WOUND MANAGEMENT FORMULARY

WOUND MANAGEMENT FORMULARY Please Note: Staff must only use Dressing Products listed on this Formulary. Any deviation from the Formulary must be authorised by a Clinical Nurse Specialist or the BCH Wound Care Service September 2010

Contents Introduction and Guidelines to using Formulary Pages 3-6 Wound Healing Continuum and appropriate products Pages 7-12 BCH Wound Management Formulary Pages 13-24 Compression Bandaging Formulary Page 25-26 Compression Hosiery Formulary Page 27-28 Other Appliances Page 29 Specialist Products Page 30 Cleansing wounds Page 31 MRSA in Wound Management Page 32-33 Criteria for use of Antimicrobial therapy in wound care Page 34 Care of Burns Page 35 Podiatry Page 36 Consultation Process Page 37

Introduction This fourth edition of the Bristol Community Health (BCH) Wound Management Formulary has been produced by the product review group representing District, Practice and Treatment Room Nurses and Clinical Nurse Specialists from across Bristol. The Formulary is an active document and practitioners across Bristol Community Health are continually engaged in evaluating and sharing experiences of wound management products. This enables us to determine which products demonstrate effective wound management and promote cost effective wound care and results in a formulary that supports best practice. Cost effectiveness remains an important focus, as it is essential that a high standard of wound care is delivered using the resources we have appropriately. Summary of Key Messages Aims: There must always be a clear rationale for the choice of dressings. Layers of expensive dressings must be avoided The Nurse managing the wound must be aware of the total cost of the dressing regime Dressing choice should reduce the frequency of dressing changes. Best practice in wound management throughout BCH. To guide practitioners in appropriate dressing choice Standardisation of appropriate practice Cost effectiveness Wound Management Dressings are applied to a wound to deliver many benefits: To facilitate rapid and cosmetically acceptable healing To reduce pain To prevent or combat infection To contain exudate To prevent or reduce scar formation To remove or contain odour To provide maximum comfort for the patient Wound healing is a dynamic process and the characteristics of a dressing required by the wound can change as the wound moves through the different phases of the healing process. The wound healing continuum found at the front of the formulary will aid clinical decision regarding appropriate dressings at each of these phases to permit effective wound healing. 3

Using the formulary All wounds should be assessed using the BCH wound assessment form. If the wound is on the lower limb the BCH leg ulcer care pathway assessment form should be used, as early diagnosis of any underlying pathology and commencement of appropriate treatment can prevent the development of leg ulceration. Pressure ulcers should be assessed in conjunction with the BCH Waterlow risk assessment tool and identified risk factors addressed. The dressings on the formulary are suitable for the majority of wounds and for each wound stage there are appropriate product choices. The first choice of dressing should be made from the formulary. However, where a satisfactory outcome is not achieved, practitioners should discuss care with the BCH Wound Care Service and following this, other products may be recommended based on a clear rationale and evidence base. Please remember: BCH Wound Care Service must be consulted for advice if nurses wish to use dressings that are on the specialist section of the Formulary. Please do not accept samples of dressings to try on patients Cost Effectiveness NHS Bristol Medicines Management and BCH wound Care service have worked together to develop a more effective method of obtaining dressings in terms of both patient care and cost. Dressings will now be ordered from NHS supply chain and delivered to practices on a weekly basis. The benefits of changing to this system are Improved accessibility of appropriate dressings in response to the wounds healing process, so enhancing patient care. Reduction of waste of unused dressings that occurs when dressings are issued on prescription for individual patients Improved Formulary compliance across BCH Improved quality assurance from an auditable process It is envisaged that Prescriptions for dressings will only be generated when access via the NHS supply route has not been possible which should be on very limited occasions. All advanced dressings should be removed from the repeat prescription items system. Any problems obtaining dressings from NHS supply chain should be reported to the BCH wound care service. Assessment of the wound and a clear rationale for dressing choice must be made. Avoid using layers of dressings as far as possible. Most dressings are designed as wound contact layers in their own right; putting them on top of one another reduces their effectiveness and is unnecessarily costly. The prescriber or Nurse requesting the dressings should be aware of the total value of the prescription and have given consideration to the necessity of all the items being requested. The dressings chosen should promote minimal interference with wounds and frequency of change should normally reflect the maximum wear time. Hospital formularies are different to those in primary care due to their availability of products. Wounds must be reassessed in the community after discharge and care planned as appropriate to the Bristol Community Health Formulary. New Products and the Review of the Formulary A product review group representing District Nursing and Treatment Room Nursing across Bristol Community Health meets every 2 months to discuss new products and review the formulary. Where a request has been made to add a product to the Formulary, a formal evaluation and trial will be undertaken. Topical Negative Pressure therapy (TNP) TNP therapy is available in Bristol Community Health either to facilitate early discharge from hospital or to prevent admission. There are strict criteria to be followed for this and all referrals must be made through the Wound Care Service. Larvae Therapy If a wound has been identified as requiring larvae therapy, please contact the Wound Care Service to discuss the use before ordering larvae. Dressing Samples Manufacturer s sales representatives have been asked not to offer staff samples of dressings. Samples must not be used to treat NHS patients and all offers from manufacturers must be declined. For any advice about using this Formulary or about the management of particular wounds please contact the Bristol Community Health Wound Care Service: Wound Care Service Knowle Clinic Broadfield Road Knowle Bristol BS4 2UH Tel: 0117 9190270 Fax: 0117 9190370 4 5

