Wound Formulary and Wound Management Guidelines

Transcription

1 Wound Formulary and Wound Management Guidelines 2014 Developed by the NHS Fife Wound and Skin Care Forum (WSCF) Group Approved: February 2014 For review: February 2017

2 Contents Introduction 2-3 Wound definition 4 Comprehensive wound assessment 4 Factors to consider when planning holistic wound care 5 Characteristics of ideal dressings 6 Guide to selection of wound dressings 7 Overgranulation 8 Bacterial burden and management of infection 9-10 Wound cleansing guidelines Monographs for dressings Barrier film 14 Vapour-permeable film 15 Non adherent dressings 16 Low adherence dressings 16 Hydrocolloid dressings 17 Foam dressings 18 Hydrofibre dressings 19 Hydrogel dressings 20 Alginate dressings 21 Deodorising dressings 22 Silicone dressings 23 Super Absorbent Dressings 24 Guidance for use of Specialised dressings and therapies Antimicrobial Dressings 27 Silver containing Dressings 27 Honey Preparations 28 Iodine containing Dressings Antimicrobial Alginate Gel 29 Pain Management Dressings 29 Debridement product 30 Tulle Dressings 30 Larvae Therapy 30 Negative Pressure Wound Therapy 31 Wound Drainage Bags 31 Glossary of wound terms 32 Reading list / Resources Appendix 1 - Woundcare Products Conversion Chart 35 Appendix 2 - Wound Assessment Chart

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

4 Acknowledgements The NHS Fife Wound and Skin Care Forum would like to thank the Glasgow Wound Guidelines Group, for allowing us to use some of their work, particularly in the teaching area of the Fife Guidelines. We would also like to thank Ruth Ropper, Tissue Viability Nurse in Lothian for her permission to use the Ropper Lothian Ladder for wound infection. We would also acknowledge the contribution of both NHS Fife Community Health Partnerships and NHS Fife Acute Services Division staff in the development of these Guidelines. NHS Fife Wound and Skin Care Forum (WSCF) Group Anne Wilson - Tissue Viability Nurse Specialist, AD (Chairperson) Anne Barns - Tissue Viability Co-ordinator, Kirkcaldy and Levenmouth CHP District Charge Nurse, Path House, Kirkcaldy Julia Chalmers - District Charge Nurse, Balmullo Health Centre Lynn Coyne - Plastics Specialist Nurse, AD Katrina Deas - Clinical Practice Development Officer, Cameron Hospital Angela Green - Podiatrist, QMH Carole Herd - Pressure Care Advisor / Tissue Viability Nurse, Benarty Medical Centre Deborah McCallum - Vascular Clinical Nurse Specialist, AD Heather McKellar - Senior Charge Nurse in OPD, Adamson Hospital Moirag Meehan - Plastics Nurse, AD Gillian Meldrum - Podiatrist, QMH David Mitchell - Principal Pharmacist, VHK Liz Mitchell - Lead Nurse, Dunfermline and West Fife CHP Jane Nicoll - Senior Staff Nurse, Tissue Viability, AD Sandra Notman - Practice Pharmacist, Glenrothes & North East Fife CHP Barbara Page - Dermatology Liaison Nurse, QMH Gillian Preston - Senior Staff Nurse, Tissue Viability, AD Susan Roemmele - Staff Nurse, Dermatology Department, QMH Sheila Robertson - Dermatology Liaison Nurse, VHK Ruth Robins - Vascular Clinical Nurse Specialist, AD Yvonne Robson - Plastics Nurse, AD Ann Russell - Staff Nurse, Dermatology Department, VHK Lesley Shiels - Acting Tissue Viability Co-ordinator, Dunfermline and West Fife CHP Mary Thompson Staff Nurse, Emergency Care Directorate Leesa Webster Tissue Viability Co-ordinator, Dunfermline and West Fife CHP 3

5 Wound Definition For the purposes of these guidelines, the following definitions apply - A simple wound is one where there is damage to the epidermal layer of the skin, including discolouration due to pressure damage. A complex /chronic wound is one which heals by granulating from the base up and requires contraction and scar tissue to close. Debridement of slough and necrotic tissue may be necessary. It is important to note that the term chronic suggests longevity; however, many wounds e.g. diabetic foot or rheumatoid lesions may be termed chronic at the onset. A more accurate term for a chronic /complex wound would be a compromised wound. It is the underlying host response to the wound, which will determine to a great extent its ability to heal. Comprehensive Wound Assessment Recognised good practice is to assess a wound using a validated wound assessment chart Compromised wound healing is usually a result of the patients underlying disease processes, ability to initiate an inflammatory response and fight infection. Intrinsic factors must therefore be taken into account whilst planning wound care. Extrinsic factors at the wound bed (slough, necrotic tissue, biochemical and bacterial burden) may inhibit the healing process and wound bed preparation must be carried out to promote proliferation and epithelialisation. The condition of the surrounding skin must be considered when recognising if there are signs of infection, tracking or undermining of the wound. Consideration must be made as to whether adhesive or non-adhesive dressings should be used dependent on the vulnerability of the surrounding skin. Address patient issues to establish if the patient/carer can be empowered to assist in their own wound care. It is important to determine if they have the ability to cope psychologically with the presence of a wound. It is important to recognise the need for adequate pain control / analgesia and this must be reviewed regularly. It is not always possible to heal wounds due to the patients underlying aetiology (e.g. in fungating tumours or advanced disease). In this instance palliative care may be the aim, with management of symptoms in a way that is acceptable to the patient. There should be an awareness in the non-healing compromised wound that further referral to the appropriate specialty may be required, e.g. vascular, dermatology, diabetic or tissue viability. Assessment tools have been developed by the National Association of Tissue Viability Nurses (Scotland) and the Scottish Wound Assessment and Action Guide can be accessed on-line at wound_assessment_action_guide.aspx 4

6 Factors to Consider when Planning Holistic Wound Care Patient Issues (Relating to wound and personal) Pain Exudate Odour Anxiety Intrinsic factors that delay healing Compromised blood flow Diabetes Oedema Poor nutrition Surrounding Skin Redness Maceration Wound Bed Healthy granulation Exposed tendon or bone Dry / Flaky Oedematous Epithelialisation Bacterial Burden Low Self Esteem Poor Mobility Connective tissue disorders Smoking Nodular Fragile Wet / Dry Slough Biochemical imbalance Nutritional Factors which may compromise wound healing Inability to access food Poor economic status Reduced mobility Inability to communicate preference Socially isolated Poor appetite Underlying disease process Medication Depression Difficulty in swallowing Stroke Neuromuscular disorders Underlying malignancy Social Isolation Loss of employment/income Malignancy Alcohol misuse Undermining Tracking Type & Colour of exudate Depth, presence of sinus or fistulae Inability to absorb adequate nutrients Gastro-intestinal disorders Malabsorption syndrome Paralytic ileus Vomiting and diarrhoea Small or large bowel resection Feeling vulnerable Need to be included with their management Drug treatment /radiotherapy Systemic infection Condition of margins Suppleness Necrosis Precise anatomical position Increase metabolic demand Trauma Sepsis Recent surgery 5

