Wound Formulary and Wound Management Guidelines

Transcription

1 Wound Formulary and Wound Management Guidelines 2017 Developed by the NHS Fife Wound and Skin Care Forum (WSCF) Group Approved: December 2016 For review: February 2020 Approved by NHS Fife ADTC Woundcare Formulary Jan 2017 FINAL DRAFT pdf 1 27/01/ :09

2 Area Drug and Therapeutics Committee Contents Introduc on 2 Wound Defini on 4 Cavity Wounds, Packing and Probing 4 Necro c Wounds & Comprehensive wound assessment 5 Factors to consider when planning holi wound care 7 Characteris of ideal dressings & Ordering products 8 Guide to selec on of wound dressings 9 Overgranula on 10 STAR Skin Tear Classifica on System 11 Bacterial burden and management of infec on 12 Wound cleansing guidelines 14 MONOGRAPHS FOR DRESSINGS o Barrier film 17 o Non adherent dressings 17 o Hydrocolloid dressings 18 o Foam dressings 19 o Hydrofibre dressings 20 o Hydrogel dressings 21 o Alginate dressings 22 o Deodorising dressings 23 o Silicone dressings 24 o Silicone Foam 25 o Super Absorbent Dressings 26 SPECIALISED DRESSINGS Guidance for use of Specialised dressings and therapies 27 Ropper Ladder 28 o Silver containing Dressings 29 o Prontosan Preparation 29 o Cutimed Range 30 o Honey Preparations 30 o Iodine containing Dressings 32 o Antimicrobial Alginate Gel 32 o Pain Management Dressings 33 o Foam/Fibre Dressings - Heavily Exuding Wounds 33 o Debridement product 33 o Tulle Dressings 34 o Technology Lipidocolloid (TLC) 34 o Specialist Plastic Surgery 35 o Larvae Therapy 37 o Negative Pressure Wound Therapy 37 o Wound Drainage Bags 38 Glossary of Wound Terms 39 Reading list / Resources 40 Related Policies 42 Appendix 1 Wound Assessment Charts 43 Appendix 2 Wound Conversion Charts Woundcare Formulary Jan 2017 FINAL DRAFT pdf 2 27/01/ :09

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, Price-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, SDT January 2017) have been added to make practitioners aware of Price. More expensive dressings may still be Price effective if used in the correct manner. Practitioners are advised to contact their local Tissue Viability nurse or Podiatrist 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 including consent for treatment and medical photography, available personnel and equipment, clinical experience of the practitioner and knowledge of most recent research findings must all be considered and decisions clearly documented in the patient s notes Woundcare Formulary Jan 2017 FINAL DRAFT pdf 3 27/01/ :09

4 Area Drug and Therapeutics Committee 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 Services and NHS Fife Acute Services Division staff in the development of these Guidelines. NHS Fife Wound and Skin Care Forum (WSCF) Guideline Group NAME Jane Nicoll Anne Barns Andy Cameron Julia Chalmers Lynn Coyne Antonia De Angelis Katrina Deas Fiona Dick Kevin Finnegan Fiona Graham Tanya Hardy Joanne Koczubik Deborah McCallum Heather McKellar Gillian Meldrum Gillian Preston Leesa Radcliffe Yvonne Robson Susan Roemmele Islay Roy Lesley Shiels Mary Thomson Caroline Turnbull Catherine Ward Karen Whatton Anne Wilson POSITION Lead Tissue Viability Nurse, ASD (Chairperson) District Charge Nurse, Path House, Kirkcaldy Senior Procurement Officer District Charge Nurse, Balmullo Health Centre Plastic Surgery Specialist Nurse, ASD Tissue Viability Nurse, ASD and Community Clinical Practice Development Officer Charge Nurse, Ward 13 VHK Assistant Procurement Administrator Highly Specialist Podiatrist Senior Staff Nurse, Plastic Surgery, ASD Plastic Surgery Nurse, ASD Clinical Nurse Practitioner, Plastic Surgery, ASD Senior Charge Nurse in OPD, Adamson Hospital Highly Specialist Podiatrist Tissue Viability Nurse, ASD Community Tissue Viability Nurse, West Fife Senior Charge Nurse, OPD, QMH Staff Nurse, Dermatology Department, QMH Plastic Surgery Nurse, ASD Tissue Viability Nurse, Community East Fife Senior Prescribing Support Nurse Plastic Surgery Nurse, ASD Staff Nurse, Ward 10 VHK Senior Prescribing Support Nurse Vascular Nurse and Senior Prescribing Support Nurse Woundcare Formulary Jan 2017 FINAL DRAFT pdf 4 27/01/ :09

