2: Minor Surgical Procedures Clinical Protocol 3: Lower Leg Ulcers

2 Overview of Practice The prevalence of wounds in the community and within the hospital setting demonstrates the need for wound care services and the role of the Nurse Practitioner (NP) in Wound management. Any client with a wound has a right to expect a high standard of care in line with best practice standards, regardless of the aetiology of their wound, where the care is delivered or by whom. When a client with a wound is managed inappropriately, they can suffer from failure to heal which results in the wound being present for longer than necessary and an increased risk of complications. Posnett and Franks (2008) stated that a high proportion of chronic wounds remain unhealed for long periods and for almost certainly longer than necessary. Ineffective management such as this can result not only in prolonged client suffering but also increased cost to healthcare organisations through ongoing resource use and increased length of stay. Non-healing chronic wounds affect client s lives emotionally, mentally, physically and socially. They can be pivotal in preventing full recovery, increasing hospital stay and increasing the need for ongoing treatments (Splisbury et al 2007). Optimal wound care is care that addresses every need of the patient in order to maximise their quality of life while they have that wound. This involves addressing concurrent issues that may impact on their health such as undernutrition, illness, infection, the environment in which care is carried out and the expertise available to provide the care. Mofffat et al (2008) suggested that this involves a complex interplay with the patient, their wound, the knowledge and skills of the healthcare professional and availability of recourses all being important in planning and progression. Although the provision of wound care should be relatively straight forward it is often not so. According to Queen et al (2004) over the last 20 or 30 years wound care has changed dramatically with significant developments in scientific research and clinical knowledge. The (NPWM) role has been established in Victoria (Warnamboo), New South Wales (Hunter Valley), Royal Perth Hospital and Sir Charles Gairdner Hospital Western Australia. Carville and Lewin (1998) reported a wound prevalence of 1699 patients with wounds across Silver Chain Services in Western Australia in Of the nursing visits 44% were devoted to wound care. Leg ulcers (including diabetic foot ulcers) were the primary group treated comprising 81.5%. Data from a Nurse Practitioner feasibility study at the Canberra Hospital (MacLellan, Gardner & Gardner, 2002) demonstrated the common wound aetiologies to be chronic leg ulcers, infected leg ulcers, cellulitis, pressure ulcers, diabetic foot ulcers, multi-trauma wounds, and fungating tumours. These Page 2 of 39

3 patterns are similar to the wound referrals currently reviewed by the Clinical Nurse Consultant Vascular/Chronic wounds at Fremantle Hospital and Health Service. The patient presenting with an Acute or Chronic wound requires a comprehensive assessment that will include the wound history, client history, and physical examination performed by the NPWC. There may be the requirement of a number of diagnostic investigations to complete a comprehensive assessment to determine an accurate diagnosis and initiate appropriate treatment. Management of care may require working in collaboration with other health care providers, prescription of medications, management of pain and topical management of skin and wound conditions. Client outcomes include wound healing or wound maintenance depending on the aetiology and the patient s Co-morbidity factors. Wound specific outcomes may include odour control, treatment of infection, debridement and pain management. Client education plays an important part in the role of the Nurse Practitioner, including promoting health and developing a partnership in care. Follow up care and discharge will be dependent on the individual patient and their management plan. The protocols that follow are inter-related and outline key processes and actions for the Nurse practitioner treating patients with Acute/Chronic Wounds. These protocols have been developed by working in parallel with those currently in use at Royal Perth Hospital and Sir Charles Gairdner Hospital therefore I would like to acknowledge their work. The information provided in these Clinical Protocols is intended for information purposes only. Clinical Protocols are designed to improve the quality of health care and decrease the use of unnecessary or harmful interventions. These Clinical Protocols have been developed to be used within South Metropolitan Health Service, and they provide advice regarding the care and management of clients presenting with Wounds. While every reasonable effort has been made to ensure accuracy of these clinical protocols, no guarantee can be given that the information is free from error or omission. The recommendations do not indicate an exclusive course of action or serve as a definitive mode of client care. Variations, which take into account individual circumstances, clinical judgement and client choice may also be appropriate. Users are strongly recommended to confirm by way of independent sources that the information contained within the Clinical Protocols is correct. Page 3 of 39

4 CLINICAL PROTOCOL 1 WOUND DIAGNOSTICS AND TREATMENT Introduction The following protocol (see Table 1) outlines the sequence of events in the assessment, investigation, diagnosis and management of a patient with a wound either Acute or Chronic, and forms the basis for the protocols which follow. This is further outlined in a flow chart (see Figure 1). Page 4 of 39

5 PROCESS ACTION GUIDANCE History A complete history is taken Medical, surgical, allergy history Current medications (prescribed and over the counter (OTC) Previous diagnostic investigations, surgery Social and occupational history (including home support/carer) Physical mobility Activities of daily living Nutritional status Smoking history Examination Investigations Physical examination of the wound and associated area Generalised assessment as necessary Establish appropriate investigations required to assist in an accurate diagnosis, or be able to provide a baseline of health status Clinical features of the wound and skin Presence of other wounds/lesions Peripheral perfusion Peripheral neurological examination (e.g. Semmes Weinstein 10g monofilament, tendon reflexes, vibration) Footwear (diabetes, lower limb/foot wounds) Physical and joint mobility Explore differential diagnosis Pathology (possible investigations) Haematology FBP,ESR,CRP,INR, Biochemistry U & Es LFT, (Total Protein, Albumin), Pre-albumin, Glucose, HbA1C Lipids Thyroid Function Immunology RH Factor Auto Antibody Screen Microbiology and Histology Wound fluid/swabs-microscopy, culture and sensitivity (MC&S) Wound/tissue biopsy-mcs and Histopathology Skin Scraping, Immunofluorescence Biopsy May be required if wound has been nonhealing, despite optimal treatment, for greater than 4-6 weeks, duration greater than 6 months, previous SCC/BCC and/or is assessed as atypical Page 5 of 39

