Formulary for the Management of Wounds in Primary and Community Care in Solihull V.3

Transcription

1 Formulary for the Management of Wounds in Primary and Community Care in Solihull V.3 Introduction It is important that within the NHS we are able to justify clinical decisions and expenditure on wound management products. It is expected that most dressings will be selected from this formulary. Should a product be required which is not listed, the rationale for this must be supplied in writing to the TVN. The wound management formulary has the explicit aims of: Promoting evidence based practice. Promoting continuity of care. Encouraging safe, effective and appropriate use of dressings. Promoting rational prescribing. Supporting the practical application of nurse prescribing. Cost effectiveness. Choice of dressings: The properties of dressings differ; there is no one product which is suitable for all wound types or all the different stages of healing. A flexible approach to the selection of wound care is required, in order to optimise the healing process. Evaluation of the dressing and wound status should be made at EVERY dressing change in order to guide choice of product. Remember that it is possible for any dressing to cause sensitisation of the wound. Products containing antimicrobials should not be used indefinitely, the normal time they are required is for up to 14 days. If the wound does not show any signs of improvement within that time consider alternative dressings, oral antibiotics and re-assess local and general factors that impair healing. Do not prescribe/ supply these dressings in quantities that exceed a 14 day supply See Top Tips below for more good practice points. Solihull Community Services has implemented a central supply of dressings scheme. In this scheme, formulary dressings are ordered directly from an NHS wholesaler and stored at the community nursing base. Then community nurses can take these dressings out to patients when required and bypass the FP10 prescription route. Use of FP10 prescriptions is reserved for clinical situations where a dressings outside the formulary is indicated. This scheme has been shown to reduce waste and therefore costs. If you have any further questions contact the Tissue Viability Nurse at: joy.rudge@heartofengland.nhs.uk Page 1 of 12 Date Issued: September 2012

2 Formulary for the Management of Wounds in Primary and Community Care in Solihull V.3 TOP TIPS for the Use of Dressings in Solihull 1. The key to successful wound management is the careful and accurate holistic assessment of the patient. It is important to understand; the healing process, factors that may affect this process and the properties of dressings to promote healing. 2. In Solihull, approximately 800,000/year is spent on dressings. This is equivalent to 2200/day. Savings made in this area can be re-invested on other areas of patient care. 3. Due to the potential for waste and costs; quantities of dressings prescribed / supplied should take into account the most likely length of the treatment and wound healing. Wound healing is a dynamic process and the characteristics of a dressing required by the wound can change as the wound moves through the different phases of the healing process. Two weeks supply is appropriate in most circumstances. 4. Items prescribed / supplied should be recorded in the patient s care plan. This is to avoid duplicate prescriptions which create waste. The prescriber or Nurse requesting the dressings should be aware of the total value of the products and have given consideration to the necessity of all the items requested. 5. Keep it simple! Do not use more than one primary dressing product per wound unless clinically indicated (and the reason should be documented in the patient s care plan) Most dressings are designed as wound contact layers in their own right; putting them on top of one another reduces their effectiveness and is unnecessarily costly. Where a secondary dressing is necessary, use the cheapest functional one. 6. Sustain treatments for long enough to allow improvements of the wound to become apparent. Prescriptions for dressings should only be generated when the nurse is completely confident that the chosen product if the most appropriate dressing. This may not be until the second or third dressing change when an effective evaluation of the dressing s performance with that wound can be made. Avoid frequent changes of dressing regime unless justified 7. Dressings containing silver: Are very high cost products with an extremely limited evidence base. Should never be used routinely i.e. just in case. Should only be considered on wounds showing clinical signs of colonisation or infection and after discussion with senior colleagues. Once the infection has resolved, treatment with silver dressing should be stopped. 8. Avoid adhesive tapes and retention bandages when possible to reduce skin complications and expense. Many dressings are self adhesive. 9. If prescribing off formulary for any reason it is essential to let the local Tissue Viability Nurse know. This will aid in the updating process of the formulary. Page 2 of 12 Date Issued: September 2012

3 Formulary for the Management of Wounds in Primary and Community Care in Solihull V.3 Index of sections 1.0 Necrotic/sloughy wounds 2.0 Granulating / epithelialising wounds 3.0 Infected wounds 4.0 Malodorous wounds 5.0 Overgranulation tissue 6.0 Healing static wounds 7.0 Fragile skin or painful wound 8.0 Exuding, lower limb eczema 9.0 Wound Contact Materials, Tapes, Bandages and Miscellaneous 10.0 Dressings for Evaluation Where, or is shown, this indicates a greater cost per price of each 10x10 (or nearest size) dressing. Larger sized dressing will be of greater cost. The exact price of dressings can be found in Part XIA of the Drug Tariff: Health professionals should be aware of the costs of all treatments they prescribe. Additional Information Consultation Tissue Viability Nurse Medicines Management Local nursing experience Product Literature Cost- effectiveness HEFT Formulary Working Group Drug and Therapeutics Committee Page 3 of 12 Date Issued: September 2012