For more information on wound assessment and wound bed preparation please refer to the following web sites: - www.worldwidewounds.com www.wounds-uk.com www.woundcare.org www.tvs.org.uk www.judy-waterlow.co.uk Wound Healing Continuum and Appropriate Products Description of wound Exudate Management Aims Product Choice Hydrogel : Purilon gel Hydrosorb Comfort Actiform cool Facilitate removal of necrotic tissue by rehydrating the wound; this is essential if the wound is to heal. No Low Exudate Black Wound Necrotic tissue which is dehydrated Film : Hydrosorb comfort and Actiform cool are sheet hydrogels which are very effective at desloughing The dressing is applied directly to the wound without the film backing removed. Leave in place for approximately 3 days. Hydrofilm Moist wound care is only appropriate for wounds with an adequate blood supply. Black wounds with an inadequate blood supply e.g. necrotic digits must be kept dry Use Purilon gel with a low adherent dressing such as Atrauman and gauze or a film. Change daily or alternate days. Covering the hydrogel directly with a film speeds the hydration and so the removal of the necrotic tissue. Patients with diabetes must be referred to Podiatry for advice Hydrocolloid : Comfeel Granuflex Tegaderm Hydrocolloid Hydrocolloid dressings will debride providing minimal exudate is present. It promotes autolytic debridement by forming a gel on contact with exudate. TIPS Protect the surrounding tissue as it can become macerated. Honey : Activon Honey will debride and is also antibacterial if bacteria burden is assessed as being a concern. Using foams on this type of wound is generally not appropriate as they reabsorb the gel and moisture that is required for the autolysis. 7 6

Description of wound Exudate Management Aims Product Choice Black Yellow Wound Necrotic tissue and yellow slough TIPS Careful consideration should be given to the choice of secondary dressing. If the wound needs daily or frequent changes, gauze or an absorbent dressing pad should be used secured with Mefix or Transpore. Foams should only be used if their use manages exudate sufficiently to significantly decrease dressing changes. Low Exudate 2 4 Mod High 6 10 Promote removal of necrotic and sloughy tissue by autolysis. Provide a moist environment. A Hydrogel is required to deslough areas on a low exuding wound. Purilon gel covered with atrauman and gauze or Hydrosorb comfort and Actiform cool which are sheet hydrogels are effective A hydrocolloid will form a gel in contact with a moist wound that will aid autolysis Honey will debride and is antibacterial if bacteria burden is a concern If the wound is wet, the exudate will need to be managed by using an absorbent dressing. Alginate dressings absorb the exudate and turns into a gel which aids autolysis. Urgosorb flat dressings can be used to pack most cavities which is the most cost effective method. If you are treating a deep cavity or sinus, use Advadraw spiral or Aquacel ribbon. Capillary action dressing are highly absorbent and use a wicking action to drain exudate and deslough. Hydrogel: Purilon gel Hydrosorb comfort Actiform cool Hydrocolloid: Comfeel Granuflex Tegaderm Hydrocolloid Honey : Activon Alginate/Hydrocolloid: Urgosorb Capillary Action Dressing: Advadraw Advadraw Spiral Dressing pad: Choice for health Hydrofibre : Aquacel Ribbon 8 Description of wound Exudate Management Aims Product choice Yellow Wound Slough is usually yellow or white Exclude possibility of pus and spreading infection TIPS Careful consideration should be given to the choice of secondary dressing. If the wound needs daily or frequent changes, gauze or an absorbent dressing pad should be used which could be secured with Mefix or Transpore. If necessary, protect the skin from the adhesive with Sorbaderm. Foams should only be used if their use manages exudate sufficiently to significantly decrease dressing changes Low Exudate 2-4 Mod High 6-10 Facilitate removal of sloughy tissue to promote healing. Provide a moist environment for autolysis to occur. Depending on the level of exudate either a gel or a hydrocolloid may be appropriate. If using Purilon gel cover with a low adherent dressing and gauze. Hydrosorb comfort and Actiform cool are sheet hydrogels which can be left in place for 3 days and will absorb exudate If the wound is wet, the exudate will need to be managed by using an absorbent dressing. Alginate dressings or capillary action dressing are highly absorbent. Urgosorb flat dressings can be used to pack most cavities this is the most cost effective method. If you are treating a deep cavity or sinus, use Advadraw spiral or Aquacel ribbon. Thicker slough may benefit from a capillary action dressing which is very effective at desloughing and managing exudate. Hydrogel: Purilon gel Hydrosorb Comfort Actiform cool Hydrocolloid: Comfeel Granuflex Tegaderm hydrocolloid Alginate/Hydrocolloid: Urgosorb Capillary Action Dressing: Advadraw Advadraw spiral Hydrofibre : Aquacel ribbon Dressing pad: Choice for health 9

