Split thickness skin grafts clinical practice standard · 2019-10-30 · A split - thickness skin graft (STSG) is a very thin shaving of normal skin taken from an undamaged area of

Title: Split Thickness Skin Grafts Clinical Practice Standard

Effective: 18 March 2015

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Contact: Program Officer Clinical Practice Standards (M.Weston) Directorate: Medical Services TRIM Record # ED-CO-15-93003

WACHS Version: 1.00 Date next review: 18/03/2018 Date Published: 2016

Purpose To establish minimum practice standards for split thickness skin grafts for plastic surgery throughout South Metropolitan Health Service (SMHS) and WA Country Health Service (WACHS). This Clinical Practice Standard (CPS) may be used in conjunction with specific site departmental requirements. Further information relating to specialty areas including Child and Adolescent Health Service (CAHS), Women and Newborn Health Services (WNHS) and Mental Health Services can be found via healthpoint.hdwa.health.wa.gov.au

Scope All medical, nursing, midwifery and allied health staff employed within SMHS and WACHS. All health care professionals are to work within their scope of practice appropriate to their level of training and responsibility. Further information can be found via healthpoint.hdwa.health.wa.gov.au.

Procedural Information Where care requires specific procedures that may vary in practice across SMHS and WACHS sites, staff are to seek senior clinician advice. Considerations Classification of STSG Types of STSG Donor Sites Indications for STSG Contraindications for STSG Harvesting Skin for STSG Application Patient Monitoring Complications STSG Management- Open or Closed STSG Application of STSG – Pre procedure Equipment Required – Open or Closed STSG Management Procedure – Application of STSG Ongoing STSG Management Trimming STSG Post STSG Assessment Ambulation Regime Post Ambulation Assessment Documentation Patient Education Discharge Planning

This CPS has been endorsed for use by WACHS and is to be applied to the WACHS clinical practice context until it is transitioned completely to a WACHS CPS.

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Considerations

Relevant Legislation / Resources For further information refer to: Operational Directive (OD)/ Information Circular (IC) Search: http://www.health.wa.gov.au • DoH Clinical Handover Policy (OD 0484/14) • DoH Correct Patient, Correct Site and Correct Procedure Policy and Guideline for WA Health

Services 2nd Edition (OD 0004/06) • DoH National Safety and Quality Health Service Standards in Western Australia (OD 0410/12) For considerations relevant to WACHS policies refer to: • WACHS Documentation Clinical Practice Standard • WACHS Impaired Skin Integrity Clinical Practice Standard • WACHS Observations-Physiological Clinical Practice Standard • WACHS Medication Administration Policy • WACHS Infection Prevention and Control Policy

General Information Split Skin Grafts are used for wounds where primary wound closure is not possible1. A split thickness skin graft (STSG) involves removing a segment of the epidermis and part of the dermis (depending on the thickness required) from the donor site and applying it to the recipient site to achieve complete wound healing2. If the entire thickness of the dermis is included, the appropriate term is full-thickness skin graft (FTSG). A full thickness skin graft (FTSG) takes the full thickness of the epidermis and dermis, and this donor site is therefore closed primarily.

Cross section of skin3

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Classification of STSG STSG can be classified and differentiated by the amount of dermis included:

• Thin (ranging from 0.15mm to 0.3mm) • Intermediate (ranging from 0.3mm to 0.4mm) • Thick (ranging from 0.45mm to 0.6mm)4 Due to part of the dermis (and therefore various adnexal skin appendages) being left behind, the

donor site is expected to heal completely with dressings5. Thickness of each type of STSG

1. Thin 2. Intermediate 3. Thick

Types of STSG

• Autograft – tissue transplanted from one location to another on the same individual. No risk of rejection between recipient and donor4.

• Isograft – tissue transplanted between identical individuals (twins)6

• Allograft (Homograft) – tissue transplanted between unrelated individuals of the same species. Allografts may be taken from a living donor but are most frequently taken from a cadaver7,8. There is a risk of rejection at approximately 10 days unless the patient is immunosuppressed6.

• Xenograft (Heterologous) – tissue transplanted between different species. These grafts can be taken from various species but the most widely used is the pig. There is a risk of hyper acute rejection within minutes to hours of application6.



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Indications for STSG

• Prevent infection by restoring the barrier and mechanical function of the skin. Including: protection, sensation, water balance, temperature regulation, vitamin production and immune response2.

• Cover vital organs until the area can be later covered with a muscle flap. • Chronic non healing wound9. • Provide permanent coverage to a wound. • Burns10,11. • Necrotising fasciitis9. • Pressure Injury. • Released contractures. • Large defects too big to close by primary or secondary intention e.g. tumour resection.

Contraindications for STSG

• Infection present • Necrotic tissue • Eschar (needs to be debrided by minor sharp debridement or dressings) • Wound beds with active bleeding • Ischaemia present12 • Wound beds with tendon, nerve and/or bone >5mm exposed (except if used as a

temporary protective cover)13

Example of exposed tendon13

Example of exposed tendon/bone contraindicated for STSG application13



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Donor Sites

A split - thickness skin graft (STSG) is a very thin shaving of normal skin taken from an undamaged area of the body. The STSG is used to cover an area of skin that has been damaged or cannot heal because of an injury or abnormality. The area’s most commonly used as donor sites for skins grafts are leg, inner thigh, upper arm, forearm and buttocks14. Colouring of the skin used for the graft may vary compared to the skin surrounding the recipient site due to differences in pigmentation (the factors that have an effect on the lightness of the grafted skin include length of time since application, lightness of the donor site, sex, the hand or the foot skin type)15. The pathophysiology of pigmentation changes after traumatic or surgical insults is not fully understood but scar tissue, once secondarily healed, is a barrier to the translocation of melanin to keratinocytes and melanocyte migration4,6.

