tissue viability guidance and formulary · page 1 of 101 tissue viability guidance and formulary...

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Tissue Viability Guidance and Formulary

The 5 key messages the reader should note about this document are:

1. Wound care is estimated to cost the NHS around £3.1 billion per year (based on 2006 costs) and is rising year on year.

2. The guidelines and formulary are based on best practice evidence and include: wound, pressure ulcer prevention strategies and management and leg ulcer management.

3. By selecting treatment that is appropriate to the cause and condition within a framework of holistic care, healthcare professionals will improve performance.

4. This guidance has been developed to maintain and enhance a standardised approach to practice.

5. Wound care practice needs to be clinically effective, cost effective and safe for the management of patients who

have acute and chronic wounds.

You & Your Care

www.bdct.nhs.uk

http://www.bdct.nhs.uk/

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This document has been approved and ratified. Circumstances may arise where staff become aware that changes in national policy or statutory or other guidance (e.g. National Institute for Health and Care Excellence (NICE) guidance and Employment Law) may affect the contents of this document. It is the duty of the staff member concerned to ensure that the document author is made aware of such changes so that the matter can be dealt with through the document review process.

NOTE: All approved and ratified policies and procedures remain extant until notification of an amended policy or procedure via Trust-wide notification, e.g. through the weekly e-Update publication or global e-mail and posting on the Intranet (Connect).

Document details: Tissue Viability Guidance and Formulary

Version: 9-01

Persons / committees consulted: Professional Council

Approved by: Professional Council

Date approved: 16/11/2015

Ratified by: Professional Council

Date ratified: 16/11/2015

Title of originator / author: Continence, Tissue Viability & Falls Service Lead; Tissue Viability Nurses

Title of responsible committee / group (or Trust Board):

Not Applicable

Title of responsible Director: Nicola Lees – Director of Service Delivery

Date issued: 09/12/2015

Review date: 09/12/2015

Frequency of review: 3 years

Target audience: All staff and those contracted to work within the Trust who manage wounds

Responsible for dissemination: Lorraine Oxborough - Continence, Tissue Viability & Falls Service Lead

Darren Shipman, Governance and Clinical Audit Manager (responsible for uploading to the Intranet/Connect).

Copies available from: Connect on BDCFT Intranet

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Where is previous copy archived

(if applicable)

Connect on BDCFT Intranet

Amendment Summary: Previous versions of this document were called the Wound Management Guidance and Formulary.

Amalgamated documents from BDCFT wound management guidance & formulary and pressure ulcer policy appendices.

Amendment detail:

Amendment number

Page Subject

1

2

3

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Contents

1 INTRODUCTION .......................................................................................................... 7

2 SCOPE ......................................................................................................................... 7

3 DEFINITIONS ............................................................................................................... 7

3.1 Holistic Assessment ................................................................................................ 7

3.2 Factors Affecting Wound Healing ........................................................................... 8

3.3 Wound Cleansing ................................................................................................... 9

3.4 Debridement ......................................................................................................... 10

3.5 Integrated Debridement Assessment Flow Chart ................................................. 11

3.6 Dressing Selection ................................................................................................ 12

3.7 Single - Use .......................................................................................................... 12

4 DUTIES ...................................................................................................................... 13

4.1 All Staff ................................................................................................................. 13

4.2 Recording Information .......................................................................................... 13

5 PRESSURE ULCER PREVENTION AND MANAGEMENT ....................................... 14

5.1 Pressure Ulcer Damage ....................................................................................... 14

5.2 Skin Assessment .................................................................................................. 14

5.3 Pressure Ulcer Prevention .................................................................................... 15

5.4 Pressure Ulcer Management Plan ........................................................................ 15

5.5 Pressure Ulcer Safety Cross................................................................................. 16

5.6 Equipment/Positioning .......................................................................................... 16

5.7 Pressure Ulcer Reporting Process – Root Cause Analysis (Level 2 Investigation) .. .............................................................................................................................. 16

5.8 Assessment Tools, Flow Charts & Guidance ........................................................ 16

5.8.1 EPUAP Pressure Ulcer Classification System (2009) .................................... 18

5.8.2 Maelor Score Risk Assessment ..................................................................... 19

5.8.3 Guidance for Completion of Maelor Score ..................................................... 20

5.8.4 Pressure Points – At Risk Areas .................................................................... 22

5.8.5 Guidance for Community Equipment Selection .............................................. 23

5.8.6 Must Assessment Tool ................................................................................... 24

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5.8.7 Positioning of Patients to Minimise Impact on Bony Prominences and Reduce Risk of Pressure Damage .............................................................................. 25

5.8.8 Skin Bundle .................................................................................................... 26

5.8.9 Safety Cross ................................................................................................... 27

5.8.10 How to use the Safety Cross ...................................................................... 28

5.8.11 24 Hour Positioning – Turning Chart ........................................................... 30

6 LEG ULCER MANAGEMENT ..................................................................................... 31

6.1 Leg Ulcer Management ........................................................................................ 31

6.2 Chronic Oedema ................................................................................................... 32

6.3 Doppler Studies .................................................................................................... 32

6.4 Diagnosis .............................................................................................................. 33

6.5 Compression Therapy .......................................................................................... 33

6.6 Ankle Brachial Pressure Index .............................................................................. 34

6.7 Venous and Chronic Oedema Pathways Explained ............................................. 36

6.7.1 Leg Ulcer Pathway and Referral Process....................................................... 37

6.7.2 Ulcer Pathway and Referral Process Guidance Notes ................................... 38

6.7.3 Venous, Chronic Oedema and Lymphovenous Disease Leg Ulcer Flow Chart Criteria............................................................................................................ 40

6.7.4 Venous Leg Ulcer Flow Chart ........................................................................ 41

6.7.5 Chronic Oedema & Lymphovenous Leg Ulcer Flow Chart ............................. 42

6.7.6 Guidance for STANDARD Flow Chart ............................................................ 43

6.7.7 Venous Leg ulcer flow chart ........................................................................... 45

6.7.8 Chronic Oedema & Lymphovenous Leg Ulcer Flow Chart ............................. 46

6.7.9 Guidance for COMPLEX Flow Chart .............................................................. 47

7 Wound types, assessment & Dressing guidance/section charts ................................. 50

7.1 Moisture Lesions ................................................................................................... 50

7.2 Wound Continuum Guidance ................................................................................ 50

7.3 Wound Dressing Guidelines ................................................................................. 51

7.4 How to Use the Continuums for Wound Assessment ........................................... 52

7.5 Dressing Selection Flow Chart ............................................................................. 53

8 Formulary products ..................................................................................................... 54

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8.1 Formulary Options ................................................................................................ 55

8.2 Bandage Options .................................................................................................. 61

8.3 Skin Protection...................................................................................................... 64

8.4 Compression Hosiery Options .............................................................................. 65

8.5 Appliances and Other Medical Devices ................................................................ 66

8.6 Tissue Viability Guidance Products ...................................................................... 67

8.7 Specialist Products ............................................................................................... 68

8.8 1st Dressing Pack for District Nurse Teams .......................................................... 69

8.9 1st Dressing How Does It Work? ........................................................................... 69

9 DRUG PROTOCOL FOR SKIN INFECTIONS ........................................................... 70

10 REFERENCES ........................................................................................................... 71

11 APPENDIX A AIREDALE NHS FOUNDATION TRUST FORMULARY FOR TISSUE VIABILITY USE ONLY ....................................................................................................... 73

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1 INTRODUCTION

This Tissue Viability Guidance and Formulary supports the Tissue Viability Policy and has been devised collaboratively by members of the Tissue Viability Board.

The guidelines are based on best practice evidence at the time of publication and include: wound, pressure ulcer prevention strategies and management and leg ulcer management.

The wide range of products included in the formulary will assist clinicians in making informed clinical management decisions appropriate for specific stages of wound healing.

In exceptional circumstances where a suitable dressing cannot be found in the formulary further information and advice must be sought from the Tissue Viability Service.

2 SCOPE

These guidelines are to ensure that all patients with a wound or ulcer have the following:

Patient centred holistic assessment in relation to wound care, pressure ulcer prevention and management and leg ulcer management

Comprehensive and accurate assessment

Rationale for the management and treatment selection

Documented evidence of patient advocacy

Contemporaneous record of all interventions

Review dates

3 DEFINITIONS

3.1 Holistic Assessment

The healing process is complex and is affected by numerous general and local factors. It is essential to treat the whole person and not just the wound/ulceration in isolation.

The initial assessment should be undertaken by a competent and registered health care professional. The assessor should have a clear understanding of the extrinsic/intrinsic factors that may relate to each individual patient and the knowledge to understand and act upon the findings of the assessment.

Using this information, the assessor will generate an immediate care plan, which should be discussed and agreed by the patient and/or carer(s). All accurate data obtained at the initial assessment will act as a baseline measurement for subsequent assessments.

The patient’s health status must be recorded and supported by use of the relevant assessment tools (e.g. Care pathways, MUST and Maelor, Waterlow).

To ensure optimum wound management and patient comfort is achieved, a holistic wound assessment must include:

Detailed Visual Examination: e.g. for signs of venous or arterial disease, skin damage from localised pressure.

Aetiology (type): e.g. ulceration, diabetic foot ulcer, pressure ulcer, moisture lesions, fungating, burn, laceration, post-surgical.

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Location: including number of wounds.

Size: including length, width, depth, position/extent of sinuses, undermining of surrounding skin.

In line with best practice a photographic record and wound tracing must be undertaken.

Exudate: including type, colour, approximate amount/extent of strike through on current wound management product, odour.

Wound Bed: e.g. healthy granulation tissue, epithelialisation, slough, brown/black eschar.

Wound Margins: e.g. increasing, decreasing, static, colour.

Surrounding Skin: e.g. dry, eczematous, fragile, maceration, oedema, colour, erythema.

Signs of Infection: e.g. suspected, confirmed and details of any swab results.

Pain: wound related, at dressing or post dressing change. That is Neuropathic or Nociceptive and/or a combination of both.

3.2 Factors Affecting Wound Healing

Age: the skin’s resistance to injury reduces with the ageing process and cell replication is slower (Guo & DiPietro, 2010). This increases susceptibility to pressure ulcer formation.

Immobility: individuals who are chair fast or bed fast are at an increased risk of pressure ulcer development. The patient’s ability to reposition him/herself affects risk. Mobility may be restricted by a patient’s conscious level, medication, acute illness, severe chronic or terminal illness, weight and pain.

Skin/Tissue Condition: this is adversely affected by age, dehydration, oedema and moisture. Other factors include malnutrition and hypoxia. Previous skin trauma such as surgical scars or previous pressure ulceration increases the risk of future pressure damage (National Institute for Clinical Excellence 2014)

Poor Circulation: delayed healing and tissue breakdown is frequently associated with poor circulation and this may be due to local pressure, vascular disease or diabetes mellitus (Vowden 1996)

Immune Response: e.g. allergies to topical applications can delay healing.

Obesity: adipose tissue has poor vascularity. No known mechanism is responsible for increased infection and wound breakdown in obese surgical patients, but these patients are at a high risk of postoperative wound problems.

