GUIDELINES FOR THE USE OF TOPICAL NEGATIVE PRESSURE (TNP) THERAPY IN WOUND MANAGEMENT

Transcription

1 GUIDELINES FOR THE USE OF TOPICAL NEGATIVE PRESSURE (TNP) THERAPY IN WOUND MANAGEMENT Aim To provide evidence based principles in the use of Topical Negative Pressure therapy and management of patients receiving the therapy. Background/Evidence The use of Topical Negative Pressure (TNP) therapy in wound care has been shown to remove excess interstitial fluid, control exudate, improve microvascular blood flow, stimulate tissue formation and reduce the wound size by pulling the wound edges together (Barnwell and Teot, 2003). It is a fairly simple treatment involving suction, or negative pressure, which is administered to a wound through a computerised therapy unit. (Mendez-Eastman, 2001) Examples of these computerised units are Vacuumed Assisted Closure (V.A.C), Wound Assist, Renasys, Exsudex and Venturi. Chariker and Jeter (1989) state that Negative Pressure Wound Therapy should be applied with a wound sealing kit whilst maintaining dressing techniques. The Cochrane review (Evans, 2001) critiqued clinical trial data and concluded that there was not enough evidence to suggest TNP was a superior wound management system. However, they do not examine cost, quality of life, healing time frames, pain or which regimen would provide the optimum outcome. A consensus report on the use of TNP by wound care expert stated that they would use TNP on chronic, acute and complex wounds as well as an adjunct to surgery to prepare the wound bed for split skin grafts or rotational flaps. They also however concluded that TNP should not be considered a panacea for all wounds and that health care professionals need to evaluate all options for the management of individual patients. It is therefore recommended that all patients need to be assessed by a wound care specialist to evaluate each of the components of delayed healing. All health care professionals should work towards treating the cause of the wound, dealing with patient centred concerns and initiating appropriate wound care, prior to implementing TNP therapy (Sibbald, 2003) Clinical Speciality Wound care Intended Users Community Nurses who have received the appropriate training from NHS Derby City Tissue Viability Nurse (TVN) Topical Negative Pressure therapy should only be undertaken by an individual who has previous practical experience in the management of wounds and when the patient has been accepted for treatment by the Tissue Viability Team Page 1 of 11

2 Target Population Controlled Document These guidelines are intended for use by community nurses following training provided by NHS Derby City Tissue Viability Team Additional specialist advice should be sought for paediatric patients Definition Topical Negative Pressure therapy is used to promote wound healing, including the removal of infectious material or other fluids, through the influence of negative pressures. Indications for use Topical Negative Pressure should only be used in appropriate situations. TNP is most beneficial for complex, difficult to heal wounds such as : Pressure ulcers Traumatic tissue loss Grafts Diabetic/Neuropathic wounds Dehisced surgical wounds Burns Necrotising fasciitis Post surgical wounds Explored sinus drainage and management Skin/muscle flaps Contraindications The following wounds are not considered to be suitable for Topical Negative Pressure Therapy : Cautions Untreated Osteomyelitis Malignancy within the wound Necrotic tissue with eschar present Exposed blood vessels or organs Wounds with difficult haemostasis Non-enteric and unexplored fistulas In the following circumstances Topical Negative Pressure Therapy should be used with caution Wounds with fistulas into a body cavity Page 2 of 11

