Wound management guidelines and formulary (Formularies)

The NHS Highland Wound Management Guidelines and Formulary (WMG&F) has been developed by theTissue Viability Leadership Group, a multidisciplinary group of professionals.

The aim of the WMG&F is to provide practitioners with guidance and a selection of products based oneffectiveness, suitability, acceptability and cost-effectiveness. Practitioners should use a formulary productwhere at all possible. In the vast majority of cases, formulary products are both on the Scottish NationalProcurement Contract (which controls products purchased by Scottish Hospitals) and the Scottish DrugTariff (which states what can be prescribed on NHS prescriptions and GP stock orders in primary caresettings).

NOTE: The product sizes listed are those available on PECOS. Additional sizes may be available onprimary care prescription.

Prices have been taken from PECOS, the Scottish Drug Tariff or MIMS (www.mims.co.uk) and are correct as of May 2018 but are subject to change.

Soft wadding synthetic

These are used under bandaging and plaster of Paris, for absorbency of exudate, protecting the area from pressure and distributing pressure more evenly.

Light support bandage crepeand light support knitted

These are used in the prevention of oedema; they are also used to provide support for mild sprains and joints, but their effectiveness has not been proven for this purpose. Since they have limited extensibility, they are able to provide light support without exerting undue pressure.

Short-stretch cohesive inelastic bandage

The short-stretch bandage has a high dynamic pressure and a low resting pressure because of the small amount of elasticity in the bandage.  When mobility occurs, in a short-stretch bandage, the pressure will increase as the muscles contract, but the bandage does not expand.  This is beneficial as it promotes venous return by assisting the calf muscle pump.  When the person wearing a short-stretch bandage elevates the limb (resting), sub-bandage pressure is reduced because the lack of elasticity in the bandage prevents recoil. 

2 Layer bandage system

Treatment is aimed at correcting, as much as possible, the long-term complications of chronic venous insufficiency.  Compression therapy systems applied externally to the lower leg increase pressure on the skin and underlying structures to counteract the force of gravity.  This can help to relieve the symptoms in the lower limb by acting on the venous and lymphatic systems to improve removal of fluid (blood and lymph) from the limb.  Their use calls for an expert knowledge of the elastic properties of the products and experience in the technique of providing careful graduated compression.  Incorrect application can lead to uneven and inadequate pressures or to hazardous levels of pressure.  In particular, injudicious use of compression in limbs with arterial disease has been reported to cause severe skin and tissue necrosis (in some instances calling for amputation).

Medicated bandages

These may require a 48-hour patch test using a small amount of the bandage applied to the skin as paste bandages can be associated with hypersensitivity reactions and should be used with caution.

Zinc paste bandage can be used with compression bandaging, short stretch bandaging and type1 and 2 bandages for the treatment of leg ulceration.  Useful for weeping exudate and/or blistering to the skin by protecting and preventing further damage from maceration.  Can be applied to skin around wounds and left insitu whilst allowing regular dressing changes to continue.

Zinc paste bandages are also used with coal tar or ichthammol in chronic lichenified skin conditions such as chronic eczema (ichthammol often being preferred since its action is considered to be milder).  Can also be used where hypersensitivity reactions have occurred with Viscopaste as the milder Ichthammol may be more easily tolerated. 

Follow the manufacturer’s instructions when applying medicated bandages to prevent constriction of the blood flow.  If a preservative-free brand is required, Zipzoc® is available.

Tubular bandages

These are available in different forms according to the function required of them. 

Elasticated tubular bandages are particularly suitable for retaining dressings, maintaining bandages on difficult parts of the body or for soft tissue injury.  They are not suitable as the only method of applying pressure to an oedematous limb or to a varicose ulcer since they exert non-graduated and often inadequate pressure.  Inappropriate use of elasticated tubular bandages can cause pressure damage and affect the shape of the limb, causing indents to fragile tissue. 

Tubular stockinette

These garments can be prescribed to assist the wet-wrapping of children and some are suitable for protecting areas to which creams and ointments have been applied.  They should not be used when potent corticosteroids are applied.  They can be used under orthopaedic casts, compression bandaging, short stretch bandaging and type 1 or type 2 bandages to protect the skin from the bandage layers. 

A 100% cotton stockinette should be considered for patients with sensitivities to synthetic materials.

Pain can affect everyone.  The psychological impact of pain cannot be measured nor underestimated and is likely to affect healing.  Poor techniques in wound care can further traumatise wounds leading to additional pain and slowed healing or other complications.  However strategies can be adopted through which pain can be avoided or minimised. 