5 Wound Definition Area Drug and Therapeutics Committee 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. Cavity Wounds Providing a single definition for a cavity wound is challenging as they vary in aetiology, size, depth and position. They may present with additional challenging features such as sinus formation, fistulae, undermining or bridging (Wounds UK, Cavity Wounds Quick Guide, 2016) For the purposes of these guidelines, the following definitions apply A wound extending beneath the layers of the dermis, potentially exposing structures such as fascia, tendon, muscle or bone. A wound requiring more than a simple flat dressing wounds that require a filler dressing. A wound deeper than 2cm. Packing and Probing wounds Guidance has been requested on how best to pack a wound and how to probe a wound to measure wound depth. A literature search was conducted; unfortunately there is no evidence to support robust guidance. However the consensus of the Fife Wound and Skin Care Forum Group is as follows: Clinicians must use their clinical judgement when deciding to pack or probe a wound. To gauge depth use a soft cotton tipped swab to gently probe, taking care not to damage tissue or structures. Podiatrists, please seek local advice regarding probe type. To pack a wound with a hydrogel or alginate gel, half fill the cavity and apply secondary dressing. To pack a wound with dressing material, the end of the wound must be established to avoid dressing material being lost within the wound, it may be more appropriate to use a gel. Pack dressing material loosely Clearly document how many pieces of dressing material have been inserted and removed from the wound Woundcare Formulary Jan 2017 FINAL DRAFT pdf 5 27/01/ :09

6 Area Drug and Therapeutics Committee Necrotic tissue Necrotic tissue is a layer of dead tissue which can be brown/ black and or waxy in colour and is caused by an inadequate blood supply or infection. It may be soft or hard on the surface. The skin can remain intact and the necrosis can be of varying depth and it may produce an offensive smell. Nursing staff must be cautious before attempting to remove necrotic tissue from a wound; this includes autolytic debridement with the use of hydrogels and dressing products. A full, holistic assessment of the patient must be undertaken first to ascertain any intrinsic or extrinsic factors which may cause complications if removal of necrotic tissue is initiated or necessary. Necrosis should not be routinely removed in an ischemic area. This may cause significant deterioration in the area. Necrosis should not be routinely removed and at the end of life in the absence of any systemic or local signs of infection unless required for symptomatic relief. For example: debridement may be necessary e.g. wound is beginning to break down, a collection of fluid is evident below the necrosis and when malodour or infection is an issue, this must be discussed with the relevant clinicians before you attempt any form of necrotic tissue removal. Specialist advice should be sought when considering sharp debridement of a wound. Mechanical or surgical removal such as sharps debridement of tissue should only be performed by specialist practitioners. Further information: Guidelines For Practice, Effective Debridement in a Changing NHS a UK Consensus, Wounds UK Available form: Healthcare Improvement Scotland (2010) Tissue Viability Scottish Wound Assessment and Action Guide...\ _Wound_Assessment_Tool_Guide_Final SWAG.pdf Comprehensive Wound Assessment Recognised good practice is to assess a wound using a validated wound assessment chart (see page ) 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 or damage to underlying structures, e.g tendon) may inhibit the healing process and wound bed preparation must be carried out to promote proliferation and epithelialisation. (See web site below) Woundcare Formulary Jan 2017 FINAL DRAFT pdf 6 27/01/ :09

7 Area Drug and Therapeutics Committee 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, podiatry, plastic surgery 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:..\ _wound_assessment_tool_guide_final SWAG.pdf Woundcare Formulary Jan 2017 FINAL DRAFT pdf 7 27/01/ :09

8 Area Drug and Therapeutics Committee Factors to Consider when Planning Holistic Wound Care Patient Issues (Relating to wound and personal) Pain Exudate Odour Anxiety Low Self Esteem Poor Mobility Social Isolation Loss of employment/income 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 Connective tissue disorders Smoking Nodular Fragile 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 Wet / Dry Slough Biochemical imbalance Difficulty in swallowing Stroke Neuromuscular disorders Underlying malignancy 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 7 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 Woundcare Formulary Jan 2017 FINAL DRAFT pdf 8 27/01/ :09

9 Area Drug and Therapeutics Committee 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. Price 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 The most Price effective ordering route for both hospital and community is via the Area Distribution Centre/National Distribution Centre (ADC/NDC). All dressings listed on the general pages of the Wound Management Guidelines are available on Drug Tariff. To order an item that is not on formulary, an Exception form must be completed and submitted to the Senior Prescribing Support Nurses (Fife-UHB.Fifeprescribingsupportnurse@nhs.net) Woundcare Formulary Jan 2017 FINAL DRAFT pdf 9 27/01/ :09

