NHS Fife Woundcare GuidelinesAnne Wilson - Tissue Viability Nurse Specialist, AD (Chairperson) Anne Barns - Tissue Viability Co-ordinator, Kirkcaldy and Levenmouth CHP District Charge

Approved: February 2014 For review: February 2017

Wound Formulary and Wound Management Guidelines

2014

Developed by the NHS Fife Wound and Skin Care Forum (WSCF) Group

Area Drug and Therapeutics Committee

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Contents

Introduction 2-3

Wound definition 4

Comprehensive wound assessment 4

Factors to consider when planning holistic wound care 5

Characteristics of ideal dressings 6

Guide to selection of wound dressings 7

Overgranulation 8

Bacterial burden and management of infection 9-10

Wound cleansing guidelines 11-13

Monographs for dressings

Barrier film 14 Vapour-permeable film 15 Non adherent dressings 16 Low adherence dressings 16 Hydrocolloid dressings 17 Foam dressings 18 Hydrofibre dressings 19 Hydrogel dressings 20 Alginate dressings 21 Deodorising dressings 22 Silicone dressings 23 Super Absorbent Dressings 24 Guidance for use of Specialised dressings and therapies 25-26 Antimicrobial Dressings 27 Silver containing Dressings 27 Honey Preparations 28 Iodine containing Dressings 28-29

Antimicrobial Alginate Gel 29 Pain Management Dressings 29 Debridement product 30

Tulle Dressings 30 Larvae Therapy 30 Negative Pressure Wound Therapy 31 Wound Drainage Bags 31

Glossary of wound terms 32 Reading list / Resources 33-34 Appendix 1 - Woundcare Products Conversion Chart 35 Appendix 2 - Wound Assessment Chart 36-38


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Introduction

Wound care consumes a significant amount of resources in terms of wound management products and professional time. The range of wound care products currently available can be bewildering and choosing the most appropriate dressing difficult. There is no such thing as the perfect dressing, so the choice is usually a compromise, trying to achieve the optimum environment to encourage the best outcomes in the shortest time. The dressing selected will invariably change as the wound healing proceeds, adding to the number of decisions necessary. The introduction of non-medical prescribing has increased both responsibility and accountability in wound management. Prescribers must therefore ensure that the choice of dressing is based on a full and accurate assessment of all the factors which may influence healing, and not just the wound itself. These guidelines aim to assist practitioners in the assessment and management of wounds. They encourage rational, cost-effective prescribing of dressings and other materials used in wound care. Demonstrating the use of evidence based treatments, and allowing practitioners to disseminate and share best practice, will promote seamless care across all sectors. On most of the pages containing information on dressings, a 1st and 2nd choice is given. Where possible, the 1st choice dressing should be used, however there may be reasons that this is not appropriate, therefore the 2nd choice dressing may be used. Staff must be able to give a rationale for choosing a dressing out with the main pages of the guidelines and this should be documented in the patients’ notes. Other dressings / treatment choices are within the specialised dressing pages. Dressing prices (Scottish Drug Tariff, February 2014) have been added to make practitioners aware of cost. More expensive dressings may still be cost effective if used in the correct manner. Practitioners’ are advised to contact their local Tissue Viability nurse for further advice, if they have a good rationale for not using the choice of dressing given. These guidelines are based on a selection of up to date research and clinical expertise of group members. We do accept that opinions vary and point out that these guidelines are not intended to be a definitive textbook, therefore a further reading list is included.

Disclaimer

Guideline users should be mindful that, as with any clinical guideline, recommendations may not be appropriate for use in all circumstances. Clearly, a limitation of any guideline is that it simplifies clinical decision making processes and recommendations. Decisions to adopt any particular recommendations must be made by the practitioner in the light of available resources, local services, policies and protocols. The particular patient’s circumstances and wishes, available personnel and equipment, clinical experience of the practitioner and knowledge of more recent research findings must all be considered and decisions must be clearly documented in the patient’s notes.


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Acknowledgements

The NHS Fife Wound and Skin Care Forum would like to thank the Glasgow Wound Guidelines Group, for allowing us to use some of their work, particularly in the teaching area of the Fife Guidelines. We would also like to thank Ruth Ropper, Tissue Viability Nurse in Lothian for her permission to use the Ropper Lothian Ladder for wound infection. We would also acknowledge the contribution of both NHS Fife Community Health Partnerships and NHS Fife Acute Services Division staff in the development of these Guidelines.

NHS Fife Wound and Skin Care Forum (WSCF) Group

Anne Wilson - Tissue Viability Nurse Specialist, AD (Chairperson) Anne Barns - Tissue Viability Co-ordinator, Kirkcaldy and Levenmouth CHP District Charge Nurse, Path House, Kirkcaldy Julia Chalmers - District Charge Nurse, Balmullo Health Centre Lynn Coyne - Plastics Specialist Nurse, AD Katrina Deas - Clinical Practice Development Officer, Cameron Hospital Angela Green - Podiatrist, QMH Carole Herd - Pressure Care Advisor / Tissue Viability Nurse, Benarty Medical Centre Deborah McCallum - Vascular Clinical Nurse Specialist, AD Heather McKellar - Senior Charge Nurse in OPD, Adamson Hospital Moirag Meehan - Plastics Nurse, AD Gillian Meldrum - Podiatrist, QMH David Mitchell - Principal Pharmacist, VHK Liz Mitchell - Lead Nurse, Dunfermline and West Fife CHP Jane Nicoll - Senior Staff Nurse, Tissue Viability, AD Sandra Notman - Practice Pharmacist, Glenrothes & North East Fife CHP Barbara Page - Dermatology Liaison Nurse, QMH Gillian Preston - Senior Staff Nurse, Tissue Viability, AD Susan Roemmele - Staff Nurse, Dermatology Department, QMH Sheila Robertson - Dermatology Liaison Nurse, VHK Ruth Robins - Vascular Clinical Nurse Specialist, AD Yvonne Robson - Plastics Nurse, AD Ann Russell - Staff Nurse, Dermatology Department, VHK Lesley Shiels - Acting Tissue Viability Co-ordinator, Dunfermline and West Fife CHP Mary Thompson – Staff Nurse, Emergency Care Directorate Leesa Webster – Tissue Viability Co-ordinator, Dunfermline and West Fife CHP


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Wound Definition

For the purposes of these guidelines, the following definitions apply -

A simple wound is one where there is damage to the epidermal layer of the skin, including discolouration due to pressure damage.

A complex /chronic wound is one which heals by granulating from the base up and requires contraction and scar tissue to close. Debridement of slough and necrotic tissue may be necessary.

It is important to note that the term chronic suggests longevity; however, many wounds e.g. diabetic foot or rheumatoid lesions may be termed chronic at the onset. A more accurate term for a chronic /complex wound would be a compromised wound. It is the underlying host response to the wound, which will determine to a great extent its ability to heal.

Comprehensive Wound Assessment

Recognised good practice is to assess a wound using a validated wound assessment chart

Compromised wound healing is usually a result of the patients underlying disease processes, ability to initiate an inflammatory response and fight infection. Intrinsic factors must therefore be taken into account whilst planning wound care.

Extrinsic factors at the wound bed (slough, necrotic tissue, biochemical and bacterial burden) may inhibit the healing process and wound bed preparation must be carried out to promote proliferation and epithelialisation.

The condition of the surrounding skin must be considered when recognising if there are signs of infection, tracking or undermining of the wound. Consideration must be made as to whether adhesive or non-adhesive dressings should be used dependent on the vulnerability of the surrounding skin.

Address patient issues to establish if the patient/carer can be empowered to assist in their own wound care. It is important to determine if they have the ability to cope psychologically with the presence of a wound. It is important to recognise the need for adequate pain control / analgesia and this must be reviewed regularly.

It is not always possible to heal wounds due to the patients underlying aetiology (e.g. in fungating tumours or advanced disease). In this instance palliative care may be the aim, with management of symptoms in a way that is acceptable to the patient.

There should be an awareness in the non-healing compromised wound that further referral to the appropriate specialty may be required, e.g. vascular, dermatology, diabetic or tissue viability.

