Top Tips QIPP messages for prescribing dressings

Transcription

1 East & outh East England pecialist Pharmacy ervices East of England, London, outh Central & outh East Coast Medicines Use and afety `Implementing Quality, Innovation, Productivity and Prevention (QIPP) initiatives in primary and community care Top Tips QIPP messages for prescribing dressings This is a controlled document which will be updated to incorporate new information. While every effort has been taken to ensure the accuracy of the information, readers are advised to check local sources. Where prices are quoted, those listed in the Drug Tariff 2013 have been used so check the latest versions for up to date prices. The Tips apply only when prescription form FP10 is the route of supply. The document has been written for use by pharmacists, nurses, GPs or other healthcare professionals involved with prescribing or selecting wound dressings for chronic wounds in primary care particularly in care homes (older adults). The Tips should be used as prompts to help rationalise prescribing and are not replacements for clinical judgement. The final decision on what to prescribe and the responsibility lies with the prescriber and should take into account the individual patient circumstance and overall treatment goal. Depending on the experience of the pharmacist and local priorities, each section can be prioritised and targeted on its own or used together. pecialist Pharmacy ervices accept no liability for improper use. This document can be used by NH staff in the course of their duties. Please acknowledge NH East & outh East England pecialist Pharmacy ervices if used in any publication. Non-NH staff should seek permission before use. Acknowledgements Developed by Janet Grier & Caroline Hunter, Tissue Viability Nurses, Guys & t Thomas NH Foundation Trust Community Health ervices and Lelly Oboh, Pharmacist, GTT Community Health ervices, on behalf of Medicines Use and afety Division, East and outh East England pecialist Pharmacy ervices Thanks to Jas Khambh, London Procurement Partnership and Helen Marlow, NH London for their contributions. East & outh East England pecialist Pharmacy ervices

2 Medicines Use and afety General prescribing Top Tip QIPP messages for prescribing dressing* Dressing sizes Quantities and repeat prescriptions Implementing these key messages o Larger dressings are usually exponentially more expensive than the smaller sizes most wounds should ideally reduce in size o Always query large size dressings on repeat to justify use o Dressings should not be prescribed as long term repeat items expectation is that the wound and dressing type will change over time REVIEW need before prescribing o Even chronic wounds may change over time so will the dressings required there should be a process to refer difficult to treat wounds to a tissue viability nurse (TVN) o Query quantities over 10 units/month most dressings can stay in place for 3-5 days except on infected wounds. Note that some patients may have multiple wound sites may require large quantities of dressings to be prescribed. o Encourage prescribers to write a dose to give an idea of how much is needed o Address underlying problems e.g. soiling from incontinence, wrong choice of dressing etc. o Refer to TVN o Add suitable prompts/reminders to computer prescribing systems o Add review date for dressing on computer system o Prescribe the actual number of dressings needed rather than 1OP o Add messages to GP prescribing systems e.g. cripswitch o Incorporate into local formulary, preferred list o Tag the use of the expensive s on epact monitor and feedback regularly *These recommendations apply when FP10 is the route of supply. Prices from Drug Tariff Jan 2013 Top Tips QIPP messages for prescribing dressings Vs.3 ept 13 (LO) updated May

3 Medicines Use and afety Prescribing specific types of dressings and s Alginate Hydrofibre & Alginate-hydrocolloid dressing Absorbent dressings padding or urgical pads Mesorb Eclypse upport bandages and tockinettes Crepe Tubigrip Tubifast o If daily change is needed, use Kaltostat or orbsan. o Aquacel is designed to hold more exudate. If nurse is having to wet Aquacel before use, it defeats the purpose and is wasteful use Kalstostat or orbsan o Use non sterile pads in most cases Zetuvit E non sterile 6p vs Zetuvit E sterile 21p (10x10cm) or Xupad sterile 15p 12x10 o Mesorb 62p (10x10cm) and Ecylpse 73p (10x10cm) are more expensive pads o Kerramax 74p (10x10cm) is super absorbent use ONLY on highly exuding wounds o Note: Tubigrip and Tubifast usually account for a significant % of total spend on stockinettes on epact o Crepe bandage and Tubigrip are support bandages for sprains etc. expensive if used as retention bandage and not effective for compression their role is limited in chronic wound management as there are more suitable alternatives o Use a retention bandage to hold dressings in place e.g. K-band vs o In cases where a retention bandage is unsuitable, use a tubular retention bandage Actifast 77p or Clinifast 7.5cm 78p less expensive than 131p or o If needed, Crepe bandage 10cm is the recommended size avoid 5cm or 15cm sizes o For tubular bandages use 3m or 5m lengths less wasteful than 1m and can accommodate various limb lengths o Consider if the less expensive and smaller sized blue (7.5cm) line bandage will suffice before prescribing the wider yellow (10cm) line bandage Top Tips QIPP messages for prescribing dressings Vs.3 ept 13 (LO) updated May