4 1.0 Necrotic/sloughy wounds Formulary for the Management of Wounds in Primary and Community Care in Solihull V.3 Alginates and equivalents Second line These dressings are for wet to very wet exuding wounds. Needs a secondary dressing. Do not wet before applying to the wound. Needs changing when there is strikethrough on secondary dressing. Needs to be in place for at least 24 hours to form a gel in contact with wound exudate. Remove gel by irrigation with warmed saline solution. Hydrogel These dressings debride or deslough. The choice is dependent on whether wound is flat, a cavity and level of exudate Hydrogels may require daily changing but can be left in place for up to 3 days. Needs a secondary dressing, which should be semi-permeable to prevent the gel drying out. Gauze is best avoided as a secondary dressing because it absorbs amorphous gel and sheds fibres into the wound. Strikethrough can appear very quickly, making the wound susceptible to infection Sorbsan packing Sorbsan Ribbon Sorbsan Flat Sorbsan plus Sorbsan plus SA Intrasite conformable Actiform Cool Aquacel Aquacel ribbon Aquacel Urgosorb Urgoclean - only to cleanse very wet and sloughy wounds Nugel Page 4 of 12 Date Issued: September 2012

5 2.0 Granulating / epithelialising wounds Formulary for the Management of Wounds in Primary and Community Care in Solihull V.3 Alginates and equivalents These dressings are for wet to very wet exuding wounds. Needs a secondary dressing. Do not wet before applying to the wound. Needs changing when there is strikethrough on secondary dressing. Needs to be in place for at least 24 hours to form a gel in contact with wound exudate. Remove gel by irrigation with warmed saline solution. Hydrocolloids These dressings are for low to medium exudate flat wounds. Needs minimum of 2cm overlap from the wound edge. Always warm prior to application to aid adherence. Do not put excessive pressure on the dressing for at least 20 minutes following application to ensure adhesion. Apply in a rolling motion, do not stretch. Dressing should be changed when soft mass increases, or it reaches 2cm from the wound edge. Foam These dressings are for moderate to heavy exuding flat wounds. They can be left in place for 2 to 7 days. Change more frequently on exuding or infected wounds. Always allow a sufficient border to ensure exudate is dispersed sideways 2 to 3cms for moderate exudate and 4 to 5cms for heavy exudate. Sorbsan packing Sorbsan Ribbon Sorbsan Sorbsan plus Sorbsan plus SA Tegaderm hydrocolloid Tegaderm Foam Tegaderm Foam Adhesive Aquacel Aquacel ribbon Aquacel Urgosorb Urgoclean - only to cleanse very wet and sloughy wounds Low/medium exudate flat Duoderm extra thin Allevyn lite / thin Allevyn / Allevyn Adhesive Allevyn Heel* Allevyn Plus *Use Allevyn heel as a primary dressing, not as a padding Page 5 of 12 Date Issued: September 2012

6 Formulary for the Management of Wounds in Primary and Community Care in Solihull V.3 Vapour permeable adhesive film These dressings are to cover blisters, protect from friction or to secure other dressings. Available as a peel on or window frame application. Allow a 5cm border from the wound edge. Change every 3-7 days. Outer coverings can be used for tracing wounds. Some have grids to aid measuring. Can be cut to size. Always remove with care by lifting the edge of dressing and stretching the film at diagonal corners. C- View C- View post op Hydrogel These dressings debride or deslough. Choice dependent on whether wound is flat, a cavity and level of exudate Hydrogels may require daily changing but can be left in place for up to 3 days. Needs a secondary dressing, which should be semi-permeable to prevent the gel drying out. Gauze is best avoided as a secondary dressing because it absorbs amorphous gel and sheds fibres into the wound. Strikethrough can appear very quickly, making the wound susceptible to infection Intrasite conformable Actiform Cool Nugel Page 6 of 12 Date Issued: September 2012