Assessment tools have been developed by the National Association of Tissue Viability Nurses (Scotland) and the Scottish Wound Assessment and Action Guide can be accessed on-line at http://www.healthcareimprovementscotland.org/programmes/patient_safety/tissue_viability_resources/wound_assessment_action_guide.aspx


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Factors to Consider when Planning Holistic Wound Care

Patient Issues (Relating to wound and personal)

Pain Odour

Exudate Anxiety

Low Self Esteem Poor Mobility

Social Isolation Loss of employment/income

Feeling vulnerable Need to be included with their management

Intrinsic factors that delay healing

Compromised blood flow Oedema

Diabetes Poor nutrition

Connective tissue disorders Smoking

Malignancy Alcohol misuse

Drug treatment /radiotherapy Systemic infection

Surrounding Skin

Redness Maceration

Dry / Flaky Oedematous

Nodular Fragile

Undermining Tracking

Condition of margins Suppleness

Wound Bed

Healthy granulation Exposed tendon or bone

Epithelialisation Bacterial Burden

Wet / Dry Slough Biochemical imbalance

Type & Colour of exudate Depth, presence of sinus or fistulae

Necrosis Precise anatomical position

Nutritional Factors which may compromise wound healing

Inability to access food Poor economic status Reduced mobility Inability to communicate preference Socially isolated

Poor appetite Underlying disease process Medication Depression

Difficulty in swallowing Stroke Neuromuscular disorders Underlying malignancy

Inability to absorb adequate nutrients Gastro-intestinal disorders Malabsorption syndrome Paralytic ileus Vomiting and diarrhoea Small or large bowel resection

Increase metabolic demand Trauma Sepsis Recent surgery


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Characteristics of Ideal Dressings

1. Provide the optimum environment for wound healing - a moist environment - at the wound/dressing interface.

2. Allow gaseous exchange of oxygen, carbon dioxide and water vapour.

3. Provide thermal insulation - wound healing is temperature dependent.

4. Impermeable to micro-organisms (in both directions).

5. Free from particulate contaminants.

6. Non-adherent (many products are described as non-adherent but are low adherent).

7. Safe to use (non-toxic, non-sensitising, non-allergenic).

8. Acceptable to the patient.

9. High absorption characteristics (for exuding wounds).

10. Cost effective.

11. Carrier for medicaments, e.g. antiseptics.

12. Capable of standardisation and evaluation.

13. Provide mechanical protection.

14. Conformable and mouldable (especially over sacrum, heels and elbows).

It is generally recognised that modern wound dressings are capable of being left on the wound bed for up to seven days, however this is dependent on exudate levels and whether there is infection present within the wound, therefore check with the instructions given within the box of dressings for further information. Ordering Dressings All dressings listed on the general pages of the Wound Management Guidelines are available on Drug Tariff in suitable sizes and forms with the exceptions of 365® Film (at time of printing). Community practitioners should order dressings on prescription (GP10/GP10N) or via stock order (GP10A) as appropriate. Hospital and Primary Care managed services e.g. NHS Fife treatment rooms, should obtain supplies of wound management products from the Area Distribution Centre, as this is the most cost-effective route of supply.


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Guide to Selection of Wound Dressings

Further examples of complex wounds are available on-line as part of the Scottish Wound Assessment and Action Guide (SWAAG). http://www.healthcareimprovementscotland.org/programmes/patient_safety/tissue_viability_resources/wound_assessment_action_guide.aspx

Epithelialising

Objectives: Thermal insulation, low adherence, moisture retention. To protect and promote new tissue growth. Choice of dressing

Extra thin hydrocolloid for low exudate levels (page 17)

Non adherent dressing with absorbent pad or foam dressing for moderate to high exudate levels (page 16, 18)

Granulating

Objectives: Fluid absorption, thermal insulation, moisture control. To encourage angiogenesis and promote wound healing. Choice of dressing

Superficial or low exudate wound, thin hydrocolloid or non-adherent dressing. (page 16,17 )

Deeper wound or moderate to high exudate levels - hydrofibre dressing or alginate dressing. (page 19,21 )

Secondary dressing non-adherent with pad or foam dressing (page 16,18 )

Sloughy

Objectives : To remove all debris and promote autolysis. Dry slough – rehydration and moisture retention. Wet slough – fluid absorption Choice of dressing

Low exudate / dry slough - hydrogel (page 20)

Secondary dressing non-adherent with pad or foam dressing (page 16,18)

Moderate to high exudate / wet slough, hydrofibre or alginate dressing with secondary dressing as above (page 19)

Necrotic

Objectives: To rehydrate eschar and promote autolysis (debridement) to facilitate healing. Please note that depending on overall aims, it may not be appropriate to break necrosis down, e.g. palliative or vascular wounds. Choice of dressing

Hydrogel and non-adherent dressing with pad or foam (page 16, 20)

Thin hydrocolloid (page 17)

Infected

Objectives: To reduce bacterial load in wound. Manage exudate levels, contain odour Choice of dressing

Superficial / low exudate levels - antimicrobial impregnated dressing (page 27)

Secondary dressing of non-adherent plus pad (page 16) deeper wound / high exudate levels - silver alginate / hydrofibre with absorbent pad (page 27, 19)

CarboFlex or Clinisorb if odour present (Page 22)


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N.B. Always assess the condition of the surrounding skin before using adhesive secondary dressings. Overgranulation An essential aspect of secondary intention wound healing is the proliferation of granulation tissue, (McGrath, 2011). Granulation incorporates a dense network of blood vessels and newly growing capillaries with an irregular upper layer created by the capillaries looping together on the wound surface. This is what gives the appearance of red lumps or granules on the wound surface. When granulation ‘over grows’ beyond the surface of the wound, this is known as overgranulation, or hypergranulation. It is clinically recognised by a soft, fleshy, friable, often shiny appearance which is raised above the level of the surrounding skin. The wound will not continue to heal as the presence of this tissue will prevent the migration of epithelial tissue across the wound bed. The exact cause of overgranulation is unknown, (Russell 2000). It is thought to be the consequence of a reaction to foreign bodies, infection/bio burden, mechanical trauma or allergies and hypersensitivities. The research to date to support treatment options for overgranulation is limited, (McGrath, 2011). Reported treatments attempt to treat the causative factor, and focus on reducing bacteria present, applying pressure, using non occlusive dressings and the use of steroid therapies. It is essential that the clinician can identify the causative factor of the overgranulation, in order to make informed clinical decisions on an effective treatment. A number of treatment options exist, and for this reason, the advice of an appropriate specialist should be sought, e.g. local Tissue Viability Nurse or Plastics Nurse.

References McGrath A (2011) Overcoming the challenge of overgranulation. Wounds UK 7(1): 42-49 Russell L (2000) Understanding physiology of wound healing and how dressings help. British Journal of Nursing 9(1): 10-21


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Bacterial Burden and Management of Infection

Bacterial burden and virulence are important factors in assessing the wound for infection. Host resistance is a major determinant in the body’s ability to fight infection and initiate an inflammatory response. This may be illustrated in the following equation: Infection = dose x virulence host resistance

Bacterial Burden Continuum

Bacterial Load Definition Wound Dressing

Contaminated Presence of non replicating bacteria in the wound

Topical antimicrobial and antibiotics not recommended.

Colonised Replicating bacteria adhering to the wound, with no detrimental effect to wound healing

As above.

Critically colonised Presence of bacteria at the wound bed, which compromises healing but does not result in infection

Topical antimicrobial dressings can be used. In general, a two week treatment is advised. If no improvement in wound after this time, seek advice from local wound care specialist

Infection Invasion and multiplication of micro-organisms in body tissues with overt host response

If there is clinical evidence of invasive infection systemic antibiotics are required. Prescribe systemic antibiotic therapy in conjunction with appropriate dressing.

Wound Swabs for Microbiology

Wound infection is recognised by the presence of clinical signs of infection rather than the isolation of bacteria from a wound swab. A wound swab should only be taken when there is concern regarding infection. They should not be taken as part of “routine practice”. Taking a wound swab will give a qualitative picture of bacteria present on the wound surface. These are most commonly colonising bacteria and not responsible for infection. (Refer to Wound Assessment Chart for signs of infection). N.B. Do not confuse signs of inflammation with infection

Organisms most commonly associated with soft tissue infections are S.aureus, and Group A, B, C, and G Streptococcus. The clinical presentation should be reviewed alongside the swab result to ensure the most appropriate treatment is prescribed.

Swabbing for culture and sensitivity is only recommended before antibiotics are commenced or to confirm that the antibiotics commenced are appropriate. If a patient fails to respond to antibiotics within 72hours, then consider re-swabbing or seek further Medical advice.

The cost incurred for each Wound Swab is in excess of £15.


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The wound bed must be cleansed prior to swabbing so as to avoid sampling slough or necrotic tissue that may only reveal surface organisms which are not causing underlying infection. Critically colonised or infected wounds can be treated with antimicrobial dressings but when significant infection is present systemic antibiotics should be commenced.

Procedure for taking a Wound Swab

Irrigate the wound with Sodium Chloride 0.9% solution.