10 Fife Health & Social Care Partnership Supporting the people of Fife together ASSESS THE WOUND IS THE WOUND? REMEMBER: A full holistic assessment of the patient must be carried out. NHS Epithelialising Granulating Sloughy Necrotic Infected OBJECTIVES: To protect and promote new tissue growth. OBJECTIVES: Encourage angiogenesis and promote granulation tissue. OBJECTIVES: To debride slough, manage exudate levels. OBJECTIVES: To rehydrate eschar. NB: Depending on overall aims, it may not be appropriate to break necrosis down, e.g. palliative or vascular wounds. OBJECTIVES: To reduce bacterial load in wounds. NB: If spreading infection (e.g. cellulitis), systemic antibiotics will be required. EXUDATE LEVELS EXUDATE LEVELS EXUDATE LEVELS EXUDATE LEVELS EXUDATE LEVELS LOW MED - HIGH LOW MED - HIGH LOW MED - HIGH LOW MED - HIGH LOW MED - HIGH Non-adherent dressing OR Thin Hydrocolloid Non-adherent dressing with absorbent pad OR Foam adhesive/ Non adhesive Non-adherent dressing OR Foam dressing Non-adherent dressing with absorbent pad OR Foam dressing Hydrogel Non-adherent with pad or foam Hydrofibre dressing & absorbent pad OR Foam dressing Hydrogel and non-adherent dressing with pad OR Hydrocolloid Foam dressing Consider. hydrogel if necrosis still needs broken down. Antimicrobial impregnated dressing & non adherent dressing. Antimicrobial or silver impregnated dressing plus absorbent secondary dressing FORMULARY DRESSINGS FORMULARY DRESSINGS FORMULARY DRESSINGS FORMULARY DRESSINGS FORMULARY DRESSINGS 1st CHOICE 365 Island dressing 2nd CHOICE Mepilex Lite Adhesive/ Non Adhesive 1st CHOICE 1st CHOICE NA Ultra plus 365 Island Kliniderm dressing 2nd CHOICE Tegaderm Foam/ Tegaderm Foam adhesive 2nd CHOICE Tegaderm Foam/ Tegaderm Foam adhesive 1st CHOICE Aquacel Extra plus Kliniderm 2nd CHOICE Tegaderm Foam/ Tegaderm Foam adhesive 1st CHOICE 1st CHOICE 1st CHOICE 1st CHOICE 1st CHOICE 1st CHOICE Aquacel Foam* Purilon gel & Mepilex Lite Purilon gel & Tegaderm Foam/ Tegaderm Foam adhesive 2nd CHOICE Tegaderm Foam/ Tegaderm Foam adhesive (if infection suspected, refer to Infected Wound section). Comfeel Plus Ulcer 2nd CHOICE 2nd CHOICE Purilon gel & Tegaderm Foam Aquacel Extra & Kliniderm 2nd CHOICE *Aquacel Foam adhesive/ non adhesive Inadine & non adherent pad 2nd CHOICE Actilite and non adherent pad Urgotul SSD & Kliniderm 2nd CHOICE Refer to Infected Wound section of Wound Guidelines (Ropper Ladder) Developed by NHS Fife Wound & Skincare Forum (WSCF) January Review Date January 2020 For further information on dressings, refer to Wound Formulary.

11 Area Drug and Therapeutics Committee 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): Stephen Haynes J. Wound Care Alliance UK: Achieving effective outcomes in patients with overgranulation Woundcare Formulary Jan 2017 FINAL DRAFT pdf 11 27/01/ :09

12 Area Drug and Therapeutics Committee Woundcare Formulary Jan 2017 FINAL DRAFT pdf 12 27/01/ :09

13 Area Drug and Therapeutics Committee Bacterial Burden and Management of Infection Bacterial burden and virulence are important factors in assessing the wound for infection. Host resistance is a major determinant in the body s ability to fight infection and initiate an inflammatory response. This may be illustrated in the following equation: 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 The Adapted Ropper Lothian Ladder). N.B. Do not confuse signs of inflammation with infection For diabetic foot wounds consult local podiatrist for advice at an early stage as signs of infection may be masked. 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 Price incurred for each Wound Swab is in excess of Woundcare Formulary Jan 2017 FINAL DRAFT pdf 13 27/01/ :09

14 Area Drug and Therapeutics Committee 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 Woundcare Formulary Jan 2017 FINAL DRAFT pdf 14 27/01/ :09

15 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. Further guidance available, wound cleansing flowchart: Woundcare Formulary Jan 2017 FINAL DRAFT pdf 15 27/01/ :09

16 Area Drug and Therapeutics Committee Wound Cleansing Guidelines 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. Bucket lined with polythene bag for lower limbs In healthcare premises, shower should be cleaned with general 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. 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. Maintains clean working environment. Ensures safe removal of exudate, loose slough and wound dressing residue. It incorporates social hygiene into wound management procedure. Maintains clean working environment. Infection Control Manual can be accessed via: Intranet / Subjects / Infection Control / Infection Control Manual C03F5A9FA592A31A&subjectid=6C965E0A-DB7D-B17A-04E54EAC6A42E839&objectid=6BE801F C6F-C0E12BB07758F Woundcare Formulary Jan 2017 FINAL DRAFT pdf 16 27/01/ :09

17 Area Drug and Therapeutics Committee 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 With Sodium Chloride 0.9% Solution - Hospital and Primary Care = Irripod 20mls 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 SDT Price Jan 2017 (Each) Irripod 20ml (25) 23p Prontosan 40ml (24) 350ml 35p 4.78 N.B. Prontosan should not be routinely used. It is for use in compromised wounds. For example, chronic or infected wounds Woundcare Formulary Jan 2017 FINAL DRAFT pdf 17 27/01/ :09