Harvesting Skin for STSG Application STSG are harvested from an area of healthy skin and lose their original blood supply. Therefore they require the blood supply of the recipient wound bed to be sufficient enough to produce granulation tissue2. The “take” of a graft is the process of revascularisation and reattachment of the STSG to the recipient site. Skin grafts will not ‘take’ on poorly vascularised beds such as bare tendons, cortical bone without periosteum, heavily irradiated areas or infected wounds12. STSG can be harvested by an Electrodermatome or a Humby knife under a general anaesthetic. The thickness of the STSG is determined by adjusting the Electrodermatome. Once harvested the surgeon can then decide whether to mesh the STSG. The thinner the STSG the greater the chance of graft “take” due to an increased number of transected vessels to enable revascularisation2. There is less primary contraction in thinner STSG as there are fewer elastin fibres resulting in less primary recoil. However there is greater secondary contraction in thinner grafts due to increased myofibroblast lifecycle and prolylhydroxylase activity2.

Electrodermatome9: uses a razor blade that oscillates rapidly back and forth to split the skin horizontally leaving a layer of dermis behind2,16

Humby (Watson) knife16



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Meshed Split Thickness Skin Graft

Once harvested in theatre the STSG can be placed onto a plastic carrier plate for meshing and placed into a meshing machine to create a “lattice” effect known as meshed STSG.

• The harvesting, meshing and application of meshed STSG in theatre

• STSG on plastic carrier

• STSG being passed through a meshing machine

• Different sizes in meshed STSG

The STSG can be meshed to a variety of sizes ranging from 1:1 through to 1:34 1:1 – meshed spaces are equal to the skin 1:1.5 – meshed spaces are one and a half times larger than the skin 1:3 – meshed spaces are three times larger than the skin9

Advantages of meshed STSG • Increases the surface area covered and decreases the size of the donor site defect4. • Allows better conformability to uneven/irregular recipient wound beds4. • Is slightly more pliable than unmeshed skin, therefore tends to be less susceptible to

shear if dressed appropriately. • Allows the escape of seroma or blood preventing lifting of the graft17.



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Disadvantages of meshed STSG • Increase in susceptibility to breakage during STSG care and with inappropriate

dressings or early mobilisation • It takes longer to heal as the recipient wound bed is exposed through the meshed

spaces • Greater mesh ratios leave more obvious scarring as the small gaps between the graft

edges close by secondary intention with wound contraction and result in a “stocking net” or “lattice” effect on the healed STSG site4.

Storage of Harvested Skin

• Container and lid must have the correct patient addressograph on it and be matched against the intended patient prior to use.

• The date harvested must be on the lid and container.

• Skin is wrapped in damp sodium chloride 0.9% soaked gauze, wrapped in sterile plastic and then stored in a labelled sterile container.

• Labelled sterile container is stored in a designated fridge at 4 degrees celsius18,19 • Harvested can be preserved for 14 days but ideally should be used within 7 days to

have sufficient viable keratinocyte forming efficiency19,20

Patient Monitoring Individualised management plan to be documented in the patients’ health records as soon as is practicable. Patient monitoring will be dependent upon (but not limited to):

• Clinical condition of the patient. • Frequency and specific observations • The extent, location and type of injury sustained. • Complications associated with injury. • Patient history, comorbidities and diagnosis for clinical conditions, medications,

psychosocial and cultural factors that could influence treatment plans • Site requirements, patient education and consent • Any restriction to intervention associated with advance health directives (AHD) or

similar. • Refer to. Standard 9: Criterion: Recognising clinical deterioration and escalating care.

National Safety and Quality Health Service Standards

http://www.safetyandquality.gov.au/our-work/accreditation/nsqhss/

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Complications Complications can occur pre and post STSG application however STSG will not be applied if any of the following are present. Refer to Wound Bed Assessment

• Infection • Sloughy/ necrotic tissue • Wound debridement • Active bleeding of wound bed • Hypergranulated tissue

Infection14

Infection may result in skin loss with the most common cause relating to the bacteria pseudomonas aeruginosa21. Assess the recipient wound bed for signs of infection including18: • Localised erythema / redness • Pain / increased tenderness • Oedema / swelling • Odour or purulent exudate • Cellulitis • Heat • Fragile granulating tissue-bleeding • Fever greater than 38 degrees celsius15

Infected wound with sloughy tissue and cellulitis surrounding tissue.

If signs or symptoms of infection are present:

• Obtain a wound swab and slide specimen for microscopy, culture and sensitivity19. Refer to: WACHS Specimen Collection (including Phlebotomy) and Pathology Results - WACHS Clinical Practice Standard

• Liaise with senior clinician or the plastic surgical team about appropriate dressings for an infected wound bed.

• Apply an antiseptic or antimicrobial dressing to the recipient wound bed and continue to dress and assess wound bed daily/PRN as directed by senior clinician or the plastic surgical team. Refer to: WACHS Impaired Skin Integrity Clinical Practice Standard

• Apply the STSG once the recipient wound bed infection has subsided.

• Document changes in the patient health records and update site specific wound management plans. Refer to Documentation.









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Sloughy / Necrotic Tissue

Slough prevents normal healing and is a mixture of cell breakdown products, fibrin, serous exudate, leukocytes and bacteria20. Assess the wound bed for signs of sloughy/ necrotic tissue

Sloughy wound

Wound bed with necrotic tissue

Wound Debridement

Debridement is only to be performed by staff experienced in the procedure of sharp mechanical debridement due to the risk of damage to tendons, nerves, arteries / veins or exposure of bone.

• Debride sloughy / necrotic tissue with fine sharp scissors or a surgical blade using an aseptic technique at all times. Inform the plastic surgical team about the presence of sloughy / necrotic tissue. The recipient wound bed may need to be further debrided in theatre before the STSG is applied.