7 Characteristics of Ideal Dressings 1. Provide the optimum environment for wound healing - a moist environment - at the wound/dressing interface. 2. Allow gaseous exchange of oxygen, carbon dioxide and water vapour. 3. Provide thermal insulation - wound healing is temperature dependent. 4. Impermeable to micro-organisms (in both directions). 5. Free from particulate contaminants. 6. Non-adherent (many products are described as non-adherent but are low adherent). 7. Safe to use (non-toxic, non-sensitising, non-allergenic). 8. Acceptable to the patient. 9. High absorption characteristics (for exuding wounds). 10. Cost effective. 11. Carrier for medicaments, e.g. antiseptics. 12. Capable of standardisation and evaluation. 13. Provide mechanical protection. 14. Conformable and mouldable (especially over sacrum, heels and elbows). It is generally recognised that modern wound dressings are capable of being left on the wound bed for up to seven days, however this is dependent on exudate levels and whether there is infection present within the wound, therefore check with the instructions given within the box of dressings for further information. Ordering Dressings All dressings listed on the general pages of the Wound Management Guidelines are available on Drug Tariff in suitable sizes and forms with the exceptions of 365 Film (at time of printing). Community practitioners should order dressings on prescription (GP10/GP10N) or via stock order (GP10A) as appropriate. Hospital and Primary Care managed services e.g. NHS Fife treatment rooms, should obtain supplies of wound management products from the Area Distribution Centre, as this is the most cost-effective route of supply. 6

8 Guide to Selection of Wound Dressings Area Drug and Therapeutics Committee Further examples of complex wounds are available on-line as part of the Scottish Wound Assessment and Action Guide (SWAAG). wound_assessment_action_guide.aspx Epithelialising Objectives: Thermal insulation, low adherence, moisture retention. To protect and promote new tissue growth. Choice of dressing Extra thin hydrocolloid for low exudate levels (page 17) Non adherent dressing with absorbent pad or foam dressing for moderate to high exudate levels (page 16, 18) Granulating Sloughy Necrotic Infected Objectives: Fluid absorption, thermal insulation, moisture control. To encourage angiogenesis and promote wound healing. Choice of dressing Superficial or low exudate wound, thin hydrocolloid or non-adherent dressing. (page 16,17 ) Deeper wound or moderate to high exudate levels - hydrofibre dressing or alginate dressing. (page 19,21 ) Secondary dressing non-adherent with pad or foam dressing (page 16,18 ) Objectives : To remove all debris and promote autolysis. Dry slough rehydration and moisture retention. Wet slough fluid absorption Choice of dressing Low exudate / dry slough - hydrogel (page 20) Secondary dressing non-adherent with pad or foam dressing (page 16,18) Moderate to high exudate / wet slough, hydrofibre or alginate dressing with secondary dressing as above (page 19) Objectives: To rehydrate eschar and promote autolysis (debridement) to facilitate healing. Please note that depending on overall aims, it may not be appropriate to break necrosis down, e.g. palliative or vascular wounds. Choice of dressing Hydrogel and non-adherent dressing with pad or foam (page 16, 20) Thin hydrocolloid (page 17) Objectives: To reduce bacterial load in wound. Manage exudate levels, contain odour Choice of dressing Superficial / low exudate levels - antimicrobial impregnated dressing (page 27) Secondary dressing of non-adherent plus pad (page 16) deeper wound / high exudate levels - silver alginate / hydrofibre with absorbent pad (page 27, 19) CarboFlex or Clinisorb if odour present (Page 22) 7

9 N.B. Always assess the condition of the surrounding skin before using adhesive secondary dressings. Overgranulation An essential aspect of secondary intention wound healing is the proliferation of granulation tissue, (McGrath, 2011). Granulation incorporates a dense network of blood vessels and newly growing capillaries with an irregular upper layer created by the capillaries looping together on the wound surface. This is what gives the appearance of red lumps or granules on the wound surface. When granulation over grows beyond the surface of the wound, this is known as overgranulation, or hypergranulation. It is clinically recognised by a soft, fleshy, friable, often shiny appearance which is raised above the level of the surrounding skin. The wound will not continue to heal as the presence of this tissue will prevent the migration of epithelial tissue across the wound bed. The exact cause of overgranulation is unknown, (Russell 2000). It is thought to be the consequence of a reaction to foreign bodies, infection/bio burden, mechanical trauma or allergies and hypersensitivities. The research to date to support treatment options for overgranulation is limited, (McGrath, 2011). Reported treatments attempt to treat the causative factor, and focus on reducing bacteria present, applying pressure, using non occlusive dressings and the use of steroid therapies. It is essential that the clinician can identify the causative factor of the overgranulation, in order to make informed clinical decisions on an effective treatment. A number of treatment options exist, and for this reason, the advice of an appropriate specialist should be sought, e.g. local Tissue Viability Nurse or Plastics Nurse. References McGrath A (2011) Overcoming the challenge of overgranulation. Wounds UK 7(1): Russell L (2000) Understanding physiology of wound healing and how dressings help. British Journal of Nursing 9(1):

10 Bacterial Burden and Management of Infection Area Drug and Therapeutics Committee Bacterial burden and virulence are important factors in assessing the wound for infection. Host resistance is a major determinant in the body s ability to fight infection and initiate an inflammatory response. This may be illustrated in the following equation: Bacterial Burden Continuum Infection = dose x virulence host resistance Bacterial Load Definition Wound Dressing Contaminated Presence of non replicating bacteria in the wound Topical antimicrobial and antibiotics not recommended. Colonised Replicating bacteria adhering to As above. the wound, with no detrimental effect to wound healing Critically colonised Presence of bacteria at the wound bed, which compromises healing but does not result in infection Topical antimicrobial dressings can be used. In general, a two week treatment is advised. If no improvement in wound after this time, seek advice from local wound care specialist Infection Invasion and multiplication of micro-organisms in body tissues with overt host response If there is clinical evidence of invasive infection systemic antibiotics are required. Prescribe systemic antibiotic therapy in conjunction with appropriate dressing. Wound Swabs for Microbiology Wound infection is recognised by the presence of clinical signs of infection rather than the isolation of bacteria from a wound swab. A wound swab should only be taken when there is concern regarding infection. They should not be taken as part of routine practice. Taking a wound swab will give a qualitative picture of bacteria present on the wound surface. These are most commonly colonising bacteria and not responsible for infection. (Refer to Wound Assessment Chart for signs of infection). N.B. Do not confuse signs of inflammation with infection Organisms most commonly associated with soft tissue infections are S.aureus, and Group A, B, C, and G Streptococcus. The clinical presentation should be reviewed alongside the swab result to ensure the most appropriate treatment is prescribed. Swabbing for culture and sensitivity is only recommended before antibiotics are commenced or to confirm that the antibiotics commenced are appropriate. If a patient fails to respond to antibiotics within 72hours, then consider re-swabbing or seek further Medical advice. The cost incurred for each Wound Swab is in excess of 15. 9

11 The wound bed must be cleansed prior to swabbing so as to avoid sampling slough or necrotic tissue that may only reveal surface organisms which are not causing underlying infection. Critically colonised or infected wounds can be treated with antimicrobial dressings but when significant infection is present systemic antibiotics should be commenced. Procedure for taking a Wound Swab Irrigate the wound with Sodium Chloride 0.9% solution. Swab the edge of the wound adjacent to the good tissue which is inflamed. It is the organism infecting the good tissue which will be the major pathogen. This would normally tend to be nearer the edge of the wound as the tissue in the centre is more often necrotic. The swab should be rotated between the fingers to ensure that all sides of the swab make contact with the wound. Infected wound below, swab area as directed by arrows Example of most Suitable areas to swab 10