Description of wound Exudate Management Aims Product choice Yellow Red Wound Slough and granulation tissue present TIPS Careful consideration should be given to the choice of secondary dressing. If the wound needs daily or frequent changes, gauze or an absorbent dressing pad should be used, which could be secured with Mefix. If necessary, protect the skin from the adhesive with Sorbaderm. Foams should only be used if their use manages exudate sufficiently to significantly decrease dressing changes Low Exudate 2-4 Mod High 6-10 Promote a moist environment to enhance healing and slough removal. Depending on the level of exudate either a gel or a hydrocolloid may be appropriate. If using Purilon gel cover with a low adherent dressing and gauze. Hydrosorb comfort or Actiform cool can be left in place for approximately 3 days and will absorb exudate If the wound is wet, the exudate will need to be managed by using an absorbent dressing. Alginate dressings or capillary action dressing are highly absorbent. Urgosorb flat dressings can be used to pack most cavities this is the most cost effective method. If you are treating a deep cavity or sinus, use Advadraw spiral or Aquacel ribbon. Thicker slough may benefit from a capillary action dressing which is very effective at desloughing and managing exudate. Hydrogel: Purilon gel Hydrosorb comfort Actiform cool Hydrocolloid: Comfeel Granuflex Tegaderm Hydrocolloid Lipido-colloid Urgotul Alginate/Hydrocolloid: Urgosorb Capillary Action Dressing: Advadraw Advadraw spiral Hydrofibre : Aquacel ribbon Dressing pad: Choice for health 10 Description of wound Exudate Management Aims Product Choice Red Wound Red granular appearance Beware of dark red tissue that bleeds easily, this can indicate high bacterial burden or infection if accompanied by other signs. Low 2 4 Moist environment to promote active healing. Leave undisturbed for as long as exudate management allows. If problems with dressing adhering to the wound bed, first consider Atrauman dressing Only used silicone based dressings if difficulty with other contact dressings adhering. Hydrocolloid: Comfeel Granuflex Tegaderm Hydrocolloid Low adherent Dressing N.A. Ultra Atrauman Urgotul Mepilex Border Red Pink Wound Granulating and epithelialising Pink epithelialisation around edge Mod High 6-10 Maintain moist environment, manage exudate. Urgosorb flat dressings can be used to pack most cavities this is the most cost effective method. Careful consideration should be given to the choice of secondary dressing. If the wound needs daily or frequent changes, gauze or an absorbent dressing pad should be used. Alginate/Hydrocolloid: Urgosorb Foam: ActivHeal foam island Allevyn Dressing pad: Choice for health Foams should only be used if their use manages exudate sufficiently to significantly decrease dressing changes 11

Signs of Critical colonisation Exudate Management Aims and use of antimicrobial products Product Choice Wound bed deterioration : Increase in slough Increase in necrosis Dark granulation tissue Bleeding tissue Increase in malodour Increase in pain Increase in wound size Wound healing static Surrounding erythema Please refer to the Criteria for use of antimicrobial dressings page 34 2 4 6-10 Explore reasons for deterioration of wound that may be associated with the patients general health and control of any underlying disease processes. Eg: Diabetic control Anaemia Nutrition Reconsider the underlying cause of the wound and ensure this has been addressed as far as possible. Eg: Pressure removed adequately if pressure ulcer Underlying aetiology If all the above have been addressed and the wound fails to heal despite correct intervention it may be due to high bacterial burden The bacterial burden can be decreased using antimicrobial products. The use of these products should be considered as a treatment and used for a short period of time to address the symptoms and then discontinued. Guide to duration of use Use the chosen dressing until symptoms have resolved and for a further one to two dressings and then discontinue. Usually about 2 3 weeks. Low exudate 2 4 Honey Flamazine Urgotul SSD Medium/ High exudate 6-10 Acticoat (Will need an absorbent dressing will not deslough) Iodoflex (Will manage exudate and will deslough) Cutimed Sorbact Dressings NB: If the wound has not responded within 2 weeks of antimicrobial therapy it should be discontinued. 12 BCH WOUND MANAGEMENT FORMULARY Dressing Type Indications and Tips Product Choice Film Dressings Vapour permeable films allow the passage of water vapour and oxygen but not water or microorganisms. Only suitable for superficial wounds with very low or no exudate. Not suitable for patients with thin friable skin as may cause damage on removal. Can be used on intact skin to prevent friction damage Hydrofilm 6 x 7cm = 17p 10 x 12cm = 38p 20 x 30cm = 1.40 Barrier Products In the first instance, protect skin from exudate using a greasy moisturiser such as white soft paraffin Where skin is broken or adhesives are necessary you may use Sorbaderm which is an alcohol free liquid barrier film which dries to form a breathable transparent coating on the skin that adhesives will adhere to. Sorbaderm can provide a protective interface between the skin and bodily wastes, fluids and adhesives for damaged skin or skin at risk of damage Sorbaderm 1ml foam applicator = 94p 3ml foam applicator = 155p 28ml spray bottle pump = 704p 13

