Silver Dressings. Sajida Khatri PrescQIPP Primary Care Lead.

Transcription

1 Silver Dressings Sajida Khatri PrescQIPP Primary Care Lead

2 Available at: 2

3 Introduction PrescQIPP Silver dressings bulletin published in March 2014 First of the PrescQIPP woundcare bulletins Inspired by Lelly Oboh s innovation award winning project Silver dressings are a high spend area within the dressings spend and often prescribing is inappropriate. Need for review of prescribing. 3

4 BNF Code Dressing type Annual Spend Percentage of spend A5.2.3 soft polymer dressings 35,667, % A5.2.5 Foam Dressings 18,728, % A5.4.1 Protease modulating matrix dressings 18,554, % A5.3.3 Silver dressings 18,312, % A5.8.3 Stockinette 10,758, % A5.2.4 Hydrocolloid dressings 7,305, % A5.8.4 Support bandages 7,259, % A5.8.8 Multi layer compression bandages 6,520, % A5.1.2 Absorbent dressings 5,512, % A5.8.7 Compression bandages 5,258, % A5.7.1 Dressing packs 5,073, % A5.2.2 Vapour permeable films and membranes 4,047, % A5.3.2 Iodine dressings 3,085, % A5.2.6 Alginate dressings 2,806, % A5.1.1 Low adherence dressings 2,652, % A5.3.4 Other Antimicrobial dressings 2,593, % A5.6.1 Topical negative pressure therapy 2,441, % A5.8.9 Medicated bandages 1,787, % A5.3.1 Honey dressings 1,695, % A5.7 Surgical adhesive tape, skin closure strips and skin tissue adhesive 1,652, % A5.7.2 Swabs 1,639, % A5.8.3 Silk/Antimicrobial garments 1,540, % A5.5 Adjunct dressings and appliances 1,437, % A5.2.1 Hydrogel dressings 1,326, % A5.4.2 Silicone keloid dressings 1,262, % A5.2.8 Odour absorbent dressings 951, % A5.8 Bandages- general 742, % A5.2.7 Capillary-action dressings 24, % none Keratin dressing % Total 170,638, % 4

5 Evidence base Antimicrobial (silver) dressings should only be used when infection is suspected as a result of clinical signs and symptoms. Systemic antimicrobials first line Antimicrobial dressings may reduce bacterial numbers in the wound. Should not be routinely used for the management of uncomplicated ulcers Not recommended for acute wounds as there is some evidence they delay wound healing. 5

6 Evidence base No robust clinical, or cost-effectiveness evidence for the use of antimicrobial dressings over non-medicated dressings for treating chronic wounds. Avoid overuse due to concerns with bacterial resistance and toxicity. 6

7 Evidence base There is insufficient evidence to show that any wound dressing (including silver) is better than simple low-adherent dressings for healing venous leg ulcers. Use of silver dressings contentious in malignant ulcer- seek specialist advice. There is insufficient evidence to determine whether silver-containing dressings or topical preparations prevent wound infection or promote wound healing. 7

8 Clinical trials Of the trial evidence available, most trials have been of poor methodological quality with high or uncertain risk of bias. Results have been varying with some trials showing that silver dressings delay wound healing. Lack of high quality trials to establish benefit over other types of dressing. Absence of direct evidence considering costs and benefits together. 8

9 Silver Sulfadiazine Avoid dressings containing silver sulfadiazine. Broad antimicrobial activity. If applied to large areas or for a prolonged time, they can cause blood disorders or skin discolouration. Check with the patient whether they have silver sensitivity. Contra-indicated in neonates, in pregnancy, and in patients with significant renal or hepatic impairment, sensitivity to sulfonamides, or G6PD deficiency 9

10 Choice of dressings CCGs should consider selecting a preferred formulary choice for silver dressings. There should be community nurse involvement and TVN involvement when selecting formulary choices. The cost of community nurse time in changing dressings should also be a factor considered for patients having their dressings changed by a healthcare professional. 10

11 Choice of dressing The formulary choice should take into account cost as well as other required characteristics such as size, adhesion, conformability and fluid handling properties. Options should be available that are appropriate for the type of wound and its stage of healing. Unless the use of a specific dressing can be adequately justified on clinical grounds it would seem appropriate for healthcare professionals to routinely choose the least costly dressing when initiating prescribing. 11

12 12 BNF Advice

13 13 Low Adherence Silver Dressings

14 14 Hydrocolloid Silver Dressings.

15 15 Soft Polymer Silver Dressings

16 16 Foam Silver Dressings

17 Cost per dressing- Alginate silver dressings 17

18 Silver Dressings- Activated Charcoal Activated charcoal dressings are designed for moderate to highly exudating, malodorous wounds. Activated charcoal reduces offensive odour but loses its odour-adsorbing properties once it becomes wet, so frequent changes are often necessary. 18

19 Rationalising prescribing Consider involving a Tissue Viability Nurse (TVN) (if capacity allows locally) when considering initiating silver dressings. Add directions to all prescriptions to avoid overuse. Silver dressings should only be prescribed as acute prescriptions and not added to a repeat prescription. A prescription for 5 dressings should be sufficient for the recommended maximum of 2 weeks treatment. Long-term use should be avoided and they should be discontinued when signs of infection resolve or if the patient experiences adverse effects from the antimicrobial. 19

20 Rationalising prescribing (cont) Stop silver dressings if the wound does not respond or once the infection is controlled. Refer to a TVN for wound assessment if there is no response within 2 weeks. An alternative (standard) dressing may be more appropriate. Do not use silver dressings when daily dressing changes are required Do not use larger sizes of dressings unless necessary as these sizes are significantly more costly. 20

21 Summary Careful consideration should be given before prescribing silver dressings, which are very expensive and only suitable for wounds where there are signs of infection. Silver dressings should only be prescribed for a short duration and not on repeat prescription. Ideally prescriptions should be for up to 5 dressings. The wound should be assessed regularly and the dressing changed to an appropriate non-silver containing dressing as soon as possible. The choice of dressings should be cost-effective and based on the type of wound, including exudate levels, healing stage, type and size of wound. Larger dressings should not be prescribed inappropriately. 21

22 Future Plans for Woundcare workstream Dressings categorisation tool applied to woundcare snapshot so CCGs using FP10 supply can easily identify where their spend is. Sterile Dressing packs published. Protease Modulating Matrix- being worked on Soft polymer next then others to follow. Will be put together in a webkit. 22

23 Any Questions?