guidelines for the use of negative pressure wound therapy · dehisced surgical wounds...

1Chair: Elaine Baylis QPM

Chief Executive: Andrew Morgan

Guidelines for the use ofNegative Pressure Wound Therapy

Reference No: G_CS_51

Version: 2.3

Ratified by: LCHS Trust Board

Date approved: 28th July 2015

Name of originator/author: LCHS Tissue Viability Team

Name of responsiblecommittee/individual:

Quality Scrutiny Group

Date issued: February 2018

Review date: April 2018

Target audience: All Clinical Staff delivering Negative PressureWound Therapy.

Distributed via: Team Meetings, Link Champions, Intranet

Chair: Elaine Baylis QPMChief Executive: Andrew Morgan

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Guidelines for the use of Negative Pressure Wound Therapy

Version Control Sheet

Copyright © 2018 Lincolnshire Community Health Services NHS Trust, All Rights Reserved. Not to be reproduced inwhole or in part without the permission of the copyright owner.

VersionSection/Para/Appendix

Version/Description ofAmendments

Date Author/Amended by

1 Jan 2015 LCHS Tissue ViabilityTeam

2 Full documentrevision

June 2015 Colette LongstaffeCNS Tissue Viability

2.1 Pages 10, 12,17 and 20

Enlarged font size,Corrected working, Replacedold version NPWT Therapyform with latest version,Corrected spelling of‘Collete’ to ‘Colette’

Colette LongstaffeCNS Tissue Viability

2.2 Extended September2017

Corporate AssuranceTeam

2.3 Extended February 2018 Corporate AssuranceTeam

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Guidelines for the use of Negative Pressure Wound Therapy

Policy Statement

BackgroundThe purpose of this standard operating procedure is toensure competency and standardise the application ofNegative Pressure Wound Therapy within LCHS NHSTrust.

StatementThis document offers guidance to ensure that all cliniciansare applying the therapy within best practice guidelinesand in a safe manner.

ResponsibilitiesCompliance with this guidance is an expectation of allpractitioners and will be the responsibility of all LCHSNHS Trust clinicians.

TrainingIt is the responsibility of operational managers andservice leads to ensure that appropriate mechanisms arein place to support the implementation and ongoingapplication of this guidance, including appropriate trainingand maintenance of competencies.

DisseminationIntranetHeads of Clinical ServicesMatronsTissue Viability Specialist Nurses & Tissue ViabilitychampionsTissue Viability/Leg Ulcer Management trainingAll practitioners trained and proficient in Dopplerassessment.

Resource implicationThis guideline has been developed to facilitatestandardised practice in the application of NPWT.Initial investment required for staff to attend training toensure competency


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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 64.1 Risks4.2 Indications4.3 Contradictions4.4 Precautions

5. Practitioner roles and responsibilities 75.1 Assessment5.2 Competency5.3 Roles and Responsibilities

6. LCHS Pathway for Negative Pressure Wound Therapy 9

7. Procedure for discharge from secondary care to LCHS NHS trust 10

8. Application of NPWT 11

8.1 Patient Preparation8.2 Procedure for Dressing Application8.3 Using Fillers and Drains 128.4 Sealing the dressing and Connection to Pump 138.5 Procedure for Dressing Removal 14

9. Related Policies

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10. References 16

Appendices

Appendix 1 Consumable Request forms17

Appendix 2 Discontinuation of NPWT 18


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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 topromote wound healing and manage some of the symptoms of the wound such as copious exudate. Assuch 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 secondarycare 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 beinvolved in managing patients being treated with NPWT and will define the principle and differenttechniques.The guidelines will define the role of the prescriber and the practitioner involved in the management ofthe patient undergoing treatment with NPWT, to reduce possible risk in the implementation.

The guideline includes assessment and wound selection criteria, recommended use, the appropriatemanagement of patients undergoing NPWT, patient information, staff competency information andoutcome measurement tools. The key to choosing an effective wound management strategy is toundertake an appropriate holistic and wound assessment.

