PROCEDURE FOR THE APPLICATION OF GAUZE BASED NEGATIVE PRESSURE WOUND THERAPY (NPWT)

PROCEDURE FOR THE APPLICATION OF GAUZE BASED NEGATIVE PRESSURE WOUND THERAPY (NPWT) First Issued Feb 2010 Issue Version Two Purpose of Issue/Description of Change To promote safe and effective care when carrying out NPWT procedure in a community setting (only if completed in-house training course) Planned Review Date 2012 Named Responsible Officer:- Approved by Date Tissue Viability Nurse Specialists Section :- Tissue Viability TV N o 04 Clinical Policy and Procedure Policy Group Impact Assessment Screening Complete Date: January 2010 August 2010 Full Impact Assessment Required Y/N UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM THE NHS WIRRAL WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION

CONTENTS LIST CONTENTS PAGE Introduction 3 Negative Pressure Wound Therapy (NPWT) 3 Target group 3 Training 3 Professional expert supervision 3 Generic care plan 3 Related policies 4 Clinical benefits of NPWT 4 Clinical indications 4 Contraindications/precautions 5 NPWT additional precautions 5 Discontinuation of NPWT 6 Assessment, patient information and consent 6 Equipment 6 Procedure for NPWT 7 Procedure for dressing removal 7 Procedure for dressing application 8 Procedure for ongoing canister change 9 Return of devices once therapy has been discontinued 10 Collection of clinical waste for disposal of dressings and 11 canisters Troubleshooting 11 Other considerations 12 Discharge process 12 Procedure for patients being discharged from Wirral 12 University Teaching Hospital NHS Foundation Trust Planned discharge, liaise with discharge coordinating team 12 Contingency plan if all NHS Wirral pumps in use 13 Patients requiring NPWT from out of area 13 Patient requiring NPWT already in the community 13 Decontamination process of equipment prior to return to 13 community equipment service Clinical incidents 14 References 14 Appendix 1- NPWT consumables guide 15 CONSULTATION Infection Control Team Clinical policy and procedures group Service Improvement Unit 2/15

PROCEDURE FOR THE APPLICATION OF GAUZE BASED NEGATIVE PRESSURE WOUND THERAPY (NPWT) INTRODUCTION The use of negative pressure wound therapy (NPWT) in wound care is one of the most important technological advancements in recent times, as it has the potential to promote wound healing, alleviate wound symptoms and improve the quality of life of patients with acute and chronic wounds with delayed or difficult healing (Best Practice Statement 2008). NEGATIVE PRESSURE WOUND THERAPY (NPWT) NPWT is the application of a uniform negative pressure across the wound bed. The benefits of NPWT therapy are recognised as promotion of healing, improved exudate management and reduction of odour and bacteria (Dougherty and Lister 2008). TARGET GROUP This procedure must only be undertaken by a competent registered nurse who has successfully completed a competency based in-house training session in the assessment, management and application of gauze based NPWT. TRAINING This procedure must only be performed by nurses who have received specific training in the use of gauze based negative pressure wound therapy. Tissue Viability Link Nurses will be trained by the Tissue Viability Service (TVS) as a resource in each community nursing team, they will have regular ongoing updates via the link nurse meetings The Tissue Viability link Nurses will train colleagues in their teams, as and when they have a patient requiring this clinical intervention. A training package will be available to staff. NPWT updates for link nurses would be every two years PROFESSIONAL EXPERT SUPERVISION Ongoing supervision and support is available for all nurses from the Tissue Viability Specialist Nurses GENERIC CARE PLAN A generic care plan is available for this procedure 3/15