Apply an appropriate dressing to assist the debridement of the recipient wound bed to achieve a clean, granulating and vascularised recipient wound bed22. Refer to WACHS Impaired Skin Integrity Clinical Practice Standard

• Liaise with senior clinician or the plastic surgical team about appropriate dressings. • Apply the STSG once the recipient wound bed is clear of sloughy/necrotic tissue11. Active Bleeding of Wound Bed

Liaise with a plastic surgical team/ senior clinician in managing actively bleeding wound bed sites. STSG are not usually applied to active bleeding areas.

• Stop active bleeding by donning sterile gloves, place gauze over the site and apply direct digital pressure until bleeding ceases/slows (two to three minutes).

• Apply a haemostatic dressing e.g. calcium alginate (Kaltostat®) to the site if it continues to bleed post removal of digital pressure and reapply digital pressure.

• A haemostatic drug agent as prescribed by the MO may be used if bleeding is continuous after removal of digital pressure. Refer to: WACHS Medication Administration Policy

• Clamp actively bleeding artery or vein with sterile curved artery forceps.

• Contact the plastic surgery team if the end of a large actively bleeding artery / vein is present and the bleeding cannot be controlled.


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Hypergranulated Tissue12

• Assess the wound bed for hyper-granulated tissue.

• Liaise with plastic surgical team or senior Clinician about appropriate dressings.

• Apply the STSG once the wound bed is healthy, flat and has granulating tissue23.

• Continue to dress and assess the recipient wound bed until the hypergranulated tissue is healthy, flat and granulating tissue is present23.

• Hypertonic dressings may require a few days to take effect and flatten the hypergranulated tissue.

• Hypertonic dressings should be discontinued once there is healthy, flat and granulating tissue12.

STSG Management Types of graft care are categorised as being open or closed.

Open STSG Management Open STSG care is when the STSG is left exposed to air, not sealed with a dressing and involves observations / assessment and graft care for the cleaning of the STSG.

It is important to promote compliance to the immobilisation regime as instructed by the plastic surgical team. If the patient is non-compliant with the required immobilisation the STSG may need to be sealed with a dressing, in this case post STSG application observations / assessment and graft care is not required. The STSG is then checked at each dressing change.

Assessment Assess and document the following: • STSG stability • Graft overlap • Haematomas • Seromas • Venous congestion (blue discolouration) • Patchy areas of STSG loss (also described as moth eaten in appearance) and any

signs of infection. Patchy areas can indicate the presence of a local bacterial infection. Psuedomas infections produce toxins and exotoxin A that are responsible for blue green colour and total lysis of skin grafts24. Refer to Infection



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Closed STSG Management The aim of a graft/recipient site dressing is to splint and hold the graft in place such that adherence can occur, and decrease the risk of shear and haematomas. On an extremity it may be deemed appropriate to splint with plaster to prevent movement of muscle groups below the graft that may cause shear25. The graft can be glued or sutured to the wound edges and sterile paraffin gauze (Jelonet®) at the base and gauze padding on top with a secondary dressing12.

A ‘bolster’ or ‘tie-over’ dressing containing sterile paraffin gauze (Jelonet®) at the base and Aquaflavin® dressing may be applied or sometimes a topical negative pressure therapy device (VAC) is applied to provide subatmospheric pressure over large areas or difficult contours25.

Tie over bolster dressing25. VAC dressing Assessment Assessment is performed and documented at each dressing change. Refer to Wound Bed Assessment



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Application of STSG To promote successful “taking” of the STSG a recipient wound bed should have a red granular base that is well vascularised to provide a blood supply for the nourishment of the connective tissue and provide capillaries that combine to make up granulation tissue2,17.

Pre Procedure • Determine if the patient is for Open STSG Management or Closed STSG Management

as per the patient health care records and post procedure instructions by the plastic surgery team.

• Patient’s STSG is stored in a sterile container, in designated ward or theatre skin fridge, labelled with patient’s addressograph and date harvested.

• Perform safety checks of patient identification and labelled container with the harvested skin.

• Determine number of staff required to perform STSG considering location of dressing and patient clinical condition.

• Explain the procedure to the patient and gain consent. • Perform and document pain score assessment. • Administer analgesia as prescribed 30 to 60 minutes prior to procedure depending on

specific analgesia prescribed and route. Continue to assess patient’s pain score and analgesia requirement. Refer to: WACHS Medication Administration Policy

Equipment Required Specific sites may have pre prepared equipment packs and contents may vary

Open STSG Management

Sterile gloves Sterile dressing pack 1-2 Sterile McIndoe forceps

Sterile pair of fine sharp scissors

Sterile gauze Sodium chloride 0.9% for irrigation 30mL

Sterile paraffin ointment (Emolient®)

Disposable underpad “bluey”

Hair net / cap

Plastic disposable gown Paper bag for waste disposal

Histoacryl® glue (may need to be sourced from Pharmacy/ Burns units)

Post day 5: Additional equipment • Wash bowl (if patient resting in bed) • Chlorhexidine gluconate 4%

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Closed STSG Management • Sterile gloves • Sterile towels • Sterile plastic cover for

trolley • 2-3 pairs McIndoe forceps • Sterile fine sharp scissors • Sterile skin adhesive / glue • Kidney dish (placed under

the sterile plastic to make a well)

• Sodium chloride 30mL • Sterile burns gauze5

• Sterile paraffin gauze e.g. Jelonet®

• Sterile paraffin ointment e.g. Emollient®

• Antiseptic dressing

• Calcium alginate • Haemostatic agent • Suture material Post day 5: Additional equipment • Sterile scissors

• Chlorhexidine gluconate

4% • Wash bowl (if patient resting

in bed) • Sterile paraffin ointment

(Emollient®) • 1-2 crepe bandage (white)

• 1-2 elastocrepe bandage

(pink) • Retention adhesive

dressing (Fixomull®) 5 • Limbs are double bandaged; other areas need to be secured

with a retention adhesive dressing as appropriate.

