* This policy is under review and is being updated. A revised policy will be added shortly * February Clinical Development Forum

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1 * This policy is under review and is being updated. A revised policy will be added shortly * Document Title: PCT Document Ref No.: Local Document Ref No.: Date of Approval: Approved by: Guidance for the use of vacuum assisted closure February 2009 Clinical Development Forum Category: Clinical Sub Category: Responsible Director: Choosing Health Services Director of Community Services and Nursing. Date policy is due for review: February 2012 Initial Equality Impact Screening: If required, full impact assessment attached: Who should read this policy: YES YES All Clinical Staff NAME OF POLICY: Guidance for the use of vacuum assisted closure. 1

2 Telford & Wrekin / Shropshire County NHS Trusts Guidance for the use of Vacuum Assisted Closure (VAC) Subject: Vacuum Assisted Closure Date of implementation: February 2009 Date of review: February 2012 Post Holders Responsible for document review: Joy Tickle: Tissue Viability Specialist. Guidance for the use of Vacuum Assisted Closure (VAC) Mission Statement Working together to improve health, care and well-being in our local communities by: Challenging the way we work Giving power to the public and our staff to initiate change Being open and honest in all our dealings with people Making the best use of resources Promoting good relations between people in different racial groups 1.0 Introduction Vacuum Assisted Closure (VAC) Therapy using Topical Negative Pressure (TNP) removes excess interstitial fluid which controls exudate levels and improves micro-circular blood flow which stimulates tissue budding and collagen production. The negative pressure exerted draws the wound edges together thus rapidly reducing the size of the wound (Demaria et al 2003, Banwell 2008). 2

3 VAC dressing is a proven method of treating wounds that resist healing, especially soft tissue wounds (Mcnulty et al 2007) and chronic complex bacterially colonised wounds (Evans & Land 2001). 2.0 Aim Provision of the rationale for and available evidence to support the appropriate use of VAC Therapy within the Primary Care environment. 3.0 Objectives 3.1 To provide evidence-based rationale for the use of VAC Therapy 3.2 To ensure the optimum environment to maximise healing potential of complex chronic wounds 3.3 To supply appropriate supportive structures for clinicians utilizing VAC Therapy within the community 4.0 What does VAC Therapy comprise of? Vacuum-assisted closure is an active wound therapy rather than a wound dressing. VAC therapy uses the application of topical negative pressure (TNP) across the wound surface using an open pore foam dressing cut to shape and inserted into the wound so that direct contact with the whole of the wound surface is attained. A transparent adhesive dressing is then applied to seal the wound. TNP is then applied using a vacuum pump (KCI 2008) via a drainage tube placed within/on the foam. One of the main strengths of VAC is its ability to promote healing in wounds with a complex aetiology and in those that have failed to heal with conventional wound care products (Joseph et al 2000, Mcnulty et al 2007) 5.0 Mode of action of VAC and guidance for use its use in clinical practice. VAC Therapy creates a hypoxic environment within the wound bed preventing aerobic bacteria survival. TNP applied across the wound forces the microcirculation to regenerate quickly encouraging capillary growth (angiogenesis). As TNP draws blood into the wound bed it brings oxygen, growth factors, macrophages and neutrophils and removes wound exudate and cell debris thereby reducing bacterial contamination, all of which promotes healthy tissue regeneration (Smith 2005, Miller & Glover 2007). It is active against Methicillin Resistant Staph Aureus (MRSA) and vancomycin resistant enterococci (Ballard & Baxter 2001). Acute infections should however be treated systemically with the appropriate antibiotics. As the wound is sealed malodour is fully controlled between dressing changes. To date there are numerous published studies that describe the benefits of TNP (Smith 2005, Penn & Rayment 2004, Mendez-Eastman 2002, Mcnulty et al 2007, Greene et al 2006). 3

