Guidelines for the use of Negative Pressure Wound Therapy

Transcription

1 Guidelines for the use of Negative Pressure Wound Therapy Reference No: G_CS_51 Version: 2 Approved by (Committee name): Trust Board Date approved: 10 July 2018 Name of originator/author: Name of responsible committee/individual: Date issued: July 2018 Review date: June 2020 Target audience: Distributed via: LCHS Tissue Viability Team Sara Brooks Effective Practice Assurance Group All Clinical Staff delivering Negative Pressure Wound Therapy. Public website Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan

2 Guidelines for the use of Negative Pressure Wound Therapy Version Control Sheet Version Section/Para/ Appendix 1 Section 5.3 P8 / Version/Description of Amendments Change from use of e clinics to contact through systm one task and telephone consultation 2 Section 6 Change of contact details for LCHS for ordering pump and consumables to LCHS pathway 3 Section 7 Change of contact details for LCHS for ordering pump and consumables to LCHS pathway 4 Section 8.3 Change of instruction from using layers of gauze to one continuous piece of gauze where possible. Added instruction to record and count number of dressings removed. Date Author/Amended by 05/07/2017 Sara Brooks 05/07/2017 Sara Brooks 05/07/2017 Sara Brooks Colette Longstaffe 05/07/2017 Sara Brooks 5 Section 9 Update of Local Policy Dates 05/07/2017 Sara Brooks Colette Longstaffe 6 Section 6 Update address 13/03/2018 Sara brooks 7 Appendix 1 Update address 13/03/2018 Sara Brooks Copyright 2018 Lincolnshire Community Health Services NHS Trust, All Rights Reserved. Not to be reproduced in whole or in part without the permission of the copyright owner. 2

3 Guidelines for the use of Negative Pressure Wound Therapy Policy Statement Background Statement Responsibilities Training Dissemination Resource implication The purpose of this standard operating procedure is to ensure competency and standardise the application of Negative Pressure Wound Therapy within LCHS NHS Trust. This document offers guidance to ensure that all clinicians are applying the therapy within best practice guidelines and in a safe manner. Compliance with this guidance is an expectation of all practitioners and will be the responsibility of all LCHS NHS Trust clinicians. It is the responsibility of operational managers and service leads to ensure that appropriate mechanisms are in place to support the implementation and ongoing application of this guidance, including appropriate training and maintenance of competencies. Intranet Heads of Clinical Services Matrons Tissue Viability Specialist Nurses & Tissue Viability champions Tissue Viability/Leg Ulcer Management training All practitioners trained and proficient in Doppler assessment. This guideline has been developed to facilitate standardised practice in the application of NPWT. Initial investment required for staff to attend training to ensure competency 3

4 Guidelines for use of Negative Pressure Wound Therapy Contents Page 1. Introduction 5 2. Purpose of Guidance 5 3. Benefits of NPWT 5 4. Risks, Indications and Contraindications for use of NPWT Risks 4.2 Indications 4.3 Contradictions 4.4 Precautions 5. Practitioner roles and responsibilities Assessment 5.2 Competency 5.3 Roles and Responsibilities 6. LCHS Pathway for Negative Pressure Wound Therapy 9 7. Procedure for discharge from secondary care to LCHS NHS trust Application of NPWT Patient Preparation 8.2 Procedure for Dressing Application 8.3 Using Fillers and Drains Sealing the dressing and Connection to Pump 8.5 Procedure for Dressing Removal Related Policies References 16 Appendices Appendix 1 Consumable Request forms 17 Appendix 2 Discontinuation of NPWT 18 4