3 Patients on anticoagulation therapy Active bleeding to the wound site Bone fragments or sharp edges are present Acute and chronic enteric fistulae are present Community considerations Further considerations are required for TNP within the community setting The position of the wound in relation to the patients normal activities of daily living The cognitive ability and compliance of the patient Ensure a holistic assessment of the patient has been completed and documented Ensure accuracy of diagnosis and address all underlying and associated comorbidities Maintain accurate use of dressings Do not tightly pack dressings into wounds: place dressings gently into the wound. Accurately record the number of dressings pieces used in the patients records. When dressings are removed count the number of dressings, verify and compare to documented number of dressings applied Check and respond to alarms If the patient can manage the their own TNP console Accessing the therapy All patients that have been deemed suitable for TNP by the community tissue viability nurse must have funding agreed, by commissioning through the relevant documentation prior to the initial application of TNP by the Tissue viability and District nurse. However all referrals for discharge into the community require a funding application to the Derby City PCT individual patient panel and an individual referral to Derby City PCT Tissue Viability Team. The community nurses will be expected to attend the foundation trust hospital with a member of the Tissue Viability team to assess the individual and their suitability of TNP therapy within the community Following acceptance for funding by Derby City PCT and by The Tissue Viability Team, appropriate training and support will be provided to the relevant community nursing staff References Guidelines for the Use of Topical Negative Pressure Therapy Derby Hospitals NHS Foundation Trust Chariker, E and Jeter, F. (1989) Effective Management of Incisional and cutaneous fistule with closed suction wound drainage. Contemporary Surgery Journal. Vol 34 Page 3 of 11

4 Banwell P and Teot. (2003) Topical Negative Pressure (TNP): the evolution of a novel wound therapy. Journal of Wound Care. 12(1): Evans D, Land L. Topical negative pressure for treating chronic wounds (Cochrane Review). In: The Cochrane Library, Issue 1, Oxford: Update Software. Mendez-Eastman S. (2001) Guidelines for using negative pressure wound therapy. Advanced Skin and Wound Care. 14(6): Sibbald R, Mahoney, J (2003) A Consensus Report On The Use Of Vacuum- Assisted Closure In Chronic Difficult To Heal Wounds. Ostomy Wound Management. November, 49(11) Written by Trina Parkin Tissue Viability Clinical Specialist Nurse Derby City PCT Ruth Le Bosquet Tissue Viability Clinical Support Nurse Derby City PCT David Nelson Tissue Viability Clinical Support Nurse Derby City PCT Page 4 of 11

5 PROCEDURE RATIONALE Assessment for TNP The patient must undergo a full holistic assessment for their suitability for TNP therapy. This should include: Cognitive ability Manual dexterity Physical ability Full nutritional assessment Pressure Ulcer Risk assessment The patients wound should be assessed for: Size and depth Pain The percentage of slough present. The risks to exposed underling organs or tissues Any osteomyelitis has been investigated and treated The wound must have a minimum 2cm intact skin around the wound. If any cavities or sinuses are present, ensure they have been explored. A risk assessment must be completed on the patients home environment. The District Nurse (DN) and Tissue Viability nurse must agree to providing TNP therapy in the community and to ensure nursing staff are familiar and competent with chosen system. A holistic assessment must be completed to ascertain the suitability of TNP So the patient can use the basic elements of TNP therapy unit. To maintain suitability of TNP for the patient To aid in dressing application and maintain a safe therapy usage So that the correct TNP is attained without the seal breaking To reduce deterioration of the wound and underling structures. To make sure the patient can mobilise with the TNP unit The district nurse must assess her staff and caseload to ascertain if she can deliver TNP in the community Application for funding Once TNP has been agreed a funding application must be sent to commissioning. If the patient already has the TNP unit in an acute setting and needs to be transferred to community then an Commissioning must agree to fund the cost of TNP before applied to the patient. Patients on TNP can be transferred from the hospital to a community setting however they still require Community Page 5 of 11

6 application must be sent from the hospital to commissioning for authorisation once agreed by the community tissue viability nurse and DN assessment by the DN and TVN Obtaining consent Consent will have been discussed with the patient. The registered Nurse taking consent must ensure that the patient understands the rationale for treatment, the interventions required to apply and maintain the therapy The nurse must refer to Derby City PCT patient consent policy. To enable the Patient to make informed choices about treatment To make sure the policy is being followed Initial wound assessment Reassess the patient to make sure they are still suitable for TNP. To ensure correct application. Ensure accuracy of diagnosis and address all underlying and associated comorbidities. Assess the patients pressure reliving needs and make sure that appropriate surfaces are in place if needed. Complete District Nursing Patient Records including wound assessment chart. To aid wound healing and prevent deterioration of pressure risk areas. Enable accurate wound assessment documentation Dressing Procedure Follow individual clinical guideline for chosen system, which is available on the tissue viability website: Different systems have different methods of application. Page 6 of 11

