CLINICAL PROCEDURE CONSERVATIVE SHARP DEBRIDEMENT FOR COMMUNITY PODIATRISTS

Transcription

1 CLINICAL PROCEDURE CONSERVATIVE SHARP DEBRIDEMENT FOR COMMUNITY PODIATRISTS Issue History Issue Version Purpose of Issue/Description of Change Planned Review Date 1 To provide Podiatrists with the fundamental principles relating to conservative sharp debridement 2015 Named Responsible Officer:- Approved by Date Head of Podiatry Services Quality, Patient Experience and Risk Group Target Audience August 2012 Section:- CP60 Podiatry staff employed by the Trust UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION

2 CONTROL RECORD Title Conservative Sharp Debridement for Community Podiatrists Purpose To provide Podiatrists with the fundamental principles relating to conservative sharp debridement Author Quality and Governance Service (QGS) Equality Assessment Integrated into procedure Yes No Subject Experts Michael Milton Document Librarian QGS Groups consulted with :- Medicines Management Group or Clinical Policies and Procedures Group Infection Control Approved August 2012 Date formally approved by August 2012 Quality, Patient Experience and Risk Group Method of distribution Intranet Archived Date 23 rd August 2012 Location:- S Drive QGS Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 1 Quality and Governance Service N New Trust procedure Status New / Revised / Trust Change 2 OF 9

3 CONSERVATIVE SHARP DEBRIDEMENT FOR COMMUNITY PODIATR IS TS INTR ODUCTION Debridement is an accepted principle of good wound care, especially when debris is acting as a focus for infection. (NICE 2001) Dead tissue in the form of hyperkeratotic tissue, 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. Debridement can be achieved either through the use of wound care products or by conservative sharp debridement. This procedure will focus on the removal of devitalised tissue by Conservative Sharp Debridement (CSD). THE PURPOSE OF DEBRIDEMENT IS TO: Determine the extent of the wound and identify any undermining Remove non-viable tissue Reduce the bacterial load and minimise risk of local and systemic infection Allow wound drainage Reduce odour Promote healing (Adapted from Edwards, 2000) Debridement is complete when 100% of the wound bed consists of healthy granulation tissue (Vowden, 1999a). Conservative sharp debridement (CSD) provides a fast and effective method of wound debridement, however, podiatrists should be aware of the other methods of debridement available. The podiatrist must have the knowledge and ability to select the appropriate method for each wound and apply it correctly. Often a combination of methods will be required to achieve rapid safe debridement. CSD may form part of an on-going maintenance program of debridement (Falanga 2004) Community podiatrists should collaborate with specialist podiatrists / tissue viability nurse to assess the most appropriate method/methods of debridement as necessary. All treatment undertaken must be documented in the patient s health records. TARGET GROUP This procedure will be undertaken by Community Podiatrists employed by the Trust. 3 OF 9

4 TR AINING All staff in the Trust are required to comply with mandatory training as specified in the Trusts Mandatory Training Matrix. Clinical Staff are also required to comply with service specific mandatory training as specified within their service training matrix. SCOPE OF PRACTICE Community Podiatrists carrying out sharp debridement in line with this procedure will be employed by the Trust will maintain their HPC registration. Podiatrists should only perform Conservative Sharp Debridement on wounds within their scope of practice which are located on the foot, distal to the malleoli. RELATED POLICIES Please refer to relevant Trust policies and procedures ASSESSMENT OF THE PATIENT PRIOR TO CONSERVATIVE SHARP DEBRIDEMENT All patients with wounds considered suitable for sharp debridement by a podiatrist should receive a holistic assessment by a podiatrist and be given sufficient information on the different options/advantages and disadvantages of the various methods of wound debridement for them to make an informed choice. The podiatrist should examine the needs of the patient and the wound and subsequently: Examine available treatment options Evaluate potential risks and benefits to patient and wound of the chosen treatment Determine if wound is suitable for CSD alone or requires adjunctive treatment such as antibiotic cover Obtain appropriate consent. CAUTIONS FOR CONSERVATIVE SHARP DEBRIDEMENT: Wounds in the presence of ischaemia Patients on long term anti-coagulant therapy, e.g. Warfarin, Aspirin Patients on short term anticoagulant therapy, e.g. subcutaneous heparin Wounds on the Achilles tendon area Vascular grafts Prosthesis Patients with blood clotting disorders Wounds that are fungating or malignant wounds Wounds situated on the dorsum of the foot* Diabetic patients Note: conservative sharp debridement in the presence of clinical infection may require systemic antibiotic cover. 4 OF 9