RELATED POLICIES Please refer to related NHS Wirral policies and procedures CLINICAL BENEFITS OF NPWT There are many benefits associated with the use of NPWT. These include: Increased local blood flow to the wound by the dilation of arterials. Reduced tissue oedema for the removal of excess fluid. Stimulation of granulation tissue resulting in progressive wound closure. Stimulation of self proliferation. Removal of free radicals from the wound. Removal of slough. Reduction in wound volume. Protection from outside contaminants. Decrease in wound bioburden. Maintenance of a moist wound healing environment. CLINICAL INDICATIONS NPWT may be used for the treatment of: partial full thickness pressure ulcers dehisced surgical wounds diabetic/neuropathic ulcers venous leg ulcers post surgical wounds sinus drainage and management traumatic wounds pre-op flap grafts post-op surgical flap grafts necrotising fasciitis burns AS WITH ALL WOUND MANAGEMENT NPWT SHOULD ONLY BE USED ON WOUNDS THAT HAVE BEEN THOROUGHLY AND ACCURATELY ASSESSED NPWT CONTRAINDICATIONS The use is contraindicated if: tissue eschar is present Dressings are placed directly over exposed vital structures (i.e. tendons, ligaments, blood vessels, anastomotic sites (organs and/or nerves) untreated osteomyelitis is noted 4/15 NPWT PRECAUTIONS Precautions should be taken when using NPWT in the following cases: patients receiving anticoagulant therapy or platelet aggregation inhibitors, or those who are actively bleeding or have weakened irradiated blood vessels or organs malnourished patients who have not received adequate nutrition/ nutritional supplements

non enterocutaneous or unexplored fistula are present there is malignancy in the wound the patient is being treated with systemic steroids the patient is unable to understand what the therapy entails or comply with the treatment children non-concordant or combative patients patients with infected wounds, as they may require more frequent dressing changes patients with burns patients with wounds in close proximity to blood vessels, delicate fascia, vital organs or exposed tendons (ensure adequate protection with overlying fascia, tissue or other protective barriers) in the presence of bone fragments, as these could puncture protective barriers, vessels or organs with enteric fistulae that require special precautions to optimise therapy NPWT ADDITIONAL PRECAUTIONS Although not contraindicated with NPWT, extra care should be taken in patients with bleeding problems, including: patients receiving long-term anticoagulant therapy patients with haemophilia patients with haemoglobinopathies, such as sickle cell disease DISCONTINUATION OF NPWT Clinicians should consider discontinuation of NPWT when: a uniformly-granulating tissue is achieved in the wound bed granulation tissue is level with the surrounding skin patient s overall condition/wound is improving patient is not physically or psychologically tolerant of NPWT no progression of the wound is observed after two consecutive dressing changes (consider discontinuation discuss with TVS) patient complains of excessive pain patient withdraws their consent to treatment exudate levels are less than 20 30mls per day wound bed is ready to take a skin graft/ flap frank pus is evident within the dressing or canister excessive bleeding haematoma is evident under the dressing an alternative treatment option is more suitable, and/or the initial goals defined at the outset of NPWT have been met 5/15

ASSESSMENT, PATIENT INFORMATION AND INFORMED CONSENT In addition to considering the use of NPWT to benefit the patient and the wound, the clinician must first undertake a holistic assessment of the patient and consider the following points: Is the therapy appropriate for the wound, and also for the patient? The practitioner should consider the patient s general wellbeing and state of health, as well as product indications and precautions, and concomitant therapies/ medication What type of wound is to be treated, where is the wound located, and what type of tissue is present? EQUIPMENT: Single use sterile dressing pack Single use disposable non sterile gloves Non-sting skin barrier applicator Sterile normal saline Single use disposable sterile scissors 1 NPWT canister and tubing 1 NPWT therapy unit (Pump) 1 NPWT dressing pack NWPT Consumables Guide (see appendix 1) Non adherent wound contact layer to prevent gauze adhering to wound bed (in dressing pack) Extra semi-permeable dressings to seal any leaks PROCEDURE FOR NEGATIVE PRESSURE WOUND THERAPY Procedure Confirm identity of patient, by asking for full name and date of birth. Clarify identity with carers if patient not able to do so Explain the procedure to the patient, obtain valid consent and document in patients health record. Assess the need for pain relief and administer prior to procedure, if required. Position the patient comfortably, to ensure safety and enable easy access to, and good visibility of the wound. Rationale To confirm correct identity of patient. To enable patient to make an informed decision about their own health care To maintain patient comfort. To allow access to and to have a clear view of the wound, providing a safe environment for patient and clinician. 6/15

