TRUST-WIDE CLINICAL POLICY DOCUMENT WOUND DEBRIDEMENT. Policy Number: 122

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1 TRUST-WIDE CLINICAL POLICY DOCUMENT WOUND DEBRIDEMENT Policy Number: 122 Scope of this Document: Recommending Committee: Approving Committee: To be applied by all Healthcare professionals within Mersey Care NHS Foundation Trust. Skin Care Service Clinical Standards Group Date Ratified: 21/08/2018 Next Review Date (by): 21/08/2020 Version Number: 08/2018 Version 11 Lead Executive Director: Lead Author(s): Director of Nursing Skin Care Service TRUST-WIDE CLINICAL POLICY DOCUMENT 2018 Version 11 Striving for perfect care for the people we serve TRUST-WIDE CLINICAL POLICY DOCUMENT 122, Wound Debridement, Version 11 Page 1 of 33

2 TRUST-WIDE CLINICAL POLICY DOCUMENT WOUND DEBRIDEMENT Further information about this document: Document name WOUND DEBRIDEMENT (122) Document summary Policy to assist clinicians in the decision making process for wound debridement including choosing a recognised method Author(s) Contact(s) for further information about this document Published by Copies of this document are available from the Author(s) and via the trust s website To be read in conjunction with Skin Care Service Telephone: skincareservice@merseycare.nhs.uk Mersey Care NHS Foundation Trust V7 Building Kings Business Park Prescot Merseyside L34 1PJ Your Space Extranet: Trust s Website Infection Control Manual 2018 Wound Assessment 2018 Infected Wound 2018 Consent to Treatment 2016 Mental Capacity Act 2015 Wound Care Formulary 2018 This document can be made available in a range of alternative formats including various languages, large print and braille etc Copyright Mersey Care NHS Trust, All Rights Reserved Version Control: Version History: Version 11 Presented to the clinical policies group 21/08/ , Wound Debridement, Version 11 Page 2 of 33

3 SUPPORTING STATEMENTS This document should be read in conjunction with the following statements: SAFEGUARDING IS EVERYBODY S BUSINESS All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including: being alert to the possibility of child / adult abuse and neglect through their observation of abuse, or by professional judgement made as a result of information gathered about the child / adult; knowing how to deal with a disclosure or allegation of child / adult abuse; undertaking training as appropriate for their role and keeping themselves updated; being aware of and following the local policies and procedures they need to follow if they have a child / adult concern; ensuring appropriate advice and support is accessed either from managers, Safeguarding Ambassadors or the trust s safeguarding team; participating in multi-agency working to safeguard the child or adult (if appropriate to your role); ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation; ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session EQUALITY AND HUMAN RIGHTS Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership. The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices. Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act. Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy 122, Wound Debridement, Version 11 Page 3 of 33

4 Contents Index Page No 1 Introduction Purpose and Aims of the Guideline Scope of the Guideline Definitions Training Requirements Documentation and Record Keeping Monitoring Tool Development of the Guideline, Contributions and Peer Review Equality Analysis Distribution/Dissemination Method Identifying tissue that requires debridement: Rationale for debridement Debridement and Skin Care Patient specific debridement/considerations Methods of wound debridement: Surgical Debridement Sharp Debridement (for nurses) Education and training Indications for conservative sharp debridement Contra-indications for conservative sharp debridement Patients not suitable for conservative sharp debridement Caution for conservative sharp debridement Autolytic Debridement Enzymatic Debridement Enzymatic debridement is no longer recommended Mechanical Debridement High Pressure Fluid Irrigation Ultrasonic Biological Debridement , Wound Debridement, Version 11 Page 4 of 33

5 19.1 Indications for use Education and training Contraindications and associated risks Availability How to Order Larvae Instructions for use: BioBag References Appendix Appendix Appendix Appendix Appendix Appendix , Wound Debridement, Version 11 Page 5 of 33

6 1 Introduction Wound debridement is the removal of non-viable tissue from the wound bed to encourage wound healing in that the unhealthy tissue impedes the natural healing process. In order to maximize the body s natural mechanisms of wound healing and potential effectiveness of many wound care products, a healthy wound bed is required (Vowden and Vowden 2002 and 2011). 2 Purpose and Aims of the Guideline This guideline has been developed to provide evidence-based guidance on the management of wounds requiring debridement. It aims to improve clinical practice and reduce variations in standards of care within the primary and intermediate care setting. 3 Scope of the Guideline This guideline is applicable to all registered health professionals employed by Mersey Care NHS Foundation Trust who are involved in the management of patients with wounds. 4 Definitions Definitions have been taken from The Free Dictionary Online (Medical ) 2013 unless otherwise indicated by a specific reference. Acute: Aetiology: having severe symptoms and a short course. Some serious illnesses that were formerly considered acute (such as myocardial infarction) are now recognised to be acute episodes of chronic conditions. the cause of a specific disease Anaerobes: an organism that lives and grows in the absence of molecular oxygen.(examples include: Clostridium perfringens and Bacteroides fragilis Auto-amputation: spontaneous detachment from the body and elimination of an appendage or an abnormal growth. Autolysis: Chronic: the disintegration of cells or tissues by endogenous enzymes describes a disease of long duration with very slow changes. A chronic wound has been described as any wound that is failing to heal as anticipated or that has been stuck in any one phase of wound healing for 6 weeks or more (Collier 2002). Desiccation: the act of drying. Devitalised tissue: dead tissue as a result of poor oxygen and nutrient supply (also referred to as necrotic tissue) Eschar: a slough produced by a thermal burn, by a corrosive application, or by gangrene. Exogenous: Having a cause external to the body 122, Wound Debridement, Version 11 Page 6 of 33