18 Area Drug and Therapeutics Committee Barrier Film Sureprep No Sting Barrier Film Sorbaderm Cream Description Sureprep No Sting Barrier Film provides long lasting skin protection for up to 72 hours. Sorbaderm Cream provides long lasting protection from bodily fluids whilst moisturising the skin Indications Intended to be used as a primary barrier and moisturiser 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. It is suitable for use in neonates. Method of Use Both film and cream should be applied to clean, dry skin. Sureprep No Sting Barrier 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 for 60 seconds before applying any adhesive dressings or surgical tapes. Reapply at least every hrs (or more frequently if required) Sorbaderm Cream should be applied in small amounts, gently smoothing into the skin over the affected area and allowed to dry for 30 seconds before applying any dressing N.B. If the after feel of the skin is oily, then too much has been applied. Sureprep No Sting Barrier Film 1ml foam applicator (25) 3ml foam applicator (25) 28ml spray bottle (1) Sorbaderm Cream 2g sachet (20) 28g (20) 92g tube (1) Non-adherent Dressings N-A Ultra Description A primary wound contact layer consisting of a knitted viscose rayon sheet with a silicone coating. 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. Secondary dressings are required to retain dressing in position. Frequency of changing the dressings depends on exudate/ strike through N-A Ultra 9.5cm x 9.5cm (40) 9.5cm x 19cm (25) Woundcare Formulary Jan 2017 FINAL DRAFT pdf 18 27/01/ :09

19 Hydrocolloid Dressings Area Drug and Therapeutics Committee First Choice: Comfeel Plus Transparent/Comfeel Plus Ulcer Second Choice: Duoderm Extra thin Comfeel Plus Transparent 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. Comfeel Plus Ulcer Absorbent hydrocolloid dressing with added alginate for absorption, a vapour-permeable film backing with bevelled edge to reduce rucking. There is a 1cm grid printed on backing to aid wound measurement. 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 in low exuding wounds. 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) Comfeel Plus Ulcer 10cm x 10cm (10) 15cm x 15cm (10) 20cm x 20cm (5) 4cm x 6cm (10) 18cm 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) Woundcare Formulary Jan 2017 FINAL DRAFT pdf 19 27/01/ :09

20 Area Drug and Therapeutics Committee Foam Dressings Tegaderm Foam / Tegaderm Foam Adhesive Tegaderm Foam Adhesive - Heel only Description Highly absorbent polyurethane foam dressing with semipermeable film backing layer. 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. Tegaderm Foam / Tegaderm Foam Adhesive Tegaderm Foam is suitable for use in moderate to highly exuding wounds. Tegaderm Foam Adhesive is suitable for low to highly exuding wounds. Can be used on clean granulating wounds or as a secondary dressing in sloughy or necrotic wounds, can be used under compression. 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. Tegaderm Foam Adhesive - Heel only A highly absorbent polyurethane foam dressing with semipermeable film backing layer and adhesive border. Comprises of four layers for high fluid absorption. Tegaderm Foam 8.8cm x 8.8cm (10) 10cm x 10cm (10) 20cm x 20cm (5) 10cm x 20cm (5) 10cm x 60cm (Roll) Tegaderm Foam Adhesive 6.9cm x 7.6cm (10) 10cm x 11cm (10) 14.3cm x 14.3cm (10) 14.3cm x 15.6cm (5) Tegaderm Foam - Heel 13.9cm x 13.9cm (5) Woundcare Formulary Jan 2017 FINAL DRAFT pdf 20 27/01/ :09

21 Area Drug and Therapeutics Committee 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) 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) Woundcare Formulary Jan 2017 FINAL DRAFT pdf 21 27/01/ :09

22 Area Drug and Therapeutics Committee Hydrogel Dressings First choice : Purilon Gel Description An amorphous gel with high water content, containing Calcium Alginate (Purilon ) 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. Purilon Sterile 8g tube (10) Sterile 15g tube (10) Woundcare Formulary Jan 2017 FINAL DRAFT pdf 22 27/01/ :09

23 Alginate Dressings Area Drug and Therapeutics Committee 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. Kaltostat 5cm x 5cm (10) 7.5cm x 12cm (10) 10cm x 20cm (10) 15cm x 25cm (10) Woundcare Formulary Jan 2017 FINAL DRAFT pdf 23 27/01/ :09