4 Medicines Use and afety Compression bandaging Film dressing Mepore film Foam dressings Lyofoam Allevyn heel Honey dressings o Limited role for expensive dressings under compression bandaging no added value. Primary contact dressing like N-A is good enough. o Application technique is more important to achieve healing than the choice of. Compression bandages should ONLY be applied by trained staff o Ensure a selection of 2 and 4- layer systems to suit various needs o K-Four 4 layer compression bandaging system o K-Two 2 layer compression bandaging system o Profore multilayer layer dressing o These dressings should be left for up to 7 days Maximum monthly prescription 5 o Compression bandaging is a short term intervention should not be on repeat prescribing o Cellulitis is often misdiagnosed when legs are swollen, eczematous or showing early signs of a venous leg ulcer seek advice re diagnosis and best treatment from TVN avoid long term topical steroids and avoid stopping abruptly as rebound symptoms may occur consider paste bandages for varicose eczema o Mepore film 122p (10x12cm) is more expensive Use Tegaderm 109p and Opsite 110p for 12x12cm o Note: Foam and Hydrocolloid are the most commonly used dressings in terms of suitability for a wide range of wound types Include at least 2 s on your list & engage with local nurses to test re practicalities etc. o Allevyn is more expensive but the local preference vs Lyofoam # o Allevyn heel 498p (10.5x13.5cm) is expensive easier to cut standard Allevyn dressing 244p (0x10cm), 392p (10x20cm)to suit as heel sizes vary o If honey needed use dressings impregnated with honey for shallow wounds less messy, easier to use and maintains concentrations needed. o Liquid Honey is best reserved for deeper wounds o Algivon is an alginate dressing permeated with honey can hold more exudate than a tulle honey dressing o Use cost effective s e.g. Activon Medical Grade Manuka Honey 25g 202p, Algivon (alginate) Activon Tulle (Knitted viscose) p Top Tips QIPP messages for prescribing dressings Vs.3 ept 13 (LO) updated May

5 Medicines Use and afety Hydrocolloids Hydrogels Iodine dressings Inadine Low adherence wound contact dressings Mepitel & Mepilex (with foam and plastic backing) Mepore Melolin & Release Protease modulating matrix dressings Promogran, Urgostart, Tegaderm matrix o Tegaderm hydrocolloid, Duoderm, Granuflex o Limited role for bordered hydrocolloids as local experience is that they don t adhere properly. Equivalent size of standard dressing is less expensive. e.g. Granuflex 10x10cm 273p vs Bordered 325p. ecure standard dressing by using adhesive tape to fix round the edges o Not much difference in the s so use least expensive. o Purilon is an alginate hydrogel and more absorbent better for heavily exuding wounds o Hydrogel sheets are best for shallow wounds less messy o Inadine dressing 5cm 2 or 9.5cm 2 The antimicrobial effect from one dressing may not last long enough and may require up to four layers of dressings Best to use Iodosorb (ointment) or Iodoflex (paste) and cover with Mepitel so iodine can stay on wound for as long as needed o Mepitel and Mepilex - ilicone are more expensive and offer no advantage over low adherent dressings o For delicate/fragile skin use N-A Ultra (silicone coated) 33p (9.5x9.5cm) OR Atrauman (impregnated with triglycerides) 27p (7.5x10cm) vs Mepitel 319p (8x10cm), Mepilex 266p (10x11cm) o Mepitel is cost effective ONLY if left in place for 7-10days (for cavity wounds leave intact, change padding and outer dressing if soiled) o Mepore, Release and Melolin are not useful for chronic wounds. Mepore may dry the skin out. Although inexpensive Melolin & Release have very low absorption so need frequent changes, use N-A ultra o Clinical benefit of these dressings is yet to be demonstrated (Ref:BNF ) current evidence is that they are not more effective than standard dressings in most cases. Reserve for unresponsive wounds or recommendation by tissue viability nurse (TVN) specialist advice only o The dressings are designed to be absorbed into the wound on contact so should be ideally used on clean wounds as slough/necrosis prevents contact with wound and reduce effectiveness Top Tips QIPP messages for prescribing dressings Vs.3 ept 13 (LO) updated May

