Wound Care Management Formulary

Transcription

1 Wound Care Management Formulary Amendment History VERSION DATE AMENDMENT HISTORY 4.0 December 2014 Previous version 5.0 September 2015 Comments Additional products added and products removed that are no longer available. 5.1 July 2018 Draft review of new Products included, comments made 6.0 July 2018 Approved by ACE REVIEWERS This document had been reviewed by: NAME DATE TITLE/RESPONSIBILITY VERSION ACE November 2015 Assurance Framework for managing clinical policies and guidelines ACE July 2018 Assurance Framework for managing clinical policies and guidelines APPROVALS This document has been approved by: NAME DATE TITLE/RESPONSIBILITY VERSION NB: The version of this policy posted on the intranet/internet must be a PDF copy of the approved version. DOCUMENT STATUS This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of the document are not controlled. RELATED DOCUMENTS These documents will provide additional information: REFERENCE DOCUMENT TITLE VERSION NUMBER APPLICABLE LEGISLATION N/A GLOSSARY OF TERMS TERM ACRONYM DEFINITION Clinical Commissioning CCG Group Area Clinical Effectiveness Committee ACE 1

2 Wound Management Formulary Group / Authors Minesh Parbat Wound Management Group Chair Prescribing Adviser, Dudley CCG Lynda Bloomer Diabetes Specialist Podiatrist Sharon Cole Clinical Nurse Specialist Vascular Sheila Coley Leg Ulcer Clinic Co-ordinator Sue Dunning Leg Ulcer Clinic Co-ordinator Angela Mur Clinical Nurse Specialist, Infection Control Gillian Hiskett Tissue Viability Lead Dawn Flavell Tissue Viability Sister Karen McBride Tissue Viability Sister Alison Whitlock Alison Whitlock Clinical Pharmacist Clinical Pharmacist Previous Authors Acknowledgement Louise Storey Practice Teacher for District Nursing Angela Murray Clinical Nurse Specialist, Infection Control Jag Sangha Pharmaceutical Adviser, Dudley CCG Claire Taylor Simon Wharton Specialist Podiatrist Consultant Plastic Surgeon Contacts Infection Control Nurse Hospital Ext 2174 Infection Prevention and Control Team Pharmacy DGNHSFT Pharmaceutical Public Health Team, Dudley CCG Health Protection Team Tissue Viability Team Hospital

3 Contents Products Page Basic Wound Contact Dressings (low adherent) 4 Film dressings 4 Soft polymer wound contact dressings 5 Foams 5 Low tac foam 6 Alginates 6 Hydrofibre 7 Hydrocolloids 7 Hydrogels 8 Charcoal dressings 8 Antimicrobial dressings 8-10 Bandages Products to be used with Tissue Viability / Specialist advice only Absorbent padding 15 Cleansing solutions 15 Skin protectants 16 Other Therapies 16 Appendix 1 Exceptions monitoring form Appendix 2 Authorisation form for silver containing wound dressing 3

4 Basic Wound Contact Dressings Perforated film absorbent dressings are suitable for lightly exuding wounds. They are not appropriate for wounds that produce large quantities of viscous exudate. Atrauman 5cm x 5cm 10cm x 20cm 7.5cm x 10cm 20cm x 30cm Non-adherent knitted polyester primary dressing impregnated with neutral triglycerides. It is suitable for use on abrasions, burns, and other superficial injuries of the skin including ulcers and post-operative wounds. Apply to overlap dry surrounding skin by at least 1cm. Moderate to heavily exuding wounds. Softpore 6cm x 7cm 10cm x 25cm 10cm x 10cm 10cm x 30cm 10cm x 15cm 10cm x 35cm 10cm x 20cm Low adherence dressing consisting viscose and rayon absorbent pad with adhesive border. It is suitable for wounds healing by primary intention. ClearPore 6cm x 7cm 6cm x 10cm 10cmx10cm 10cmx20cm 10cm x 25cm 10cm x 30cm Vapour-permeable adhesive film dressing with absorbent pad. Please note the wound contact pad sizes are approximately 4 to 5cm square smaller than the overall size of the dressing. Shower proof. 9.5 x 19cm 9.5cm x 9.5cm 19cm x19cm An alternative to tulle dressings for exuding wounds. It can be used as the initial layer of multi-layer compression bandaging in the treatment of venous leg ulcers. Film Dressings Vapour permeable films allow the passage of water vapour and oxygen but not water or micro-organisms. They are highly conformable, convenient to use and provide a moist healing environment. Clearpore 6cm x 10cm 10cm x 20cm 4.4cm x 4.4cm* 10cm x 10cm 10cm x 25cm 10cm x 12cm* 10cm x 15cm 10cm x 30cm 10cm x 25cm* 20cm x 30cm* Film dressing that can be used on superficial and epithelialising wounds as a primary contact layer or as a secondary retention dressing. * Hospital only sizes 4