Dressing Type Indications and Tips Product choice Low Adherent Wound Contact Dressings Atrauman is a non medicated, polyester mesh dressing impregnated with neutral triglycerides. Urgotul is a polyester mesh dressing impregnated with hydrocolloid particles dispersed in a matrix of petroleum jelly. Used as a contact layer to prevent the secondary dressing adhering. Dressing of choice under compression therapy. Atrauman has been found to be an effective non adherent dressing in most instances. Where adherence is a problem or wounds are very painful eg burns - use Urgotul. Urgotul should be used on wounds where they can be left in place for a minimum of 3 days, otherwise they are not appropriate. Inadine contains Povidone Iodine, useful for superficial wounds that may have been exposed to bacteria. Bactigras is used by Podiatrists after nail surgery Atrauman 5 x 5 = 15p 7.5 x 10 = 18p 10 x 20 = 36p 20 x 30 = 1.04 N.A.Ultra 9.5 x 9.5 = 39p Urgotul 5 x 5 = 1.95 10 x 10 = 3.21 Inadine 5 x 5 = 39p 9.5 x 9.5 = 59p Bactigras 5 x 5 = 24p Simple Adhesive For superficial wounds with low exudate such as surgical wounds or for use as a secondary dressing on wounds that require frequent changes due to external soiling. Softpore 6 x 7 = 4p 10 x 10 = 7p 10 x 15 = 12p 10 x 20 = 15p 10 x 25 = 17p 10 x 30 = 25p 14 Dressing Type Indications and Tips Product choice Hydrocolloids Suitable for desloughing wounds and promoting granulation so hydrocolloids can be used at any stage of wound healing. For light to moderate exuding wounds. Granuflex Bordered 6 x 6 = 78p 10 x10 = 2.90 Triangle 10 x 13 = 3.53 Interactive when in contact with wound exudate. Absorbs fluid and becomes a gel Only suitable for low exudating wounds Caution should be taken when using occlusive dressings with patients who have Diabetes as they can increase the risk of anaerobic infection. Comfeel Plus 4 x 6 = 93p 10 x 10 = 2.22 15 x15 = 4.67 Discontinue hydrocolloids if hypergranulation becomes evident. Tegaderm hydrocolloid 10 x 12 = 2.16 13 x 15 = 4.13 May cause overgranulation 15

Dressing Type Indications and Tips Product Choice Alginate dressings Calcium Alginate is a natural polymer extracted from various species of brown seaweed. It has absorbency and gelling properties and provides a moist environment at the wound bed. Hydrocolloid particles increase the absorbency. Highly absorbent, appropriate for medium to heavily exuding wounds. Not suitable for dry or low exuding wounds. Urgosorb flat dressings can be laid into shallow or deep wounds and can be left in the wound for 3 7 days. Please use these flat dressings wherever possible. Urgosorb 5 x 5 = 80p 10 x 10 = 2.18 10 x 20 = 3.52 Alginates have a haemostatic component and are useful to stem bleeding in a wound. If you have a deep cavity or sinus please use Advadraw spiral or Advadraw to avoid the risk of dressing particles being left at the bottom Where a sinus is very small consider the use of a gel to avoid trauma caused by packing. Hydrofibre Hydrofibre dressing composed of sodium carboxymethylcellulose Highly absorbent, appropriate for heavily exudating wounds Only for use in very deep cavity dressings Aquacel ribbon 2 x 45 = 16 Dressing Type Indications and Tips Product choice Capillary Action dressings Not suitable for use on vascular and bleeding wounds Non adherent, capillary action absorbent wound dressing which has a wicking effect. Rapidly desloughs and capable of managing large amounts of exudate. Can be used to deslough dry necrotic areas by using under a film dressing Advadraw 5 x 7.5 = 69p 10 x 10 = 1.07 10 x 15 = 1.45 15 x 20 = 1.91 Advadraw spiral 0.5 x 40cm = 1.00 Hydrogels Gels can rehydrate wounds and provide a moist environment Requires a secondary dressing Rehydrates necrotic and sloughy wounds to promote debridement. Apply the gel every 1 3 days. Hydrosorb comfort and Actiform cool will absorb and hold exudate change every 3 days or as required. Can be used at any stage of healing from debridement to granulation. Gels are not recommended for heavily exuding wounds. Purilon gel 8g = 1.56 Hydrosorb comfort 4.5 x 6.5 = 85p 7.5 x 10 = 1.15 12.5 x 12.5= 1.48 Actiform cool 5 x 6 = 1.65 10 x 10 = 2.40 10 x 15 = 3.50 17.