6 PROCESS ACTION GUIDANCE Investigations (cont) Radiology/Medical Imaging Ankle Brachial Pressure Index (ABPI) Toe Pressures Photo plethysmography (PPG) Duplex Scan (Arterial/Venous) X-Ray Angiogram: MRA/CTA/DSA (Consultant decision) Bone Scan/MRI (Consultant decision) Arterial Duplex: To determine presence and/or severity of Arterial Disease or Graft/Bypass patency in lower limb Venous Duplex: To determine disease or impairment of superficial, deep or perforating veins and their valves. ABPI- Performed on all patients with a leg ulcer. If the ABPI does not complement the clinical assessment or is inconclusive then further diagnostic investigations may be required Arterial/Venous Duplex Scan Noninvasive investigation recommended for initial diagnosis X-Ray An X-Ray may be required if there is a suspicion of osteomyelitis, sinus, significant undermining or foreign body. Bone Scan/MRI - If there is a suspicion of Osteomyelitis, then a bone scan or MRI may be ordered following consultation with an Infectious Diseases Physician or Vascular Surgeon Diagnosis Make provisional Diagnosis On clinical picture, available assessment data and results of investigations Management Urgent Referrals: Life/limb threatening infection Abnormal test results that require medical intervention Treatment required outside the NP scope of practice Acute DVT New patients with an ABI <0.7 or ankle systolic < 80mmHg Patient that requires surgical intervention Referrals If the wound fails to heal despite optimal therapy following best practice, then consultation with other health care practitioners and further investigations may be required. Page 6 of 39

7 PROCESS ACTION GUIDANCE Management (cont) Ulcers on the planter aspect of the foot to have immediate Podiatry referral Significant deterioration in wound since last review Patient systemically unwell Management Partnerships Nurse Practitioner: Non-Pharmacological treatment Patient Education For Self Care Pharmacological treatment Based on diagnostic investigations, clinical assessment and Therapeutic Guidelines Appropriate referrals to assist in overall management Non-Pharmacological treatment Appropriate dressing and/or compression therapy based on diagnosis and patient lifestyle Cleaning and debridement of wound Client/Carer Education for self care Hygiene (Cleansing self care and waterproofing i.e. leg bags as required Diet (importance of essential vitamins and minerals as required) Lifestyle changes (smoking cessation, optimal weight,blood pressure and lipids, structured exercise regime) Bandaging/stocking/dressing techniques Pain management (Adjunct therapy) Medications Disease and health maintenance Indications to seek medical assistance (To include relevant consumer handouts) Pharmacological Treatment Analgesics Topical antimicrobials/antifungals Local anaesthetic Topical corticosteroids Oral antibiotics Moisturisers/barrier ointments, skin cleansers Other Health Professional as required: Medical: Vascular Surgeon/Registrar Plastic Surgeon Infectious Disease Physician Dermatologist Endocrinologist Pain Management Service Palliative Care Geriatrician/Rehabilitation Physician Page 7 of 39

8 General Practitioner PROCESS ACTION GUIDANCE Management Partnerships (cont) Ongoing Management Follow-Up Allied Health: Dietician Podiatrist/Orthotist Diabetic Educator Physiotherapist Occupational Therapist Hospital in The Home (HITH) /Rehabilitation in The Home (RITH) Pharmacist Social Worker Community Care Providers: Silver Chain Nursing HITH/RITH GP Practice Nurses Other home care providers Review as appropriate: Monitor progress Test results Maintenance of wound Review of treatment plan in accordance with investigative results Separation Discharge from service As Appropriate: Wound healing achieved Referral to community services for longterm management Referral for specialist care Page 8 of 39

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10 CLINICAL PROTOCOL 2 MINOR SURGICAL PROCEDURES Introduction There are occasions when wound biopsies or sharp debridement procedures are required to manage the wound, both procedures can be classified as minor surgical procedures. The flow chart demonstrates the protocol (see figure 2). Biopsy Skin biopsy is a biopsy technique in which a segment of skin is removed and sent to the pathologist to render a microscopic diagnosis. The common punch size used to diagnose most inflammatory skin conditions is the 3.5 or 4mm punch. Ideally, the punch biopsy includes the full thickness skin and subcutaneous fat in the diagnosis of skin disease. Curettage biopsy can be done on the surface of tumours or on small epidermal lesions with minimal to no topical anaesthetic using a round curette blade. Diagnosis of basal cell carcinoma can be made with some limitation, as morphology of the tumour is often disrupted. The pathologist needs to be aware of the type of anaesthetic used, as topical anaesthetic can cause infarct in the epidermal cells. Debridement Wound healing is delayed by the presence of devitalised tissue (National Institute for Clinical Excellence 2001). An ulcer or open wound can not be thoroughly assessed until all devitalised tissue is removed. Dead or foreign material in a wound adds to the risk of infection and sepsis and inhibits wound healing (Leaper 2002). Debridement is the removal of necrotic or foreign material from and around a wound to optimise wound healing. There are many different methods that can be used to debride a wound. They can broadly classified as surgical/sharp, mechanical, biological, chemical, enzymatic and autolytic. Conservative sharp debridement (CSWD) is a procedure used to debride nonviable tissue from a wound down to non-bleeding tissue using sharp instruments (e.g. scalpel, scissors). Sharp debridement may be necessary in either acute wounds (e.g. skin tears) or chronic wounds (e.g. pressure ulcers). Consideration to perform the procedure requires consideration of both local and systemic factors. Debridement may also be undertaken in preparation for skin grafting, application of skin substitutes, or topical negative pressure therapy (e.g. VAC- Vacuum Assisted Closure). Page 10 of 39