5 Soft Polymer Wound Contact Dressing Dressings with soft polymer in a non-adherent layer are suitable for use on lightly to moderately exuding wounds. They have gentle adhesive properties and can be used on fragile skin areas or where it is beneficial to reduce the frequency of primary dressing changes. For highly exuding wounds, an absorbent secondary dressing is required. Soft polymer dressings should not be used on heavily bleeding wounds as blood clots can cause the dressing to adhere to the wound surface. Urgotul 5cm x 5cm 10cm x 10cm 15cm x 20cm 10cm x 40cm 20cm x 30cm Non adherent soft polymer contact dressing with Lipido-Colloid Technology. It can be left in place for 14 days. It is suitable for use on any acute or chronic low exuding wound. A secondary dressing is required. Mepitel One 6cm x 7cm 9cm x 10cm 13cm x 15cm 24 cm x 27.5cm For use on fragile skin or where it is beneficial to reduce the frequency of primary dressing changes. Can be left in-situ for up to 14 days. A secondary dressing is required. Foam Dressings Dressings containing hydrophilic polyurethane foam (adhesive or non-adhesive) with or without plastic film-backing are suitable as a primary dressing. Foam dressings are not intended as a debriding agent. Some foam dressings have a moisture-sensitive film backing with variable permeability dependant on the level of exudate. If used under compression bandaging or compression garments, the fluid-handling capacity of the foam dressing may be reduced. Lyofoam Max 7.5 cm x 7.5 cm 10 cm x 17.5 cm 15cm x 15cm 10 cm x 10 cm 15 cm x 20 cm 20cm x 20cm For low to moderately exuding wounds. Useful on over-granulating wounds. A secondary dressing is required. Use with oxidising solutions 5

6 Low Tac Foams (Soft Polymer Dressings with Absorbent Pad) Wound contact dressings coated with soft silicone have gentle adhesive properties and are for use on fragile skin only. Allevyn Gentle 5cm x 5cm 10cm x 10cm 10cm x 20cm Allevyn Gentle Border Allevyn Gentle Border (Heel) Allevyn Gentle Border (Sacrum) 15cm x 15cm 20cm x 20cm 7.5cm x 7.5cm 10cm x 10cm 12.5cm x 12.5cm 17.5cm x 17.5cm 23cm x 23.2cm 16.8cm x 17.1cm For low to moderately exuding wounds. A secondary dressing or bandaging may be required. Alginates Alginate dressings are derived from seaweed. Alginates form a firm moist gel on contact with wound exudate to conserve moisture at the wound interface, or aid autolytic debridement. Calcium alginate dressings also aid haemostasis in minor bleeding wounds by providing a matrix to support blood clot formation. They are highly absorbent and indicated for use in moderate to heavily exuding wounds. Sorbsan Flat 5cm x 5cm 10cm x 10cm 10cm x 20cm Sorbsan Ribbon/ Packing 40cm (with probe) 30cm (2g with probe) Sorbsan Plus 7.5cm x 10cm Non adhesive 10cm x 15cm Non adhesive 10cm x 20cm Non adhesive 15cm x 20cm Non adhesive Sorbsan Calcium alginate fibre. It is should be changed depending on the level of exudate, but can be left in-situ for up to 7 days. A secondary dressing is required. Do not wet before applying to the wound. Sorbsan Plus Alginate dressing bonded to a secondary absorbent viscose pad. It is suitable for moderate to heavily exuding wounds. A secondary dressing is required. 6