Medication: prescribed and over the counter e.g. Anti-Inflammatory drugs (can suppress the preliminary inflammatory response), topical or systemic corticosteroids (can repress the immune system and decrease the multiplication of fibroblasts).

Skin Blanching: blanching is an evaluation that can be performed when repositioning the patient. Finger pressure on the skin of a pressure area should cause the skin to go white initially, but to turn red again within seconds.

If non-blanching (whitening) occurs, then a pressure ulcer is present and its category should be documented.

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For patients with dark pigmented intact skin, redness in pressure areas is equivalent to a localised skin colour change, a taut, shiny surface to the skin with increased skin temperature.

Pain: a detailed pain history is integral to alleviating stress and anxiety and improving quality of life. This includes the patient’s perception of pain such as specificity, frequency, immediate or post dressing change, severity etc. Pain assessment should identify Nociceptive or Neuropathic pain or a combination of both.

Nociceptive pain is typically well localised, constant and often with an aching or throbbing quality. It is often found in patients who have chronic wounds.

Neuropathic pain is the result of an injury or malfunction in the peripheral or central nervous system. Nerves can be infiltrated or compressed by scar tissue or inflamed by infection. The pain frequently has burning, lancing or electric shock qualities. It is frequently of a chronic nature.

Combination of Nociceptive and Neuropathic pain is a nervous system dysfunction that triggers the neural release of inflammatory mediators and subsequent neurogenic inflammation.

Psychological Status: stress and worry increases the production of hormones such as Glucocorticoids which can stem the inflammatory phase and slow down healing (Guo & DiPietro 2010).

Sensory Functioning: this is the loss a protective response which is a major factor in pressure damage. The inability to feel discomfort or pain, e.g. spinal injury, CVA, MS or neuropathy related conditions such as Diabetes Mellitus, may decrease the usual response to discomfort of changing position.

Social Factors: e.g.

Smoking - as the effects of nicotine and carbon monoxide in cigarette smoke causes tissue hypoxia (Guo & DiPietro 2010).

Alcohol - misuse can lead to delayed wound healing by impairing the early inflammatory response, inhibiting wound closure, angiogenesis, collagen production and altering the protease balance at the wound site (Guo & DiPietro 2010).

Illicit Drug Abusers - may become compromised by repeated intravenous vascular access and injection of toxic drug substances. This has devastating effects on the veins, skin, muscles and joints of the lower extremities, thus increasing the risk of chronic venous disease and venous ulcers that tend to be multiple and large by the time wound care is sought (Williams & Southern 2005).

3.3 Wound Cleansing

The aim of wound cleansing is to remove gross contamination with minimal pain and tissue trauma. NICE guidelines for the prevention and treatment of surgical site infection state that sterile saline should be used for wound cleansing up to 48 hours after surgery, after which tap water should be used (NICE 2008).

Tap water is therefore mostly used in the community for cleansing wounds. It is easily accessible, efficient and cost effective. Where tap water is of high quality (drinkable) it is as good as other methods such as sterile water or saline and more cost-effective. (Fernandez & Griffiths 2008). The fluid should be close to body temperature.

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The use of liners in bowls or buckets reduces the risk of cross infection.

Wounds should only be cleansed to:

Remove excess exudate

Remove slough and / or necrotic tissue

Remove remnants of previous dressing products

Facilitate accurate assessment of the wound

Promote patient comfort

3.4 Debridement

Dead tissue in the form of slough and necrosis can, if present in a wound, delay healing and promote infection. Debridement describes any method by which such materials are removed and as a consequence the potential to achieve wound healing enhanced.

Debrisoft monofilament debridement pad is a convenient and easy to use product that is well tolerated by patients and is effective for sloughy wounds and hyperkeratotoc skin around acute or chronic wounds (NICE 2014).

Debridement can also be achieved either through the use of wound care products (including Larvae) or by conservative sharp debridement.

If conservative sharp debridement is necessary referral must be made to the relevant professional (Haycocks & Chadwick 2008).

The TVN or Podiatrist carrying out sharp debridement will have completed a validated educational programme in the subject.

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3.5 Integrated Debridement Assessment Flow Chart

Integrated Debridement Assessment flow chart

Assess the wound; Underlying cause, site, size, Signs of infection, condition of Peri-wound skin/wound bed

Trigger Questions Do I need to accelerate debridement? What are the risks? What are the expected outcomes? What are my options?

Assess the patient; Co-morbidities, medications, concordance, psychological issues, nutritional status

Implement debridement treatment plan and document in patient records

DISCUSS with patient

Decide debridement goals/desired treatment outcomes – Am I certain what to do?

Consult with MDT if further advice needed: E.g. contraindications/unsure how to proceed or refer to MDT if specialist debridement method required

Debride if competent in chosen method

Do not debride E.g. ischemic limbs/high risk

Keep wound dry, e.g. mummified diabetic toes (some areas such as exposed tendons may need to be kept moist)

Autolytic (generalist); Mechanical (generalist); Larval (generalist); Hydro-surgery

(competent practitioner); Sharp (competent practitioner); Surgery (surgeon)

Reassess at dressing change and review goals/treatment plan and change method if appropriate

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3.6 Dressing Selection

To optimise healing a moist wound environment is desirable. This encourages the breakdown of fibrin and dead tissue, promotes the interaction of growth factors that stimulates healing and prevents tissue dehydration.

However where ischaemic or thrombolytic aetiology is suspected it is essential that the area is kept dry.

Dressing selection should include the following characteristics:

Maintenance of a moist environment (where appropriate)

Controlled exudate management

Allow gaseous exchange

Provide thermal insulation

Non – adherent to wound bed

Be non – allergic and non – sensitising

Impermeable to micro – organisms

Comfortable and conforming

Acceptable to the patient

Cost effective

3.7 Single - Use

A device (dressing products, bandages, scissors, forceps etc.) designated for ‘single use’ must not, under any circumstances be re – used.

It should only be used on an individual patient during a single procedure and then discarded.

It is not intended to be reprocessed and used again, even on the same patient.

The symbol below is used on medical device packaging indicating ‘do not re – use’ and may replace any wording (MHRA 2006).

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4 DUTIES

4.1 All Staff

Staff will work to the Tissue Viability Policy and utilise these guidelines to support best practice.

Staff will only use products listed in the Tissue Viability Guidelines and Formulary unless arrangements are made by a specialist e.g. Tissue Viability Nurse, to use an alternative product on a named patient basis.

Patients who present with a wound will have a holistic assessment by a competent registered health care professional, wound/s assessment, have their wound/s cleansed as required in accordance with best practice, have an individualised wound management plan ensuring clinically effective dressing selection is in line with this formulary.

Staff will identify training needs and make their line manager aware of training deficit.

Staff will report to their line manager all clinical incidents pertaining to wound management.

4.2 Recording Information

It is a legal requirement that all interventions are fully documented in the patient’s treatment record.

The organisations Wound Management Chart hard copy and electronic patient clinical system should be used to record all information.

All staff must ensure that rationale is fully recorded for any interventions thought to be clinically inappropriate e.g. full skin inspection/photograph and/or mapping and MUST assessment.

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5 PRESSURE ULCER PREVENTION AND MANAGEMENT

5.1 Pressure Ulcer Damage

European Pressure Ulcer Advisory Panel (EPUAP) 2009 Pressure Ulcer Definition is:

A pressure ulcer is localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.

Assessment and treatment includes:

Removing the cause i.e. pressure and shear

Assessing the extent of the tissue damage, the state of the wound bed, the level of

bacterial load, the condition of the surrounding skin and the perfusion of the wound

area

Deciding on treatment objectives for the wound

Where appropriate create a healing environment at the wound surface by:

o Debriding dead tissue/slough

o Reducing undermining

o Identifying and treating infection

o Reducing contamination by faeces or urine

o Supporting healthy granulation tissue

Improve the patients general condition including their nutritional status

Managing Pain and psychological stress

5.2 Skin Assessment

Skin assessment should take into account patient’s dignity and privacy with their consent.

Full body skin inspection should be offered to all patients deemed at high risk and outcome documented, including if patient refuses. All vulnerable areas need to be inspected; these are typically bony prominences. A comprehensive skin inspection should include techniques for identifying blanching response, localised heat, oedema and induration (hardness). Individuals who are identified as being at risk of pressure ulceration require regular skin inspections for signs of redness using the European Pressure Ulcer Advisory Panel Classification System.

Pressure – this is caused by sitting or lying for prolonged periods which results in a diminished blood supply to the tissue causing capillary occlusion. The most common sites for pressure damage in adults are: sacrum, heels, femoral trochanter and buttocks but damage can also occur elsewhere e.g. spine, ears or elbows.

Shear – shearing forces occur when deeper tissues near the bone slide, while the skin remains at its point of contact with the supporting surface (Waterlow 2005). This most

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commonly occurs when any part of the supported body is on a gradient. Mimura (2009) has demonstrated how bed positioning and body shape and size influence focal shear forces.

5.3 Pressure Ulcer Prevention

The involvement of the patient and/or carer in the prevention of pressure ulcers is vital. Explanation should be given about pressure ulcer risk factors, their implications and strategies for their prevention. The patient and/or carer’s experience in successfully preventing pressure ulcers should be taken into account when planning care. Patient information should be verbal, supported by written information as appropriate. The patient/carer should be involved in the long term care planning which may involve other members of the Community Health Care Team.

There are three principles of action to prevent pressure ulcers:

1. Redistribution of Pressure

2. Preventing damage to the skin

3. Improving tissue resistance

SSkin Care Bundle

The SSKIN Care Bundle is a powerful tool as it defines & ties best practice and the elements of prevention and assessment together. The bundle also makes the process of preventing pressure ulcers visible to all. This minimises variation in care practices.

It is a series of actions which are required in order to achieve a desired outcome (such as a reduction in the number of pressure ulcers). It ensures all elements of the care bundle are delivered & completed at every care opportunity, thus improving the pressure area care that a person receives.

By checking the skin more regularly when delivering care, early signs of pressure damage will be identified sooner by staff/carers.

5.4 Pressure Ulcer Management Plan

Following assessment an individualised plan of care needs to be formulated, together with patient and carer(s) to ensure a multidisciplinary team approach is implemented.

This should include:

Equipment selection, positioning/repositioning, wound treatment plan, nutritional treatment plan, pain management plan and education and advice for patients and carer(s).

Patients with identified risk factors may require referral to other members of the multidisciplinary team where appropriate i.e. Tissue Viability, Dietician, Physiotherapy, Wheelchair Services and Continence.

Patient education is an important piece of pressure ulcer prevention and management. The patient, family and care givers are key to prevention, management and treatment of pressure ulcers.

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5.5 Pressure Ulcer Safety Cross

The safety cross is a tool that will provide a sound baseline over time enabling the ongoing monthly collection of real time pressure ulcer incidence data that will assist teams to see their progress and to use the information gathered to continually improve.

The safety cross is not intended to replace current reporting systems that are already in place, rather the safety cross should complement them by encouraging early detection, leading to zero tolerance.

5.6 Equipment/Positioning

Pressure redistribution is the main approach used in the prevention of pressure ulcers (Dealey 2005). The overall aim is to reduce the magnitude and duration of any pressure exposure (McInnes et al 2008).