12 Wound Cleansing Guidelines Area Drug and Therapeutics Committee To Clean or Not To Clean? There is no single correct way to clean a wound or the surrounding skin, although there are a number of important considerations Does the wound really need cleansing? What is the safest method that causes no ill effect and maintains the wound temperature? What is acceptable to the patient? Simple wound cleansing procedure (e.g. suture lines, superficial breaks) Gentle skin washing with warm tap water (e.g. showering). A minimalist approach is recommended to reduce interference at the wound bed. Dry surrounding skin with non woven gauze to allow adherence of wound dressing. Compromised / complex wound cleansing procedure Aims: Remove excess exudate, debris or old dressing materials. Minimize pain and trauma. Prevent infection. Procedure 1 Explain procedure and rationale to patient. 2 Wash hands thoroughly as per hand hygiene policy prior to and following procedure. 3 Dressing packs are not always necessary. 4 Requirements: non woven swabs, clean surface, non-sterile gloves. 5 Remove dressing as per manufacturer s instructions. 6 Assess wound type and carry out appropriate irrigation procedure (see pages 11 and 12). 7 Dry surrounding area with non woven swabs. 8 Do not touch surface of wound with swabs. 9 Apply new dressing. See also Fife Wound Care Policy W7 accessed via 717D C6F-C07ADBCEF2FC

13 Wound Cleansing Guidelines Area Drug and Therapeutics Committee Preparation Procedure Rationale With tap water Gentle showering of wound area during Run shower for three minutes. Ensures free flowing warm clean water. routine social hygiene Gently irrigate wound with warm water using shower head. Ensures safe removal of exudate, loose slough and wound dressing residue. In healthcare premises, shower should be cleaned with general Maintains clean working environment. purpose neutral detergent/cream cleanser before and after use. In the home care setting patients own household cleaner should be used to clean the shower and/or bath before and after the procedure. Refer to Infection Control Manual. Bucket lined with polythene bag for lower limbs Infection Control Manual can be accessed via: Gently wash limb. Dry skin surrounding wound prior to application of new dressing. Avoid direct contact with wound bed. In healthcare premises, bucket should be cleaned with general purpose neutral detergent and warm water, rinsed and dried. Buckets should be stored dry and inverted. Patients own household cleaner should be used in home care setting. Refer to Infection Control Manual. Intranet / Subjects / Infection Control / Infection Control Manual C03F5A9FA592A31A&subjectid=6C965E0A-DB7D-B17A-04E54EAC6A42E839&objectid=6BE801F C6F-C0E12BB07758F462 Ensures safe removal of exudate, loose slough and wound dressing residue. It incorporates social hygiene into wound management procedure. Maintains clean working environment. 12

14 Warm Sodium Chloride 0.9% solution pods by running under hot water Does not require alcohol swab to wipe pod prior to use Available on prescription Area Drug and Therapeutics Committee With Sodium Chloride 0.9% Solution - Hospital = Miniversol 45ml / Primary Care = Irripod Irrigate wound area with Sodium Chloride 0.9% solution to remove surface exudate and loose slough or dressing residue. If slough is not easily removed by irrigation, further hydration with wound dressing products will be necessary. With Prontosan 40ml / 350ml FOR COMPROMISED WOUNDS ONLY Use soak of Prontosan Solution with gauze swabs for 10 minutes at dressing change, then discard. To maintain optimum temperature for healing. Deeper cleansing of wound and biofilm removal Drug Tariff Cost - Feb 2014 (Each) Irripod 20ml (25) 23p Prontosan 40ml (24) 350ml 58p 4.71 N.B. Prontosan is for use in chronic or infected wounds only. 13

15 Monographs for Dressings Barrier Film Cavilon No Sting Barrier Film/ Secura Cavilon Cream Description Cavilon No Sting Barrier Film provides long lasting skin protection for up to 72 hours. Cavilon Cream provides long lasting protection from bodily fluids whilst moisturising the skin. Secura is for use as a topical barrier between the skin and adhesives e.g. around peri-wound areas. Indications Intended to be used as a primary barrier against irritation from bodily fluids e.g. from urine and/or faeces. The no sting film acts as a protective barrier against adhesive wound dressings and surgical tapes, provides peri-wound protection from exudate damage and provides protection from damage caused by friction and shear. The barrier cream acts as a moisturiser for severely dry skin and as a protection for skin damage associated with incontinence. Method of Use Both film and cream should be applied to clean, dry skin. Cavilon film should be applied in a uniform coating over the entire treatment area when using the foam applicator. If using the spray, hold the nozzle 10-15cm from the treatment area and apply a smooth, even coat. Allow to dry before applying any adhesive dressings or surgical tapes. Reapply at least every hrs (or more frequently if required) Cavilon Cream should be applied in small amounts, gently smoothing into the skin over the affected area. N.B. If the after feel of the skin is oily, then too much has been applied. Cavilon No Sting Barrier Film 1ml foam applicator (5) 3ml foam applicator (5) 28ml spray bottle (1) Cavilon Cream 2g sachet (20) 28g tube (1) 92g tube (1) Secura 1ml foam applicator (5) 3ml foam applicator (5) 28ml spray bottle (1) Drug Tariff Cost Feb 2014 (Each)

16 Vapour-permeable Adhesive Film Hospital/ Managed Service : 365 Film Primary Care : Tegaderm Film Description A sterile, transparent semi-permeable adhesive film. Permits visual inspection of the wound at all times and allows water to pass through from the skin as moisture vapour. Indications Provides a moist environment and allows the passage of oxygen but not of micro organisms. May be used on superficial epithelialising wounds, and to protect sites which are liable to break down due to friction or moisture. It can be used as a secondary dressing for other products. Method Of Use Use an appropriate size film to provide a 4cm margin in all directions around the edges of the wound to ensure good adhesion. The wound site should be checked daily. If no leakage occurs, the dressing can be left undisturbed for up to seven days. Care should be taken on removal, stretching the dressing to break the adhesive without lifting the skin. N.B. Water vapour loss may occur at a slower rate than exudate is generated, therefore fluid accumulates under the dressing, which can lead to tissue maceration and wrinkling at adhesive contact site. Drug Tariff Cost Feb 2014 (Each) 365 Film 6cm x 7cm (100) 10cm x 12cm (50) Not drug tariff item Hospital/Managed service order only 15cm x 20 cm (30) Tegaderm Film* 6cm x 7cm (100) 12cm x 12cm (10) 15cm x 20cm (10) *Tegaderm Film is for community use only as 365 Film is not available on prescription or on stock orders placed via community pharmacy. 15