Swab the edge of the wound adjacent to the good tissue which is inflamed. It is the organism infecting the good tissue which will be the major pathogen. This would normally tend to be nearer the edge of the wound as the tissue in the centre is more often necrotic.

The swab should be rotated between the fingers to ensure that all sides of the swab make contact with the wound.

Infected wound below, swab area as directed by arrows

Example of most Suitable areas to swab


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Wound Cleansing Guidelines

To Clean or Not To Clean?

There is no single correct way to clean a wound or the surrounding skin, although there are a number of important considerations

Does the wound really need cleansing?

What is the safest method that causes no ill effect and maintains the wound temperature?

What is acceptable to the patient?

Simple wound cleansing procedure (e.g. suture lines, superficial breaks)

Gentle skin washing with warm tap water (e.g. showering).

A minimalist approach is recommended to reduce interference at the wound bed.

Dry surrounding skin with non woven gauze to allow adherence of wound dressing.

Compromised / complex wound cleansing procedure

Aims:

Remove excess exudate, debris or old dressing materials.

Minimize pain and trauma.

Prevent infection.

Procedure

1 Explain procedure and rationale to patient.

2 Wash hands thoroughly as per hand hygiene policy prior to and following procedure.

3 Dressing packs are not always necessary.

4 Requirements: non woven swabs, clean surface, non-sterile gloves.

5 Remove dressing as per manufacturer’s instructions.

6 Assess wound type and carry out appropriate irrigation procedure (see pages 11 and 12).

7 Dry surrounding area with non woven swabs.

8 Do not touch surface of wound with swabs.

9 Apply new dressing.

See also Fife Wound Care Policy W7 accessed via http://intranet.fife.scot.nhs.uk/Publications/index.cfm?fuseaction=publication.display&objectID=0E0A717D-5056-8C6F-C07ADBCEF2FC4663


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Wound Cleansing Guidelines

Preparation Procedure Rationale

With tap water

Gentle showering of wound area during routine social hygiene

Run shower for three minutes. Ensures free flowing warm clean water.

Gently irrigate wound with warm water using shower head. Ensures safe removal of exudate, loose slough and wound dressing residue.

In healthcare premises, shower should be cleaned with general purpose neutral detergent/cream cleanser before and after use.

Maintains clean working environment.

In the home care setting patients own household cleaner should be used to clean the shower and/or bath before and after the procedure. Refer to Infection Control Manual.

Bucket lined with polythene bag for lower limbs

Gently wash limb. Dry skin surrounding wound prior to application of new dressing. Avoid direct contact with wound bed.

Ensures safe removal of exudate, loose slough and wound dressing residue. It incorporates social hygiene into wound management procedure.

In healthcare premises, bucket should be cleaned with general purpose neutral detergent and warm water, rinsed and dried. Buckets should be stored dry and inverted. Patients own household cleaner should be used in home care setting. Refer to Infection Control Manual.

Maintains clean working environment.

Infection Control Manual can be accessed via: Intranet / Subjects / Infection Control / Infection Control Manual http://intranet.fife.scot.nhs.uk/subjects/index.cfm?fuseaction=service.display&pageid=7A5F5BB2-5056-8C6F-C03F5A9FA592A31A&subjectid=6C965E0A-DB7D-B17A-04E54EAC6A42E839&objectid=6BE801F1-5056-8C6F-C0E12BB07758F462

http://intranet.fife.scot.nhs.uk/subjects/index.cfm?fuseaction=service.display&pageid=7A5F5BB2-5056-8C6F-C03F5A9FA592A31A&subjectid=6C965E0A-DB7D-B17A-04E54EAC6A42E839&objectid=6BE801F1-5056-8C6F-C0E12BB07758F462

http://intranet.fife.scot.nhs.uk/subjects/index.cfm?fuseaction=service.display&pageid=7A5F5BB2-5056-8C6F-C03F5A9FA592A31A&subjectid=6C965E0A-DB7D-B17A-04E54EAC6A42E839&objectid=6BE801F1-5056-8C6F-C0E12BB07758F462


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With Sodium Chloride 0.9% Solution - Hospital = Miniversol® 45ml / Primary Care = Irripod®

Warm Sodium Chloride 0.9% solution pods by running under hot water Does not require alcohol swab to wipe pod prior to use Available on prescription

Irrigate wound area with Sodium Chloride 0.9% solution to remove surface exudate and loose slough or dressing residue.

To maintain optimum temperature for healing.

If slough is not easily removed by irrigation, further hydration with wound dressing products will be necessary.

With Prontosan® 40ml / 350ml

FOR COMPROMISED WOUNDS ONLY Use soak of Prontosan® Solution with gauze swabs for 10 minutes at dressing change, then discard.

Deeper cleansing of wound and biofilm removal

Dressing Size (Pack Size) Drug Tariff Cost - Feb 2014 (Each)

Irripod®

20ml (25) 23p

Prontosan®

40ml (24) 350ml

58p £4.71

N.B. Prontosan is for use in chronic or infected wounds only.


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Monographs for Dressings

Barrier Film

Cavilon® No Sting Barrier Film/ Secura® Cavilon® Cream Description Cavilon® No Sting Barrier Film provides long lasting skin protection for up to 72 hours. Cavilon® Cream provides long lasting protection from bodily fluids whilst moisturising the skin. Secura® is for use as a topical barrier between the skin and adhesives e.g. around peri-wound areas.

Indications

Intended to be used as a primary barrier against irritation from bodily fluids e.g. from urine and/or faeces. The no sting film acts as a protective barrier against adhesive wound dressings and surgical tapes, provides peri-wound protection from exudate damage and provides protection from damage caused by friction and shear. The barrier cream acts as a moisturiser for severely dry skin and as a protection for skin damage associated with incontinence.

Method of Use

Both film and cream should be applied to clean, dry skin. Cavilon® film should be applied in a uniform coating over the entire treatment area when using the foam applicator. If using the spray, hold the nozzle 10 - 15cm from the treatment area and apply a smooth, even coat. Allow to dry before applying any adhesive dressings or surgical tapes. Reapply at least every 48 - 72 hrs (or more frequently if required) Cavilon® Cream should be applied in small amounts, gently smoothing into the skin over the affected area. N.B. If the after feel of the skin is oily, then too much has been applied. Dressing Size (Pack Size) Drug Tariff Cost – Feb 2014 (Each)

Cavilon® No Sting Barrier Film

1ml foam applicator (5) 3ml foam applicator (5) 28ml spray bottle (1)

£0.85 £1.37 £5.77

Cavilon® Cream

2g sachet (20) 28g tube (1) 92g tube (1)

£0.33 £3.46 £7.04

Secura®

1ml foam applicator (5) 3ml foam applicator (5) 28ml spray bottle (1)

£0.71 £1.14 £4.81


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Vapour-permeable Adhesive Film

Hospital/ Managed Service : 365® Film

Primary Care : Tegaderm® Film

Description A sterile, transparent semi-permeable adhesive film. Permits visual inspection of the wound at all times and allows water to pass through from the skin as moisture vapour. Indications Provides a moist environment and allows the passage of oxygen but not of micro organisms. May be used on superficial epithelialising wounds, and to protect sites which are liable to break down due to friction or moisture. It can be used as a secondary dressing for other products. Method Of Use Use an appropriate size film to provide a 4cm margin in all directions around the edges of the wound to ensure good adhesion. The wound site should be checked daily. If no leakage occurs, the dressing can be left undisturbed for up to seven days. Care should be taken on removal, stretching the dressing to break the adhesive without lifting the skin. N.B. Water vapour loss may occur at a slower rate than exudate is generated, therefore fluid accumulates under the dressing, which can lead to tissue maceration and wrinkling at adhesive contact site. Dressing Size (Pack Size) Drug Tariff Cost – Feb 2014 (Each)

365® Film®

6cm x 7cm (100) 10cm x 12cm (50) 15cm x 20 cm (30)

Not drug tariff item Hospital/Managed service order only

Tegaderm® Film*

6cm x 7cm (100) 12cm x 12cm (10) 15cm x 20cm (10)

£0.39 £1.10 £2.39

*Tegaderm® Film is for community use only as 365® Film is not available on prescription or on stock orders placed via community pharmacy.


