NPUAP Mission. Clinical Practice Guidelines: Wound Dressings for the Management of Pressure Injuries. npuap.org

Transcription

1 Clinical Practice Guidelines: Wound Dressings for the Management of Pressure Injuries Margaret Goldberg, MSN, RN, CWOCN June 29, 2016 NPUAP Mission The National Pressure Ulcer Advisory Panel (NPUAP) serves as the authoritative voice for improved patient outcomes in pressure injury prevention and treatment through public policy, education and research. npuap.org 1

2 International Guideline NPUAP in collaboration with the European Pressure Ulcer Advisory Panel (EPUAP) and the Pan Pacific Pressure Injury Alliance (PPPIA) has worked to develop a NEW pressure ulcer prevention and treatment Clinical Practice Guideline and a companion Quick Reference Guide. Purchase your copy today at npuap.org NPUAP Monograph Released in November 2012, the 254-page, 24 chapter monograph, Pressure Ulcers: Prevalence, Incidence and Implications for the Future was authored by 27 experts from NPUAP and invited authorities and edited by NPUAP Alumna Dr. Barbara Pieper. The monograph focuses on pressure ulcer rates from all clinical settings and populations; rates in special populations; a review of pressure ulcer prevention programs; and a discussion of the state of pressure ulcers in America over the last decade. Purchase the monograph today at E-version $49 Individual Chapters $19 npuap.org 2

3 Save the date Save the date 3

4 25 29 September THANK YOU to the following companies that have provided support for this webinar! American Medical Technologies ArjoHuntleigh Augustana Care ConvaTec EHOB, Inc. First Quality Healthcare Hill-Rom Leaf Healthcare Medline Industries Mölnlycke Health Care Span America Wellsense The NPUAP webinar commercial supporters did not have any input regarding the content of this presentation. 4

5 Faculty Disclosure The following faculty member has listed a financial interest/arrangement with one or more of the corporate organizations listed below, however no conflict of interests exists for this webinar. Margaret Goldberg, MSN, RN, CWOCN Member of the Nursing Advisory Panel for Acelity. Planning Committee Disclosures Sharon Baranoski, MSN, RN, CWCN, APN- CCNS, FAAN Joyce Black, PhD, RN, CWCN, FAAN Jeffrey Levine, MD Mary Litchford, PhD, RD, LDN Sally O Neill, PhD Mary Sieggreen, MSN, CNS, NP, CVN The planning committee members have listed no financial interest/arrangements that would be considered a conflict of interest. 5

6 Objective Describe criteria for wound dressing selection from the clinical practice guidelines Strengths of Evidence - The body of evidence supporting each recommendation was given a level of evidence A. The recommendation supported by direct scientific evidence controlled trials on pressure ulcers in humans (level 1 studies) B. Supported by direct scientific evidence from clinical series on pressure ulcers in humans (level 2, 3, 4, 5 studies) C. Supported by indirect evidence (e.g. studies in healthy humans, humans with other types of chronic wounds, animal models) and/or expert opinion 6

7 Introduction to wound dressings for treatment of pressure ulcers Wound dressings are a central component of pressure ulcer care Dressings for Pressure Ulcers Since the 1960 s, it has been accepted that wound healing is optimized when the wound is kept in a moist environment rather than air-dried (OTA) dried with heat lamps treating with topically applied drying agents 7

8 Dressings Occlusive or semi-occlusive wound dressings that maintain wound bed moisture promote re-epithelialization and wound closure Wound dressings for pressure ulcers are designed to: Improve wound healing time Absorb blood and tissue exudate Minimize pain associated with application and removal Absorb and control malodour Reduce injury to periwound skin 8

9 General Recommendations Wound dressing selection is based on the: Ability to keep the wound bed moist Need to address bacterial bioburden Nature/volume of wound drainage Condition of the tissue in the ulcer bed Condition of peri-ulcer skin Ulcer size, depth and location Presence of tunneling and/or undermining Goals of the individual with the ulcer SOE = C General Recommendations A clean granulating pressure ulcer requires a dressing that remains in contact with the wound bed or a skin barrier that keeps the periwound dry and prevents maceration. As the ulcer either heals or deteriorates over time, the type of wound dressing most appropriate for promotion of healing may change. For example wound exudate usually decreases as the pressure ulcer heals. This statement is based on expert opinion 9

10 General Recommendations Protect peri-ulcer skin (SOE = C) General Recommendations Assess pressure ulcers at every wound dressing change and confirm the appropriateness of the current dressing regimen. SOE = C 10

11 General Recommendations Follow manufacturer recommendations, especially related to frequency of dressing change (SOE = C) General Recommendations Change dressing if feces seep beneath the dressing (SOE = C) 11