7 Fistula: A Fistula is a permanent abnormal passageway between two organs in the body or between an organ and the exterior of the body. Fungating wounds: fungating, malignant wounds are caused by tumour infiltration of the skin and it s supporting lymph and blood vessels. They classically appear like necrotic cauliflower type structures Gangrene: Gangrene is the term used to describe the decay or death of an organ or tissue caused by a lack of blood supply. Granulation: The formation of minute, rounded, fleshy connective tissue projections on the surface of a wound, ulcer, or inflamed tissue surface in the process of healing; Hydrocolloid: A flexible dressing made of an adhesive, gumlike (hydrocolloid) material such as karaya or pectin covered with a water-resistant film. The dressing keeps the wound surface moist, but, because it excludes air, it may promote anaerobic bacterial growth. Hydrogel: a generic dressing type with a high water content. Available as a flat sheet or an amorphous gel. Usually starch based. Individual hydrogels may contain other active ingredients appropriate to wound management. Infection: micro-organisms are not only present but are multiplying and producing an associated host reaction. This reaction may take various forms and identification of infection may prove difficult for the novice. Ischaemia: Inadequate flow of blood to any part of the body. It is a serious disorder usually due to narrowing, from disease, of the supplying arteries. Macrophage: a large scavenger cell present in connective tissue and many major organs and tissues. It is capable of engulfing and digesting bacteria, protozoa, cells and cell debris and plays a major role in the body s defence mechanism Necrosis: Pathologic death of one or more cells, or of a portion of tissue or organ, resulting from irreversible damage; The tissue is often black/brown in colour and leathery in texture Proteolytic: describes the action of the digestive enzymes that break down protein molecules e.g. protease Re-vascularisation: development of a new or replenished blood supply to the tissues either by natural processes (new capillary formation) or by surgical intervention e.g. angioplasty, arterial bypass grafting Secondary intention: granulation this is when the edges of a wound are left open and allowed to heal by Slough: Wound: devitalised tissue that has a yellow/white/grey hue a break in the structure of an organ or tissue caused by an external agent Wound contraction: a function of the healing process in granulating wounds whereby the edges of the wound are drawn towards each other 122, Wound Debridement, Version 11 Page 7 of 33

8 5 Training Requirements Mersey Care employees will be expected to act at all times in such a manner as to safeguard and promote the interests of patients and clients. Registered health professionals must have knowledge and skills and effective practice; recognise and work within the limits of personal competence (Nursing and Midwifery Council (NMC), 2015 and 2018) All employees must be made aware of the organisations guidelines before commencement in post, as part of their local induction process. 6 Documentation and Record Keeping Effective documentation is of paramount importance for the following reasons: To comply with NMC guidance on record keeping Contemporaneous written records provide the evidence and rationale on which care delivery is based and are legal requirement. They could be scrutinised at any time in a court of law and must therefore accurately reflect and justify the actions and decisions made by health care professionals Accurate records improve communication between health care professionals regarding individual patient care Accurate, comprehensive records enhance continuity of care 7 Monitoring Tool Audit of this guideline will be undertaken as per Mersey Care locality audit plan for individual services, using the wound assessment audit tool available on Mersey Care intranet site. Audit results and any actions will be discussed with the Skin Care Service 8 Development of the Guideline, Contributions and Peer Review The guideline was developed and peer reviewed by members of the Skin Care Service, Podiatry Service and ratified by Mersey Care Clinical Policies Group. This guideline should be used in conjunction with the Following Clinical Guidelines and Policies Wound Assessment 2018 Infected Wound 2018 Consent to Treatment 2016 Mental Capacity Act 2015 Wound Care Formulary 2018 Aseptic and Clean Dressing Techniques for Clinical Practice 2013 Hand Hygiene 2013 Infection Prevention and Control Manual Equality Analysis This guideline is believed to have no differential impact for any group or groups. A full impact assessment is not required however a screening process recording proforma has been completed and accepted by the equality and diversity team and a copy hand held by the skin care service. See Appendix 6 122, Wound Debridement, Version 11 Page 8 of 33

9 10 Distribution/Dissemination Method Once approved, this guideline will be added to the Clinical Policies database and communicated to Mersey Care NHS Foundation Trust Health employees via the communications bulletin 11 Identifying tissue that requires debridement: Moist necrotic tissue green, yellow or grey appearance Dry necrotic tissue dry and leathery, it appears as hard black/brown eschar Slough stringy moist necrotic tissue grey or yellow that adheres to the wound bed (should not be mistaken for fibrin, a yellow gelatinous coating occasionally seen on the wound surface and a normal feature of wound healing that does not need removal). (Adapted from Baranoski and Ayello 2004, and O Brien 2002) For further information - See Appendix Rationale for debridement Dead or devitalised tissue can prevent the practitioner from gaining an accurate assessment of the wound as true extent of tissue destruction may not be visible. This is particularly relevant in pressure ulcers and diabetic foot ulcers. Dead or devitalised tissue acts as a medium for bacterial growth, particularly anaerobes and can lead to overproduction of exudate and odour The presence of dead or devitalised tissue within the wound bed leads to a prolonged inflammatory response, delaying the wound healing process. Dead or devitalised tissue retards wound contraction, the principal contribution to wound closure when wounds are left to heal by secondary intention. (Leaper 2002, Weir et al 2007, Vowden and Vowden 2011) Debridement should not be considered as a single event (Falanga 2002). In order to promote continuous healing and prevent wound deterioration, it may be necessary to consider alternative methods of maintenance debridement once the initial removal of devitalised tissue has been achieved. In some instances, debridement is NOT an appropriate option. When there is evidence of underlying peripheral arterial disease associated with gangrene, it is not appropriate to remove necrotic tissue. Grangrenous digits should be kept dry and allowed to auto-amputate as creation of a moist environment may precipitate wet, infected gangrene, which is potentially limb and/or life threatening (Leaper 2002, Vowden and Vowden 2002). Limb revascularisation should be considered and treatment goals realistic, based on the assessed potential for wound healing. Alternatively for a palliative patient with eschar in a wound, the clinical goal may be to maintain comfort and debridement not appropriate (Stephen-Haynes, Thompson 2007.) Prior to debridement of pressure ulcers on the lower leg, practitioners should ensure there is an adequate blood supply to rule out arterial insufficiency (NPUAP-EPUAP 2014) 11.2 Debridement and Skin Care Removal of hyperkeratotic tissue surrounding leg ulcers is perceived by many as picking rather 122, Wound Debridement, Version 11 Page 9 of 33

