ASSOCIATED DOCUMENT: Community Wound Formulary

DOCUMENT REFERENCE

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VERSION No

1

LEAD AUTHOR’S NAME

Janine Ashton

LEAD AUTHOR’S ROLE & DEPARTMENT

Tissue Viability Nurse

Nurse Directors Unit

APPROVAL BODY 1

NMLG

DATE APPROVED: APPROVAL BODY 1

14.09.2015

APPROVAL BODY 2

PDRG

DATE APPROVED: APPROVAL BODY 2

REVIEW DATE

November 2017

THIS DOCUMENT RELATES TO

Guideline Title: Integrated Tissue Viability Guidance and Formulary

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Named person is responsible for ensuring only current copy is in use. Department managers are responsible for their own areas for ensuring only current copies are in use

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ContentsContents21Introduction32Statement of intent33Community Wound Formulary43.1Formulary Products54Bandage options124.1Compression bandage use124.2Other Bandages145Emollients156Skin Protection167Compression Hosiery Options168Appliances and Other Medical Devices189Community Tissue Viability Guidance Products1910Specialist Products20111st Dressing Pack for District Nurses Teams21121st Dressing How Does it Work?2113Drug Protocol for Skin Infections2214References23

Introduction

The Integrated Wound Formulary for ANHSFT Acute Hospital supports the Integrated Tissue Viability Policy and Wound Management Guidelines. It has been devised collaboratively by the members of the Airedale NHS Foundation Trust (ANHSFT) and Bradford District Care Foundation Trust (BDCFT) Integrated Tissue Viability Service.

The wide range of products included in the Community Wound 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 Integrated Tissue Viability Service.

Statement of intent

Airedale NHS Foundation Trust fully recognises that the obligation to implement guidance should not override any individual clinician to practice in a particular way if that variation can be fully justified in accordance with Bolam Principles. Such variation in clinical practice might be both reasonable and justified at an individual patient level in line with best professional judgement. In this context, clinical guidelines do not have the force of law. However, the Trust will expect clear documentation of the reasons for such a decision and for this variation. In addition, any decision by an individual patient to refuse treatment in line with best practice must be respected, escalated to the consultant and fully documented in the appropriate records of care/treatment

Community Wound Formulary

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

Formulary Products

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, cannulas

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

Recommended Product Group

Cost code

Alternative Product

Cost code

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 LipidoColliod 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

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

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

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

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 exdate, allowing controlled and sustained release of silver ions into the wound.

G

Bandage options

Compression bandage use

All bandages must be applied in accordance with manufactures 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 a 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 (manufactures 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

Integrated Tissue Viability Guidance and Formulary

Page 2 of 23

DEPARTMENT

Other Bandages

Recommended Product Group

Cost code

Alternative Product

Cost code

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

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

Emollients (All can be used as soap substitutes)

Emulsifying Ointment 500g

G

Hydromol Ointment

A

Epaderm Cream

G

Double base Gel

G

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

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 is 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 – 36 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

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.

Community 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, and 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 critically 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.

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)

1st Dressing Pack for District Nurses 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 Integrated 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 Integrated Tissue Viability Guidance and Formulary 2015

1st Dressing How Does it Work?

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

The following products is available through NHS Supplies

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

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.

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.

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:clarithromycin

250 -500mg QDS

For treatment failure or severe infection refer for possible hospital admission

7 – 14 days

Diabetic foot ulcers with surrounding soft tissue infection

 

Staph aureus inc 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

 

Adapted from Bradford Teaching Hospitals NHSFT document by Alistair Tinto

Assistant Director of Pharmacy - Community and Mental Health Bradford Teaching Hospitals NHS Trust

Airedale Wharfedale Craven CCG Use of Antimicrobial in Primary Care

References

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

SIGN (2010) Guideline 120: Management of chronic venous leg ulcer – Annex 3

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