24 Area Drug and Therapeutics Committee Deodourising Dressings First choice : Second choice : Clinisorb CarboFlex Clinisorb Description Clinisorb is an activated charcoal cloth dressing, produced by carbonising and activating woven viscose rayon that is sandwiched between two layers of a nylon and viscose rayon blend. Clinisorb has the optimum combination of microporous activity and activated charcoal cloth weight, for significantly reducing odour by attracting and permanently trapping bacteria. It is non-adhesive and contained in a sterile peel pack. Indications Clinisorb can be used to manage malodourous wounds such as fungating breast lesions, pressure ulcers, leg ulcers and diabetic foot ulcers. Method Of Use Clinisorb can be used as a primary or secondary dressing and its soft, flexible construction can be cut to fit practically any wound. Even unusually shaped fungating wounds on curved body sites can be easily dressed. Clinisorb is highly effective wet or dry, can be used either side down, and can be left in place for up to one week. CarboFlex Description A sterile non-adhesive dressing consisting of five layers - film layer, absorbent padding, activated charcoal cloth, film layer and absorbent wound contact layer containing Kaltostat and Aquacel. Indications For use in the management of malodourous acute and chronic wounds. May be used as a primary dressing for shallow wounds or as a secondary dressing over wound fillers with deeper wounds. Method Of Use This dressing must not be cut to size or shape. The fibrous surface is placed directly on to the wound. This may be left undisturbed for up to three days depending on the level of exudate. Clinisorb 10cm x 10cm (10) 10cm x 20cm (10) 15cm x 25cm (10) CarboFlex 8cm x 15cm (5) Oval 10cm x 10cm (10) 15cm x 20cm (5) Woundcare Formulary Jan 2017 FINAL DRAFT pdf 24 27/01/ :09

25 Silicone Dressings 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 One prevents the outer dressing sticking to the wound. The porous structure of Mepitel One 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 One 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 One 6cm x 7cm (5) 9cm x 10cm (5) 13cm x 15cm (5) 24cm x 27.5cm (5) Mepilex Lite Description A thin absorbent foam dressing with soft silicone contact layer and film backing Indications For use on non to low exuding woumds. May also be used as a protective dressing on compromised or fragile skin. Method of Use Apply directly to wound or wound bed. Mepilex Lite can be easily cut to fit an individual wound and makes it ideal for difficult to dress wounds, such as armpits, breast etc. Mepilex Lite 6cm x 8.5cm (5) 10cm x 10cm (5) 15cm x 15cm (5) 20cm x 50cm (5) Woundcare Formulary Jan 2017 FINAL DRAFT pdf 25 27/01/ :09

26 Silicone Foam Dressings Allevyn Gentle / Alleyvn Gentle Border Description An absorbent hydrocelluar pad sandwiched between a perforated soft gel adhesive wound contact layer and highly permeable waterproof outer film. Alleyvn Gentle Border benefits from an easy application and removal of the dressing with the ability to reposition through an adhesive technology based on the soft silicone gel in the dressing. 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. Method of Use During the early stages of wound management, Allevyn Gentle Border dressings should be inspected frequently. Where the product is used on infected wounds, the infection should be inspected and treated as per local clinical protocol. Dressings can be left in place for up to 7 days depending on the condition of the wound and the surrounding skin or until exudate is visible and approaches to within 1.5cm of the edge of the dressing pad, whichever is sooner. If required, Allevyn Gentle can be cut. Contraindications Do not use Allevyn Gentle Border dressings with oxidising agents such as hypochlorite solutions (e.g. Eusol or Hydrogen peroxide, as these can break down the absorbent polyurethane component of the dressing. If reddening or sensitisation occurs discontinue use. Allevyn Gentle Border 7.5cm x 7.5cm (10) 10cm x 10cm (10) 12.5cm x 12.5cm (10) 15cm x 15cm (10) 17.5cm x 17.5cm (10) 10cm x 20cm (10) Allevyn Gentle 5cm x 5cm (10) 10cm x 10cm (10) 15cm x 15cm (10) 10cm x 20cm (10) 20cm x 20cm (10) Allevyn Gentle Border Sacrum 16.8cm x 17.1cm (10) 21.6cm x 23cm (10) Allevyn Gentle Border Lite 5cm x 5cm (10) 7.5cm x 7.5 cm (10) 10cm x 10cm (10) 15cm x 15cm (10) 5.5cm x 12cm (10) 8cm x 15cm (10) 10cm x 20cm (10) Woundcare Formulary Jan 2017 FINAL DRAFT pdf 26 27/01/ :09

27 Super Absorbent Dressings Kliniderm Description Super absorbent secondary dressing compromising of four layers: a hydrophillic wound contact layer, a distribution layer, a super absorbent inner core and a fluid repellent wound conact layer Indications Moderate to heavily exuding wounds. May be used under compression Indications Not to be used on dry wounds, heavy bleeding wounds and surgical implantation. The dressing must not be cut. Eclypse Description Super absorbent secondary dressing Indications Moderate to heavily exuding wounds Indications Not to be used on arterial bleeds or heavily bleeding wounds. If a wound has a potential to dry out, a non adherent wound contact layer should be applied beforehand. Do not cut dressing. Kliniderm 10cm x 10cm (50) 10cm x 15cm (10) 20cm x 20cm (15) 20cm x 30cm (10) Eclypse 15cm x 15 cm (20) 20cm x 30 cm (20) 60cm x 40cm (10) Woundcare Formulary Jan 2017 FINAL DRAFT pdf 27 27/01/ :09