The effects of pressure and shear can be minimised by:

1. Correct positioning of the patient e.g. use of a profiling bed

2. Protection of high risk areas e.g. offloading pressure from heels

3. Using appropriate moving and handling techniques and equipment

The use of the 30 degree tilt to position patients in such a way to minimise the impact on bony prominences can also reduce the risk of pressure damage.

The frequency of timing and positional change will be determined by the individual’s tissue tolerance, vulnerable areas, level of mobility, general medical condition and overall treatment objectives. The frequency of timing and positional change will be determined by the individual’s tissue tolerance, vulnerable areas, level of mobility, general medical condition and overall treatment objectives. The frequency of repositioning must be included in the patients care plan and repositioning chart.

It is the responsibility of the health care professional to provide the most appropriate support surface to meet the individual patient needs for pressure redistribution, microclimate control and comfort (EPUAP 2009)

5.7 Pressure Ulcer Reporting Process – Root Cause Analysis (Level 2 Investigation)

Document all pressure ulcers category 2 and above as an incident using the trust clinical incident reporting system.

All category 3 and 4 pressure ulcers acquired in our care may be subject to a Level 2 Investigation, where acts or omissions in the patients care have been identified.

5.8 Assessment Tools, Flow Charts & Guidance

The following pathways, assessment tools and charts offer guidance with regards to:

EPUAP Pressure Ulcer Classification System (5.7.1)

Maelor Score Risk Assessment (5.7.2)

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Guidance for completion of Maelor Score (5.7.3)

Pressure points – at risk areas (5.7.4)

Guidance for community equipment selection (5.7.5)

MUST Assessment Tool (5.7.6)

Positioning of patients to minimise impact on bony prominences and reduce risk of

pressure damage (5.7.7)

Skin Bundle (5.7.8)

Pressure Ulcer Safety Cross (5.7.9)

Pressure Ulcer Safety Cross guidance (5.7.10)

24 hour re-positioning – turning chart (5.7.11)

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5.8.1 EPUAP Pressure Ulcer Classification System (2009)

The following EPUAP Pressure Ulcer Classification System should be used in conjunction with the Maelor risk assessment tool as part of a holistic assessment, as described in the Pressure Ulcer Prevention & Management Policy (Vowden 2010)

Please note grading only applies to Pressure Damage and should not be used to describe other type of wounds.

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5.8.2 Maelor Score Risk Assessment

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5.8.3 Guidance for Completion of Maelor Score

Assigning a Numerical Value to each Category

Choose the level within the category that best describes the patient, and record the corresponding numerical value in the assessment column.

One value must be recorded for each of the nine categories.

Ambulation

This refers to the ability of the patient to walk. If you cannot decide between chair fast and bed fast, record a score of 5.

Mobility

This refers to the ability of the patient to move different parts of the body. Immobility may be due to a variety of factors e.g. severe pain, paralysis, coma. If a patient is receiving regular, passive exercise, record the score corresponding to the number of carers needed to produce body movement during each exercise session

Skin Condition

This refers to the skin condition in pressure areas only. Redness (blanches with finger pressure) refers to an evaluation you can perform while repositioning the patient. Finger pressure on the skin of pressure areas should cause the skin to go white initially, but to turn red again within seconds. If no blanching (whitening) occurs, then a pressure ulcer is present and its grade should be documented below the total score. For patients with darkly pigmented, intact skin, redness in pressure areas is equivalent to a localized skin colour change, a taut, shiny surface to the skin and increased skin temperature.

Predisposing Disease

An acute or critical stage of an illness refers to the period of approximately 48 hours immediately after an incident such as myocardial infarction, cerebrovascular accident or major surgical intervention, before the patient becomes stabilised. Chronic unstable refers to an acute phase of an otherwise chronic condition, which normally also last approximately 48 hours e.g. hypoglycaemia or hyperglycaemia in a diabetic patient. Once the patient has stabilised, the condition is chronic stable. Terminal stage of illness refers to many conditions e.g. heart, liver or kidney disease, not just to terminal cancer.

Pain

The score registered should represent the patient’s perception of pain whenever possible. Where this is not possible you should use your clinical judgment and observe the patient for signs of pain such as facial expression, splinting and protection of painful areas.

Total Score

The total Score obtained by adding together the numerical values from each of the 9 categories indicate the overall risk of the patient.

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Follow up Action

It is imperative that patients identified as being at high risk of pressure ulcer development and any patients already with pressure ulcers are placed on a suitable support surface and a management plan implemented and evaluated. For information on prevention and management including suitable support surfaces refer to the Tissue Viability Guidelines.

Frequency of Assessment

The frequency of pressure ulcer risk assessment will depend on the condition of the patient. Assessment will normally be on a daily basis for medium and high risk patients.

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5.8.4 Pressure Points – At Risk Areas

From Seating and Pressure Ulcer: Clinical Practice Guideline (Tissue Viability Society 2009)

The “at risk” areas are:

Ischial tuberosities

Sacrum

Trochanter

Popliteal Fossa

Scapula

Heels

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5.8.5 Guidance for Community Equipment Selection

Patient at risk of

developing pressure

damage?

Is patients pressure

areas free from

persistant erthema?

Continue to reassess as care

plan using risk tools

Can patient change

position

independently and

frequently?

Is the patient in bed

or chair for more

than 12 hours each

day Perform Skin

Inspection

Mattress

Replacement foam or air filled

Cushion

Pressure redistribution

memory foam or air filled

*Consider foot protectors if

known Peripheral Vascular

Disease, Diabetes, or

previous heel ulcers

Is the skin to the

patients pressure

areas intact?

Is there pressure

damage or a

pressure ulcer

present Grade 2 or

above, deteriorating

3, 4 or ungradable

Is the patient in

bed or chair for

more than 12

hours each day?

Mattress

Alternating cell mattress or

air filled static

Cushion

Alternating cell cushion or air

filled static

Is the patient totally

dependant for all cares,

palliative etc

Is the patient un able to

tolerate an alternating

system

Mattress & Cushion

Alternating cell

Mattress C

Consider dual action

mattress

Cushion

Alternating cell or air

filled cushion if unable

to tolerate

Yes

No

No

Yes

Yes

Yes

Yes

Yes

Yes

No No

No

No

No

Yes

No

Mattress Guide Cushion Guide

Replacement foam mattress – A Low to Medium Risk category 1-2 and can relieve own pressure

Pressure redistributing memory foam

Alternating cell mattress - B Medium to High Risk, deteriorating category 2 and 3 or 4 and has some degree of relieving own pressure

Alternating cell cushion

Mercury Advance/Nimbus or equivalent dependant on equipment store store availability – C Very High risk Deteriorating grade 3 and 4 or ungradable and unable to Relieve own pressure areas/always discuss with TVN/PU team

Foot and Heel protectors Consider Repose foot protectors or Repose wedge Wedge to offload heels. KerraPro / use of pillows (ensuring knees are flexed and free of pressure)

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5.8.6 Must Assessment Tool

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5.8.7 Positioning of Patients to Minimise Impact on Bony Prominences and Reduce Risk of Pressure Damage

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5.8.8 Skin Bundle

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5.8.9 Safety Cross

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5.8.10 How to use the Safety Cross

It is important to stress that each care team should have a clear aim in what they are trying to achieve, otherwise the Safety Cross is seen merely as a reporting tool.

There are three fundamental questions to think about, the answers to which form the basis of improvement:

1. What do you want to accomplish? (e.g. reduce pressure ulcers by X% within X amount of months )

2. How will you know that a change is an improvement? (i.e. use the Safety Cross to enable you to see incidence locally and act on it)

3. What changes can you make that will result in improvement and zero tolerance? Safety Cross Guidance

Each Safety Cross represents one calendar month

Within each cross there are 31 boxes, as each box represents a single day.

To the left of the cross is a key which lets you know that each colour represents an outcome of a single day.

Green = no new pressure ulcer found.

Orange = admitted with pressure ulcer.

Red = new pressure ulcer found (acquired).

Each box should be coloured at the end of the day (i.e. close of play) using the appropriate colour.

Where possible, only one colour should be used per day.

However it may be necessary for you to record ‘multi coloured’ days especially if you have a high turnover of patients over a short time (i.e. if more than one colour is required for a given day, consider splitting the date box).

The golden rule is to keep the format simple in order to make the occurrence of a pressure ulcer immediately obvious.

You can use either a coloured pen or colour stickers to shade the boxes.

For the days that are coloured in either orange or red, you are encouraged to record the number of pressure ulcers found on that day. You can record this figure within the small box given for the appropriate day.

You only count an ulcer once.

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In order to minimise double counting of pressure ulcers, it is recommended that you record this in the table provided when a pressure ulcer is identified by recording the date the ulcer was discovered for a particular patient, and the location of that pressure ulcer.

Remember that patient/client data needs to remain confidential at all times, so consider putting the table on the back of the Safety Cross.

A pressure ulcer should be recorded regardless of whether the patient developed an ulcer in your caseload/area or was transferred into your team with an ulcer.

The Senior Nurse in Charge has responsibility for ensuring the safety cross is completed. However the task of completing the Safety Cross can be delegated to any member of the team.

Collecting the data

It is recommended that you keep all completed Safety Crosses for your own records.

At local level you can decide who should gather in the Safety Crosses at the end of the month for tallying.

You can then display this data in the form of run charts.

This enables the team to celebrate the number of days that have gone by since a pressure ulcer developed. This information should be updated on a regular basis (daily if possible)

Staff take great pride in knowing they have improved their care.

Results from each team will be shared and celebrated within the trust e.g. District Nurse Forum, reports to trust board, commissioners etc.

Acknowledgement

With kind permission, sought by the authors and granted 30th July 2015 by ‘NHS Scotland, Knowledge Management Team’, these guidelines have been adapted from the ‘Healthcare Improvement Scotland (2009), NHS Scotland Pressure Ulcer Safety Cross document’

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5.8.11 24 Hour Positioning – Turning Chart

Name:

Address

Date of Birth:

NHS:

Mattress type:

Cushion:

Use of Wedge/Foot trough: Yes □ No □

Frequency of repositioning:

(e.g. 2 to 4 hourly):

Sitting in chair

Inspect skin for evidence of change at each repositioned change

Reassess at every positional change and document below

Reposition the patient to reduce the risk of pressure ulcer damage, e.g. using the 30 degree tilt

Follow Moving and Handling policy and use of equipment to minimise risk of friction and shear

If required, provide suitable seating equivalent to the mattress specification and encourage repositioning/mobilisation where possible

Document change on positional changes chart and electronic patient record (e.g. system One)

Date& time Patients position (e.g.30 degree left/ back/ 30 degree right/Sitting out)

Skin condition (e.g. Intact/ Marking

Pressure Ulcer (if applicable) Category/ location

Signature & designation

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6 LEG ULCER MANAGEMENT

A leg ulcer is a loss of skin below the knee of the leg or foot which takes more than 4 – 6 weeks to heal (Dale et al. 1983).

There is no single aetiology; however it is thought that approximately 70% of people with a leg ulcer are as a result of venous hypertension (Moffatt and Franks 1994; Chen and Rogers 2007). Arterial or mixed arterial/venous disease is responsible for a further 20% and the remaining are from other conditions such as diabetes, rheumatoid disease, malignancy and vasculitic conditions (Chen and Rogers 2007).

