Wound Care Guidelines Dressing Formulary - and NHS Cambridgeshire and Peterborough CCG - Cambridgeshire and ...

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Wound Care Guidelines Dressing Formulary - and NHS Cambridgeshire and Peterborough CCG - Cambridgeshire and ...
Wound Care Guidelines
                                    and
                             Dressing Formulary

       NHS Cambridgeshire and Peterborough CCG
          Cambridgeshire Community Services
    Cambridgeshire and Peterborough Foundation Trust

April 2018 – Version 4.0                           Page 1 of 26
Wound Care Guidelines Dressing Formulary - and NHS Cambridgeshire and Peterborough CCG - Cambridgeshire and ...
Background

The Wound Care Guidelines have been written by the Tissue Viability Team, and is based on a wide range of clinical evidence and peer
reviews.

A group of district nurses, practice nurses, tissue viability nurses (TVN), clinical management and members of the Medicine Management
Team (MMT) have selected the dressings for the Wound Care Formulary.

The present products were selected on the current clinical evidence and cost consideration. A steering group meets four times a year to
review any clinical evidence on new products as well as its cost implication. Any suggestions on new products can be made by contacting
either the TVN or MOT;

Medicines Optimisation Team                                         Tissue Viability Team
Tel: 01480 387125                                                   Tel: 01223 266540
E-mail CAPCCG.prescribingpartnership@nhs.net                        E-mail: cpm-tr.tissueviability@nhs.net

Tissue Viability Team
Version 3.0
Date: January 2018
Review: January 2020

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Wound Care Guidelines Dressing Formulary - and NHS Cambridgeshire and Peterborough CCG - Cambridgeshire and ...
Contents

                                                                                   Page
Wound Assessment and Management Guidelines                                           4
TIME – Principals of Improved Wound Healing                                          8
Antibacterial Guidelines                                                             9
Guideline 1: Necrotic Wounds                                                        11
Guideline 2: Black Heels/Toes                                                       12
Guideline 3: Sloughy Wounds                                                         13
Guideline 4: Granulating Wounds                                                     14
Guideline 5: Infected Wounds                                                        15
Guideline 6: Epithelialising Wounds                                                 16
Guideline 7: Skin Tears/Pre-Tibial Lacerations                                      17
Guideline 8: Non-Complex Burns (Suitable for Outpatient/Primary Care Management)    18
Supplementary Guideline for Complex Burns Assessment                                19
Guidelines for the Assessment and Management of Leg Ulcers                          20
Dressings Criteria/Characteristic                                                   21
Formulary Choices                                                                   22
References                                                                          24
Appendix 1 – Wound Assessment Form                                                  26

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Wound Care Guidelines Dressing Formulary - and NHS Cambridgeshire and Peterborough CCG - Cambridgeshire and ...
Wound Assessment and Management Guidelines
1.       Scope
         Cambridgeshire and Peterborough Foundation Trust, general practices and nursing homes for those caring for patients with
         wounds, Cambridgeshire Community Services (children services).
2.       Purpose

         To ensure the correct assessment and management of patients with wounds.

3.       Introduction

             Choosing a wound dressing depends greatly on a holistic assessment of the patient and their wound; the patient should be at
              the centre of all care decisions made.
             Wound assessment should be a systematic process accurately documented on the wound assessment and management care
              plan.
             Dressings should be selected from the Trust Wound Care Formulary unless otherwise advised by a specialist.
             Patients with complex needs should be referred to the most appropriate speciality.

4.       Responsibilities
         All health care professionals involved in the direct assessment and management of wounds.

5.       Wound assessment

             A documented holistic and wound assessment should be done as soon as possible after admission to the caseload.
             The evaluation does not need to be completed at every dressing change if there is little change in the wound condition but
              document “no change in wound condition”. Dressing change must be recorded, signed and dated.
             Progress of the wound must be fully reassessed, signed and dated.

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Wound Care Guidelines Dressing Formulary - and NHS Cambridgeshire and Peterborough CCG - Cambridgeshire and ...
    Any deteriorating wound must have a full re-assessment/evaluation completed and action taken (see general wound care
              guidelines).
             In the case of a chronic wound (at 2-4 weeks), the wound should be reassessed weekly (every two weeks at a minimum).

5.1      Completion guide for page one of updated wound assessment form
         Patient details & date of initial assessment
         All details must be completed.

         Type of wound
         Circle the relevant box

         How long has the wound been present?
         Write length of duration, not the date when the patient came on caseload unless they coincided

         Factors which may delay wound healing
         Tick all relevant boxes, add extra information as appropriate (check patient’s medical notes).

         Medications
         Tick all relevant boxes, add extra information as appropriate.

         Date referred to
         Tick all relevant boxes; discuss referrals with colleagues and GPs. Do not over-refer to similar specialities, e.g. plastics,
         dermatology, tissue viability (see general wound care guidelines below for appropriate routes of referral).

         Drawing/photograph
         Please illustrate wound. Use photography (verbal or written consent) – tape measures are available in the dressing packs. Write
         date, patient initials only and the NHS patient’s number four (4) last numbers on the tape measure. Download and attach to
         SystmOne or protected system used.

         Location of wound/s
         Please indicate on body map where the wound is situated.

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Wound Care Guidelines Dressing Formulary - and NHS Cambridgeshire and Peterborough CCG - Cambridgeshire and ...
5.2      Completion guide for page two of wound assessment form
         Wound dimension
         Please measure as accurately as possible or indicate if this is an estimation.
          Length = head to toe furthest points, measured in centimetres.
          Width = side to side furthest points, measured in centimetres.
          Depth = may be estimated as very difficult to assess safely and accurately. A sterile gloved finger or wound swab can be used
            to probe.
          Grade PU = if the wound is a pressure ulcer please indicate its grade.
          Undermining = area tracking, measure with a probe and indicate direction.

         Wound bed
         Please estimate percentage of different tissue type in each box.

         Suture/clips
         Specify and indicate removal date.