12 General Recommendations The plan of care should guide usual dressing wear times and contain provisionary plans for dressings changes if needed (for family, individual and staff) due to soiling, loosening, etc. (SOC = C) General Recommendations Ensure dressing material completely removed with each dressing change (SOE = C) 12

13 Hydrocolloid Dressings Use for clean Stage 2 pressure ulcers in body areas where they will not roll or melt. (SOE = B) Consider use for noninfected, shallow Stage 3 pressure ulcers. (SOE = B) Consider using filler dressings beneath hydrocolloid dressings in deep ulcers to fill in dead space. (SOE = B) Hydrocolloid Dressings Remove carefully on fragile skin to reduce skin trauma (SOE = B) HCPC Codes A6234 A6241 For use on wounds with light to moderate exudate. Usual dressing change for covers or fillers, is up to 3 times per week. 13

14 Transparent Film Dressings Consider using for autolytic debridement when the individual is not immunocompromised. (SOE = C) Consider using as a secondary dressing for pressure ulcers treated with alginates or other wound filler that will likely remain in the ulcer bed for an extended period of time (e.g., 3-5 days). (SOE = C) Carefully remove film dressings on fragile skin to reduce skin trauma. (SOE = C) Transparent Film Dressings (cont.) Do not use as the tissue interface layer over moderately to heavily exudating ulcers. (SOE = C) Do not use as the cover dressing over enzymatic debriding agents, gels or ointments. (SOE = C) HCPC A6257-A6259 Covered when used on open partial thickness wounds with minimal exudate or closed wounds. Usual dressing change is up to 3 times per week. 14

15 Hydrogel Dressings Consider use on shallow, minimally exudating pressure ulcers. (SOE = B) Consider the use of amorphous hydrogel for pressure ulcers that are not clinically infected and are granulating. (SOE = B) Consider use for treatment of dry ulcer beds (SOE = C) Consider use for painful pressure ulcers. (SOE = C) Hydrogel Dressings (Cont.) Consider the use of hydrogel sheet dressings for pressure ulcers without depth and contours and/or on body areas that are at risk for dressing migration. (SOE = C) Consider the use of amorphous hydrogel for pressure ulcers with depth and contours and/or on body areas that are not at risk for dressing migration. (SOE = C) HCPC A6231-A6233 A6242-A6248 Pads, Ribbons Used on full thickness wounds with minimal or no exudate (e.g., stage 3 or 4 ulcers).usual dressing change for hydrogel wound cover without adhesive border or hydrogel wound fillers is up to once per day. 15

16 Alginate Dressings Consider for the treatment of moderately and heavily exudating ulcers. (SOE = B) Consider in clinically infected ulcers when there is appropriate concurrent treatment of infection. (SOE = C) Gently remove the alginate dressing, irrigating it first to ease removal if necessary. (SOE = C) Consider lengthening the interval or changing the type of dressing if the alginate dressing is still dry at the scheduled time for dressing change. SOE = C) Alginate Dressings HCPC A6196-A Alginate or other fiber gelling dressing For moderately to highly exudative full thickness (e.g., stage 3 or 4 ulcers): and alginate or other fiber gelling dressing fillers for moderately exudative full thickness wound cavities (e.g., stage 3 or 4 ulcers). Not medically necessary for dry wounds or covered with eschar. Change once per day. 16

17 Foam Dressings Consider using on exudative Stage 2 and shallow stage 3 pressure ulcers. (SOE = B) Avoid using single small pieces of foam in exudating cavity ulcers. (SOE = C) Consider using gelling foam in highly exuding pressure ulcers. (SOE = C) HCPC A6209-A6215 Foam Dressings Used on full thickness wounds (e.g., stage 3 or 4 ulcers) with moderate to heavy exudate. Dressing change up to 3 times week. Foam wound fillers up to once per day. Silver-Impregnated Dressings Consider use for pressure ulcers that are clinically infected or heavily colonized. (SOE =B) Use for ulcers at high risk of infection. (SOE =B) Avoid prolonged use, discontinue when wound infection is controlled. (SOE = C) HCPC 4649 Surgical Supply Misc. 17

18 Honey-Impregnated Dressings Consider use of dressings impregnated with medical-grade honey for the treatment of Stage 2 and 3 pressure ulcers. (SOE = C) Cadexomer Iodine Dressings Consider use in moderately to highly exudating pressure ulcers. (SOE = C) HCPC A6261-Gel HCPC A6262-Pad Reduces bacterial load. Once daily dressing change

