Wound Care Guidelines and Dressing Formulary

Transcription

1 Wound Care Guidelines and Dressing Formulary NHS Cambridgeshire and Peterborough CCG Cambridgeshire Community Services Cambridgeshire and Peterborough Foundation Trust January 2018 Version 4.0 Page 1 of 62

2 Background The Wound Care Guidelines have been written by the Tissue Viability Team, and is based on a wide range of clinical evidence and peer reviews. A group of district nurses, practice nurses, tissue viability nurses (TVN), clinical management and members of the Medicine Management Team (MMT) have selected the dressings for the Wound Care Formulary. The present products were selected on the current clinical evidence and cost consideration. A steering group meets four times a year to review any clinical evidence on new products as well as its cost implication. Any suggestions on new products can be made by contacting either the TVN or MMT; Medicines Management Team Tissue Viability Team Tel: Tel: Fax: Fax: CAPCCG.prescribingpartnership@nhs.net ccs-tr.tissueviability@nhs.net Tissue Viability Team Version 3.0 Date: September 2014 Review: August 2015 January 2018 Version 4.0 Page 2 of 62

3 Contents Page Wound assessment and management guidelines 4 TIME Principals of improved wound healing 8 Antibacterial Guidelines 9 Guideline 1: Necrotic Wounds 11 Guideline 2: Black Heels/ Toes 12 Guideline 3: Sloughy wounds 13 Guideline 4: Granulating Wounds 14 Guideline 5: Infected Wounds 15 Guideline 6: Epithelialising wounds 16 Guideline 7: Skin tears/ Pre-tibial lacerations 17 Guideline 8: Non-Complex burns (suitable for outpatient/ primary care management 18 Supplementary guideline for complex burns assessment 19 Guidelines for the assessment and management of leg ulcers 20 Dressings criteria/characteristics of the ideal wound dressing 21 Formulary Choices 22 References 24 Appendix 1 Wound Assessment Form 26 Appendix 2 Foam 28 Appendix 3 Hydrocolloid 32 Appendix 4 Hydrofibre 38 Appendix 5 Alignate 40 Appendix 6 Island Dressing 41 Appendix 7 Non adherent 43 Appendix 8 Bacteria control 44 Appendix 9 Semi-permeable film 54 Appendix 10 Dressing retention 56 Appendix 11 Skin barriers 57 January 2018 Version 4.0 Page 3 of 62

4 1. Scope Wound Assessment and Management Guidelines Cambridgeshire Community Services, general practices and nursing homes for those caring for patients with wounds (excluding normally healing post-surgical wounds). 2. Purpose To ensure the correct assessment and management of patients with wounds. 3. Introduction Choosing a wound dressing depends greatly on a holistic assessment of the patient and their wound; the patient should be at the centre of all care decisions made. Wound assessment should be a systematic process accurately documented on the wound assessment and management care plan. Dressings should be selected from the Trust Wound Care Formulary unless otherwise advised by a specialist. Patients with complex needs should be referred to the most appropriate speciality. 4. Responsibilities All health care professionals involved in the direct assessment and management of wounds. 5. Wound assessment A wound assessment form should be fully completed for all wounds. The evaluation does not need to be completed at every dressing change if there is little change in the wound condition but the dressing change must be recorded, signed and dated. Progress of the wound must be fully reassessed, signed and dated. Any deteriorating wound must have a full re-assessment/evaluation completed and action taken (see general wound care guidelines). In the case of a chronic wound, the wound should be reassessed every two weeks at a minimum. January 2018 Version 4.0 Page 4 of 62

5 5.1 Completion guide for page one of wound assessment form Patient details & Date of initial assessment All details must be completed. Type of wound Circle the relevant box How long has the wound been present? Write length of duration Factors which may delay wound healing Tick all relevant boxes, add extra information as appropriate (check patient s medical notes). Medications Tick all relevant boxes, add extra information as appropriate. Date referred to Tick all relevant boxes; discuss referrals with colleagues and GPs. Do not over-refer to similar specialities, e.g. plastics, dermatology, tissue viability (see general wound care guidelines below for appropriate routes of referral). Drawing/photograph Please illustrate wound. Use photography (consent and guidelines available on Intranet) tape measures are available on dressing packaging or from Tissue Viability. Location of wound/s Please indicate on body map where the wound is situated. January 2018 Version 4.0 Page 5 of 62

6 5.2 Completion guide for page two of wound assessment form Wound dimension Please measure as accurately as possible or indicate if this is an estimation. Length = head to toe furthest points, measured in centimetres. Width = side to side furthest points, measured in centimetres. Depth = may be estimated as very difficult to assess safely and accurately. A sterile gloved finger or wound swab can be used to probe. Grade PU = if the wound is a pressure ulcer please indicate its grade. Wound bed Please estimate percentage of different tissue type in each box. Exudate levels Please complete using the following guidelines High = needs daily or more dressing changes and saturated each time. Moderate = needs dressing changes every 2-3 days and soiled but not soaked. Low = needs weekly or less dressing changes and dressing dry or minimally soiled. Wound margin/surrounding skin Please indicate here and show area described on wound illustration. Macerated / Oedematous / Excoriated / Fragile / Dry / Eczema / Healthy Please indicate. Pain Please assess patient and indicate action place. Please refer for medical intervention/pain team. January 2018 Version 4.0 Page 6 of 62