5 *Referral should be made to the Tissue Viability Specialist for joint assessment and management if required. CONTR AINDIC ATIONS Podiatrists must restrict sharp debridement to wounds located distal to the malleoli Fungating or malignant wounds Wounds of a non-ambulatory origin* *Referral should be made to the Tissue Viability Specialist for joint assessment and management if required. CONSENT Valid consent must be given voluntarily by an appropriately informed person prior to any procedure or intervention. No one can give consent on behalf of another adult who is deemed to lack capacity regardless of whether the impairment is temporary or permanent. However such patients can be treated if it is deemed to be within their best interest. This must be recorded within the patient s health records with a clear rationale stated at all times. Refer to Trust Consent Policy for further information and guidance. EQUIPMENT Podiatry standard instrument pack. Containing:- 1 Scalpel Handle 1 Nail Nippers 1 Blacks File 1 Probe 1 Nail File Appropriate wound care dressings according to local wound formulary Single use disposable apron Sterile dressing pack Single use disposable non-sterile gloves Single use disposable sterile gloves Single use disposable sterile scissors Appropriate cleansing solution (e.g. sterile saline 0.9%) Post procedure dressing Sharps container Tube gauze applicator. 5 OF 9

6 PROCEDURE ACTION Verbally confirm the identity of the patient by asking for their full name and date of birth. If client unable to confirm, check identity with family/carer Introduce yourself as a staff member and any colleagues involved at the contact Wear identity badge which includes name status and designation Ensure verbal consent for the presence of any other third party is obtained Explain procedure to patient including risks and benefits and gain valid consent. Establish patient has no known allergies, check in patient s records and also ask patient/family of any known relevant previous medical history Explain procedure and any potential risks and fully document risks and benefits explained to patient in the patient s health care records. Obtain valid consent and document within the patient s health care records. Follow Trust Consent Policy when patient is unable to provide valid consent as treatment may need to be provided in the patient s best interests using Consent Form 4. If a patient is attending a follow-up appointment check the care plan in the patients health care records for there specific plan of care. Prepare the environment, e.g. lighting, seating. Ensure the patient is comfortable and in a position where the wound can be easily accessed and viewed. The podiatrist carrying out the procedure should adopt an appropriate and comfortable position Decontaminate hands prior to procedure RATIONALE To avoid mistaken identity To promote mutual respect and put client at their ease For patients to know who they are seeing and to promote mutual respect Students for example, as the client has the choice to refuse To ensure client understands procedure and relevant risks To reduce the risk of allergic reactions. Ensures understanding on the patient s behalf and allows the patient to provide valid consent if they wish to proceed with the intervention. Evidence that consent has been provided by the patient and they agree to the proposed plan of care. To inform planned procedure and ensure continuity of care. To ensure good visibility of the wound bed and enables health care staff to conduct an environmental/infection control risk assessment. To allow access to area for safe debridement To promote a safe working environment for the practitioner To reduce the risk of transfer of transient micro-organisms on the healthcare workers hands 6 OF 9