7 3.0 Infected wounds Antimicrobials Formulary for the Management of Wounds in Primary and Community Care in Solihull V.3 * The treatment aim is to reduce bacterial load for colonized or infected wounds. Products containing silver, honey or iodine should not be used indefinitely. If the wound does not show any signs of improvement within 14 days consider alternative dressings and re-assess local and general factors that impair healing. Inadine Urgosorb silver Algivon Flamazine Actilite Protosan *Antimicrobial dressings are a high cost product with a limited evidence base. They should never be used routinely and only be considered on wounds showing clinical signs of colonisation or infection and after discussion with TVN or Senior Colleagues. Once the infection has resolved, treatment with the antimicrobial dressing should be stopped. 4.0 Malodorous wounds Odour absorbing dressings These dressings are for malodorous wounds. They can be left in place for up to 7 days dependant on degree of odour and level of exudate. Their use should be seen as second line, after first line measures to identify and the cause of malodour and containment of exudates have been instigated. Clinisorb Actisorb silver Page 7 of 12 Date Issued: September 2012

8 5.0 Overgranulation tissue Formulary for the Management of Wounds in Primary and Community Care in Solihull V.3 Foam These dressings are used to resolve overgranulation tissue They can be left in place for 2 to 7 days. Change more frequently on exuding or infected wounds. Always allow a sufficient border to ensure exudate is dispersed sideways 2 to 3cms for moderate exudate and 4 to 5cms for heavy exudate. 6.0 Healing clean but static wounds Protease modulating matrix These dressings are used only when the wound is clean but static and other treatments have failed. The treatment aim is to kick start healing See manufacturer s instructions If the wound does not show any signs of improvement within 14 days consider alternative dressings and re-assess local and general factors that impair healing. Lyofoam Lyofoam extra Lyofoam extra adhesive Healan Tape Urgotul Start These dressings are of high cost and a limited evidence base. Advice should be sought from senior colleague before initiating. Page 8 of 12 Date Issued: September 2012

9 7.0 Fragile skin or painful wound Formulary for the Management of Wounds in Primary and Community Care in Solihull V.3 Low adherent dressings and wound contact materials Fragile skin or painful wounds only. The treatment aim is to prevent further tissue damage and reduce discomfort. These products should only be considered if adhesive foam is likely to cause skin damage on removal. Please check that the patient has appropriate analgesia. 8.0 Exuding, lower limb eczema Mepilex border Lite Mepilex Mepilex border Urgotul Allevyn Gentle Allevyn Gentle border Medicated bandages These dressings are used to soothe and reduce varicose eczema. Can be left in place for up to 7 days Viscopaste PB7 or Icthopaste Zip-zoc Page 9 of 12 Date Issued: September 2012

10 Formulary for the Management of Wounds in Primary and Community Care in Solihull V Wound Contact Materials, Tapes, Bandages and Miscellaneous Debridement Debrisoft Absorbent padding Superabsorber Wound contact materials Sterile saline Surgical adhesive tape Zetuvit E Eclypse Drymax N/A Ultra Atraumen Irripod Clinipore Scanpor (For applying dressings to the skin Mefix ) Tubular gauze bandage For retention of dressings Clinifast or Actifast Light-weight conforming bandages For retention of dressings K band Support bandages For retention of dressings K lite High compression bandages For venous leg ulcers 4 layer- K Four 2 layer- K 2 Page 10 of 12 Date Issued: September 2012

11 Formulary for the Management of Wounds in Primary and Community Care in Solihull V.3 Short stretch compression bandages For venous leg ulcers/ control of oedema Actico Comprilan (washable) Cohesive bandages For venous ulcers Ko-flex Subcompression wadding For protection and absobancy K soft Cellona (Less irritating, better base for lymphoedema bandaging) Absorbent perforated dressing with adhesive border For the protection of wounds with low exudate Softpore Cosmopor E Barrier preparations Cavilon Pro Shield Gauze Swab Non woven Gauze swabs Gauze swabs VAC Please refer to SCS VAC Guidelines for full details VAC Granufoam VAC Freedom Canisters Simplace Dressing Kit Telfa Light NB: Please order IV dressing and dressings aids / packs via stores Page 11 of 12 Date Issued: September 2012

12 10.0 Dressings for FP10 Prescription Formulary for the Management of Wounds in Primary and Community Care in Solihull V.3 The following dressings are being evaluated in Solihull and do not have full formulary status. They will be considered for future formulary revisions. Community nurses wanting to initiate patients on these dressings should in the first instance consult the TVN and/or Senior Colleague. The use of these dressings will be monitored via epact prescribing data and shared with senior district nurses and team managers. GPs should not be asked to prescribe dressings for patients routinely. Sorbion Sachet S Sorbion Sana Oxyzyme Iodzyme Vibropulse Any new product that requires evaluation should have been seen by the Tissue Viability Nurse and suitability for evaluation agreed prior to initiation of the dressing. Page 12 of 12 Date Issued: September 2012