7 Hydrofibre Hydrofibre dressings are highly absorbent and made from hydrocolloid which is spun and made into a soft, non-woven fleece like dressing. The dressing converts to a soft gel when in contact with wound exudate, providing a moist wound healing environment. The absorptive capacity of the dressing is higher than both alginates and gauzes making it suitable for moderate to heavily exuding wounds. Aquacel Extra 5cm x 5cm 4cm x 10cm 2cm x 45cm Ribbon 10cm x10cm 4cm x 20cm 15cm x15cm 4cm x 30cm It is suitable as a primary dressing for moderate to highly exuding wounds. Aquacel is applied to the wound with an overlap of at least 2.5cm. Cavity wounds should be filled with care to avoid over packing, leaving a 2cm tail outside the cavity wound to facilitate easy dressing removal. A secondary dressing is required. It can be left in-situ for up to 7 days in acute and chronic wounds and up to 14 days in partial thickness burns. Aquacel Foam 7.5cm x 7.5cm 11cm x 11cm 15cm x 15cm (Adhesive) Aquacel Foam 5cm x 5cm 10cm x 10cm 15cm x 15cm (Non-Adhesive) 20cm x 20cm 15cm x 20cm It is suitable as a primary dressing for moderate to highly exuding wounds. Aquacel foam is applied the same as Aquacel Extra but with the added benefit of a protective waterproof outer layer and absorbent soft pad. The adhesive dressing has a gentle adhesive and can be used without a secondary dressing. The non-adhesive would need to be secured with bandage or similar retention product. Known allergies Hydrocolloids Hydrocolloid dressings are usually presented as a hydrocolloid layer on a vapour-permeable film or foam pad. These dressing form a gel in the presence of exudate to facilitate rehydration in lightly exuding wounds and promote autolytic debridement of dry, sloughy, or necrotic wounds. They are also suitable for promoting granulation and removal of hyperkeratosis. Duoderm Extra Thin 7.5cm x 7.5cm 5cm x 10cm 9cm x 15cm 10cm x 10cm 5cm x 20cm* 9cm x 25cm 15cm x 15cm 4.3cm x 3.8cm* 9cm x 35cm For light exuding wounds as a primary dressing. Apply to extend 2cm beyond the wound edge. Infected wounds and diabetic foot ulcers 7

8 Hydrogels Hydrogel dressings are generally used to donate liquid to dry, sloughy wounds and facilitate autolytic debridement of necrotic tissue Kerralite Cool (Non-Border) Kerralite Cool (Border) 5cm x 6.5cm 10cm x 10cm 10cm x 15cm 20cm x 20cm 8cm x 8cm 11cm x 11cm 15cm x 15cm Hydrogel sheet dressing. Limited fluid handling capacity so avoid highly exuding wounds. It is usually recommended to secure in place with a film dressing or bandage if using the non-adhesive version. The dressing should be applied so that the dressing covers the wound and extends by approximately 25mm on to the skin. The dressing can be cut to the shape of the wound should maceration be a problem. Infected wounds Charcoal Charcoal dressings are used to absorb and mask odours produced by fungating lesions, faecal fistulae, necrotic pressure ulcers and heavily exuding ulcers. The main aim is to control odour as rapidly as possible. Malodour may indicate the presence of infection and must be treated according to wound care guidance. Clinisorb 10cm x 10cm 10cm x 20cm 15cm x 25cm Activated charcoal non - absorbent secondary dressing. Apply over a suitable primary dressing and secure. Antimicrobial Dressing Products Prior to prescribing and applying any antimicrobial dressing, please refer to wound care guidelines. Iodine Based Products Povidone-iodine fabric dressing (Povitulle) is a knitted viscose dressing with povidoneiodine. The iodine has a wide spectrum of antimicrobial activity but it is rapidly deactivated by wound exudate. Cadexomer-iodine (Iodosorb / Iodoflex), like povidone-iodine, releases free iodine when exposed to wound exudate. The free iodine acts as an antiseptic on the wound surface, the cadexomer absorbs wound exudate and encourages de-sloughing. The maximum single application is 50g and maximum weekly application is 150g. Systemic absorption of iodine may occur, particularly form large wounds or with prolonged use. Therefore, a three month duration of treatment is recommended. Iodine can be used with caution in children under 6 months and patients with thyroid disease but is contraindicated in use on patients with severe renal impairment, pregnancy, breast feeding. Iodosorb and iodoflex are also contraindicated in patients receiving lithium treatment. 8