17 Non-adherent Dressings N-A Ultra Description A primary wound contact layer consisting of a knitted viscose rayon sheet. Indications Provides moisture retention or rehydration, thermal insulation and low-adherence. A secondary dressing is required to dress more heavily exuding wounds. Method Of Use Apply directly to the wound surface. Bandages or tape are required to retain dressing. Secondary dressings can be changed independently leaving N-A Ultra in position for up to seven days. N-A Ultra 9.5cm x 9.5cm (40) 9.5cm x 19cm (25) Drug Tariff Price Feb 2014 (Each) Low Adherence Dressings Premierpore Description An adhesive absorbent island dressing. A one way stretch non-woven dressing with a latex free SIS acrylic adhesive that provides soft, secure fixation. The wound pad is covered with a low adherence film to enable easy removal. Indications It can be used on wounds with low to moderate exudate levels, including post operative wounds. Can also be used as a secondary dressing with hydrogels, hydrofibres and alginates. Also for use as a primary dressing for clean wounds and where protection is required from fluid, dirt and bacteria. N.B. There is a possibility of skin irritation in some individuals. Method Of Use Apply directly to the wound area. Ensure the skin surrounding the wound is clean and dry. The adhesive will adhere well once warmth of the skin is in contact with the dressing. Dressing Size (Pack size) Drug Tariff Price Feb 2014 Premierpore 5cm x 7cm (50) cm x 10cm (50) 10cm x 15cm (50) 10cm x 20cm (50) 10cm x 25cm (50) 10cm x 30cm (50) 10cm x 35cm (50)

18 Hydrocolloid Dressings Area Drug and Therapeutics Committee First choice : Comfeel Plus Transparent Second choice : Duoderm Extra Thin Description A hydrocolloid dressing is a micro granular suspension of various natural or synthetic polymers, e.g. gelatin or pectin, in an adhesive matrix. The dressings are interactive with wound exudate - by slowly absorbing fluid. They physically change to form a gel, which may be cohesive, and/or hydrophilic. Indications Aids debridement in wounds covered with black necrotic tissue, suitable for softening eschar and promoting granulation. Suitable for low to moderately exuding wounds. May also be used prophylactically on areas prone to breakdown and as a secondary dressing. Method Of Use Apply dressing of sufficient size to provide at least 2cm overlap onto intact skin. Smooth dressing into place - warmth of the hand improves initial adhesion. For best results aim to leave dressing in place for at least 3 days. Dressings may be left in place for up to 7 days. N.B. Owing to the occlusive nature of their backing hydrocolloids are not considered suitable for the treatment of clinically infected or very heavily exuding wounds. Comfeel Plus Transparent 5cm x 7cm (10) 5cm x 25cm (5) 9cm x 14cm (10) 10cm x 10cm (10) 15cm x 15cm (10) 20cm x 20cm (5) Duoderm Extra Thin 5cm x 10cm (10) 7.5cm x 7.5cm (5) 9cm x 15cm (10) 9cm x 25cm (10) 9cm x 35cm (10) 10cm x 10cm (10) 15cm x 15cm (10) Drug Tariff Price Feb 2014 (Each)

19 Foam Dressings First choice: Biatain / Biatain Adhesive Moderately exudating wounds First choice: Tielle Plus/ Tielle Xtra - Highly exudating wounds First choice: Tegaderm Foam Adhesive - Heel only Description Foam dressings in general provide thermal insulation, do not shed fibres or particles and can be cut or shaped to fit the wound (non-adhesive). They help to maintain a moist environment at the surface of the wound and are gas permeable and non adherent. Should be used on moderate to highly exuding wounds. Biatain / Biatain Adhesive For use in moderately exuding wounds. Can be used on clean granulating wounds or as a secondary dressing in sloughy or necrotic wounds. Adhesive version is beneficial for patients wishing to bathe or shower. Dressing should be renewed when exudate has reached within 1cm of the edges of the dressing. The dressing may be left in place for 3-7 days depending on the level of exudate. Tielle Plus / Tielle Xtra A hydropolymer foam dressing for use in heavily exuding wounds, with fluid locking technology to reduce the risk of leakage. Has a vapour-permeable film backing. Can be used under compression. Contraindications Third degree burns or wounds with active vasculitis. Biatain 5cm x 7cm (10) 10cm x 10cm (10) 10cm x 20cm (5) 15cm x 15cm (5) 20cm x 20cm (5) Biatain Adhesive 7.5cm x 7.5cm (10) 10cm x 10cm (10) 12.5cm x 12.5cm (10) 15cm x 15cm (5) 18cm x 18cm (5) 18cm x 28cm (5) Tielle Plus 11cm x 11cm (10) 15cm x 15cm (10) 15cm x 20cm (5) Tielle Xtra 11cm x 11cm (10) 15cm x 15cm (10) Tegaderm Foam Adhesive - heel dressing only Drug Tariff Price Feb 2014 (Each) cm x 20cm (5) 13.9cm x 13.9cm (5)

20 Hydrofibre Dressings Aquacel Extra/ Aquacel Description A soft, non woven pad composed of hydrocolloid fibres. This interacts with wound exudate and forms a soft gel which is easy to remove with little or no damage to healing tissue. Indications Used in the management of moderate to heavily exuding wounds. Can be used in acute and chronic wounds, e.g. abrasions, lacerations, leg ulcers, pressure sores. Infection is not a contraindication to use. Method Of Use Apply directly to the wound surface. Irrigation facilitates removal. Secondary dressing is required. May be left in place for up to seven days - depending on the level of exudate. NB If packing a wound with Aquacel Extra, always leave a small piece outside of the wound to facilitate removal. Also record the number of pieces of used. (See wound chart). Aquacel Extra 5cm x 5cm (10) 10cm x 10cm (10) 15cm x 15cm (5) Aquacel 1cm x 45cm Ribbon (5) 2cm x 45cm Ribbon (5) Drug Tariff Cost Feb 2014 (Each) Hydrofibre Foam Dressing Aquacel Foam Aquacel foam dressings have a soft absorbent pad, an aquacel contact layer, a gentle silicone adhesive and a waterproof/ bacteria barrier. It can be used on a variety of moderate to heavily exuding wounds. Aquacel Foam Non Adhesive 5cm x 5cm (10) 10cm x 10cm (10) 15cm x 15cm (5) 15cm x 20cm (5) 20cm x 20cm (5) Aquacel Foam Adhesive 8cm x 8 cm (10) 10cm x 10cm (10) 12.5cm x 12.5cm (10) 17.5cm x 17.5cm (10) 21cm x 21cm (5) 25cm x 30cm (5) Drug Tariff Cost Feb 2014 (Each)

21 Hydrogel Dressings First choice : Purilon Second choice : ActivHeal Hydrogel Description An amorphous gel with high water content, containing Calcium Alginate (Purilon ) or a collection of water insoluble polymer chains (ActivHeal Hydrogel). Indications Hydrogels facilitate autolysis by rehydrating necrotic tissue and effecting debridement. They provide a moist environment which promotes healing. They are non-adherent and do not harm viable tissue or surrounding skin. Bacterial colonisation of the wound is not a contraindication to the use of a hydrogel. Method Of Use Apply the gel directly into the wound. A secondary moisture - retentive dressing is required e.g. Hydrogel should be changed when the cover dressing leaks. Intervals should not exceed 3 days when used on sloughy or necrotic wounds or 7 days if used on clean granulating wounds. N.B. When using in cavity wounds only half fill the cavity. Due to the effective debridement of necrotic tissue, a wound being treated with gel may appear larger at first dressing change, however, this is a natural step in the healing process. Drug Tariff Price- Feb 2014 (Each) Purilon Sterile 8g tube (10) Sterile 15g tube (10) ActivHeal Hydrogel Sterile 15g tube (10)* 1.41 * 8g tube available but more cost-effective to use the 15g tube. 20