4 Service providers have finite resources with which to deliver healthcare, therefore cost is always a factor in any treatment. The cost of VAC may initially appear expensive (Clubley & Harper 2005) but published case histories support the therapy as being very cost effective (Penn & Rayment 2004). Phibeck et al (1999) found that specific pressure ulcers healed 61% faster with TNP therapy when compared with saline soaked gauze which equated to a cost reduction of 38%. Smith (2005) compared TNP therapy against the use of hydrocolloid and alginate dressings which showed that VAC therapy successfully out performed these traditional dressings in terms of length of treatment time, patient satisfaction and overall cost factors by very significant amounts. 6.0 Indications 6.1 All staff considering VAC therapy for patients must inform the Tissue Viability Nurse and complete the VAC request form and send in accordance with the Proforma (see appendix 4,5,6). The request must then follow the agreed procedure guidelines and flow chart. (See appendix 1, 2, 3) Types of wounds suitable for the use of VAC Therapy within Primary Care Type of wound Reason for use Cavity wounds Pressure ulcers Chronic, not responding to traditional treatment Leg ulcers High exudate, wound unresponsive, with limb unsuitable for compression Diabetic wounds Unresponsive and circulation is poor Dehisced surgical wounds Heavily exuding wounds with possible infection Note. This table should be considered as a guide only The patient with chronic wounds must have had an assessment of their nutritional needs, and must be willing to comply with nutritional advice. 6.3 There must be a minimum of 3.5cm intact skin around the wound to maintain a seal. 6.4 The patient understands: the rationale for the VAC therapy the interventions required to apply and maintain VAC therapy And is aware that: 4

5 the dressings may be painful to begin with, and adequate analgesia should be arranged for dressing change they will be given an information leaflet describing treatment and contact numbers for 24hr assistance 6.5 The VAC therapy will be administered in accordance with the guidelines for application (Appendix 1). Quick Reference User Guide (appendix 2). 6.6 Gaining consent assumes that the person has capacity to either give or withhold consent. Capacity must be assumed unless there is reason to doubt it (Mental Capacity Act, Department of Constitutional Affairs, 2005). If the patient does not have capacity to consent to treatment, treatment can still go ahead under the Mental Capacity Act (2005) providing that it is in the person s best interest and the appropriate steps have been taken to assess and document this. This process must follow the Shropshire County Primary Care Trust and Telford and Wrekin Primary Care Trust policy on consent. 6.7 A signed and dated consent form is filed within the patient s notes (Appendix 3). 6.8 Link nurses with additional training/experience in VAC Therapy will provide support to nursing teams using this treatment 6.9 Agreement for the commencement of VAC Therapy will be gained from the Tissue Viability Service by supplying a request form and if possible full assessment documentation and digital image of the wound Contraindications: the patient refuses osteomyelitis which is not being treated with appropriate antibiotics patients on anticoagulant therapy necrotic tissue with eschar malignancy within the wound exposed arteries, veins or vascular grafts NB: Fistula to organs or body cavities may be treated using specialised dressings. Specialist help must be sought. 7.0 Documentation All wound assessment and reviews will be documented fully within the patient held nursing record. 5

6 8.0 Training Registered nurses undertaking wound management using VAC must receive training from an experienced link nurse/wound care specialist and demonstrate competence in the relevant skills. Registered nurses must accept accountability for maintaining competence through regular clinical experience and supporting theoretical knowledge. The practitioner and their supervisor who is competent to perform this procedure will determine the number of supervised practices required to achieve competence. This will take into account the practitioners own learning needs. 9.0 Audit The Tissue Viability Service will lead an annual audit. The audit will include the examination of untoward incidents associated with the use of VAC Therapy. The audit will include: Adherence of staff to the guidelines Clinical outcomes/performance management Infections/healing rates Service benefits Patient satisfaction / quality of life outcome Admission avoidance Cost savings If there are untoward incidents associated with the use of Vacuum Assisted Closure (VAC) Therapy the immediate consequences will be dealt with by the practitioner, reported to head of department and reported to the Tissue Viability Nurse Specialist. An incident form will be completed and sent to the risk management department 10.0 Key to Abbreviations: VAC Vacuum Assisted Closure. TNP Total Negative Pressure KCI Manufacturing Company Consultation Joy Tickle Tissue Viability Nurse Specialist 6

7 12.0 References Ballard, K. Baxter, H. (2001) Vacuum-Assisted Closure is a useful adjunctive therapy for the management of a wide variety of wounds. Nursing Times, 9 (35), Banwell, P.E. (2008) Negative pressure Therapy in Wound care. The Journal of wound Care 8: Baxandall, T. (1996) Healing Cavity Wounds with Negative Pressure. Nursing Standard, 11 (6) Baynham, S. Kohlman, P. Katner, H. (1999) Treating Stage 1V pressure ulcers with negative pressure therapy: a case report. Ostomy Wound Management, 45, Clubley, L. Harper, L. (2005) Using negative pressure therapy for healing of a sternal wound. Nursing Times, 101 (16), Demaria, R. Giovannini, U. Teot, L. Frapier, J. Albat, B. (2003). Topical negative pressure therapy. A very useful new method to treat severe infected vascular approaches in the groin. Journal of Cardiovascular Surgery, 44 (6) Deva, A.K. (1997) Vacuum Assisted Closure of a sacral pressure sore. The Journal of Wound Care 6 (7) Jul Evans, D.Land, L. (2001) Topical negative pressure for treating chronic wounds a systematic review. British Journal of Plastic Surgery, 54, Joseph, E. et al (2000) A prospective randomised trial of vacuum-assisted closure V standard therapy in chronic non-healing wounds. Wounds, 12 (3), K.C.I. Guidelines for the use of VAC. (2008) McNulty, (2007) Negative Pressure Therapy. The Journal of Wound Care 8(9) sept Mendez-Eastman, S. (2002) New treatment for an old problem: Negative Pressure Wound Therapy. Nursing, 32 (5), Miller, M. Glover, D. (2007) Wound Management: Theory and Practice. Nursing Times Books, London Motykwas,M.J., Argenta,L.C., Wilson-Salem,N.C., Non Surgical Modalities to enhance healing and care of soft tissue wounds. Journal of Southern Orthopaedic Association, Vol. 6.No.4 Winter