3. Benefits of NPWT

NPWT promotes healing in various types of open wounds by removing wound fluids and wastematerials through the creation of negative pressure at a well-sealed wound site. NPWT systems consistof the following parts:

A pump that generates a vacuum and is capable of creating a negative pressure environment withina 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


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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 notmonitored. (FDA, 2010).

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.


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5. Practitioner roles and responsibilities.

5.1 Assessment

A practitioner undertaking the application and removal of NPWT should be a registered practitioner atBand 5 or above and be competent to undertake and document a comprehensive holistic assessmentof the patient and their wound.

All the assessments including the wound assessment need to be completed fully together with clinicalphotography with patient consent.

IMPORTANT: When the patient has been referred and discharged from hospital it is essential toensure that the dimensions of the wound are consistent with those detailed on the referral form at thefirst 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 referredto 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 toaddressed prior to commencing/recommencing NPWT e.g. Does the use of NPWT increase risk offalls?

Before initiating NPWT any potential barriers to wound healing should be addressed e.g. patientsshould have appropriate repositioning, pressure reducing/relieving surfaces, nutritional support (whereappropriate 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 theuse of NPWT.

When additional clinical support is required it is the responsibility of the practitioner to seek supportfrom a Tissue Viability Link champion or another competent practitioner within the team. Additionalsupport 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 asdetailed in section 8. This can be achieved through formal training sessions which all link Championsand Case managers will have the opportunity to attend and through shadowing other competentpractitioners in practice, (e.g. Case managers/link champions who have attended training) and seekingguidance 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 ofthe NPWT pump and consumable to the community nurses base/ inpatient unit.

DocumentationThe practitioner will be responsible for ongoing assessment and care planning of the patient and theneed for continued NPWT together with completion of SystmOne templates.


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All care planning should include details of the size and quantity of dressings used e.g. foam/gauze. Theuse of one continuous dressing is recommended however where the wound required more thanone piece of dressing the number of dressings applied and removed must be recorded at eachdressing change.

The practitioner will undertake or request further clinical investigations where appropriate for example asinus of unknown depth. The practitioner should gain consent for NPWT. They should be aware oftheir 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 informationleaflet 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 thepatient’s home. Consumables will be delivered to and must be kept at the Community Nursing Base.

Wound assessments/SystmOne templates must be completed immediately prior to request forconsumables to ensure appropriate review may be undertaken by TVN. To promote cost effectivenessand avoid waste uunused consumables should be returned to the relevant TVN for distributionelsewhere within the business unit.

The practitioner should be aware of the possible complications that may arise and what to do. If anyadverse 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 areavailable and that they obtain by using the Consumables Request Form (Appendix 1). Please give 2working 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 weekintervals. This may be arranged by booking e-clinic appointment via the Tissue Viability Team. Thepractitioner will identify when NPWT can be discontinued and replaced by alternative woundmanagement products.

Upon completion of treatment it is the responsibility of the practitioner to return the pump and case totheir base. They should alert the Tissue Viability Department regarding cancellation details and arrangecollection of the equipment from their base/relevant department through the SPA Admin Team(See Flow chart page 10)


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6. Procedure for NPWT Request from LCHS Staff

LCHS Pathway for Negative Pressure Wound Therapy

SPA is based at Louth County Hospital telephone number 01507 608342 and fax number01507 354957. SPA is open Monday to Friday 0900-1700pm excluding Bank holidays.


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7. Procedure for discharge from secondary care to LCHS NHS Trust

NPWT Discharge Process from Secondary Care to LCHS

SPA is based at Louth County Hospital telephone number 01507 608342

and fax number 01507 354957. SPA is open Monday to Friday 0900-1700pm

excluding Bank holidays.