19 Gauze Dressing Avoid using for open pressure ulcers that have been cleansed and debrided because they are labor-intensive, cause pain when removed if dry, and lead to desiccation of viable tissue if they dry. (SOE = C) When other forms of moisture-retentive dressings are not available, continually moist gauze is preferable to dry gauze. (SOE = C) Use as a cover dressing to reduce evaporation when the tissue interface layuer is moist. (SOE= C) 37 Gauze Dressing Use loosely woven gauze for highly exuding ulcers: tightly woven gauze used for minimally exuding ulcers. SOE = C Loosely fill (rather than tightly pack) ulcers with large tissue defects and dead space with saline-moistened gauze when moisture retentive dressing are not available SOE = C Change gauze often enough to manage exudate SOE = C 38 19

20 Gauze Dressing Use a single gauze strip to fill deep ulcers; Do not use multiple gauze dressings, because retained gauze in the ulcer bed can serve as a source of infection. (SOE = C) Consider using impregnated forms of gauze to prevent evaporation of moisture from continuously moist gauze dressing. (SOE = C) Gauze non-impregnated A6216-A6221, A ,A6407 Gauze, impregnated w/other than water, normal saline, hydrogel or zinc paste A6222-A6224, A6266 Gauze impregnated water or normal saline A6228-A6230) 39 Silicone Dressings Consider using as a wound contact layer to promote atraumatic dressing changes. (SOE = B) Consider using to prevent periwound tissue injury when periwound tissue is fragile or friable. (SOE = B) HCPC A6025 Gel Sheet 40 20

21 Collagen Matrix Dressings Consider use for non-healing Stage 3 and 4 pressure ulcers. (SOE = C) HCPC A6010-Collagen based wound filler, dry form A6011 Collagen based wound filler gel/paste A6021-A6024 Sterile sheet may be used as a primary or secondary dressing. 41 Composite Dressings Many of the dressing types listed here are manufactured in combinations. Various composite dressings with new components for specific purposes emerge in the wound dressing market

22 Biological Dressings Biologicals function as protective wound cover and may be cellular (contain living cells) or acellular (bioglogically inert). Due to insufficient evidence to support or refute the use of biological dressings in the treatment of pressure ulcers, biological dressings are not recommended for routine use at this time. SOE= C 43 Growth Factors: Recombinant Platelet-Derived Growth Factor Consider using Platelet-Derived Growth Factors for treatment of stage 3 and 4 pressure ulcers that have delayed healing. SOE = B 44 22

23 Growth Factors: Other growth factors Due to insufficient evidence to support or refute the use of growth factors (other than recombinant platelet-derived growth factor) in the treatment of pressure ulcers they are not recommended for routine use at this time. SOE = C 45 Prophylactic Dressings Emerging evidence supports a role of prophylactic dressing in decreasing friction and reducing localized shear forces. Consider applying a polyurethane foam dressing to bony prominences (e.g., heels, sacrum) for the prevention of pressure ulcers in anatomical areas frequently subjected to friction and shear. SOE = B 23

24 Prophylactic Dressings When selecting a prophylactic dressing consider: Ability of the dressing to manage microclimate Ease of application and removal Ability to regularly assess the skin Anatomical location where the dressing will be applied The correct dressing size SOE = C Prophylactic Dressings Continue to use all other preventative measure necessary when using prophylactic dressings SOE = C Assess the skin for signs of pressure ulcer development at each dressing change or at least daily, confirm appropriateness of current regiment SOE= C Replace the dressing if damaged, displaced loosened or excessively moist. SOE = C 24

25 Negative Pressure Wound Therapy (NPWT) NPWT used as wound treatment modality for decades Used as late treatment for recalcitrant wounds Now being used as a first line treatment More research is needed to identify which participants are most likely to benefit from NPWT Negative Pressure Wound Therapy (NPWT) NPWT has greatest efficacy in reducing wound volume Serves as an adjuvant therapy when combined with debridement and other treatments that promote wound healing such as nutritional support and pressure redistribution. 25

26 Negative Pressure Wound Therapy (NPWT) 1. Consider as an early adjuvant for the treatment of deep Stage 3 or 4 pressure ulcers SOE B 2. Debride Pressure Ulcer of necrotic tissue prior to NPWT SOE = C 3. Follow a safe regimen in applying and removing NPWT system SOE = C Negative Pressure Wound Therapy (NPWT) 4. Evaluate the pressure ulcer with each dressing change 5. If pain is anticipated consider: nonadherent interface dressing lowering the level of pressure, change type of pressure use moist gauze filler instead of foam 6. Educate the individual and caregivers about NPWT when used in the community setting 26

27 Apply Evidence to Practice Be sure to carefully read dressing package inserts to ensure appropriate interventions It is every clinician s responsibility to educate other healthcare providers and to provide references for their consideration Contemporary practice should always incorporate evolving evidence 53 Inspire change in your practice setting! CEU Test Information To earn the 1.0 continuing education credit from today s webinar please visit the link below. This information will also be ed out to participants ONE HOUR after the conclusion of the webinar. m/sv_6gomj9kpyq1lo7b 27