10 than debridement. It is therefore considered without risk and not to require special skills. While this may promote patient comfort, it involves the removal of devitalised tissue (sharp debridement) with forceps, and carries a risk of tissue damage (Myers 2004). Removal of this tissue is good practice in leg ulcer care; however conscientious washing and moisturising of the leg should help prevent the build-up. Removal of persistent hyperkeratotic tissue should be performed by a competent nurse (Anderson 2006) Patient specific debridement/considerations Once it is established that the wound will benefit from debridement, it is necessary to consider the following points when choosing the most appropriate method of debridement: The timescale in which debridement should take place. The relevant risks and benefits of each method in the context of each individual patient assessment Level of pain experienced by the patient Presence or absence of infection The patients attitude to debridement and perception of the individual methods Available skills, products and resources The effectiveness, rationale and strength of supporting evidence will be documented for each method, within this guideline. Whilst there is insufficient robust evidence to promote the use of one debriding agent over another or which is the most effective (NICE 2005), it is accepted principle of good wound care, particularly when the debris is acting as a focus for infection (NICE 2001), with recent evidence supporting the benefits when debridement is compared with no debridement (Williams et al 2005) 11.4 Methods of wound debridement: Surgical Sharp Autolytic with dressings Enzymatic Mechanical Biological Hydrosurgical Ultrasonic 12 Surgical Debridement Surgical debridement involves the excision or wide resection of necrotic tissue, often removing viable tissue from the wound margins (Fairburn et al 2002). The aim of surgical debridement is to convert a chronic wound into an acute wound and therefore re-initiate the wound healing process (Falanga 2002). Surgical debridement is reserved for wounds requiring extensive debridement. A surgeon in the theatre setting carries out surgical debridement. It is not appropriate to carry out the technique in primary care. 122, Wound Debridement, Version 11 Page 10 of 33

11 In general, surgical debridement should be considered only if other techniques are ineffective or the condition of the patient requires rapid, major intervention. 13 Sharp Debridement (for nurses) Sharp debridement is defined as The removal of dead or necrotic tissue or foreign material from and around the wound to expose healthy tissue using a sterile scalpel, scissors or both (Leaper 2002). The level of debridement is determined not only on the needs of the patient/wound and clinical environment, but upon the competence of the nurse; Podiatrists may debride necrotic tissue extending as deeply and proximally as necessary until healthy, bleeding soft tissue and bone are encountered, removing any callus tissue surrounding the ulcer (Fryberg 2006). However the competency level that nurses attain would advocate a more conservative approach to sharp debridement, hence the term Conservative Sharp Debridement (CSD) defined as: the removal of loose dead tissue that has become partially separated from the wound, using a scalpel or scissors, above the level of viable tissue (NICE 2014), and as such forms the basis for this guidance and procedure Education and training The following are prerequisites of any practitioner undertaking the procedure of conservative sharp debridement: The practitioner must be a registered health professional The practitioner must agree to undertake the procedure of sharp debridement as identified in the knowledge and skills framework that is applied to their current role The practitioner must have undertaken a recognised course covering the relevant theory and practice surrounding sharp debridement to ensure that they have the required knowledge, skills and competence. This should include an understanding of the underlying structures encountered during debridement The practitioner must keep their knowledge and skills up-to date whilst actively practising the procedure of sharp debridement. Both the practitioner and the employing organisation must be satisfied that the practitioner has acquired and continues to maintain the requisite knowledge and skills 13.2 Indications for conservative sharp debridement Sharp debridement is best suited to wounds where there is a clear distinction between healthily and devitalised tissue and where the patient is unlikely to experience significant pain (Bradley 1999) 13.3 Contra-indications for conservative sharp debridement If the wound is on the foot* (excluding heel region) Patients with ischaemic digits Patients with clotting disorders Any fungating/malignant wounds or wounds that are prone to bleed easily If the wound involves or is close to the following structures, nurses should not consider sharp debridement. A referral should be made to the relevant 122, Wound Debridement, Version 11 Page 11 of 33

12 Consultant Surgeon and the GP informed. o Vascular structures o Dacron grafts o Prosthesis o Dialysis fistula Sharp debridement of wounds located on the foot should be referred to the Podiatry Team for joint assessment If the wound is located on the hands or face 13.4 Patients not suitable for conservative sharp debridement Those with inadequately controlled pain Confused and agitated patients Patients who do not have an adequate blood supply in order to promote healing when the wound is debrided 13.5 Caution for conservative sharp debridement Patients who have ischaemia of the lower limbs*. Patients on anti-coagulant therapy e.g. warfarin, aspirin, heparin Wounds on heels. ** Wounds on the Achilles tendon area. ** *Decision with regard to whether or not the debridement of ischaemic lower limbs is appropriate should be made in conjunction with vascular consultant. **Referral should be made to the podiatrist for joint assessment and management if required Procedure for conservative sharp debridement See Appendix 2 122, Wound Debridement, Version 11 Page 12 of 33