Procedure - Application of STSG For all types of STSG application the following is applicable:

• Refer to site specific policy for disposal and STSG storage

• Maintain aseptic non touch technique throughout the procedure. Refer to WACHS Impaired Skin Integrity Clinical Practice Standard

• Dispose of waste products as per DoH Clinical and Related Waste Management Policy OD 0651/16

• Assist as required in positioning the patient in an appropriate position. • Perform hand hygiene. • Assemble equipment. • Perform hand hygiene, don non sterile gloves and remove old dressing (as

appropriate). • Remove and discard soiled gloves, PPE equipment/dressing. • Put on hair net/ cap and disposable plastic gown. • Place kidney dish on trolley surface if sterile plastic used as sterile dressing surface. • Maintaining aseptic technique open the dressing pack (if used instead of sterile plastic

sheet) and appropriate equipment dependent on visual assessment of wound bed. • Perform hand hygiene and don sterile gloves. • Clean wound bed with sodium chloride 0.9% soaked gauze or appropriate solution

antiseptic9. • Dispose of used products / equipment appropriately. • Leave the STSG on the paraffin gauze backing and cover with sodium chloride 0.9%

soaked gauze if not used immediately, to prevent the STSG from drying out.





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• Use sterile McIndoe forceps to measure size of recipient wound bed using a non-touch technique.

• Mirror the measurements of the recipient wound bed onto the STSG to estimate size required Consider any depressions/cavities in the recipient wound bed. A 3-5mm margin is recommended due to the contraction properties of STSG as they heal26.

Non Fenestrated Application • Whilst leaving the non-fenestrated STSG on the paraffin

gauze, proceed to fenestrate by cutting slits 2-5mm in length at intervals. Fenestrations allow excess fluids (blood and serous fluid) to escape preventing the accumulation of seromas and haematomas under the STSG.

• Apply the STSG on the paraffin gauze backing to the recipient wound bed. Leaving the STSG on the paraffin gauze aids in maintaining the shape of the STSG and prevents it from rolling / folding in on itself. Avoid wrinkling or excessive stretching of the STSG. Use the McIndoe forceps to gently remove the paraffin gauze backing sheet from STSG.

• Using the flat surface of the McIndoe forceps apply gentle pressure to ensure that the STSG is smooth, aligned, and free of all air bubbles, seromas or haematomas.

• Apply small amount of “skin glue” Histocryl® at infrequent intervals around edges of the STSG or joins. Small limited amounts are used as revascularization is unable to occur in the area where the “skin glue” is applied. Histocryl® (glue) can be obtained from pharmacy or plastics/burns wards after hours. This assists with stabilising the position of the STSG on the wound bed11.

• Ensure the STSG remains wrinkle free and in correct alignment when applying ointment helps to keep STSG moist.

• Remove, discard used equipment and PPE appropriately • Perform hand hygiene



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Meshed STSG Application • Remove meshed STSG from sterile plastic and determine if the dermis (inner) side is facing

uppermost or facing the carrier. The dermis side is characterised by a “shiny” surface and the edges will roll / curl inwards towards the dermis. If the dermis (inner) side is facing the carrier: Place a piece of paraffin gauze onto the STSG. Gently lift the carrier from the meshed STSG and paraffin gauze using sterile McIndoe forceps to apply gentle pressure to the STSG as the carrier is lifted off. The dermis (inner) side will then face the uppermost and be ready for application.

• Transfer the meshed STSG on the plastic carrier to the recipient wound bed.

• Leave the meshed STSG on the paraffin gauze backing and cover with sodium chloride 0.9% soaked gauze if it is not used immediately. Prevents the STSG from drying out27.

• Using the flat surface of the McIndoe forceps apply gentle pressure to ensure that the STSG is smooth, aligned and free of all air bubbles, seromas or haematomas.

• Apply small amount of “skin glue” Histocryl® at infrequent intervals around edges of the STSG or joins. Small limited amounts are used as revascularization is unable to occur in the area where the “skin glue” is applied. Histocryl® (glue) can be obtained from pharmacy or plastics/burns wards after hours. This assists with stabilising the position of the STSG on the wound bed11.

Meshed skin can have open graft care or cover with a compress dressing28. Step 1: Cover the meshed STSG with paraffin gauze and apply 0.9% sodium chloride moistened gauze. Provides support for the graft, to prevent movement or shear during the 3 stages of revascularization29.

Step 2: Cover sterile paraffin gauze with sodium chloride 0.9% moistened gauze.

Step 3: Cover moistened gauze compress with sterile paraffin gauze.

Step 4: Cover paraffin gauze with gauze pad.

Step 5: Cover gauze with a retention dressing.

• Remove, discard used equipment and PPE appropriately • Perform hand hygiene



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Care of Unused STSG (Sheet and Meshed)

• Don sterile gloves. • Leave excess meshed STSG on the plastic carrier plate paraffin gauze. • Fold STSG onto self if on paraffin gauze. • Place on damp sodium chloride 0.9% soaked gauze. • Fold gauze around plate or paraffin gauze. • Wrap gauze in the saved sterile plastic to encase the meshed STSG and prevent it

drying out • Place in sterile container. • STSG is stored in a sterile container in a fridge at 4 degrees celsius30 and can be

preserved for 14 days but ideally should be used within 7 days to have sufficient viable keratinocyte forming efficiency31,32.