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8. Application of Renasys Negative Pressure Wound Therapy

8.1 Patient Preparation

8.2 Procedure for Dressing Application

ACTION RATIONALEDecontaminate hands prior to procedure andApply a single use disposable apron

To reduce the risk of transfer of transientmicro-organisms on the practitionershands and uniform

Using an aseptic non touch technique prepare allequipment and open sterile dressing pack onto apre-cleaned field and place all sterile single useequipment required within the sterile field.

To maintain asepsis and preventcontamination of sterile equipment.

Apply non-sterile single use disposable gloves,measure and photograph the wound. Change glovesas necessary. Take care not to physically touch thewound with the gloves.

To provide a baseline and enable futurereassessments and evaluations. (Ifphotographing wound completephotography consent on WoundManagement or SSKIN Template asappropriate).

ACTION RATIONALE

Using an aseptic non touch technique, cleanse thewound and peri wound area, if required, by irrigatingwith warm sterile saline.

To promote hygiene and reduce bacterialcontamination.

Ensure the surrounding skin is dry and apply non-sting skin barrier to peri wound skin.

To aid application of drape and protectskin integrity.

Line wound with a single layer of sterile non-adherent wound contact material in the followingcircumstances:

To protect underlying bone, tendon, bloodvessels and granulation tissue.

ACTION RATIONALEConfirm the identity of the patient, by asking for fullname and date of birth. Clarify identity with carer ifpatient not able to do so.

To confirm the correct identity of thepatient.

Explain the procedure to the patient, obtain validconsent and document in patients notes.

To enable the patient to make an informeddecision about their own health care.

Assess the need for pain relief and administer priorto the procedure, if required.

To maintain patient comfort.

Position the patient comfortably, to ensure safetyand enable easy access to and good visibility of thewound. If patient requires physical assistance topositioning or the wound dressings are to beremoved, hands must be decontaminated and orPPE in line with local policy must be applied prior toassisting them.

To allow access to and to have a clearview of the wound, providing a safeenvironment for patient and practitioner


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Wound contains exposed bone or tendon Dressing is next to exposed, anatomy 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 withmultiple sterile wound contact layers to protectunderlying organs.

Document in the patients notes theamount and size of liner used on insertionand extraction on dressing change.

8.3 Using Fillers and Drains

ACTIONIf using AMD gauze as a filler:

RATIONALE

Soft Port application: Apply a layer of saline-moistened anti-microbial gauze to wound bedcontinue to apply in layers until the gauze is looselyfills the wound.

Avoid over packing the wound as this may causedelayed wound healing.

If multiple pieces of gauze are needed, count andrecord how many pieces are present.

Follow guidance for applying film dressing.

Cut a hole no smaller than 2cms in the centreof the film over the gauze.

Remove the adhesive backing panel fromthe back of the port dressing and align directlyover the hole in the film. Use gentle pressure toanchor to the film. Smooth the dressing down whileremoving the top layer of the dressing.

Flat Drain: Measure the wound and cut the flatdrain using sterile single use scissors to fit thewound bed, so that the drain is 1-2cm smaller thanthe largest wound dimension.Saturate a single layer of gauze with sterile saline.The drain and gauze should be inserted looselyinto the cavity. Fill remaining cavity with additionalmoistened AMD gauze if required.

Round Drain:This drain is particularly suited to wounds with asinus, tunneling and/or undermining.

To fit the dressing and drain to the shapeof the wound.


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For tunneling or sinus the round drain may beinserted directly into the cavity using a standardaseptic technique.

Follow guidance for applying film.

ACTIONIf Using Foam as a filler:

RATIONALE

Soft Port: Cut the foam using sterile single usescissors to an appropriate size corresponding withthe dimensions of the wound cavity.

Follow guidance for applying film and Soft port..

Flat Drain: Make an incision in the foam, Cut thedrain to size and insert into the foam and placegently into the wound cavity.

Follow guidance for applying film.

If multiple pieces of foam are used to fill thewound, count and record how many pieces arepresent to ensure all pieces are removed atdressing change.