22 Alginate Dressings First choice : Tegaderm Alginate Second choice : Kaltostat Description The basic elements of alginates are extracted from brown seaweed (Phaeophyceae). Their clinical composition means that they are highly absorbent and biodegradeable. Alginates vary in composition (calcium/sodium salts of alginic acid) and in the arrangement of fibres. Indications Alginate dressings are suitable for moderate to heavily exuding wounds. They form a gel on contact with the wound exudate, and are effective at absorbing exudate, debriding slough and encouraging granulation tissue. Where bleeding is involved, Kaltostat may be considered as a haemostatic agent. Method Of Use Apply to the wound surface/cavity, secondary dressing required to secure. Frequency of change will depend on level of exudate. Tegaderm Alginate 5cm x 5cm (10) 10cm x 10cm (10) Kaltostat 5cm x 5cm (10) 7.5cm x 12cm (10) 10cm x 20cm (10) 15cm x 25cm (10) Drug Tariff Price Feb 2014 (Each)

23 Deodourising Dressings Clinisorb First choice : Clinisorb Second choice : CarboFlex Description Clinisorb is an activated charcoal cloth dressing, produced by carbonising and activating woven viscose rayon that is sandwiched between two layers of a nylon and viscose rayon blend. Clinisorb has the optimum combination of microporous activity and activated charcoal cloth weight, for significantly reducing odour by attracting and permanently trapping bacteria. It is non-adhesive and contained in a sterile peel pack. Indications Clinisorb can be used to manage malodourous wounds such as fungating breast lesions, pressure ulcers, leg ulcers and diabetic foot ulcers. Method Of Use Clinisorb can be used as a primary or secondary dressing and its soft, flexible construction can be cut to fit practically any wound. Even unusually shaped fungating wounds on curved body sites can be easily dressed. Clinisorb is highly effective wet or dry, can be used either side down, and can be left in place for up to one week. CarboFlex Description A sterile non-adhesive dressing consisting of five layers - film layer, absorbent padding, activated charcoal cloth, film layer and absorbent wound contact layer containing Kaltostat and Aquacel. Indications For use in the management of malodourous acute and chronic wounds. May be used as a primary dressing for shallow wounds or as a secondary dressing over wound fillers with deeper wounds. Method Of Use This dressing must not be cut to size or shape. The fibrous surface is placed directly on to the wound. This may be left undisturbed for up to three days depending on the level of exudate. Clinisorb 10cm x 10cm (10) 10cm x 20cm (10) 15cm x 25cm (10) CarboFlex 8cm x 15cm Oval (5) 10cm x 10cm (10) 15cm x 20cm (5) Drug Tariff Price Feb 2014 (Each)

24 Silicone Dressings Mepitel / Mepitel One Description A sterile transparent soft silicone wound contact layer, which is non adherent to a moist wound bed. Indications For use in a wide range of painful, chronic and traumatic wounds and wounds with compromised or fragile surrounding skin. The soft silicone adheres gently to the surrounding skin and ensures removal with minimal trauma and pain. Mepitel prevents the outer dressing sticking to the wound. The porous structure of Mepitel allows exudate to pass to an outer absorbent dressing. Method Of Use Apply directly to the wound or wound bed. It can be cut to size or shape of wound if desired. Requires a secondary dressing which can be changed independently as the Mepitel can remain in place for up to 10 days. Mepitel One may offer advantages when primary dressings are required to stay in place for longer periods, since it is adhesive on one surface only. Mepitel 5cm x 7cm (5) 8cm x 10cm (5) 12cm x 15cm (5) 20cm x 32cm (5) Mepitel One 6cm x 7cm (5) 9cm x 10cm (5) 13cm x 15cm (5) 24cm x 27.5cm (5) Drug Tariff Price Feb 2014 (Each) Mepilex / Mepilex Border Indications Designed for a wide range of moderate to highly exuding wounds e.g. leg, foot and pressure ulcers, traumatic wounds and secondary healing wounds. Suitable for use in combination with gels. Method of Use Overlap dry surrounding skin by at least 2cm. Do not stretch. If required, Mepilex can be cut. Can be left in place for several days depending on condition of wound and surrounding skin. Mepilex 5cm x 5cm (5) 10cm x 11cm (5) 11cm x 20cm (5) 15cm x 16cm (5) 20cm x 21cm (5) 20cm x 50cm (2) Mepilex Border 7cm x 7.5cm (5) 10cm x 12.5cm (5) 10cm x 20cm (5) Drug Tariff Price Feb 2014 (Each)

25 Mepilex Border Sacrum Area Drug and Therapeutics Committee 10cm x 30cm (5) 15cm x 17.5cm (5) 17cm x 20cm (5) 15cm x 15cm (5) 18cm x 18cm (5) 23cm x 23cm (5) Super Absorbent Dressings KerraMaxCare Description Primary or secondary dressing for medium to heavily exuding wounds. Exudate and MMPS are absorbed and bound inside the dressing with no leakage. May be used under moderate compression bandaging. Soft, conformable and stackable. Indications Management of moderate to heavily exuding wounds. Eclypse Description Super absorbent secondary dressing. Indications Moderate to heavily exuding wounds. KerraMaxCare 10cm x 10cm (10) 10cm x 22cm (10) 20cm x 22cm (10) 20cm x 30cm (5) Eclypse 10cm x 10cm (20) 15cm x 15cm (20) 20cm x 30cm (20) 60cm x 40cm (10) Drug Tariff Cost Feb 2014 (Each)

26 Specialised Dressings & Therapies Initiation of these products should be on the advice of the local Tissue Viability service (Acute Division Only) or relevant specialist nurse and follow local policies for use. Antimicrobial Dressings Antimicrobials are agents which kill or inhibit the growth and division of micro-organisms. Commonly used in wound management are honey, iodine and silver. There is no robust clinical evidence that dressings containing antimicrobials (e.g. silver, iodine or honey) are more effective than unmedicated dressings for the prevention of wound infections. Indiscriminate use of topical antimicrobial dressings should also be discouraged because of concerns over bacterial resistance and toxicity. You may be asked by your local pharmacist, GP Practice or Wound Specialist Nurse to give a rationale for using these products. Please use the following tips to aid your selection. 10 top tips when using Antimicrobial Dressings General points Is the wound clinically infected o Check for signs of infection o Don t confuse normal signs of inflammation with infection Systemic antibiotics are indicated in cases of overt wound infection where classical signs are evident Check the correct antimicrobial is chosen according to the wound exudate levels If no improvement in wound after two weeks, review wound and antimicrobial choice Check cautions as stated in manufacturer instructions, and BNF when using antimicrobial preparations. Please see Ropper Lothian Ladder on next page for further guidance Silver dressings Some silver products oxidise in contact with air and this may be displayed as a brown/black discolouration on the wound bed and/or surrounding skin Honey products Patients may experience pain due to osmotic effects of dressing on wound (e.g. drawing sensation ). Monitor pain levels, consider simple analgesia and only remove if the dressing is not tolerated. Wound exudate may increase when using honey ointments and therefore use an appropriate absorbent secondary dressing. Iodine preparations These products are rapidly deactivated by wound exudate therefore consider other antimicrobials for moderate highly exudating wounds All iodine products change from orange/brown to white when iodine is inactive/ used up. 25