5 1. Introduction The use of Negative Pressure Wound Therapy (NPWT) has increased significantly over recent years. With surgical intervention on an elderly compromised patient population becoming more common, health professionals are faced with many complex wound healing challenges. NPWT is used to promote wound healing and manage some of the symptoms of the wound such as copious exudate. As such it can improve both the healing of the wound and the quality of life for the patient. 2. Purpose of Guidance The use of NPWT in primary care is increasing, enabling earlier discharge for patients from secondary care with complex wounds. The NPWT available in LCHS NHS Trust is Smith and Nephew, Renasys. These guidelines have been produced to support practitioners in LCHS NHS Trust who may be involved in managing patients being treated with NPWT and will define the principle and different techniques. The guidelines will define the role of the prescriber and the practitioner involved in the management of the patient undergoing treatment with NPWT, to reduce possible risk in the implementation. The guideline includes assessment and wound selection criteria, recommended use, the appropriate management of patients undergoing NPWT, patient information, staff competency information and outcome measurement tools. The key to choosing an effective wound management strategy is to undertake an appropriate holistic and wound assessment. 3. Benefits of NPWT NPWT promotes healing in various types of open wounds by removing wound fluids and waste materials through the creation of negative pressure at a well-sealed wound site. NPWT systems consist of the following parts: a pump that generates a vacuum and is capable of creating a negative pressure environment within a sealed wound; dressing materials used to pack the wound and seal it; tubing for fluid removal from the wound area; canister to collect waste materials that are removed from the wound area by suction. The following are documented benefits of the application of Negative Pressure Wound Therapy: Increased local blood flow Reduced tissue oedema Stimulation of granulation tissue Stimulate cell proliferation Removal of inflammatory mediators and free radicals Reduction of bacterial load Draws the wound edges together (EWMA 2007, Wounds UK 2008) 4. Risks, Indications and Contraindications for use of NPWT There are risks involved in the application of NPWT and serious complications can arise if these are not monitored. (FDA, 2010). 5

6 4.1 Risks include: Adherence of the dressing to the wound Retention of foam dressing pieces in the wound Discomfort throughout therapy Potential risk of bleeds Potential risk of intestinal fistulae 4.2 Indications Partial/full thickness pressure ulcers Dehisced surgical wounds Diabetic/neuropathic ulcers Venous leg ulcers Post-surgical wounds Sinus drainage and management Traumatic wounds Pre and post op flaps and grafts Burns 4.3 Contraindications Necrotic tissue/eschar Direct placement over exposed structures e.g. tendons, ligaments, blood vessels, anastomosis sites, organs and nerves Untreated osteomyelitis Non enteric or unexplored fistulae Malignancy in the wound spinal cord injury (stimulation of sympathetic nervous system) The patient is unable to understand what the therapy entails, or comply with treatment. (Please refer to the Mental Capacity Act 2005). The patient may be at risk of falls if they are unable to safely carry the pump console. 4.4 Precautions should be taken for patients With active bleeding With difficult wound haemostasis Who are taking anticoagulant therapy platelet aggregation inhibitors 4.5 Precautions should be taken in the following situations When placing in close proximity to blood vessels, organs or exposed tendons. Ensure these are adequately protected with overlying fascia, tissue or other protective barriers. With weakened, irradiated or sutured blood vessels or organs In the presence of bone fragments or sharp edges With enteric fistulae, which require special precautions 5. Practitioner roles and responsibilities. 5.1 Assessment 6