         Exudate levels
         Please complete using the following guidelines:
             High = needs daily or more dressing changes and saturated each time.
             Moderate = needs dressing changes every 2-3 days and soiled but not soaked.
             Low = needs weekly or less dressing changes and dressing dry or minimally soiled.

         Wound edges/surrounding skin
         Please indicate as outlined.

         Pain
         Please assess patient and indicate action. Please refer for medical intervention/pain team.

         Clinical signs of infection
         Please indicate and swab if necessary. If the patient is at risk of developing an infection, ensure that daily vital signs are taken.

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Wound Care Guidelines Dressing Formulary - and NHS Cambridgeshire and Peterborough CCG - Cambridgeshire and ...
Treatment objectives
         These objectives should be suitable for most patients but a more individualised care plan may need to be added.
         Use the appropriate objectives according to the phases of healing

          1. Patient comfort – although could be used for most patient’s wound care it is more suitable for “end of life” patient where no
             active treatment (e.g. debridement) is suitable. Can be associated with odour control
          2. Absorption: for wound with large exudate where the main objective is containing the fluid.
          3. Infection control: for infected wound. It can be associated with odour control
          4. Odour control: see above
          5. Debridement: active treatment
          6. Promote granulation: active treatment – post or concurrent to debridement
          7. Promote epithelialisation: active treatment – concurrent to granulation

         Cleansing solution
         Please document saline or water. Other solutions are not recommended unless required for a specific clinical need.
         Clean surrounding skin and wound to remove some slough, dressing debris or exudate.

         Dressing choice
         Choose from Wound Care Formulary, review wound progress or deterioration and document the rationale for dressing changes
         during period of care.

         Frequency of dressing change
         Please document, dependent on exudates, dressing used and progress of wound.

         Signed/print name/designation
         This is a legal requirement and must be accompanied by printing name legibly.

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Wound Care Guidelines Dressing Formulary - and NHS Cambridgeshire and Peterborough CCG - Cambridgeshire and ...
TIME – Principles of Improved Wound Healing (Wound Bed Preparation)
                                        To use for chronic wounds alongside the current Wound Care Guidelines
          Clinical Observations                  WBP clinical actions             Impact of your clinical actions              Clinical outcomes
                                           Debridement (episodic or
                                           continuous)                                                                     Viable wound bed
                           T                                                      Restoration of wound base and
                                            Autolytic, sharp surgical,
       Tissue non-viable or deficient                                             repair of the damaged tissue
                                             enzymatic, mechanical or
                                             biological
                                                                                  Reduced bacterial counts or
                                                                                  controlled inflammation:
                                           Remove infected foci
                                                                                                                           Resolution of bacterial
                           I                  Topical/systemic antibiotics           Inflammatory cytokines               imbalance and reduced
                                              Topical antimicrobials                                                      inflammation.
          Infection or inflammation                                                   protease activity
                                              Anti-inflammatories

                                                                                      growth factor activity
                                           Apply moisture balancing dressings
                                                             Or                      Maceration avoided
                                           Compression
                                                                                     Reduction in excessive fluid
                           M                                 Or
                                                                                     Reduced oedema
                                                                                                                           Moisture balance
             Moisture imbalance            NPWT (negative pressure wound
                                           therapy)                                  Desiccation avoided
                                                             Or                      Restored epithelial cell migration
                                           Other methods of removing fluid
                                           Re-assess cause or consider
                                           corrective therapies                   Migrating keratinocytes and
                           E                  Debridement                        responsive wound cells.                  Advancing edge of wound
     Edge of wound non-advancing or
                                              Skin grafts                        Restoration of appropriate
              undermined                                                          Protease profile.
                                              Biological agents
                                              Adjunctive therapies

     Adapted from: Wound Bed Preparation. Schultz et al (2003) Wound Rep Reg Vol 11 pp1-28 .Extending the TIME Concept. Leaper D et al (2012)

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Antibacterial Guidelines

        Evidence concerning the efficacy of topical antimicrobial agents in the management of wounds remains inconclusive.
        Independent and better designed trials to assess efficacy and cost implications are needed.
        Reports of resistance are limited; but misuse of these products especially silver products must be avoided.

                            Reassess the management of all wounds treated with antibacterial products after two weeks.
                   Consider the clinical effectiveness (has the wound progressed?) as well as the cost effectiveness of the product.

        Iodine products are recommended as first choice antibacterial dressings unless the patient has a history of allergy.

        Iodine products should be used with caution and under close medical observation for patients with thyroid disease.

Inadine™ (Acelity/Systagenix)            Suitable for superficial, low exudate wounds
Non-adherent dressing                    Useful for drying ischaemic wounds
impregnated with 10% povidine            Dressing colour fading from dark brown to white indicates loss of antibacterial efficacy and needs
iodine ointment                           to be changed

Iodoflex™ (Smith & Nephew)               Suitable for sloughy, exuding wounds
Cadexomer (starch) iodine                Mouldable to shape of wound
(0.9%) paste.                            Dressing colour fading from dark brown to white indicates loss of antibacterial efficacy and needs
Iodine released is proportional to        to be changed
the exudate absorbed by the
starch in the dressing

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Other Antimicrobials

Honey: Activon ™ Tulle                 Suitable for sloughy wounds, will debride effectively.
(Advancis)                             Might cause minimal discomfort at first due to osmotic effect.
                                       Controls odour very effectively.
                                       Cut to size so the tulle can be in direct contact with the wound base or use viscous honey (tube).
2d choice AB dressing                  Dressing colour will fade as the honey is absorbed
                                       No toxicity. Suitable for diabetic.

Silvercel™ (Acelity/Systagenix)        Useful for debriding wounds
Silver impregnated alginate            Useful to control odour
dressing                               Pack wound lightly
                                       Do not change daily. The silver in the dressing is active for 3 days
3d choice AB dressing                  Use only if other antibacterial dressings have been tried or are inappropriate.