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Non-adherent Dressings

N-A® Ultra Description A primary wound contact layer consisting of a knitted viscose rayon sheet. Indications Provides moisture retention or rehydration, thermal insulation and low-adherence. A secondary dressing is required to dress more heavily exuding wounds. Method Of Use Apply directly to the wound surface. Bandages or tape are required to retain dressing. Secondary dressings can be changed independently leaving N-A® Ultra in position for up to seven days. Dressing Size (Pack Size) Drug Tariff Price – Feb 2014 (Each)

N-A® Ultra 9.5cm x 9.5cm (40) 9.5cm x 19cm (25)

£0.33 £0.63

Low Adherence Dressings

Premierpore® Description An adhesive absorbent island dressing. A one way stretch non-woven dressing with a latex free SIS acrylic adhesive that provides soft, secure fixation. The wound pad is covered with a low adherence film to enable easy removal. Indications It can be used on wounds with low to moderate exudate levels, including post operative wounds. Can also be used as a secondary dressing with hydrogels, hydrofibres and alginates. Also for use as a primary dressing for clean wounds and where protection is required from fluid, dirt and bacteria. N.B. There is a possibility of skin irritation in some individuals. Method Of Use Apply directly to the wound area. Ensure the skin surrounding the wound is clean and dry. The adhesive will adhere well once warmth of the skin is in contact with the dressing. Dressing Size (Pack size) Drug Tariff Price – Feb 2014

Premierpore® 5cm x 7cm (50) 10cm x 10cm (50) 10cm x 15cm (50) 10cm x 20cm (50) 10cm x 25cm (50) 10cm x 30cm (50) 10cm x 35cm (50)

£0.05 £0.12 £0.18 £0.32 £0.36 £0.45 £0.52


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Hydrocolloid Dressings

First choice : Comfeel® Plus Transparent Second choice : Duoderm® Extra Thin

Description A hydrocolloid dressing is a micro granular suspension of various natural or synthetic polymers, e.g. gelatin or pectin, in an adhesive matrix. The dressings are interactive with wound exudate - by slowly absorbing fluid. They physically change to form a gel, which may be cohesive, and/or hydrophilic. Indications Aids debridement in wounds covered with black necrotic tissue, suitable for softening eschar and promoting granulation. Suitable for low to moderately exuding wounds. May also be used prophylactically on areas prone to breakdown and as a secondary dressing. Method Of Use Apply dressing of sufficient size to provide at least 2cm overlap onto intact skin. Smooth dressing into place - warmth of the hand improves initial adhesion. For best results aim to leave dressing in place for at least 3 days. Dressings may be left in place for up to 7 days. N.B. Owing to the occlusive nature of their backing hydrocolloids are not considered suitable for the treatment of clinically infected or very heavily exuding wounds. Dressing Size (Pack Size) Drug Tariff Price– Feb 2014 (Each)

Comfeel® Plus Transparent

5cm x 7cm (10) 5cm x 25cm (5) 9cm x 14cm (10) 10cm x 10cm (10) 15cm x 15cm (10) 20cm x 20cm (5)

£0.66 £2.53 £2.39 £1.25 £3.27 £3.34

Duoderm® Extra Thin 5cm x 10cm (10) 7.5cm x 7.5cm (5) 9cm x 15cm (10) 9cm x 25cm (10) 9cm x 35cm (10) 10cm x 10cm (10) 15cm x 15cm (10)

£0.75 £0.79 £1.74 £2.78 £3.89 £1.30 £2.81


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Foam Dressings

First choice: Biatain® / Biatain® Adhesive – Moderately exudating wounds First choice: Tielle® Plus/ Tielle® Xtra - Highly exudating wounds First choice: Tegaderm® Foam Adhesive - Heel only

Description Foam dressings in general provide thermal insulation, do not shed fibres or particles and can be cut or shaped to fit the wound (non-adhesive). They help to maintain a moist environment at the surface of the wound and are gas permeable and non adherent. Should be used on moderate to highly exuding wounds. Biatain® / Biatain® Adhesive For use in moderately exuding wounds. Can be used on clean granulating wounds or as a secondary dressing in sloughy or necrotic wounds. Adhesive version is beneficial for patients wishing to bathe or shower. Dressing should be renewed when exudate has reached within 1cm of the edges of the dressing. The dressing may be left in place for 3 - 7 days depending on the level of exudate. Tielle® Plus / Tielle® Xtra A hydropolymer foam dressing for use in heavily exuding wounds, with fluid locking technology to reduce the risk of leakage. Has a vapour-permeable film backing. Can be used under compression. Contraindications Third degree burns or wounds with active vasculitis. Dressing Size (Pack Size) Drug Tariff Price – Feb 2014 (Each)

Biatain® 5cm x 7cm (10) 10cm x 10cm (10) 10cm x 20cm (5) 15cm x 15cm (5) 20cm x 20cm (5)

£1.29 £2.35 £3.87 £4.32

£6.42

Biatain® Adhesive

7.5cm x 7.5cm (10) 10cm x 10cm (10) 12.5cm x 12.5cm (10) 15cm x 15cm (5) 18cm x 18cm (5) 18cm x 28cm (5)

£1.05 £1.73 £2.52 £3.78 £5.09 £7.54

Tielle® Plus


£2.63 £4.30 £5.39

Tielle® Xtra


£2.24 £3.37 £5.51

Tegaderm® Foam Adhesive - heel dressing only

13.9cm x 13.9cm (5) £4.18


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Hydrofibre Dressings

Aquacel® Extra/ Aquacel® Description A soft, non woven pad composed of hydrocolloid fibres. This interacts with wound exudate and forms a soft gel which is easy to remove with little or no damage to healing tissue. Indications Used in the management of moderate to heavily exuding wounds. Can be used in acute and chronic wounds, e.g. abrasions, lacerations, leg ulcers, pressure sores. Infection is not a contraindication to use. Method Of Use Apply directly to the wound surface. Irrigation facilitates removal. Secondary dressing is required. May be left in place for up to seven days - depending on the level of exudate. NB If “packing” a wound with Aquacel® Extra, always leave a small piece outside of the wound to facilitate removal. Also record the number of pieces of used. (See wound chart). Dressing Size (Pack Size) Drug Tariff Cost – Feb 2014 (Each)

Aquacel® Extra


£0.99 £2.36 £4.44

Aquacel®

1cm x 45cm Ribbon (5) 2cm x 45cm Ribbon (5)

£1.81 £2.42

Hydrofibre Foam Dressing Aquacel® Foam Aquacel® foam dressings have a soft absorbent pad, an aquacel contact layer, a gentle silicone adhesive and a waterproof/ bacteria barrier. It can be used on a variety of moderate to heavily exuding wounds. Dressing Size (Pack Size) Drug Tariff Cost Feb 2014 (Each)

Aquacel® Foam Non Adhesive

5cm x 5cm (10) 10cm x 10cm (10) 15cm x 15cm (5) 15cm x 20cm (5) 20cm x 20cm (5)

£1.31 £2.48 £4.17 £5.77 £6.88

Aquacel® Foam Adhesive

8cm x 8 cm (10) 10cm x 10cm (10) 12.5cm x 12.5cm (10) 17.5cm x 17.5cm (10) 21cm x 21cm (5) 25cm x 30cm (5)

£1.37 £2.12 £2.63 £5.26 £7.70 £9.96


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Hydrogel Dressings

First choice : Purilon®

Second choice : ActivHeal® Hydrogel Description An amorphous gel with high water content, containing Calcium Alginate (Purilon®) or a collection of water insoluble polymer chains (ActivHeal® Hydrogel). Indications Hydrogels facilitate autolysis by rehydrating necrotic tissue and effecting debridement. They provide a moist environment which promotes healing. They are non-adherent and do not harm viable tissue or surrounding skin. Bacterial colonisation of the wound is not a contraindication to the use of a hydrogel. Method Of Use Apply the gel directly into the wound. A secondary moisture - retentive dressing is required e.g. Hydrogel should be changed when the cover dressing leaks. Intervals should not exceed 3 days when used on sloughy or necrotic wounds or 7 days if used on clean granulating wounds. N.B. When using in cavity wounds only half fill the cavity. Due to the effective debridement of necrotic tissue, a wound being treated with gel may appear larger at first dressing change, however, this is a natural step in the healing process. Dressing Size (Pack Size) Drug Tariff Price- Feb 2014 (Each)

Purilon® Sterile 8g tube (10) Sterile 15g tube (10)

£1.72 £2.24

ActivHeal® Hydrogel Sterile 15g tube (10)* £1.41

* 8g tube available but more cost-effective to use the 15g tube.