7 Clinical signs of infection Please indicate and swab if necessary. Treatment objectives These objectives should be suitable for most patients but in certain cases a more individualised care plan may need to be added. Cleansing solution Please document saline or water. Other solutions are not recommended unless required for a specific clinical need. Only clean wound if necessary; to remove dressing debris or exudate from surrounding skin. Dressing choice Choose from Wound Care Formulary and document if and why choice changes during period of care. Frequency of dressing change Please document, dependent on exudates, dressing used and progress of wound. Signed / Print name / Designation This is a legal requirement and must be accompanied by printing name legibly. January 2018 Version 4.0 Page 7 of 62

8 TIME Principles of improved wound healing (wound bed preparation) To use for chronic wounds alongside the current Wound Care Guidelines Clinical Observations WBP clinical actions Impact of your clinical actions Clinical outcomes Debridement (episodic or Restoration of wound base and Viable wound bed continuous) repair of the damaged tissue T Tissue non-viable or deficient I Infection or inflammation Autolytic, sharp surgical, enzymatic, mechanical or biological Remove infected foci Topical/systemic antibiotics Topical antimicrobials Anti-inflammatories Reduced bacterial counts or controlled inflammation: Inflammatory cytokines protease activity growth factor activity Resolution of bacterial imbalance and reduced inflammation. M Moisture imbalance E Edge of wound non-advancing or undermined Apply moisture balancing dressings Or Compression Or NPWT (negative pressure wound therapy) Or Other methods of removing fluid Re-assess cause or consider corrective therapies Debridement Skin grafts Biological agents Adjunctive therapies Maceration avoided Reduction in excessive fluid Reduced oedema Desiccation avoided Restored epithelial cell migration Migrating keratinocytes and responsive wound cells. Restoration of appropriate Protease profile. Moisture balance Advancing edge of wound Adapted from: International Advisory Board on Wound bed Preparation Schultz, Sibbald, Falanga et al (2003) Wound Rep Reg Vol 11 pp1-28 January 2018 Version 4.0 Page 8 of 62

9 Antibacterial Guidelines Evidence concerning the efficacy of topical antimicrobial agents in the management of wounds remains inconclusive. Independent and better designed trials to assess efficacy and cost implications are needed. Reports of resistance are limited; but misuse of these products especially silver products must be avoided. Reassess the management of all wounds treated with antibacterial products after two weeks. Consider the clinical effectiveness (has the wound progressed?) as well as the cost effectiveness of the product. Iodine products are recommended as first choice antibacterial dressings unless the patient has a history of allergy. Iodine products should be used with caution and under close medical observation for patients with thyroid disease. Inadine (Systagenix) Non-adherent dressing impregnated with 10% povidine iodine ointment Suitable for superficial, low exudate wounds Useful for drying ischaemic wounds Dressing colour fading from dark brown to white indicates loss of antibacterial efficacy and needs to be changed Iodoflex (Smith & Nephew) Cadexomer (starch) iodine (0.9%) paste. Iodine released is proportional to the exudate absorbed by the starch in the dressing Suitable for sloughy, exuding wounds Mouldable to shape of wound Dressing colour fading from dark brown to white indicates loss of antibacterial efficacy and needs to be changed Other Antimicrobials January 2018 Version 4.0 Page 9 of 62

10 Honey: Activon Tulle (Advancis) 2d choice AB dressing Silvercel (Systagenix) Silver impregnated alginate dressing 3d choice AB dressing Acticoat (Smith & Nephew) Nanocrystalline silver coated low adherent dressing Suitable for sloughy wounds, will debride effectively. Might cause some discomfort at first due to osmotic effect. Controls odour very effectively. Cut to size so the tulle can be in direct contact with the wound base. Dressing colour will fade as the honey is absorbed No toxicity. Suitable for diabetic. Can be available as an alginate, phone TVN. Useful for debriding wounds Useful to control odour Pack wound lightly Do not change daily. The silver in the dressing is active for 3 days Use only if other antibacterial dressings have been tried or are inappropriate. Rapid release/ fast action silver Can stain surrounding skin Needs to be activated by water prior to use Silver active for minimum of 3 days Useful for managing overgranulation Use only if other antibacterial dressings have been tried or are inappropriate. Use for 2 weeks then review. Toxicity of silver on the healing process is still unclear but caution in its usage is recommended. Contact Tissue Viability Nurses if prolonged use is necessary as alternative products might be more suitable. January 2018 Version 4.0 Page 10 of 62

11 January 2018 Version 4.0 Page 11 of 62 Wound care Guidelines Guideline 1: Necrotic Wounds Aim: To aid debridement by providing a moist environment Is the wound on the heel or foot? Refer to guideline 2 (Black heels/ toes) No Is the wound infected? Refer to Guideline 5 (Infected Wounds) No Is the wound exudate Low Medium Large Dressing Choice Hydrogel (Aquaform ) AND Hydrocolloid (Tegaderm Hydrocolloid / Granuflex )* Hydrofibre (Aquacel ) AND Hydrocolloid (Tegaderm Hydrocolloid / Granuflex )* Hydrofibre (Aquacel ) AND Foam (ActivHeal / Allevyn ) or Padding Wound Care Apply gel to base of wound Cover with hydrocolloid Change when exudate marking is visible 1cm from edge of dressing or if leaking / dislodged Loosely pack/ cover wound with hydrofibre Cover with hydrocolloid Change as above Loosely pack/ cover wound with hydrofibre Cover with foam or padding and secure Change as above Notes Depth: May be difficult to assess fully until necrosis has lifted. Surrounding Skin: If wound exuding or skin is fragile, protect with no sting barrier film. Nutrition: Assessment must be carried out and appropriate referral made. Specialist Input: Sharp debridement must be carried out by a doctor or Tissue Viability Nurse only. Seek further advice for patients with diabetes or arterial problems.