7 A practitioner undertaking the application and removal of NPWT should be registered practitioner at Band 5 or above and be competent to undertake and document a comprehensive holistic assessment of the patient and their wound. All the assessments including the wound assessment need to be completed fully together with clinical photography with patient consent. IMPORTANT: When the patient has been referred and discharged from hospital it is essential to ensure that the dimensions of the wound are consistent with those detailed on the referral form at the first assessment/visit. (The referral form can be found in the patient s records under communications ). Where a significant difference is observed the wound should be reassessed and if necessary referred to a case manager, tissue viability Link Champion or Tissue viability Nurse for further assessment. In addition all risk assessments, should be completed and any immediate risks identified need to addressed prior to commencing/recommencing NPWT e.g. Does the use of NPWT increase risk of falls? Before initiating NPWT any potential barriers to wound healing should be addressed e.g. patients should have appropriate repositioning, pressure reducing/relieving surfaces, nutritional support (where appropriate referral to dieticians), management of systemic conditions and incontinence. 5.2 Competency Practitioners are responsible for ensuring the safe application of NPWT and must be competent in the use of NPWT. When additional clinical support is required it is the responsibility of the practitioner to seek support from a Tissue Viability Link champion or another competent practitioner within the team. Additional support can be requested from Smith and Nephew following prior arrangement. It is the responsibility of each clinician to ensure they are competent in the application of NPWT as detailed in section 8. This can be achieved through formal training sessions which all link Champions and Case managers will have the opportunity to attend and through shadowing other competent practitioners in practice. (e.g. Case managers/link champions who have attended training) and seeking guidance from LCHS tissue viability CNS and or the clinical support nurse from Smith and Nephew. 5.3 Roles and Responsibilities The tissue viability team will be responsible for agreeing to fund and arrange delivery through SPA of the NPWT pump and consumable to the community nurses base/ inpatient unit. Documentation The practitioner will be responsible for ongoing assessment and care planning of the patient and the need for continued NPWT together with completion of Systm One templates. All care planning should include details of the size and quantity of dressings used e.g foam/gauze. The use of one continuous dressing is recommended however where the wound required more than one piece of dressing the number of dressings applied and removed must be recorded at each dressing change. 7

8 The practitioner will undertake or request further clinical investigations where appropriate for example a sinus of unknown depth. The practitioner should gain consent for NPWT. They should be aware of their responsibilities and be able to inform the patient/carer about the NPWT. The patient/carer should be instructed by the practitioner: How to use the system The signs/symptoms of possible potential complications and what to do if complications arise. Contact details of the team managing the wound. The practitioner should ensure that: The patient/carer can demonstrate their knowledge of the system and understands the warnings. The practitioner caring for the patient will ensure that: adequate provision is made for monitoring the therapy An understanding of the alarms of the therapy console. This should be supported by written information supplied with the pump to include a patient information leaflet and details of the Smith and Nephew 24 hour help line. Staff should take in one dressing change and ensure there is a spare dressing and canister in the patient s home. Consumables will be delivered to and must be kept at the Community Nursing Base. Wound assessments/systm One templates must be completed immediately prior to request for consumables to ensure appropriate review may be undertaken by TVN. To promote cost effectiveness and avoid waste uunused consumables should be returned to the relevant TVN for distribution elsewhere within the business unit. The practitioner should be aware of the possible complications that may arise and what to do. If any adverse events occur, such as skin reactions, pain or haemorrhage therapy should be stopped. It is the responsibility of the practitioner to ensure an adequate supply of dressings and canisters are available and that they obtain by using the Consumables Request Form (Appendix 1). Please give 2 working days notice to allow for delivery, to ensure that Consumables are delivered on time. The practitioner should contact the TVN for consultation regarding continuation of NPWT at 2 week intervals. This may be arranged by Systm One Task and subsequent telephone consultation with a member of the Tissue Viability Team. The practitioner will identify when NPWT can be discontinued and replaced by alternative wound management products. Upon completion of treatment it is the responsibility of the practitioner to return the pump and case to their base. They should alert the Tissue Viability Department regarding cancellation details and arrange collection of the equipment from their base/relevant department through the SPA admin team (See Flow chart p 9). 6. Procedure for NPWT Request from LCHS Staff 8

9 LCHS Pathway for Negative Pressure Wound Therapy 1 New patient referral request to be sent to TVN via (Tissue.Viability@lincs chs.nhs.uk) referral, task and telephone confirmation. Community team to order pump and consumables via Louth Admin who will order from Smith & Nephew and arrange delivery to community base. 2 3 Community team to inform admin at Louth NPWT pump serial number and to record on patient reminder on Systm one notes on day of arrival. Community team to Louth Admin with consumable request form before 2pm for next day delivery. Team to order a maximum of two week therapy consumables at one time (maximum of 5 items). Louth admin is based at Louth County Hospital telephone number and fax number SPA is open Monday to Friday pm excluding Bank holidays. 7. Procedure for discharge from secondary care to LCHS NHS Trust NPWT Discharge Process from Secondary Care to LCHS 9