11 The outline of assessment process, investigations and management are outlined in Table 2 Table 2 Assessment and Management: Minor Surgical Procedures PROCESS ACTION GUIDANCE History A complete history is taken Medical, surgical, allergy history/ co-morbidities Wound history Current medications (prescribed and OTC) Previous diagnostic investigations Social and occupational history including carer or home support Physical mobility Activities of daily living Examination Investigations Physical examination of the wound and associated are/limb More generalised assessment as necessary Biopsy of wound for histology and/or microbiology Findings from assessment of complex, infected wounds, leg ulcers and diabetic foot ulcers Abnormal clinical presentation: Raised/unusual clinical features Suspicion of neoplastic disease Senescent tissue Hypergrannulation tissue Non healing wound despite optimal treatment Presence of: Infection not responding to antibiotic treatment Contaminated/non-viable material Foreign bodies Histology To confirm wound aetiology Microbiology To identify organisms and sensitivities Diagnosis Make provisional diagnosis On clinical picture, available assessment data and results of investigations Management Urgent referrals: Life/Limb threatening infection Abnormal test results that require medical intervention Treatment required outside NP scope of practice Significant deterioration in wound since last review Notify medical practitioners of investigations ordered and referrals organised If the wound fails to heal despite optimal therapy then consultation with other health care practitioners and further investigations may be required at that time Page 11 of 39

12 PROCESS ACTION GUIDANCE Management (cont) Management Partnership Nurse Practitioner: Non-Pharmacological treatment Client education for self care Pharmacological treatment Based on diagnostic investigations, clinical assessment, and Therapeutic Guidelines Conservative sharp surgical Debridement Appropriate referrals to assist in overall management Non-Pharmacological treatment Appropriate dressings/bandaging based on diagnosis and patient lifestyle preferences Cleansing and debridement of wound Client/Carer education for self care Hygiene (cleansing self and wound waterproofing as required) Diet (the importance of essential vitamins and minerals as required) Signs and symptoms of complications Bandaging/dressing techniques Exercise regimes Lifestyle factors/changes Disease process and health maintenance Prevention of recurrence Pain management Medications (Include relevant consumer literature in the form of leaflets/booklets) Pharmacological treatment Analgesics Topical antimicrobials/antifungals Local anaesthetics Topical corticosteroids Oral antibiotics Conservative Sharp Surgical Debridement To remove: Contaminated material Foreign bodies Non viable tissue To prepare the wound environment for: Topical Negative Pressure Therapy (VAC) Skin Grafts Substitutes to accelerate the healing process Other Health Professionals as required: General Practitioner Plastic Surgeon Dermatologist Infectious Diseases Physician Vascular Surgeon Consultation with the medical practitioner if required for further treatment and investigations Page 12 of 39

13 PROCESS ACTION GUIDANCE Management Partnership (cont) Allied Health: Dietician Podiatrist Diabetes Educator Occupational Therapist Pharmacist Community Care Providers: Silver Chain Nursing Other home care providers Ongoing Care Follow-Up Review as appropriate: Test results Monitor progress Maintenance of wound Review treatment plan in accordance in investigative results Separation Discharge from service As appropriate: Wound healing achieved Referral to community services for long term management Referral for specialist care Page 13 of 39

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15 CLINICAL PROTOCOL 3 LOWER LEG ULCERS Introduction This protocol has been designed to guide and facilitate the NPWM in diagnosing and providing appropriate care for clients with leg ulcers. Lower leg ulcers are a common and expensive problem for the healthcare system (Bergqvist, and Lindagen 1996). The prevalence of leg ulcers increases markedly with age particularly the older group (Baker et al 1991) It is estimated that 2 3 percent of people over the age of 65 suffer from open or healed venous ulceration (Bradbury et al 2001). The cost to treat these chronic wounds is estimated at A$3 billion per annum representing a significant burden on the health care dollar. Venous ulcers are notorious for recurring despite best practice/interventions, with recurrence rates as high as 69% (Walker et al 2002). Leg ulceration is not a diagnosis, it is the underlying aetiology that defines the ulcer and its associated management decisions. It is crucial that a client is assessed before treatment decisions are made, and that ongoing assessment takes place, as disease processes such as venous insufficiency can be progressive, or other diseases such as arterial disease may progress or become apparent (Vowden & Vowden 1996). Risk factors for ulceration and delayed wound healing need to be identified at assessment (Morrison & Moffatt 2004). Venous Ulcers The socioeconomic impact of chronic venous insufficiency is enormous, as venous leg ulcers are more prevalent in the elderly, this financial burden will escalate as the population ages. In addition to the clinical and cost-of-care implications, disability from venous leg ulcers results in significant amount of lost working days and has a major impact on quality of life (Laing, W 1992). Chronic venous insufficiency is a significant health problem affecting an estimated 13% of the adult population (Bradbury et al 2001). Approximately 20% of chronic venous insufficiency clients have concomitant arterial insufficiency. Venous ulcers are the most serious consequence of chronic venous insufficiency (Laing,1992). Chronic leg ulcers can result in disfigurement, disability and a lifelong need for medical treatment (Weingarten, 2001). These ulcers develop due to ambulatory hypertension, which arises as a result of ineffective venous return from the lower legs. This increases the pressure in the superficial venous system on exercise, which affects the exchange of nutrients in the capillary bed. Fluid is not reabsorbed effectively into the venous system from the interstitial spaces, resulting in oedema. Page 15 of 39