Dressing Type Indications and Tips Product choice Foam Adhesive Dressings Absorbent polyurethane foam. Foams absorb excess exudate from the wound surface whilst maintaining a moist healing environment. Available as flat sheets with or without an adhesive border. The rationale for using foams is extending wear time and comfort for the patient. A daily change of a foam dressing is not cost effective. If frequent dressing changes are required consider using gauze and an absorbent dressing pad instead secured with mefix. ActivHeal foam Island dressing 10 x 10= 97p 12.5 x 12.5 = 1.34 15 x 15 = 1.71 20 x 20 = 2.69 Allevyn Adhesive 7.5 x 7.5 = 1.60 10 x 10 = 2.30 12.5 x 12.5 = 2.90 12.5 x 22.5 = 4.50 17.5 x 17.5 = 4.93 If necessary the surrounding skin can be protected from the adhesive with Sorbaderm Mepilex Border Foam dressing with soft silicone contact layer for use where patient s skin is very fragile or when dressings adhering to the wound bed are a problem. Mepilex Border 7 x 7.5 = 1.46 10 x 12.5 = 2.90 15 x 17.5 = 4.97 Mepilex Border lite 7.5 x7.5 = 1.45 10 x 10 = 2.65 15 x 15 = 4.32 18 Dressing Type Indications and Tips Product choice Gelling foam Dressing A gelling foam which combines a top polyurethane foam with an absorptive nonwoven fibrous blend layer Absorbent foam dressing which gels when in contact with exudate provides a moist healing environment. Both adhesive or non adhesive available Versiva XC 10 x 10 = 2.31 14 x 14 = 3.12 19 x 19 = 4.98 Versiva XC Non adhesive 11 x 11 = 2.26 15 x 15 = 4.17 Foam Non adhesive dressings Foams absorb excess exudate from the wound surface whilst maintaining a moist healing environment. The rationale for using foams is extending wear time and comfort for the patient. Biatain 10x 10 = 2.14 Circular 5cm = 1.10 8cm = 1.55 A daily change of a foam dressing is not cost effective. 19

Dressing Type Indications and Tips Product Choice Gauze and Dressing Pads Where exudate is a considerable problem requiring frequent dressing changes the secondary dressing should be gauze and dressing pads secured with Mefix or Transpore and K band or Hospicrepe. Non sterile Gauze 10cm x 10cm x 100 = 3.27 Sterile Non woven in 5s 25 pkts in a box = 1.05 Exudate Management An effective primary dressing should first be chosen to provide an optimal environment for the wound to heal. Consideration needs to be given to the cause of high levels of exudate and possible referral to the wound care service for advice. Superabsorbent dressings are also available, refer to appropriate section. Lower limbs that are exudating may benefit from compression or supportive bandages where appropriate. Seek advice if unsure about the suitability of compression. Dressing pads Choice for Health Non Sterile 10 x 10 (50 in box) = 74p 20 x 20 (25 in box) = 95p 20 x 40 (12 in box) = 91p Sterile 10 x10 (25 in box) = 96p 20 x 20 (15 in box) = 1.15 20 x 40 (8 in box) = 1.22 Paste Bandages Use to reduce inflammation and to treat varicose eczema in the lower limb. Ichthopaste 7.5cm x 6m = 4.85 Viscopaste 7.5cm x 6m = 4.81 Zipzoc 4.21 20 Dressing Type Indications and Tips Product Choice Highly absorbent Dressings These superabsorbent dressings are designed not to release fluid back out of the dressing. For the management of highly exuding wounds. The use of these superabsorbent dressings should reduce the amount of dressing changes required. Where the wound is very wet a contact layer is not required. If there is concern over adhesion a primary dressing such as Atrauman or N A ultra may be used Eclypse pad 10 x 10 = 77p 15 x 15 = 93p 20 x 30 = 2.07 Kerramax 10 x 22 = 1.07 20 x 22 = 1.90 Cutisorb Ultra 10 x10 = 1.33 10 x 20 = 1.48 20 x 20 = 2.56 20 x 30 = 4.20 Odour Absorbing Dressings Activated charcoal dressing that absorbs the molecules released by the wound which may be responsible for wound odour Useful in managing malodorous wounds such as leg ulcers or fungating wounds. Clinisorb is used as a secondary dressing. Clinisorb 10 x10 = 1.79 10 x 20 = 2.40 21

Dressing Type Indications and Tips Product Choice Retention Bandages and Elasticated Viscose Stockinette To secure dressings in place. Use Cotton stockinette under compression bandages Hospiform 8cm x 4m = 12p 10cm x 4m = 14p 12cm x 4m = 20p Hospicrepe 10cm x 4.5m = 65p Use Comfifast as an outer layer to hold dressings in place if required Cotton Stockinette 6m x 10cm = 4.23 Comfifast Green Line 5cm x 10m = 3.05 Comfifast Blue Line 7.5cm x 10m = 3.26 Comfifast Yellow Line 10.75cm x 10m = 4.78 Tape Securing dressings and bandages Transpore White 1.25 x 9.14m = 24p 2.5 x 9.14m = 47p 5cm x 9.14m = 94p Mefix 5cm x 5m = 1.78 5cm x 10m = 2.77 22 Dressing Type Indications and Tips Product Choice Antimicrobial Dressings High bacterial burden (critical colonisation) in a wound is a barrier to healing. Antimicrobial dressings should be used when there are clinical signs of critical colonisation present which are preventing the wound from healing. NB. Diabetics do not always have Cellulitis with infection and extra care should be taken with this group. Antimicrobials may reduce the bacterial burden and prevent further development of infection. Where Cellulitis is present a swab should be taken and systemic antibiotics commenced. Iodoflex is not suitable for dry or wounds with little exudate. NB: Iodine dressings should be used with caution with patients who have thyroid or renal disease. They should not be used on patients who are receiving Lithium or pregnant woman. The amount and time used must adhere to the manufacturers guidelines. Acticoat is not suitable for use on a dry wound These products are not for routine use. There must be a clear rationale for need Iodoflex 5g = 4.42 10g = 8.85 17g = 14.00 Iodosorb 10g = 4.89 20g = 9.78 Acticoat Flex 5 x 5 = 3.80 10 x10 = 8.09 Antimicrobial dressings are very expensive and their use must be backed with a clear rationale. Acticoat Flex 7 5 x 5 = 6.61 10 x 10 = 16.99 They should be used for a short period and discontinued when the wound bed has improved. Please see the antimicrobial guidelines on page 34 23