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Alginate Dressings

First choice : Tegaderm® Alginate Second choice : Kaltostat®

Description The basic elements of alginates are extracted from brown seaweed (Phaeophyceae). Their clinical composition means that they are highly absorbent and biodegradeable. Alginates vary in composition (calcium/sodium salts of alginic acid) and in the arrangement of fibres. Indications Alginate dressings are suitable for moderate to heavily exuding wounds. They form a gel on contact with the wound exudate, and are effective at absorbing exudate, debriding slough and encouraging granulation tissue. Where bleeding is involved, Kaltostat® may be considered as a haemostatic agent. Method Of Use Apply to the wound surface/cavity, secondary dressing required to secure. Frequency of change will depend on level of exudate. Dressing Size (Pack Size) Drug Tariff Price – Feb 2014 (Each)

Tegaderm® Alginate

5cm x 5cm (10) 10cm x 10cm (10)

£0.81 £1.71

Kaltostat®

5cm x 5cm (10) 7.5cm x 12cm (10) 10cm x 20cm (10) 15cm x 25cm (10)

£0.94 £2.05 £4.03 £6.92


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Deodourising Dressings

First choice : Clinisorb®

Second choice : CarboFlex® Clinisorb® Description Clinisorb® is an activated charcoal cloth dressing, produced by carbonising and activating woven viscose rayon that is sandwiched between two layers of a nylon and viscose rayon blend. Clinisorb® has the optimum combination of microporous activity and activated charcoal cloth weight, for significantly reducing odour by attracting and permanently trapping bacteria. It is non-adhesive and contained in a sterile peel pack. Indications Clinisorb® can be used to manage malodourous wounds such as fungating breast lesions, pressure ulcers, leg ulcers and diabetic foot ulcers. Method Of Use Clinisorb® can be used as a primary or secondary dressing and its soft, flexible construction can be cut to fit practically any wound. Even unusually shaped fungating wounds on curved body sites can be easily dressed. Clinisorb® is highly effective wet or dry, can be used either side down, and can be left in place for up to one week. CarboFlex® Description A sterile non-adhesive dressing consisting of five layers - film layer, absorbent padding, activated charcoal cloth, film layer and absorbent wound contact layer containing Kaltostat® and Aquacel®. Indications For use in the management of malodourous acute and chronic wounds. May be used as a primary dressing for shallow wounds or as a secondary dressing over wound fillers with deeper wounds. Method Of Use This dressing must not be cut to size or shape. The fibrous surface is placed directly on to the wound. This may be left undisturbed for up to three days depending on the level of exudate. Dressing Size (Pack Size) Drug Tariff Price – Feb 2014 (Each)

Clinisorb® 10cm x 10cm (10) 10cm x 20cm (10) 15cm x 25cm (10)

£1.86 £2.48 £3.99

CarboFlex® 8cm x 15cm Oval (5) 10cm x 10cm (10) 15cm x 20cm (5)

£3.78 £3.15 £7.17


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Silicone Dressings

Mepitel® / Mepitel® One Description A sterile transparent soft silicone wound contact layer, which is non adherent to a moist wound bed. Indications For use in a wide range of painful, chronic and traumatic wounds and wounds with compromised or fragile surrounding skin. The soft silicone adheres gently to the surrounding skin and ensures removal with minimal trauma and pain. Mepitel® prevents the outer dressing sticking to the wound. The porous structure of Mepitel® allows exudate to pass to an outer absorbent dressing. Method Of Use Apply directly to the wound or wound bed. It can be cut to size or shape of wound if desired. Requires a secondary dressing which can be changed independently as the Mepitel® can remain in place for up to 10 days. Mepitel® One may offer advantages when primary dressings are required to stay in place for longer periods, since it is adhesive on one surface only. Dressing Size (Pack Size) Drug Tariff Price – Feb 2014 (Each)

Mepitel® 5cm x 7cm (5) 8cm x 10cm (5) 12cm x 15cm (5) 20cm x 32cm (5)

£1.59 £3.19 £6.45

£17.57

Mepitel® One 6cm x 7cm (5) 9cm x 10cm (5) 13cm x 15cm (5) 24cm x 27.5cm (5)

£1.59 £3.19 £6.45

£17.38

Mepilex®/ Mepilex® Border Indications Designed for a wide range of moderate to highly exuding wounds e.g. leg, foot and pressure ulcers, traumatic wounds and secondary healing wounds. Suitable for use in combination with gels. Method of Use Overlap dry surrounding skin by at least 2cm. Do not stretch. If required, Mepilex® can be cut. Can be left in place for several days depending on condition of wound and surrounding skin. Dressing Size (Pack Size) Drug Tariff Price – Feb 2014 (Each)

Mepilex® 5cm x 5cm (5) 10cm x 11cm (5) 11cm x 20cm (5) 15cm x 16cm (5) 20cm x 21cm (5) 20cm x 50cm (2)

£1.21 £2.66 £4.39 £4.82 £7.28

£29.07

Mepilex® Border

7cm x 7.5cm (5) 10cm x 12.5cm (5) 10cm x 20cm (5)

£1.39 £2.72 £3.69


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Mepilex® Border Sacrum

10cm x 30cm (5) 15cm x 17.5cm (5) 17cm x 20cm (5) 15cm x 15cm (5) 18cm x 18cm (5) 23cm x 23cm (5)

£5.55 £4.74 £6.07 £3.34 £4.85 £7.91

Super Absorbent Dressings

KerraMaxCare®

Description

Primary or secondary dressing for medium to heavily exuding wounds. Exudate and MMPS are

absorbed and bound inside the dressing with no leakage. May be used under moderate compression

bandaging. Soft, conformable and stackable.

Indications Management of moderate to heavily exuding wounds. Eclypse® Description Super absorbent secondary dressing. Indications Moderate to heavily exuding wounds. Dressing Size (Pack Size) Drug Tariff Cost – Feb 2014 (Each)

KerraMaxCare®

10cm x 10cm (10) 10cm x 22cm (10) 20cm x 22cm (10) 20cm x 30cm (5)

£1.27 £1.67 £2.95 £3.37

Eclypse® 10cm x 10cm (20) 15cm x 15cm (20) 20cm x 30cm (20) 60cm x 40cm (10)

£0.73 £0.97 £2.14 £8.15


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Specialised Dressings & Therapies

Antimicrobial Dressings

Antimicrobials are agents which kill or inhibit the growth and division of micro-organisms. Commonly used in wound management are honey, iodine and silver. There is no robust clinical evidence that dressings containing antimicrobials (e.g. silver, iodine or honey) are more effective than unmedicated dressings for the prevention of wound infections. Indiscriminate use of topical antimicrobial dressings should also be discouraged because of concerns over bacterial resistance and toxicity. You may be asked by your local pharmacist, GP Practice or Wound Specialist Nurse to give a rationale for using these products. Please use the following tips to aid your selection.

10 top tips when using Antimicrobial Dressings General points

Is the wound clinically infected o Check for signs of infection o Don’t confuse normal signs of

inflammation with infection

Systemic antibiotics are indicated in cases of overt wound infection where classical signs are evident

Check the correct antimicrobial is chosen according to the wound exudate levels

If no improvement in wound after two weeks, review wound and antimicrobial choice

Check cautions as stated in manufacturer instructions, and BNF when using antimicrobial preparations.

Silver dressings

Some silver products oxidise in contact with air and this may be displayed as a brown/black discolouration on the wound bed and/or surrounding skin

Honey products

Patients may experience pain due to osmotic effects of dressing on wound (e.g. “drawing sensation”). Monitor pain levels, consider simple analgesia and only remove if the dressing is not tolerated.

Wound exudate may increase when using honey ointments and therefore use an appropriate absorbent secondary dressing.

Iodine preparations

These products are rapidly deactivated by wound exudate therefore consider other antimicrobials for moderate – highly exudating wounds

All iodine products change from orange/brown to white when iodine is inactive/”used up”.

Please see Ropper Lothian Ladder on next page for further guidance

Initiation of these products should be on the advice of the local Tissue Viability service (Acute Division Only) or relevant specialist nurse and follow local policies for use.