12 January 2018 Version 4.0 Page 12 of 62 Guideline 2: Black Heels/ Toes Aim: To protect and maintain infection free Is the wound infected? Refer to Guideline 5 (Infected Wounds) No Is the patient diabetic? No Check blood glucose for undiagnosed diabetes No Refer to GP and TVN Refer to Foot Clinic/ Podiatry for further investigation Refer to physician Dressing Choice Inadine AND Padding Wool bandage Crepe bandage or Tubular bandage Wound Care Apply Inadine to wound Cover with padding Apply wool bandage Secure with Tubular bandage (Comfifast ) or Crepe bandage. All bandages must be from Toe to Knee Pressure: must be relieved to prevent further damage by using a Repose foot protector or pillow (see guideline) Notes Bandages: Tight or compression bandages must not be used for patients with diabetes or arterial problems unless under close supervision of Specialist team. Surrounding Skin: If wound is exuding or skin is fragile, protect with no sting barrier film. Nutrition: Assessment must be carried out and appropriate referral made. Does the wound present as a blister? (Blood or clear fluid filled) Remove source of friction/ pressure Do not apply dressing Aim to keep blister intact and allow natural reabsorption Specialist Input: Seek further advice for patients with diabetes or arterial problems.

13 January 2018 Version 4.0 Page 13 of 62 Guideline 3: Sloughy wounds Aim: To aid debridement of slough by providing a moist environment Is the wound infected? Refer to Guideline 5 (infected wounds) No Is the slough dry? Treat as necrotic (Guideline 1) No Is the wound exudate Dressing Choice Wound Care Notes Slow/ static debridement: consider larvae therapy. Low Hydrogel (Aquaform ) AND Hydrocolloid (Tegaderm Hydrocolloid / Granuflex )* Apply gel to base of wound Cover with hydrocolloid Change when exudates marking is visible 1cm from edge of dressing or if leaking / dislodged Cavities: Consider Topical Negative Pressure therapy, refer to Tissue Viability Nurse for advice. Very High Exudate: consider wound drainage bags, refer to Tissue Viability Nurse for advice. Medium Large Hydrofibre (Aquacel ) AND Hydrocolloid (Tegaderm Hydrocolloid / Granuflex )* Hydrofibre (Aquacel ) AND Foam (ActivHeal / Allevyn ) or Padding Loosely cover/ pack wound with hydrofibre Cover with hydrocolloid Change as above Loosely cover/ pack wound with hydrofibre Cover with foam or padding and secure Change as above Surrounding Skin: If wound exuding or skin fragile, protect with no sting barrier film. Nutrition: Assessment must be carried out and appropriate referral made. Specialist Input: Sharp debridement must be carried out by a doctor or Tissue Viability Nurse only. Seek further advice for patients with diabetes or arterial problems.

14 January 2018 Version 4.0 Page 14 of 62 Guideline 4: Granulating Wounds Aim: To promote granulation and provide a healthy base for epithelialisation Is the wound infected? Refer to Guideline 5 (infected wounds) No Is the wound hypergranulating? Check for infection and refer to TVN for advice No Is the wound exudate Dressing Choice Wound Care Notes Bleeding; use an alginate to act as a haemostat (Kaltostat ). Low Hydrocolloid (Tegaderm Hydrocolloid / Duoderm )* OR Foam (ActivHeal / Allevyn ) Apply Hydrocolloid or Foam Change when exudates marking is visible 1cm from edge of dressing or if leaking / dislodged Hydrocolloid can be in place 5-7 days Cavities: Consider Topical Negative Pressure therapy, refer to Tissue Viability Nurse for advice. Very High Exudate: consider wound drainage bags, refer to Tissue Viability Nurse for advice. Medium Large Hydrofibre (Aquacel ) AND Hydrocolloid (Tegaderm Hydrocolloid / Granuflex )* Hydrofibre (Aquacel ) AND Foam (ActivHeal / Allevyn ) or Padding Loosely pack/ cover wound with hydrofibre Cover with hydrocolloid Change as above Loosely pack/ cover wound with hydrofibre Cover with foam or padding and secure Change as above Surrounding Skin: If wound exuding or skin fragile, protect with no sting barrier film. Nutrition: Assessment must be carried out and appropriate referral made. Specialist Input: Seek further advice for patients with diabetes or arterial problems.