Inadequate assessment and ineffective treatment may result in the persistence of ulcers for many years, some never healing

6.1 Leg Ulcer Management

The guidelines aim to ensure that all patients presenting with a leg ulcer receive a comprehensive assessment and subsequent diagnosis from a registered health care professional who have additional competencies in leg ulcer management.

The first step is recognising the wound as a leg ulcer. Wounds that commonly fall into this category are pre – tibial lacerations (or other trauma wounds) and surgical incisions where veins have been harvested for coronary bypass grafts (Moffatt et al 2007).

A detailed assessment of the patient’s general health and past medical history is vital when diagnosing and determining treatment of the ulcer and should be carried out using trust assessment tools incorporated within these guidelines.

It is essential that underlying disease processes are addressed and stabilised to ensure maximum potential to heal.

The leg should be assessed for signs of venous disease, in particular, varicose veins, venous dermatitis, haemosiderin deposition, lipodermatosclerosis and atrophie blanche.

Oedema should be assessed and non – venous causes of unilateral and bilateral oedema ruled out.

Joint mobility, particularly of the ankle is an important factor of the function of the calf muscle pump and should be recorded.

The following conditions require specific treatment and should be looked for in initial assessment (SIGN 2010):

Peripheral Arterial Disease: approximately 20% of patients with a leg ulcer will have arterial disease.

A history of intermittent claudication, cardiovascular disease, or stroke may indicate that the patient has arterial disease. Absence of symptoms does not exclude the presence of peripheral arterial disease.

Rheumatoid Arthritis and Systemic Vasculitis: around 9% of patients with a leg ulcer have rheumatoid arthritis. These patients may have venous, arterial or vasculitic ulcers. Systemic vasculitis occurs as a feature of several collagen vascular diseases when leg ulcers will usually be multiple, necrotic, deep and have an atypical distribution.

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Diabetes Mellitus: approximately 5% of patients will have diabetes. These patients may have venous, arterial or neuropathic ulcers, or may have diabetic bullae which subsequently ulcerate.

6.2 Chronic Oedema

This broad term is used to describe oedema of more than 3 months where normal lymphatics have failed to remove the overload of fluid mainly due to chronic venous insufficiency (Partsch and Moffatt 2012).

Lymphovenous Disease

It is essential that early detection such as swollen or wet leaky legs are recognised and treated accordingly to help prevent progression to a chronic oedema state where worsening skin changes and enhanced skin folds are present (Todd 2012).

• Enhanced skin folds - caused by over-stretching of skin due to oedema. Ankles and toes are mainly affected but the mid-calf and knee can also be involved.

• Papillomatosis - are blind-ended superficial lymphatic vessels that swell due to back pressure and protrude through the skin (warty appearance).

• Lymphorrhoea/exudate - if there is oedema and a break in the skin fluid can leak onto the skin surface. This is often called ‘wet legs’.

• Lipodermatosclerosis - fibrosis and indurations of the skin around the ankle area, caused by prolonged inflammation, giving a ‘woody’ feel, especially around the ankle. If allowed to progress, this results in the ‘upturned champagne bottle’ shape of the leg.

• Stemmer’s test - results in either a positive or negative sign for long standing chronic oedema. To perform it, try to pinch and lift a skin fold at the base of the second toe. If you can pinch and lift the skin, Stemmer’s sign is negative. If you can’t, the sign is positive. False positives never occur.

• Cellulitis - is infection of the skin and soft tissue caused by bacterial infiltration of the stagnant protein-rich fluid. It is usually caused by group streptococci, but may also involve Staphylococcus aureus, especially if folliculitis is present.

Antibiotics are the main treatment for cellulitis, oral for a mild infection but intravenous antibiotics can be needed.

Living with chronic oedema can be devastating for the patient and his or her family. Having to adapt clothing/footwear, disguise large and unsightly limbs, and deal with exuding wounds is embarrassing and affects body image, self-esteem and personal relationships (Moffatt et al 2003).

6.3 Doppler Studies

It is important to assess arterial supply with respect to safety of compression therapy, which is the standard treatment for venous leg ulcers.

Measurement of the ankle brachial pressure index (ABPI) of both lower limbs by Doppler device is the most reliable way to detect peripheral arterial disease (PAD), (SIGN 2010).

ABPI must be carried out as soon as possible after the initial presentation.

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Objective evidence to substantiate the presence or absence of PAD is obtained reliably (except in those with heavily calcified vessels) by obtaining an ABPI in both legs at the initial assessment.

Doppler assessment is twofold:

• Interpretation of signals and

• Pressure index

Patients who have a normal arterial circulation will have an Ankle systolic pressure that is the same as, or higher than, their Brachial pressure. Ankle pressures lower than the Brachial pressures are indicative of arterial disease.

Care must be taken in interpreting ABPI results in patients with heavily calcified vessels, such as in some patients with diabetes and advanced chronic renal failure, where they may be misleadingly high (SIGN 2010).

6.4 Diagnosis

After completing a holistic assessment and Doppler studies, treat the patient according to the underlying pathology of their diagnosis using the following flowcharts.

Patients who have a mixed picture may be treated along the lines of their predominant pathological presentation.

Patients where diagnosis is unclear should be referred to the Tissue Viability Team.

6.5 Compression Therapy

The key to the successful healing of chronic venous ulcers will be to correct the underlying venous hypertension using graduated compression therapy (EWMA, 2003, Moffatt 2007).

In the first instance the venous leg ulcer / chronic oedema pathway should be initiated unless clinical and Doppler studies indicate otherwise. Referral to the Tissue Viability Team may be required.

Alternative compression bandages are documented in the compression section of the formulary.

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6.6 Ankle Brachial Pressure Index

ABPI 0.8 to 1.3

ABPI Greater than 1.3

Normal Doppler Index with Triphasic & Biphasic sounds.

No significant arterial factors

Follow venous leg ulcer pathway for standard or complex care.

For chronic oedema (lymphovenous disease) follow chronic oedema pathway

Normal Doppler Index but with Biphasic and Monophasic sounds that are difficult or muffled and significant arterial factors are present, indicate possible arterial component.

Reduced compression building to full compression if tolerated

Follow venous leg ulcer or chronic oedema (lymphovenous disease) pathway.

Address pain, any underlying disease and refer if unstable.

Address dermatology issues – refer as needed to TVN for advice, GP with special interests, secondary care.

Ulcer healed - Prevent reoccurrence

Measure for and fit Class 2 or 3 European classifications, circular knit Hosiery.

For patients with limb distortion due to chronic oedema measure for and fit flat knit hosiery Class 2 or 3.

As appropriate and via GP - referral to vascular surgeon may be indicated for assessment and treatment of varicose veins as per NICE guidance (2013).

Ulcer not improving or deteriorating

Reassess and re Doppler

Refer to Tissue Viability Team

For Doppler Index above 1.3 refer to Venous Leg Ulcer pathway guidance

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ABPI 0.8 – 0.6

ABPI Less than 0.5

Biphasic and Monophasic sounds that are difficult or muffled and significant arterial factors indicate a mixed venous and arterial ulcer.

Follow venous leg ulcer pathway for standard or complex care.

For chronic oedema (Lymphovenous disease) follow chronic oedema pathway

Monophasic sounds and significant arterial components indicate an arterial ulcer.

Refer to Tissue Viability Team for opinion

Address pain, any underlying disease and refer if unstable.

Address dermatology issues – refer as needed to TVN for advice, GP with special interests, secondary care.

Ulcer healed

Prevent reoccurrence

Measure for and fit Class 1 or 2 European classifications, circular knit Hosiery dependant on Doppler Index.

For patients with limb distortion due to chronic oedema measure for and fit flat knit hosiery Class 1 or 2, dependant on Doppler Index.

Routine referral to vascular services if experiencing claudication pain

For re-occurring ulcers refer to Tissue Viability Team for advice.

Ulcer not improving or deteriorating

Refer to Tissue Viability Team


Urgent referral to vascular services if 0.5 or less

No compression and Urgent referral to vascular services

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6.7 Venous and Chronic Oedema Pathways Explained

The venous leg ulcer and chronic oedema pathway sets out the processes to follow for patients with care management needs and has been adapted for the work of Gardner (2013).

The pathways are supported by guidance notes that outline the action to be taken, by whom and the supporting documents including referral as required.

The criterion for inclusion into the pathway is also outlined.

This includes details of the most appropriate allocation to a flowchart for either venous or chronic oedema management.

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6.7.1 Leg Ulcer Pathway and Referral Process

Patient with Leg Ulcer (LU) or lower limb wound

Full lower limb assessment as per LU Pathway document including Doppler within 2 weeks of presentation

Diagnosis of Aetiology

With or without chronic oedema

ABPI > 1.3 or unable to Doppler (e.g. due to oedema) Refer to TVN for advice Referral to vascular services may be required

ABPI – 0.8 to 1.3

Manage with compression bandaging as per Standard or Complex venous or Chronic Oedema Leg

Ulcer Flow Chart

ABPI – 0.6 to 0.8 Mixed venous and arterial aetiology

ABPI 0.5 or less Severe Arterial Insufficiency

Uncertain Diagnosis

Diabetic with ulcer below malleoli

Wound surface area fails to reduce by 40% at 6 weeks

1) Move to Complex Leg Ulcer Flow Chart.

2) Refer to TVN for advice.

Refer to guidance re reduced compression and/or refer to TVN.


Urgent referral to vascular services

Refer to Podiatry

Refer to TVN

Refer to TVN

Referral is to be made to the TVN Team via the referral form

Follow up will be in accordance with specialist advice and shared care. Ongoing support from TVN team as required

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6.7.2 Ulcer Pathway and Referral Process Guidance Notes

No Action to be Taken By Whom Supporting Documents

1 Carry out full lower limb assessment to determine aetiology

This should be done within 2 weeks of presentation

Registered Nurse competent in leg ulcer assessment, management & Doppler studies

Tissue Viability Policy

Tissue Viability Guidance & Formulary document

Leg Ulcer Pathway

2 Establish Aetiology

Choose Standard or Complex pathway for venous leg ulcer or chronic oedema/lymphovenous disease.

Registered Nurse competent in leg ulcer assessment, management & Doppler studies

Contact TVN for advice if uncertain

DN Standard document

Tissue Viability Referral Form LU1 (*E-Referral when available)

3 Ensure that all underlying co morbidities are optimally managed.

Consider the need for bloods.

Effective pain Management

Patients GP Leg Ulcer Pathway Pain Assessment Tool

4 Venous aetiology (ABPI 0.8-1.3) allocate patient to the Standard or Complex flow chart and implement recommended care.

If wound fails to reduce in surface area by 40% at 6 weeks then if on Standard Flow Chart should transfer to Complex with associated referral to TVN

Registered Nurse Standard Leg Ulcer Flow Chart for venous leg ulcer or chronic oedema/lymphovenous disease.

Complex Leg Ulcer Flow Chart

Tissue Viability Referral Form LU1 (E-Referral when available)

5 Mixed Aetiology (ABPI 0.6-0.8)

Refer to guidance re reduced compression and/or refer to TVN

Registered Nurse

Reduced Compression Guidance


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6 Routine referral to vascular services if experiencing claudication pain

GP for referral to vascular services as required

7 Arterial Aetiology (ABPI<0.5)

DO NOT apply compression.