13 14 Autolytic Debridement Autolytic debridement relies on enhancing the natural process of selective liquefaction, separation and digestion of necrotic tissue. Autolysis occurs as part of the wound healing process through macrophage and endogenous proteolytic activity (Meekes 2001). It is enhanced by the use of moisture-retentive dressings such as hydrogels and hydrocolloids (Jones and Milton 2000) that promote re-hydration of necrotic tissue by creating a moist wound healing environment. The accumulating wound exudate contains white blood cells and enzymes that break down necrotic tissue. Autolytic debridement is probably the most common method of wound debridement, but is traditionally time-consuming and there is a risk of maceration, (Bentley 2005) therefore practitioners should ensure that the method of debridement is the most suitable for the individual patient and the goals of care Dressings used to promote autolytic wound debridement include : (Anderson 2006) Hydrogels, vapour permeable films and hydrocolloids - which promote wound moisture (hydrate necrotic tissue) Foams, Alginates, Hydrofibres absorb wound fluid whilst maintaining a moist wound bed (generally for wet slough) Cadexomer iodine may be useful in some (wet) wounds to effect debridement (Bianchi 2001) Additionally Honey creates an osmotic effect to facilitate protease break down of slough and necrotic tissue (Molan 2002) Capillary dressings (in conjunction with semi permeable film) draws exudate from the wound bed to hydrate necrotic tissue (Lisle 2002) Procedure for Autolytic debridement - See Appendix 3 15 Enzymatic Debridement This process involves addition of proteolytic and other exogenous enzymes to the wound surface that assist in the breakdown of necrotic tissue. The only enzymatic agent licensed for use for wound debridement in the UK is Varidase. Enzymatic debridement can be hazardous. It is costly, requiring twice daily application to effect debridement and there is no evidence to support its use NICE 2001, (Bradley et al 1999) Enzymatic debridement is no longer recommended. 16 Mechanical Debridement Wet to dry Mechanical debridement is the use of non-discriminatory physical force to remove necrotic tissue and debris from the wound surface (Vowden and Vowden 2002). It usually involves the use of wet-to-dry gauze dressings. It is the general consensus of expert opinion that this procedure damages healthy, granulating tissue, is extremely painful for the patient, leads to wound dessication and is not used in the UK (Bradley et al 1999, Rutter 2000). Newer methods of mechanical debridement include removal of non-viable tissue from a wound using a monofilament soft pad (Debrisoft, Activa Healthcare). Debrisoft can be more 122, Wound Debridement, Version 11 Page 13 of 33

14 selective and can also achieve effective removal of hyperkeratosis with little pain experienced by the patient. Debrisoft is not suitable for dry necrosis and is not suitable for already painful wounds (Wounds UK, 2013). There is also evidence to support the use of the product as a means of more rapid debridement for patients with associated cost savings by comparison to other methods/products (NICE 2014). 17 High Pressure Fluid Irrigation Versajet is a relatively new system using high-pressure fluid. It is in effect a form of surgical debridement as the jet of water acts as a scalpel and can be targeted directly at precise areas of necrotic tissue. At the same time a vacuum effect is created, which sucks up the loose debris in a collection chamber. Additional evidence of its effectiveness is required particularly in comparison to other methods of mechanical debridement (Anderson 2006). 18 Ultrasonic Devices deliver Ultrasound either in direct contact with the wound bed or via an atomised solution (MIST ; Celleration). Most include an built-in irrigation system and are supplied with a variety of probes for different wound types. The treatment is immediate and selective with evidence of some antimicrobial activity. Availability is however limited due to higher costs than other methods of debridement and specialist training is required to carry out. (Wounds UK 2013) 19 Biological Debridement Biological debridement is carried out by the use of maggots (Larval therapy).maggot therapy is widely used by health care practitioners throughout the UK for the management of necrotic and sloughy wounds. Maggots of the greenbottle fly, Lucilia sericata, have been shown to rapidly remove devitalised tissue from all wound types, irrespective of their underlying aetiology Indications for use Whilst maggots cannot be regarded as the treatment of choice for all types of wounds requiring debridement, they do have a valuable role to play, particularly in situations where other methods of debridement have proved ineffective. Maggots should be considered for: Wounds in which sharp debridement may expose bone, joint or tendon A wound in which autolytic debridement has failed or is contra-indicated A secondary debridement method after sharp debridement or prior to skin grafting Wounds where the demarcation between devitalised and healthy tissue is difficult to define as maggots will only eat dead tissue Maggots are effective against infections caused by a wide variety of microorganisms, There is no evidence to support a claim that loose larvae or the BioBag Dressing can have an effect on the resistant bacterium methicillin resistant Staphylococcus aureus (MRSA). However if the wound is colonised with MRSA, then in studies have shown that the MRSA is removed from the wound bed during debridement with larvae. This implies that debridement is the key to the removal of MRSA 19.2 Education and training Any practitioner involved in the use of maggot therapy should have undergone 122, Wound Debridement, Version 11 Page 14 of 33