28 Specialised Dressings & Therapies Initiation of these products should be on the advice of the relevant specialist e.g. Acute or Community Tissue Viability Nurse, Podiatry, Vascular, Plastic Surgery or Dermatology Service. onthe advice of the relevant specialist, Acute or Community 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 undedicated 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 Woundcare Formulary Jan 2017 FINAL DRAFT pdf 28 27/01/ :09

29 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 START 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 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 & reproduced with permission of R. Ropper, TVN CNS NHS Lothian Woundcare Formulary Jan 2017 FINAL DRAFT pdf 29 27/01/ :09

30 Specialised Dressings & Therapies Initiation of these products should be on the advice of the relevant specialist practitioner and follow local policies for use. Silver Containing Dressings Aquacel Ag+ Ribbon Aquacel Ag+ Extra Urgotul SSD Aquacel Ag+ Ribbon/Extra Description Aquacel Ag+ Ribbon is a versatile primary dressing. The combination of Hydrofiber Technology with ionic silver (Ag+), enhanced with anti biofilm technology, produces a dressing that is highly absorbent and has favourable gelling characteristics with the aid of broad-spectrum antimicrobial activity Indications For use in moderate to highly exuding chronic and acute wounds where there is infection or an increased risk of infection. Also suitable for cavity wounds Contraindications Should not be used on patients who are sensitive to, or have had an allergic reaction to silver or sodium carboxymethycellulose. Urgo SSD Description A non adherent, non occlusive, antibacterial contact layer. The contact layer is a polyester mesh impregnated with hydrocolloid petroleum jelly and silver sulphadiazine particles. Indications For use on non to lightly exuding wounds with signs of infection. Can be combined with an absorbent layer for heavily exuding wounds. Can also be used in cavity wounds. Contraindications Do not use on patients with a known sensitivity to any components of the dressing. Caution: Do not use on patients undergoing MRI scans. Avoid contact with electrodes or conductive gels during electronic measurement procedures. Aquacel Ag+ Ribbon 1cm x 45cm (5) 2cm x 45cm (5) Aquacel Ag+ Extra 5cm x 5cm (5) 10cm x 10cm (5) 15cm x 15cm (5) 2cm x 30cm (5) 4cm x 10cm (5) 4cm x 20cm (5) 4cm x 30cm (5) Urgotul SSD 10cm x 12cm (10) 15cm x 20cm (10) Woundcare Formulary Jan 2017 FINAL DRAFT pdf 30 27/01/ :09

31 Prontosan Solution Prontosan solution is a wound irrigation solution containing betaine, a gentle surfactant that penetrates, disturbs and removes Biofilm and wound debris, and PHMB to help control bacteria levels on the wound. Prontosan Solution 40ml ampoule (24) 350ml bottle Prontosan Wound Gel Prontosan Wound Gel contains betaine, is a gentle surfactant that penetrates, disturbs and removes biofilm and wound debris, it also contains PHMB to help control bacterial levels on the wound. Prontosan Wound Gel 30g 50g 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. Cutimed Sorbact Hydroactive is a Semipermeable polyurethane film which contains Bacteria-binding Sorbact acetate mesh N.B. Using the dressing in combination with cream/ointments impairs the effect of the DACC. Cutimed Sorbact Ribbon Cutimed Sorbact Swab Cutimed Sorbact Hydroactive 2cm x 50cm (20) 5cm x 200cm (10) 4cm x 6cm (5) unfolded 11cm x 16cm 7cm x 9cm (5) unfolded 17cm x 27cm 7cm x 8.5cm (10) 14cm x 14cm (10) 19cm x 19cm (10) 14cm x 24cm (10) 24cm x 24cm (10) Woundcare Formulary Jan 2017 FINAL DRAFT pdf 31 27/01/ :09

32 Initiation of these products should be on the advice of the relevant specialist practitioner and local policies should be followed. Honey Preparations Honey provides a moist healing environment with antibacterial and deodorizing properties as well as autolytic and osmotic debriding actions. It can be used on a variety of acute and chronic wounds. Medihoney Products For use in acute and chronic wounds: leg/foot ulcers, pressure ulcers, sloughy wounds, necrotic wounds, infected wounds, malodorous wounds, donor and recipient graft sites, and burns, diabetic wounds and surgical wounds. Activon Products Activon (ointment) is ideal for debriding necrotic tissue. Ideal for topping up dressings where the honey is washed away or for using directly into cavities. Can be washed out using normal saline solution. Actilite Actilite is a light viscose net dressing coated with antibacterial Manuka honey & Manuka oil. The dressing is designed to protect a wound, promote healing and allow the passage of exudate. The antibacterial effect of Actilite has been enhanced by combining high grade antibacterial Manuka oil with Manuka honey. The combination of Manuka honey and Manuka oil has been demonstrated in-vitro to be effective against a number of major wound infecting organisms including MRSA and VRE. Medihoney Antibacterial Honey Apinate Medihoney Tulle 5cm x 5cm (10) 10cm x 10cm (5) 5cm x 5cm (5) 10cm x 10cm (5) Medihoney Antibacterial Medical 20g tube (5) Honey Activon Medical Grade Manuka 25g tube (12) Honey Actilite 5cm x 5cm (10) 10cm x 10cm (10) 10cm x 20cm (10) ADC only 9.00 Prescription only Woundcare Formulary Jan 2017 FINAL DRAFT pdf 32 27/01/ :09