PROCEDURE FOR DRESSING REMOVAL Procedure Press ON/OFF button on unit. Decontaminate hands prior to procedure Apply single use disposable apron and single use disposable non-sterile gloves Raise tubing connectors above the level of the unit. Tighten clamp on dressing tubing. Separate canister and dressing tubing, allow unit to draw any exudate into the canister from the canister tubing. Gently stretch and release drape to deactivate adhesive, and slowly remove from skin. Gently lift dressing from wound bed. NB: If it adheres to the wound bed, soak dressing off using warmed, sterile, normal saline, and consider applying non-adherent contact layer to wound bed. Remove and dispose of PPE to comply with waste management policy Decontaminate hands following removal of PPE Rationale To deactivate pump. To reduce the risk of transfer of transient micro-organisms on the healthcare workers hands To protect clothing or uniform from contamination and potential transfer of microorganisms To ensure drainage of exudate, and prevent spillage. To reduce risk of contamination. To ensure drainage of exudate and to prevent spillage. To prevent trauma to peri wound area. To reveal wound and prevent trauma to granulation tissue. To prevent cross infection and environmental contamination To remove any accumulation of transient and resident skin flora that may have built up under gloves and possible contamination following removal of PPE PROCEDURE FOR DRESSING APPLICATION Procedure Decontaminate hands prior to procedure Prepare all equipment and open sterile dressing pack onto a clean field and place all sterile single use equipment required within the sterile field. Apply single use disposable apron Apply non-sterile single use disposable gloves and follow procedure for dressing removal Complete wound assessment and record wound dimensions on wound assessment chart, If possible, photograph wound. Remove gloves and decontaminate hands Rationale To reduce the risk of transfer of transient micro-organisms on the healthcare workers hands To maintain asepsis and prevent contamination of sterile equipment To protect clothing or uniform from contamination and potential transfer of microorganisms To reveal the wound. To provide a baseline and enable future reassessments and evaluations. (If photographing wound complete consent form) To remove any accumulation of transient and resident skin flora that may have built up under gloves and possible contamination following 7/15

Apply single use disposable sterile gloves in a manner which prevents the outer surface of the sterile glove being touched by a non-sterile item. Cleanse wound and periwound area, if required, by irrigating with warm sterile saline. Ensure surrounding skin is dry and apply non-sting skin barrier to periwound skin. Line wound with a single layer of non-adherent wound contact material (document that liner has been used) in the following circumstances: Wound contains exposed bone or tendon Dressing is next to exposed, anastomosed or irradiated blood vessels Dressing is to be left in situ for more than 48 hours Dressing adheres to wound If using gauze as a filler Moisten wound filler, mould to the shape of the wound, and place at least one layer into the wound cavity, covering the entire wound base, sides, tunnels, and undermined areas. If using Foam Cut the foam to fit the wound perfectly ensuring it is level with the surrounding skin. If multiple pieces of foam are inserted into a cavity wound please ensure all pieces are in contact with one another and there is no dead space. You must document in the patients health records the number of pieces of foam used and on the dressing. When using gauze Insert chosen drain into the wound bed, either cutting it to fit, so that the drain is 1-2 cm smaller than the largest wound dimensions, or coiling it into the wound bed and securing it with strip paste. Use the remaining moistened gauze to fill remaining wound defect to the level of the surrounding skin. N.B. Do not over-compress the dressing or over-pack the wound. If using foam skip this section and go to section below applying drape Fit new canister removal of PPE to maintain asepsis, reduce the risk of microbial contamination and prevent the spread of infection. To promote hygiene and reduce bacterial Contamination. To aid application of drape and protect skin integrity. To protect underlying bone, tendon, blood vessels and granulation tissue. Previous incidents of liner remaining in wound, document in and when removed. To fit the dressing to the shape of the wound. Do not over-compress the dressing or overpack the wound. If using foam the edges of the foam can be beveled to avoid contact with the surrounding skin as the dressing collapses To fill the wound and facilitate the removal of exudate To ensure fluid collection. Connect tubing from drain to canister tubing, To ensure suction is provided by the pump. and ensure clamps are open. Connect canister to the pump. Place unit on a level surface, or hang at base To prevent damage to the unit. of the bed. Turn unit on, select the amount of suction To commence NPWT. 8/15