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The Adapted Ropper Lothian Ladder

Guidelines for identifying infected wounds and when to start & stop using topical antimicrobial dressings

Each stage builds on the previous signs noted

Stage 4: Overt signs of local infection and signs of systemic infection: may lead to sepsis if not treated Spreading cellulitis

Pus/abscess

Patient systemically unwell

e.g. confusion

Pyrexia

Raised white cell count/CRP

Malodour of wound

Stage 4 – Treatment

If systemic signs only, consider other source of infection

Swab wound using standardised method

Consider taking blood cultures prior to starting antibiotics

Start broad spectrum systemic antibiotics* while awaiting culture results

Consider combination therapy with topical antimicrobials** e.g. in PVD, diabetes

Monitor wound progress, review wound at 2 weeks and stop topical antimicrobials when signs of infection cease

Once topical antimicrobial stopped continue with correct dressing regime for wound/tissue type

Stage 3: Overt signs of local infection: evidence of surrounding tissue involvement, wound deteriorating Localised cellulitis

Discoloured or bleeding granulation tissue

Pain in or around wound

Exudate: thick, haemopurulent or purulent and/or high volumes

Localised oedema

Malodour


Swab wound using standardized method

Drain any local collections of pus/fluid

Consider combination therapy with broad spectrum systemic antibiotics* and topical antimicrobials**

Monitor wound progress, review wound at 2 weeks and stop topical antimicrobials when signs of infection cease


If no progress after two weeks and/or signs of systemic infection move to Stage 4

Stage 2: Increasing signs of infection (Critical colonisation): healing not progressing normally

Exudate – high volumes

Malodour

Pain in or around wound

Discolouration of granulation tissue

Slough/Necrosis


Select topical antimicrobial**

Monitor wound progress, review wound 1-2 weeks

If no improvement:

i. Consider swabbing wound using standardised method

ii. Consider alternative topical antimicrobial**

If improved stop topical antimicrobials when signs of infection cease


If no progress after two weeks and/or increasing signs of systemic infection move to Stage 3

Stage 1: Few subtle signs: healing progressing normally

Exudate – low to moderate volume

Pain – minimal

Odour – minimal

Slough/necrosis – minimal


Promote moist wound healing using correct dressing regime for wound/tissue type & exudate level

Monitor wound progress, if no improvement in 1-2 weeks reassess wound and dressing choice

Check underlying aetiology of wound, if required refer to appropriate specialist e.g. vascular, diabetic podiatry, tissue viability, lymphoedema etc.

If no progress after a further 1-2 weeks and/or increasing signs of infection/critical colonisation move to Stage 2

START

This guidance should be used along with clinical judgement in complex patients; in particular patients with diabetic wounds, vascular problems and immuno compromised patients may require topical antimicrobials for prophylaxis as well as treatment. *Systemic Antibiotics – Follow NHS Fife Antibiotic Guidance for the Treatment of Community Managed Infections Sept 2010. **Topical Antimicrobial – NHS Fife Joint Wound Formulary 2010. Topical antimicrobials can include honey, iodine, silver, PHMB, DACC and enzymatic products. Contact TVN team for more info if required.

References: European Wound Management Association (2005) Position Document: Identifying criteria for wound infection, MEP, London European Wound Management Association (2006) Position Document: Management of wound infection, MEP, London Best Practice Statement: Use of topical antiseptic/antimicrobial agents in wound management, Wounds UK, Aberdeen (2010) Good Practice Recommendation for Antimicrobial Use in Frail Elderly 2013

Adapted and reproduced with permission of R. Ropper, TVN CNS NHS Lothian


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Specialised Dressings & Therapies

Silver Containing Dressings

First choice : Melgisorb® Ag Second choice : Askina® Calgitrol Ag

Melgisorb® Ag

A highly absorbent antimicrobial alginate dressing. It is indicated for the management of infected, highly exuding wounds, and can be used under compression bandaging. As the dressing contains alginate, it may support the control of minor bleeding in superficial wounds. It can be left in place for up to 7 days.

Askina® Calgitrol Ag A layer of silver alginate matrix. This forms a soft gel when in contact with exudate. For infected or critically colonised wounds. Dressing Size (Pack Size) Drug Tariff Cost – Feb 14 (Each)

Melgisorb® Ag 5cm x 5cm (10) 10cm x 10cm (10) 15cm x 15cm (10) 3cm x 44cm Ribbon (10)

£1.80 £4.32 £7.60 £4.47

Askina® Calgitrol Ag


£3.18 £6.15

£14.36

Antimicrobial Dressings

Cutimed® Sorbact Cutimed® Sorbact dressings are coated with a fatty acid derivative (DACC) which give them highly hydrophobic properties. In the moist environment of an infected wound, bacteria are attracted to the dressing and become bound to it. The bacteria cannot multiply and are removed with the dressing. N.B. Using the dressing in combination with cream/ointments impairs the effect of the DACC.

Dressing Size (Pack Size) Drug Tariff Cost – Feb 2014 (Each)

Cutimed® Sorbact Ribbon Cutimed® Sorbact Swab

2cm x 50cm (20) 5cm x 200cm (10) 4cm x 6cm (unfolded 11cm x 16cm) (5) 7cm x 9cm (unfolded 17cm x 27cm) (5)

£3.96 £7.81 £1.62

£2.70

Initiation of these products should be on the advice of the local Tissue Viability service (Acute Division only) or relevant specialist nurse and follow local policies for use.


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Honey Preparations

Honey provides a moist healing environment with antibacterial and deodorizing properties as well as autolytic and osmotic debriding actions. It can be used on a variety of acute and chronic wounds.

Medihoney® Products

For use in acute and chronic wounds: leg/foot ulcers, pressure ulcers, sloughy wounds, necrotic wounds, infected wounds, malodorous wounds, donor and recipient graft sites, and burns, diabetic wounds and surgical wounds.

Activon® Products

Activon®(ointment) is ideal for debriding necrotic tissue. Ideal for topping up dressings where the honey has washed away or for using directly into cavities. Can be washed out using normal saline solution. Actilite® Actilite® is a light viscose net dressing coated with antibacterial Manuka honey & Manuka oil. The dressing is designed to protect a wound, promote healing and allow the passage of exudate. The antibacterial effect of Actilite has been enhanced by combining high grade antibacterial Manuka oil with Manuka honey. The combination of Manuka honey and Manuka oil has been demonstrated in-vitro to be effective against a number of major wound infecting organisms including MRSA and VRE. Dressing Size (Pack Size) Drug Tariff Cost - Feb 2014 (Each)

Medihoney® Antibacterial Honey Apinate Medihoney® Tulle


£2.00 £3.40 £2.98

Activon® Medical Grade Manuka Honey

25g tube (12) £2.05

Actilite®

5cm x 5cm 10cm x 10cm (10) 10cm x 20cm (10)

£0.57 £0.98 £1.90

Iodine Dressings

CAUTION : Care must be taken when these dressings are used with Thyroid and Renal patients !!!

Inadine® A sterile low-adherent fabric dressing impregnated with 10% povidone iodine in a water soluble slow release base. Povidone iodine is a potent antibacterial agent with a broad spectrum of activity It is used as a primary wound dressing providing prophylactic treatment against infections in superficial wounds and minor skin injuries. The dressing should be changed daily or when the orange/ brown colour turns to white. lodoflex®

Initiation of these products should be on the advice of the local Tissue Viability service (Acute Division only) or relevant specialist nurse and follow local policies for use.


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Iodoflex is a sterile Cadexomer Iodine paste containing Iodine in an inert base. The sachet consists of the paste sandwiched in protective gauze. Used for the topical treatment of a variety of chronic and acute wounds. When applied to the wound lodoflex® cleans and reduces' bacteria at the wound surface and is particularly useful in highly exuding wounds. Remove the protective gauze on both sides of the paste, lodoflex® can then be moulded into shape and applied to the wound surface. An appropriate secondary dressing can then be applied. The dressing should be changed every 72 hours. N.B. Maximum single application is 50g; weekly maximum must not exceed 150g; treatment duration should not exceed three months. Dressing Size (Pack Size) Drug Tariff Cost – Feb 2014 (Each)

Inadine® 5cm x 5cm (25) 9.5cm x 9.5cm (10)

33p 49p

Iodoflex® 5g (5) 10g (3) 17g (2)

£4.01 £8.01

£12.69

Antimicrobial Alginate Gel

Flaminal®

Flaminal® is an antimicrobial alginate gel, indicated for a variety of wounds. It maintains a moist wound environment, helps debride and restore bacterial balance. It comes in two preparations, Flaminal® Forte for medium to heavily exuding wounds, and Flaminal® Hydro for low to moderately exuding wounds. Dressing Size (Pack Size) Drug Tariff Cost – Feb 14 (Each)

Flaminal® Forte 15g (5) 50g (5)

£7.61 £25.18

Flaminal® Hydro 15g (5) 50g (5)

£7.61 £25.18

N.B. Flaminal® preparations are intended for single patient use, but can be used for multiple applications on the same patient, as this will make the product more cost effective.