8 Penn, E. Rayment, S. (2004) Management of a dehisced abdominal wound with VAC therapy. British Journal of Nursing, 13 (4), Philbeck, T. et al (1999) The clinical cost effectiveness of externally applied negative pressure wound therapy in the treatment of wounds in Home Healthcare Medicare patients. Ostomy and Wound Management, 45 (11) Smith, N. (2005) The benefits of VAC Therapy in the management of pressure ulcers. British Journal of Nursing, 13 (22), Bibliography Argenta, L. Morykwas, M. (1997) Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Annals of Plastic Surgery, 38 (6) Collier, M., (1997) A guide to Vacuum Assisted Closure (VAC) Nursing Times Jan 29. Franks.Y., (1999) Using negative pressure technology in the management of wounds Journal Clinical Nursing. Sep.Vol Mendez-Eastman S., (1998). Negative Pressure Wound therapy. Plastic Surgery Nursing, 61 (1), NMC (2004) Code of Professional Conduct. NMC London Signature for Ratification Date

9 Guidelines for the application Of TNP Therapy Appendix 1 Shave hair on the margins around the wound, if applicable. An open pore sponge is placed on or in the wound. This is cut to a slightly smaller size than the actual wound. No foam should extend beyond the wound margin as this can damage the edges of the wound. More than one piece of foam can be applied to the wound. A clear plastic film is then applied to cover all of the sponge and at least 2cm of intact skin around the wound edges to provide a complete seal. Cavilon barrier film can be used to protect the surrounding skin. A slit is then made in the film to facilitate attachment of the special vacuum plastic tubing (supplied with the dressing) which should then be connected to the canister tubing, which will be inserted into the pump unit. Make sure both clamps are open. This is connected to the negative pressure suction pump, via a canister and the pressure is applied depending on the type of wound. (See chart for guidance). The sponge will shrink and appear firm when touched. Check that the tube is not causing pressure on the edges of the wound. The sponge may adhere to the wound surface so it is advisable to apply a non-adhesive layer to the wound bed such as Mepitel or NA Ultra. Clean the wound at each dressing change by irrigating with normal saline. Canisters should be changed every 3-5 day or when full (unit will alarm). The patient should be observed for the first 24 hours in case there is any severe pain caused by the TNP therapy Points to consider The therapy should not be switched off for longer than 30 minutes and no more than 4 times in 24 hours. If the seal cannot be achieved and maintained the therapy should be discontinued. The patient s clinical condition should be continually assessed to determine the appropriateness of continuing the TNP therapy. 9

10 The therapy should be discontinued when the treatment aims are achieved i.e. Wound is prepared for further surgery, such as a skin graft. The wound is granulating and can be managed with conventional dressings. Full documentation of the therapy should be made for the patient s notes. 10

11 Appendix2 Recommended Guidelines for Treating Wounds in The Primary Care Environment Quick Reference User Guide Initial Cycle Pressure ulcer Diabetic ulcer Acute /traumatic Leg ulcers Surgical wounds Indication for use Chronic nonresponding or preparing for surgical intervention Non-responding Poor circulation Deep nonresponding and/or awaiting surgical intervention Non-responding or to clean and prepare for other intervention. Surgical wound dehiscence Target Pressure 125 mmhg Reduce by 25mmHg increments weekly To minimum 75mmHg mmHg 125mmHg Cycle Continuous Change to intermittent after 48 hours Intermittent Continuous Throughout therapy Continuous Throughout therapy Intermittent Continuous for sternotomy patients Dressing changes 2-3 days Daily if there is infection 2-3 days daily if there is infection 2-3 days 2-3 days daily if there is infection 2-3 days Daily if there is infection All pressure target figures are for Black Foam If the patient is experiencing pain the target pressure can be reduced by 25mmHg increments until pain is relieved. The above provides a guide and should not replace clinical assessment or judgement Adapted from: Negative Pressure Wound Therapy Mendez-Eastman (1998) Equipment used for VAC Treatment: The VAC negative pressure unit (portable Freedom model) 39 per day The VAC PAC dressing (available in various sizes) containing foam packing, suction tubing, occlusive transparent drapes 19 each (med size) A 300 ml canister to collect the wound exudate and tubing for connection A sterile dressing pack Sterile Gloves Scissors 11