• Remove and dispose of PPE and perform hand hygiene. • Close lid of sterile container and label with patient addressograph if not already insitu

or not intact. • Place sterile container into ward designated “skin” fridge31. • Document the application of STSG in the patient health record update appropriate

charts reflecting wound management plan as per STSG Assessment – post application of STSG.

Ongoing STSG Management

• Refer to site specific policy for disposal and STSG storage • Maintain aseptic non touch technique throughout the procedure. Refer to WACHS

Impaired Skin Integrity Clinical Practice Standard • Dispose of waste products as per DoH Clinical and Related Waste Management Policy

OD 0651/16

Open STSG ongoing management Equipment - Open Refer to Open STSG Management; include additional equipment if post 5 days of application.





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Procedure - Open • Assist as required in positioning the patient in an appropriate position. • Perform hand hygiene. • Assemble equipment. • Perform hand hygiene, don non sterile gloves and remove old dressing (as

appropriate). • Remove and discard soiled gloves, PPE equipment/dressing. • Put on hair net/ cap and disposable plastic gown (optional). • Perform hand hygiene. • Don sterile gloves. • Clean wound bed with 0.9% sodium chloride soaked gauze/or appropriate antiseptic

solution. • Express seromas or haematomas if present: A new

fenestration (slit) is made by using sterile sharp fine scissors to cut a 2-5mm slit in the STSG over the collection.

• Use the flat surface of the sterile McIndoe and apply gentle pressure to express the fluid towards a fenestration (slit) in the STSG. Do not roll the fluid

collection across the recipient wound bed. • Dab sterile dry gauze on the STSG to absorb the expressed fluid. • Realign STSG if shearing has occurred: Use the flat surface of sterile McIndoe

forceps to realign, smooth and remove air bubbles trapped between STSG and recipient wound bed.

• Clean any crusty collection away from the graft surface and around the edges of the STSG that has collected with sodium chloride 0.9% soaked sterile gauze.

• If signs of infection present: Collect a wound swab and slide specimen for microscopy, culture and sensitivity. Refer to SMHS Specimens Collection Pathology Results CPS (in draft).

• Liaise with Plastic Surgery team or senior clinician about specific dressings that may be required.

• Apply a thin smear of sterile paraffin ointment over the STSG to assist in keeping the graft moist and stabilises the edge of the STSG preventing desiccation.

• Dispose of unused products appropriately. • Liaise with physiotherapist and plastic surgical team as required for a splint to

immobilise the joint. Splinting is used to prevent movement and potential shearing forces that disrupt the STSG adherence. If a splint is applied instruct the patient to immediately report any pressure or pain related to the splint.

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Closed STSG ongoing care Equipment - Closed Refer to Closed STSG Management; include additional equipment if post 5 days of application. Procedure – Closed

• Assist as required in positioning the patient in an appropriate position. • Perform hand hygiene. • Assemble equipment. • Perform hand hygiene, don non sterile gloves (as appropriate). • Remove old paraffin gauze gently by using forceps to gently lift paraffin gauze while applying

gentle counter pressure on the STSG with the flat edge of the McIndoe forceps. • Remove and discard soiled gloves, PPE equipment/dressing. • Put on hair net/ cap and disposable plastic gown (optional). • Perform hand hygiene. • Don sterile gloves. • Clean wound bed with 0.9% sodium chloride soaked gauze/or appropriate antiseptic solution. • Apply a thin smear of sterile paraffin ointment over the STSG with a sterile gloved finger (helps

keep the graft moist, stabilises the edge of the STSG and prevents desiccation).

• Apply sterile paraffin gauze over STSG with a small margin overlapping onto the surrounding skin. Place dry “fluffy” gauze (use burns gauze for large areas) onto the paraffin gauze. Refer to figure 28 - “Fluffy” gauze refers to unfolding the gauze to its thinnest and then scrunching it up.

Fluffy gauze acts as a cushion to promote STSG adherence to the recipient wound bed aiming to prevent seromas, haematomas and STSG movement13,33.

• Cover “fluffy” gauze with the appropriate sized flat gauze.

• Apply double bandaging to assist in immobilisation of the graft, prevent shearing, seroma and haematoma formation13 e.g. double bandaging for lower limb.

• Apply one layer of crepe bandage (white) in a uniform spiral technique applying gentle pressure from extremity towards the heart followed by a second layer of elastocrepe bandage (pink) using the same technique.



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Trimming STSG Trimming overlapping STSG is necessary to reduce the risk of infection to the STSG. Overlapping STSG will begin to dry out after 2 or 3 days because it is not in contact with the recipient wound bed and therefore not receiving a blood supply. Trimming of the STSG is performed when the STSG is stable (usually day 3-5 post application of the STSG). Equipment Refer to: Equipment Required; include additional equipment if post 5 days of application. Procedure

• Assist as required in positioning the patient in an appropriate position. • Perform hand hygiene. • Assemble equipment. • Perform hand hygiene, don non sterile gloves (as appropriate). • Remove old paraffin gauze gently by using forceps to gently lift paraffin gauze while applying

gentle counter pressure on the STSG with the flat edge of the McIndoe forceps as appropriate.

• Remove and discard soiled gloves, PPE equipment/dressing. • Put on hair net/ cap and disposable plastic gown (optional). • Perform hand hygiene. • Don sterile gloves. • Clean wound bed with 0.9% sodium chloride soaked gauze/or appropriate antiseptic solution.

• Gently lift overlapping edges of the STSG with sterile McIndoe forceps with the flat side of the sterile fine sharp scissors against the skin trim overlapping STSG along the line of demarcation.

• A line of demarcation is clearly visible at the edges of the wound where the STSG has stopped adhering25.