15 January 2018 Version 4.0 Page 15 of 62 Guideline 5: Infected Wounds Aim: To treat infection systemically and decrease bacterial burden at the wound site - Does the wound look infected? (See notes) Take swab and treat infection with systemic antibiotics until symptoms resolve Check guidelines for use of antibacterials; follow flow chart below for dressing choice Treat wound for two weeks then review Avoid topical antibiotics Is the wound exudate Dressing Choice Wound Care Low Medium Large Is wound condition unchanged after 2 weeks of above care plan? Iodine (Inadine ) OR Activon Tulle Appropriate secondary dressing Iodine (Iodoflex ) OR Activon Tulle Foam (ActivHeal / Allevyn ) or padding Iodine (Iodoflex ) OR Activon Tulle Silvercel OR Acticoat (must be activated with water before use) for 2 weeks Appropriate secondary dressing Apply Inadine or honey Change Inadine daily, Honey every 2 d to 3d day. Apply Iodoflex or honey to the wound Cover with foam Change every 2-3 days Apply as above Cover with foam or appropriate padding Change as above or if leaking Cut to size of wound and apply Change every 3 days depending on odour and amount of exudate Notes Clinical signs of infection: Inflammation, erythema (redness), increased pain, odour, pus, heat, pyrexia, friable (bleeds easily). Surrounding Skin: If wound exuding or skin fragile, protect with no sting barrier film. Nutrition: Assessment must be carried out and appropriate referral made. Specialist Input: Seek further advice for patients with diabetes or arterial problems. For further antibacterial advice refer to the TV Team

16 January 2018 Version 4.0 Page 16 of 62 Guideline 6: Epithelialising wounds Aim: To provide a moist, atraumatic environment to complete healing Is the wound reducing in size? No Refer to TVN for advice Is the wound exudate? Dressing Choice Wound Care Low Hydrocolloid thin (Duoderm )* OR Low adherent (Atrauman ) and pad Apply hydrocolloid or low adherent to wound Change if exudates marking is 1cm from edge of dressing or if the dressing is dislodged Hydrocolloid can be in place for 5-7 days. Notes Protection: Of the wound site is essential for complete healing/ maturation. Surrounding Skin: If wound exuding or skin fragile protect with no sting barrier film. Medium Reassess wound as unlikely to be epithelialising and refer to appropriate guideline Nutrition: Assessment must be carried out and appropriate referral made. Large Reassess wound as unlikely to be epithelialising and refer to appropriate guideline. Fragile/ sensitive skin: Mepitel can be considered as alternative dressing. Specialist Input: Seek further advice for patients with diabetes or arterial problems.

17 January 2018 Version 4.0 Page 17 of 62 Guideline 7: Skin tears/ Pre-tibial lacerations Aim: To provide a protective environment to promote healing and prevent further trauma Is the wound presenting a large surface area or deep tissue exposed? No Refer to A&E or Plastic Surgeons Dressing Choice Wound Care Is the wound bleeding? No Can wound edges be brought together without force No Is there partial or complete skin loss? Kaltostat AND Padding Appropriate secondary dressing Steri-strip without tension Low adherent (Atrauman / Mepitel ) Padding Appropriate secondary dressing Do not attempt to steri-strip or force edges together Low adherent (Atrauman / Mepitel ) Padding Appropriate secondary dressing Apply pressure when securing If bleeds through do not remove, apply further padding on top and refer to A&E if bleeding persists Check wound after 2 days Leave Steri-strips for further 3-5 days Can consider hydrocolloid (Tegaderm Hydrocolloid or Granuflex )*, can be left in place up to 5 days. Use caution on fragile skin. Notes Surrounding Skin: If wound exuding or skin fragile, protect with no sting barrier film. Nutrition: Assessment must be carried out and appropriate referral made. Specialist Input: Seek further advice for patients with diabetes or arterial problems. Lower limb injury: Secure dressing with wool bandage and crepe bandage applied from toe to knee. Is there a significant haematoma with or without skin trauma? Hydrogel (Aquaform ) - for open wounds only Foam (ActivHeal / Allevyn ) or padding Appropriate secondary dressing Apply gel to open haematoma only Foam or padding to protect Refer to A&E or Plastic surgeons for debridement

18 January 2018 Version 4.0 Page 18 of 62 Guideline 8: Non-Complex burns (suitable for outpatient/ primary care management) Aim: To provide a protective environment to promote healing and ensure appropriate referral for complex burns Is the burn complex? (See guideline overleaf) Refer to A&E or Plastic Surgeons No Is the burn superficial? Skin is dry & intact Red, blanches under pressure Minimal tissue damage Painful No Is the burn superficial-partial thickness? Blisters immediately Red in areas, moist & exuding Brisk capillary refill Painful & sensitive to temperature changes No Is the wound deep-partial thickness (deep dermal)? Pale/white/creamy in colour, may have large blisters Less moist initially Difficult to assess capillary refill Sensitive to deep pressure but not to pin-prick No Is the wound full thickness? No May appear waxy white, cherry red, grey or leathery Minimal or no pain, no response to pressure or temperature May have less deep & very painful peripheries Dressing Choice Topical moisturiser (Aqueous cream) or; Low adherent (Atrauman ) with appropriate secondary dressing Low adherent (Atrauman ) Toppers or absorbent padding, depending on exudate Secure with appropriate secondary dressing Low adherent (Atrauman ) Loosely applied cling film Low adherent (Atrauman ) Loosely applied cling film Wound Care Check wound after 48 hours Should heal within 2-3 days Can consider a hydrocolloid thin (Duoderm ) if no blistering Check wound after 48 hours Should heal within days if no infection Can consider Flamazine if antibacterial is indicated Refer to Emergency Department for urgent specialist Plastic Surgical advice Refer to Emergency Department for urgent specialist Plastic Surgical advice Notes Surrounding Skin: If wound exuding or skin fragile, protect with no sting barrier film. Nutrition: Assessment must be carried out and appropriate referral made. See over for Burns assessment guidelines.