16 This means that the tissues are undernourished and waste metabolites in the interstitial spaces. Red cells and protein also leak into the tissues resulting in haemosiderin deposits and tissue fibrosis. Staining of the skin results, varicose eczema may form and skin integrity may be compromised by infections such as cellulitis. This can ultimately lead to ulceration (Morrison & Moffat 2004). The aim of treatment is to reduce venous reflux, ambulatory venous hypertension and oedema. Arterial Ulcers Arterial ulcers result from insufficient perfusion of the skin and subcutaneous tissues in the lower limb leading to ischaemia and tissue necrosis (Holloway, 2001) This may be due to partial arterial obstruction or arterial occlusion. Atherothrombosis and arteriosclerosis are common processes that can lead to arterial insufficiency. Blood flow through the arteries is impaired due to atherosclerotic plaque lining the arterial wall. This reduces the lumen of the vessel and subsequently affects the oxygen and nutrients to the lower leg. Poorly perfused tissue is at risk of sudden and dramatic ulceration following injury. The lack of adequate oxygen supply means that the wound can be very slow to heal, or may not heal at all (Herbert, 1997). Additional risks include thrombus formation in areas of atheroma, which occlude the vessel completely. Surgical intervention may help restore circulation. If the disease is extensive and not reconstructable, then the management of the arterial ulcer centres on symptom management particularly pain and wound management (Herbert 1997). Mixed Aetiology Ulcers Clients with these ulcers have venous disease and a significant level of arterial disease, but their blood supply is not yet compromised to cause critical ischaemia. The key clinical factor in mixed aetiology ulceration is that, without intervention arterial disease is progressive, and eventually the arterial problem will take precedence over the venous problem in treatment decisions. Population Clients presenting with leg ulcers will be received into the leg ulcer clinic for assessment via a referral from General Practitioners, Consultants/Registrars within the hospital setting, Emergency Department, in-patients and out-patients at Fremantle Hospital and Health Service. Referrals will also be accepted from within Western Australia if suitable for the Ulcer Clinic. Presentation Rates The Leg Ulcer Clinic at Fremantle Hospital and Health Service has in excess of 1750 presentations of active leg ulcers per year, and offers a chronic wound management out-patient clinic. The service also provides a prophylactic Page 16 of 39

17 programme in the management of healed clients, with the prescription of compression hosiery be it custom made or off the shelf, and yearly assessments. Direct referrals will be possible with the designation of a Nurse Practitioner in Wound Management. Expected Outcomes of the Protocol Leg ulcer outcomes will be aligned with aetiology, predicted healing rates, and recurrence rates. The increased scope of the Nurse Practitioner will increase the effectiveness and efficiency of the care offered to clients with lower leg ulcers. The Lower Leg Ulcer Protocols will: improve client outcomes including improved wound healing, quality of life, and prevention of leg ulcer recurrence reduce health costs through improved wound healing rates reduce variation in clinical practice improve client satisfaction enhance continuity of care with other health care providers improve community awareness of professional wound services available. Venous leg ulceration and chronic venous insufficiency represents a significant health problem and the key to successful management lies in the use of compression therapy. Compression is a potent therapy, used correctly it can promote healing and change a client s quality of life. Used incorrectly it can result in delayed healing, pain, trauma or even the loss of a limb. According to Barwell et al (2004) anticipated healing rates of venous leg ulcers are expected to be around weeks, 68-83% of the time. Those with ulcers of longer duration will be expected to have longer time to healing (Vowden et al 1997). Of those who heal recurrence will be dependent on client participation in care and management of Co-morbidity factors. For those clients with arterial ulcers and evidence of arterial disease, the focus of outcomes may be to relieve pain, improve mobility and independence, wound care and improve quality of life if possible. Assessment Assessment of the individual client will follow as per Protocol 1., Wound Diagnostics and Management. The following information outlines in more detail the specific process for the NPWM in managing clients with lower leg ulcers (see Table 3) using evidence grading. A flow chart outlining the Lower Leg Clinical Protocol is shown in figure 3 and the guidelines for compression bandages are represented in Figure 4. An explanation of compression bandaging components is outlined in Appendix 1. Page 17 of 39

18 Table 3 Assessment and management of Lower Leg Ulcers PROCESS ACTION LEVEL OF EVIDENCE GUIDANCE History A complete history is taken: medical, surgical, allergy history Wound history Current medications (prescribed and OTC) Previous diagnostic investigations Social and occupational history including carer/or home support Physical mobility Activities of daily living Assess history of Ulcers duration of current ulcer mechanism of injury previous methods of treatment Assess for Venous Insufficiency: Family history of venous disease Client history of DVT/PE Lower limb fractures or other major leg injury Previous vein surgery or sclerotherapy Prior history of ulceration with or without compression therapy Assess for Arterial Insufficiency: History of intermittent claudication or rest pain Previous graft surgery/interventions Hypertension Heart disease Diabetes Ischaemic stroke/tia Smoking (or stopped < 5 years) In the presence of mixed disease (arterial + venous, client may present with both Assess for diabetes, rheumatoid arthritis and systemic vasculitis (specialist assessment/referral should be considered) Assess for correctable factors that may delay healing, including smoking, anaemia, and evidence poor nutrition Assess for pain and formulate plans that involve exercise (including ankle exercises) and leg elevation for venous ulcers and adequate analgesia irrespective of aetiology C C B A B C C Page 18 of 39