27 The Adapted Ropper Lothian Ladder Guidelines for identifying infected wounds and when to start & stop using topical antimicrobial dressings Each stage builds on the previous signs noted Stage 4: Overt signs of local infection and signs of systemic infection: may lead to sepsis if not treated Spreading cellulitis Pus/abscess Patient systemically unwell e.g. confusion Pyrexia Raised white cell count/crp Malodour of wound Stage 3: Overt signs of local infection: evidence of surrounding tissue involvement, wound deteriorating Localised cellulitis Discoloured or bleeding granulation tissue Pain in or around wound Exudate: thick, haemopurulent or purulent and/or high volumes Localised oedema Malodour Stage 2: Increasing signs of infection (Critical colonisation): healing not progressing normally Exudate high volumes Malodour Pain in or around wound Discolouration of granulation tissue Slough/Necrosis Stage 1: Few subtle signs: healing progressing normally Exudate low to moderate volume Pain minimal Odour minimal Slough/necrosis minimal Stage 4 Treatment If systemic signs only, consider other source of infection Swab wound using standardised method Consider taking blood cultures prior to starting antibiotics Start broad spectrum systemic antibiotics* while awaiting culture results Consider combination therapy with topical antimicrobials** e.g. in PVD, diabetes Monitor wound progress, review wound at 2 weeks and stop topical antimicrobials when signs of infection cease Once topical antimicrobial stopped continue with correct dressing regime for wound/tissue type Stage 3 Treatment Swab wound using standardized method Drain any local collections of pus/fluid Consider combination therapy with broad spectrum systemic antibiotics* and topical antimicrobials** Monitor wound progress, review wound at 2 weeks and stop topical antimicrobials when signs of infection cease Once topical antimicrobial stopped continue with correct dressing regime for wound/tissue type If no progress after two weeks and/or signs of systemic infection move to Stage 4 Stage 2 Treatment Select topical antimicrobial** Monitor wound progress, review wound 1-2 weeks If no improvement: i. Consider swabbing wound using standardised method ii. Consider alternative topical antimicrobial** If improved stop topical antimicrobials when signs of infection cease Once topical antimicrobial stopped continue with correct dressing regime for wound/tissue type If no progress after two weeks and/or increasing signs of systemic infection move to Stage 3 Stage 1 Treatment Promote moist wound healing using correct dressing regime for wound/tissue type & exudate level Monitor wound progress, if no improvement in 1-2 weeks reassess wound and dressing choice Check underlying aetiology of wound, if required refer to appropriate specialist e.g. vascular, diabetic podiatry, tissue viability, lymphoedema etc. If no progress after a further 1-2 weeks and/or increasing signs of infection/critical colonisation move to Stage 2 START This guidance should be used along with clinical judgement in complex patients; in particular patients with diabetic wounds, vascular problems and immuno compromised patients may require topical antimicrobials for prophylaxis as well as treatment. *Systemic Antibiotics Follow NHS Fife Antibiotic Guidance for the Treatment of Community Managed Infections Sept **Topical Antimicrobial NHS Fife Joint Wound Formulary Topical antimicrobials can include honey, iodine, silver, PHMB, DACC and enzymatic products. Contact TVN team for more info if required. References: European Wound Management Association (2005) Position Document: Identifying criteria for wound infection, MEP, London European Wound Management Association (2006) Position Document: Management of wound infection, MEP, London Best Practice Statement: Use of topical antiseptic/antimicrobial agents in wound management, Wounds UK, Aberdeen (2010) Good Practice Recommendation for Antimicrobial Use in Frail Elderly Adapted and reproduced with permission of R. Ropper, TVN CNS NHS Lothian

28 Specialised Dressings & Therapies Silver Containing Dressings First choice : Melgisorb Ag Second choice : Askina Calgitrol Ag Area Drug and Therapeutics Committee Initiation of these products should be on the advice of the local Tissue Viability service (Acute Division only) or relevant specialist nurse and follow local policies for use. Melgisorb Ag A highly absorbent antimicrobial alginate dressing. It is indicated for the management of infected, highly exuding wounds, and can be used under compression bandaging. As the dressing contains alginate, it may support the control of minor bleeding in superficial wounds. It can be left in place for up to 7 days. Askina Calgitrol Ag A layer of silver alginate matrix. This forms a soft gel when in contact with exudate. For infected or critically colonised wounds. Melgisorb Ag 5cm x 5cm (10) 10cm x 10cm (10) 15cm x 15cm (10) 3cm x 44cm Ribbon (10) Askina Calgitrol Ag 10cm x 10cm (10) 15cm x 15cm (10) 20cm x 20cm (10) Drug Tariff Cost Feb 14 (Each) Antimicrobial Dressings Cutimed Sorbact Cutimed Sorbact dressings are coated with a fatty acid derivative (DACC) which give them highly hydrophobic properties. In the moist environment of an infected wound, bacteria are attracted to the dressing and become bound to it. The bacteria cannot multiply and are removed with the dressing. N.B. Using the dressing in combination with cream/ointments impairs the effect of the DACC. Cutimed Sorbact Ribbon Cutimed Sorbact Swab 2cm x 50cm (20) 5cm x 200cm (10) 4cm x 6cm (unfolded 11cm x 16cm) (5) 7cm x 9cm (unfolded 17cm x 27cm) (5) Drug Tariff Cost Feb 2014 (Each)

29 Honey Preparations Area Drug and Therapeutics Committee Initiation of these products should be on the advice of the local Tissue Viability service (Acute Division only) or relevant specialist nurse and follow local policies for use. Honey provides a moist healing environment with antibacterial and deodorizing properties as well as autolytic and osmotic debriding actions. It can be used on a variety of acute and chronic wounds. Medihoney Products For use in acute and chronic wounds: leg/foot ulcers, pressure ulcers, sloughy wounds, necrotic wounds, infected wounds, malodorous wounds, donor and recipient graft sites, and burns, diabetic wounds and surgical wounds. Activon Products Activon (ointment) is ideal for debriding necrotic tissue. Ideal for topping up dressings where the honey has washed away or for using directly into cavities. Can be washed out using normal saline solution. Actilite Actilite is a light viscose net dressing coated with antibacterial Manuka honey & Manuka oil. The dressing is designed to protect a wound, promote healing and allow the passage of exudate. The antibacterial effect of Actilite has been enhanced by combining high grade antibacterial Manuka oil with Manuka honey. The combination of Manuka honey and Manuka oil has been demonstrated invitro to be effective against a number of major wound infecting organisms including MRSA and VRE. Medihoney Antibacterial Honey Apinate Medihoney Tulle Activon Medical Grade Manuka Honey Actilite Drug Tariff Cost - Feb 2014 (Each) 5cm x 5cm (10) cm x 10cm (5) cm x 10cm (5) g tube (12) cm x 5cm 10cm x 10cm (10) 10cm x 20cm (10) Iodine Dressings CAUTION : Care must be taken when these dressings are used with Thyroid and Renal patients!!! Inadine A sterile low-adherent fabric dressing impregnated with 10% povidone iodine in a water soluble slow release base. Povidone iodine is a potent antibacterial agent with a broad spectrum of activity It is used as a primary wound dressing providing prophylactic treatment against infections in superficial wounds and minor skin injuries. The dressing should be changed daily or when the orange/ brown colour turns to white. lodoflex 28