19 January 2018 Version 4.0 Page 19 of 62 Supplementary guideline for Complex burns assessment Seek further advice for: Patient <5yrs or >60yrs Patient is <16yrs & burn is dermal or full thickness involving >5% Total Body Surface Area (TBSA) Patient is adult & burn is dermal or full thickness involving >10% Total Body Surface Area (TBSA) Burn is on face, hands, perineum, feet, flexures Burn is circumferential dermal or full thickness to limbs, torso or neck Burn is chemical, acid, ionising radiation, high pressure steam, electrical, suspicion of non-accidental injury Burn is an inhalation injury Patient also has; cardiac or respiratory problems, immunological conditions, pregnancy, or associated injuries Guidelines

20 January 2018 Version 4.0 Page 20 of 62 VENOUS ARTERIAL OTHERS Venous ulcers Phlebitis TIA Hypertension CVA Claudication MI Arterial surgery DVT/PE Family history Leg fracture Pregnancies Varicose veins Previous venous surgery Rheumatoid arthritis Diabetes Malignancy (ulcer associated) Varicose veins Ankle flare Brown pigmentation Woody, indurated skin Eczema Examination of foot and leg (disease indicators) Shiny/thin/hairless skin Night pain - Skin cold/blue/white relieved when Poor capillary filling leg dependent Joint abnormalities Evidence of Neuropathy Gaiter region / internal & external malleolus Sloping edge / irregular margin Examination of ulcers On foot or anywhere on lower limb Deep and punched out High on calf /on foot Rolled edge Investigations Surrounding skin Pain Doppler, BP, Blood sugar, HB/FBC, ESR, Healthy, Oedematous, Red, Macerated Assess using pain scale If available BMI, Urinalysis, Swab if clinically infected Eczematous / Contact dermatitis Identify cause of ulcer. Treat wound according to guidelines. Treat underlying cause ABPI ABPI < 0.6 Evidence of Venous Disease Treat as Venous Ulcer - Apply compression - Keep dressing simple ABPI With evidence of venous disease Refer to TVN / Routine Vascular referral apply reduced compression Vascular Referral (URGENT if <0.5) No compression ABPI > 1.3 with evidence of diabetes, RA or Arterial Disease Refer to TVN / Vascular Referral No compression Evidence of Vasculitis, Malignancy or Contact Dermatitis Refer to TVN Dermatology Referral Reassessment at 12 weeks Healed After care Doppler 3-6 monthly Definite signs of healing Continue treatment and reassess every week. No signs of healing at weeks Refer to Community leg ulcer clinic or TVN. Seek advice from TVN for referral to Combined leg ulcer clinic at Addenbrooke s Hospital. These recommendations are for guidance only. Based on Royal College of Nursing (2006) Clinical Practice Guidelines: The Management of Patients with Venous Leg Ulcers. RCN, London. Dressings Criteria (Turner 1982) Remove excess exudate and toxic components

21 January 2018 Version 4.0 Page 21 of 62 Maintain high humidity at wound dressing interface Allows gaseous exchange Provide thermal insulation Impermeable to micro-organisms Free from Toxic contaminants Removable without causing trauma Non-adherent Impermeable to bacteria Capable of maintaining a high humidity at the wound site while removing excess exudate Thermally insulating Non-toxic and non-allergenic Characteristics of the ideal wound dressing (Bryant R, Nix D, 2007) Comfortable and comformable Capable of protecting the wound from further trauma Requires infrequent dressing changes Cost effective Long shelf-life Available both in hospital and in the community Turner T.D (1982) Which dressings and why? Nursing times 78:29 (suppl.), 1-3 Bryant R, Nix, D (2007) Acute and Chronic Wounds. Current Management Concepts (3 rd ed). Mosby. St Louis.USA