Patients may experience pain as a result of:  

• Products or techniques used to cleanse wounds
• Trauma to the tissues and surrounding skin when products are removed
• Skin excoriation from exudates or wound drainage
• Lack of empathy
• Failure to record patients earlier reports of pain
• Infection, which can exacerbate existing wound pain
• Poor technique when using compression bandaging

Careful wound assessment is required to expose the causes, type and severity of pain that the patient is experiencing.  All practitioners have a professional responsibility to implement effective pain reducing strategies.

The correct dressing can aid comfort and reduce pain, especially during dressing change.

Emotional responses can also influence the perception of pain and the distress of having a wound.  Clinically, pain, like wound types, can be classified as acute or chronic, but will be related to:

• The type of injury
• The location of the wound
• Patient perception and previous experience
• The healing process and approaches to wound management, e.g. choice of dressing and provision of analgesia.

Assessment of Pain 

Accurate assessment depends on subjective reporting by the patient.  Pain can be assessed effectively during ongoing therapy by asking the patient to rate his/her pain.  It is recommended that a simple visual analogue scale is used.  The patient should be asked if the pain is worse at any particular time or during a particular activity so that analgesic doses can be timed appropriately.  Patients should be closely observed throughout the dressing procedure for reaction to treatment. (BPS)

Analgesia 

Whatever analgesia is used in wound care, its effectiveness should be evaluated continuously.  Failure to achieve pain relief may contribute to the depression and anxiety associated with chronic pain.

The type of analgesia to be used depends upon: 

• The type of wound
• Whether the wound is acute or chronic
• The level of pain reported by the patient
• Patients individual circumstances e.g. other medicines, co-morbidities

Effective doses of analgesics should be given.  In chronic pain, treatment should be given regularly to provide continuous pain relief.  This is preferable to giving analgesics only whennecessary, allowing pain to recur before giving further treatment.

Analgesics should also be given in anticipation of pain, giving careful consideration to any activities which exacerbate pain.  In the case of acute pain there is little time to titrate the dose against the patient’s response.  Analgesics should be chosen according to assessment of the factors mentioned above.

The use of non-steroidal anti-inflammatory drugs (NSAIDs) eg aspirin, ibuprofen, Diclofenac etc, is common in treating minor injuries and in long-term inflammatory conditions.  This is due to their action of inhibiting the production of prostaglandins (inflammatory mediators).  If wound pain is ongoing it may not be appropriate to use an NSAID due to their side effects.

The WHO analgesic ladder forms the basis of many approaches to the use of analgesic medicines.

There are three essential steps on this ladder.

The WHO Analgesic Ladder 

References

• Campbell, J. (1995) Making sense of pain management. Nursing Times 91, 34-35.
• An Independent Advisory Group (2004).
• Casey, G. (1998) The management of pain in wound care. Nursing Standard 13, 49-54.
• Dealey, C. (2005) The Care of Wounds, 3rd ed. Oxford: Blackwell Science.
• World Health Organization (1996) WHO Guidelines: Cancer Pain Relief, 2nd ed. Geneva, World Health Organization.

The principles of good skin care depend on:

• keeping the skin clean and dry
• avoiding the excessive use of soap as this can dry the skin
• using showers in preference to baths where possible
• keeping the skin moisturised

Assessment

The state of the skin surrounding a wound should be assessed at each dressing change.   Observe for the following:

• dry skin - may break down and provide a portal for infection
• maceration - caused by poor management of exudates
• inflammation - consider contact sensitivity to dressings or infection

Emollients

Choice of emollient is very personal; it can mean the difference between treatment success and failure.  Patients will not use a topical therapy that irritates their skin and they will be reluctant to use one that doesn’t feel right or suit their needs.  Emollients are moisturisers that soothe and hydrate the skin.  They are indicated for all dry or scaling disorders.  Most are best applied after washing but their effects are short-lived so they must be applied frequently and regularly to maintain improvement.  They should continue to be applied even after improvement occurs.  Emollients should be applied in the direction of hair growth.   Some ingredients may rarely cause sensitisation and this should be suspected if an eczematous reaction occurs.

There are different types of product available.  These include ointments, creams, lotions and gels.  Effectiveness depends upon the correct choice of product and correct use.   Choice will depend upon:

• the severity of the condition
• patient preference
• the site of application
• cost of preparation

Ointments

Ointments are greasy and generally insoluble in water so can be difficult to wash off, and do not suit all patients. They are recommended as the first choice of formulation in most skin conditions and are particularly useful for chronic dry conditions.  Examples: Epaderm ointment, liquid and white soft paraffin ointment 50:50.