Urgent referral to vascular services.

Refer to TVN for interim care advice.

Registered Nurse

GP for referral to vascular services


8 If the patient is diabetic and has an ulcer below the malleoli refer to community podiatry foot clinic

Registered Nurse.

9 If the patient has an ulcer of unknown aetiology (e.g. malignancy, vasculitis, pyoderma gangrenosum, contact dermatitis) refer to TVN team as referral to Dermatology or other specialism may be required.

Registered Nurse.

*E – Referral An E – Referral process is being developed at the time of publication of this document. Once the process is available it should be used for all referrals to the Tissue Viability Service.

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6.7.3 Venous, Chronic Oedema and Lymphovenous Disease Leg Ulcer Flow Chart Criteria

Inclusion Patients should meet ALL of the following to be allocated to a flow chart

Patient should be concordant (ensuring all reasonable strategies have been employed to gain concordance e.g. pain managed etc.)

Underlying co-morbidities should be optimally managed (e.g. diabetes, anaemia)

The patient should not be end of life Allocation to a specific flow chart The patient should satisfy one or more of the criteria below IF THE PATIENT HAS A RECURRENT ULCER THEY WILL AUTOMATICALLY BE ALLOCATED TO THE COMPLEX FLOW CHART. Allocation to the STANDARD Venous Leg Ulcer Flow Chart

ABPI 0.8-1.3

First Ulcer

Ulcer less than 3 months old

Less than 3 episodes of wound infection

Less than 100cm2 in size

Patient currently in or willing to have high compression therapy Allocation to the COMPLEX Venous Leg Ulcer Flow Chart

ABPI 0.8-1.3

Ulcer greater than 3 months old

History of recurring ulcer/s

More than 3 episodes of wound infection

Greater than 100cm2 in size

Possibility of elevated protease activity

Patient currently in or willing to have high compression therapy

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6.7.4 Venous Leg Ulcer Flow Chart

STANDARD

24 Week Healing Target

To be used in conjunction with guidance. Products identified are first line choice.

Initial leg ulcer assessment Diagnosis of venous ulceration (ABPI 0.8-1.3)

Ulcer present for less than 3 months

Free from Slough and infection/critical colonisation

Colonised & Sloughy Critical colonisation or local wound infection (with or without slough)

Treat with UrgoClean, Zetivit Plus as required & KTwo bandage system until the wound bed is clean. If debridement not achieved in 4 weeks refer to community TVN

Following expected healing (has achieved at least 40% reduction in wound surface area)

Treat with antimicrobial from formulary, Zetuvit Plus as required and KTwo bandage system for 2 weeks. Contact community TVN for advice if no improvement

Continue of Standard VLU Flow Chart

Move to Complex VLU Flow Chart. Refer to community TVN

Treat with Atrauman, Zetuvit Plus as required and KTwo bandage system

HEALED

Commence preventative hosiery

Reassess every 6 weeks

Photograph, map and measure wound surface area in cm2

Not following expected healing (less than 40% reduction in wound surface area in 6 weeks)

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6.7.5 Chronic Oedema & Lymphovenous Leg Ulcer Flow Chart

STANDARD

To be used in conjunction with guidance. Products identified are first line choice

Initial leg ulcer assessment Diagnosis of chronic oedema/Lymphovenous disease with ulceration

(ABPI 0.8-1.3) Ulcer Present for less than 3 months

Critical colonisation or local wound infection (with or without slough)

Treat with antimicrobial for 2 weeks from formulary, Zetuvit Plus as needed and appropriate bandage system. Contact community TVN for advice if no improvement

Move to Complex VLU Flow Chart. Refer to community TVN

Treat with Atrauman, Zetuvit Plus as required and prescribed bandage system

Not following expected healing (less than 40% reduction in wound surface area in 6 weeks)

Free from Slough and infection/critical colonisation

Colonised & Sloughy

Treat with UrgoClean, Zetivit Plus as required Bandage System toe to knee or toe to thigh dependant on level of oedema with KTwo, Coban 2 or Actico multilayer dependant on clinical judgement and patient choice. Toe bandages as required.

If debridement not achieved in 4 weeks refer to community TVN

Following expected healing (has achieved at

least 40% reduction in wound surface area)

Continue with Standard Flow Chart

HEALED Commence preventative hosiery

This must be European standard either circular knit for patients without limb distortions,

Flat knit for patients with limb distortions

Refer to TVN for advice as required

Reassess every 6 weeks. Photograph, map and measure wound surface area in cm2

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6.7.6 Guidance for STANDARD Flow Chart

No Action to be Taken Documents/Guidance/Tools

1 Venous aetiology should be established by undertaking a full leg ulcer assessment utilising the Leg Ulcer Pathway document and a Doppler ABPI.

Leg Ulcer Pathway

Wound Measurement Guidelines.

Ensure that the wound has been mapped and the surface area has been calculated.

2 Doppler ABPI assessment. ABPI should be between 0.8 and 1.3

District Nursing Standard

Flow Chart Inclusion Criteria

3 Assess wound for slough


4 If slough needs to be removed from the wound bed the primary dressing should be Urgoclean. Hydro-desloughing fibres trap sloughy residues. It provides a non-adherent atraumatic wound contact layer. Use in the first instance for 4 weeks.

Urgoclean Product Guide


5 Assess the wound bed for critical colonisation


6 If the wound bed has local critical colonisation commence a 2 week course of topical antimicrobial therapy identified in the wound care formulary


7 If the wound is free from slough and critical colonisation then commence Atrauman as a wound contact layer

Atrauman Product Guide

8 Choose the size of Zetuvit Plus based on the level of exudate.

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9 For venous ulcer pathway apply compression therapy utilising the KTwo bandage system. An alternate bandage system may be selected as second line if the KTwo is not deemed as suitable, e.g. to obtain patient concordance.

For chronic oedema/lymphovenous disease select bandage system in accordance with the pathway (all named are licensed for oedematous conditions)

KTwo Product Guide

Actico Product Guide

Coban 2 Product Guide

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6.7.7 Venous Leg ulcer flow chart

COMPLEX

24 Week Healing Target

To be used in conjunction with guidance Products are first line choice

Critical colonisation or local wound infection (with or without slough)

Treat with antimicrobial from formulary, Zetuvit Plus as required and KTwo bandage system for 2 weeks. Contact community TVN for advice if no improvement.

Initial leg ulcer assessment Diagnosis of venous ulceration (ABPI 0.8-1.3) Ulcer present for more than 3 months

Free from Slough and infection/critical

colonisation Colonised & Sloughy

Treat with UrgoClean, Zetuvit Plus and KTwo bandage system until the wound bed is clean. If debridement not achieved in 4 weeks refer to community TVN.

Continue with UrgoStart Contact

Reassess at 12 weeks. Photograph, map and measure wound surface area in cm2. Discontinue UrgoStart, commence Atrauman. If less than 40% reduction since last assessment refer to community TVN

Week 24 assessment

Continue with current treatment regime until healing. If would fails to progress or becomes static, refer to community TVN. Following healing commence preventative hosiery

Treat with UrgoStart Contact, Zetuvit Plus as required and KTwo bandage system

Reassess at 18 weeks

Continue with Atrauman. If less than 40% reduction since last assessment refer to community TVN

Reassess every 6 weeks.

Photograph, map and measure wound surface area in cm2. Has there been a reduction of wound surface area of 20% since commencing UrgoStart Contact?

Discontinue UrgoStart Contact and change to Atrauman

YES NO

Refer Community TVN

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6.7.8 Chronic Oedema & Lymphovenous Leg Ulcer Flow Chart

COMPLEX

24 Week Healing Target To be used in conjunction with guidance Products identified are first line choice

Initial leg ulcer assessment Diagnosis of chronic oedema/ Lymphovenous disease (ABPI 0.8-1.3)

Ulcer present for more than 3 months

Free from Slough and

infection/critical colonisation

Colonised & Sloughy Critical colonisation or local wound infection

(with or without slough) Treat with UrgoClean. Zetuvit Plus as required Bandage System toe to knee or toe to thigh dependant on level of oedema with KTwo, Coban 2 or Actico multilayer dependant on clinical judgement and patient choice. Toe bandages as required If debridement not achieved in 4 weeks refer to community TVN

Continue with UrgoStart Contact

Treat with antimicrobial for 2 weeks from formulary, Zetuvit Plus as needed and appropriate bandage system. Contact community TVN for advice if no improvement

Reassess at 12 weeks. Photograph, map and measure wound surface area in cm2. Discontinue UrgoStart, commence Atrauman. If less than 40% reduction since last assessment refer to community TVN

Week 24 assessment.

Continue with current treatment regime until healing. If would fails to progress or becomes static,

refer to community TVN. Following healing commence preventative hosiery.

This must be European standard either circular knit for patients without limb distortions,

Flat knit for patients with limb distortions

Refer to TVN for advice as required

Treat with UrgoStart Contact, Zetuvit Plus as required and bandage system

Reassess at 18 weeks

Continue with Atrauman. If less than 40% reduction since last assessment refer to community TVN

Reassess every 6 weeks. Photograph, map and measure wound surface area in cm2. Has there been a reduction of

wound surface area of 20% since commencing UrgoStart Contact?

Discontinue UrgoStart Contact and change to Atrauman

YES NO

Refer Community TVN

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6.7.9 Guidance for COMPLEX Flow Chart

No Action to be taken Documents/Guidance/Tools

1 Venous aetiology should be established by undertaking a full leg ulcer assessment utilising the Leg Ulcer Pathway document and a Doppler ABPI.

Ensure that the wound has been mapped and the surface area has been calculated.

Tissue Viability Policy



2 Doppler ABPI assessment. ABPI should be between 0.8 and 1.3

District Nursing Standard

Flow Chart Inclusion Criteria

3 Assess wound for slough


4 If slough needs to be removed from the wound bed the primary dressing should be Urgoclean. Hydro-desloughing fibres trap sloughy residues. It provides a non adherent atraumatic wound contact layer. Use in the first instance for 4 weeks.

Urgoclean Product Guide

5 Assess the wound bed for critical colonisation


6 If the wound bed has local critical colonisation commence a 2 week course of topical antimicrobial therapy identified in the wound care formulary


7 When any critical colonisation has been resolved and wound bed is less than 30% slough, commence Urgostart. This is a protease

Urgostart Product Guide

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inhibitor that reduces the high level of harmful MMPs (enzymes) that commonly occur in chronic wounds.

8 For venous ulcer pathway apply compression therapy utilising the KTwo bandage system. An alternate bandage system may be selected as second line if the KTwo is not deemed as suitable, e.g. to obtain patient concordance.

For chronic oedema/lymphovenous disease select bandage system in accordance with the pathway (all named are licensed for oedematous conditions)

KTwo Product Guide

Actico Product Guide

Coban 2 Product Guide

9 Reassess every 6 weeks. Photograph, map and measure wound surface area in cm2. Calculate % reduction in surface area over the past 6 weeks. If the wound has not reduced in surface area by 20% stop using the Urgostart. Refer to Community Tissue Viability and commence using Atrauman as a wound contact layer.