22 Formulary Choices Dressing Size NPC code Supplier Code Unit Issue Cost per dressing FOAM ACTIVHEAL FOAM (non adhesive) 5cm x 5cm ELA Pack of ACTIVHEAL FOAM (non adhesive) 10cm x 10cm ELA Pack of ACTIVHEAL FOAM (non adhesive) 18cm x 10cm ELA Pack of BIATAIN (non-adhesive) 10cm x 10cm ELA Pack of ACTIVHEAL FOAM (adhesive) 10cm x 10cm ELA Pack of ACTIVHEAL FOAM (adhesive) 12.5cm x 12.5cm ELA Pack of BIATAIN SILICONE (adhesive) 7.5cm x 7.5cm ELA Pack of BIATAIN SILICONE (adhesive) 10cm x 10cm ELA Pack of BIATAIN SILICONE (adhesive) 12.5cm x 12.5cm ELA Pack of HYDROCOLLOID GRANUFLEX (Modified) 10cm x 10cm ELM141 S150 Pack of GRANUFLEX (Bordered) 6cm x 6cm ELM151 S155 Pack of GRANUFLEX (Bordered) 10cm x 10cm ELM053 S156 Pack of GRANUFLEX (Bordered) 15cm x 15cm ELM155 S157 Pack of DUODERM (Extra Thin Film) 5cm x 10cm ELM317 S163 Pack of DUODERM (Extra Thin Film) 7.5cm x 7.5cm ELM311 S160 Pack of DUODERM (Extra Thin Film) 10cm x 10cm ELM050 S161 Pack of DUODERM (Extra Thin Film) 15cm x 15cm ELM051 S162 Pack of TEGADERM (Oval) 10cm x 12cm ELM Pack of TEGADERM (Oval) 13cm x 15cm ELM Pack of TEGADERM (Oval) 19cm x 22.2cm ELA Pack of HYDROFIBRE AQUACEL EXTRA 5cm x 5cm ELY377 S7500 Pack of AQUACEL EXTRA 10cm x 10cm ELY378 S7501 Pack of AQUACEL RIBBON 1cm x 45cm ELY Pack of AQUACEL RIBBON 2cm x 40cm ELY013 S7503 Pack of ALGINATE KALTOSTAT 5cm x 5cm ELS Pack of SORBSAN RIBBON 1g x 40cm ELS Pack of HYDROGEL AQUAFORM 8g tube ELG C Pack of ISLAND DRESSING COSMOPOR E 5cm x 7.2cm EIJ Pack of COSMOPOR E 8cm x 10cm EIJ Pack of COSMOPOR E 8cm x 15cm EIJ Pack of COSMOPOR E 10cm x 20cm EIJ Pack of NON ADHERENT WOUND SEMI-PERMIABLE FILM ATRAUMAN 7.5cm x 7.5cm EKA Pack of ATRAUMAN 10cm x 20cm EKA Pack of AUTRAMAN 20cm x 30cm EKA Pack of CLEARFILM 6cm x 7cm ELW Pack of CLEARFILM 10cm x 12cm ELW Pack of CLEARFILM 15cm x 20cm ELW Pack of January 2018 Version 4.0 Page 22 of 62

23 OPSITE POST-OP (For surgical wounds only) 9.5cm x 8.5cm ELW Pack of OPSITE POST-OP (For surgical wounds only) 6.5cm x 5cm ELW Pack of BACTERIAL CONTROL (Use according to antibacterial guidelines) DRESSING RETENTION SKIN BARRIERS MULTILAYER BANDAGES SHORT STRETCH COMPRESSION ADHESIVE SURGICAL TAPE SPECIALIST DRESSINGS INADINE 5cm x 5cm EKB501 P01481 Pack of INADINE 9.5cm x 9.5cm EKB502 P01512 Pack of ACTICOAT 10cm x 10cm ELY Pack of ACTICOAT 5cm x 5cm ELY Pack of SILVERCEL 11cm x 11cm ELS150 CAD011 Pack of SILVERCEL 5cm x 5cm ELS149 CAD050 Pack of ACTIVON TULLE 5cm x 5cm EJE027 CR3761 Pack of ACTIVON TULLE 10cm x 10cm EJE028 CR3658 Pack of IODINE PASTE 5g tube EKB Pack of ICTHOPASTE 7.5cm x 6m EFA Each 5.78 VISCOPASTE 7.5cm x 6m EFA Each 5.22 K-BAND 10cm x 4m EDB Pack of COMFIFAST (Green) 5cm x 10m EGP006 F25 Each 2.20 COMFIFAST (Blue) 7.5cm x 10m EGP007 F35 Each 2.35 COMFIFAST (Yellow) 10.75cm x 10m EGP008 F45 Each 3.45 MEDI DERMA-S STERILE NON STING MEDICAL BARRIER FILM 1ml ELY532 MB61076 Pack of MEDI DERMA-S BARRIER CREAM NON_STERILE 2g sachet ELY536 MB60338 Pack of K-FOUR K-SOFT (Layer #1) 10cm x 3.5m EPA Pack of K-FOUR K-LITE (Layer #2) 10cm x 4.5m ECA Pack of K-FOUR K-PLUS (Layer #3) 10cm x 8.7m ECA Pack of K-FOUR KO-FLEX (Layer #4) 10cm x 6m ECD Pack of ACTICO ACTIVA 8cm x 6m EBA Each 4.10 ACTICO ACTIVA 10cm x 6m EBA Each 4.25 ACTICO ACTIVA 12cm x 6m EBA Each 5.42 MICROPORE 1.25cm x 9.14m EHU Pack of MICROPORE 2.5cm x 9.14m EHU Pack of MEPITEL (For sensitive skin only) 5cm x 7cm EKH Pack of MEPITEL (For sensitive skin only) 8cm x 10cm EKH Pack of MISCELLANEOUS TEGADERM SUPERABSORBER 20cm x 10cm EKH Pack of TEGADERM SUPERABSORBER 20cm x 30cm EKH Pack of NON WOVEN SWABS 10cm x 10cm ENK Pack of STRIPS 6mm x 75mm EIR Pack of NORMASOL 25ml MRB Pack of ABSORBANT DRESSING PAD 10cm x 20cm EJA Pack of cm x 40cm EJA Pack of Small EJA Pack of SOFTDRAPE DRESSING PACK VITREX Medium EJA Pack of January 2018 Version 4.0 Large EJA Pack of Page 23 of 62