10 SPA is based at Louth County Hospital telephone number and fax number SPA is open Monday to Friday pm excluding Bank holidays. 8. Application of Renasys Negative Pressure Wound Therapy 8.1 Patient Preparation ACTION RATIONALE 10

11 Confirm the identity of the patient, by asking for full name and date of birth. Clarify identity with carer if patient not able to do so. Explain the procedure to the patient, obtain valid consent and document in patients notes. Assess the need for pain relief and administer prior to the procedure, if required. Position the patient comfortably, to ensure safety and enable easy access to and good visibility of the wound. If patient requires physical assistance to positioning or the wound dressings are to be removed, hands must be decontaminated and or PPE in line with local policy must be applied prior to assisting them. To confirm the correct identity of the patient. To enable the patient to make an informed decision about their own health care. To maintain patient comfort. To allow access to and to have a clear view of the wound, providing a safe environment for patient and practitioner 8.2 Procedure for Dressing Application ACTION Apply a single use disposable apron. Decontaminate hands prior to procedure. Using a standard aseptic technique prepare all equipment and open sterile dressing pack onto a pre-cleaned field and place all sterile single use equipment required within the sterile field. Apply non-sterile single use disposable gloves, measure and photograph the wound. Change gloves as necessary. Take care not to physically touch the wound with the gloves. ACTION Using aseptic non touch technique, cleanse the wound and peri wound area, if required, by irrigating with warm sterile saline. Ensure the surrounding skin is dry and apply non-sting skin barrier to peri wound skin. Line wound with a single layer of sterile nonadherent wound contact material in the following circumstances: Wound contains exposed bone or tendon Dressing is next to exposed, anatomy RATIONALE To reduce the risk of transfer of transient micro-organisms on the practitioners hands. To maintain asepsis and prevent contamination of sterile equipment. To maintain asepsis, reduce the risk of microbial contamination and prevent the spread of infection. To provide a baseline and enable future reassessments and evaluations. (If photographing wound complete photography consent on Wound Management or SSKIN Template as appropriate). RATIONALE To promote hygiene and reduce bacterial contamination. To aid application of drape and protect skin integrity. To protect underlying bone, tendon, blood vessels and granulation tissue. Document in the patients notes the amount and size of liner used on insertion and extraction on dressing change 11

12 or irradiated blood vessels. Dressing is to be left in situ for more than 48 hours Dressing adheres to the wound Deep open abdominal wounds should be lined with multiple sterile wound contact layers to protect underlying organs. 8.3 Using Fillers and Drains ACTION If using AMD gauze as a filler: Soft Port application: Apply one (where possible) continuous saline-moistened antimicrobial gauze to wound bed to loosely fill the wound. RATIONALE To fit the dressing and drain to the shape of the wound. Avoid over packing the wound as this may cause delayed wound healing. If multiple pieces of gauze are needed, count and record how many pieces are present and subsequently removed at each dressing change. Follow guidance for applying film dressing. Cut a hole no smaller than 2cms in the centre of the film over the gauze. Remove the adhesive backing panel from the back of the port dressing and align directly of the whole in the film. Use gentle pressure to anchor to the film. Smooth the dressing down while removing the top layer of the dressing. Flat Drain: Measure the wound and cut the flat drain using sterile single use scissors to fit the wound bed, so that the drain is 1-2cm smaller than the largest wound dimension. Saturate a single layer of gauze with sterile saline. The drain and gauze should be inserted loosely into the cavity. Fill remaining cavity with additional moistened AMD gauze if required. Round Drain: This drain is particularly suited to wounds 12