                                       Rapid release/ fast action silver
Acticoat™ (Smith & Nephew)
                                       Can stain surrounding skin
Nanocrystalline silver coated low
adherent dressing                      Needs to be activated by water prior to use
                                       Silver active for minimum of 3 days
                                       Useful for managing overgranulation
                                       Use only if other antibacterial dressings have been tried or are inappropriate.
                                       Use for 2 weeks then review.

                  Toxicity of silver on the healing process is still unclear but caution in its usage is recommended.
             Contact Tissue Viability Nurses if prolonged use is necessary as alternative products might be more suitable.

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Wound Care Guidelines

Guideline 1: Necrotic Wounds
Aim: To aid debridement by providing a moist
environment
     Is the wound on the    Yes                  Refer to guideline 2 (Black heels/ toes)
         heel or foot?

                 No

   Is the wound infected?
                            Yes                  Refer to Guideline 5 (Infected Wounds)

                 No

    Is the wound exudate                 Dressing Choice                         Wound Care               Notes
                                                                                                          Depth: May be difficult to assess
                                                                                                          fully until necrosis has lifted.
                                                                      Apply gel to base of wound
                                  Hydrogel (Aquaform®)
                            Yes                                       Cover with hydrocolloid             Surrounding Skin: If wound exuding
               Low                AND
                                                                      Change when exudate marking is      or skin is fragile, protect with no
                                  Hydrocolloid (Tegaderm™
                                                                      visible 1cm from edge of dressing   sting barrier film.
                                  Hydrocolloid / Granuflex®)*
                                                                      or if leaking / dislodged
                                                                                                          Nutrition: Assessment must be
                                  Hydrofibre (Aquacel®)               Loosely pack/cover wound with       carried out and appropriate referral
                            Yes   AND                                 hydrofibre                          made.
             Medium
                                  Hydrocolloid (Tegaderm™             Cover with hydrocolloid
                                  Hydrocolloid / Granuflex®)*         Change as above                     Specialist Input:
                                                                                                          Sharp debridement must be carried
                                                                      Loosely pack/ cover wound with      out by a doctor or Tissue Viability
                                  Hydrofibre (Aquacel®)
              Large                                                   hydrofibre                          Nurse only.
                            Yes   AND
                                                                      Cover with foam or padding and      Seek further advice for patients
                                  Foam (ActivHeal® / Biatain®) or
                                                                      secure                              with diabetes or arterial problems.
                                  Padding
                                                                      Change as above

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Guideline 2: Black Heels/Toes
Aim: To protect and maintain infection free

  Is the wound infected?     Yes                           Refer to Guideline 5 (Infected Wounds)

               No

                                   Refer to Foot Clinic/          Dressing Choice                   Wound Care
  Is the patient diabetic?   Yes
                                   Podiatry for further      Inadine™                       Apply Inadine™ to wound
                                      investigation          AND                                                           Notes
               No
                                                             Padding                        Cover with padding
                                                                                                                           Bandages: Tight or
                                                                                                                           compression bandages
   Check blood glucose                                       Wool bandage                   Apply wool bandage
                             Yes                                                                                           must not be used for
     for undiagnosed                                         Crepe bandage or Tubular       Secure with Tubular
                                                                                                                           patients with diabetes or
         diabetes            Yes             Refer to        bandage                        bandage (Comfifast®) or
                                                                                                                           arterial problems unless
                                            physician                                       Crepe bandage.
               No                                                                                                          under close supervision of
                                                                                            All bandages must be from
                                                                                                                           Specialist team.
                                                                                            Toe to Knee
                                                                                                                           Surrounding Skin: If wound
  Refer to GP and TVN                                                                                                      is exuding or skin is fragile,
                                                                                                                           protect with no sting barrier
                                                                                                                           film.
                                                               Pressure: must be relieved to prevent further damage by
                                                                using a Repose foot protector or pillow (see guideline)    Nutrition: Assessment must
                                                                                                                           be carried out and
                                                                                                                           appropriate referral made.

                                                                                                                           Specialist Input:
     Does the wound
                                                                                              Aim to keep blister intact   Seek further advice for
   present as a blister?     Yes    Remove source of
                                                                  Do not apply dressing         and allow natural re-      patients with diabetes or
   (Blood or clear fluid             friction/ pressure
                                                                                                     absorption            arterial problems.
          filled)

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Guideline 3: Sloughy Wounds
Aim: To aid debridement of slough by providing a moist environment

  Is the wound infected?   Yes                  Refer to Guideline 5 (infected wounds)

               No

     Is the slough dry?    Yes                      Treat as necrotic (Guideline 1)

               No                                                                                         Notes
                                                                                                          Slow/static debridement: consider larvae
  Is the wound exudate                  Dressing Choice                        Wound Care                 therapy.
                                                                                                          Cavities: Consider Topical Negative
                                                                                                          Pressure therapy, refer to Tissue Viability
                                                                     Apply gel to base of wound
                                 Hydrogel (Aquaform®)                                                     Nurse for advice.
                                                                     Cover with hydrocolloid
                                 AND
              Low          Yes                                       Change when exudates marking         Very High Exudate: consider above or
                                 Hydrocolloid (Tegaderm™
                                                                     is visible 1cm from edge of          wound drainage bags, refer to Tissue
                                 Hydrocolloid / Granuflex®)*
                                                                     dressing or if leaking / dislodged   Viability Nurse for advice.
                                                                                                          Surrounding Skin: If wound exuding or skin
                                 Hydrofibre (Aquacel®)               Loosely cover/ pack wound with       fragile, protect with no sting barrier film.
                                 AND                                 hydrofibre
                           Yes                                                                            Nutrition: Assessment must be carried out
           Medium                                                    Cover with hydrocolloid
                                 Hydrocolloid (Tegaderm™                                                  and appropriate referral made.
                                                                     Change as above
                                 Hydrocolloid / Granuflex®)*
                                                                                                          Specialist Input: Sharp debridement must
                                 Hydrofibre (Aquacel®)               Loosely cover/ pack wound with       be carried out by a doctor or Tissue
                                 AND                                 hydrofibre                           Viability Nurse only.
             Large         Yes                                       Cover with foam or padding and
                                 Foam (ActivHeal® / Biatain®) or
                                 Padding or Superabsorbent           secure                               Seek further advice for patients with
                                 dressing                            Change as above                      diabetes or arterial problems.