required, and press ON/OFF button to commence therapy. Observe that there is no sign of air leakage when the dressing is in a collapsed state. If a leak is suspected, gently press around the tubing and drape to aid a better seal, and add drape patches if necessary. On completion of procedure remove and dispose of PPE to comply with waste management policy. Decontaminate hands following removal of PPE. At each dressing change reassess wound and Healing rates, observe for any signs of complication and document progress towards healing in the patients notes as per trust policy. To ensure dressing has collapsed and NPWT has commenced. To prevent cross infection and environmental contamination. To remove any accumulation of transient and resident skin flora that may have built up under gloves and possible contamination following removal of PPE. To ensure appropriateness of NPWT. PROCEDURE FOR ONGOING CANISTER CHANGE Procedure Change the canister weekly, or when full press ON/OFF button on unit Decontaminate hands prior to procedure Apply single use disposable apron and single use disposable non-sterile gloves Raise tubing connectors above the level of the unit Tighten clamp on the dressing tubing Disconnect canister tubing from dressing tubing Remove canister from unit and dispose of according to Trust policy Replace canister and open any closed clamps On completion of procedure remove and dispose of PPE to comply with waste management policy. Ensure unit settings are correct and recommence by pressing the ON/OFF button Document each canister change and level of exudate in the patients notes / as per trust policy Rationale To ensure cost-effectiveness and to control odour To prevent unit from alarming To reduce the risk of transfer of transient micro-organisms on the healthcare workers hands To protect clothing or uniform from contamination and potential transfer of microorganisms To ensure drainage of exudate and prevent spillage To reduce contamination risk To release canister To ensure correct disposal To enable continuation of therapy To prevent cross infection and environmental contamination. To continue therapy Ensure correct procedures are followed/ use of resource is effective 9/15

RETURN OF DEVICES ONCE THERAPY HAS BEEN DISCONTINUED Procedure Decontaminate hands, apply single use disposable apron and single use disposable non sterile gloves to decontaminate the unit,,in line with cleaning and disinfection policy. Clean with detergent wipe then 70% alcohol hard surface disinfectant wipe. Dry and assemble all equipment in transfer box. Rationale As per manufacturer s instructions to ensure equipment cleaned correctly (Wipe all the external surfaces and pay particular attention to the controls panel and bottom edges of the pump and the cabling). COLLECTION OF CLINICAL WASTE FOR DISPOSAL OF DRESSINGS AND CANISTERS Complete and submit a request for home clinical waste collection form which is available on the intranet. TROUBLESHOOTING If the dressing adheres to the wound base Moisten points of adhesion with warmed sterile saline, and remove gently after 3 5 minutes Try introducing saline through the tubing. Cut the end off the tubing distal to the tubing clamp, use a 20ml syringe to instill the warmed saline, close the tubing clamp and leave for 20 minutes Note: if the dressing and wound have dried, there may be a small air leak. Ensure the dressing is sealed, and check regularly between dressing changes for leaks To help prevent adherence, consider imposing a single layer of non-adhesive material supplied in the pack between the dressing and the wound, or consider lowering the target pressure Note: pressures below -40mmHg are sub-optimal, and discontinuation of the therapy should be considered If the patient experiences discomfort during dressing changes or NPWT If due to adherence, see previous tips For wounds on extremities, or near the anus, ensure the dressing fits the wound, so there is not a large step between the tissue and the top of the dressing For fragile peri wound skin, use skin preparation wipes prior to drape application, or frame the wound with a layer of Duoderm (cut the drape to a size large enough to If the dressing does not collapse Air leaks can be identified by a whistling sound and may be caused by the following: Wrinkles in the drape An incomplete seal where the drain exits the wound These can be identified and corrected using the following approach: Check to ensure that all tubing clamps are open Ensure the pump is properly switched on Moving your hand around the dressing and border, and applying light pressure may help identify the leak If the set pressure is achieved when applying pressure at a certain point and drops when this is removed, use excess drape to patch the leak Large and deep wounds The dressing should be applied to fit the wound exactly - multiple dressings can be used, as long as they touch each other Record the number of multiple dressings in the patient s notes and, if possible, on the drape 10/15