Creams

Creams are emulsions of oil and water and often contain an antimicrobial preservative . They are therefore more likely to cause both irritant and allergic reactions.  For this reason creams are best avoided first line but are often more cosmetically acceptable for some patients.  Creams can be better than ointments for some acute conditions due to a cooling effect as they evaporate from the skin.  Example: Diprobase.

Gels

Gels also have a high-water content and produce a cooling effect on evaporation from the skin.  They are suitable for use on the face and scalp.  Example: Doublebase gel.

Barrier Preparations

Wounds which are heavily exuding or have friable surrounding skin are at risk of excoriation, epidermal stripping and maceration.  A barrier can be used on the surrounding skin prophylactically to protect the skin.  Barrier preparations should be reapplied at dressing changes.

NB - Sudocrem should not be used as a barrier in wound management. 

Some patients will experience leakage of urine or accidents, so the skin can become exposed to urine and faeces.  This can cause the skin to become wet and soggy (moisture lesion) and can develop into a painful rash.  See HIS: pressure ulcer grading and excoriation tool.  Incontinence dermatitis can cause distress and embarrassment.  The use of oil-based barrier creams interferes with the pad absorbency and can lead to urine staying in contact with the skin.  The use of water-based creams is advised.

Signs and symptoms  

Will appear as a red and painful skin rash, usually irregular in shape and may/may not be over bony prominences.  It may also be itchy and flaking, crusty or weeping.

Treatment  

• Genital Skin Care Leaflet
• Regular inspection of the skin is vital by a suitably trained practitioner. 
• Use the lowest possible absorbancy of pad.
• Moisture causes damage to the skin so keeping the skin dry is imperative.  Pat the skin dry and avoid rubbing.
• Appropriate product selection and correct fitting is vital - training is available to ensure knowledge and skills are up to date.
• If skin is wet, it can be cleaned with plain water – soap can make the skin dry and irritated.
• Any faeces on the skin must be removed promptly .
• Foam cleansers can be useful if used correctly 
  • spray foam directly onto skin. 
  • leave for 1-2 minutes to loosen and breakdown debris on the skin.
  • remove with dry wipe only. 
  • always adhere to manufacturer’s instructions for each product as this may vary.
• Barrier creams can help protect the skin – it is important to use a water-based cream so as not to interfere with product absorbency.   Please see wound management guidelines and formulary product list for the barrier creams.  The use of Sudocrem or other oil-based creams affects the absorbent ability of the pad.
• A film type of gel/dressing would not be used routinely in a skin care regime but may be used when extra protection of the skin is required.  It can be used on "at risk" skin as a prophylactic and also on broken skin to form a barrier and a protection for adjacent skin.  If skin is damaged, then a review of the skin care regime is required.
• Talcum powder should not be used in conjunction with body worn continence products.  When dampened by sweat or urine, talc can form encrustations, which may cause discomfort and increase potential for frictional damage.
• An all-in-one product which is too large or too small may cause leakage and skin irritation.  With a shaped product, fixation pants or patients own pants must be close-fitting. 

Contact 

If the problems persist and further guidance is required, please contact Jenny Munro AP Physiotherapist & Independent Prescriber - Continence nhsh.continencecare@nhs.scot.

As a general rule, routine cleansing of wounds to remove bacteria or to reduce infection is unlikely to be effective (Miller and Gilchrist 1997).

Wound cleansing may be advocated to remove contaminants in the following instances:

• To remove visible debris after a wound has occurred to aid assessment.
• To remove excess slough and exudates.
• To remove any remaining dressing material.
• Prior to obtaining a microbiology swab.
• Adult Wood Cleansing Guideline NATVN.

Frequent washing of wounds is unnecessary and undesirable.

Cleansing Solutions 

In the past wounds were cleansed with antibacterial solutions.  Studies comparing the effectiveness of antibacterial solutions to tap water, normal sodium chloride 0.9% and distilled water have foundno difference in lowering bacterial countand no increased incidents of infection(Dire & Welsh 1990; Rodeheaver et al. 1982).  Antiseptic solutions have been reported to cause tissue damage and hinder the healing process and are unlikely to be effective (Hellewell et al. 1997).

Sterile sodium chloride 0.9%, which is an isotonic solution, does not impede the healing process, cause allergic reactions or alter the bacterial flora of the skin.  It should be used in the following situations, where tap water is not recommended:

• On exposed bone or tendon.
• On skin or bypass graft.
• For severely immunosuppressed patients.

Methods of Cleansing 

Irrigation is the cleansing mechanism recommended for removal of contaminants.  Scrubbing causes pain and local tissue oedema, which decreases host defences.  Vigorous cleansing may however be necessary, in some instances, to remove grease and dirt from traumatic wounds which, if left in situ, can cause unsightly tattooing of the skin (Miller & Glover 1999).

Summary 

• Does the wound need to be cleansed? If not, don’t do it.
• Always warm the irrigation fluid being used. Cooling the wound inhibits cell mitosis.
• Never use cotton wool or gauze swabs to clean wounds as they damage granulating tissue and shed fibres, which increase the risk of infection.

References

• Dire, D.J. & Welsh, A.P. (1990) A comparison of wound irrigating solutions used in the emergency department. Annals of EmergencyMedicine 19, 704-708.
• Hellewell, T.B., Major, D.A., Foresman, P.A., Rodeheaver, G.T. (1997) A cytotoxicity evaluation of antimicrobial and non-antimicrobial woundcleansers. Wounds 9, 15-20.
• Miller, M. & Gilchrist, B. (1997) Understanding Wound Cleaning and Infection. London: Macmillan.
• Miller, M. & Glover, D. (1999) Wound Management: theory and practice. London: Emap Healthcare Ltd.
• Rodeheaver, G., Bellamy, W., Kody, M. et al. (1982) Bactericidal activity and toxicity of iodine-containing solutions in wounds. Archives ofSurgery 117, 181-186.

Other considerations (key points) 

• Simple primary wound contact layers are recommended in the management of uncomplicated venous ulcers.
• Bacterial swabs should only be taken where there is clinical evidence of infection. 
• Antimicrobial dressings should be considered if indicated and advised by trained practitioners.
• Sharp debridement should only be carried out by appropriately trained practitioners.

References

• WUK BPS: Best Practice Statement: Addressing complexities in the management of venous leg ulcers
• Scottish wound assessment and action guide

Leg ulceration is common and prevalence increases with age.  Approximately 1% of the population will suffer from leg ulceration at some point in their lives.  Venous ulceration is the most common type of leg ulceration followed by arterio-venous ulceration and arterial ulceration.  Accurate, holistic assessment of the ulcer including ankle brachial pressure index (ABPI) or assessment by a trained practitioner is the key to successful treatment and must be performed prior to the application of any compression therapy.

Patients with the following features should be referred to the appropriate specialist at an early stage of management: see Referral Pathways.  We also have a new nugget on the intranet to support appropriate referral.

• Suspicion of malignancy
• Peripheral arterial disease (ABPI<0.8)
• Rheumatoid/vasculitis
• Suspected contact dermatitis or dermatitis resistant to topical steroids
• Diabetes mellitus
• Atypical distribution of ulcers
• Non-healingulcerafter 4 to 6 months
• May benefit from surgical intervention such as foam sclerotherapy

Other considerations

• Latex free brands of compression bandages should be used routinely. 
• Compression and short stretch cohesive inelastic bandaging should only be applied by staff with appropriate training and in accordance with the manufacturer’s instructions.
• Patients should be assessed for skin complications within 24 to 48 hours following initiation of compression.
• Recurrence of venous ulcers can be substantially reduced by continuous application of compression hosiery.
• Below knee graduated compression hosiery is recommended to prevent recurrence of venous leg ulcers.  Patients should be offered the highest class of compression which they can tolerate to prevent recurrence, with 2 pairs being supplied on a 6 monthly basis.
• Nutrition: There is evidence to demonstrate that adequate levels of protein, fat, carbohydrates, vitamins and trace elements are necessary in wound healing, especially in collagen formation and maturation.
• Pain control is an important factor in patient concordance to any treatment regime and a programme of pain management should be tailored to the needs of each individual patient.
• Associated dermatitis which has not responded to topical steroid therapy should be considered for a referral to Dermatology. 

Further Reading

• European Society for Vascular Surgery – 2017 ESVS Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases.
• Revision of the CEAP Classification for Chronic Venous Disorders: consensus statement. Journal of Vascular Surgery; 40: 1248-1252. 
• Understanding Compression Therapy: EWMA.
• www.vascularsociety.org.uk.

References

• Best Practice Statement: Compression Hosiery.
• www.vascularsociety.org.uk

The following dressings can be used on the direction of a specialist in secondary care eg Dermatologist, Plastic Surgeon, Vascular Surgeon, Leg Ulcer Specialist Nurse, Vascular Specialist Nurse and Plastic Surgery Nurse Specialist.  A non-catalogue Pecos order would be required with a clear indication of who has agreed to order a non-formulary compliant product.

Debrisoft: For use in long standing hyperkeratotic tissue and diabetic foot ulceration where standard formularyproducts have failed.

Prontosan irrigation fluid 1litre with adapter: for use with Veraflo irrigation system.  Available on product formulary and Pecos.

Cutimed Sorbact: This dressing binds and inactivates pathogenic bacteria and fungi which are removed from the wound at every dressing change thus preventing reproduction of micro-organisms. Useful in managing biofilms, the wound bioburden and vascular wounds. Suitable for fungal infections in the groin, skin folds or between digits particularly in diabetic patients.

Jelonet: For use in infective and irritant dermatitis, to soothe and calm the affected area whilst allowing free drainage of exudate into a secondary dressing.  Also indicated for use where irritant contact dermatitis caused by reactions to wound care products and/or wound exudates produces high exudate levels This dressing contains Paraffin and is flammable.  Patients should be made aware and advised to wash clothes if seepage occurs and caution near open flames.

Larvae: Larvae therapy is appropriate in the management of wounds requiring rapid debridement of slough and necrotic tissue including leg ulcers, pressure ulcers, infected surgical wounds, diabetic foot ulcers and burns.  Please contact pharmacy for availability of prescription.

Medicated Bandages - Zinc Paste Bandage BP (Viscopaste®) 7.5 x 6M, Zinc Paste and Ichthammol Bandage BP (Ichthopaste®) 7.5cm x 6m:may require a 48-hour patch test using a small amount of the bandage applied to the skin as paste bandages can be associated with hypersensitivity reactions and should be used with caution.

Zinc Paste Bandage can be used with compression bandaging, short stretch bandaging and type1 and 2 bandages for the treatment of leg ulceration. Useful for weeping exudate and/or blistering to the skin by protecting and preventing further damage from maceration.  Can be applied to skin around wounds and left insitu whilst allowing regular dressing changes to continue.

Zinc paste bandages are also used with coal tar or ichthammol in chronic lichenified skin conditions such as chronic eczema (ichthammol often being preferred since its action is milder).  Can also be used where hypersensitivity reactions have occurred with Viscopaste as the milder Ichthammol may be more easily tolerated. 

Follow the manufacturer’s instructions when applying medicated bandages to prevent constriction of the blood flow.  If a preservative-free brand is required, Zipzoc® is available.

Lymphoedema is swelling primarily due to lymphatic insufficiency.  This may be an inherited or congenital primary lymphoedema, or an acquired lymphoedema that is secondary to cancer treatment, or non-cancer causes including surgery and infection. 

Some individuals develop chronic swelling (chronic oedema) that starts with a non-lymphatic cause.  Several factors may contribute to a sustained increase in interstitial fluid, overwhelming and compromising the lymphatic system, often leading to lymphoedema, and delayed wound healing. 

For further management advice and referral pathway, please refer to lymphoedema guidelines and Compression Hosiery Formulary.

Further reading 

• Partsch, H. & Mortimer, P., Compression in leg wounds, British Journal of Dermatology, 173, p359-369.

For the Wet Legs Care Plan click here

Pressure ulcers are damage caused by extrinsic factors (pressure, shearing forces, friction) and intrinsic forces (illness, age, nutritional status, drug therapy).  The toes, heels, sacrum and ischial tuberosites are at most risk of developing pressure ulcers.  All pressure damage, regardless of grade, is reportable via Datix incident reporting.  Moisture lesions should not be classified as pressure ulcers.  For further guidance please refer to HIS: Pressure ulcer excoriation tool and for further product information see Incontinence Dermatitis.

Other considerations 

• It may be necessary to exclude potential osteomyelitis when dealing with deep wounds.
• For wound infection see relevant section.
• For cavities wounds and sinus tracts see relevant section.

In the event of tissue necrosis extending to underlying bone tendon or joint capsule, advancing cellulitis, or ulcer related sepsis, surgical intervention may be necessary, refer to vascular or plastic surgery. 

End of life: Management aims should be focused on patient comfort and quality of life.

Provide the patient with the Pressure Ulcer patient information leaflet available on the Intranet.

References 

• NHSH Patient Information Leaflet: Preventing Pressure Ulcers.
• European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel.  Treatment of pressure ulcers: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009.  Available at: www.epuap.org.
• National Institute for Health and Clinical Excellence (NICE). Pressure Ulcers; September 2005.
• NHS Highland Pressure Ulcer Prevention and Management Policy.
• Standards for the Prevention and Management of Pressure Ulcers.

Integrated Pathway for Diabetes & ALL Foot Ulceration

At first presentation ensure all referrals are directed to podiatry services with a completed referral form.

The goal of any foot ulcer management is to:

• Create ulcer free days
• Give ulcer remission
• Limb salvage
• Quality of life
• Decrease mortality

Adherence to locally established guidance and protocols may reduce length of hospital stay and major complication rates. Wound healing and foot saving amputations can be achieved in the presence of multidisciplinary foot care teams. International Diabetes Federation recommends that every individual with diabetes receive the best possible care (IWGDF, 2019).

Risk Factors  

The following factors can cause vulnerability to foot ulcers:

• previous history of foot ulceration
• neurological factors
• ischaemia
• foot deformity/posture
• callus
• oedema/lymphoedema
• neglect

Categorisethe diabetic foot using risk stratification related to SCI-Diabetes foot risk stratification tool (SIGN 116, 2010, updated May 2021).

Diabetes foot ulcer classification, utilising TEXAS classification system aids recording of wound characteristics, improves communication, predicts clinical outcomes and supports audit & research.  The Scottish Diabetes Foot Action Group advocates the use of this tool when classifying foot ulcers.

The Scottish adaptation of the European Pressure Ulcer Advisory Panel (EPUAP) Pressure Ulcer Prevention Tool is used in NHS Highland when classifying pressure wounds.

Assessment

1. Vascular – consider clinical features; perform appropriate vascular tests in line with local vascular pathway.
2. Infection – clinical features; differential diagnosis; sampling; AMWD.
3. Pressure/load distribution– appropriate footwear; appropriate device for load distribution.
4. Evidence based wound care assessment & management– debridement; dressings.
5. Holistic management– optimise management of relevant co-morbidities.  Support peoples’ health & wellbeing through making every contact count.

Differential Diagnosis 

If pain is experienced in a neuropathic foot, consider the possibility of infection or Charcot foot.  A significant number of diabetes foot ulcers will be of mixed aetiology which can be identified with appropriate assessment.

Standards of Care 

Treatment Aim 

• to prevent deterioration of the wound
• to promote rapid closure with the minimum of tissue damage 
• to prevent recurrence of foot ulceration
• to liaise with MDT foot/vascular if required.

References 

• https://iwgdfguidelines.org/guidelines/guidelines/
• Management of Infection Guidance NHS Highland (2016)
• https://www.sign.ac.uk/assets/sign116.pdf
• https://www.woundsinternational.com/resources/details/best-practice-guidelines-wound-management-diabetic-foot-ulcers
• https://tam.nhsh.scot/healthcare-professional-information/therapeutic-guidelines/diabetes/diabetic-complications/diabetic-foot-infections/
• https://tam.nhsh.scot/healthcare-professional-information/antimicrobial-guidance/skin-soft-tissue/diabetic-foot-infection/

Referral

Referrals from any health care professional are accepted.  For governance purposes they must include a podiatry referral (self-referral, sci- referral or hospital referral) to the local podiatry generic email address and include written communication eg letter, completed SCI-Diabetes comments/ulcer management section, e-clinic proforma.

Digital images should also be included with the referral.

NHS HIGHLAND HOT FOOT

High-risk foot Service covering all NHS Highland foradvice email: nhsh.diabetesfootclinic@nhs.scot

Podiatry Contacts

Argyll & Bute:

• Campbeltown -Tel: 01586 788977, email:nhsh.podiatrycampbeltown@nhs.scot
• Helensburgh - Tel: 01436 655132
• Lochgilphead -Tel: 01546 462199, email:nhsh.podiatrymidargyll@nhs.scot
• Oban - Tel: 01631 788977, email: nhsh.podiatryoban@nhs.scot
• Rothesay & Dunoon - Tel: 01700 501529, email:nhsh.cowal.podiatrychronicwounds@nhs.scot

North: 

• Caithness East - Tel: 01955 880435, email: nhsh.podiatrynorthdivision@nhs.scot
• Caithness West & North West Sutherland - Tel: 07748 761899, email: nhsh.podiatrynorthdivision@nhs.scot
• East Sutherland - Tel: 01408 633157, email: nhsh.podiatrynorthdivision@nhs.scot

South and Mid (including Raigmore Hospital): 

• South and Mid - Tel: 01463 723250, email:nhsh.southandmidpodiatry@nhs.scot

West:

• Lochaber - Tel: 01397 709800, email:nhsh.podiatrylochaber@nhs.scot
• Skye & Lochalsh & Wester Ross - Tel: 01478 613200, email:nhsh.podiatryslwr@nhs.scot

AVULSION/ABLATION OFTOENAILS

Background 

The object of performing toenail avulsion/ablation is to: alleviate discomfort; reduce risk of sub-ungual ulceration; prevent recurrence and so treat the problem.  Avulsion may be carried out on part of the nail or the whole nail.  A combination of avulsion with or without matrix destruction may be performed.  Podiatry destroys the matrix using chemical ablation, and this should prevent regrowth of the nail.  Studies show chemical avulsion dramatically reduces the rate of symptomatic recurrence.  Podiatry uses a 10% sodium hydroxide solution to carry out this chemical ablation.

Use of sodium hydroxide (NaOH) 

• 10% NaOH solution is applied to the area being treated
• Chemical ablation procedures have a slightly higher chance of becoming infected
• Chemical ablation procedures may produce delayed healing. 
• Drainage is common for 3 to 4 weeks post-operatively 
• Any query should be directed to the clinician who has performed the procedure.

Hypergranulation 

Hypergranulation is a relatively common complication of ingrown toenails.  Hypergranualtion may distort the end of the toe, however a small amount may be left after nail avulsion without concern and will regress following removal of the offending spicule of nail.

Post-Operative Management 

Immediately Post-Operatively, with Significant Bleeding:

• Primary dressing: alginate dressing
• Secondary dressing: polyurethane foam film dressing 
• Retaining dressing: surgical stockinette

Immediately Post-Operatively, with no Significant Bleeding:

• Primary dressing: polyurethane foam film dressing
  
• Retaining dressing: surgical stockinette

initial post-operative dressing change by patient, following chemical ablation, should be performed at 24 to 48 hours.  If the dressing is adhered to the wound, it may be soaked off with tap water or sterile saline depending on availability.

• packing of the wound should be discouraged as this prevents drainage of exudate.
• packing causes the dressing to become hard and can cause discomfort when removal is attempted.
• further redressing should be governed by wound status eg slough, granulation etc.

References 

• Eekhof J, Wyk, BV, Neven AK, van der Wouden, JC (2012) Interventions for Ingrowing toenails
  
• FernandezR., Griffiths,R (2012) Water for wound cleansing
  
• http://emedicine.medscape.com/article/1126725-treatment
  
• http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001541.pub3/full

Burns management (NHS Highland intranet access required)

Infection is the invasion of living tissue by micro-organisms.  The number of micro-organisms and their degree of pathogenicity determine the establishment of infection.  The presence of bacteria does not always indicate that a wound is infected.  All chronic wounds are colonised with bacteria, but they only become problematic when healing is compromised.  Wound stasis or deterioration may be caused when the host defenses are unable to resist the bacterial load.  Internal and external factors related to the patient’s condition must be taken into consideration when planning care of an infected wound.  Factors such as immunosuppression, poor nutritional status, metabolic disease, ischemia or presence of a foreign body will affect a host’s ability to control bacterial load. 

Other considerations 

Diagnosing Clinical Infection - Resources to guide the management of suspected infection in chronic wounds (healthcareimprovementscotland.org.

Signs of infection include erythema, pain, swelling and localised heat.  In addition, wound infection can be identified with the following potential signs: increased discharge, delayed healing, wound breakdown, pocketing at the base of the wound, epithelial bridging, unexpected pain or tenderness, friable granulation tissue, discolouration of the wound bed, abscess formation or malodour.

Inflammatory response may be inhibited in some people.  Those who are immunosuppressed or have diabetes mellitus may not display typical signs and symptoms of wound infection.  It may be necessary to exclude potential osteomyelitis when dealing with deep wounds.

Wound Swabs  

Wound swabs should only be taken for infection that is spreading or where systemic infection is suspected. 

• Prior to obtaining a wound swab, wounds should be cleansed as normal.
• Take swab from deeptissue (as close to the wound bed as possible).
• The swab should be moved across the wound surface in a zigzag motion, at the same time as being rotated between the fingers.
• Where possible, submit actual tissue samples - these may be sent in universal containers.
• A specimen of pus is more valuable than a pus swab when sampling abscesses at incision and drainage.
• When delay in transit is unavoidable, keep at room temperature or refrigerate at 4°C.
  

Antimicrobial Dressings

Use of antimicrobial dressings should be limited to two to three weeks unless there is clear clinical justification to continue for longer.  If the wound is unchanged at three weeks, it is recommended that an alternative topical antimicrobial agent is used.   If the wound begins to show further signs of infection, the use of a systemic antibiotic should be considered.