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8.4 Sealing the dressing and connection to the pump.

ACTION RATIONALE

AMD Gauze/ Foam with Viewpad:To secure the dressing and ensure a goodseal.

A poor seal increases the risk of exudatespreading and may lead to periwoundmaceration.

Dressing leaks may lead to a break intherapy and result in repeated dressingchanges

To ensure safe and effective woundmanagement and increase patient toleranceto therapy

These are the recommended therapeuticlevels of NPWT that have been determinedwhen undertaking RCTs

Cut the film using sterile single use scissors tothe appropriate size allowing a 3-4cm marginonto the skin.

Remove panel #1 of the film dressing exposingthe adhesive. Apply over the wound and removepanel #2 to seal. Once placed, remove the top#3. Continue to apply until the gauze/foam iscompletely covered and sealed.

Connect the drain to the canister tubing bypushing the connectors together. An audible clickindicates that connection is secure.

Switch on device and set to desired pressuresetting dependent on patients wound, location,exudate levels and patient tolerance.

General guide: foam:-120mm/hg and gauze –.80mm /hg.

Once the negative pressure is applied, thedressing will have a “raisin-like” appearance andbe firm to the touch.

Indicating a good seal and administration ofnegative pressure.

Evaluate efficacy of the treatment after eachdressing change. If there is no improvement after2 weeks of treatment, consider alternativetreatment options. Liaise with the TVN for furtheradvice.

To ensure the treatment offered is the mostappropriate option for the patients wound.

The dressing should be changed every 48 – 72hours and disposed of via an appropriate wasteroute. Frequency of dressing changes should bebased on an evaluation of the wound conditionrather than standard recommendations.

Provide individualised patient care.


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8.5 Procedure for Dressing Removal

ACTION RATIONALE

Wash hands and apply a single use disposableapron and non-sterile gloves

To protect clothing or uniform fromcontamination and potential transfer of micro-organisms.

Switch off pump To deactivateRaise tubing connectors above the level of theunit.

To ensure drainage of exudate and to preventspillage.

Disconnect canister and dressing tubing, allowunit to draw any exudate into the canister from thecanister tubing.

To ensure drainage of exudate and to preventspillage.

Gently stretch and release drape to deactivateadhesive and slowly remove from skin.

To prevent trauma to the periwound area.

Gently lift dressing from wound bed using a ‘nontouch’ aseptic technique. NB: If it adheres to thewound bed, soak dressing off using warmedsterile, normal saline. Dispose of dressings viathe appropriate route as identified in the wastepolicy.

To reveal wound and prevent trauma togranulation tissue.

Remove and dispose of PPE to comply withwaste management policy.

To prevent cross infection and environmentalcontamination.

Decontaminate hands following removal of PPE. To remove any accumulation of transient andresident skin flora that may have built up undergloves and possible contamination followingremoval of PPE.

Removal/return of unit See page 10 for instructions for cancellation.

9. Related local policies

Wound Management Formulary (2015)

Pressure Ulcer Prevention and Management Guidance (2014)

Clinical Guidelines for The Assessment and Management of LowerLimb Ulceration within Adult Community Services (2014)

Asepsis, non-touch technique and clean technique (2014)

Infection prevention and control policy (2014)

Health Care Waste Management Policy (2012)

Decontamination of patient equipment (2011).


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10. References

EWMA (2007) Topical negative pressure in wound management, Position Document, MedicalEducation Partnership Ltd, London.

FDA (2010) FDA Safety Communication: UPDATE on Serious Complications Associated with NegativePressure Wound Therapy Systems; Date Issued: February 24, 2011http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm244211.htm

NICE (2009) Negative pressure for the open abdomen (Interventional Procedures Consultation)http://www.nice.org.uk/guidance/index.jps?action=article&o=44725

Wounds UK (2008) Gauze based negative pressure wound therapy, Best Practice Statement, WoundsUK, Aberdeen.