12 Appendix 3 Consent for Topical Negative Pressure (TNP) Therapy Patient label or: Patient Name Registration Number Date of birth Address Consent for use of Topical Negative Pressure Therapy. I, consent to having my wound treated with Topical Negative Pressure The therapy and its benefits have been explained to me along with the potential complications. I have had the opportunity to discuss this therapy with the nurse/clinical specialist. Patient s Signature Date Nurse s Name (print) Designation Nurse s signature 12

13 Appendix6 Vacuum Assisted Closure Therapy Request Appendix for VAC 3 Therapy: Proforma document to be completed and sent to appropriate Commissioning Body for each PCT and to joy tickle.joy.tickle@telfordpct.nhs.uk, fax VAC Proforma request received by Commissioning Body. Consent to funding agreed/not agreed by Joy Tickle Tissue Viability Nurse visits patient and carries out an assessment Clinical decision made for/against VAC Therapy Time period for treatment identified. Review date set Request made to company for VAC machine and appointment made for in house training for nurses and patient Dressings and canisters prescribed by GP surgery on FP10 Commissioning Body informed of decision All invoices for payment to be sent to named Commissioner Problems with VAC machine? Direct contact with company to enable repair or replacement Problem with treatment or condition of wound? Contact TV nurse Joy Tickle and company.joy.tickle@telfordpct.nhs. uk, fax Tissue Viability Nurse Joy Tickle reviews VAC Therapy after agreed treatment time. Decision made to continue/discontinue VAC Therapy Outcome of VAC Therapy evaluated and documented Commissioning Body informed of treatment outcomes 13

14 Appendix4 V.A.C Therapy Funding Request Patient Details: Name Address G.P Details: Name Address Tel: Number D.O.B Age Hospital In-Patient Details: Consultant Name Ward Hospital Tel Number Fax number Procedure: Wound details: Type:- History:- Location:- Sinus/ Fistula / Undermining (please highlight) V.A.C Therapy Objectives: (please tick all that apply) Wound granulation Wound complete healing Vascularisation Wound stability Wound bed preparation Exudate management Tel Number VAC Model (please circle or tick) ATS Freedom InfoVac ActiVac Planned discharge date Wound dimensions : Width Length Depth Exudate levels: Low Moderate High Current V.A.C Therapy details Unit type Type of foam mmhg setting Pressure setting: intermittent / continuous Start date of therapy Anticipated period of V.A.C Therapy at home 1 week 1-2 weeks 2-4 weeks Does the patient meet the PCT s VAC Criteria YES / NO If NO please refer to the PCT TVN for further discussion. Anticipated Wound reassessment date: Out-Patient Department Appt date: 14

15 Appendix 5 Community Request for V.A.C. Therapy Nursing staff request a wound assessment from TVN Service Referral form faxed or ed TVN Service Fax: Joy.tickle@telfordpct.nhs.uk or tissueviability@.nhs.net Joy.tickle@telfordpct.nhs.uk No Joy.tickle.nhs.uk A clinical decision is made by TVN Service. Joy Tickle TVN approves funding Joy Tickle: Yes Alternative treatment is undertaken Alternative treatment is undertaken Community Nursing Team contact KCI Medical V.A.C. Clinical Specialists. Natasha Sterling: or Emma French: To organize V.A.C. initiation, support and training Informed patient consent gained adhering to the Mental Health Capacity Act. When V.A.C. is discontinued the Community Nurse to contact KCI on to cancel the rental period and to notify TVN Service with patient process update Community Nurses to to utilise utilise the the prescription prescription service service for the for consumables. Any V.A.C. item not currently available on the consumables. Any V.A.C. item not currently FP10 please contact TVN Service available on FP10 please contact TVN Service Ensure patient transitioned with: 1. 2 x Dressings & 1 x Canister 2. Discharge V.A.C. Therapy Letter 3. Black carry box & plug 15 Patient is being transitioned into hospital on V.A.C. liaise with Acute TVN Service