Pain Management Dressing ActiFormCool® A transparent, non-adhesive high water content hydrogel, formed around a supporting blue polyethylene matrix. It can be particularly useful for painful wounds, e.g. leg ulcers and diabetic ulcers. Dressing Size (Pack Size) Drug Tariff Cost – Feb 2014 (Each)

ActiFormCool® 5cm x 6.5cm (5) 10cm x 10cm (5) 10cm x 15cm (5) 20cm x 20cm (5)

£1.78 £2.61 £3.75 £7.86


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Debridement Product Debrisoft® pad Debrisoft® consists of soft, polyester fibres which are secured and knitted together. These fibres are cut at a special angle, length and thickness to ensure good effect and flexibility. The pad comes in a 10cm x 10cm size and is used to remove slough and other debris from the wound bed to aid debridement. It can be used on sloughy leg ulcers and surrounding skin to remove debris. Dressing Size (Pack Size) Drug Tariff Cost – Feb 2014 (Each)

Debrisoft® pad 10cm x 10cm (5) £6.27

Tulle Dressings Physiotulle® A knitted polyester net impregnated with hydrocolloid particles suspended in petroleum. Indicated for the treatment of acute and chronic wounds following wound cleansing and until healing. Dressing Size (Pack Size) Drug Tariff Cost – Feb 2014 (Each)

Physiotulle® 10cm x 10cm (10) 15cm x 20cm (10)

£2.23 £6.80

Larvae Therapy Larvae reduce or eliminate odour and combat infection by ingesting and killing bacteria. Sterile larvae of the common green-bottle Lucilia Sericata are used to treat most types of sloughy, infected or necrotic wounds. They may also reduce wound pain and stimulate the formation of granulation tissue. Larvae therapy is available on a GP10 prescription. Refer to local policy. Dressing Size (Pack Size) Drug Tariff Cost – Feb 2014 (Each)

BioBag® Dressing 2.5cm x 4cm (1) 5cm x 6cm (1) 10cm x 10cm (1)

£195.00 £245.00 £295.00


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Negative Pressure Wound Therapy (NPWT) Negative Pressure Wound Therapy (NPWT) is a treatment used across the wound through a dressing positioned in the wound cavity or over a flap or graft. Excess fluid is collected in a disposable canister. NPWT helps to reduce oedema, increase blood supply and decrease bacterial colonisation. It has proven to be effective with acute surgical wounds, pressure ulcers, chronic wounds, including diabetic feet, and skin grafts.

Patients may be discharged from the Acute Services Division into Community with NPWT in situ. Community staff should consult local policy, as permission must be granted from the Lead Nurse for hire of unit and dressings. From February 2014, the NPWT pumps used (KCI) will be free of charge. Dressings and canisters are available on drug tariff. All pumps once discontinued must be returned to the Acute services Division. (Ward 52).

PICO® (Disposable NPWT system) A disposable and portable system designed to kick start wound healing. It can be used on both acute and chronic wounds, diabetic or pressure ulcers, flaps and grafts and surgically closed incision sites. The pack contains one PICO® device and two PICO® dressings. Advice should be sought from the local tissue viability nurse before using. Contraindications Contraindicated in the presence of: malignancy in the wound bed or wound margins (except in palliative care to enhance quality of life). Dressing Size (Pack Size) Drug Tariff Cost – Feb 2014 (Each)

PICO® 10cm x 20cm (1) 10cm x 30cm (1) 10cm x 40cm (1) 15cm x 15cm (1) 15cm x 20cm (1) 15cm x 30cm (1) 20cm x 20cm (1) 25cm x 25cm (1)

£123.50 £123.50 £141.61 £123.50 £123.50

£141.61 £141.61 £141.61

Wound Drainage Bag Wound drainage bags have a central hydrocolloid island that can be cut and shaped to fit the wound. They are particularly useful in large abdominal wounds with high levels of exudate, where conventional dressings would need to be changed more than twice daily. Dressing Size (Pack Size) Drug Tariff Cost – Feb 2014 (Each)

Biotrol® Draina S Fistula Mini (30) Medium (20) Large (20)

£2.43 £3.64 £4.48

Eakin® Wound Pouches (various closures)

Small (10) Medium (10) Large (10) Extra Large (5)

From £4.52 From £6.58 From £8.60

From £15.17

Other sizes/styles are available, contact companies directly for sizes and prices.


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Glossary of Wound Terms

Angiogenesis Generation of new blood vessels initially seen at the base of a wound.

Autolysis Breakdown of devitalised tissue by leucocytes.

Biofilm A thin but robust layer of mucilage adhering to a solid surface and containing a community of bacteria and other organisms.

Cellulitis A spreading non-suppurative infection of the soft tissue. Colonisation Multiplication of micro-organisms without a corresponding

host reaction. Contraction Function of the healing process in granulating wounds

whereby the edges of the wound are drawn towards each other.

Debridement Removal of devitalised tissue and foreign matter from a wound.

Epithelialisation Final stage of the proliferative phase. Eschar Scab consisting of dried serum and devitalised dermal cells. Granulation Formulation of new tissue filling the defect which takes place

during the proliferative phase of healing. The name is derived from the fact that the buds of new tissue take on the appearance of small granules.

Healing by first intention Also called Primary Intention. Wounds are closed leaving a minimal defect.

Healing by secondary intention Wound left open and allowed to heal by granulation. Healing by third intention Also called Tertiary intention, or delayed closure. Wound left

open often to assist drainage and closed surgically at a later date.

Hypergranulation Granulation tissue is raised above the peri-wound area. Infection Micro-organisms present and multiplying, producing an

associated host reaction. Reaction may take various forms. Maceration Softening or sogginess of the tissue owing to retention of

excessive moisture. Necrosis Local death of tissue. Tissue is often black/brown in colour

and leathery in texture. Slough Devitalised tissue which has yellow/white/grey hue.


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Reading List

Cooper R (2009) Biofilms: hard to detect, easy to under estimate, but most definitely here to stay. Wounds UK. 9 (1) p.12. Dow G (2003) Bacterial swabs and the chronic wound: When, how and what do they mean. Ostomy Wound Management. 49; 5A supplement: p. 8-13. Drugs and Therapeutic bulletin (2010) Silver dressings - do they work? Dtb.bmj.com. p. 38-42. European Wound Management Association (2004) Position Document Wound bed preparation in practice. London: MEP Ltd. European Wound Management Association (2005) Position Document Identifying criteria for wound infection. London: MEP Ltd. European Wound Management Association (2006) Position Document Management of wound Infection. London: MEP Ltd. European Wound Management Association (2007) Position Document Topical Negative Pressure In wound Management. London: MEP. Ltd European Wound Management Association (2008) Position Document Hard-to-heal wounds: A holistic approach. London: MEP Ltd. Gottrup F, Apelqvist J et al (2013) EWMA Document: Antimicrobials and Non-healing wounds- Evidence. Controversies and suggestions. Journal of Wound Care. 22 (5 suppl): S1-S92. Guy H (2012) The Difference Between Moisture Lesions and Pressure Ulcers. Wound Essentials. Vol. 1 p. 36-44. Available at: www.wounds-uk.com Kean J. (2010) The effects of smoking on the wound healing process Journal of Wound Care. 19 (1) p.5-8. King B (2003) A review of research investigating pain and wound care. Journal of Wound Care. 12(6) p. 219-223. Medlin S (2012) Nutrition For Wound Healing. British Journal of Nursing (Tissue Viability Supplement) Vol, 21, No 12. S11-15. NHS Quality Improvement Scotland (2009) Best Practice Statement. Prevention and Management of

Pressure Ulcers. Available at www.healthcareimprovementscotland.org

Phillips PL, Wolcott RD, et al. (2010) Biofilms Made Easy. Wounds International 1(3). Available at www.woundsinternational.com

http://www.wounds-uk.com/

http://www.woundsinternational.com/


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Strohal R, Apelqvist J, Dissemond J et al (2013) EWMA Document: Debridement. Journal of Wound Care. 22 (suppl.1) S1-S52. Toit DF (2009) An in vitro evaluation of the cell toxicity of honey and silver dressings. Journal of Wound Care. 18 (9) p.383-399. Yates S (2012) Differentiating Between Pressure Ulcers and Moisture Lesions. Wound Essentials. Vol 2. p.16-22. Available at www.wounds-uk.com. White R, Cutting K (2008) Critical colonisation of chronic wounds: microbial mechanisms. Wounds UK. 4(1) P70-78. Wounds International (2012) Appropriate use of Silver Dressings in Wounds. An expert working group consensus. London. Available to download from www.woundsinternational.com Wounds UK (2010) PHMB and its potential contribution to wound management. Wounds UK, Aberdeen. Available at www.wounds-uk.com. Winter GD (1962) Formation of the scab and rate of epithelialisation of superficial wounds in the skin of young domestic pig. Nature 193: 293-294.