Post STSG Assessment Post STSG application observations / assessment are performed including: • Seromas (accumulation of serum)34. • Haematomas (accumulation of extravasated blood trapped in the tissue)35. • The formation of seromas and haematomas under the STSG cause separation

between the dermis layer of the STSG and the recipient wound bed. They can occur more often when the STSG is left exposed due to the lack of pressure keeping the STSG and recipient wound bed interfaces in contact with each other25.

• Mechanical shearing, such as out of alignment or the STSG rolling back onto itself. Shearing forces lead to disruption to the micro circulation of the recipient bed which prevents revascularization of the graft.

• Signs of infection. • Loss of any of the STSG. • Inform the plastic surgical team or most senior clinician if any concerns or if loss of any

part of the STSG is observed • Document assessment and graft care in the patient health record. Refer to

Documentation Clinical Practice Standard




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Assessment Frequency • Performed to ensure the graft remains stable and in optimal position. • Refer to site specific policies and/or specific plastic team instructions and/ or graft

condition. • If there is a presence of haematomas, seromas, or movement then the frequency of

STSG observations and graft care needs to be increased Recommended regime will include performing and documenting observations, assessment and graft care: • One hourly (1/24) for the first 8 hours (re-adjust STSG as required and remove excess

haematoma /seromas collection) • Two hourly (2/24) until 24 hours post application. • Continue 2 – 4 hourly for 48 hours post application. • Four hourly (4/24) after 48 hours if the STSG is stable.

Ambulation Regime There is an increasing trend towards early mobilisation post STSG applications to lower limbs36. Where ever possible, ambulant graft care (immediate mobilisation) should be undertaken. • Clinical evaluation will need to override this if the case is not appropriate. • Generally small grafts in patients with no co-morbidities will be appropriate. Alternatively, after 2-5 days or when the STSG is adhered the patient may ambulate short distances as determined by the plastics surgical team and/or most senior clinician. The regime for ambulation is based on the patient factors, position on the body and graft stability if ambulant graft care has not been used. Prior to ambulation: • Perform and document the condition of the STSG is assessed for stability, colour,

seromas and haematomas that may delay ambulation. Refer to STSG Assessment – post application of STSG.

• The STSG needs to be sealed to protect against shearing forces and assist with preventing the formation of seromas / haematomas.

• Apply sterile paraffin gauze over STSG with a small margin overlapping onto the surrounding skin. Place dry “fluffy” gauze (use burns gauze for large areas) onto the paraffin gauze. Refer to figure 28 - “Fluffy” gauze refers to unfolding the gauze to its thinnest and then scrunching it up.

• Fluffy gauze acts as a cushion to promote STSG adherence to the recipient wound bed aiming to prevent seromas, haematomas and STSG movement13,33.

• Cover “fluffy” gauze with the appropriate sized flat gauze. • Apply double bandaging to assist in immobilisation of the graft,

prevent shearing, seroma and haematoma formation13 e.g. double bandaging for lower limb.

• Apply one layer of crepe bandage (white) in a uniform spiral technique applying gentle pressure from extremity towards the heart followed by a second layer of elastocrepe bandage (pink) using the same technique.



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Recommended Regimens Liaise with plastic surgery team, senior clinician or health care professional experienced in care of STSG prior to ambulation:

Ambulation with Upper Limb STSG Elevate the limb above the level of the heart when ambulating. Use a sling if appropriate to assist with elevation.

Ambulation with Torso STSG The patient should bend at the knees with a straight back and avoid leaning over. This position keeps the STSG above the level of the heart and aides with decreasing venous congestion at the STSG site.. The patient may be able to ambulate at 48 hours post application of STSG. The plastic surgical team will provide specific instructions for ambulation37.

Ambulation with Lower Limb STSG Unless specified by the plastic surgical team or senior clinician the patient must remain resting in bed for 5 days post application of STSG if laid over a joint .To promote adhesion and prevent shearing forces related to patient movement37. Use a commode chair with leg extension/s to transport the patient for hygiene requirements. Liaise with physiotherapist as appropriate. Early ambulation will be determined by the size and position of the STSG38: • Ensure non weight bearing on limb with STSG until plastic surgical team instructs otherwise37.

Once it has been established that the patent can weight bear this should be undertaken with a mobility aid for balance, unless otherwise contraindicated.

• Ambulation may be commenced earlier (2-5 days) as directed by the plastic surgical team. • The patient may at risk of falling due to the foot bandages and appropriate strategies should be

documented for prevention. Refer to: WACHS Falls Prevention and Management Clinical Practice Standard

Post Ambulation Assessment • The STSG may go dusky in colour post ambulation due to the increased blood flow and

the destruction of the microcirculation. Continuing to ambulate will alter the viability of the STSG36,37.

• STSG sealed dressing is removed and the STSG assessment is performed for stability and haematomas post each period of ambulation. Refer to STSG Assessment – post application of STSG.

• If the STSG remains stable and pink the patient may continue to ambulate for short distances with sealing / “double bandaging”.

• If the STSG is fragile and developing haematomas on review post first ambulation attend to appropriate STSG graft care. Refer to Ongoing STSG Management.

• The ambulation period is decreased if venous congestion is present. Suggested decreased ambulation regime is 5 minutes twice a day. Increase as STSG viability improves.

• Post ambulation assessment must be documented in the patient health record. Refer to Post Ambulation Assessment.

• The patient can potentially be discharged if the STSG remains pink post ambulation.





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Documentation Failure to accurately and legibly record, and understand what is recorded, in patient health records contribute to a decrease in the quality and safety of patient care. Document changes in patient health record and site specific Wound Management Plan. The following assessments must be documented in the patients’ health record – Refer to WACHS Documentation Clinical Practice Standard.