24 References Baranosky S, Ayello E (2004) Wound Care Essentials. Lippincott Williams & Wilkins. London. Bryant R, Nix D (2007) Acute and Chronic Wounds (3d ed) Mosby. USA Cutting K (2008) Trends in Wound Care. Volume V. Quay Books. London. Dowsett C, Claxton K (2006) reviewing the evidence for wound bed preparation. Journal of Wound Care.15 (19): Dunn K, Edwards-Jones V. (2004) The role of Acticoat with nanocrystalline silver in the management of burns. Burns suppl. 30 (1): S1-S9. European Wound Management Association (EWMA). Position Document: Management of Wound Infection. London: MEP Ltd, European Wound Management Association (EWMA). Position Document: Identifying Criteria for Wound Infection. London: MEP Ltd, European Wound Management Association (EWMA). Position Document: Pain at Wound Dressing Changes. London: MEP Ltd, Grey JE, Harding KG. (2006) ABC of Wound Healing. Blackwall Publishing. Oxford. Hettiaratchy S., Papini R. and Dziewvlski P. (2005) ABC of Burns. Oxford, United Kingdom. Blackwell. Lansdown ABG, Williams A, Chandler S, Benfield S. (2005) Silver absorption and antibacterial efficacy of silver dressings. Journal of Wound Care. 14 (4): Moffatt C, Martin R, Smithdale R (2007) Leg Ulcer Management. Blackwell. Oxford. National Institute for Clinical Excellence (2001) Guidance for the use of debriding agents and specialist wound care clinics for difficult to heal surgical wounds. The Stationary Office. London. National Institute for Clinical Excellence (2005) The Prevention and Treatment of Pressure Ulcers. NICE, London. Royal College of Nursing (2006) Clinical Practice Guidelines: The Management of Patients with Venous Leg Ulcers. RCN, London. Thomas S (1997) A guide to dressing selection. Journal of Wound Care. 6 (10): January 2018 Version 4.0 Page 24 of 62

25 Turner T.D. (1982) Which dressing and why? Nursing Times 78: 29 (suppl.), 1-3 Wounds UK. Best Practice Statement: Care of the Older Persons Skin. Wounds UK, a subsidiary of HealthComm UK Limited, Aberdeen, Wound Care Handbook. The comprehensive guide to product selection in association with the Journal of Wound care. MA Healthcare LTD. London Watret L. (2004) Wound bed preparation and the journey through TIME. British Journal of Nursing suppl. 13 (8): S27-S30 White R (2008) Advances in Wound Care. Wounds UK Ltd. Aberdeen The following documents are available to download on: Wound exudate and the role of dressings - A consensus document (2007) MEP Ltd Vacuum assisted closure: recommendations for use - A consensus document (2008) MEP Ltd Diagnosis and wounds - A consensus document (2008) MEP Ltd Wound infection in clinical practice.an international consensus document (2008). MEP Ltd World Wide Wounds The Leg Ulcer Forum European Wound Management Association. January 2018 Version 4.0 Page 25 of 62

26 Appendix 1 Wound Assessment and Management chart Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0 Page 26 of 62

27 Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0 Page 27 of 62

28 Appendix 2 Foam ActivHealFoam Adhesive Dressing Product Description INDICATED FOR MODERATE TO HEAVILY EXUDING WOUNDS ActivHeal Foam Adhesive dressings are sterile wound dressings, consisting of a pink waterproof polyurethane bacterial barrier, membrane coated with pressure sensitive acrylic adhesive, with a centrally located hydrophilic absorbent polyurethane foam pad. Indications ActivHeal Foam Adhesive dressings may be used throughout the healing process and are indicated for chronic and acute wounds including pressure ulcers, venous leg ulcers, diabetic ulcers, lacerations, abrasions, post operative surgical wounds, superficial and partial thickness burns and cavity wounds, as a secondary dressing. ActivHeal Foam Adhesive dressings are suitable for use under compression bandaging. Precautions Do not use on patients with a known sensitivity to polyurethane films or foams. Do not use with oxidising solutions such as hypochlorite or hydrogen peroxide, as these can break down the absorbent polyurethane component of the dressing. Do not reuse in whole or in part, as it may compromise sterility and/or the performance of the dressing. For external use only. For long term repeated use, a clinical assessment by a clinician / healthcare professional is recommended. Directions for Use 1. Select a size of ActivHeal Foam Adhesive where the foam pad is slightly larger than the wound. 2. The foam pad size should be such that it extends well beyond the open wound (at least 0.75 [2cm]) in all directions. 3. Remove the release liners from the wound dressing, avoid touching the central part of the dressing that will be placed directly onto the wound. 4. Centre the dressing on the wound and apply it gently to the wound site. Press the dressing on the surrounding skin by gentle application of pressure. Dressing Change and Removal 1. ActivHeal Foam Adhesive can remain in situ up to 7 days, dependent on patient condition and the level of exudate. Change the dressing when significant signs of exudate are visible on the dressing. Initially, it may be necessary to change the dressing every 24 hours or whenever good wound care practice dictates. 2. Remove the dressing by peeling off from a corner using gentle pressure. 3. Gently remove the dressing from the wound bed and discard. 4. If required, cleanse the wound site with a suitable wound cleanser prior to application of a new dressing. Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0 Page 28 of 62