9 Povitulle Iodosorb (ointment) Iodoflex (paste) 5cm x 5cm 9.5cm x 9.5cm It is suitable for use as a wound contact layer for low exuding abrasions and superficial burns. A secondary dressing is required. Foams as a secondary dressing with exception of application to areas where bandaging is inappropriate or impractical. 10g 20g It is suitable for treatment of light to moderately exuding wounds. A secondary dressing is required. Foams as a secondary dressing with exception of application to areas where bandaging is inappropriate or impractical. 5g 10g 17g Cadexomer-iodine in a paste basis with gauze backing which should be removed prior to application. It is suitable for treatment of moderate exuding wounds. A secondary dressing is required. Foams as a secondary dressing with exception of application to areas where bandaging is inappropriate or impractical. Medical Grade Honey Medical grade honey has antimicrobial and osmotic properties, producing an environment that promotes autolytic debridement and can help control wound malodour. Honey dressings should not be used on patients with extreme sensitivity to honey, bee stings or bee products. Patients with diabetes should be monitored for changes in blood-glucose concentrations during treatment with topical honey or honey-impregnated dressings, follow diabetic guidelines on blood glucose monitoring. Actilite 10cm x 10cm 10cm x 20cm Knitted viscose impregnated with medical grade honey and manuka oil. It is suitable for low exuding wounds. A secondary dressing is required. Activon 25g tube Medical grade honey is applied directly to the wound and covered with a primary low adherence wound dressing. It is suitable for low to moderate exuding wounds. A secondary dressing is required. Algivon Plus 5cm x 5cm 10cm x 10cm Algivon Plus Ribbon 2.5cm x 20cm Absorbent, non-adherent calcium alginate dressing impregnated with medical grade manuka honey. For moderate exuding wounds and will require a secondary dressing. 9

10 Flaminal Flaminal is a hydro-activate alginate gel dressing which has a naturally occurring enzyme system that specifically targets bacterial cells. The gel is in a tube which single patient use only. The tube reseals itself so that it can be used multiple times without risk of contamination. Ensure the wound bed is covered with at least 5 10mm thick layer of gel. Flaminal Hydro Gel Flaminal Forte Gel 15g tube 50g tube For light to moderately exuding wounds. Will donate moisture to wound bed and promote autolytic debridement. A secondary dressing is required. 15g tube 50g tube For moderate to heavily exuding wounds as it will absorb large quantities of exudate. A secondary absorbent dressing is required. KERLIX PHMB Antimicrobial Gauze specialist use only Cutimed Sorbact 11.4cm x 3.7m Impregnated gauze to prevent bacterial penetration for moderate to heavily exuding wounds as it will absorb large quantities of exudate. A secondary absorbent dressing is required. Use with known sensitivities to PHMB Round Swab 3cm Swab 4cmx6cm Swab 7cmx9cm Do not use with ointments and creams. Silver Dressing Products Aquacel Ag extra plus 5cmx5cm 10cmx10cm Swab15cmx15cm An antimicrobial dressings for use in wounds that are infected or at risk of infection. There is debate around the efficacy of silver containing dressing products and they are expensive. Where you perceive there to be a clinical need for silver dressings, you will need to discuss with one of the following individuals: Tissue Viability and Vascular Nurse Specialist or Diabetes Specialist Podiatrist. Once the patient has been reassessed and a need for prescribing silver containing dressings is confirmed then an authorisation form for silver containing wound dressings will need to be obtained and signed by one of these designated individuals see appendix 2 10