15 appropriate education and training and work within the limits of personal competence Contraindications and associated risks Contraindications Bagged or loose larvae must not be used on wounds that have a tendency to bleed or on wounds close to an exposed major blood vessel. Complex wounds such as sinuses (known as fistulae) should be treated with caution in conjunction with medical supervision Bagged or loose larvae should not be used on a patient on wounds with dry necrotic eschar; rehydration is required in the first instance, or wounds where there is insufficient blood supply to allow ongoing healing to take place. Bagged or loose larvae should not be used on a patient on anticoagulants where the relevant clotting marker is not within an acceptable clinical range. Application of maggots to patients whose clotting marker falls within acceptable clinical range may be suitable for bagged larval therapy in the community setting as long as sufficient provision is made for regular observation of the dressing to observe for increased bleeding which would give cause concern and may require removal of the larvae. These patients would require individual risk assessment prior to application of the therapy. Bagged or loose larvae should be used with caution on wounds over adjacent exposed organs or leading to a body cavity, and only under the close supervision of the doctor or nurse responsible for the patient. Bagged or loose larvae can be used on suspected necrotising fasciitis, but only once a thorough assessment has been carried out and surgical intervention rejected, or as an adjunct to surgery Associated risks Increased pain at wound site (particularly in wounds where pain is already present prior to the application of larval therapy and some wounds with an ischaemic component. Ensure that the patient s wound pain is assessed prior to and during treatment and any required adjustments to analgesia are made. If severe pain experienced, it will be immediately alleviated with removal of the larvae and wound is irrigated. Bleeding can result from damage to small capillaries and regular daily inspection of the wound bed is recommended. (All Wales Tissue Viability Nurse Forum 2013) 19.4 Availability Loose maggots for direct application to the wound surface (Larvae100/200 free range maggots BioMonde). Suitable for cavity wounds and wounds with undermining / sinus. Maggots contained in a sealed net bag (BioBag Dressing BioMonde) suitable for ease of application / removal, may be more aesthetically acceptable to the patient How to Order Larvae The following guidelines outline the process of prescribing maggots, to ensure that the correct pack is prescribed for the patient. 122, Wound Debridement, Version 11 Page 15 of 33

16 The prescription goes to the Pharmacy just like any other prescription. The Pharmacist then rings BioMonde to place the order. Providing the order is placed before12 midday the larvae will be delivered back to the pharmacy the following day. Alternatively, the Pharmacist can request delivery for a future date. Larvae can be delivered Monday to Saturday. Ensure that a prescription for any additional equipment requested by the practitioner for larvae application has also been prescribed and supplied for the patient. If all the required equipment is not available, the practitioner will not be able to apply the larvae and they will be wasted. Larvae must be applied to the wound on the day that they are delivered Instructions for use: Measure the dimensions of the wound and compare with the wound sizes indicated on the side of the calculator. Move horizontally across the table to the column that most likely corresponds to the percentage of the wound area covered with slough. The number of pots required is indicated by the colour shown. Although these recommendations are based on extensive clinical experience with the technique, the final decision on the number of pots to be applied must remain the responsibility of the practitioner providing the treatment. For advice on the number of pots for the treatment of specific wounds please contact BioMonde on or orders@biomonde.com For assistance outside normal working hours, please call our Clinical Helpline After 5pm Monday to Friday, and all day Saturday and Sunday 19.7 BioBag The larvae are sealed within a dressing which is a finely woven net pouch containing a small piece of foam, which aids the growth of the larvae. BioBag comes in varying sizes and are applied according to the nature and size of the wound being treated. The larvae remain sealed within the dressing throughout the treatment. See Appendix 4 and Appendix 5 for application and ordering of Larvae 122, Wound Debridement, Version 11 Page 16 of 33

17 References Acton, C. (2007) A know-how guide to using larval therapy for wound debridement. Wound Essentials Vol All Wales Tissue Viability Nurse Forum, (2013), All Wales Guidance for the use of: Larval Debridement Therapy pg 8, Wounds UK, London Anderson,I. (2006) Debridement methods in wound care. Nursing Standard.20, 24, Baranoski, S, Ayello,A. (2004) Wound Care Essentials: Practice Principles. Lippincott, Williams and Wilkins, Philadelphia. Bentley J. (2005) Choosing the right prescribing options in wound debridement. Nurse Prescribing. Vol3 No3. Pp Bianchi,J.(2001) Cadexomer-iodine in the treatment of venous leg ulcers: what is the evidence? Journal of Wound Care. 10,6, Bradley M, Cullum N, Sheldon T (1999) The debridement of chronic wounds: a systematic review. Health Technology Assessment 3 (17) Part 1 Collier M (2002) A ten-point assessment plan for wounds Journal of Community Nursing 16 (6) Edwards J (2000). Sharp debridement of wounds. Journal of Community Nursing. 14 (1) Falanga V (2002) in Falanga V and Harding K, Eds (2002). The Clinical Relevance of Wound Bed Preparation. Springer-Verlag Berlin Heidelberg, Germany Fairburn K et al (2002). A sharp debridement procedure devised by specialist nurses. Journal of Wound Care 11 (10) Frykberg RG. (2006) Diabetic foot disorders: a clinical practical guideline. American College of Foot and Ankle Surgeons. Journal Foot and Ankle Surgery. Sep-Oct ;45 (5):S2-66 Leaper D (2002). Sharp technique for wound debridement. World Wide Wounds. accessed 9th January 2010 Lisle, J. (2002) Debridement of necrotic tissue and eschar using a capillary dressing and semipermeable film dressing. Wound Care. 9. pp Meekes JR (2001) Autolytic debridement. In Cherry GW, Harding KG, Ryan TJ Eds. Wound Bed Preparation. London. Royal Society of Medicine Press Ltd Molan,P. (2002) Re-introducing honey in the management of wounds and ulcers- theory and practice. Ostomy/Wound Management. 48, 11, NICE (2001) Guidance on the use of debriding agents and specialist wound care clinics for difficult to heal surgical wounds. Technology Appraisal Guidance No.24 NICE (2014) Pressure ulcers: Prevention and Management care CG , Wound Debridement, Version 11 Page 17 of 33