RESOURCES/ LINKS

Tissue Viability Resource: www.healthimprovementscotland.org/tissueviability

Skin tear Guidelines: www.tissueviabilityscotland.org

Best practice for leg ulcer management: www.legulcerforum.org Diabetic Foot Infection Guidelines: Available on the NHS Fife Intranet Evidence based practice: www.joannabriggs.edu.au The JBI approach to evidence-based health care is unique. The JBI considers evidence-based health care to be reliant on the evidence, the context in which care is delivered, individual client preference and the professional judgement of the health professional.

RELATED POLICIES

NHS Fife SOP for Wound Care (July 2010) NHS Fife Policy for Prevention of Pressure ulcers (Operational Division 2010) NHS Fife The use of Sterile Larvae in wound management CP-15 (January 2011) SIGN Guidelines 120. Management of Chronic Venous Leg Ulcers (August 2010)


http://www.woundsinternational.com/


http://www.healthimprovementscotland.org/tissueviability

http://www.tissueviabilityscotland.org/

http://www.legulcerforum.org/

http://www.joannabriggs.edu.au/


35

Appendix 1 - Woundcare Products Conversion Chart

Product Group First Choice Second Choice Examples of Non Formulary Products Barrier Films Cavilon® No Sting Barrier

Film Cavilon® Cream Secura®

Brava® Clinifilm® Cutimed® Protect LBF ® No Sting Barrier Film

Medi® Derma-S Ostoguard® Pelican® Protect Peri-Prep® SkinSafe®

Sorbaderm® Sudocrem® Trio Silesse®

Vapour Permeable Adhesive Films

365® Film - Hospital Tegaderm® Adhesive Film - Community

Askina® Derm Bioclusive® C-View® ClearFilm® Hydrofilm®

Hypafix® Leukomed® T Mepitel® Film Mepore® Film Opsite® Flexigrid

Polyskin® II Protectfilm® Suprasorb® F Vacuskin®

Non Adherent Dressings

N-A® Ultra N-A® dressing Primary® Tricotex®

Low Adherence Dressings

Premierpore® Cosmopor® E Leukomed® Medipore®

Medisafe® Mepore® Primapore®

Softpore® Sterifix® Telfa® Island

Hydrocolloid Dressings Comfeel® Plus Transparent

Duoderm® Extra Thin ActivHeal® Askina® Biofilm Transparent Duoderm® Signal

Flexigran® (& Thin) Granuflex® Hydrocoll® Nu-Derm® (& Thin)

Suprasorb® H Tegaderm® Hydrocolloid Ultec® Pro

Foam Dressings Biatain®/ Biatain® Adhesive Tielle® Plus/ Tielle® Xtra Tegaderm® Foam Adhesive (Heel only)

ActivHeal® Foam Allevyn® Allevyn® Adhesive Allevyn® Gentle Border

Allevyn® Plus Adhesive

Permafoam® /

Permafoam® Comfort

Polymem® Tegaderm® Foam Adhesive

Trufoam®

Hydrofibre Dressings Aquacel® Extra Activheal Aquafibre

Hydrofibre Foam Dressings

Aquacel® Foam

Hydrogel Dressings Purilon®

ActivHeal®Gel Askina® gel Aquaflo® Aquaform® Coolie® Flexigran® Gel

Gel FX® Geliperm® Granugel® Hydrosorb® Intrasite®

Mesitran® Novogel® Nu-Gel®

Alginate Dressings Tegaderm® Alginate Kaltostat ® Activheal® Alginate Algisite® M

Algosteril® Cutimed® Alginate Melgisorb®

Sorbalgon® Sorbsan® Flat

Deodorising Dressings Clinisorb® Carboflex® Askina® Carbosorb Carbopad® VC Sorbsan® Plus Carbon

Silicone Dressings Mepitel® Mepitel® One Mepilex® Mepilex® Border

Allevyn® Gentle Allevyn® Gentle Border

Allevyn® Life Askina® SilNet Cutimed® Siltec

Mepilex® Transfer Silflex® Silon -TSR®

Super Absorbent Dressings

KerraMaxCare®

Eclypse® Flivasorb® Mesorb® Zetuvit-E®

Silver containing Dressings

Melgisorb® Ag

Askina® Calgitrol Ag Acticoat® Flex 3 Acticoat® Flex 7 Acticoat® Moisture Control Actisorb® Silver Algisite® Ag Allevyn® Ag etc

Atrauman® Ag Aquacel® Ag Biatain® Ag Mepilex® Ag Physiotulle® Ag Polymem® Silver Silvercel® & NA

Sorbsan® Silver Tegaderm® Alginate Ag Urgocell® Silver Urgosorb® Silver Urgotul® Silver

Antimicrobial Dressings Cutimed® Sorbact

Honey Preparations Medihoney® Apinate Medihoney® Tulle Activon® ointment Actilite®

Activon® Tulle

Algivon® Mesitran®

Iodine containing Dressings

Inadine® Iodoflex®

Iodosorb® Iodozyme® Oxyzyme®

Antimicrobial Alginate Gel

Flaminal® Forte Flaminal® Hydro

Pain Management Dressings

ActiFormCool®

Biatain® IBU

Debridement Product Debrisoft® pad

Tulle Dressings Physiotulle® Jelonet® Paragauze® Urgotul®

36

Appendix 2 – Wound Assessment Chart

Assessment Chart for Wound Management For multiple wounds complete formal wound assessment for each wound. Add Inserts as needed.

Factors which could delay healing: (Please tick relevant box)

Immobility □ Poor Nutrition □ Diabetes □ Incontinence □ Respiratory / Circulatory Disease □ Anaemia □ Medication □ Chemotherapy □

Wound Infection □ Previous History of MRSA Infection □

Inotropes □ Anti-Coagulants □ Oedema □ Steroids □

Other ………….. Allergies & Sensitivities ………………………. Body Diagram Front Back

Mark location with ‘X’ and number each wound Type of Wound Total number & duration of each type of wound

Leg Ulcer ………………………………….. Surgical Wound ………………………………. Diabetic Ulcer ………………………….… Pressure Ulcer ……………………………….. Other, specify ………………………………

Feet Diagram

Right Left

Mark location with ‘X’ and number each wound Date referred to:

TVN …………….Physiotherapist……………. Podiatrist………………Dietician……………...

Other (please specify)………………………….

Assessors signature: ………………………..

Date: ………………………..…………………...

WRITE, IMPRINT OR ATTACH LABEL Surname ……………….... CHI No ….………….. Forenames ………………… Sex………………….. DoB ……………….. Location……………………………………………………

37

Formal Wound Assessment Complete on initial assessment and thereafter complete at every dressing change

Date of Assessment

Number of wound

Analgesia required

(Refer to local pain assessment tool)

Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No

Regular/ongoing analgesia

Pre-dressing only

Wound Dimensions (enter size) Length (cm/mm) Width (cm/mm) Depth (cm/mm) Or trace wound circumference Is wound tracking/undermining Photography Tissue type on wound bed ( enter percentages)

Necrotic (Black)

Sloughy (Yellow/Green)

Granulating (Red)

Epithelialising (Pink)

Hypergranulating (Red)

Haematoma

Bone/tendon

Wound exudate levels/ type (tick all relevant boxes)

Low

Moderate

High *

Serous (Straw)

Haemoserous (Red/Straw)

Purulent (Green/Brown/Yellow)*

Peri-wound skin (tick relevant boxes)

Macerated (White)

Oedematous *

Erythema (Red)*

Excoriated (Red)

Fragile

Dry/scaly

Healthy/intact

Signs of Infection * 1 or more of these signs may indicate possible infection

Heat *

New slough/necrosis(deteriorating wound bed)*

Increasing pain*

Increasing exudate*

Increasing odour*

Friable granulation tissue*

Treatment objectives (tick relevant box)

Debridement

Absorption

Hydration

Protection

Palliative / conservative

Reduce bacterial load

Assessors Print Initials

Dressing Renewed (planned or unplanned dressing change)

Re-assessment date

38

Wound Treatment Plan and Evaluation of Care

To be completed when treatment or dressing type / regime altered NB Please write clearly

Date Wound

Number Cleansing Method, Dressing Choice & Rationale

Frequency

Evaluation & Rationale for changing dressing type

Signature

Packing Yes / No (circle) Amount …………………





Documents

NHS Fife Woundcare GuidelinesAnne Wilson - Tissue Viability Nurse Specialist, AD (Chairperson) Anne Barns - Tissue Viability Co-ordinator, Kirkcaldy and Levenmouth CHP District Charge