11 Bandages Sub-Compression Wadding Bandage K Soft 10cm x 3.5m 10cm x 4.5m (K soft long) Primary layer for compression bandaging. May require stockinette prior to application if allergic to the wadding. Apply in a spiral with 50% overlap from toe to knee. Cellona 5cm x 2.75m 10cm x 2.75m 7.5cm x 2.75m 15cm x 2.75m Use For lymphoedema patients only as a primary layer for compression bandaging. May require stockinette prior to application if allergic to the wadding. Apply in a spiral with 50% overlap from toe to knee. Light Weight Conforming Bandage Lightweight conforming bandages are used for dressing retention, with the aim of keeping the dressing close to the wound without inhibiting movement or restricting blood flow. They are therefore useful bandaging digits for lymphoedema patients, in dressing retention in patients with confirmed arterial disease or patients with uncontrolled heart failure. Easifix (Type 1) 5cm 7.5cm 10cm 15cm K Band (Type 1) 5cm 7.5cm 10cm 15cm Mollelast (Latex free) (Type 1) 4cm 6cm Support Bandages Since they have limited extensibility, they are able to provide light support without exerting undue pressure. They can be used to prevent oedema. K Lite (type 2) 5cm x 4.5m 7cm x 4.5m 10cm x4.5m 15cm x 5.2m K Lite (long type2) 10cm x 5.2m Use Profore # 1 or K soft under these support bandages to aid patient comfort and absorb any exudate 11

12 Compression Bandages Doppler assessment is required prior to the application of compression therapy. Doppler assessment and application of compression should only be undertaken by those clinicians who are trained and competent to do so. Light compression (type 3a) K-Plus (type 3a) 10cm x 8.7m 10cm x 10.25m High Compression K 3c (High) 10cm x 3m Venous leg ulceration and lymphoedema. Arterial disease, arterial ulcers, diabetes and those with small vessel disease. Cohesive bandage Ko Flex (Type 3a) 10cm x 6m 10cm x 7cm (long) Short Stretch Compression Bandages Actico bandage 4cm x 6m 8cm x 6m 12cm x 6m 6cm x 6m 10cm x 6m Short stretch bandage for venous leg ulceration and lymphoedema. For use with those patients that are mobile i.e. able to walk to the toilet independently. Applied at full stretch using circular, spiral or figure of 8 technique. Arterial disease, arterial ulcers, diabetes and those with small vessel disease. Two Layer Systems Compression is achieved by the combined effects of two extensible bandages applied over a primary dressing. 3M Coban 1 size only Coban lite 10cm x 6m For patients with ABPI 0.5 and above K-Two 0 short cm 25 32cm Use & Tips Measure ankle circumference before application Actico 2 C 18 25cm kit Comfort Layer 1 10cm x 3.5 m Compression Layer 2 10cm x 6m Actico 2 C cm kit Comfort Layer 1 10cm x 3.5 m + 10cm x 2m Compression Layer 2 10cm x 9m 12

13 Medicated Bandages Zinc paste bandage can be used to treat mild eczema and / or leg ulceration, after a patch test has been applied to assess for allergic reaction. They can be used under compression if Holistic and Doppler assessment indicates. A retention bandage or wadding plus support bandage will be required. Caution in patients with arterial insufficiency. Viscopaste PB7 Ichthopaste 7.5cm x 6cm Zinc oxide paste (10%). It can be used in association with compression for the treatment of venous leg ulcers. Apply toe to below knee by pleating bandage every turn at the front of the leg or can be used in strips. Secure with retention bandage. Zinc allergy. Hydroxybenzoates allergy. Not for macerated skin or severe eczema. 7.5cm x 6cm Zinc oxide 6.32% and ichthammol 2% paste. It can be used in association with compression for the treatment of venous leg ulcers. Used in the treatment of chronic eczema and dermatitis where occlusion is indicated. Apply toe to below knee by pleating bandage every turn at the front of the leg or can be used in strips. Secure with retention bandage. Zinc allergy. Hydroxybenzoates allergy. Products to be used by Tissue Viability/Vascular Nurse Advice / Diabetes Specialist Podiatrist /Leg Ulcer Service only LarvaE Available in BioBag 4cm x 5cm 5cm x 6cm 6cm x 12cm 10cm x 10cm 2.5cm x 4cm Half pot Full pot for wounds 2cm x 2cm for wounds 5cm x 5cm Sterile maggots for wet, sloughy wounds. For information or to request treatment, contact Tissue Viability Service. Negative Pressure Refer to dressing order form or Procurement for in-patient use. Wound Therapy Topical therapy to assist with closure of a wound by total negative pressure. Will reduce the bacterial burden of the wound, stimulate granulation, and accelerate wound closure. Specialist technique. Must be applied only by trained, competent practitioners. PolyMem Foam Thin polyurethane foam dressings containing a non-toxic cleanser and a moisturiser with a semi-permeable film backing. Caution Due to the action of the dressing, wounds can become wetter. maceration by use of barrier film. Jelonet / Paraffin 10cm x 10cm Gauze For plastics use only 13