19 Physical examination of the wound and associated area/limb Examination Conduct lower limb examination of both legs (e.g. the presence of varicose veins LSV/SSV in venous disease) Examine for signs of arterial insufficiency: Lower skin temperature, palpation of peripheral pulses (weak absent), unilateral signs may be present where there is acute deterioration Assess for malignancy can be a cause or may be a sequel of leg ulceration Signs suggestive of malignancy are: irregular nodular appearance of the surface of the ulcer, raised or rolled edge, raised granulation tissue above the ulcer base, failure to respond to treatment, rapid increase in ulcer size and abnormal pigmentation Assess the wound and surrounding tissue: The surface area should be measured at regular intervals or photographed to monitor progress Venous Ulcers are generally shallow, moist and appear on the gaiter area of the leg Eczema, haemosiderin pigmentation, ankle oedema and ankle flare are often present Varicose veins, atrophe banche and lipodermatosclerosis may also be present Arterial Ulcers have a punched out appearance, a poorly perfused base and are pale, dry and may have necrotic tissue in the base Surrounding skin is shiny and taut, dependant rubor is present Lower Limb Pulses palpable pulses alone are insufficient to rule out arterial disease More generalised assessment as necessary Clinical features of the wound and skin Presence of other wounds/lesions Peripheral perfusion Neurological examination (e.g. using Semmes Weinstein 10g monofilament) Signs and symptoms of infection Footwear (diabetes, lower limb/foot wounds) Physical and joint mobility) B A B C B C C Page 19 of 39

20 PROCESS ACTION LEVEL OF EVIDENCE - GUIDANCE Explore differential diagnosis Investigations Ankle Brachial Pressure Index (ABPI) to be performed on all in-patient and out-patient leg ulcer clients. If the ABPI does not complement the clinical assessment or is inconclusive then further diagnostic investigations may be required. Measurement of ABPI by handheld Doppler ABPI - Normal A ratio of <0.8 indicates the presence of peripheral arterial disease (PAD) Further investigations should be considered prior to initiating compression therapy if a patient has an ABPI > 0.8 in the presence of signs and symptoms of PAD, rheumatoid arthritis, systemic vasculitis or diabetes mellitus Doppler determination of ABPI should not be used in isolation from clinical assessment Repeat measurements of ABPI when an ulcer deteriorates, is not fully healed by 3/12; or when a client presents with recurrence. Toe Doppler Pressures/index and arterial Photophlethysmography (PPG) are adjunct tests to ascertain arterial insufficiency particularly where diabetes, incompressible vessels or calcification are present. Venous PPG will provide information on venous refilling time as an assessment of venous insufficiency (<25 seconds) Determine which investigations may be required to assist in a diagnosis or provide a baseline of nutrition and health Pathology Haematology FBP Biochemistry U&E LFT, total protein, albumin Glucose, HbA1C Lipid profile Thyroid function CRP A B A C A B Page 20 of 39

21 PROCESS ACTION LEVEL OF EVIDENCE - GUIDANCE Investigations (cont) Immunology Rheumatoid Factor ANF Microbiology and Histology Wound fluid/swabs microscopy, culture and sensitivity (MC&S) Wound/ tissue biopsy MCS and histopathology Skin scraping, Immunofluorescence Note: Routine bacteriological swabs are unnecessary unless there is evidence of clinical infection B Biopsy This may be required if the wound has been non-healing for 4-6 weeks with optimal treatment, is assessed as atypical, or has been present greater than 6 months. Radiology/Medical Imaging Duplex Scan (Arterial/Venous) X-Ray Arterial/Venous Duplex Scans Non-invasive investigation is recommended for initial diagnosis Arterial Duplex Scan: To determine presence and/or severity of arterial disease in the lower limb. Venous Duplex Scan: To determine disease or impairment of superficial, deep, and perforating veins and valves. On clinical picture, available assessment data and results of investigations X-Ray If there is suspicion of osteomyelitis, sinus, significant undermining or foreign body, then an X-ray may be ordered. Diagnosis Make provisional diagnosis On clinical picture, available assessment data and results of investigations Page 21 of 39

22 PROCESS ACTION LEVEL OF EVIDENCE - GUIDANCE Management Urgent Referrals: Life/limb threatening infections Abnormal test results that require medical intervention Treatment required outside the NP scope of practice DVT New patients with a ABPI <0.7 or ankle systolic <80mmHg Client that requires surgical intervention Ulcers on the plantar aspect of the foot/toes/heels subject to pressure from weight-bearing or footwear to have immediate podiatry referral Significant deterioration in wound since last review Nurse Practitioner: Non-Pharmacological Treatment: Compression bandaging should be applied when venous insufficiency is present, and should be based on the ABPI and interpretation of clinical signs and additional data (Figure 2), NB. Compression stockings may be patients choice and be accepted practice Compression bandaging (inelastic & elastic ) has been demonstrated effective in the healing of venous leg ulcers Reduced compression may be effective in selected patients with mixed disease (venous + arterial) where the ABPI is however these clients should be monitored closely for signs of reduced circulation/ischaemia in a specialised clinic Dressing technique should be clean and aimed at preventing cross-infection strict asepsis is not necessary Ulcers can be cleaned with either portable water or sterile saline. Referrals If the wound fails to heal despite optimal therapy then consultation with other health care practitioners and further investigations may be required A B C C C Page 22 of 39