29 ActivHeal Non-Adhesive Foam Dressing Product Description INDICATED FOR MODERATE TO HEAVILY EXUDING WOUNDS ActivHeal Non-Adhesive Foam dressings are sterile wound dressings, consisting of hydrophilic absorbent polyurethane foam laminated to a pink, low friction waterproof polyurethane film, which also provides a bacterial barrier. Indications ActivHeal Non-Adhesive Foam dressings may be used throughout the healing process and are indicated for chronic and acute wounds including pressure ulcers, venous leg ulcers, diabetic ulcers, lacerations, abrasions, post operative surgical wounds, superficial and partial thickness burns and cavity wounds, as a secondary dressing. ActivHeal Non-Adhesive Foam dressings are suitable for use under compression bandaging. Precautions Ensure the dressing is applied to the wound pink side up. Do not use on patients with a known sensitivity to polyurethane films or foams. Do not use with oxidising solutions such as hypochlorite or hydrogen peroxide, as these can break down the absorbent polyurethane component of the dressing. Do not reuse in whole or in part, as it may compromise sterility and/or the performance of the dressing. For external use only. For long term repeated use, a clinical assessment by a clinician / healthcare professional is recommended. Directions for Use 1. Select a size of ActivHeal Non-Adhesive Foam that is slightly larger than the wound. If necessary the dressing can be cut (using sterile scissors) to the wound size. 2. Centre the dressing on the wound and apply it gently to the wound site. 3. Fix the dressing in place with a suitable tape to ensure the dressing remains in position. Dressing Change and Removal 1. ActivHeal Non-Adhesive Foam can remain in situ up to 7 days, dependent on patient condition and the level of exudate. Initially, it may be necessary to change the dressing every 24 hours or whenever good wound care practice dictates. 2. Gently remove the dressing from the wound bed and discard. 3. If required, cleanse the wound site with a suitable wound cleanser prior to application of a new dressing. Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0 Page 29 of 62

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33 Appendix 3 Hydrocolloid Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0 Page 33 of 62

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39 Appendix 4 - Hydrofibre Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0 Page 39 of 62

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41 Appendix 5 Alignate Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0 Page 41 of 62

42 Appendix 6 Island Dressing Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0 Page 42 of 62

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44 Appendix 7 Non adherent Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0 Page 44 of 62

45 Appendix 8 Bacterial control Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0 Page 45 of 62

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55 Appendix 9 Semi-permeable film Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0 Page 55 of 62

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57 Appendix 10 Dressing retention Ichthopaste Bandages PRODUCT SAFETY DATA SHEET 1. PRODUCT NAME(S): ICHTHOPASTE 2. INTENDED USES: For the treatment of venous leg ulcers and chronic eczema/ dermatitis (where occlusion is indicated). 3. COMPOSITION: Ichthopaste bandages consist of a gauze bandage impregnated with a formulated paste containing the following;- purified water, glycerol BP, zinc oxide BP, gelatin BP, emulsifying wax BP, phenoxyethanol BP and Ichthammol BP. The bandage is wound onto a polypropylene core, wrapped in a polythene sheet and sealed in a polythene pouch. 4. PHYSICAL AND CHEMICAL PROPERTIES: Combustible solid. 5. HEALTH HAZARD: Product contains substances that are/ have: Risk of serious damage to eyes Irritating to eyes Harmful if swallowed Irritating to skin on prolonged or frequent exposure However, exposure is likely to be low due to relative concentrations/ incorporation within the formulation. Product should not be used in known cases of sensitivity or allergy to any of the ingredients. 6. FIRE HAZARD AND EMERGENCY ACTION: The product is combustible and can give off toxic fumes when ignited. In the case of fire, any standard fire extinguishers can be used. Wear self contained breathing apparatus. 7. HANDLING AND STORAGE PRECAUTIONS: Store in a cool dry place < 25 C. Keep away from source s of ignition. 8. TRANSPORT PRECAUTIONS: Not Applicable. 9. EXPOSURE CONTROL/ PRESONAL PROTECTION: Other than areas of treatment, gloves may be worn to prevent frequent or prolonged exposure. 10. DISPOSAL: Controlled incinerated/ landfill according to local environmental health guidelines. 11. FIRST AID: a) Inhalation: Not Applicable b) Contact with skin: Wash affected part with soap and water. c) Contact with eyes: Irrigate well with clean water. Seek medical advice d) Ingestion: Do not induce vomiting. Seek medical advice 12. STABILITY AND REACTIVITY: Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0 Page 57 of 62

58 Not Applicable under normal conditions. 13. ACCIDENTAL RELEASE MEASURES: Can be contained and swept up mechanically. Dispose of in accordance with section ECOLOGICAL INFORMATION: Product contains substances that are dangerous to the environment; do not discharge into waste water or waterways. 15. REGULATORY INFORMATION: Not Applicable 16. TOXICOLOGICAL INFORMATION: See information detailed in section ADDITIONAL INFORMATION: Product sold as a CE marked Medical Device. 18. NAME, ADDRESS AND TELEPHONE NUMBER OF SUPPLIER: Documentation and Records Department Smith & Nephew Wound Management Division P.O. Box 81 Hessle Road Hull HU3 2BN Tel: (01482) REFERENCE NUMBER, DATE OF ISSUE: PSDS 032 December 2008 This information is provided in accordance with the requirements of the UK Health and Safety at Work Act 1974, and specifically in order to assist users of the product to make their assessment of health risks as required by the UK Control of Substances Hazardous to Health Regulation 2002 (COSHH assessments). Provision of this information does not preclude users from seeking advice from other sources as indicated in the COSHH guidelines. The information is intended to cover potential hazards at the place of work and does not detail medical uses, indications, contra-indications and precautions for the treatment of patients. Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0 Page 58 of 62

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60 Appendix 11 Skin barriers Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0 Page 60 of 62

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