14 Urgostart All sizes Soft adherent foam dressing made of a TLC layer (technology Lipido Colloid) with healing accelerator (NOSF nanooligosaccharide factor) to rebalance wound equilibrium and neutralise proteases. Promotes multiplication of dermal fibroblasts Hydro-Polymer Gel Wound Contact Dressing Hydro Tac 6cm Circular 10cm x 10cm 12.5cm x 12.5cm 15cm x 15cm 20cm x 20cm 18.5 x 18.5 Heel A Hydro responsive wound dressing with Aqua Clear technology. It is suitable for use on any acute or chronic low to moderate exuding wound during the granulation and epithelialisation phases of wound healing. A secondary dressing is required. Hydro-Polymer Gel Wound Contact Dressing Hydro Tac Comfort 8cm x 8cm 12.5cm x 12.5cm 15cm x 15cm 10cm x 20cm 20cm x 20cm 18cm x 18cm (Sacral) A self Adhesive Hydro responsive wound dressing with Aqua Clear technology. It is suitable for use on any acute or chronic low to moderate exuding wound during the granulation and epithelialisation phases of wound healing. A secondary dressing is required. 14

15 Absorbent Padding Non-woven Fabric Swabs 7.5cm x 7.5 cm 5 pads 10cm x 10cm 100 pads Non-sterile gauze swabs for general use swabbing & cleansing. Use dry to swab and moistened to cleanse. Direct contact with wound bed. Zetuvit E Note: Sterile and 10cm x 10cm 10cm x 20cm 20cm x 20cm Non Sterile 20cm x 40cm Zetuvit Plus 10cm x 10cm 10cm x 20cm 15cm x 20cm (sterile) 20cm x 25cm 20cm x 40cm To absorb exudate in moderate to highly exuding wounds as a secondary dressing Kliniderm 10cm x 10cm 10cm x 22cm 20cm x 22cm 20cm x 30cm 20cm x 50cm 5cm x 5cm Super absorbent dressing. Can be used as a primary or secondary dressing Cleansing Solutions As recommended in the Wound Care Guidance, sterile saline should be used for aseptic technique and tap water is sufficient for socially clean cleansing of chronic wounds. Skin Care Good skin care is important to prevent damage that may occur from excess moisture, pressure damage, trauma and dehydration. The aim of skin care is to maintain a healthy tissue condition and reduce the risk of infection Emollients Zerobase 50g 500g For inflamed, damaged or dry skin 50/50 250g tubs This ointment for cutaneous use contains Liquid Paraffin 50% w/w, White Soft Paraffin 50% w/w. 15