33 Iodine Dressings CAUTION: Care must be taken when these dressings are used for patients with Thyroid or 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 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) 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) 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 Price effective Woundcare Formulary Jan 2017 FINAL DRAFT pdf 33 27/01/ :09

34 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) Foam/Fibre Dressing For Heavily Exuding Wounds Allevyn Life A dressing which is a multi-layered design incorporating hydrocellular foam with a hyper-absorber lock away core. It has a highly waterproof outer film and incorporates a mesh screen on the pad which allows the levels of exudate to be visible. This indicates when the dressing should be changed. Alleyvn LIfe 10cm x 10.3cm (10) 12.9cm x 12.9cm (10) 15.4cm x 15.4cm (10) 21cm x 21cm (10) Cutimed Sorbion Sachet S A versatile fibre dressing with high wearing comfort for highly exuding wounds. The dressing absorbs wound exudate and locks it in, creating a moist wound environment by gel formation. It provides a large capacity for wound exudate and ensures high retention of absorbed fluids. Cutimed Sorbion Sachet S 7.5cm x 7.5cm (10) 10cm x 10cm (10) 20cm x 10cm (10) 20cm x 20cm (10) SDT Price Jan 2017(Each) Debridement Products 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 10xm 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 Woundcare Formulary Jan 2017 FINAL DRAFT pdf 34 27/01/ :09

35 Debrisoft Lolly Comprises of monofilament polyester fibres with a blue X-ray detectable polypropylene thread. The Debrisoft Lolly is intended for the debridement of deep including surgically invasive to superficial wounds for wound bed preparation. It is used to absorb exudates, debris and keratoses during debridement. SDT Price -Jan 2017(Each) Debrisoft Pad 10cm x 10cm (5) 6.45 Debrisoft Lolly 5.79 Tulle Dressings Urogtul A non adherent, non occlusive flexible contact layer derived from Technology Lipido-Colloid (TLC Technology). It is composed of a flexible polyester mesh impregnated with hydrocolloid and petroleum jelly particles. Can be used on acute wounds, skin abrasions and may be left for up too 7 days. Urgotul 5cm x 5cm (10) 10cm x 10cm (10) 15cm x 15cm (10) 10cm x 40cm (10) 15cm x 20cm (10) 20cm x 30cm (5) Technology Lipidocolloid (TLC) - Urgo Dressings Urgo Clean Pad & Rope Description A TLC Healing Matrix dressing which allows a pain free desloughing action, trapping and binding slough with its polyabsorbent fibres. It is also available as a rope which has similar absorption properties to Aquacel Indications For use in moderate to heavily exuding wounds. Change Urgo Clean 1-2 days during the desloughing phase, then as often as required (up to 7 days)depending on levels of exudate. Contraindications Do not use Urgo Clean in combination with hydrogen peroxide organomercuric antiseptics or heocamidine. Urgo Clean Pad 6cm x 6cm(10) 10cm x 10cm (10) 20cm x 15cm (10) Urgo Clean Rope/Probe 5cm x 40cm (10) 2.5cm x 40cm (10) Woundcare Formulary Jan 2017 FINAL DRAFT pdf 35 27/01/ :09

36 Urgo Start/Urgo Start Contact Description Urgo Start is a soft adherent TLC foam dressing which stimulates fibroblast proliferation. The dressing neutralises excess proteases and re establishes wound equilibrium. The semi-permeable backing prevents maceration. Urgo Start Contact is a contact layer which should be used with a pad or absorbent dressing for heavily exuding wounds. Indications For use on low to moderately exuding chronic wounds, leg ulcers, pressure and diabetic foot ulcers, Can be used under compression and may be left in place for 7 days. Urgo Start Contact can also be used in cavity wounds. Contraindications Urgo Start/Urgo Start Contact should not be used on infected or critically colonised wounds. Not to be used in cancerous or fistula wounds which may reveal a deep abcess. It is also not recommended to use as first line treatment in acute wounds or in the treatment of Epidermolysis Bullosa (EB). Urgo Start 6cm x 6cm (10) 10cm x 10cm (10) 20cm x 15cm (10) Urgo Start Contact 5cm x 7cm (10) 10cm x 10cm (10) 15cm x 20cm(10) 16cm x 21cm (10) SDT Price Jan 2017 (Each) Specialist Plastic Surgery Dressings PolyMem Description PolyMem is polyurethane foam dressing with a vapour permeable backing. Dressing structure contains a tissue friendly wound cleansing agent and glycerol. PolyMem is available in a non adhesive and adhesive version. Indications Low to moderatley exuding wounds including skin tears and other traumnatic wounds Contraindications Not suitable for full thickness burns. Do not use in conjunction with solutions containing hypochlorite Polymem Non-Adhesive 8cm x 8cm (15) 10cm x 10cm (15) 13cm x 13cm (15) Woundcare Formulary Jan 2017 FINAL DRAFT pdf 36 27/01/ :09