Dressing Type Indications and Tips Product Choice Urgotul SSD is an open weave soft polyester mesh with lipido-colloid oating impregnated with silver sulphadiazine. Urgotul SSD 10 x 12 = 5.52 Antimicrobial Dressings High bacterial burden (critical colonisation) in a wound is a barrier to healing. Antimicrobial dressings should be used when there are clinical signs of critical colonisation present which are preventing the wound from healing. Cutimed Sorbact is a hydrophobic dressing designed to absorb exudate and bind bacteria to it under moist conditions. These dressings may be used on wounds that have been identified as being critically colonised or infected. Cutimed Sorbact dressing pad 7 x 9 = 3.54 10 x 10 = 5.55 Cutimed Sorbact Swab 4 x 6 = 1.66 7 x 9 = 2.77 Cutimed Sorbact ribbon 2 x 50cm = 3.70 NB. Diabetics do not always have Cellulitis with infection and extra care should be taken with this group. In line with the antimicrobial protocol, all antimicrobial dressings should be used for a short period and discontinued when the wound bed has improved. Honey has antibacterial, desloughing and deodorising properties. Activon Tulle is a non adherent knitted viscose primary dressing impregnated with action honey. Algivon is an absorbent, non adherent calcium alginate impregnated with Activon Honey 25g = 2.43 Tulle 5 x 5 = 2.15 10 x 10 = 3.67 Algivon 5x5 = 2.80 10 x10 = 3.50 24 Dressing Type Indications and Tips Product Choice Compression Bandages Multi layer elastic systems for venous leg ulceration and mixed aetiology ulceration K soft 10cm x 3.5m = 53p K lite 10cm x 4.5m = 70p K plus 10cm x 8.7m = 1.81 Ko flex 10cm x 6m = 3.24 Use in accordance with the BCH Leg Ulcer Care Guidelines. Longer length K-soft 10cm x 4.5m = 59p K-lite 10cm x 5.25m = 1.15 K-plus 10cm x 10.25m = 2.24 Ko-flex 10cm x 7m = 3.43 High Compression Adva co 10cm x 3m = 195 Adva soft 10cm x 3.5m = 39 Tensopress 10cm x 3m = 3.09 2 Layer K2 systems Size 18-25cm = 9.12 Size 25-32cm = 9.71 25

Dressing Type Indications and Tips Product Choice Compression Bandages Actico short stretch system for venous leg ulceration, mixed aetiology and lymphoedema Actico short stretch 10cm x 6m = 4.10 Flexi ban 10cm x 3.65m = 26p Use in accordance with the Bristol PCT Leg Ulcer Care Guidelines. Actiban short stretch, high compression cotton bandage for use in the management of lymphoedema Actiban 8cm x 5m = 3.78 10cm x 5m = 4.07 12cm x 5m = 4.94 26 Dressing Type Indications and Tips Product Choice Hosiery See the BCH Leg ulcer guidelines for more information It is important that the hose is renewed regularly to maintain the correct compression rates (at least every 6 months) 10mmHg Liners per pack need renewing more often. British Classification. Circular knit: The use of hosiery in the management of leg ulceration has expanded in recent years. The three areas in which it is predominantly used are: Healing Secondary prevention- maintaining a healed state. Primary prevention. British Standards (BS6612 1985) Circular Knit Class 1 (14-17mmHg) Class 2 (18-24mmHg) Class 3 (25-35mmHg) Activa Full compression kit Clinidu 40 leg ulcer kit Activa leg ulcer kit Liner pack (3 liners) 27.

Dressing Type Indications and Tips Product Choice Hosiery Mediven plus price is per pair Good for chronic oedema This range comes in 7 sizes European standard (ENV 12718 2001) Class1 (18-21mmHg) Class 2 (23-32mmHg) See the BCH Leg ulcer guidelines for more information It is important that the hose is renewed regularly to maintain the correct compression rates (at least every 6 months) 10mmHg Liners per pack need renewing more often. Lymphoedema Leg Garments (Good for chronic oedema as well) Jobst Elvarex Flat bed knit ( Price per hose) Class1, Class2 Class 3, The above garments are available with additional options; these are added to the cost. E.g. Zipper or Silicone band Class 3 (34-46mmHg) Mediven ActiLymph Standard or Petite length Jobst Full compression kit Mediven 20/20 ulcer kit 7 sizes short &long Liners are 20mmHg 28 Other Appliances Seal tight wound care protector Adult short leg = 10.50 Adult wide short leg = 10.50 Limbo waterproof protector Slim build = 10.20 Slim build short leg = 10.20 Normal build = 10.20 Normal build short leg = 10.20 Large build = 10.20 Large build short leg = 10.20 Actiglide hosiery applicator = 13.01 Kerraped all purpose boot Small,Med,Large, X Large = 16.63 All prices approximate Please only order these appliances if you are sure the patient can manage to use them 29.