7 Frequency of dressing changes Frequency of dressings will be determined by individual factors and following assessment and reassessment by practitioner in charge of care Each wound is individual and dressing changing frequency may be different. Bridging Wounds in close proximity need to be bridged. Seek Tissue Viability advice and support Prevent damage to intact skin To maintain a seal into wounds To ensure exudates from one wound is not drawn into an adjacent wound Tunnelling Do not place foam into blind or unexplored tunnels All cavities need exploring Dressing removal Close clamp on dressing tubing To prevent spillage of exudate Press on/off button to deactivate pump Gently remove the old dressing Thoroughly inspect wound to ensure all pieces of dressings are removed. If dressing adheres to wound bed Increase frequency of dressing change Line wound with non adherent dressing. Pre-moisten dressing with saline 15 minutes before removal ( this can be introduced via tubing) If pain is experienced during dressing change consider analgesia Preventing further trauma to wound bed Ease removal dressing To enable patient comfort Maintain patient comfort To aid patient comfort Page 7 of 11

8 Cannister change Cannister should be changed when full or weekly at a minimum Control odour and prevent infection Tighten clamps on canister and dressing tubing Disconnect the two tubes Remove the canister from the unit Dispose of canister as per infection control policy Follow up dressing integrity Patient to check dressing frequently to ensure seal maintained If not, make sure : The unit switched on Tubing not kinked Topical negative pressure should be applied for at least 22 out of every 24 hours, to reduce the risk of tissue damage. Wound reassessment Wound assessment chart should be completed at regular intervals Photographs or mappings should be obtained at regular intervals as identified in the care plan Holistic assessment and aids reassessment To monitor wound progress accurately If no response or treatment in the wound is observed within two weeks, reassess the treatment plan Make sure the planned TNP regime has been implemented The nurse might have to change the treatment plan depending on wound TNP treatment may not be suitable for wound If the planned regime has not implemented due to problems, TNP might not be suitable for the patient TNP applications may need to be modified depending on wound status Page 8 of 11

9 status changes changes Equality and Diversity Nurses should be aware of equality and diversity issues of individuals. Including Darkly pigmented skin Where erythema in darkly pigmented skin may present differently i.e lighter or darker pigmented skin around the wound edges Homeless and chaotic lives. Individuals with Mental health needs, Sensory impairment or physical disabilities. Race or ethnicity (language barriers) Consider concordance/compliance issues. Carers/relatives may need to be present to assist the individual. Consider use of interpreters, multi lingual leaflets, Consider privacy and dignity of the individual receiving TNP. On completion of treatment Discontinuation of TNP is when the goal of the therapy is met. For example: The wound is healed Conventional dressing can be applied. It may also be when The wound shows no signs of progression. The patient declines the treatment. To maintain cost effective care and allow return to normal living for patient To discontinue costs incurred from unit Discontinuation of treatment should be authorised by a member of the tissue viability team. Collection of hired unit should be arranged on same day that treatment is discontinued by the Tissue Viability Nurse Ensuring correct discontinuation of therapy The unit must be refurbished and disinfected. The TNP company should be contacted : to arrange collection Page 9 of 11

10 During this telephone encounter the company will ask for : A designated surgery or health centre for collection of unit The individual unit serial number and the invoice number. Page 10 of 11

11 Derby City PCT flowchart for the use of Topical Negative Therapy (tnp) A patient identified with an acute or chronic wound that may be difficult to heal Is TNP confirmed suitable? Yes No Consider alternate treatments Contact Community Tissue Viability Nurse (TVN) TVN will assess the patient for TNP with District Nurse (DN) present Is TNP Suitable? No Consider alternate treatments Yes TVN Responsibilities TVN to assess which TNP unit will be applied to the wound and instruct DN to obtain dressings TVN will complete funding documentation and send it to commissioning TVN will educate and support DN and patient with TNP TVN will arrange for TNP unit to be collected and discontinued DN Responsibilities DN will access TNP policy and print selected TNP unit instructions from DN will organise a joint visit at patients house with TVN DN will apply TNP with support of TVN and complete relevant documentation, eg patient records and wound evaluation Page 11 of 11