23 PROCESS ACTION LEVEL OF EVIDENCE - GUIDANCE Management (cont) Wound debridement may be undertaken where necrotic/non viable tissue is present. There is no evidence to favour one method of debridement, whether mechanical, surgical, biosurgical, autolytic, chemical or enzymatic and choice would be based on patient assessment (Also see minor procedures protocol) Client/Carer education for self care Hygiene (cleansing self and waterproofing as required) Diet (the importance of essential vitamins and minerals as required, in particular Vitamin C and Zinc) Signs and symptoms of complications Bandaging/dressing technique Exercise regimes Exercise programmes can improve calf muscle function, walking distances and pain for clients with intermittent claudication Lifestyle changes Disease process and health maintenance Prevention of recurrence Pain management Medications (Includes relevant consumer handouts) Pharmacological treatment Based on diagnostic investigations, clinical assessment, and Therapeutic Guidelines Analgesics Oral antibiotics Topical antimicrobials Topical anti-fungal Topical corticosteroids Local anaesthetic Moisturisers Barrier ointments, creams, wipes Skin cleansers Note: Clients can become sensitised at any time. Products which commonly cause sensitivity such as those containing lanolin, cetyl alcohol or topical antibiotics are best avoided. C A B Page 23 of 39

24 PROCESS ACTION LEVEL OF EVIDENCE - GUIDANCE Management (cont) Management Partnerships Associated Clinical Practice Guidelines: Wound management and diagnostics Minor surgical procedures Appropriate referrals to, or liaison with other health professionals to assist in overall management Medical: Vascular surgeon Plastic surgeon Infectious diseases physician Endocrinologist Pain management General practitioner Dermatologist Note: Clients with dermatitis which do not resolve following the removal of common sensitisers and treatment with moderate topical steroids should be considered for referral to a Dermatologist Venous surgery followed by graduated compression hosiery is an option for consideration in clients with superficial venous insufficiency C B Allied Health: Dietician Podiatry Diabetes Educator Occupational Therapist Physiotherapist Pharmacist Community care providers: Silver Chain Nursing Hospital in the Home Residential care agencies Other home care providers Page 24 of 39

25 PROCESS ACTION LEVEL OF EVIDENCE - GUIDANCE Ongoing Management Review as appropriate ** Test results Monitor progress Maintenance of the wound Prophylactic review (e.g. 6/12 review for clients with healed venous ulcersprescription for graduated compression stockings ** Patient reviews will be determined according to: Whether the client is new to the service Whether compression therapy is initiated Access to transport and their location Availability of appointments Partnership of care in place Client and wound factors Clients commencing compression therapy for the first time - review is usually 2-3 weeks. Ongoing review will be 4-6 weeks or earlier if required. Those clients will healed venous ulcers will have their stockings renewed six monthly and have an annual review and ABPI recorded. As with all client related visits all relevant findings will be documented in the client s integrated medical records and leg ulcer data base. Review treatment plan in accordance with response to treatment and investigative results. Separation Discharge from service As appropriate: Wound healing achieved Referral to community services for long term management Referral for specialist care Page 25 of 39

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28 Multi-layer Elastic May be used across range of mobile and immobile patients but particularly indicated for immobile patients or those with reduced ankle mobility/fixed ankle deformity where calf muscle contraction is limited. Provide sustained compression with minor variations during walking. Inelastic Suitable for actively mobile clients where the bandage reinforces or supports the action of the calf muscle pump. They provide high pressure on moving and low resting pressures. May be more effective in patients with extensive deep vein reflux (Marston & Vowden, 2003). COMPRESSION BANDAGING SYSTEMS Layers usually 3-4 layers and may include either elastic or inelastic compression bandages, cohesive/adhesive bandages, crepe bandages and/or padding layers. Zinc bandages - elastic and rigid varieties. Wound & skin contact layer. Underpadding - cotton or synthetic padding to protect the skin/bony prominences from bandage trauma and may have additional absorbent capacity. Used as base layer under most compression bandage systems - Wraps - e.g. Kerlix, Velband - Tubular knitted padding - e.g. Tubular Plus Compression bandages - elastic with various degrees of elasticity - inelastic Cohesive elastic wraps e.g. Coban, CoPlus or elastic tubular support e.g. Tubigrip Single layer e.g. Setopress Multilayer systems: - e.g. Profore system, Proguide Multilayer light (reduced) compression (15-25 mm Hg versus High compression mm ankle) e.g. Profore Light, Lastodur Light Number of layers according to ABPI, full compression usually 2 layers sub-bandage pressures will vary according to a number of factors including wear-time and oedema e.g. Comprilan Note: The degree of compression in governed by La Place s law P = pressure exerted by bandage where sub-bandage pressure is demonstrated thus: N = number of layers P is proportional to : N x T T = bandage tension (elasticity) C x W C = circumference of limb W = bandage width Page 29 of 39

29 Evidence Base The clinical protocol for management of lower leg ulcers is based on the systemic identification and synthesis of the best available scientific evidence and review of clinical guidelines. Existing clinical; practice guidelines utilised and reviewed included: Compression for venous leg ulcers (Review), The Cochrane Collaboration (Cullum, Nelson, Fletcher, &Sheldon, 2001) The care of patients with chronic leg ulcers. The Scottish Intercollegiate Guidelines Network (SIGN, 1998). Guidelines for the treatment of arterial insufficiency ulcers (Hopf, Ueno, Aslam, at al., 2006) Nursing best practice guidelines: Assessment and management of venous ulcers, Registered Nurses association of Ontario (RNAO, 2004) Guideline for the management of wounds in patients with lower-extremity arterial disease, Wound Ostomy and Continence Nurses Society (WOCN, 2002) Guidelines for the assessment and management of leg ulcers, Irish Clinical Resource Efficiency Support Team (CREST, 1998). The above guidelines have utilised different systems for classifying and they have been broadly categorised as follows: Statement of Evidence Level 1a Level 1b Level 11a Level 11b Level 111 Level 1v Evidence obtained from meta-analysis of randomised controlled trials Evidence obtained from at least one randomised controlled trial Evidence obtained from well designed controlled study without randomisation Evidence obtained from at least one other type of welldesigned quasi-experimental study Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies Evidence obtained from expert committee reports or opinions and/or clinical experiences or respected authorities Page 30 of 39