District Nurse Standard

TVN referral

Complex Venous Leg Ulcer Flow Chart


10 Continue Urgostart if reduction in surface area is 20% or greater.

Wound measurement Guidelines.



TVN Referral

11 Reassess at 12 weeks. Photograph, map and measure wound surface area in cm2. Calculate % reduction in surface area over the past 6 weeks. Discontinue Urgostart and commence Atrauman. If the wound has not reduced in surface area by 40% since last assessment refer to




TVN Referral

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Community TVN team

12 Reassess at 18 weeks. Continue Atrauman. If less than 40% reduction in surface area since last assessment refer to Community TVN team



TVN Referral

13 Week 24 assessment. Continue with current treatment regime until healing. If wound fails to progress or becomes static, refer to community TVN. When healed commence emollient therapy and preventative hosiery



TVN Referral


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7 WOUND TYPES, ASSESSMENT & DRESSING GUIDANCE/SECTION CHARTS

7.1 Moisture Lesions

Moisture associated skin damage (MASD) is defined as inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudates, mucus or saliva (Grey et al. 2011).

7.2 Wound Continuum Guidance

Clinicians are encouraged to use the wound continuums to assess, document and evaluate the treatment in a common language.

The Wound Healing Continuum

The wound healing continuum is an aid to understanding the type of tissue present in the wound and how it should progress.

The continuum helps to identify colour changes of the wound from black to pink; it correlates with the healing stages.

The Wound Infection Continuum

This wound infection continuum is a simple sliding scale to aid clinical decision-making regarding the level of bacterial colonisation of a wound.

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7.3 Wound Dressing Guidelines

HEALING INFECTION EXUDATE

Necrotic Sloughy Granular Epithelial

*Spreading Local Critically Colonised Infection Infection Colonised

Hi Moisture/exudate descriptors

Leaking:Exudate not contained by dressing Wet: Exudate contained but dressing saturated Moist: Exudate at optimum levels Dry: Insufficient moisture at wound bed

0 – 8) SI LI CC Col

AIM Attain 100% ‘Epithelial’ tissue Attain a healthy bacterial wound bed Attain moist wound environment

OBJECTIVE Remove Necrotic and/or

Sloughy Tissue * Promote Granulation and Epithelial tissue

Treat infection

Treat infection

Reduce bacterial

levels

Maintain bacterial

levels Manage exudate

TREATMENT Autolysis or re-hydration

Use dressing to promote a moist wound healing.

Use systemic antibiotic on Spreading Infection (see page 28)

No a

ntim

icro

bia

l re

quire

d

Highly absorptive products

Moderately exudate

absorption

Low exudate absorption

NECROTIC (Dry)* HYDROGEL HONEY HYDROCOLLOID SLOUGHY (Moist/wet) HONEY HYDROCOLLOID ALGINATE CADEXOMER IODINE

FOAMS HYDROCOLLOID ALGINATE FILM LOW ADHERENT (Leg ulcers) NON ADHERENT (if required)

ANTIMICROBIAL

- Silver Dressings

- Iodine Dressings

- Honey

SUPER ABSORBANT

ALGINATE HYDROFIBRE

FOAM ALGINATE HYDROFIBRE

LOW ADHERENT HYDROCOLLOID

FOAM

Skin protecting creams/ lotions to surrounding skin may be required to prevent maceration

* Please note in some cases it may not be appropriate to re-hydrate necrosis. In such cases Inadine may be the most appropriate product

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7.4 How to Use the Continuums for Wound Assessment

Diagram 1 - The Wound Healing Continuum

BLACK BLACK /YELLOW YELLOW YELLOW /RED RED RED /PINK PINK

Diagram 2 - The Wound Infection Continuum

Spreading Infection Local Infection Critically Colonised Colonised

3 2 1 0

STEP ONE – The Wound Healing Continuum

This is an aid to understanding the type of tissue present in the wound and how it should progress. Thought of as a continuum of colour changes (See diagram 1) from black to pink, it correlates with the healing stages of the wound. Not all wounds progress across the whole spectrum e.g. not all wounds will have a black stage.

USING THE WOUND HEALING CONTINUUM

Identify the colour of the wound that is furthest to the left of the continuum. For example, if the wound contains yellow slough and red granulating tissue it would be defined as a yellow/red wound. The management plan would focus on the removal of the yellow, sloughy tissue and promotion of red granulation tissue. As this objective is achieved, the patient can progress along the wound healing continuum towards the right and therefore a pink / healing status.

STEP TWO – The Wound Infection Continuum There are four criteria which work from left to right with the most severe, “Spreading Wound Infection” on the left (Diagram 2). The continuum moves right, through “Local Infection”, “Critical Colonisation”, to “Colonisation.”

USING THE WOUND INFECTION CONTINUUM

Spreading infection can be a life threatening condition. Local signs & symptoms associated with a spreading soft tissue infection includes; spreading redness (>2cm around wound margin), very high exudate levels, pain, malodour, heat in the surrounding tissues & blistering.

Localised infection is characterised by <2cm of redness around the wound margin, symptoms similar to spreading infection may also be present but to a lesser degree.

Critical colonisation is characterised by delayed healing, malodour & raised exudate levels, (slough may also be present). However, the wound will not present as if locally infected.

A Colonised wound is the normal healing state of a wound. A reduction in wound size over a

two-week period would suggest an acceptable level of colonisation.

This Wound Infection Continuum is a simple sliding scale to aid clinical decision-making regarding the level of bacterial colonisation of a wound. A patient may never move to the furthest point on the right (Colonised) on the continuum during their entire treatment. However, lower bacterial levels found in colonised wounds generally lead to better healing. The status of a wound, which has Spreading Infection, Localised Infection or is Critically Colonised, should be considered when developing a treatment plan.

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7.5 Dressing Selection Flow Chart

Assessment Goal Action Plan

Necrotic Tissue

Black wounds

Sloughy Tissue Green & yellow wounds

Granulation Tissue Red & pink wounds

Healing Wound Pink Epithelialisation

Non healing Wound

• Look for possible cause of non healing e.g. patient or wound factors

• Refer to Tissue Viability Service for advice and/or assessment

No

No

No

No

Yes

Yes

Yes

Debride (If unsure of arterial status keep dry as below)

Deslough

Promote healing

Hydrocolloid Hydrogel Cadexomer Iodine Sharp Debridement (TVN or Podiatry only)

Low exudate; Hydrocolloid Hydrogel Maggots High exudate; Gelling fibre Alginate Foam Maggots

Low exudate; Hydrocolloid Hydrogel Film Low Adherent Wound contact High exudate; Gelling fibre Alginate Foam

Infection resolved/wound healing

No

Yes

Stop antimicrobial – review

Mummify/ Keep dry Low exudate;

Povidone Iodine High exudate Cadexomer Iodine (Avoid foams if aim is to keep dry)

Infection – attain a healthy bacterial wound bed Antimicrobial Products (use for 14 days & reassess); Silver, Honey, Cadexomer Iodine (use beyond 14 days to be discussed with TVN) Systemic antibiotics for spreading (Section 8)

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8 FORMULARY PRODUCTS

All products listed are available on Prescription unless indicated.

* indicates items only available from NHS Supplies or direct from manufacturers.

The following rating is a cost code system for products within the recommended product groupings;

Green, is for ‘go’

Amber, is for ‘caution’

Red, is for ‘stop and think’

Green indicates items that are comparable in cost within their product group

G

Amber indicates items are costly. Also more costly than the comparisons in the green product group

A

Red indicates items that are more costly than the comparisons in the green or amber product group

R

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8.1 Formulary Options

Recommended Product Group Cost code

Alternative Product Cost code

Dressing Packs

Nurse It – Sterile Dressing Pack Small / Medium gloves Medium / Large gloves

G

Softdrape Small, Medium or Large gloves State size of gloves required *Only available through NHS supplies

G

Gauze Swabs Sterile pack 5 x 4ply swabs To be used to cleanse wounds or as alternative to dressing pack

G

Wound Measurement Grids

Wound Care Grid (Coloplast) Box of 50

*Only available through NHS

Supplies

G

Tape

Clinipore Range Paper based – suitable for sensitive skin & long term use

G Hyperfix Range Fabric based – suitable for securing dressings, catheters, cannulae

A

Wound Contact Layers

Softpore Range Self-adhesive absorbent perforated plastic film faced dressing for low to moderately exuding wounds

G

Non to Low Adherent

Atrauman Range (one of 1st line products for Leg Ulcer Pathway) Non-Adherent polyester mesh wound contact layer impregnated with neutral triglycerides. Effective for up to 7 days

G

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Adaptic Touch Range Non-adhering silicone dressing, flexible open mesh wound contact layer.

A

Urgo Start Range (one of 1st line products for Leg Ulcer Pathway) Non-adherent non-occlusive contact layer derived from LipidoColloid technology. Composed of polyester mesh impregnated with hydrocolloid and petroleum jelly and Nano-Oligosaccharides Factor particles to promote faster healing in chronic wounds. Use for minimum of 4 weeks to see benefits.

A

Hydrogels

Intrasite Gel Range Amorphous Hydrogel partially hydrated to donate moisture. For low to moderately exuding wounds shallow, deep and excoriated skin

G

Kerralite Cool The dressings are constructed of a fluid-repellent, flexible and highly breathable polyurethane film layer with a Pro-ionic gel contact layer. Soothing, debriding and moisture-balancing dressings

G

Films

Tegaderm Film Range Transparent vapour permeable dressing for non or lightly exuding superficial epithelialising and minor wounds

G

IV3000 Range Film dressing for IV/subcutaneous therapy sites

G

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Film with Silicone

Mepitel Film Breathable film dressing with soft silicone adhesive, for treatment of superficial skin injuries, surgical wounds, burns & pressure ulcer grades 1 & 2

G

Hydrocolloids

DuoDerm Extra Thin Range Thin adhesive Hydrocolloid dressing. For dry to low exuding wounds

G

Tegaderm Hydrocolloid Range Adhesive Hydrocolloid with film backing layer. Highly absorbent for moderate to heavily exuding wounds. Does not contain gelatine or animal derivatives.

G

Protease Modulators

Flivasorb Range Super absorbent wound dressing with non-adherent contact layer containing sodiumpolyacrylate and super absorbent particles. Suitable for heavily exuding wounds e.g. lymphorrhea. Can be used under compression.

G

UrgoClean Range (one of 1st line products for leg ulcer pathway) Soft adherent hydro de-sloughing absorbent dressing for non-infected, exuding and/or sloughy wounds

G

Gelling Fibre

Exufiber Sterile non – woven dressing designed to be used on a range of highly exuding wounds including leg ulcers, foot ulcers and surgical wounds. When dressing comes into contact with exudate it transforms into a gel.

G Aquacel Extra Range Non-woven pad or ribbon dressing composed of sodium carboxymethylcellulose. Has extra absorbent properties and transforms to a soft gel. Also has protease modulating properties.

A

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Alginates

Sorbsan Range Calcium alginate fibre non-woven highly absorbent for moderate to heavy exuding wounds. Not suitable for dry or necrotic wounds.