30 Iodoflex is a sterile Cadexomer Iodine paste containing Iodine in an inert base. The sachet consists of the paste sandwiched in protective gauze. Used for the topical treatment of a variety of chronic and acute wounds. When applied to the wound lodoflex cleans and reduces' bacteria at the wound surface and is particularly useful in highly exuding wounds. Remove the protective gauze on both sides of the paste, lodoflex can then be moulded into shape and applied to the wound surface. An appropriate secondary dressing can then be applied. The dressing should be changed every 72 hours. N.B. Maximum single application is 50g; weekly maximum must not exceed 150g; treatment duration should not exceed three months. Inadine 5cm x 5cm (25) 9.5cm x 9.5cm (10) Iodoflex 5g (5) 10g (3) 17g (2) Drug Tariff Cost Feb 2014 (Each) 33p 49p Antimicrobial Alginate Gel Flaminal Flaminal is an antimicrobial alginate gel, indicated for a variety of wounds. It maintains a moist wound environment, helps debride and restore bacterial balance. It comes in two preparations, Flaminal Forte for medium to heavily exuding wounds, and Flaminal Hydro for low to moderately exuding wounds. Flaminal Forte 15g (5) 50g (5) Flaminal Hydro 15g (5) 50g (5) Drug Tariff Cost Feb 14 (Each) N.B. Flaminal preparations are intended for single patient use, but can be used for multiple applications on the same patient, as this will make the product more cost effective. Pain Management Dressing ActiFormCool A transparent, non-adhesive high water content hydrogel, formed around a supporting blue polyethylene matrix. It can be particularly useful for painful wounds, e.g. leg ulcers and diabetic ulcers. ActiFormCool 5cm x 6.5cm (5) 10cm x 10cm (5) 10cm x 15cm (5) 20cm x 20cm (5) Drug Tariff Cost Feb 2014 (Each)

31 Debridement Product Debrisoft pad Debrisoft consists of soft, polyester fibres which are secured and knitted together. These fibres are cut at a special angle, length and thickness to ensure good effect and flexibility. The pad comes in a 10cm x 10cm size and is used to remove slough and other debris from the wound bed to aid debridement. It can be used on sloughy leg ulcers and surrounding skin to remove debris. Drug Tariff Cost Feb 2014 (Each) Debrisoft pad 10cm x 10cm (5) 6.27 Tulle Dressings Physiotulle A knitted polyester net impregnated with hydrocolloid particles suspended in petroleum. Indicated for the treatment of acute and chronic wounds following wound cleansing and until healing. Physiotulle 10cm x 10cm (10) 15cm x 20cm (10) Drug Tariff Cost Feb 2014 (Each) Larvae Therapy Larvae reduce or eliminate odour and combat infection by ingesting and killing bacteria. Sterile larvae of the common green-bottle Lucilia Sericata are used to treat most types of sloughy, infected or necrotic wounds. They may also reduce wound pain and stimulate the formation of granulation tissue. Larvae therapy is available on a GP10 prescription. Refer to local policy. BioBag Dressing 2.5cm x 4cm (1) 5cm x 6cm (1) 10cm x 10cm (1) Drug Tariff Cost Feb 2014 (Each)

32 Negative Pressure Wound Therapy (NPWT) Negative Pressure Wound Therapy (NPWT) is a treatment used across the wound through a dressing positioned in the wound cavity or over a flap or graft. Excess fluid is collected in a disposable canister. NPWT helps to reduce oedema, increase blood supply and decrease bacterial colonisation. It has proven to be effective with acute surgical wounds, pressure ulcers, chronic wounds, including diabetic feet, and skin grafts. Patients may be discharged from the Acute Services Division into Community with NPWT in situ. Community staff should consult local policy, as permission must be granted from the Lead Nurse for hire of unit and dressings. From February 2014, the NPWT pumps used (KCI) will be free of charge. Dressings and canisters are available on drug tariff. All pumps once discontinued must be returned to the Acute services Division. (Ward 52). PICO (Disposable NPWT system) A disposable and portable system designed to kick start wound healing. It can be used on both acute and chronic wounds, diabetic or pressure ulcers, flaps and grafts and surgically closed incision sites. The pack contains one PICO device and two PICO dressings. Advice should be sought from the local tissue viability nurse before using. Contraindications Contraindicated in the presence of: malignancy in the wound bed or wound margins (except in palliative care to enhance quality of life). PICO 10cm x 20cm (1) 10cm x 30cm (1) 10cm x 40cm (1) 15cm x 15cm (1) 15cm x 20cm (1) 15cm x 30cm (1) 20cm x 20cm (1) 25cm x 25cm (1) Drug Tariff Cost Feb 2014 (Each) Wound Drainage Bag Wound drainage bags have a central hydrocolloid island that can be cut and shaped to fit the wound. They are particularly useful in large abdominal wounds with high levels of exudate, where conventional dressings would need to be changed more than twice daily. Biotrol Draina S Fistula Mini (30) Medium (20) Large (20) Eakin Wound Pouches Small (10) (various closures) Medium (10) Large (10) Extra Large (5) Other sizes/styles are available, contact companies directly for sizes and prices. 31 Drug Tariff Cost Feb 2014 (Each) From 4.52 From 6.58 From 8.60 From 15.17

33 Glossary of Wound Terms Angiogenesis Autolysis Biofilm Cellulitis Colonisation Contraction Debridement Epithelialisation Eschar Granulation Healing by first intention Healing by secondary intention Healing by third intention Hypergranulation Infection Maceration Necrosis Slough Area Drug and Therapeutics Committee Generation of new blood vessels initially seen at the base of a wound. Breakdown of devitalised tissue by leucocytes. A thin but robust layer of mucilage adhering to a solid surface and containing a community of bacteria and other organisms. A spreading non-suppurative infection of the soft tissue. Multiplication of micro-organisms without a corresponding host reaction. Function of the healing process in granulating wounds whereby the edges of the wound are drawn towards each other. Removal of devitalised tissue and foreign matter from a wound. Final stage of the proliferative phase. Scab consisting of dried serum and devitalised dermal cells. Formulation of new tissue filling the defect which takes place during the proliferative phase of healing. The name is derived from the fact that the buds of new tissue take on the appearance of small granules. Also called Primary Intention. Wounds are closed leaving a minimal defect. Wound left open and allowed to heal by granulation. Also called Tertiary intention, or delayed closure. Wound left open often to assist drainage and closed surgically at a later date. Granulation tissue is raised above the peri-wound area. Micro-organisms present and multiplying, producing an associated host reaction. Reaction may take various forms. Softening or sogginess of the tissue owing to retention of excessive moisture. Local death of tissue. Tissue is often black/brown in colour and leathery in texture. Devitalised tissue which has yellow/white/grey hue. 32