37 17cm x 19cm (15) 10cm x 61cm (4) roll 20cm x 60cm (4) roll Polymem Adhesive 5cm x 5cm (15) 15cm x 15cm (15) 10cm x 13cm (15) 5cm x 7.6cm (15) 8.8cm x 12.7cm (15) oval 16.5cm x 20.9cm (10) oval 18.4cm x 20cm (10)Sacral Scar Management Products Mepiform Dressing Description Self adherent, silicone gel scar dressing Mepiform Dressing 5cm x 7cm (5) 9cm x 18cm (5) 4cm x 31cm (5) Kelcote Spray Dermatix Gel Description Silicone spray/gel for the reduction or prevention of hypertrophic & keloid scars Kel-cote Spray 100mls Dermatix Gel 15g 60g Specialist Use Only ( Dermatology, Vascular, Podiatry) Granulox Spray Description Granulox Spray increases levels of oxygen at the wound bed, speeding up the rate of healing Granulox Spray 12mls Woundcare Formulary Jan 2017 FINAL DRAFT pdf 37 27/01/ :09

38 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. BioBag Dressing 2.5cm x 4cm (1) 5cm x 6cm (1) 10cm x 10cm (1) 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. The NPWT pumps used (Acelity) are free of charge. Dressings and canisters are available on drug tariff. All pumps once discontinued must be returned to the original source. Within the Acute Services Division return units to Ward 33. For community rentals, return to Acelity. 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 or specialist 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) SDT Price Jan 2017 (Each) Woundcare Formulary Jan 2017 FINAL DRAFT pdf 38 27/01/ :09

39 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 (30) Large (20) Eakin Wound Pouches (fold and tuck or bung closures) Small (10) Medium (10) Large (10) Extra Large (5) Other sizes/styles are available, contact companies directly for sizes and prices From 4.77 From 6.89 From 9.00 From Woundcare Formulary Jan 2017 FINAL DRAFT pdf 39 27/01/ :09

40 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 Infection Maceration Necrosis Overgranulation Slough 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 micro organisms that cannot be seen by the naked eye, 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 with sutures, staples or skin glue, 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. 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/waxy in texture. Granulation tissue is raised above the peri-wound area. Devitalised tissue which has yellow/white/grey hue Woundcare Formulary Jan 2017 FINAL DRAFT pdf 40 27/01/ :09

41 Reading List Barwell et al (2015) Diabetes Foot Infection Antibiotic Protocol Briggs et al (2004) Principles of best practice: Minimising pain at wound dressing related procedures. A consensus document Cooper R (2009) Biofilms: hard to detect, easy to under estimate, but most definitely here to stay. Wounds UK. 9 (1) p.12. Cope G (2014) The effects of smoking on wound healing. Wounds UK Vol 10 (2) 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: Healthcare Improvement Scotland (2015)., Antimicrobial Wound Dressings for Chronic Wounds HTA Report 13, Edinburgh: HIS. Available at 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 Woundcare Formulary Jan 2017 FINAL DRAFT pdf 41 27/01/ :09

42 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 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 (2016) Cavity Wounds, Quick Guide 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 Local Tissue Viability Resource: Tissue Viability Resource: Tissue Viability Resource: Skin Tear Guidelines: Best practice for leg ulcer management: NHS Fife Tissue Viability Webpage (Intranet) Diabetic Foot Infection Guidelines:..\..\Desktop\Diabetic Foot Guidance Final - April 2014.pdf Learn Pro Modules: Preventing and Managing Pressure Ulcers, CPR For Feet (NHS Education for Scotland) Woundcare Formulary Jan 2017 FINAL DRAFT pdf 42 27/01/ :09

43 Related policies, standard operating procedures and guidance NHS Fife Procedure for Prevention and Management of Pressure Ulcers (2016) NHS Fife Policy for Obtaining Informed Consent (2013) SIGN Guidelines 120. Management of Chronic Venous Leg Ulcers (August 2010) Healthcare Improvement Scotland, Prevention and Management of Pressure Ulcer Standards, \..\Desktop\HIS Pressure Ulcer Standards 2016.pdf NHS Fife Podiatry Foot Protection and Offloading Guidance 2015 NHS Fife Community Exception Form The lists above are not exhaustive. It is the practitioner s responsibility to be aware of up to date policies and procedures Woundcare Formulary Jan 2017 FINAL DRAFT pdf 43 27/01/ :09

44 WRITE, IMPRINT OR ATTACH LABEL Appendix 1 Wound Assessment Chart Surname... Forenames DoB.. CHI No... Sex.. Assessment Chart for Wound Management Location 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: Woundcare Formulary Jan 2017 FINAL DRAFT pdf 44 27/01/ :09