G Kaltostat Range Calcium sodium alginate fibre dressing for moderate to heavily exuding wounds. Promotes haemostasis.

A

Foams Adhesive and Non-adhesive

Tegaderm Foam Range Polyurethane foam dressing with semi-permeable film backing layer for low to moderate exuding wounds

G

Urgotul Absorb Border Absorbent foam dressing with shower proof silicone border. Has a TLC healing matrix in contact with the wound to promote healing and an extra absorbent layer to collect excess exudate.

G Mepilex Range Absorbent foam with soft silicone contact layer and film backing

A

Lyofoam Range Polyurethane foam dressing

G

Absorbent Dressings

Zetuvit E Range Absorbent cellulose dressing with fluid repellent backing. Moderate to heavily exuding wounds. Can be used under compression.

G

Super Absorbent Dressings

Zetuvit Plus Range Super absorbent wound dressing pad for the treatment of superficial, heavily exuding wounds. Can be used under compression.

G Flivasorb Range Super absorbent wound dressing, non-adherent contact layer. Suitable for heavily exuding wounds e.g. lymphorrhea. Can be used under compression

G

Odour Control

Clinisorb Range Use as secondary dressing Activate charcoal cloth between layers of nylon/viscose rayon. Exudate will reduce dressing effectiveness. Suitable for malodorous wounds.

G

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Carboflex Range Non-adhesive primary dressing with absorbent wound contact layer, activated charcoal central pad and a water resistant top layer Suitable for malodorous wounds

A

Actisorb Silver 220 Primary dressing Activated charcoal dressing designed to trap wound malodour whilst protecting the wound from infection. For most types of chronic wounds i.e. malodorous infected, carcinomas, ulcerative, traumatic and surgical wounds.

G

Antimicrobials

Silvercel Non-Adherent Range Silver alginate inner layer which releases silver ions into wound fluid and a non-adherent outer layer. Use as primary dressing for moderate to heavily exuding wounds where there is infection or increased risk of infection. Use for limited period of time. Use for 2 weeks and reassess.

G Aquacel Ag+Extra Range Non-woven dressing silver impregnated Hyrdofibre and enhanced with anti-biofilm technology. For moderate to high exuding wounds that are infected and where bacteria are a suspected cause or factor in chronicity and non-progression. Use for 2 weeks and reassess.

A

Inadine Range Non-adherent dressing impregnated with 10% povidone iodine. For mummification of wounds such as diabetic foot wounds.

G

Iodoflex Cadexomer iodine dressing with iodine for the treatment of chronic exuding wounds. Contains 0.9% povidone iodine

A

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Medihoney Range Standardised antibacterial honey dressing Medihoney tube: standardised medical grade honey - single patient use tube Medihoney Wound Gel: standardised medical grade honey with combined waxes and oils – single patient use tube Medihoney Apinate: contains calcium alginate Medihoney Gel Sheet: contains sodium alginate Medihoney Tulle Dressing: non-adherent impregnated dressing. Medihoney HCS: Hydrogel Colloidal sheet

G

Askina Calgitrol Range Alginate matrix that forms a gel when in contact with exudate, allowing controlled and sustained release of silver ions into the wound.

G

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8.2 Bandage Options

Compression Bandage Use All bandages must be applied in accordance with manufacturer’s instructions e.g. spiral, figure of eight etc. Two layer bandage systems offer less bulk, greater mobility of the limb and promote better concordance than 4 layer systems. KTwo, Coban 2 and Actico systems are all licensed for use in venous, lymphovenous and oedematous conditions. These systems exert high pressure peaks intermittently during mobility and a lower resting pressure. These pressure variations allow the lymph vessels to fill and thus facilitate lymph flow. KTwo The first layer is a short-stretch compressive fabric The second layer is a cohesive, compressive elastic bandage The ankle circumference must be measured to ensure the correct kit size is selected KTwo reduced compression kits available. Latex free kits available Coban 2 The first layer is an inner comfort latex free foam layer The second layer is a compressive bandage The kit is suitable for all ankle circumferences Coban 2 Lite (reduced) compression kit available Actico Layer 1. Undercast padding is required for all limbs. Normal shaped limbs will require 1 or more rolls of padding. For lymphovenous disease, oedematous limb shape distortion use as many as required to equalise the pressure, reshape the limb, fill hollows etc. Layer 2. Cohesive short stretch bandage. Application is dependent on care management plan and if dealing with normal or oedematous distorted limb shapes.

All offer various bandages sizes, when treating lymphovenous disease, distorted limb shapes. It is essential that the correct bandage width is selected and padding is applied in accordance with manufacturer’s guidance Sizes used are generally (manufacturer’s width may vary)

8cm bandage toe to ankle

10cm bandage ankle to knee

12cm bandage knee to mid or high thigh (as required)

Toe bandages if toes are swollen (conforming bandage) must be applied Long Stretch multi-layer bandaging is a compression bandaging system (sub-bandage pressure 35-40mmHg at the ankle) that incorporates elastic layers to achieve a sustained level of compression over time and NOT suitable for patients with lymphovenous disease, oedematous limb shape distortion (sustained pressure significantly reduces lymphatic refill).

Long Stretch Multi-layer generally consists of: - Layer 1: Under-cast padding; Layer 2: Retention bandage; Layer 3: Compression bandage class 3a or 3c depending on ankle size; Layer 4: Cohesive compression bandage

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Tubular Bandages

Comfifast Elasticated viscose stockinette retention bandage

G Actifast 2-way stretch For abnormally shaped oedematous limbs ActiFast 2-way stretch tubular retention bandage, cut to size

G

Bandage Wadding & Undercast Padding

Cellona Range Padding layer for under compression

G K-Soft Range Compression sub bandage wadding

G

Light Weight Conforming Bandage

Actiwrap Range e.g. 6cm x 4m size for chronic oedema toe bandaging

G

Retention Bandages

K-Lite Type 2 light support 10cm x 4.5m, 10cm x 5.25m

G

Elastic Compression Bandages and Kit Components

K-Plus 10cm x 8.7m K-Plus long 10cm x 10.25 3a compression Ko-Flex 10cm x 6m 3a cohesive compression K-Three C 3c high compression bandage for ankles greater than 25cm

G

Short Stretch Inelastic Compression Bandages

Actico Cohesive short stretch cotton bandages suitable for venous leg ulceration and chronic oedema 8cm x 6m; 10cm x 6m; 12cm x 6m

G

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2 Layer Compression Systems

K Two system Range Composite 1st layer short stretch compressive fabric & 2nd layer cohesive elastic bandage. Also available as reduced option. Suitable for venous oedema

G

Coban system Latex free foam padding layer & cohesive compression bandage. Also available as lite option. Suitable for chronic oedema

G

Emollients (All can be used as soap substitutes)

Emulsifying Ointment 500g

G Hydromol Ointment A

Epaderm Cream

G

Double base Gel

G

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8.3 Skin Protection

SKIN PROTECTION

Cavilon No Sting Barrier Film Range To be used as barrier against body fluids (e.g. urine, faeces) or adhesives. Protects for up to 72 hours. Can be used on broken skin. Use for 2 weeks & reassess.

Cavilon Durable Barrier Cream Range To be used as barrier against irritation from body fluids & prevention of skin damage. Daily or every 3rd wash. Not for use on broken skin. Use for 2 weeks & reassess.

Medihoney Barrier Cream Range Silicone based containing Medihoney Antibacterial Honey. Helps prevent maceration & excoriation around wounds, skin folds, and pressure areas. Apply as required. Protects against body fluid (incontinence) & maintain skin pH. Use for 2 weeks & reassess

Proshield Foam and Spray Cleanser Moisturising cleanser designed to minimise irritation of intact or injured skin associated with incontinence

Proshield Plus Barrier cream indicated for use on intact or injured skin associated with incontinence

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8.4 Compression Hosiery Options

Compression Hosiery Classification and Use Compression hosiery is available in different sizes, lengths and compression classifications. Legs must be measured in accordance with each manufacturers own guide. Readymade and made to measure are available in all classifications. It should be noted that there is a difference of compression between:

Circular knit (2 way stretch) are suitable for patients with no or minimal oedema and limb shape distortion

Flat knit made to measure (1 way stretch) are suitable for patients with minimal to gross chronic limb oedema / distortion and/or rebound oedema as the hosiery does not curl, twist or tourniquet (Doherty Morgan & Moffatt 2006)

British standards – circular knit only for patients without limb oedema (garment life

span 12 weeks)

European standards – circular knit and flat knit for patients with limb oedema (garment life span 24 weeks) (Johnson 2002)

Two layer hosiery kits comprising of a liner and outer stocking when combined give 40mmHg compression or worn as separate components are available in British and European classifications (SIGN 2010)

Compression Class British Classification

For Patients WITHOUT oedema

European Classification

For Patients WITH oedema

Class 1 14 – 17 mmHg 18 – 21 mmHg

Class 2 18 – 24 mmHg 23 – 32 mmHg

Class 3 25 – 35 mmHg 34 – 46 mmHg

Class 4 Not available 49 – 70 mmHg

When considering the type of compression to use, practitioners should take into account:

Practitioner level of expertise and knowledge of products available

Hosiery that meets clinical needs that is, patients should be offered the strongest compression that maintains concordance (SIGN 2010)

Patient preference, lifestyle and likely concordance

Required frequency of application e.g. ability to don on and off

Size and shape of leg (if readymade or made to measure is required)

Chronic Oedema, defined as long standing oedema of greater than 3 months duration must be treated with European circular or flat knit hosiery dependant on limb distortion

Latex allergy (Latex free hosiery is available)

Quality of product and cost comparisons

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8.5 Appliances and Other Medical Devices

Exudate Management

Draina S (B Braun), Wound Drainage Pouch For management of small to large wounds with low to high levels of exudate. Available in 3 sizes: mini, medium and large. Can be cut to size and available with clip or port.

All Purpose Boot

Kerraped All purpose boot that keeps dressings and toes clean and dry. Available in a range of sizes to accommodate bulky dressings and bandages. Kerraped Plantar Ulcer Offloading Therapeutic Shoe System A shoe designed to mechanically offload pressure from the ulcer and peri-ulcer area.

Dressing Protection

Limbo Range Transparent limb-shaped plastic cover with flexible seal at the opening. Used to keep leg or foot dressings dry during bathing or showering. Seal-Tight Range Waterproof dressing protector, latex free, can be fully submerged. Used to keep leg or foot dressings dry during bathing or showering.

Redistribution Pressure Product

KerraPro Pressure Reducing Pads Silicone pads that help to protect the skin of at risk patients as part of a pressure ulcer prevention programme. Can be reused on the same patient. Only use on healthy intact or recently healed skin.

Physical Debridement Pad

Debrisoft Soft and flexible fleecy pad that binds to debris, locking it into the fibres. It removes wound debris, necrotic material, slough, exudate and long standing hyperkeratotic tissue from surrounding skin.

Dermasilk Undersocks

Silk garment for use in the management of contact dermatitis.

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8.6 Tissue Viability Guidance Products

THE FOLLOWING ITEMS SHOULD ONLY BE USED FOLLOWING DISCUSSION WITH A TISSUE VIABILITY NURSE.