13 with a sinus, tunneling and/or undermining. For tunneling or sinus the round drain may be inserted directly into the cavity using a standard aseptic technique. Follow guidance for applying film. ACTION If Using Foam as a filler: Soft Port : Cut the foam using sterile single use scissors to an appropriate size corresponding with the dimensions of the wound cavity. Follow guidance for applying film and Soft port.. Flat Drain: Make an incision in the foam, Cut the drain to size and insert into the foam and place gently into the wound cavity. RATIONALE To fit the dressing to the shape of the wound. To fill the wound and facilitate the removal of exudate. Do not over-compress the dressing or overpack the wound. If using foam the edges of the foam can be beveled to avoid contact with the surrounding skin as the dressing collapses. Follow guidance for applying film. If multiple pieces of foam are used to fill the wound, count and record how many pieces are present and ensure all pieces are removed and recorded at dressing change. 8.4 Sealing the dressing and connection to the pump. ACTION AMD Gauze/ Foam with Viewpad: RATIONALE 13

14 Cut the film using sterile single use scissors to the appropriate size allowing a 3-4cm margin onto the skin. Remove panel #1 of the film dressing exposing the adhesive. Apply over the wound and remove panel #2 to seal. Once placed, remove the top #3. Continue to apply until the gauze/foam is completely covered and sealed. Connect the drain to the canister tubing by pushing the connectors together. An audible click indicates that connection is secure. Switch on device and set to desired pressure setting dependent on patients wound, location, exudate levels and patient tolerance. General guide: foam:-120mm/hg and gauze 80mm/hg. To secure the dressing and ensure a good seal. A poor seal increases the risk of exudate spreading and may lead to periwound maceration. Dressing leaks may lead to a break in therapy and result in repeated dressing changes To ensure safe and effective wound management and increase patient tolerance to therapy. These are the recommended therapeutic levels of NPWT that have been determined when undertaking RCTs. Once the negative pressure is applied, the dressing will have a raisin-like appearance and be firm to the touch. Evaluate efficacy of the treatment after each dressing change. If there is no improvement after 2 weeks of treatment, consider alternative treatment options. Liaise with the TVN for further advice. The dressing should be changed every hours and disposed of via an appropriate waste route. Frequency of dressing changes should be based on an evaluation of the wound condition rather than standard recommendations. Indicating a good seal and administration of negative pressure. To ensure the treatment offered is the most appropriate option for the patients wound. Provide individualised patient care. 8.5 Procedure for Dressing Removal ACTION Press ON/OFF button on unit. RATIONALE To deactivate pump. 14

15 Apply single use disposable apron, wash hands and put on single use non-sterile gloves. Raise tubing connectors above the level of the unit. Disconnect canister and dressing tubing, allow unit to draw any exudate into the canister from the canister tubing. Gently stretch and release drape to deactivate adhesive and slowly remove from skin. Gently lift dressing from wound bed using a standard aseptic technique. NB: If it adheres to the wound bed, soak dressing off using warmed sterile, normal saline. Dispose of dressings via the appropriate route as identified in the waste policy. Remove and dispose of PPE to comply with waste management policy. Decontaminate hands following removal of PPE. Removal/return of unit To protect clothing or uniform from contamination and potential transfer of micro-organisms. To ensure drainage of exudate and to prevent spillage. To ensure drainage of exudate and to prevent spillage. To prevent trauma to the periwound area. To reveal wound and prevent trauma to granulation tissue. To prevent cross infection and environmental contamination. To remove any accumulation of transient and resident skin flora that may have built up under gloves and possible contamination following removal of PPE. See page 2 for instructions for cancellation. 9. Related local policies Wound Management Formulary (2017) Pressure Ulcer Prevention and Management Guidance (2017) Clinical Guidelines for The Assessment and Management of Lower Limb Ulceration within Adult Community Services (2017) Asepsis, non-touch technique and clean technique (2017) Infection prevention and control policy (2016) 15