cover the dressing and Duoderm layer only) OTHER CONSIDERATIONS Inspect the wound area frequently between dressing changes, watching for signs of infection and/ or other complications The level of negative pressure should be the same throughout the enclosed system, if the dressing is in contact with the whole of the wound surface If adipose tissue is present, it may necrose during the course of the treatment, and may be debrided at the bedside by a Tissue Viability Specialist Nursealternatively, cease treatment and apply a moisture-retentive dressing that facilitates autolysis, as per NHS Wirral formulary More than one wound may be treated simultaneously by either bridging wounds that are in close proximity, or using sterile Y connectors for wounds which are further apart (please refer to clinical guidelines or quick reference dressing guide for further details and application technique) In extremely debilitated patients with multiple wounds, only one wound may respond at a time - once one wound is healed, the next may show signs of improvement For wounds around the anus, use a skin preparation wipe with strip paste, and/ or Duoderm to frame the wound and ensure a good seal If maceration occurs around the wound site, consider the use of a skin preparation/duoderm as a framed dressing around the wound NPWT is intended to be on for 24 hours a day - if it has to be discontinued for more than two hours per day, an alternative wound dressing should be used DISCHARGE PROCESS Procedure for patients requiring Negative Pressure Wound Therapy (NPWT) Renasys-Go (S&N) gauze based system. NHS Wirral has purchased this system for all patients requiring NPWT. Procedure for patients discharged from Wirral University Teaching Hospital (WUTH) including Clatterbridge Hospital. Decisions to continue NPWT in the community, should be made by consultant or Tissue Viability nurse specialist. Planned discharge, liaise with discharge coordinators team. Pumps & consumables ordered via Community Equipment Store (CES). Ordering officer to complete CES requisition form, using smith & nephew codes (Appendix 1) for dressing packs & canisters. The pump is written down as Renasys- Go pump 11/15

This is then faxed to the CES dept, stating a number of options for delivery Delivered to the patients home Directly to the ward for attaching the pump to existing dressings to allow transfer from hospital to community pump (ordering officer to contact ward if discharge subsequently delayed) Member of CES staff to contact patients home 24 hrs later to confirm discharge If ordered before 14:00hrs can be delivered that day Contingency plan if all available NHS Wirral pumps are in use Initiate rental of pump funding approved first by service manager Contact Smith & Nephew customer care with invoice number initiated via online ordering system. Still complete CES requisition form for consumables, including a Renasys-Go pump to replace rental pump as soon as one becomes available. Additional information to include rental pump in use. After sending the fax to CES the ordering Officer needs to follow up referral with telephone call. Ensure rental pump is cancelled, once NHS Wirral pump is delivered (rental pump incurs a daily rental charge) Patients requiring NPWT from outside area Discuss with Tissue Viability service Ordering officer to Fax completed CES form for pump and consumables Delivered to patients home Patient requiring NPWT already in the community Tissue Viability Link nurse in community team Discuss with Tissue Viability service Complete CES requisition form for pump and consumables Decontamination of equipment prior to return to Community Equipment Service (CES) Clean as per infection control policy (cleaning & disinfection) e.g. detergent wipe then use of 70% alcohol hard surface wipers e.g. azowipes, cliniwipes, tuffiwipes Dispose of canisters & dressings from patients own home as per clinical waste policy waste policy Complete form CWRFO4. Waste care contractor contactable on 01270 539860 check with Tasmin Harvey for accuracy 12/15

