CLINICAL PROCEDURE PROCEDURE FOR CONSERVATIVE DEBRIDEMENT Issue History Issue Version One Purpose of Issue/Description of Change To promote safe and effective sharp debridement by Tissue Viability Specialists only Planned Review Date 2016 Named Responsible Officer:- Approved by Date Tissue Viability Service Quality, Patient Experience and Risk Group November 2013 Section:- CP16 Target Audience Tissue Viability Service
UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSIONCONTROL RECORD Title Procedure for conservative sharp debridement Purpose To promote safe and effective sharp debridement by Tissue Viability Specialists only Author Quality and Governance Service (QGS) Equality Assessment Integrated into procedure Yes No Subject Experts Ian Mansell/Maria Hughes Document Librarian QGS Groups consulted with:- Clinical Policies and Procedures Group Infection Control Approved 15.11.2013 Date approved by Quality, Patient Experience and Risk Group Aim November 2013 Method of Distribution Email Intranet:- Staff Zone Archived Date Location:- Datix Librarian Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 1 I Mansell N Status New / Revised / Trust Change 2
INTRODUCTION PROCEDURE FOR CONSERVATIVE SHARP DEBRIDEMENT (CSD) Dead tissue in the form of 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). TARGET GROUP The procedures applies to Tissue Viability Specialist Nurses (TVN) only TRAINING 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. TVN carrying out sharp debridement in line with this procedure will be employed by the Trust and will have completed a validated educational programme in wound management approved by their line manager. Evidence their ongoing Continuing Professional Development to be shared at their annual performance development review. RELATED POLICIES Please refer to relevant Trust policies and procedures DEFINITION Debridement is an accepted principle of good wound care, especially when debris is acting as a focus for infection. (NICE, 2001) METHODS OF DEBRIDEMENT The main methods of debridement are: Hydrosurgery (Versajet) Autolytic Chemical Enzymatic Mechanical Sharp Biosurgery 3
INDICATIONS 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, there are other methods of debridement available. 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). CONTRAINDICATIONS Wounds on ischaemic digits Patients with blood clotting disorders Wounds that are fungating or malignant wounds Wounds on the foot* (excluding heel region) Wounds on the hands and face Sharp debridement should not take place for wounds that involve or are near the following structures:- Arterial structures Vascular grafts Prosthesis Dialysis fistula For the above a referral should be made to the appropriate consultant surgeon and the GP informed CAUTIONS FOR CONSERVATIVE SHARP DEBRIDEMENT:- Lower limb 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 4
Wounds on heels** Wounds on the Achilles tendon area** Note: conservative sharp debridement in the presence of clinical infection may require systemic antibiotic cover * Decisions with regard to whether or not the debridement of ischaemic lower limbs is appropriate should be made in conjunction with the Vascular Surgical Consultant. ** If referral is required for Podiatry Services, TVN can refer via the patients GP however; if the patient is diabetic the podiatry service would have to refer the patient to secondary care. POTENTIAL COMPLICATIONS If any complications arise i.e. pain, damage to underlying structures or excessive bleeding the procedure should be stopped immediately. The patient should be reassured, appropriate action taken which may involve seeking medical assistance. The complications and subsequent action should be documented in the patient s health records; other health care professionals caring for the patient must be informed and clinical incidents or near misses must be reported via the Trust s Datix Incident Reporting System on the same working day 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 Patient Information and Consent Policy for further information and guidance or the Clinical Protocol for Assessing Mental Capacity and Best Interests. EQUIPMENT Disposable scalpel (Swann-Morton Size 10, 11, 15. Consider retractable scalpels to reduce risk of injury Debridement pack (7822) Robinson Health Care Containing:- 1 Toothed Forceps 1 Mosquito Forceps 1 IRD Scissor Curved 1 Silver Eye Probe Sterile gauze Haemostatic dressing according to local wound formulary Single use sterile dressing pack Single use non sterile gloves 5
Appropriate cleansing solution (e.g. sterile saline 0.9%) An appropriate post procedure dressing Camera Consent form for photograph Sharps container 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. Clarify if patient requires a formal chaperone Complete and document a wound assessment form Decontaminate hands Using ANTT, open sterile single use dressing pack onto a clean field and place all sterile single use equipment required within aseptic field, maintaining key parts protection at all times. If in a clinic as requirement open sterile single use dressing pack onto dressing trolley Apply single use disposable apron Apply single use non sterile gloves Remove old dressing 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 It is patients choice to have a chaperone To provide a baseline of wound status prior to CSD and check safety issues before proceeding To reduce risk of transfer of transient microorganisms on the healthcare workers hands. To prevent contamination of key parts To protect clothing or uniform from contamination and potential transfer of micro-organisms To protect hands from contamination with organic matter and transfer of micro organisms 6