Flamazine Broad spectrum white hydrophilic antibacterial cream containing Silver Sulfadiazine 1% in an oil and water base. Effective topical antimicrobial active against most strains of gram positive and gram negative bacteria.

Prontosan Solution Wound irrigation solution containing Betadine which is a gentle effective surfactant which penetrates disturbs and removes bio-film and wound debris. Polyhexamethylene Biguanide (PHMB) helps control bacterial levels.

Urgotul A flexible wound contact layer with lipido-colloid technology for dry to heavily exuding wounds. Can be left in-situ for 7 days. Requires secondary dressing.

Urgotul SSD Non adherent, non-occlusive, antibacterial contact layer for non to lightly exuding wounds with signs of infection or critical colonisation.

Acticoat, Acticoat Flex and Acticoat Absorbent range Acticoat: Antimicrobial dressing with absorbent rayon/polyester core between 2 layers of nanocrystalline sliver-coated, low adherent polyethylene net. Acticoat Flex: Antimicrobial barrier with flexible, low adherent polyester layer coated with nanocrystalline silver. Acticoat Absorbent: Calcium alginate fibre coated on other surfaces with nanocrystalline silver. Combines the absorbency of alginates with the antimicrobial properties of silver.

Polymem Range Polyurethane foam containing a non-ionic surfactant which is activated by moisture and claimed to facilitate wound cleansing, a humectant (glycerol) which prevents the dressing drying out and adhering to the wound bed, and a starch copolymer to enhance the fluid handling properties of the foam. Also available with silver.

Promogram Range Promogram: Composite of oxidised regenerated cellulose and collagen. Inactivates proteases and protects grow factors. Can be used under compression. Promogram Prisma: Composite of oxidised regenerated cellulose, collagen and silver. Inactivates proteases and protects grow factors. Can be used under compression.

Drawtex A hydro-conductive debridement dressing used to debride the wound where barriers exist e.g. excess exudates, increased bio-burden, and devitalised sloughy tissue. Modulates harmful MMPs

Comfeel Plus Pressure Relieving Dressing Hydrocolloid based dressing pad with 6mm thick foam in 3 concentric rings that can be removed to match the size of the pressure ulcer beneath.

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8.7 Specialist Products

The following products can ONLY be commenced by Podiatry or following referral to a Tissue Viability Nurse.

Negative Pressure Wound Therapy Negative Pressure Wound Therapy (NPWT) is a mechanical wound care treatment that uses controlled negative pressure to assist and accelerate wound healing. Wounds that may benefit from NPWT include; partial / full thickness pressure ulcers, dehisced surgical wounds, diabetic / Neuropathic ulcers, venous leg ulcers, post-surgical wounds.

Larval Therapy / Larval Therapy Bio-Bag Sterile larvae of ‘Lucilia Sericata’ suitable for debridement of sloughy and wet necrotic wounds. (Biomonde Clinical Helpline 08452306806)

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8.8 1st Dressing Pack for District Nurse Teams

The pack is designed to provide District Nurses with access to a legal and safe emergency supply of wound care products for use on initial assessment of a patient.

The patient would then obtain future wound care supplies on prescription, as assessed by the District Nurse with reference to the BDCFT Tissue Viability Guidance and Formulary 2015.

The first dressing pack has been reviewed against:

• Current best practice

• Pact data of items currently prescribed by District Nurses

• District Nurses opinions

• The BDCFT Tissue Viability Guidance and Formulary 2015

8.9 1st Dressing How Does It Work?

Each member of the District Nurse Team will have a re-sealable plastic bag or wallet which will contain the items listed below:

The following products are available through NHS Supplies:

When visiting a new patient with a wound the nurse uses the most suitable items from the pack and then generates a prescription for further wound care products in accordance with the wound assessment.

The pack is then replenished from stock held at the District Nurse base.

Please find order codes for the 1st dressing pack products on the following page.

It is stressed that the pack is intended for the first dressing only, after which the patient should be prescribed the most appropriate product in accordance with the Tissue Viability Guidance and Formulary.

2 x Cellona 10cm 2 x K-Lite 10cm

10 x Softpore 10cm x 10cm

5 x Allevyn Gentle border 10cm x 10cm

1 x Clinipore 2.5cm

10 x Atrauman 10cm x 7.5cm

5 x Mepitel Film 6.5cm x 7cm

5 x Aquacel Extra 5cm x 5cm

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9 DRUG PROTOCOL FOR SKIN INFECTIONS

SELECTION of ANTIMICROBIALS for TREATMENT of COMMON SKIN INFECTIONS in ADULTS

INFECTION COMMENTS DRUG DURATION OF TREATMENT

Cellulitis / soft tissue infection, including Diabetic leg ulcer

Strep pyogenes, Staph aureus

*Mild - Flucloxacillin 500mg qds

*Penicillin allergy: clindamycin 300mg QDS Stop if diarrhea occurs For treatment failure or severe infection refer for possible hospital admission

7 – 14 days

Diabetic foot ulcers with surrounding soft tissue infection

Staph aureus including MRSA, streptococci, anaerobes, Gram-negative organisms

Refer to GP Refer diabetic foot ulcers for specialist podiatry opinion

Leg ulcers Only use antibiotics if clinical signs of infection present

Malodorous ulcers

As for cellulitis

Add Metronidazole 400mg qds

*Excerpt from September 2015 ‘Guidance for Antibiotic Prescribing in Primary Care’ document Produced by Medicine Management Bradford City and Districts CCG in conjunction with BTHFT microbiology department

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10 REFERENCES

Chen WY, Rogers AA (2007) recent insights into causes of chronic leg ulceration in venous disease and implications on other types of chronic wounds. Wound Rep Regen 15: 434-9.

Dale J.J, Callam M.J, Ruckley C.V, Harper D.R. and Berry P.N. (1983) Chronic Ulcers of the leg: a study of prevalence in a Scottish community. Health Bulletin.41:310-314.

Dealey,C (2005)The Care of Wounds: a guide for nurses, Blackwell Scientific, London

Doherty Morgan & Moffatt (2006) Role of hosiery in lower limb Lymphoedema in Lymphoedema Framework, Template for Practice: compression hosiery in Lymphoedema. London: MEP Ltd, 2006. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (2009) Treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel http://www.epuap.org European Wound Management Association, (EWMA) (2005) Position Document. Identifying criteria for wound infection, MEP Ltd London. Available online at http://ewma.org/fileadmin/user_upload/EWMA/pdf/position_Documents/2005_wound _Infection_/English_pos_doc_final.pdf Haycocks, Paul Chadwick Fernandez R, Griffiths R. (2008), Water for wound cleansing Cochrane Database of Systematic Reviews Issue 1. Art. No.:CD003861. DOI: 10.1002/14651858.CD003861.pub2. Foldi M, Junger M, Partsch H (2005) The science of Lymphoedema bandaging In: European Wound Management Association (EWMA) Focus Document Lymphoedema Bandaging in Practice MEP Ltd, London: 1–4

Gardner S (2013) Using treatment pathways to improve healing of venous leg ulceration; Wounds UK Vol 9 (1): 67 – 75 Gray, D. White, R. Cooper, P, Kingsley, A (2010) Applied wound management and using the wound healing continuum in practice. Wound Essentials Vol. 5 Grey M., Black JM., Baharestani MM., et al (2011) Moisture associated skin damage: an overview and pathophysiology. Wound Ostomy Continence Nurse. 38 (3) pp. 233-241 Guo L.A. and DiPietro (2010) Factors Affecting Wound Healing JDR March 2010 vol. 89 no. 3, pp 219-229 Haycocks, S. and Chadwick, P (2008) Sharp debridement of diabetic foot ulcers and the importance of meaningful informed consent. Wounds UK, Vol. 4, No 1y Healthcare Improvement Scotland (2009), NHS Scotland Pressure Ulcer Safety Cross, http://www.healthcareimprovementscotland.org/our_work/patient_safety/tissue_viability_resources/nhsscotland_safety_cross.aspx

http://jdr.sagepub.com/search?author1=S.+Guo&sortspec=date&submit=Submit

http://jdr.sagepub.com/search?author1=S.+Guo&sortspec=date&submit=Submit

http://jdr.sagepub.com/search?author1=L.A.+DiPietro&sortspec=date&submit=Submit

http://www.healthcareimprovementscotland.org/our_work/patient_safety/tissue_viability_resources/nhsscotland_safety_cross.aspx

http://www.healthcareimprovementscotland.org/our_work/patient_safety/tissue_viability_resources/nhsscotland_safety_cross.aspx

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Johnson S (2002), Compression hosiery in the treatment and prevention of leg ulcers, World Wide Wounds http://www.worldwidewounds.com/2002/september/Johnson/Compression-Hosiery-Leg-Ulcers.html McInnes E, Bell-Syer SE, Dunville JC, Legood R, Cullum N A. (2008) Support surfaces for pressure ulcer prevention, Cochrane database of systematic reviews (Online) 4:CD001735 Moffatt, C. (2007) Compression Therapy in Practice. Aberdeen. Wounds UK Moffatt CJ, Franks PJ, Doherty DC (2003) Lymphoedema: an underestimated health problem. Q J Med 96: 731–8 Moffatt C. Franks P. (1994) A prerequisite underlining the treatment programme; risk factors associated with venous disease. Professional Nurse. 9. (9):637-642 MHRA Device Bulletin Single-use Medical Devices: Implications and Consequences of Reuse DB2006 (04) October 2006 National Institute for Health and Clinical Excellence NICE (2008) Prevention and Management of surgical site infection NICE clinical guideline 74 National Institute for Health and Clinical Excellence NICE (2013) Varicose veins in the legs: The diagnosis and management of varicose veins, NICE clinical guideline National Institute for Health & Clinical Excellence NICE (2014) Pressure ulcers: prevention and management of pressure ulcers NICE guidelines [cg179]

National Institute for Health and Clinical Excellence NICE (2014) The Debrisoft monofilament debridement pad for use in acute or chronic wounds, NICE medical technology guidance 17

Partsch H, Moffatt C (2012), chapter 2, An overview of the science behind compression bandaging for lymphoedema and chronic oedema, in Best Practice for the management of lymphoedema – 2nd edition; International Lymphoedema Framework SIGN (2010) Guideline 120: Management of chronic venous leg ulcer – Annex 3 http://www.sign.ac.uk/guidelines/fulltext/120/annexes.html

Tissue Viability Society, 2009, Seating and Pressure Ulcer: Clinical Practice Guideline (TVS)

Vowden K (2010) Pressure Ulcer Prevention & Management Policy, Bradford Teaching Hospital; Bradford & Airedale NHS; Bradford & Airedale Community Health Services Williams, A.M and Southern S.J (2005) Conflicts in the treatment of chronic ulcers in drug addicts case series and discussion.

http://www.worldwidewounds.com/2002/september/Johnson/Compression-Hosiery-Leg-Ulcers.html

http://www.worldwidewounds.com/2002/september/Johnson/Compression-Hosiery-Leg-Ulcers.html

http://www.sign.ac.uk/guidelines/fulltext/120/annexes.html

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11 APPENDIX A AIREDALE NHS FOUNDATION TRUST FORMULARY FOR TISSUE VIABILITY USE ONLY

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