Wound Bed Assessment – pre application of STSG At a minimum the assessment to include: • Condition of wound bed • Presence of sloughy and/or necrotic material • Presence of bone or tendon on view • Signs or symptoms of infection

STSG Assessment – post application of STSG At a minimum the assessment to include: • Colour of STSG • Area/s of STSG that have not adhered • Any loss of STSG • Report any loss of STSG to Plastic Surgery team/ Senior Clinician • Signs or symptoms of infection / patchy appearance • Presence of any seromas / haematomas • Presence of sloughy and/ or necrotic material • Presence of bone or tendon on view

Post Ambulation Assessment At a minimum the assessment to include: • Ambulation regimen +/- any specific instructions • Time of actual ambulation • Colour of STSG

• Pink • Dusky

• Presence of any seromas / haematomas Discharge Planning

Document in the patient health records: • All allied health referrals and services • Importance of keeping follow up appointments • Discharge education – patient and/or carer • Ongoing STSG management and assessment requirements

Patient Education Patients and/or carers will need ongoing education and support during the time as an inpatient and to feel comfortable with the ongoing management not only of the STSG care but any associated considerations involved in this type of surgical procedure.




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All aspects of patient education / explanations, including patient concerns and actions are to be documented by all clinical disciplines in the patient health record. Refer to Documentation Clinical Practice Standard Education and explanations should include (but are not limited to): • Re-innervation of nerves begins at 2 months with pain sensation returning followed by

touch hot and cold distinction and finally perspiration4. • The STSG rarely contain sweat glands or hair. Hair rarely grows from STSG as the

follicles are not transferred with the graft. Sweat gland regeneration is dependent on re-innervation of the STSG with recipient bed sympathetic nerve fibres 12.

• The patient will have a decreased heat regulation and sweating ability. • Avoidance of UV exposure, application of sun block and wearing protective clothing are

recommended to the STSG site (as well as the donor site) for the first year post application to protect the new skin2. Direct sunlight and prolonged exercise can increase temperature of graft, as there are no melanocytes in grafted tissue so burns easily2.

• The need to rest frequently for the first two weeks following discharge and to avoid overexerting the STSG area.

• Keep limb/s that have had STSG applied elevated when not ambulating for at least 4 weeks post application39 as this reduces congestion of blood in the graft, haematomas, oedema, shearing forces.

• How to apply and remove splint devices correctly if required • Instruct the patient in the wearing of pressure garments (Jobst® garment / Second

Skin®) – for 12-18 months 39 as appropriate. • Time off work may be required. • Arrange appropriate social work services and medical certificates

Discharge Planning All aspects of discharge planning are to be documented in the patient health record by all clinical disciplines participating in patient care and management. Refer to WACHS Patient Discharge, Escort, Transfer and Transportation Clinical Practice Standard To promote STSG viability “take” appropriate discharge education and planning is required. Ensure the patient has: • Ensure patient has and is aware of the outpatient appointment prior to discharge. • Appropriate follow up appointment/s have been made. • Liaise with plastic surgical team and/ or senior clinician • Appropriate equipment for dressings and ongoing STSG management • Dressings are to continue for approximately 4 weeks post application to protect the still

fragile “taken” STSG. (Consider using double tubular compression dressing (e.g. Tubigrip®) for support of STSG on discharge)39.

Services

Assess the patient to determine what services may be required to assist the patient to manage their STSG care and activities of daily living once discharged. Services and available resources may be more limited in WACHS and rural settings. At a minimum consider and ensure the following are catered for:






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• Wound care / dressings • Assistance to activities of daily living • Allied Health services e.g. Physiotherapy, Occupational Therapy and Social Worker • GP or local community nursing posts / hospitals for rural patients

Allied Health Professionals Specific allied health disciplines may be involved as a multidisciplinary approach to immediate in-patient care and ongoing management post discharge so it is important to establish early access to these services. Where services may overlap the specific departments will be in liaison and actions to be documented in the patient health record. Refer to Documentation Clinical Practice Standard

Occupational Therapist • Provision of immobilisation splints or pressure garments.

• Scar management: massage/stretching/contact media/pressure garments/splinting –dynamic and static/skin care

• Pressure garments can be fitted as an outpatient (OT will arrange appointments) and worn once the STSG is stable/“taken” until the STSG is completely mature and flattened to reduce complications related to contractures and scarring.

• Assistance with splinting • May need to undertake home assessment – activities of daily living.

Dietitian • Assess and encourage patients to maintain a balanced, nutritious diet, supplemented with high

protein drinks as necessary to promote STSG “taking”. • Assist with patient education and supplies of supplement drinks as appropriate to promote

wound healing.

Physiotherapist • Ambulatory aids/ splints • Advice on appropriate exercise and mobilisation • Assist with care of splinting

Psychosocial (Community Support Networks, Psychologist, Psychiatrist)

• Support for self, family and friends • Assistance and counselling in relation to altered body image may need to be addressed • Developing coping strategies • Impact of decreased income and work related issues • Potential for altered mental health complications e.g. depression, pacing, pain management,

decreased mobility of affected area





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Social Worker

• Impact of decreased income and work related issues – financial assessment, liaison with relevant agencies, workers compensation

• Support network for groups for self, family and friends

General Practitioner • Smoking cessation monitoring if required • Medical certificates • Ongoing assessment and referrals as required • Support for self and family

Clinical Handover Information exchange should adhere to the WA Health Clinical Handover Policy (iSoBAR) (iSoBAR).

Compliance Monitoring Evaluation, audit and feedback processes should be in place to monitor compliance.