6 Medicines Use and afety ilver(ag) dressings aline irrigation solutions terile dressing packs (DP) urgical adhesive tapes Mefix Micropore o ***Note: Ag dressings will usually be in your Top 10 dressings spend on epact *** o Not recommended for routine use in chronic venous leg ulcers (IGN), uncomplicated ulcers, acute wounds (BNF) o If needed, Ag dressings to be applied every 3-7 days for 2 weeks only not more than 5 dressings per script o Acticoat 7 is designed to be used once a week not more than 2 dressings per prescription in any 2 weeks o If the wound needs daily change, don t use Ag dressings use standard dressings and consider systemic antibiotic if indicated OR leave inner Ag dressing intact and change soiled outer dressing o ilver dressing must be in contact with skin to be effective so poor rationale for prescribing silver foam dressings like Allevyn Ag, Mepilex Ag. They are not intended to provide treatment for infected wounds, see manufacturer s summary. o Check GP computer prescribing system to see if Ag dressings come first in picking list move down the list to prevent it being ordered by mistake o Practice staff should be educated that Ag means silver to reduce the risk of a silver dressing being prescribed inadvertently o Generally, good practice is to use warm tap water to soak leg ulcers or irrigate clean wounds, NOT aline But sometimes, it is not possible to do so for practical reasons. o Irripod is the least expensive and easy to use practically o ***Note: DP will usually be in your Top 10 dressings spend on epact *** o Role is limited to providing a sterile or clean work surface. Care home environment should be clean enough! o 52p is cost effective (apron, gloves, no cotton wool, measuring tape), (apron, gloves, drape, no cotton wool) o Mefix 101p (2.5cmx5m) 179p (5cmx5m) should be reserved for use when direct application to skin is needed for patient s whose skin is frail/likely to tear easily. Good for securing padding to pressure ulcers. The apertured structure allows it to be more extensible and conform to the body o In other cases or when the purpose is to secure dressings together, use surgical adhesive tapes. canpor (67p & 116p) vs Micropore (89 & 157p) for 2.5 and 5cm sizes o Mepitac 348p and iltape 560p (2cmx3m) are expensive silicone tapes and should not be used routinely Top Tips QIPP messages for prescribing dressings Vs.3 ept 13 (LO) updated May

7 Medicines Use and afety Other expensive s o Urgotul (lipo-colloid) dressings is not more effective than other non-adherent primary wound contact dressings like N-A ultra Reserve for unresponsive wounds or recommendation by tissue viability nurse (TVN). o Prontosan solution is an antiseptic/antimicrobial solution for long term chronic wounds exercise caution as with other topical antimicrobials. pecialist advice ONLY 458p/350ml should last 3-4 weeks. Must be left on, for about 10minsto soak the wound. o uprasorb X dressing 5cm 9cm - biocellulose dressing for mild to moderately exuding wounds query advantage over hydrocolloids, hydrogel, foam or alginate dressings # Local evidence that some staff had difficulties differentiating between the inner wound contact layer and the outer layer of Lyofoam leading to the dressings being applied wrongly. Top Tips QIPP messages for prescribing dressings Vs.3 ept 13 (LO) updated May