CLINICAL INCIDENTS Any related incidents arising from this procedure which may involve a clinical error or near miss must be reported following NHS Wirral Incident Reporting Policy REFERENCES Best Practice Statement - Gauze Based Negative Pressure Therapy. Wound UK, Aberdeen, 2008. Bottemly V. 2007. Forward; Skin Breakdown. The Silent Epidemic. Smith and Nephew Foundation, Hull. Dougherty and Lister (2008) The Royal Marsden Hospital Manual of Clinical Nursing procedures. 7 th Edition, Wiley- Blackwell Oxford. Negative Pressure Wound Therapy (NPWT) Competency Workbook Smith & Nephew (2009) 13/15

APPENDIX 1 NWPT CONSUMABLES GUIDE Order Pump & Consumables using NHS Wirral Community Equipment Service (CES) Requisition form and fax to 482-8610 DRESSING KITS# DIAGRAM ORDER CODE CONTENTS DESCRIPTION PRICE RENASYS -G Small Flat 66800492 1 non-adherent gauze 1 pk gauze 2 small drapes 10cm x 12cm Small wounds, shallow or deep Minimal Heavy drainage 15.96 RENASYS-G Medium Flat 66800494 1 non-adherent gauze 1 pk gauze 2 medium drapes 15cm x 20cm Small Medium wounds, shallow or deep Minimal Heavy drainage 20.00 RENASYS-G Large Flat 66800496 3 non-adherent gauze 1 roll gauze 2 large drapes 20cm x 30cm Medium Large wounds, shallow or deep Minimal Heavy drainage 25.39 RENASYS-G Medium Channel 66800493 1 non-adherent gauze 1 pk gauze 2 medium drapes 15cm x 20cm Non-Hollow, Non-Perforated Minimal Moderate drainage Insert into tunnel/sinus no need to wrap in gauze 20.00 RENASYS-G Small Round (10Fr) 66800491 1 non-adherent gauze 1 pk gauze 2 small drapes 10cm x 12cm Small wounds, shallow Minimal drainage Can be curled onto wound bed 15.96 RENASYS-G Large Round (19Fr) 66800495 3 non-adherent gauze 1 roll gauze 2 large drapes 20cm x 30cm Medium Large wounds, Medium Deep (at least 1cm depth) Moderate Heavy drainage Can be curled onto wound bed or into undermining 25.39 RENASYS-G Large Irrigation/ Aspiration 66800212 3 non-adherent gauze 2 roll gauze 2 large drapes 20cm x 30cm Medium Large wounds, Medium Deep Heavy Thick/sediment drainage Dual lumen allows irrigation Treatment/management of fistulae 28.07 14/15

APPENDIX 1 NWPT CONSUMABLES GUIDE - continued Order Pump & Consumables using NHS Wirral Community Equipment Service (CES) Requisition form and fax to 482-8610 RENASYS-F Small Kit RENASYS-F Medium Kit RENASYS-F Large Kit RENASYS-F X- Large Kit 66800411 Foam 10cm x 8 cm x 3cm 2 IV3000 film dressings 1 drape 20cm x 30cm 1 large round drain 66800412 Foam 20cm x 12.5cm x 3cm 2 IV3000 film dressings 2 drapes 20cm x 30cm 1 large round drain 66800413 Foam 25cm x 15cm x 3cm 2 IV3000 film dressings 3 drapes 20cm x 30cm 1 large round drain 66800414 Foam 43cm x 30cm x 3cm 2 IV3000 film dressings 5 drapes 20cm x 30cm 1 large round drain Small 18.50 Medium 21.50 Large 25.50 X-Large 43.75 RENASYS GO 300ml Canister 66800165 Solidifier sachet & bacterial filter Minimal to moderate drainage 18.00 RENASYS Y Connector 66800504 1 unit Allows treatment of 2 wounds with 1 pump 3.00 15/15