Wound Cleansing products Cleansing wounds Most wounds do not require cleansing; it is more beneficial to leave the wound bed undisturbed. Rationale for wound cleansing include: To remove debris To remove dressing residue To remove purulent or excessive exudate Surrounding skin should be cleansed from exudate to prevent excoriation If it is considered necessary to irrigate the wound bed, the solution should be warmed to body temperature Specialist Product Formulary Tegaderm Absorbant 11.1 x 12.7 = 3.79 14.2 x 15.8 = 5.32 16.8 x 19 = 9.92 Acticoat Flex 10 x 20 = 12.60 Duoderm extra thin 10 x10 = 1.18 Tegaderm Foam Roll 10cm x 60cm = 12.42 Urgotul 15 x 20 = 9.61 Eclypse Adherent 10 x10 = 3.18 10 x 20 = 3.90 Urgotul SSD 15 x 20 = 10.50 Flaminal 15g = 7.78 Flaminal hydro 15g = 7.78 Urgotul Start 5 x 7 = 2.94 11 x 11 = 4.30 16 x 21 = 10.15 Sorbion 7.5 x 7.5 = 1.88 12 x 5 = 1.99 10 x 10 = 2.47 Silflex 5 x 7 = 1.25 8 x 10 = 2.55 12 x 15 = 5.15 20 x 30 = 13.25 Suprasorb + PHMB 5 x 5 = 3.63 9 x 9 = 7.11 14 x 20 = 16.47 30 Although chlorinated tap water from a reliably clean source is considered safe to use in most wound care, careful consideration needs to be given to the practicalities of using tap water and the risk of contamination. For this reason sterile saline is considered the safest option, however in some instances, it may be appropriate for patients to bathe or shower at home between dressing changes. Essential skin care in leg ulcer management should consist of warmed tap water with an emollient in a lined bucket Prontasan is a wound cleansing detergent - it is not advocated for general use as it is often not required. However for those wounds where there is difficulty with recurrent bacterial burden or infection, its use may assist in reducing the bacterial load. Irripods 25 x 20ml = 5.36 Prontasan 350ml = 4.18 31

Methicillin Resistant Staphylococcus Aureus (MRSA) and wound management Treatment of MRSA in a wound Open wounds will often be colonised with micro organisms including MRSA, though these wounds do not always go on to develop infection. Many of these wounds will continue to heal despite this colonisation and no specific treatment is required other than good wound management. It is only when a wound is failing to heal and showing signs of critical colonisation and infection that treatment using topical antimicrobial therapy should be considered and in the case of clinical infection, the use of antibiotics. Routine swabbing to determine if MRSA is in a wound is not advocated. Wound swabbing should only be carried out when clinical signs of infection are present. Where critical colonisation or infection has been identified, topical antimicrobial therapy may be used to address this. Please see the flow chart on the next page. Individuals with clinical infection caused by MRSA should always be treated promptly as with any other infection. The appropriate antibiotic to use should be discussed with a local microbiologist. If the individual is has received systemic antibiotics but the wound remains clinically infected following the completed course of antibiotics, a wound swab should be undertaken 48 hours after treatment is completed, stating post MRSA and treatment given. Individuals who are colonised with MRSA will not generally require decolonisation unless it is known or is likely that the individual will be admitted to hospital in the foreseeable future. Discuss with the Infection Control Nurse. MRSA Positive Wound healing steadily Treat wound according to Wound management formulary Antimicrobial therapy is not required. Ensure wound is covered at all times with a secure dressing to prevent cross infection. Adhere to infection control Guidance: Hand washing Apron Disposal of dressings If cellulitis is present systemic antibiotics will be required. Refer to microbiologist MRSA Positive Wound static or deteriorating Clinical signs of critical colonisation or infection For exuding wounds ACTICOAT IODOFLEX or CUTIMED SORBACT for 2 4 weeks For very low exudating wounds MUPIROCIN 2% Applied up to 3 times daily for 5 10 days NB: Only use Mupirocin on low exudating wounds and if you are able to apply it at least daily. Do not use topical antimicrobials for more than 4 weeks without consulting a Specialist Nurse or Podiatrist Monitor wound closely. If no improvement refer to a BCH Specialist Nurse or Podiatrist 32 33