30 Grades of Recommendations Grade A Grade B Grade C Requires at least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation (Evidence levels 1a,1b) Requires the availability of well conducted clinical studies but no randomised trials on the topic of recommendation. (Evidence levels 11a,11b,111) Requires evidence obtained from expert committee report or opinions and/or clinical experiences of respected authorities. Indicates the absence of directly applicable clinical studies of good quality. (Evidence level 1v) The initiation and type of bandage therapy is based on the International Leg Ulcer Advisory Boards recommendations (Stacey, Falanga, Marston, et al 2002) and the European Wound Management Association position document Understanding Compression Therapy (Caine, 2003). Review These clinical protocols will become effective once approval and designation have been agreed and will be reviewed every 2 years or earlier if significant research becomes available to change practice or there are new developments in the drug formulary listings. Further protocols will be developed in relation to chronic wounds and diabetic foot ulcers. Implementation Plan Implementation of the NPWM Protocols will occur at the appointment of the at Fremantle Hospital and Health Service. The time frame will be approximately two months to allow for the introduction of the role of the NP into the organisation. Evaluation Plan Submitted protocols will be reviewed annually and evaluated using the Clinical Governance Framework. Reporting will be provided to the key line manager of the designated NP (Nursing Director Surgical Services at Fremantle Hospital and Health Service), and the Director General of Health as outlined by the Office of Chief Nursing Officer (Department of Health Western Australia, 2003). Page 31 of 39

31 Professional Development and Management The NP will set realistic objectives and a professional development plan in collaboration with their Nursing Director Surgical Services. Educational requirements to professional colleagues will be ongoing. The NP will be involved in research pertinent to their clinical field. Participation in Hospital and Health Sector activities undertaken in role related guidelines, policies and standards will be identified. Clinical Risk The NP in Wound Management will have input into relevant practice guidelines, relevant research and ensure that standards following evidence based best practice are undertaken, working closely with Wound West and other clinical experts. Potential risks, including clinical incidents and adverse effects will be identified, managed and reported as part of the annual NP review and reporting process to the Department of Health. There will be ongoing liaison with the FHHS Clinical Governance Unit. Consumer Value Consumer satisfaction/complaints will be ascertained via satisfaction and complaints surveys of key customer groups. Auditing of practice may be benchmarked against best practice/guidelines that are available to ensure consumer satisfaction and expectations are met. Consumer input into protocols or patient education material will also be considered. Page 32 of 39

32 Drug Formulary Wound Management Classification Drug Dosage Analgesic Paracetamol 500mg 4-6 hourly Analgesic Paracetamol+/-Codeine 500mg/8mg 4-6 hourly Antibiotic Amoxycillin Clavulanate 500/ /125mg 12 hourly Antibiotic Cephalexin mg 6 hourly Antibiotic Flucloxacillin mg 6 hourly Antibiotic **Ciprofloxacin mg twice daily Antibiotic **Clindamycin mg 8 hourly Antibiotic Metronidazole mg 8-12 hourly Topical Antibiotic Metronidazole 0.5% twice daily Topical Antibiotic Silver Sulphadiazine Chlorhexidine digluconate 1%, 0.2% 1-2 x/day Topical Antifungal Clotrimazole 1% 3 x/day Topical Antifungal Terbinafine 1% 1-2 x/day Topical Antifungal Nystatin 100,000units/g 2-3 x/day Topical Antiseptic, Anti-infective **Mupirocin 2% 3 x/day Topical Corticosteroid Hydrocortisone 0.5-1% 1-2 x/day Topical Corticosteroid Hydrocortisone acetate 0.5-1% 1-2 x/day Topical Corticosteroid Triamcinolone Acetonide 0.02% 1-2 x/day Topical Corticosteroid Betamethasone valerate % 1-2 x/day Topical Corticosteroid Betamethasone dipropionate 0.05% 1-2 x/day Topical Anaesthetic Lignocaine % Pre-procedure Local Anaesthetic Lignocaine with Adrenaline % Pre-Procedure Local Anaesthetic Lignocaine with Prilocaine % Pre-Procedure ** IDD APPROVAL Page 33 of 39

33 Classification Indications Considerations Analgesics Mild pain: Paracetamol 500mg 4-6 hourly, maximum daily dose 4000mg Mild to moderate pain: Paracetamol with codeine 500mg/8mg 1-2 tablets 4 to 6 hourly maximum dose 4000mg paracetamol OR Tramadol 50mg to 100mg 4 to 8 hourly maximum daily dose 400mg (300mg maximum dose for elderly) (Therapeutic Guidelines: Analgesics, 2002) For more severe pain, review causative factors and refer to appropriate specialist (e.g. Pain Service, Vascular Surgeon) Antibiotics (topical) Antibiotics (systemic) Localised skin infections, critical colonisation of wounds (e.g. leg ulcers and pressure ulcers) and minor burn prophylaxis Silver sulfadiazine (SSD) 1% + chlorhexidine 0.2% cream topically, once or twice daily (contraindicated if sulpha or chlorhexidine allergy) Impetigo, infected small skin lesions (mild or localised infections) and elimination of Staph. aureus carriage Mupirocin 2% topical, following skin cleansing 3 times per day for up to 10 days. Cancerous malodorous wounds Metronidazole gel 0.75% topically Silver sulfadiazine (SSD) 1% + chlorhexidine 0.2% cream topically, once or twice a day (Sibbals, Orsted, Shultz et al., Therapeutic Guidelines: Antibiotic 2006; Therapeutic Guidelines: Dermatology, 2002) Skin and soft tissue infection Empirical antibiotics to be commenced whilst waiting for sensitivities Alternatives to consider include silver, povidoneiodine and cardexomer iodine dressing products Approval is required from a Clinical Microbiologist or ID Physician for Mupirocin use The routine use of antibiotics is not advocated in chronic wounds Antibiotic to be commenced only when there is clinical evidence of infection (e.g. localised erythema, localised pain. Localised heat. Cellulitis and oedema) Page 34 of 39