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Guideline 4: Granulating Wounds
Aim: To promote granulation and provide a healthy base for epithelialisation

  Is the wound infected?   Yes                  Refer to Guideline 5 (infected wounds)

               No

   Is the wound hyper-     Yes              Check for infection and refer to TVN for advice
        granulating?

               No                                                                                         Notes
                                                                                                          Bleeding: Use an alginate to act as a
  Is the wound exudate                  Dressing Choice                        Wound Care                 haemostat (Kaltostat®).
                                                                                                          Cavities: Consider Topical Negative
                                                                     Apply Hydrocolloid or Foam           Pressure therapy, refer to Tissue
                                 Hydrocolloid (Tegaderm™             Change when exudates marking         Viability Nurse for advice.
                           Yes   Hydrocolloid / Duoderm®)*           is visible 1cm from edge of          Very High Exudate: Consider wound
              Low                                                    dressing or if leaking / dislodged
                                 OR                                                                       drainage bags, refer to Tissue
                                 Foam (ActivHeal® / Biatain®)        Hydrocolloid can be in place 5-7     Viability Nurse for advice.
                                                                     days
                                                                                                          Surrounding Skin: If wound exuding
                                                                                                          or skin fragile, protect with no sting
                                 Hydrofibre (Aquacel®)               Loosely pack/ cover wound with
                                                                                                          barrier film.
                                 AND                                 hydrofibre
           Medium          Yes
                                 Hydrocolloid (Tegaderm™             Cover with hydrocolloid              Nutrition: Assessment must be
                                 Hydrocolloid / Granuflex®)*         Change as above                      carried out and appropriate referral
                                                                                                          made.

                                 Hydrofibre (Aquacel®)               Loosely pack/ cover wound with       Specialist Input: Seek further advice
                                 AND                                 hydrofibre                           for patients with diabetes or arterial
                                 Foam (ActivHeal® / Biatain®) or     Cover with foam or padding and       problems.
             Large         Yes
                                 Padding or Superabsorbent           secure
                                 dressing                            Change as above

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Guideline 5: Infected Wounds
Aim: To treat infection systemically and decrease bacterial burden at the wound site

-                                 Take swab and treat infection with systemic antibiotics until symptoms resolve
                                  Check guidelines for use of antibacterials; follow flow chart below for dressing
    Does the wound look     Yes                                       choice
    infected? (See notes)                            Treat wound for two weeks then review
                                                             Avoid topical antibiotics

    Is the wound exudate                   Dressing Choice                              Wound Care

                                  Iodine (Inadine™)                        Apply Inadine™ or honey                   Notes
             Low            Yes
                                  OR                                                                                 Clinical signs of infection:
                                  Activon Tulle                                                                      Inflammation, erythema
                                                                           Change Inadine™ daily, Honey every
                                  Appropriate secondary dressing                                                     (redness), increased pain,
                                                                           2 d to 3d day.
                                                                                                                     odour, pus, heat, pyrexia,
                                                                                                                     friable (bleeds easily).
                                  Iodine (Iodoflex™)                       Apply Iodoflex™ or honey to the
                                  OR                                       wound                                     Surrounding Skin: If wound
            Medium                Activon Tulle                            Cover with foam                           exuding or skin fragile, protect
                            Yes   Foam (ActivHeal® / Biatain®) or          Change every 2-3 days                     with no sting barrier film.
                                  padding
                                                                                                                     Nutrition: Assessment must
                                                                                                                     be carried out and
    Large                                                                                                            appropriate referral made.
                                                                                                                     Specialist Input: Seek further
                            Yes                                                                                      advice for patients with
                                                                                                                     diabetes or arterial problems.

     Is wound condition           Silvercel® OR
                                                                           Cut to size of wound and apply
     unchanged after 2            Acticoat™ (must be activated with                                                     For further antibacterial
                            Yes                                            Change every 3 days depending on
    weeks of above care           water before use) for 2 weeks                                                       advice refer to the TV Team
                                                                           odour and amount of exudate
           plan?                  Appropriate secondary dressing

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Guideline 6: Epithelialising Wounds
Aim: To provide a moist, atraumatic environment to complete healing

  Is the wound reducing   No                             Refer to TVN for advice
          in size?

             Yes

  Is the wound exudate?                  Dressing Choice                           Wound Care

                                                                      Apply hydrocolloid or low adherent to   Notes
                                                                      wound                                   Protection: Of the wound site is
                                Hydrocolloid thin (Duoderm®)*                                                 essential for complete healing/
                                                                      Change if exudates marking is 1cm
              Low         Yes   OR                                                                            maturation.
                                                                      from edge of dressing or if the
                                Low adherent (Atrauman®) and
                                                                      dressing is dislodged                   Surrounding Skin: If wound exuding
                                Foam/Cosmopore
                                                                      Hydrocolloid can be in place for 5-7    or skin fragile protect with no sting
                                                                      days.                                   barrier film.
                                                                                                              Nutrition: Assessment must be
                                                                                                              carried out and appropriate referral
                                Reassess wound as unlikely to be                                              made.
           Medium         Yes   epithelialising and refer to
                                appropriate guideline                                                         Fragile/Sensitive Skin: Mepitel®
                                                                                                              can be considered as alternative
                                                                                                              dressing as it can remain on the
                                                                                                              wound for 7 days.
                                                                                                              Specialist Input: Seek further
                                Reassess wound as unlikely to be                                              advice for patients with diabetes or
             Large        Yes
                                epithelialising and refer to                                                  arterial problems.
                                appropriate guideline.

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Guideline 7: Skin tears/ Pre-tibial lacerations
Aim: To provide a protective environment to promote healing and prevent further trauma

        Is the wound
    presenting a large      Yes                          Refer to A&E or Plastic Surgeons
   surface area or deep
     tissue exposed?
                                            Dressing Choice                            Wound Care
             No

                                  Kaltostat®                               Apply pressure when securing
        Is the wound              AND                                      If bleeds through do not remove,
          bleeding?         Yes
                                  Padding                                  apply further padding on top and          Notes
             No
                                  Appropriate secondary dressing           refer to A&E if bleeding persists
                                                                                                                     Surrounding Skin: If wound
                                                                                                                     exuding or skin fragile, protect
  Can wound edges be              Steri-strip without tension              Check wound after 2 days                  with no sting barrier film.
    brought together              Low adherent (Atrauman® /                Leave Steri-strips for further 3-5 days   Nutrition: Assessment must
                            Yes
      without force               Mepitel®)                                                                          be carried out and
                                  Padding                                                                            appropriate referral made.
             No                   Appropriate secondary dressing
                                                                                                                     Specialist Input: Seek further
                                                                                                                     advice for patients with
                                  Do not attempt to steri-strip or force   Can consider hydrocolloid                 diabetes or arterial problems.
                                  edges together                           (Tegaderm™ Hydrocolloid or
     Is there partial or    Yes   Low adherent (Atrauman® /                Granuflex®)*, can be left in place up     Lower limb injury: Secure
    complete skin loss?           Mepitel®)                                to 5 days. Use caution on fragile skin.   dressing with wool bandage
                                  Padding                                                                            and crepe bandage applied
                                  Appropriate secondary dressing                                                     from toe to knee.

                                  Hydrogel (Aquaform®) - for open          Apply gel to open haematoma only
   Is there a significant         wounds only                              Foam or padding to protect
    haematoma with or             Foam (ActivHeal® / Biatain®) or          Contact TVN for use of another gel.
   without skin trauma?     Yes   padding                                  Refer to A&E or Plastic surgeons for
                                  Appropriate secondary dressing           debridement

July 2018 – Version 4.0                                                                                                                       Page 17 of 26
Guideline 8: Non-Complex burns (suitable for outpatient/ primary care management)
Aim: To provide a protective environment to promote healing and ensure appropriate referral for complex burns

       Is the burn complex? (See guideline overleaf)       Yes              Refer to A&E or Plastic Surgeons
                           No

  Is the burn superficial?                                             Dressing Choice                  Wound Care
        Skin is dry & intact                                                                  Check wound after 48 hours
        Red, blanches under pressure                      Yes
                                                                 Topical moisturiser or
                                                                                               Should heal within 2-3 days
        Minimal tissue damage                                   Low adherent (Atrauman®)
                                                                                               Can consider a hydrocolloid
        Painful                                                 with appropriate secondary
                                                                                               thin (Duoderm®) if no
                                                                 dressing                                                      Notes
                           No                                                                  blistering
                                                                                                                               Surrounding
  Is the burn superficial-partial thickness?                     Low adherent (Atrauman®)      Check wound after 48 hours      Skin: If wound
        Blisters immediately                                    Gauze or absorbent padding,   Should heal within 10-21 days   exuding or skin
        Red in areas, moist & exuding                           depending on exudate          if no infection                 fragile, protect
                                                           Yes
        Brisk capillary refill                            Yes   Secure with appropriate       Can consider Flamazine® if      with no sting
        Painful & sensitive to temperature changes        Yes   secondary dressing            antibacterial is indicated      barrier film.
                           No                                                                                                  Nutrition:
                                                                                                                               Assessment
  Is the wound deep-partial thickness (deep dermal)?                                                                           must be carried
        Pale/white/creamy in colour, may have large                                                                           out and
          blisters                                                                                                             appropriate
                                                                                               Refer to Emergency
        Less moist initially                              Yes                                                                 referral made.
                                                                 Low adherent (Atrauman®)      Department for urgent
        Difficult to assess capillary refill
                                                                 Loosely applied cling film    specialist Plastic Surgical
        Sensitive to deep pressure but not to pin-prick                                       advice                          See over for
                           No                                                                                                  Burns
  Is the wound full thickness?                                                                 Refer to Emergency              assessment
                            No
                                                                 Low adherent (Atrauman®)      Department for urgent           guidelines.
        May appear waxy white, cherry red, grey or
          leathery
                                                           Yes   Loosely applied cling film    specialist Plastic Surgical
        Minimal or no pain, no response to pressure or                                        advice
          temperature
        May have less deep & very painful peripheries

July 2018 – Version 4.0                                                                                                           Page 18 of 26
Supplementary Guideline for Complex Burns Assessment

  Seek further advice for:
          Patient 60yrs
          Patient is 5% Total Body Surface Area (TBSA)
          Patient is adult & burn is dermal or full thickness involving
           >10% Total Body Surface Area (TBSA)
          Burn is on face, hands, perineum, feet, flexures
           Burn is circumferential dermal or full thickness to limbs,
           torso or neck
          Burn is chemical, acid, ionising radiation, high pressure
           steam, electrical, suspicion of non-accidental injury
          Burn is an inhalation injury
          Patient also has; cardiac or respiratory problems,
           immunological conditions, pregnancy, or associated injuries

July 2018 – Version 4.0                                                     Page 19 of 26
Leg ulcers guidelines: a holistic assessment, Doppler ABPI, treatment plan is to be performed at first/second
visit (a wound is considered chronic between 2 to 4 weeks duration.
                          VENOUS                                ARTERIAL                                              OTHERS
        DVT/PE                 Venous ulcers Phlebitis             TIA                           Hypertension           Rheumatoid arthritis
        Family history Leg fracture   Pregnancies                  CVA                           Claudication           Diabetes
        Varicose veins Previous venous surgery                      MI                           Arterial surgery       Malignancy (ulcer associated)
                                                                                                                        Lymphoedema

                                                                Examination of foot and leg (disease indicators)
        Varicose veins            Woody, indurated skin         Shiny/thin/hairless skin       Night pain -                Joint abnormalities
        Ankle flare               Eczema                        Skin cold/blue/white           relieved when               Evidence of Neuropathy
        Brown pigmentation                                      Poor capillary filling         leg dependent               Chronic oedema : large exudate
                                                                Thickened toenails            Weak/no pulses

                                                                             Examination of ulcers
        Gaiter region / internal & external malleolus           On foot or anywhere on lower limb                          High on calf /on foot
        Sloping edge / irregular margin                         Deep and punched out                                       Rolled edge
                                                                                                                           Chronic oedema: whole leg can be affected

        Investigations                                                    Surrounding skin                                            Pain
        Doppler, BP, Blood sugar, HB/FBC, ESR, CRP                       Healthy, Oedematous, Red, Macerated                          Assess using pain scale
        If available BMI, Urinalysis, Swab if clinically infected        Eczematous / Contact dermatitis

                   Identify cause of ulcer.                           Treat wound according to guidelines.                    Treat underlying cause
              ABPI 0.8 – 1.29                    ABPI 0.6 – 0.79                 ABPI < 0.6                    ABPI > 1.3              Evidence of Vasculitis,
        Evidence of Venous Disease                With evidence                                        Arterial Disease (arterial      Malignancy or Contact
                                                of venous disease                                            calcification)                  dermatitis
        Treat as Venous Ulcer                                                                                                            Sub-acute infection
        - Apply compression                  Refer to TVN / Routine           Vascular Referral         Refer to TVN / Vascular             Refer to TVN
        - Keep dressing simple               Vascular referral –apply        (URGENT if
   Non-adherent
Dressings Criteria
                                                              Impermeable to bacteria
   Remove excess exudate and toxic components
                                                              Capable of maintaining a high humidity at the wound site while
   Maintain high humidity at wound dressing interface         removing excess exudate

   Allows gaseous exchange                                   Thermally insulating

   Provide thermal insulation                                Non-toxic and non-allergenic

   Impermeable to micro-organisms                            Comfortable and comformable

   Free from Toxic contaminants                              Capable of protecting the wound from further trauma

   Removable without causing trauma                          Requires infrequent dressing changes

                                                              Cost effective

                                                              Long shelf-life

                                                              Available both in hospital and in the community

Characteristics of the ideal wound dressing (Bryant R, Nix D, 2016)

    July 2018 – Version 4.0                                                                                            Page 21 of 26
Formulary Choices
                                                                                                                                 Cost per
Dressing                                                                   Size         NPC code   Supplier Code   Unit Issue
                                                                                                                                 dressing
FOAM                      ACTIVHEAL FOAM (non adhesive)                  5cm x 5cm       ELA214      10009113      Pack of 10     £0.77
                          ACTIVHEAL FOAM (non adhesive)                 10cm x 10cm      ELA216      10009115      Pack of 10     £1.14
                          ACTIVHEAL FOAM (non adhesive)                 18cm x 10cm      ELA246      10009116      Pack of 10     £2.06
                          BIATAIN (non-adhesive)                        10cm x 10cm      ELA039        3410        Pack of 10     £1.82
                          ACTIVHEAL FOAM (adhesive)                     10cm x 10cm      ELA210      10009109      Pack of 10     £1.19
                          ACTIVHEAL FOAM (adhesive)                   12.5cm x 12.5cm    ELA211      10009110      Pack of 10     £1.52
                          BIATAIN SILICONE (adhesive)                  7.5cm x 7.5cm     ELA425     3343431006     Pack of 10     £1.40
                          BIATAIN SILICONE (adhesive)                   10cm x 10cm      ELA451     3343531006     Pack of 10     £2.03
                          BIATAIN SILICONE (adhesive)                 12.5cm x 12.5cm    ELA426     3343631006     Pack of 10     £2.56

HYDROCOLLOID              GRANUFLEX (Modified)                          10cm x 10cm      ELM141        S150        Pack of 10     £1.99
                          GRANUFLEX (Bordered)                            6cm x 6cm      ELM151        S155        Pack of 5      £1.50
                          GRANUFLEX (Bordered)                          10cm x 10cm      ELM053        S156        Pack of 10     £2.13
                          GRANUFLEX (Bordered)                          15cm x 15cm      ELM155        S157        Pack of 5      £3.83
                          DUODERM (Extra Thin Film)                      5cm x 10cm      ELM317        S163        Pack of 10     £0.70
                          DUODERM (Extra Thin Film)                    7.5cm x 7.5cm     ELM311        S160        Pack of 5      £0.74
                          DUODERM (Extra Thin Film)                     10cm x 10cm      ELM050        S161        Pack of 10     £1.22
                          DUODERM (Extra Thin Film)                     15cm x 15cm      ELM051        S162        Pack of 10     £2.64
                          TEGADERM (Oval)                               10cm x 12cm      ELM084        90001       Pack of 5      £2.07
                          TEGADERM (Oval)                               13cm x 15cm      ELM373         9003       Pack of 5      £4.08
HYDROFIBRE                AQUACEL EXTRA                                  5cm x 5cm       ELY377       S7500        Pack of 10     £0.92
                          AQUACEL EXTRA                                10cm x 10cm       ELY378       S7501        Pack of 10     £2.21
                          AQUACEL RIBBON                                1cm x 45cm       ELY368       420127       Pack of 5      £1.82
                          AQUACEL RIBBON                                2cm x 40cm       ELY013       S7503        Pack of 5      £2.32
ALGINATE                  KALTOSTAT                                     5cm x 5cm        ELS229        1004        Pack of 10     £0.67
                          SORBSAN RIBBON                                1g x 40cm        ELS016        1412        Pack of 5      £2.11
HYDROGEL                  AQUAFORM                                        8g tube        ELG017       1419C        Pack of 10     £1.82
ISLAND DRESSING           COSMOPOR E                                   5cm x 7.2cm       EIJ038    5000485091970   Pack of 50     £0.07
                          COSMOPOR E                                    8cm x 10cm       EIJ039    5000485091987   Pack of 50     £0.10
                          COSMOPOR E                                    8cm x 15cm       EIJ040    5000485091994   Pack of 50     £0.15
                          COSMOPOR E                                   10cm x 20cm       EIJ041    5000485092007   Pack of 50     £0.23
NON ADHERENT              ATRAUMAN                                     7.5cm x 7.5cm     EKA032       499553       Pack of 50     £0.21
WOUND                     ATRAUMAN                                      10cm x 20cm      EKA036       499536       Pack of 30     £0.44
                          AUTRAMAN                                      20cm x 30cm      EKA016       499515       Pack of 10     £1.37
SEMI-PERMIABLE            CLEARFILM                                      6cm x 7cm      ELW646        815067       Pack of 100    £0.08
FILM                      CLEARFILM                                     10cm x 12cm     ELW696        815101       Pack of 10     £0.29
                          CLEARFILM                                     15cm x 20cm     ELW697        815152       Pack of 10     £0.67
                          OPSITE POST-OP (For surgical wounds only)    9.5cm x 8.5cm    ELW051       66000709      Pack of 20     £0.66
                          OPSITE POST-OP (For surgical wounds only)     6.5cm x 5cm     ELW052       66000708      Pack of 100    £0.20