Criteria for use of antimicrobial therapy in wound care If whilst managing a wound or ulcer it becomes static or deteriorates, you should first explore reasons for this that may be associated with the patients general health and control of any underlying disease processes. Eg: Diabetic control / Adequate nutrition / Anaemia. You should also reconsider the underlying cause of the wound and ensure this has been addressed as far as possible. Eg: Pressure removed if a pressure ulcer Underlying aetiology of leg ulcer Antimicrobial therapy is not normally required in wound healing and should only be considered if the wound is static or deteriorating Wounds should be assessed and measured using the BCH wound assessment form and measurements recorded for accurate determination that the wound is failing to heal. Wounds can deteriorate due to a high bacterial burden; this may be evident from the following signs and symptoms. If these symptoms are present antimicrobial may be considered Signs and symptoms of high bacterial burden. Wound bed deterioration, increase in slough, necrosis Wound exudate increased and change in colour Wound has become malodorous Increase in pain / discomfort Discolouration of granulation tissue Friable bleeding granulation tissue Recommended duration of antimicrobial therapy Tick Antimicrobial therapy should only be used whilst the symptoms are present to address the bacterial load and then discontinued. This may take up to 2 weeks, monitor the symptoms and once resolved use for a further one to two dressing changes and then discontinue. NB: If the wound does not respond within 2 weeks of antimicrobial therapy, it is not going to be effective and should be discontinued. Care of Burns Superficial Epidermal / Superficial Dermal Appearance: Pink with blisters or with patchy white/yellow areas usually painful Causes: Scalds, radiation and sunburn Blisters should be deroofed over areas of function or where they may burst. Deroofing blisters involves the removal of the dead skin and blister fluid, not just expressing the blister fluid. Thick walled blisters can be left intact (palm of hands). Aims of treatment: To prevent infection To control exudate To promote epithelialisation To promote function Dressing choice: Flamazine may be used to prevent development of infection and aid desloughing. When Flamazine and Atrauman are used together there is not usually a problem with the Atrauman adhering to the wound bed. If Flamazine is not used Silflexl or Mepilex border can be used. Deep Dermal / Full thickness Appearance: Mottled pink/yellow/white or black/brown necrotic tissue full thickness usually painless Causes: Flame, Scald, chemical, contact Aims of treatment: To prevent infection To control exudate To promote epithelialisation To promote function To prepare for excision and grafting Dressing choice: Flamazine may be used to prevent development of infection and aid desloughing. When Flamazine and Atrauman are used together there is not usually a problem with the Atrauman adhering to the wound bed. If excess swelling and exudate, use polybags with flamazine, otherwise choose according to distribution of burn. High elevation is essential to reduce oedema and pain Remember that function is of the utmost importance, particularly when the burn is on hands, feet or and area that normally has a large range of movement. Dressings should be light to enable movement, exercises should be taught and dressing changes minimal. Non Formulary product for use for Burns where formulary products unsuitable - Silflex 34 35

Wound Care in Podiatry Consultation Process FOOT ULCERATION Patients who present with foot ulceration are likely to have neuropathy, ischaemia or a combination of both. Treatment should vary depending on the underlying pathology therefore it is essential that the sensation and vascular supply are checked and the wound should be classified as either neuropathic, ischaemic or neuro-ischaemic. Many dressings perform very differently when applied to a foot due to the need to weightbear. Care should be taken that tapes and bandages are not too tight on feet and toes as this can constrict the blood flow to the affected area. Groups consulted Bristol Community Health Product Review Group present at review Date completed Neuropathic ulcers are typically found on weight-bearing areas of the foot and are painless (caution should be taken when a neuropathic patient complains of pain from an ulcer as it may indicate deep/spreading infection). Heavy callus formation is likely, which hides the true size and depth of the wound if this occurs please refer to Podiatry for sharp debridement and pressure relief. Ischaemic ulcers are typically found on the tips of toes and the borders of the foot. True ischaemic wounds (rather than neuro-ischaemic) are painful, produce little callus and are slow to heal. Dopplers, ABPIs and vascular referral should be considered. Necrotic toes should NOT be re-hydrated. Use simple, non-adhesive dressings. If you require any help with foot wounds (not just diabetic foot ulcers) please refer to Podiatry- our referral form is on the staff section of the Bristol Community Health website or ring us on 0117 9190275 Tina Checketts Nadine Everson Louise Fry Sheila Gay Simon Hall Kizzy Harris Val Helliar Beth John Jacqui Mc Grath Sue Murphy Gail Powell Rachel Steeper Sue Whitchurch Dermatology Nurse Treatment Room Sister Community Nurse Practice Nurse District Nurse Diabetes Lead Podiatrist Wound Care Nurse District Nurse District Nurse Tissue Viability Nurse Clinical Nurse Specialist Community Diabetes Podiatrist Practice Nurse 14.07.2010 Diabetic foot ulceration Diabetic foot ulceration is responsible for: 20% of hospital admissions 45-70% of non-traumatic lower limb amputations 13% mortality rate of people admitted to hospital with lower limb ulceration as the primary diagnosis The classic signs of infection such as heat, redness, pain, swelling can be masked in the diabetic foot and can change rapidly. Dressings therefore need more frequent checking/changing. Any patient with diabetes and foot ulceration should be made known to podiatry for a full assessment. Hydrocolloids and gels should generally be avoided on diabetic foot ulcers unless advised to do so by a Diabetes specialist Podiatrist It is vital that the diabetic foot pathway is followed also available on the BCH website. Any diabetic foot wounds that are infected, deteriorating or not improving within four treatments are referred to the diabetic foot team for a multi-disciplinary assessment. 36 37

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