7 Apply single use disposable apron Open sterile dressing pack onto a clean area and place all sterile single use equipment required within aseptic field whilst using key part protection at all times Apply single use disposable non-sterile gloves and remove any current dressing and dispose of waste according to Trust policy. Assess current wound size, shape, depth, position and site to assess for signs of improvement, wound infection or deterioration If patient is attending a follow-up appointment, record any changes in wound etiology within the patient s health care records. Remove single use non-sterile disposable gloves and decontaminate hands Apply single use disposable sterile gloves in a manner which prevents the outer surface of the sterile glove being touched by a non sterile item Using an aseptic non-touch technique apply suitable tension to the surrounding skin and debride carefully with a scalpel. The podiatrist should stop the procedure if requested to do so by the patient or if any complications arise. Reassess the wound bed further and document findings in the patient s healthcare records. Using an aseptic non-touch technique redress the wound bed according to wound etiology following holistic assessment, Trust wound care guidelines and care plan if still relevant. On completion of the procedure remove and dispose of PPE to comply with waste management policy In addition dispose of single use equipment, sharps and debrided tissue as per clinical waste policy Return re-usable instruments for decontamination in line with department protocols and contractor instructions To protect clothing or uniform from contamination and potential transfer of micro-organisms To ensure asepsis and prevent contamination of key parts To enable assessment of the wound bed and adherence to Trust Infection and Prevention Control guidelines To provide a baseline of wound status prior to CSD and check safety issues before proceeding. Forms part of the holistic wound assessment To reduce the risk of transfer of transient micro-organisms on the healthcare workers hands To ensure asepsis, reduce the risk of microbial contamination and prevent contamination of key parts To minimize pain and damage to healthy tissue To ensure continuing evidence of consent throughout the duration of the procedure To establish extent of debridement and provide communication to other visiting podiatrists via the healthcare records. To provide an optimum wound healing environment. To prevent cross infection and environmental contamination To prevent inoculation injury To enable prompt and effective decontamination of instruments 7 OF 9

8 Decontaminate hands following removal of PPE Clean equipment in line with Trust policy and manufacturers instructions Document the treatment undertaken and record any improvement or deterioration evident to the wound etiology. Document the outcome of the procedure and dressing regime within the patient s healthcare records Inform the patient and relevant members of the multi-disciplinary team of the process and outcome of CSD To remove any accumulation of transient and resident skin flora that may have built up under gloves and possible contamination following removal of PPE. Decontamination of medical equipment is essential for the effective delivery of patient care. To ensure continuity of care and the patient s healthcare records are current and accurate To provide an accurate account of the care provided to the patient and the outcome of the CSD. To share information regarding the changes to the wound status and further wound care plan. EQUIPMENT All Podiatry instruments must be decontaminated after each episode of care once the instrument pack has been opened. All instruments are sterilised in compliance with ISO 9001(2008), ISO 13485(2003) and Medical Devices Directive 93/42EEC. WERE TO GET ADVICE FROM Trust staff should contact their Line Manager when advice is required in relation to conservative sharp debridement. INCIDENT REPORTING Clinical incidents or near misses must be reported via the Trust s incident reporting system. SAFEGUARDING In any situation where staff may consider the patient to be a vulnerable adult, they need to follow the Trust Safeguarding Adult Policy and discuss with their line manager and document outcomes. REFERRALS Any referrals to health professionals, therapists or other specialist services must be followed up and all professional advice or guidance documented in the patients health records. 8 OF 9

9 EQUALITY ASSESSMENT During the development of this procedure the Trust has considered the clinical needs of each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). There is no evidence of exclusion of these named groups. If staff become aware of any clinical exclusions that impact on the delivery of care a Trust Incident form would need to be completed using the Trust s incident reporting system and an appropriate action plan put in place. REFERENCES Edwards, J. (2000) Sharp debridement of wounds, Journal of Community Nursing, 14, 1. Falanga, V (2004) Wound bed preparation: science applied to practice. European Wound Management Association Position Document. Medical Education Partnership, London. National Institute Clinical Effectiveness (NICE 2001) Guidance on the use of debriding agents and specialist wound care clinics for difficult to heal surgical wounds. Technology Appraisal Guidance No. 24. NICE (2005) The management of pressure ulcers in primary and secondary care DRAFT (Full version for 1st round of consultation 5 Jan 2 Feb 2005) NMC (2008) The NMC Code of professional conduct: standards for conduct, performance and ethics. Vowden, K.R., Vowden, P. (1999a) Wound debridement, Part 1: non-sharp techniques. Journal of Wound Care, 8, 5, Vowden, K., Vowden P (1999b) 9 OF 9