16 Skin Protectants Cavilon Barrier cream First line treatment Use Cavilon Barrier film Use Second Line Treatment Proshield Plus Barrier cream Use 2g sachet 28g tube 92g tube Prevent skin damage associated with incontinence or for moisturising dry skin 1ml foam applicator 3ml foam applicator 28ml spray bottle Prevent skin damage associated with incontinence, wound exudate, adhesive trauma and friction 115g Second line when Cavilon ineffective. For moisture lesions only. Prevent skin damage associated with incontinence or for moisturising severely dry skin Other Therapies Debrisoft Debrisoft Lolly 10cm x 10cm 5cm x 2.5cm Physical Debridement Pad. Do not use as a dressing Stop use once the wound is red and vascular Do not use if the patient experiences pain during debridement Debrisoft is a soft pad consisting of monofilament knitted fibres which can be used to aid rapid, safe and easy debridement. The pad can be used to debride stubborn slough and necrosis as well as hyperkeratosis. The pad should be moistened with normal saline or water then with gentle pressure applied to the surface in a circular motion for a few minutes until the required amount of debridement has been achieved. The pad may need to be used again on a separate occasion. All emollients must be washed off before using Debrisoft as they can reduce the effectiveness of the product. Kerrapro Kerraped Footwear All sizes NOT A DRESSING this is a pressure reducing pad for use in the prevention of pressure ulcer formation on intact skin. All sizes For patients with neuropathic foot ulcer or patients with bulky bandages who cannot wear normal shoes, this footwear offers a supportive alternative. 16

17 Appendix 1 Non Formulary Exception Reporting Form To be completed when a non-formulary product is to be used. This will help monitor the appropriateness of the present formulary and influence future decision-making. Patient NHS No:..Team/Ward:... GP Practice:. Tick all that apply Type of wound Wound bed description Skin Tear/ Laceration Wound depth Exudate levels Aim of treatment Epithelialising Superficial Dry Protection Surgical Granulating Shallow Minimal Warm moist environment Pressure Ulcer Sloughy Cavity Moderate Rehydration Venous Ulcer Arterial Ulcer Diabetic Ulcer Other Critically Colonised Deep cavity Heavy Desloughing Infected Sinus Absorption Necrotic Fungating Odour control Antimicrobial effect Current Products in use Formulary Products Used Duration Used Reasons discontinued / not suitable

18 (Continued overleaf) Information relating to non-formulary products used Name of product chosen Time used Rationale for choice Did this product achieve the aims that were highlighted in the rationale for choice? Yes No If no please give reasons Name of person submitting this report: Base/Hospital:.. Contact number: Date:. Signature and Designation: Please return completed forms to Tissue Viability Service, Russells Hall Hospital. 18

19 Appendix 2 Authorisation Form Silver-Containing Wound Dressings Patients Name (NHS number).. Location GP/ Consultant Indications for use: (Tick appropriate box) Prophylaxis and treatment of infection in burns. Short term treatment of infection in leg ulcers and pressure sores. Diabetic foot ulcer Prophylaxis of infection in skin graft and donor sites. Other State. Signs of infection (3 or more must be present) Increased erythema/swelling around wound Cellulitis Increased/unexpected pain Delayed healing and breakdown of the wound Bridging of the wound Wound that probes to bone/exposed bone Pus/abscess formation Fever Malodour Increased exudate Friable and/or discoloured/exuberant granulation tissue New areas of devitalised tissue(slough/necrosis) Wound swab taken? Yes No Microbiology results (if known).. Date.. History of any oral antibiotics- Name Dose and Frequency Duration Date started Yes No Details of any previous topical Antimicrobials used;... 19

20 You must have considered the products below first Iodine based products Yes No Honey Yes No Flaminal Yes No Requested Silver-containing product UrgoTul SSD Aquacel Ag *Other... Rationale for use... *(Other products are not stocked in hospital pharmacy and would require D&T approval before ordering) Treatment must not exceed 14 days. Not to be issued as a repeat Any further comments/actions... Prescribers Name... Contact Number.. Designation... Signature.. Recommended by... NB Please submit this form to one of the below clinicians as appropriate. Tissue viability nurse Diabetes Podiatrist Specialist Nurse Prescribing Lead Vascular nurse specialist Plastic surgeon Leg ulcer specialist Authorised / not authorised (please circle) Authorised Signature: Date: Return completed form to: Hospital pharmacy with the dressing request (in the case of A/E return forms with stock requests- a separate form for each patient) Community requests forward to the Tissue Viability service, Russells Hall hospital 20