16 10. References EWMA (2007) Topical negative pressure in wound management, Position Document, Medical Education Partnership Ltd, London. FDA (2010) FDA Safety Communication: UPDATE on Serious Complications Associated with Negative Pressure Wound Therapy Systems; Date Issued: February 24, NICE (2009) Negative pressure for the open abdomen (Interventional Procedures Consultation) Wounds UK (2008) Gauze based negative pressure wound therapy, Best Practice Statement, Wounds UK, Aberdeen. DoH (2005) Mental Health Capacity Act. Department of Health 16

17 Appendix 1 NPWT THERAPY CONSUMABLE REQUEST FORM Countywide Patient Name and Home postcode: FAO NHS Number: Code Description RENASYS GO Machine Soft Port Kits Gauze Renasys G Small Gauze Kit Renasys G Medium Gauze Kit Renasys G Large Kit Renasys G X Large Kit Soft Port Kits Foam Renasys F Small Foam Kit Renasys F Medium Foam Kit Renasys F Large Foam Kit Renasys F X Large Foam Kit Drain Kits Renasys G 10mm Flat Drain Kit Renasys G 15fr Channel Drain Kit Canisters Renasys Go 300ml Canister Renasys Go 800ml Canister Accessories Stand Alone Port Y Connector Gauze Wound Filler (Squares, Pack of 5) Renasys Adhesive Gel Patch Pack of 10) Large AMD Gauze Rolls (Pack of 5) Transparent Film 20cm x 30cm (Pack of 10) Quantity Required in single items Name of requesting Nurse and mobile telephone number: 17

18 Signature: Date: This form should be faxed FAO Louth Admin to or - For Office Use only Smith & Nephew general enquiries : hour Helpline : Pump Serial Number: Appendix 2 Discontinuation of NPWT 18

19 Monitoring Template Minimum requirement to be monitored Process for monitoring e.g. audit Responsible individuals/ group committee Frequency of monitoring /audit Responsible individuals / group committee ( multi - disciplinary) for review of results Responsible individuals group / committee for developmen t of action plan Responsible individuals group / committee for monitoring of action plan Number and type of incidents connected with NPWT Review of the themes from the incident reports CNS TV All Clinical Team Leads/ Matrons community Nursing Staff Annual Quality and Scrutiny Group Quality and Scrutiny group members Quality and Scrutiny Group 19

20 Equality Analysis Name of Policy/Procedure/Function* Guidelines for the use of Negative Pressure Wound therapy Date: Equality & Human Rights lead: Rachel Higgins Director/General Manager: *In this template the term policy/service is used as shorthand for what needs to be analysed. Policy/Service needs to be understood broadly to embrace the full range of policies, practices, activities and decisions: essentially everything we do, whether it is formally written down or whether it is informal custom practice. This includes existing policies and any new policies under development. Section 1 to be completed for all policies A. Briefly give an outline of the key objectives of the policy; that its intended outcome is and who the intended beneficiaries are expected to be B. Does the policy have an impact on patients, carers or staff, or the wider community that we have links with? Please give details C. Is there any evidence that the policy/service relates to an area with The purpose of these Negative Pressure Wound Therapy guidelines is to work towards standardization of the practice of Negative Pressure wound therapy across the organisation. Implementation and compliance within the guidelines will be the responsibility of all the staff. No 20

21 known inequalities? Please give details D. Will/Does the implementation of the policy/service result in different impacts for protected characteristics? Yes No Disability X Sexual Orientation X Sex X Gender Reassignment X Race X Marriage/Civil Partnership X Maternity/Pregnancy X Age X Religion or Belief X Carers X If you have answered Yes to any of the questions then your are required to carry out a full Equality Analysis which should be approved by the Equality and Human Rights Lead please go to section 2 The above named policy has been considered and does not require a full equality analysis Equality Analysis Carried out by: Date: 21