34 Reading List Area Drug and Therapeutics Committee Cooper R (2009) Biofilms: hard to detect, easy to under estimate, but most definitely here to stay. Wounds UK. 9 (1) p.12. Dow G (2003) Bacterial swabs and the chronic wound: When, how and what do they mean. Ostomy Wound Management. 49; 5A supplement: p Drugs and Therapeutic bulletin (2010) Silver dressings - do they work? Dtb.bmj.com. p European Wound Management Association (2004) Position Document Wound bed preparation in practice. London: MEP Ltd. European Wound Management Association (2005) Position Document Identifying criteria for wound infection. London: MEP Ltd. European Wound Management Association (2006) Position Document Management of wound Infection. London: MEP Ltd. European Wound Management Association (2007) Position Document Topical Negative Pressure In wound Management. London: MEP. Ltd European Wound Management Association (2008) Position Document Hard-to-heal wounds: A holistic approach. London: MEP Ltd. Gottrup F, Apelqvist J et al (2013) EWMA Document: Antimicrobials and Non-healing wounds- Evidence. Controversies and suggestions. Journal of Wound Care. 22 (5 suppl): S1-S92. Guy H (2012) The Difference Between Moisture Lesions and Pressure Ulcers. Wound Essentials. Vol. 1 p Available at: Kean J. (2010) The effects of smoking on the wound healing process Journal of Wound Care. 19 (1) p.5-8. King B (2003) A review of research investigating pain and wound care. Journal of Wound Care. 12(6) p Medlin S (2012) Nutrition For Wound Healing. British Journal of Nursing (Tissue Viability Supplement) Vol, 21, No 12. S NHS Quality Improvement Scotland (2009) Best Practice Statement. Prevention and Management of Pressure Ulcers. Available at Phillips PL, Wolcott RD, et al. (2010) Biofilms Made Easy. Wounds International 1(3). Available at 33

35 Strohal R, Apelqvist J, Dissemond J et al (2013) EWMA Document: Debridement. Journal of Wound Care. 22 (suppl.1) S1-S52. Toit DF (2009) An in vitro evaluation of the cell toxicity of honey and silver dressings. Journal of Wound Care. 18 (9) p Yates S (2012) Differentiating Between Pressure Ulcers and Moisture Lesions. Wound Essentials. Vol 2. p Available at White R, Cutting K (2008) Critical colonisation of chronic wounds: microbial mechanisms. Wounds UK. 4(1) P Wounds International (2012) Appropriate use of Silver Dressings in Wounds. An expert working group consensus. London. Available to download from Wounds UK (2010) PHMB and its potential contribution to wound management. Wounds UK, Aberdeen. Available at Winter GD (1962) Formation of the scab and rate of epithelialisation of superficial wounds in the skin of young domestic pig. Nature 193: RESOURCES/ LINKS Tissue Viability Resource: Skin tear Guidelines: Best practice for leg ulcer management: Diabetic Foot Infection Guidelines: Available on the NHS Fife Intranet Evidence based practice: The JBI approach to evidence-based health care is unique. The JBI considers evidence-based health care to be reliant on the evidence, the context in which care is delivered, individual client preference and the professional judgement of the health professional. RELATED POLICIES NHS Fife SOP for Wound Care (July 2010) NHS Fife Policy for Prevention of Pressure ulcers (Operational Division 2010) NHS Fife The use of Sterile Larvae in wound management CP-15 (January 2011) SIGN Guidelines 120. Management of Chronic Venous Leg Ulcers (August 2010) 34

36 Appendix 1 - Woundcare Products Conversion Chart Product Group First Choice Second Choice Examples of Non Formulary Products Barrier Films Vapour Permeable Adhesive Films Non Adherent Dressings Low Adherence Dressings Hydrocolloid Dressings Foam Dressings Cavilon No Sting Barrier Film Cavilon Cream Secura 365 Film - Hospital Tegaderm Adhesive Film - Community Brava Clinifilm Cutimed Protect LBF No Sting Barrier Film Askina Derm Bioclusive C-View ClearFilm Hydrofilm Medi Derma-S Ostoguard Pelican Protect Peri-Prep SkinSafe Hypafix Leukomed T Mepitel Film Mepore Film Opsite Flexigrid Sorbaderm Sudocrem Trio Silesse Polyskin II Protectfilm Suprasorb F Vacuskin N-A Ultra N-A dressing Primary Tricotex Premierpore Comfeel Plus Transparent Duoderm Extra Thin Biatain / Biatain Adhesive Tielle Plus/ Tielle Xtra Tegaderm Foam Adhesive (Heel only) Cosmopor E Leukomed Medipore ActivHeal Askina Biofilm Transparent Duoderm Signal ActivHeal Foam Allevyn Allevyn Adhesive Allevyn Gentle Border Medisafe Mepore Primapore Flexigran (& Thin) Granuflex Hydrocoll Nu-Derm (& Thin) Allevyn Plus Adhesive Permafoam / Permafoam Comfort Softpore Sterifix Telfa Island Suprasorb H Tegaderm Hydrocolloid Ultec Pro Polymem Tegaderm Foam Adhesive Trufoam Hydrofibre Dressings Aquacel Extra Activheal Aquafibre Hydrofibre Foam Aquacel Foam Dressings Hydrogel Dressings Purilon ActivHeal Gel Askina gel Aquaflo Aquaform Gel FX Geliperm Granugel Mesitran Novogel Nu-Gel Coolie Flexigran Gel Hydrosorb Intrasite Alginate Dressings Tegaderm Alginate Kaltostat Activheal Alginate Algosteril Cutimed Alginate Sorbalgon Sorbsan Flat Algisite M Melgisorb Deodorising Dressings Clinisorb Carboflex Askina Carbosorb Carbopad VC Sorbsan Plus Carbon Silicone Dressings Mepitel Mepitel One Mepilex Mepilex Border Allevyn Gentle Allevyn Gentle Border Allevyn Life Askina SilNet Cutimed Siltec Mepilex Transfer Silflex Silon -TSR Super Absorbent Dressings Silver containing Dressings Antimicrobial Dressings Honey Preparations Iodine containing Dressings KerraMaxCare Eclypse Flivasorb Mesorb Zetuvit-E Melgisorb Ag Askina Calgitrol Ag Acticoat Flex 3 Acticoat Flex 7 Acticoat Moisture Control Actisorb Silver Algisite Ag Allevyn Ag etc Cutimed Sorbact Medihoney Apinate Medihoney Tulle Activon ointment Actilite Inadine Iodoflex Atrauman Ag Aquacel Ag Biatain Ag Mepilex Ag Physiotulle Ag Polymem Silver Silvercel & NA Sorbsan Silver Tegaderm Alginate Ag Urgocell Silver Urgosorb Silver Urgotul Silver Activon Tulle Algivon Mesitran Iodosorb Iodozyme Oxyzyme Antimicrobial Alginate Gel Flaminal Forte Flaminal Hydro Pain Management ActiFormCool Biatain IBU Dressings Debridement Product Debrisoft pad Tulle Dressings Physiotulle Jelonet Paragauze Urgotul 35

37 WRITE, IMPRINT OR ATTACH LABEL Appendix 2 Wound Assessment Chart Surname... Forenames DoB.. CHI No... Sex.. Location Assessment Chart for Wound Management For multiple wounds complete formal wound assessment for each wound. Add Inserts as needed. Factors which could delay healing: (Please tick relevant box) Immobility Poor Nutrition Diabetes Incontinence Respiratory / Circulatory Disease Anaemia Medication Chemotherapy Wound Infection Previous History of MRSA Infection Inotropes Anti-Coagulants Oedema Steroids Other.. Allergies & Sensitivities. Body Diagram Feet Diagram Front Back Right Left Mark location with X and number each wound Type of Wound Total number & duration of each type of wound Leg Ulcer.. Surgical Wound. Diabetic Ulcer. Pressure Ulcer.. Other, specify Mark location with X and number each wound Date referred to: TVN.Physiotherapist. Podiatrist Dietician... Other (please specify). Assessors signature:.. Date: