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 April 2018 Version 4.0 Page 1 of 26

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 MOT; Medicines Optimisation Team Tel: CAPCCG.prescribingpartnership@nhs.net Tissue Viability Team Tel: cpm-tr.tissueviability@nhs.net Tissue Viability Team Version 3.0 Date: January 2018 Review: January 2020 April 2018 Version 4.0 Page 2 of 26

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: n-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/Characteristic 21 Formulary Choices 22 References 24 Appendix 1 Wound Assessment Form 26 April 2018 Version 4.0 Page 3 of 26

4 1. Scope Wound Assessment and Management Guidelines Cambridgeshire and Peterborough Foundation Trust, general practices and nursing homes for those caring for patients with wounds, Cambridgeshire Community Services (children services). 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 documented holistic and wound assessment should be done as soon as possible after admission to the caseload. The evaluation does not need to be completed at every dressing change if there is little change in the wound condition but document no change in wound condition. Dressing change must be recorded, signed and dated. Progress of the wound must be fully reassessed, signed and dated. April 2018 Version 4.0 Page 4 of 26

5 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 (at 2-4 weeks), the wound should be reassessed weekly (every two weeks at a minimum). 5.1 Completion guide for page one of updated 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, not the date when the patient came on caseload unless they coincided 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 (verbal or written consent) tape measures are available in the dressing packs. Write date, patient initials only and the NHS patient s number four (4) last numbers on the tape measure. Download and attach to SystmOne or protected system used. Location of wound/s Please indicate on body map where the wound is situated. April 2018 Version 4.0 Page 5 of 26

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. Undermining = area tracking, measure with a probe and indicate direction. Wound bed Please estimate percentage of different tissue type in each box. Suture/clips Specify and indicate removal date. 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 edges/surrounding skin Please indicate as outlined. Pain Please assess patient and indicate action. Please refer for medical intervention/pain team. Clinical signs of infection Please indicate and swab if necessary. If the patient is at risk of developing an infection, ensure that daily vital signs are taken. April 2018 Version 4.0 Page 6 of 26

7 Treatment objectives These objectives should be suitable for most patients but a more individualised care plan may need to be added. Use the appropriate objectives according to the phases of healing 1. Patient comfort although could be used for most patient s wound care it is more suitable for end of life patient where no active treatment (e.g. debridement) is suitable. Can be associated with odour control 2. Absorption: for wound with large exudate where the main objective is containing the fluid. 3. Infection control: for infected wound. It can be associated with odour control 4. Odour control: see above 5. Debridement: active treatment 6. Promote granulation: active treatment post or concurrent to debridement 7. Promote epithelialisation: active treatment concurrent to granulation Cleansing solution Please document saline or water. Other solutions are not recommended unless required for a specific clinical need. Clean surrounding skin and wound to remove some slough, dressing debris or exudate. Dressing choice Choose from Wound Care Formulary, review wound progress or deterioration and document the rationale for dressing 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. April 2018 Version 4.0 Page 7 of 26

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 T Tissue non-viable or deficient I Infection or inflammation Debridement (episodic or continuous) Autolytic, sharp surgical, enzymatic, mechanical or biological Remove infected foci Topical/systemic antibiotics Topical antimicrobials Anti-inflammatories Restoration of wound base and repair of the damaged tissue Reduced bacterial counts or controlled inflammation: Inflammatory cytokines protease activity growth factor activity Viable wound bed 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: Wound Bed Preparation. Schultz et al (2003) Wound Rep Reg Vol 11 pp1-28.extending the TIME Concept. Leaper D et al (2012) April 2018 Version 4.0 Page 8 of 26

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 (Acelity/Systagenix) n-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 April 2018 Version 4.0 Page 9 of 26

10 Other Antimicrobials Honey: Activon Tulle (Advancis) 2d choice AB dressing Suitable for sloughy wounds, will debride effectively. Might cause minimal 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 or use viscous honey (tube). Dressing colour will fade as the honey is absorbed toxicity. Suitable for diabetic. Silvercel (Acelity/Systagenix) Silver impregnated alginate dressing 3d choice AB dressing Acticoat (Smith & Nephew) Nanocrystalline silver coated low adherent dressing 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. April 2018 Version 4.0 Page 10 of 26

11 Guideline 1: Necrotic Wounds Aim: To aid debridement by providing a moist environment Is the wound on the heel or foot? Wound Care Guidelines Refer to guideline 2 (Black heels/ toes) Is the wound infected? Refer to Guideline 5 (Infected Wounds) 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 / Biatain ) 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 tes 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. July 2018 Version 4.0 Page 11 of 26

12 Guideline 2: Black Heels/Toes Aim: To protect and maintain infection free Is the wound infected? Refer to Guideline 5 (Infected Wounds) Is the patient diabetic? Check blood glucose for undiagnosed diabetes Refer to Foot Clinic/ Podiatry for further investigation Refer to physician Inadine AND Padding Dressing Choice 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 tes Bandages: Tight or compression bandages must not be used for patients with diabetes or arterial problems unless under close supervision of Specialist team. Refer to GP and TVN Pressure: must be relieved to prevent further damage by using a Repose foot protector or pillow (see guideline) 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. July 2018 Version 4.0 Page 12 of 26

13 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) Is the slough dry? Treat as necrotic (Guideline 1) tes Is the wound exudate Low Dressing Choice Hydrogel (Aquaform ) AND Hydrocolloid (Tegaderm Hydrocolloid / Granuflex )* Wound Care Apply gel to base of wound Cover with hydrocolloid Change when exudates marking is visible 1cm from edge of dressing or if leaking / dislodged Slow/static debridement: consider larvae therapy. Cavities: Consider Topical Negative Pressure therapy, refer to Tissue Viability Nurse for advice. Very High Exudate: consider above or wound drainage bags, refer to Tissue Viability Nurse for advice. Medium Large Hydrofibre (Aquacel ) AND Hydrocolloid (Tegaderm Hydrocolloid / Granuflex )* Hydrofibre (Aquacel ) AND Foam (ActivHeal / Biatain ) or Padding or Superabsorbent dressing 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. July 2018 Version 4.0 Page 13 of 26

14 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) Is the wound hypergranulating? Check for infection and refer to TVN for advice tes Is the wound exudate Low Medium Dressing Choice Hydrocolloid (Tegaderm Hydrocolloid / Duoderm )* OR Foam (ActivHeal / Biatain ) Hydrofibre (Aquacel ) AND Hydrocolloid (Tegaderm Hydrocolloid / Granuflex )* Wound Care 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 Loosely pack/ cover wound with hydrofibre Cover with hydrocolloid Change as above Bleeding: Use an alginate to act as a haemostat (Kaltostat ). 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. Surrounding Skin: If wound exuding or skin fragile, protect with no sting barrier film. Nutrition: Assessment must be carried out and appropriate referral made. Large Hydrofibre (Aquacel ) AND Foam (ActivHeal / Biatain ) or Padding or Superabsorbent dressing Loosely pack/ cover wound with hydrofibre Cover with foam or padding and secure Change as above Specialist Input: Seek further advice for patients with diabetes or arterial problems. July 2018 Version 4.0 Page 14 of 26

15 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 Large Low Medium Iodine (Inadine ) OR Activon Tulle Appropriate secondary dressing Iodine (Iodoflex ) OR Activon Tulle Foam (ActivHeal / Biatain ) or padding 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 tes 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. Is wound condition unchanged after 2 weeks of above care plan? Silvercel OR Acticoat (must be activated with water before use) for 2 weeks Appropriate secondary dressing Cut to size of wound and apply Change every 3 days depending on odour and amount of exudate For further antibacterial advice refer to the TV Team July 2018 Version 4.0 Page 15 of 26

16 Guideline 6: Epithelialising Wounds Aim: To provide a moist, atraumatic environment to complete healing Is the wound reducing in size? Refer to TVN for advice Is the wound exudate? Dressing Choice Wound Care Low Medium Hydrocolloid thin (Duoderm )* OR Low adherent (Atrauman ) and Foam/Cosmopore Reassess wound as unlikely to be epithelialising and refer to appropriate guideline 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. tes 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. Nutrition: Assessment must be carried out and appropriate referral made. Fragile/Sensitive Skin: Mepitel can be considered as alternative dressing as it can remain on the wound for 7 days. Large Reassess wound as unlikely to be epithelialising and refer to appropriate guideline. Specialist Input: Seek further advice for patients with diabetes or arterial problems. July 2018 Version 4.0 Page 16 of 26

17 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? Dressing Choice Refer to A&E or Plastic Surgeons Wound Care Is the wound bleeding? Can wound edges be brought together without force 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. tes 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 / Biatain ) or padding Appropriate secondary dressing Apply gel to open haematoma only Foam or padding to protect Contact TVN for use of another gel. Refer to A&E or Plastic surgeons for debridement July 2018 Version 4.0 Page 17 of 26

18 Guideline 8: n-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 Is the burn superficial? Skin is dry & intact Red, blanches under pressure Minimal tissue damage Painful Is the burn superficial-partial thickness? Blisters immediately Red in areas, moist & exuding Brisk capillary refill Painful & sensitive to temperature changes 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 Is the wound full thickness? 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 or Low adherent (Atrauman ) with appropriate secondary dressing Low adherent (Atrauman ) Gauze 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 tes 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. July 2018 Version 4.0 Page 18 of 26

19 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 July 2018 Version 4.0 Page 19 of 26

20 Leg ulcers guidelines: a holistic assessment, Doppler ABPI, treatment plan is to be performed at first/second visit (a wound is considered chronic between 2 to 4 weeks duration. 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) Lymphoedema 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 Thickened toenails Weak/no pulses Joint abnormalities Evidence of Neuropathy Chronic oedema : large exudate 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 Chronic oedema: whole leg can be affected Investigations Surrounding skin Pain Doppler, BP, Blood sugar, HB/FBC, ESR, CRP 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 ABPI > 1.3 With evidence Arterial Disease (arterial of venous disease calcification) ABPI Evidence of Venous Disease Treat as Venous Ulcer - Apply compression - Keep dressing simple Refer to vascular team. Healed Doppler 6 monthly : Diabetic patient -mixed ulcers Doppler 12 monthly: venous Renew hosiery or other management plan Refer to TVN / Routine Vascular referral apply reduced compression Vascular Referral (URGENT if <0.5) compression Reassessment weekly Definite signs of healing Continue treatment and reassess every week. Refer to TVN / Vascular Referral compression Evidence of Vasculitis, Malignancy or Contact dermatitis Sub-acute infection Refer to TVN Dermatology/Lymphoedema team accordinglyl signs of healing at 8 to 10 weeks Refer complex ulcers to TVN or vascular and dermatology teams. Based on: Management of Chronic Venous Leg Ulcers. Scottish Intercollegiate Guidelines Network (SIGN, 2010 ). Nice Guidelines. Varicose veins (2013) Wound UK. Best Practice Statement. Holistic Management of Venous Leg Ulceration (2016) July 2018 Version 4.0 Page 20 of 26

21 Dressings Criteria Remove excess exudate and toxic components Maintain high humidity at wound dressing interface n-adherent Impermeable to bacteria Capable of maintaining a high humidity at the wound site while removing excess exudate Allows gaseous exchange Thermally insulating Provide thermal insulation n-toxic and non-allergenic Impermeable to micro-organisms Comfortable and comformable Free from Toxic contaminants Capable of protecting the wound from further trauma Removable without causing trauma Requires infrequent dressing changes Cost effective Long shelf-life Available both in hospital and in the community Characteristics of the ideal wound dressing (Bryant R, Nix D, 2016) July 2018 Version 4.0 Page 21 of 26

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 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 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 July 2018 Version 4.0 Page 22 of 26

23 BACTERIAL CONTROL (Use according to antibacterial guidelines) DRESSING RETENTION SKIN BARRIERS MULTILAYER BANDAGES SHORT STRETCH COMPRESSION ADHESIVE SURGICAL TAPE SPECIALIST DRESSINGS POVITULLE 5cm x 5cm ELZ Pack of POVITULLE 0.5cm x 9.5cm ELZ 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 KERRAMAX 22cm x 10cm EME023 PRD Pack of KERRAMAX 20cm x 30cm EME025 PRD 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 Large EJA Pack of July 2018 Version 4.0 Page 23 of 26

24 References Bryant R, Nix D (2016) Acute and Chronic Wounds (5th ed) Mosby. USA European Wound Management Association (EWMA). Position Document: Management of Wound Infection. London: MEP Ltd, European Wound Management Association (EWMA). Position Document: Antimicrobials and non healing wounds. London: MEP Ltd, European Wound Management Association (EWMA). Position Document: Debridement London: MEP Ltd, Flanagan M (2013) Wound healing and skin integrity. Wiley-Blackwell, West Sussex National Institute for Clinical Excellence (2014) The Prevention and Treatment of Pressure Ulcers. NICE, London. National Institute for Clinical Excellence (2013) Varicose Veins NICE, London. Royal College of Nursing (2006) Clinical Practice Guidelines: The Management of Patients with Venous Leg Ulcers. RCN, London. Sign (2010) Management of chronic venous ulcer: a national clinical guideline 120. Thomas S (2010) Wound dressing, London. Turner T.D. (1982) Which dressing and why? Nursing Times 78: 29 (suppl.), 1-3 Wounds UK.(2016) Best Practice Statement: Care of the Older Persons Skin London :Wounds UK Wounds Uk (2016). Best practice Statement: Holistic Management of Venous Leg Ulceration. London :Wounds UK Wound Care Handbook ( ). The comprehensive guide to product selection in association with the Journal of Wound care. MA Healthcare LTD, London. Resources : World Wide Wounds European Wound Management Association July 2018 Version 4.0 Page 24 of 26

25 Appendix 1 Wound Assessment and Management Chart Name NHS DOB Address GP/Surgery Tel DN Team Tel Postcode Residential/Nursing Home Tel Tel Ward Tel Standard: In conjunction with Trust Wound Care Guidelines, an assessment and care-plan should be completed for all patients with wounds. Date of Initial Assessment DD/MM/YY Type of Wound(s) (Please circle) How long has wound been present? Pressure Ulcer Grading Leg Ulcer Moisture Lesion Surgical Skin Tear Burn Other Factors which may delay wound healing (tick if present, tick nil identified if no factors present) Medical Conditions Rheumatoid Arthritis Diabetes Mellitus Cardiac Disease Anaemia Chronic respiratory disease Venous/Arterial Disease Decreased sensation Allergies Skin sensitivities Severe acquired immune defects Immobility Incontinence Infection Obesity Malnutrition Poor nutrition Smoking Alcohol Concordance Issues Please specify Medications Steroids Immunosuppressive Biologics Anti coagulants Cytotoxics n steroidal anti-inflammatory Other.. Nil identified Date referred to: Tissue Viability Team... /../. Dietician.../../... Dermatology../../. Podiatry/Foot Team../../.. Vascular Surgeon../../. Plastic Surgeon../../.. Others../../.. specialist referral required... Full pain assessment completed and appropriate actions taken N/A Wound care-plan discussed/agreed with the patient Verbal Written If pressure ulcer, Waterlow risk assessment, SSKIN and check list fully completed and reviewed If to any of the above, reason for non-completion: Is it necessary to raise a safeguarding concern? Drawing/Photograph Number of Wounds. Location of wound(s) Lower limb un-healed wounds require full assessment with Doppler measurements at 4 weeks completed? / Reason for non-completion Name:... NHS.. DOB Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0 Page 25 of 26

26 Please sign and date every dressing change. Reassess wound as needed using clinical judgement and record any changes. Wound dimensions need to be measured at least weekly. Ensure that a separate form is used for each wound. Dressing Change Date and Time DD/MM/YY 0.00hrs Wound Dimension (cm) Maximum length Maximum width Maximum depth Undermining Visible Tendon/bone / Wound Bed (approx % cover) Necrotic black Sloughy yellow green Granulating red Epithelialising pink Wound edges Healthy H Rolled RO Raised R Undermined U Suture/clips //removal date Exudate levels High H Moderate M Low L Type and colour Surrounding Skin Macerated M Oedematous O Excoriated E Fragile F Dry D Eczema X Healthy H Wound Pain scale 1-10 (10 high) Continuous C Dressing D ne N Clinical signs of infection present: i.e. 2 or more of the following present; pus, odour, deterioration, spreading erythema, heat, increased pain, increased exudate, abscess, friable tissue. Infection present? yes/no If yes, swab taken (date) Antibiotic therapy commenced (date) Treatment Objectives Patient comfort PC Absorption A Infection Control IC Debridement D Odour Control OC Promote granulation G Promote epithelialisation E Cleansing Solution Dressing Choice (if Topical Negative Therapy in use, document details here) Skin Emollient/Cream Frequency of dressing change (number of days) Date of review or healed Signed Print name Designation Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0 Page 26 of 26