July 2018 – Version 4.0                                                                                                            Page 22 of 26
BACTERIAL                 INADINE                                    5cm x 5cm      EKB501     P01481     Pack of 25   £0.41
CONTROL (Use              INADINE                                  9.5cm x 9.5cm    EKB502     P01512     Pack of 25   £0.60
according to              ACTICOAT                                  10cm x 10cm     ELY071    66000791    Pack of 12   £8.91
antibacterial             ACTICOAT                                   5cm x 5cm      ELY141    66000808    Pack of 5    £3.83
guidelines)               SILVERCEL                                 11cm x 11cm     ELS150     CAD011     Pack of 10   £3.79
                          SILVERCEL                                  5cm x 5cm      ELS149     CAD050     Pack of 10   £1.65
                          ACTIVON TULLE                              5cm x 5cm      EJE027     CR3761     Pack of 5    £1.79
                          ACTIVON TULLE                             10cm x 10cm     EJE028     CR3658     Pack of 5    £2.96
                          IODINE PASTE                                5g tube       EKB007    66001301    Pack of 5    £4.63
DRESSING                  ICTHOPASTE                                7.5cm x 6m      EFA051      4959        Each       £5.78
RETENTION                 VISCOPASTE                                7.5cm x 6m      EFA011      4948        Each       £5.22
                          K-BAND                                     10cm x 4m      EDB039     811040     Pack of 20   £0.15
                          COMFIFAST (Green)                          5cm x 10m      EGP006      F25         Each       £2.20
                          COMFIFAST (Blue)                          7.5cm x 10m     EGP007      F35         Each       £2.35
                          COMFIFAST (Yellow)                       10.75cm x 10m    EGP008      F45         Each       £3.45
SKIN BARRIERS             MEDI DERMA-S STERILE NON STING MEDICAL
                                                                        1ml         ELY532    MB61076     Pack of 5    £0.61
                          BARRIER FILM
                          MEDI DERMA-S BARRIER CREAM NON_STERILE     2g sachet      ELY536    MB60338     Pack of 20   £0.17
MULTILAYER                K-FOUR K-SOFT (Layer #1)                  10cm x 3.5m     EPA028     761035     Pack of 24   £0.56
BANDAGES                  K-FOUR K-LITE (Layer #2)                  10cm x 4.5m     ECA100     771045     Pack of 16   £0.76
                          K-FOUR K-PLUS (Layer #3)                  10cm x 8.7m     ECA162     781087     Pack of 24   £2.03
                          K-FOUR KO-FLEX (Layer #4)                  10cm x 6m      ECD018     791060     Pack of 18   £3.48
SHORT STRETCH             ACTICO ACTIVA                               8cm x 6m      EBA032    314-0886      Each       £4.10
COMPRESSION               ACTICO ACTIVA                              10cm x 6m      EBA016    271-5431      Each       £4.25
                          ACTICO ACTIVA                              12cm x 6m      EBA033    314-0894      Each       £5.42
ADHESIVE                  MICROPORE                                1.25cm x 9.14m   EHU111     1530-0     Pack of 24   £0.19
SURGICAL TAPE             MICROPORE                                 2.5cm x 9.14m   EHU006     1530-1     Pack of 12   £0.38
SPECIALIST                MEPITEL (For sensitive skin only)          5cm x 7cm      EKH002     290500     Pack of 5    £1.47
DRESSINGS                 MEPITEL (For sensitive skin only)         8cm x 10cm      EKH003     290700     Pack of 5    £2.93
MISCELLANEOUS             KERRAMAX                                  22cm x 10cm     EME023   PRD500-120   Pack of 10   £1.59
                          KERRAMAX                                  20cm x 30cm     EME025   PRD500-380   Pack of 5    £2.89
                          NON WOVEN SWABS                           10cm x 10cm     ENK132      1870      Pack of 25   £0.07
                          365 STRIPS                                6mm x 75mm      EIR126    36519064    Pack of 50   £0.11
                          NORMASOL                                     25ml         MRB358    99766774    Pack of 25   £0.13
                                                                    10cm x 20cm     EJA080     485-503    Pack of 30   £0.12
                          ABSORBANT DRESSING PAD
                                                                    20cm x 40cm     EJA082     485-510    Pack of 25   £0.36
                                                                       Small        EJA045     908810     Pack of 20   £0.42
                          SOFTDRAPE DRESSING PACK VITREX              Medium        EJA046     908820     Pack of 20   £0.42
                                                                       Large        EJA047     908830     Pack of 20   £0.42

July 2018 – Version 4.0                                                                                                 Page 23 of 26
References
  Bryant R, Nix D (2016) Acute and Chronic Wounds (5th ed) Mosby. USA

  European Wound Management Association (EWMA). Position Document: Management of Wound Infection. London: MEP Ltd, 2006.

  European Wound Management Association (EWMA). Position Document: Antimicrobials and non healing wounds. London: MEP Ltd, 2013.

  European Wound Management Association (EWMA). Position Document: Debridement London: MEP Ltd, 2013.

  Flanagan M (2013) Wound healing and skin integrity. Wiley-Blackwell, West Sussex

  National Institute for Clinical Excellence (2014) The Prevention and Treatment of Pressure Ulcers. NICE, London. www.nice.org.uk

  National Institute for Clinical Excellence (2013) Varicose Veins NICE, London. www.nice.org.uk

  Royal College of Nursing (2006) Clinical Practice Guidelines: The Management of Patients with Venous Leg Ulcers. RCN, London.

  Sign (2010) Management of chronic venous ulcer: a national clinical guideline 120.

  Thomas S (2010) Wound dressing, London .

  Turner T.D. (1982) Which dressing and why? Nursing Times 78: 29 (suppl.), 1-3

  Wounds UK.(2016) Best Practice Statement: Care of the Older Persons Skin London :Wounds UK www.wounds-uk.com

  Wounds Uk (2016). Best practice Statement: Holistic Management of Venous Leg Ulceration. London :Wounds UK www.wounds-uk.com

  Wound Care Handbook (2017-2018). The comprehensive guide to product selection in association with the Journal of Wound care. MA
  Healthcare LTD, London.

  Resources : www.wounds-uk.com
                      www.worldwidewounds.com World Wide Wounds
                      www.ewma.org European Wound Management Association

July 2018 – Version 4.0                                                                                                          Page 24 of 26
Appendix 1 – Wound Assessment and Management Chart

 Name                                            NHS No                                    DOB
 Address                                         GP/Surgery                                Tel
                                                 DN Team                                   Tel
 Postcode                                        Residential/Nursing Home                  Tel
 Tel                                             Ward                                      Tel

Standard: In conjunction with Trust Wound Care Guidelines, an assessment and care-plan should
be completed for all patients with wounds.
Date of Initial Assessment                      DD/MM/YY

 Type of Wound(s)                Pressure               Leg         Moisture               Skin
    (Please circle)                                                            Surgical                Burn        Other
                               Ulcer Grading           Ulcer         Lesion                Tear
 How long has wound
 been present?

 Factors which may delay wound healing (tick if present, tick nil identified if no factors present)
 Medical Conditions                                                  Medications
 Rheumatoid Arthritis               Immobility                       Steroids
 Diabetes Mellitus                  Incontinence                     Immunosuppressive
 Cardiac Disease                    Infection                        Biologics
 Anaemia                            Obesity                          Anti coagulants
 Chronic respiratory disease        Malnutrition                     Cytotoxics
 Venous/Arterial Disease            Poor nutrition                   Non steroidal anti-inflammatory
 Decreased sensation                Smoking                          Other …………………………..
 Allergies                          Alcohol
 Skin sensitivities                 Concordance Issues               Nil identified……………………
 Severe acquired immune defects     Please specify ……............
                                    …………………………….....

 Date referred to:                       Tissue Viability Team ...…/.…./….         Dietician...../…../.…..
 Dermatology …../.…./….                  Podiatry/Foot Team …../…../…..           Vascular Surgeon …../…../….
 Plastic Surgeon …../…../…..             Others …../…../….. No specialist referral required.……………………..

 Full pain assessment completed and appropriate actions taken                             Yes   No    N/A
 Wound care-plan discussed/agreed with the patient                                        Yes   No    Verbal      Written
 If pressure ulcer, Waterlow risk assessment, SSKIN and check list fully                  Yes   No
 completed and reviewed
 If No to any of the above, reason for non-completion:
 Is it necessary to raise a safeguarding concern?                                         Yes   No

 Drawing/Photograph                       Number of Wounds …………….                    Location of wound(s)

 Lower limb un-healed wounds require full assessment with Doppler measurements at 4 weeks completed?
 Yes/No
 Reason for non-completion ……………………………………………………………

Name: ……………………………………….... NHS…………….……………………. DOB……………………

Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0                           Page 25 of 26
Please sign and date every dressing change. Reassess wound as needed using clinical judgement
and record any changes. Wound dimensions need to be measured at least weekly. Ensure that a
separate form is used for each wound.

Dressing Change
Date and Time DD/MM/YY 0.00hrs
Wound Dimension (cm)
Maximum length
Maximum width
Maximum depth
Undermining
Visible Tendon/bone       Yes/No
Wound Bed (approx % cover)
Necrotic – black
Sloughy – yellow green
Granulating – red
Epithelialising – pink
Wound edges
Healthy H Rolled RO Raised R
Undermined U
Suture/clips Yes/No/removal date
Exudate levels
High H Moderate M Low L
Type and colour
Surrounding Skin
Macerated M Oedematous O
Excoriated E      Fragile F Dry D
Eczema X         Healthy H
Wound Pain scale 1 -10 (10 high)
Continuous C Dressing D None N
Clinical signs of infection present: i.e. 2 or more of the following present; pus, odour, deterioration,
spreading erythema, heat, increased pain, increased exudate, abscess, friable tissue.
Infection present?            yes/no
If yes, swab taken (date)
Antibiotic therapy commenced (date)
Treatment Objectives
Patient comfort PC
Absorption A Infection Control IC
Debridement D Odour Control OC
Promote granulation G
Promote epithelialisation E
Cleansing Solution
Dressing Choice
(if Topical Negative Therapy in use,
document details here)
Skin Emollient/Cream
Frequency of dressing change
(number of days)
Date of review or healed
Signed
Print name
Designation

Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0                 Page 26 of 26
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