DoH (2005) Mental Health Capacity Act. Department of Health

http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm244211.htm


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Appendix 1

Patient Name and Homepostcode:

Community Nursing address: NHS Number:

Code DescriptionQuantity Required in

single items

66800164 RENASYS GO Machine

Soft Port Kits - Gauze

66800933 Renasys - G Small Gauze Kit

66800934 Renasys - G Medium Gauze Kit

66800935 Renasys G - Large Kit

66800936 Renasys - G X-Large Kit

Soft Port Kits - Foam

66800794 Renasys F - Small Foam Kit

66800795 Renasys F - Medium Foam Kit

66800796 Renasys F - Large Foam Kit

66800797 Renasys F - X-Large Foam Kit

Drain Kits

66801256 Renasys - G 10mm Flat Drain Kit

66801257 Renasys G - 15fr Channel Drain Kit

Canisters

66800914 Renasys Go 300ml Canister

66800916 Renasys Go 800ml Canister

Accessories

66800799 Stand Alone Port

66800971 Y- Connector

66801020 Gauze Wound Filler (Squares, Pack of 5)

66801082 Renasys Adhesive Gel Patch Pack of 10)

66800391 Large AMD Gauze Rolls (Pack of 5)

66800394 Transparent Film 20cm x30cm (Pack of 10)

Name of requesting Nurse and mobile telephone number:

Signature:

Date:This form should be faxed FAO Louth SPA to 01507 354957For Office Use only Smith & Nephew general enquiries : 0845 2501031

24 hour Helpline : 0800 9155394Pump Serial Number: Please be aware orders for next day delivery must be sent

to SPA by 2:30pm to ensure ordering before Smith andNephew’s cut off point of 2:45pm.

NPWT THERAPY CONSUMABLE REQUEST FORMCountywide


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Discontinuation of NPWT


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Monitoring Template

Minimum-requirement to bemonitored

Process formonitoringe.g. audit

Responsibleindividuals/groupcommittee

Frequencyofmonitoring/audit

Responsibleindividuals /groupcommittee( multi -disciplinary)for review ofresults

Responsibleindividualsgroup /committeefordevelopment of actionplan

Responsibleindividualsgroup/ committee

formonitoringofaction plan

Numberand type ofincidentsconnectedwith NPWT

Review of thethemes fromthe incidentreports

CNS – TV AllClinical TeamLeads/MatronscommunityNursing Staff

Annual Quality andScrutinyGroup

Quality andScrutinygroupmembers

Quality andScrutinyGroup

Equality Analysis

Name of Policy/Procedure/Function*Guidelines for the use of Negative Pressure Wound therapyDate: June 2015Equality & Human Rights lead: Rachel Higgins

Director/General Manager: Sue Cousland

*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 orwhether it is informal custom practice. This includes existing policies and any new policiesunder development.


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Section 1 – to be completed for all policies

A. Briefly give an outline of the key objectivesof the policy; that its intended outcome isand who the intended beneficiaries areexpected to be

The purpose of these Negative Pressure WoundTherapy guidelines is to work towardsstandardization of the practice of Negative Pressurewound therapy across the organisation.

B. Does the policy have an impact onpatients, carers or staff, or the widercommunity that we have links with?Please give details

Implementation and compliance within the guidelineswill be the responsibility of all the staff.

C. Is there any evidence that thepolicy/service relates to an area withknown inequalities?Please give details

No

D. Will/Does the implementation of thepolicy/service result in different impacts forprotected characteristics?

Yes NoDisability XSexual Orientation XSex XGender Reassignment XRace XMarriage/Civil Partnership XMaternity/Pregnancy XAge XReligion or Belief XCarers XIf you have answered “Yes” to any of the questions then your are required to carry out afull 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 analysisEquality Analysis Carried out by: Colette LongstaffeDate: June 2015

guidelines for the use of negative pressure wound therapy · dehisced surgical wounds...

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