Record wound size shape, depth, position and site. Remove non sterile gloves and dispose of Personal Protection Equipment (PPE) to comply with waste management policy Decontaminate hands Check the patient has signed consent form for photograph, and photograph the wound, One copy of the photograph is to be kept in the patient s health records and a copy for base notes if required Estimate the depth of necrosis and assess the skin around wound margin. Note proximity to structures or anatomical features e.g. grafts, prosthesis, bone, tendon etc. Vascular assessment (ABPI) to be completed, if the area to be debrided is on the lower leg or foot Explain conservative sharp debridement procedure to patient and ensure informed consent has been obtained Consider the need for: administration of analgesia (systemic, local or topical) antibiotic cover if clinical signs of infection are present Prepare the environment e.g. lighting, couch. Ensure that the patient is comfortable and in a position where the wound can be accessed and viewed easily Ensure the TVN nurse carrying out this procedure is in an appropriate and comfortable position Decontaminate hands To provide accurate measurements To prevent cross infection and environmental contamination To reduce risk of transfer of transient microorganisms on the healthcare workers hands. To comply with Trust Consent Policy Use Trust Consent Form for Photography. As part of wound assessment To determine the vascular status and check the appropriateness of CSD To inform the patient of procedure, other options available and adhere to local consent policy. As only dead tissue will be incised, the procedure should not increase pain. However additional analgesia may be required if viable tissue is unintentionally incised or if manipulation of dead tissue pulls on underlying viable tissue. To treat any underlying tissue infection and to comply with local Antibiotic Formulary To ensure good visibility of the wound bed and to conduct an environmental / infection control To allow access to the 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 7
Apply single use disposable sterile gloves in a manner which prevents the outer surface of the sterile glove being touched by a nonsterile item Using ANTT, to ensure that only sterile single use items are used to keep exposure of the susceptible site to a minimum Lift the necrotic tissue with suitable grasping forceps and cut it carefully with a scalpel or scissors. The angle of the scalpel or scissors should be parallel to or angled away from the wound bed. Necrotic tissue should be removed in layers The nurse should stop the procedure if the patient requests to stop or if any complications arise Reassess the wound bed and photograph Redress according to local wound care guidelines and care plan On completion of the procedure remove and dispose of Personal Protective Equipment (PPE) to comply with waste management policy Decontaminate hands Document the outcome of the procedure in the patient s health records Inform patient and relevant members of the multi-disciplinary team of the process and outcome of CSD To maintain asepsis, reduce the risk of microbial contamination and prevent the spread of infection To prevent contamination of key sites and key parts To minimise pain and damage to healthy tissue To ensure nurse responds to patients request To minimize risk of complications To establish extent of debridement To provide optimum wound healing environment. To prevent cross infection and environmental contamination To reduce the risk of transfer of transient micro-organisms on the healthcare workers hands To accurately record the process and outcome of CSD. To share information regarding the changes to the wound status and further wound care plan. WERE TO GET ADVICE FROM Tissue Viability Service INCIDENT REPORTING Clinical incidents or near misses must be reported via the Trust s Datix 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. 8
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. 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 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. 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: A Clinical Practice Guideline. http://www.nice.org.uk/nicemedia/pdf/cg029fullguideline.pdf UKCC (1992) The Scope of Professional Practice, London. NMC (2004) The NMC Code of professional conduct: standards for conduct, performance and ethics. London. Vowden, K.R., Vowden, P. (1999a) Wound debridement, Part 1: non-sharp techniques. Journal of Wound Care, 8, 5, 237-240. Vowden, K., Vowden P (1999b) Wound debridement, Part 2; sharp techniques Journal of Wound Care, 8, 6, 291-294. Williams, C. (2000) Stages of care in chronic wounds. Practice Nurse, 19,2, 64-68. OTHER USEFUL REFERENCES Bale S (1997) A guide to wound debridement, Journal of Wound Care, 6, 4, 179-182 Fowler E, van Rijswijk, L (1995) Using wound debridement to help achieve the goals of care. Ostomy/Wound Management, 41, 7a (supplement)23s-35s Poston J. (1996) Sharp debridement of devitalised tissue: the nurse s role British Journal of Nursing, 5,11, 655-662. 9