18 NICE (2014) The Debrisoft monofilament pad for use in acute or chronic wounds Medical Technology Guidance (MTG17) NMC (2015) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives London. NMC (2018) Future Nurse: Standards of Proficiency for registered nurses. London. NPUAP-EPUAP (2014) Prevention and Treatment of Pressure Ulcers as accessed on the 06/08/2018 O Brien, M. (2002) exploring methods of wound debridement Wound Care. 12. pp O Brien M (2003) Debridement: ethical, legal and practical considerations. British Journal of Community Nursing, Wound Care Supplement. March 2003, Sibbald, G. (2002) in Falanga V and Harding K, Eds (2002). The Clinical Relevance of Wound Bed Preparation, Springer-Verlag Berlin Heidelberg, Germany Stephen-Haynes, J. Thompson G. (2007) The different methods of wound debridement Wound Care. 6. S8-S16. Strohal,R., Apelqvist, J., Dissemond, J. (2013) EWMA document: Debridement, Journal of Wound Care, 22 (Suppl. 1), S31-S34 TVNA (2005) Conservative Sharp debridement procedure, competencies and training. Available at: Thomas, S(2006) Cost of managing chronic wounds in the UK, with particular emphasis on maggot debridement therapy. Journal Of Wound Care15 (10): Vowden, KR and Vowden, P. (1999) Wound debridement, Part 2: sharp techniques. Journal of Wound Care, 8 (6) Vowden, KR. and Vowden, P. (2002) Wound Bed Preparation World Wide Wounds Accessed July 2018 Vowden, KR and Vowden, P (2011) Debridement Made Easy Wounds UK 7, (4), 1-5 Weir D., Scarborough P.,Niezgoda J.A. (2007) Wound Debridement, In: Krasner DL (ed) Chronic Wound Care: A Clinical Source Book for Healthcare Professionals (4th edn), HMP Communications, Malvern :35; Williams D, Enoch S, Miller D, et al. (2005) Effect of sharp debridement using curette on recalcitrant non-healing venous leg ulcers: a concurrently controlled, prospective cohort study. Wound Rep Reg.; 13(2): , Wound Debridement, Version 11 Page 18 of 33

19 Appendix 1 Tissue Types and Underlying Structures Tissue Subcutaneous Muscle Bone Tendons Ligament (Adapted from Edwards 2000) Description Mostly yellow fat. There are some blood vessels but generally there is poor vascularity Dull red in colour, highly vascular and tears easily. Protects bones, nerves, joints and vessels Hard, bright and white. Desiccates rapidly if exposed and turns yellow. Strong, gleaming white, shiny, elastic, fibrous tissue. They attach muscle to bone and have poor vascularity A sheet or band of tough, fibrous tissue connecting bones or cartilages at a joint or supporting an organ 122, Wound Debridement, Version 11 Page 19 of 33

20 Appendix 2 Procedure for conservative sharp debridement Prior to conservative sharp debridement for nurses ACTION Carry out a full, holistic patient assessment including vascular assessment using Doppler ultrasound, if the wound is situated on a lower limb. Discuss the merits of the different debridement options and define treatment objectives. Explain the procedure and identify potential risks, benefits to the patient and carer/next of kin. Obtain informed consent and document within nursing records. See Mersey Care Consent to Treatment Policy 2016 for further guidance. If patient lacks capacity to consent, ensure mental capacity assessment is completed as per Merseycare Mental Capacity Act Policy 2015 and that it can be demonstrated acting in best interests. Consider the need for: Administration of prescribed analgesia prior to procedure. Antibiotic cover if clinical signs of infection are present (as per infected wound guideline and trust antibiotic formulary) Prepare the environment i.e lighting, couch and clinical procedure equipment: Sterile scalpel and handle with size 10 or 15 blade or sharp sterile scissors. Forceps capable of grasping and holding necrotic tissue. Sterile probe for assessing tracking and depth of wound. Sterile, non-woven gauze swabs. Heamostatic wound dressing as per wound formulary. Apron Sterile, non-latex gloves or sterile dressing pack containing non-latex gloves. Sterile saline for wound cleansing Camera for wound photography. RATIONALE To ensure that the patient is suitable for sharp debridement. Exclude any contraindications/caution factors to the procedure. To ensure the patient has an adequate peripheral arterial supply in order to promote wound healing. To ensure the patient is able to provide informed consent to the procedure. To ensure the clinician is able to provide robust evidence of informed consent and if applicable that mental capacity assessment has taken place to inform acting the best interests of the patient. Debridement of necrotic tissue should not increase pain however; viable tissue may be pulled or cut which may necessitate additional analgesia. To treat any underlying tissue infection. To ensure good visibility of the area for wound debridement and required procedure equipment available. 122, Wound Debridement, Version 11 Page 20 of 33

