Wounds & Dressings – key slides

1. Wounds & Dressings – key slides • Chronic wounds, factors affecting healing, wound assessment & cleansing • The evidence supporting the wound care treatments we currently choose to use in primary care.

2. Wound care therapeutics • Wound care is a high cost area for patients and NHS in terms of prescribing costs, patient QoL and NHS workforce time • Prescribing costs average £14 million per month, about 2% of the total primary care drugs bill. • The evidence base for therapeutics in much of this area is very limited and within each type of treatment there is little to suggest that one wound care product is better than another • Value for money for the NHS is an important factor when choosing treatments. • Local formularies and provision of unbiased information surrounding new products may help to improve patient care and increase value for money. • Dressings are not drugs - there are other systems of supply which do not require prescription.

3. Holistic assessment of chronic woundsSIGN 26 Care of patients with chronic leg ulcers 1998NHSSB wound management manual 2005 • Wound healing is complex and affected by intrinsic (patient related) and extrinsic (wound related) factors and this affects the choice of treatment • Holistic assessment - treat the whole person (e.g. full medical history, factors which may delay healing such as immobility, poor nutrition, obesity, personal circumstances) • Signs of clinical infection • Accurate assessment and documentation will improve communication between professionals and improve continuity of care and track progress or deterioration in wound healing

4. Wound assessment NHSSB wound management manual 2005 • Measurement - linear, tracing or photography • Depth can be measured using sterile probe/spatula • Wound bed colour & tissue type • Exposed bone, tendon or muscle • Exudate colour & amount • Wound odour • Wound pain • Clinical infection or spreading infection • Condition of surrounding skin • Pain assessment • Good clinical practice requires regular wound reassessments and measurements for signs of healing

5. Cleaning wounds : Infection Control Health Protection Agency Infection Control Guidelines in Community Settings 2007 • Good hand hygiene and clean technique should always be followed when dressing wounds • Gloves and aprons should be used • Clean technique aims to prevent the spread of pathogens in wounds healing by secondary intention which are already colonised with microbes e.g. pressure ulcer • Aseptic technique aims to reduce the risk of microbial contamination into a wound e.g. wound healing by primary intention such as surgical wound • See your local Trust guidelines on which technique to use

6. Cleaning wounds: Sterile Dressing PacksNHS Prescription Pricing Division February 2009 Some facts & figures: • Half a million boxes of SDPs issued on NHS primary care prescriptions in year to September 2008. • Cost of these prescriptions = £2.4 million • Half of SDPs prescribed were for Spec 10 or Spec 35 SDPs (as defined in Drug Tariff) Some Questions: • How useful is this? • How much of it is actually used? • What is thrown away? • What’s missing that should be there if using aseptic technique?

7. Routine use of sterile dressing packs on FP10.. expensive and unnecessary?Burrill P. Chemist & Druggist 1997 • The contents of most commonly used dressing pack: • Gauze & Cotton Tissue Pad • 4 Gauze swabs • 4 Cotton wool balls • Paper Towel • Water repellent inner wrapper • Cost c.48p each i.e. £5.76 a box (NHS Drug Tariff Jan 2009) • Cotton wool and gauze can shed fibres into the wound, increase the risk of infection and delay the healing process • If gauze is required to dry the surrounding skin during the dressing procedure either sterile or non-sterile non-woven gauze may be appropriate substitutes • A central PCO supply of suitable dressing packs may be an alternative, but storage and distribution issues would need to be resolved

8. How can we be smarter about improving the cost effectiveness of NHS money spent on SDPs? • Keep SDPs for ASEPTIC procedures? • When needed, use SDPs with more useful contents e.g. gloves/apron included (see Drug Tariff for contents list) • Consider a non-FP10 supply

9. Wound CleansingSIGN 26 Care of patients with chronic leg ulcers 1998NICE Clinical Guideline No29 September 2005NHSSB wound management manual 2005 • Wound cleansing should be for patient benefit - cleanse only if foreign material or debris is present • Wash hands before changing dressings • Venous leg ulcers should first be washed in tap water, with bathing or showering at dressing changes, and dried carefully at each assessment. • Irrigate the wound (don’t swab) with potable tap water (or saline if clinically indicated) • Use solutions at body temperature to prevent wound cooling • Antiseptics: no evidence that they provide additional protection against infection - some may inhibit wound healing.