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Acknowledgement of previous site endorsed work used to compile this standard We would like to thank the following people for their contribution to the project: FHHS, Skin Graft, Application of Split Skin Graft Procedure, Nursing Practice Manual, 2012

Cowell, R - A/CNM B7N. FHHS, Skin Graft, Application of Support Dressing and Bandage to Skin Graft Site Prior to Mobilization Procedure, Nursing Practice Manual, 2010. FHHS, Skin Graft, Care of the Open Graft Procedure, Nursing Practice Manual, 2010. FHHS, Skin Graft, Care of Donor Site Following Split Skin Graft Protocol, Nursing Practice Manual, 2009.

Withers, M – CNMB7N. RPH, The Application and Management of Split Thickness Skin Graft (STSG) for Plastic Surgery, Nursing Practice Standard, 2012.

Campbell, L – A/SDE Evidence Based Practice, Education Centre Fong, J – CNS/Burns Unit, Surgical Division Jellicoe, B – SDN, Surgical Division Stokes, K – CNS/Plastic Surgery, Surgical Division

Contributors Edgar, D – Allied Health, RPH. Duncan-Smith, M – HOD Plastic Surgery, RPH Jellico, B - Staff Development Nurse, Surgical Division, RPH Paterson, P - CNM B8S, FHHS Stanley, K – Senior Project Officer, SMHS Stokes, K – CNS, RPH Weston, M - Coordinator /Project Manager, Clinical Practice Standards Project SMHS Legislation Acts Amendment (Consent to Medical Treatment) Act 2008 Carers Recognition Act 2004 Civil Liability Act 2002 Disability Services Act 1993 Equal Opportunity Act 1984, Equal Opportunity Regulations 1986 Guardianship and Administration Act 1990 Health Practitioner Regulation National Law (WA) Act 2010 Mental Health Act 1996 Occupational Safety and Health Act 1984 Occupational Safety and Health Regulations 1996 OSH Regulations, 1996 Poisons Act 1964 Poisons Regulations 1965 Poisons Amendment Regulations 2010 Public Sector Management Act, 1994



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Standards EQuIPNational www.achs.org.au/ National Standards for Mental Health Services (NSHMS)

WA Department of Health Policies (Operational Directives) healthpoint.hdwa.health.wa.gov.au www.health.wa.gov.au Clinical and Related Waste Management – Clinical Wastes (OD 0259/09) Clinical Handover Policy, 2012 (OD 0484/14) Clinical Incident Management Policy, 2012 (OD 0421/13) Consent to Treatment Policy for the Western Australian health system, 2011 (OD 0324/11) Correct Patient, Correct Site and Correct Procedure Policy and Guideline for WA Health Services 2nd Edition (OD 0004/06) Implementation of the Australian Health Service Safety and Quality Accreditation Scheme and the National Safety and Quality Health Service Standards in Western Australia (OD 0410/12) National Hand Hygiene Initiative in Western Australian Healthcare Facilities (OD 0429/13) Post-Fall Management Guidelines in Western Australian Healthcare Settings (OD 0442/13) The Policy for Credentialling and Scope of Clinical Practice for Medical Practitioners 2nd Edition 2009 (OD 0177/09) Western Australian Clinical Alert (Med Alert) Policy (OD 0511/14) Western Australian Clinical Deterioration Policy (OD 0501/14) Western Australian Patient Identification Policy 2014 (OD 0486/14) SMHS Policies healthpoint.hdwa.health.wa.gov.au Aboriginal and Multicultural Groups (SMAHS CF: 02) Bariatric Management: (SMAHS COC: 06) Consumer and Carer Participation: (SMAHS CF: 03) Consumer and Carer Participation in Mental Health: (SMHS CF: 07) Health Record Documentation Policy and Standards (SMAHS COC: 03) Infection Prevention and Management Policy (SMHS PS:06) Mandatory Training Governance Policy (SMHS HR: 04) OSH: Manual Handling (SMAHS SPE: 04) Single Use/Single Patient Use Medical Devices: (SMAHS SPE: 40)

http://www.achs.org.au/


http://www.health.wa.gov.au/circularsnew/index.cfm




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Standardised Logos EQuIPNational www.achs.org.au/

Governance for Safety and Quality in Health Service Organisations

Partnering with Consumers

Preventing and Controlling Healthcare Associated Infections

Medication Safety

Patient Identification and Procedure Matching

Clinical Handover

WA Department of Health iSoBAR - Guide to Handover Content and Structure

i IDENTIFY Introduce yourself and your patient

S SITUATION Describe the reason for handing over

o OBSERVATIONS Include vital signs and assessments

B BACKGROUND Pertinent patient information

A AGREE A PLAN Given the situation, what needs to happen

R READ BACK Clarify shared understanding

Blood and Blood Products

Preventing and Managing Pressure Injuries

Recognising and Responding to Clinical Deterioration in Health Care

Preventing Falls and Harm from Falls

Service Delivery

Provision of Care

Workforce Planning and Management

Information Management

Corporate Systems and Safety





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38. Kho Y. Lower Limb Split Thickness Skin Grafts: Mobilization and Ambulation (evidence summary). Adelaide: Joanna Briggs Institute; 2013: http://fhlibresources.health.wa.gov.au/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=jbi&AN=JBI3354.

39. Edgar D. Mobilisation and Ambulation after Lower Limb Split Skin Graft (recommended practice). Adelaide: Joanna Briggs Institute; 2013: http://fhlibresources.health.wa.gov.au/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=jbi&AN=JBI6264.

This document can be made available in alternative formats on request for a person with a disability Copyright to this material is vested in the State of Western Australia unless otherwise indicated. Apart from any fair dealing for the purposes of private study, research, criticism or review, as permitted under the provisions of the Copyright Act 1968, no part may be reproduced or re-used for any purposes whatsoever without written permission of the State of Western Australia.





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Split thickness skin grafts clinical practice standard · 2019-10-30 · A split - thickness skin graft (STSG) is a very thin shaving of normal skin taken from an undamaged area of