21 Complete a wound assessment and document as per trust guidance estimating the depth of the necrosis and assess the skin around the wound margin. Photograph the wound and place in the patients records, as per trust guidance. To provide a baseline of wound appearance During conservative sharp debridement Ensure the patient is comfortable and in a position where the wound can be accessed and viewed easily. Ensure the practitioner carrying out the procedure is in an appropriate and comfortable position. Ensure that the appropriate equipment is easily accessible. Prepare an aseptic area and ensure the dressing technique is performed as per trust guidance, paying particular attention to Hand Hygiene. Lift the necrotic tissue with forceps and cut it carefully with a scalpel/scissors, taking it down in layers. The practitioner should stop if he/she or the patient becomes uncomfortable at any time during the procedure. If bleeding occurs, initially apply constant local pressure. Use a haemostatic dressing if required. To maintain patient comfort and allow access to the area, throughout the procedure. To provide a safe working environment for the practitioner. To ensure the procedure runs safely and smoothly. To reduce the risk of acquiring or transmitting of micro-organisms. Healthy tissue is less likely to be damaged. To prevent unnecessary discomfort to the patient/practitioner and to maintain a safe environment. To ensure blood loss is minimal. To prevent further tissue damage and patient discomfort. If bleeding persists, stop the procedure immediately and seek medical advice. 122, Wound Debridement, Version 11 Page 21 of 33

22 Post conservative sharp debridement Photograph the wound post debridement. To evaluate the extent of debridement that has occurred. Reassess and evaluate the procedure, ensuring documentation is appropriate and comprehensive. Reassess wound bed and redress as per trust formulary. Dispose of equipment, sharps and debrided tissue as per clinical waste policy. Inform the patient and relevant members of the multi-disciplinary team of the process and outcomes of CSD. To assist in the treatment decisions regarding on-going wound management. To provide an ideal wound healing environment. To prevent injury and cross infection. To share information regarding the changes to the wound status and further wound care plan. Potential complications Complication Possible reason Action Pain Damage to underlying structures May be due to viable tissue being pulled or cut. Physiological anomalies. Insufficient care taken during the procedure. Insufficient knowledge of underlying structures. Ensure analgesia is given. Stop the procedure. Stop the procedure. Document in the patient notes. Complete Clinical Incident Report. Report to appropriate doctor. Perform corrective measures. Bleeding Sign of viable tissue Stop the procedure and stop the bleeding as per action below. 122, Wound Debridement, Version 11 Page 22 of 33

23 Appendix 3 Procedure for Autolytic debridement ACTION A holistic patient assessment should be carried out prior to dressing selection Discuss the merits of the different debridement options and define treatment objectives. Explain the procedure and identify potential risks, benefits to the patient and carer/next of kin. Obtain informed consent and document in nursing records. See Merseycare Consent to Treatment Policy 2016 for further guidance If patient lacks mental capacity to consent, ensure mental capacity assessment is completed as per Mersey Care Mental Capacity Act Policy 2015 and that it can be demonstrated acting in Best Interests Regular, ongoing and documented review of wound progress RATIONALE To ensure that all other factors that could delay wound healing have been considered and optimised. To ensure that autolytic debridement is the most appropriate method of wound debridement. To ensure that the patient and carer fully understand why the particular treatment has been chosen, what the expected benefits are and what the possible side effects may be. To ensure that the patient is in agreement with the planned treatment. To ensure the clinician is able to provide robust evidence of informed consent and if applicable that mental capacity assessment has taken place to inform acting in Best Interests of patient. To ensure that the chosen method of wound debridement is effective and that the planned goals are being achieved To prompt reassessment of the wound and the patient s potential for wound healing if debridement is not taking place as planned. To allow for changes to the treatment plan and initiation of an alternative method of debridement if appropriate. 122, Wound Debridement, Version 11 Page 23 of 33

24 Appendix 4 Procedure for the use of larval therapy ACTION Patient assessment A holistic patient assessment should be performed and wound assessment Discuss the merits of the different debridement options and define treatment objectives. Explain the procedure and identify potential risks, benefits to the patient and carer/next of kin. Obtain informed consent and document in nursing records. See Mersey Care Consent to Treatment Policy 2016 for further guidance If patient lacks mental capacity to consent, ensure mental capacity assessment is completed as per Mersey Care Mental Capacity Act Policy 2015 and that it can be demonstrated. The patient and carer should be provided with a patient information leaflet produced either by the Trust or by BioMonde, to support the decision making process. Ordering Larval therapy Determine the type and quantity of larvae therapy required (see Free Range calculator BioBag sizes and ordering information below). Sterile larvae can be ordered by telephone, fax or from BioMonde at the address shown at the end of this document for delivery Monday to Saturday. Larvae can be prescribed by Medical and Non Medical Prescribers on FP10. Orders be placed through the community pharmacy* Orders received by 2pm can be delivered the following day. Storing sterile larvae Larvae delivered on Mondays should be used on the day of delivery. Larvae delivered on any other day, if not used, can be stored and used the following day. The expiry date will be the day after delivery except on Mondays when expiry date will be date of delivery. RATIONALE To provide a baseline and ensure that biological debridement is the most appropriate method of wound debridement To ensure that the patient and carer fully understand why the particular treatment has been chosen, what the expected benefits are and what the possible side effects may be. To ensure that the patient is in agreement with the planned treatment. To ensure the clinician is able to provide robust evidence of informed consent and if applicable that mental capacity assessment has taken place to inform acting in Best Interests of patient. NB. There are no major ethical considerations when using maggots. The flies lay eggs on lambs liver, with which the maggots have no contact. To ensure effective debridement BioMonde is the principal supplier of sterile larvae in the UK. When placing an order, provide details of the delivery address, the number of larvae required, the date and time of delivery and the address to which the invoice should be sent. Keeping the larvae stored at the correct temperature prolongs their life and ensures that they are at their most active when applied to the wound. Storage of larvae a too cool a temperature will mean that they may not be as effective when Larvae should be stored between 6-25 C and applied to the wound not in the fridge Contained within each larvae kit Larvae100/ , Wound Debridement, Version 11 Page 24 of 33