10. Saline vs. tap water?Fernandez R et al Cochrane Water for Wound Cleansing 2008Moore Z, Cowman S, Wound cleaning for pressure ulcers 2005 ‘There is no evidence that using tap water to cleanse acute wounds in adults increases infection, and some evidence that it reduces it. However, there is not strong evidence that cleansing wounds per se increases healing or reduces infection. In the absence of potable tap water, boiled and cooled water as well as distilled water can be used as wound cleansing agents’ Another Cochrane review in 2005 examined the effect of wound cleaning solutions and techniques in the management of pressure ulcers. Very few studies in this review were eligible for inclusion due to poor quality, but of those that were the conclusion was that ‘there was no good evidence to support the use of any particular wound cleaning solution’.

11. Saline solutions - NHS prescriptions 12 months to September 2008NHS Prescription Pricing DivisionFebruary 2009 • c.640,000 prescriptions a year • Cost £3.7 million • Items have increased by 25% compared to 2005 • Costs have increased by 20% compared to 2005 • 35% scripts for the most expensive product, although less costly alternatives are available • c.50% scripts for ‘sprays’ not solutions (can a spray irrigate gently and be used at body temperature?) • Good value for NHS money?

12. Cost comparison of saline preparationsNHS Drug Tariff Costs January 2009 Equivalent costs for 500ml (though pack sizes vary): • Aerosols £6.75 to £6.14 • Pods £7.36 to £5.50 • Sachets c. £4.80

13. Managing infected woundsNICE CG Pressure Ulcer No29 September 2005,SIGN 26 Care of patients with chronic leg ulcers 1998NHSSB wound management manual 2005 • Infection = when bacterial numbers in chronic wound overwhelm the immune response & clinical signs of infection appear • In the presence of systemic and clinical signs of infection systemic antimicrobial therapy should be considered • Swab only if clinical signs of spreading infection present:- Pyrexia, heat, redness, swelling or pain (new or increasing) • Review antibiotic choice and duration when swab results available • Change dressing daily or alternate days, depending on exudate • Reduce the risk of infection and enhance wound healing by correct hand washing, infection control, wound cleansing and debridement. • If purulent material or foul odour is present, more frequent cleansing and possibly debridement are required. • Protect wounds from exogenous sources of contamination

14. Topical antimicrobialsNICE Pressure Ulcer Guideline 2005NHSSB wound management manual 2005 • As a general rule, avoid topical antimicrobial agents as systemic antibiotics should be given where there is clinical sign of infection • Options available: • Silver dressings • Povidone-iodine • Silver sulphadiazine • Honey • Metronidazole (malodorous wounds) • Short term use only

15. Povidone Iodine SheetNHSSB wound management manual 2005 • For prophylaxis and treatment of infection in wounds • Apply directly to wound surface and cover with secondary dressing • Do not use if: • Pregnant/breastfeeding • Children under 6 months • Iodine allergy • Impaired renal function & diabetics monitor T3 & T4 levels • May interfere with thyroid function and lithium levels • Change daily or alternate days as antimicrobial activity lost after 2 days • Review use after 7 days

16. Silver DressingsNHSSB wound management manual 2005 • Dressings impregnated with silver ions • Apply directly to wound surface • Review every three days • Dressing should not dry out • Do not use: • On dry wounds • In patients with renal impairment • For prolonged periods (Argyria & low WBC) • Define appropriate treatment length

17. Silver impregnated dressings prescribed on NHS prescription to September 2008NHS Prescription Pricing DivisionFebruary 2009 • c.400,000 prescriptions • Cost £24 million • More expensive than non silver dressings • Good value for NHS money in light of recent systematic reviews?

18. Wound Care Summary - Part One • A moist wound bed is needed for all stages of wound healing • Wound healing is affected by many factors: age, vascular state, nutritional state, co-morbidity, some drug therapy, debris and infection • A systematic assessment of the wound is essential to to evaluate healing & treatment efficacy • Regular wound reassessments required • Infection control guidelines should be followed in the management of all wounds • Potable tap water may be used to wash and cleanse most chronic wounds • Cleansing solutions should be at body temperature to prevent wound cooling • A local review of the use of sterile dressing packs and saline solutions may save money

19. Wound Care Summary Part Two • Methodological flaws are an issue affecting the validity of studies in chronic wound care • There is insufficient evidence to determine if one type of dressing is superior to another. • Clinical infection should be treated with systemic antibiotics not topical antimicrobials • Routine wound swabs are not recommended. • Topical antimicrobial dressings, where used, should be for short term use only • The frequency of dressing changes, type and location of wound and patient acceptability, including impact on comfort and odour control, are important factors in the choice of dressing for a particular wound