34 Classification Indications Considerations For mild to moderate infection with surrounding cellulitis, use: Flucloxacillin mg orally 6- hourly for at least 5 days For clients hypersensitive to penicillin (excluding immediate hypersensitivity) use: Cephalexin 500mg 6-hourly for at least 5 days Diarrhoea is a common adverse effect and the client should be told to seek medical attention should this persist If no clinical improvement within one week (next visit) or worsening of symptoms, for medical review For more severe infections, particularly where systemic symptoms are present, and for intravenous antibiotics, medical review will be required Alternatively, if Gram-Negative organisms are suspected or known to be involved, use: Amoxycillin+Clavulanate mg orally, 12 hourly for 5 days Gram-negative organisms often colonise ulcers, therefore for less severe infections, antibiotics against gram positive organisms should be used initially. If the infection is not responding then broadening to include gram-negative cover can be considered. (Therapeutic Guidelines: Antibiotic 2006) Diabetic foot infections: For mild to moderate infection with no evidence of osteomyelitis or septic arthritis, use: Amoxycillin+clavulanate mg orally, 12 hourly for at least five days OR Cephalexin 500mg orally, 6 hourly, for at least five days Plus Metronidazole 400mg orally, 12 hourly for at least five days Inform patients that nausea, diarrhoea and metallic taste is an adverse effect whilst taking metronidazole. To seek medical attention for persistent nausea and diarrhoea Antibiotic susceptibilities of gram negative organisms should be reviewed and advice obtained from a Clinical Microbiologist or ID Physician for organisms resistant to amoxicillin + clavulanate For severe limb-or life threatening infection (systemic toxicity/ septic shock, bacteraemia, marked necrosis or gangrene, ulceration to deep tissues, severe cellulitis, presence of osteomyelitis) medical review is required Page 35 of 39

35 Classification Indications Considerations For clients with penicillin hypersensitivity, use: Ciprofloxacin 500mg orally, 12 hourly for at least five days To seek medical attention if the client develops a rash, nausea, vomiting, diarrhoea, abdominal pain, and/or dyspepsia Plus Clindamycin 300mg to 450mg orally, t.d.s for at least five days Patients must be informed of the adverse effects of diarrhoea with a risk of pseudomembranous colitis, whilst taking clindamycin. Clients must be told to report these side effects and seek medical attention (Therapeutic Guidelines: Antibiotic, 2006) Approval is required from a clinical Microbiologist or ID Physician for ciprofloxacin and Clindamycin use Topical Antifungal Tinea (Body,limbs,face and interdigital) Terbinafine 1% topically, daily for 7 days Or an imidazole: Clotrimazole 1% topically, 2 to 3 times daily for 2 to 4 weeks, continued for 14 days after symptoms resolve. Cutaneous candidiasis Clotrimazole 1% topically, 2 to 3 times daily for 2 to 4 weeks, continued 14 days after symptoms resolve. If necessary for inflammation, add Hydrocortisone cream 1% topically, 2 to 3 times daily (Therapeutic Guidelines: Dermatology, 2004) Diagnosis of fungal infections can be confirmed via microscopy and culture of skin scrapings, subungual debris, nails or plucked hair Page 36 of 39

36 Classification Indications Considerations Topical Corticosteroids Stasis/contact dermatitis Mild Hydrocortisone cream 1% topically, 2 to 3 times daily Or Hydrocortisone acetate 1% cream or ointment 30g. Apply once or twice a day. Moderate Betamethasone valerate 0.02%-0.5% cream or ointment topically, once or twice a day. Severe Betamethasone dipropionate cream or ointment 0.05%, topically once or twice daily (use sparingly, and for as short a period of time as possible, due to potency and potential adverse effects (Therapeutic Guidelines: Dermatology, 2004) Uncomplicated stasis dermatitis is common in chronic leg ulcers. Stasis dermatitis is frequently complicated by allergic contact dermatitis, which usually resolves with the removal of the sensitising agents (frequently encountered in many dressing products) and treatment with a mild/moderate topical corticosteroid If poor response, refer to a Dermatologist Local anaesthetic Biopsy Lignocaine (7mg/kg) with Adrenaline (5 micrograms/ml). Lignocaine/Adrenaline 1: , 5mL Lignocaine 1%, 5mL Local Wound Debridement (pre procedure) where appropriate Lignocaine with Prilocaine 0.05%-1% topically Rossi (Ed), 2005; Therapeutic Guidelines: Dermatology, Lignocaine with adrenaline should not be used on an extremity such as a digit, especially in the presence of PAD, to avoid potential necrosis. For infiltration 1-2 ml is sufficient to provide anaesthesia and will not distort histology Page 37 of 39