25 Vial(s) of larvae Pod of sterile saline Net of choice (flat or boot) Sleek Tape Hydrocolloid dressing Yellow clinical waste bag and tie Application and care guide BioBag BioBag dressing Sudocrem Yellow Clinical Waste Bag and Tie Application and Care Guide All other required consumables must be ordered separately ie. low adherent absorbent dressing (Release or Melolin ), gauze, securing bandages and tape (if applicable), sterile dressing pack, saline (to moisten gauze). * There is a separate ordering procedure for requesting Larvae in Intermediate care units refer to Skin Care Service for details Removal of larvae from a wound Loose Larvae (Larvae100/200) First position a clinical waste disposal bag (yellow bag) under the wound. Depending upon the location and size of the wound, remove the net retention dressing with or without the hydrocolloid frame, and gently remove the larvae with a gloved hand or a pair of forceps. Any larvae that have found their way into the depths of a wound will generally come to the surface if the wound is irrigated with a stream of sterile water or saline. This is to catch any larvae that fall out of the wound. It is generally easier to remove the hydrocolloid and net in one piece. They have to come to the surface to breathe. Larvae will not pupate or turn into flies within a wound and they cannot multiply or breed. If further larvae are to be applied, it does not matter if a few individual larvae are missed, as these will easily be retrieved at the time of the next dressing change by which time they should be fully grown. BioBag Dressings Remove outer absorbent padding then remove BioBag Dressing(s) and place in clinical waste bag. In the event of patient death whilst undergoing maggot therapy 122, Wound Debridement, Version 11 Page 25 of 33

26 If a patient dies unexpectedly during larval therapy, the larvae should be removed from the wound prior to transfer of the patient and disposed of as above This is to respect the dignity of the patient and the sensitivities of the family and/or carers Disposal of maggots removed from wounds Larvae should be place in the yellow clinical waste bag supplied in the pack, tied and boxed in the yellow box supplied. They must As soon as larvae come into contact with tissue or body fluid, they become contaminated. then be disposed of as any other type of dressing residue or clinical waste in accordance with Mersey Care Waste Management Policy (they should not be put in the patient s household waste collection) Reassessment of the wound When all the larvae have been removed, the wound should be reassessed If full debridement has been facilitated, further larvae therapy is normally not required. The wound can then be treated with conventional therapy appropriate to the stage of wound healing. If partial debridement only has occurred then further larvae therapy may be indicated Problem/potential problem Displacement of dressing and/or escape of larvae Production of offensive wound odour Aim/goal/objective To contain larvae at wound site and prevent further escapees To reduce/eliminate wound odour Intervention Ensure each dressing system has been applied in accordance with the treatment guidelines. Re-seal the dressing edges with Sleek tape as required. Retrieve any maggots that have escaped from the dressing and place in a sealed container for disposal. NB. Consider BioBag dressings rather than free-range for areas where securing larvae may be problematic. Change soiled bandages and outer padding as often as necessary 122, Wound Debridement, Version 11 Page 26 of 33

27 Leakage of wound fluid from beneath the dressing Poor viability of larvae To prevent soiling of patients clothes/bed linen. To prevent excoriation of healthy peri-wound skin To ensure the maggots are applied in good condition and maintained in an environment that will allow them to perform optimally Apply adequate absorbent padding. Replace padding and bandaging as often as required. Consider use of skin protectant and a waterproof layer on the bed to protect bed linen. Do not enclose the area/limb in a plastic bag or occlusive dressing as this will lead to suffocation of the larvae. Ensure the maggots are ordered, stored and applied in accordance with the instructions provided by the supplier. Ensure the wound environment is suitable for the maggots i.e. not too dry or too wet. If the wound is extremely wet, it will require more frequent re-padding and the maggots will not require watering. Ensure complete removal of any topical agents from the wound site that may affect maggot survival i.e. hydrogels. If the wound is clinically infected with Pseudomonas species, ensure that clinical infection is treated prior to maggot therapy as maggot therapy will only remove slough and/or necrotic tissue. For free range applications use an extra pot of maggots as Pseudomonas can have a detrimental effect on the growth or survival of the maggots and reduce the effectiveness of the standard treatment. Ensure that the primary net dressing is not totally occluded with tape or a film dressing and that the outer dressings do not become saturated with wound fluid. 122, Wound Debridement, Version 11 Page 27 of 33

28 Young maggots drying out and dying Dark staining to outer dressing Wound starts to reslough when treatment is discontinued To provide a moist environment to ensure maggot survival To determine cause of staining Prevent reoccurrence of slough Moisten the maggots a per guideline. Check condition of dressing 2 3 times daily if the patient is nursed on a low air loss bed as this will dry out the environment. If the wound is covered with hard, eschar it will require re-hydrating prior to maggot application. The maggots cannot penetrate eshcar and will die in dry conditions. Some staining is normal due to breakdown of necrotic tissue by maggot enzymes. Remove outer padding and examine the wound through the net to exclude the possibility that bleeding has occurred. A minimal amount of blood stained exudate is normal, as the maggots will debride down to viable tissue. If the bleeding is frank, fresh or copious, remove the maggots, apply a haemostatic dressing and treat appropriately. If bleeding cannot be stopped, seek medical advice Consider applying multiple applications after wound is cleaned to prevent it re- sloughing and promote granulation. 122, Wound Debridement, Version 11 Page 28 of 33

29 Appendix 5 122, Wound Debridement, Version 11 Page 29 of 33

30 122, Wound Debridement, Version 11 Page 30 of 33