Honey Dressings

Honey dressings have antimicrobial and anti-inflammatory properties and promote autolytic debridement.  This osmotic effect may cause pain and analgesia may be required.  Patients with diabetes should have their control monitored whilst using topical honey, especially when applied to large areas.  Honey dressings should be avoided in patients with extreme sensitivities to honey, bee stings or bee products.

Iodine Dressings

Iodine dressings release free iodine when exposed to wound exudate which acts as an antiseptic on the wound surface.  System absorption may occur from large wounds or with prolonged use.  Caution in those with severe renal impairment or history of thyroid disease.  Contra-indicated in children, those receiving lithium, thyroid disorders, pregnancy and breastfeeding.  Inadine® has the propensity to dry out and adhere to the wound surface and indicates frequent dressing changes.

Other Antimicrobial Dressings

Flaminal® is a dressing with enzymatic antimicrobial activity.  Experience with these dressings is limited and therefore it may be prudent to limit their use to mild infection until their place in therapy has been established.

Silver Dressings

Silver ions exert an antimicrobial effect in the presence of wound exudate and have broad antimicrobial activity.  Practitioners should ensure good wound bed contact and conformability for full benefit from these dressings. 

Topical antibiotic creams are not recommended.

Systemic antibiotics

Asprescribed by medical team. 

Malodour

Maladourcan be the most distressing symptom for patients, family and care givers.  See Fungating Wounds for management advice.

Secondary Dressings

See WMF section according to wound type for appropriate choice of secondary dressings.

References

• Wounds UK. Best Practice Statement.  The use of topical antiseptic/antimicrobial agents in wound management.  Aberdeen May 2011. 
• World Union of Wound Healing Societies (WUWHS). Wound Infection in Clinical Practice. An International Consensus. London: Medical Education Partnership Ltd. International Wound Journal: Vol 5; 3, 2008.
• National Prescribing Centre. Evidence-based prescribing of advanced wound dressings for chronic wounds in primary care. MeReC Bulletin 2010; 21(01): 1-7.
• Silver dressings – do they work? Drug & Therapeutics Bulletin. 2010; 48(4): 38-42. 
• Wounds International. Ten top tips for taking a wound swab. Available at Wounds International. 

As with all complex wounds a full assessment to determine the cause and extent of the wound is essential.  “A wound sinus is a discharging blind-ended tract that extends from the surface of an organ to an underlying area or abscess cavity”.  The cause of a sinus must always be determined by in-depth assessment.  A cavity wound may be chronic or acute and falls into the categories described below. 

Other considerations 

The amount of packing inserted into the wound should be documented to ensure it is all removed at the next dressing change.

Rope should be inserted very loosely as a wick to facilitate drainage and not cause a back flow of exudate into the body cavity. A 2cm tail should be left out with the wound to enable easy removal. Wounds should not be overfilled.

Sinus: Often end in an abscess/cavity which contains foreign material.  This needs to be removed and healing promoted or the sinus is likely to become chronic.

Patient Assessment

• Establish the site and extent of tissue damage
• Consider barrier film to prevent maceration from exudate
• Nutrition
• Pain management
• Surgical intervention
• Multi-disciplinary approach

If wound infection is suspected refer to the Infection section.

References 

• Butcher M (1999), Management of Wound Sinuses, Journal of Wound Care, Oct, 8: 9-1999; 415-453.
• NHS QIS. Prevention and Management of Pressure Ulcers. Best Practice Statement, March 2009.

Overgranulation can sometimes occur in the latter stages of healing and clinical action can help reduce the granulation.

Type	Indicator/descriptor	Management aims	Treatment options
	Overgranulation, also referred to as proud flesh, hypergranulation, hypertrophic granulation, hyperplasia of granulation tissue or wound oedema, occurs at the proliferative stage of the wound healing process.  It presents clinically as granulation tissue raised above the level of the surrounding skin. The presence of overgranulation tissue prevents progress to the maturation stage of the wound healing process and so delays wound healing. Early recognition and treatment are essential to wound progression and healing.	To reduce further development of granulation tissue To promote epithelialisation over the surface of the wound To effectively manage wound exudate To provide a dressing that is comfortable and acceptable to the patient	Examine the wound bed carefully; it is sometimes possible to see and remove dressing fibres and other potential irritants. Identify wound infection, a key cause of inflammation in wounds. Overgranulation can be a symptom of wound colonisation. Treat with topical antimicrobials, ie Inadine, Silvercel for 7 days and review. Select secondary dressing, if required, on the   basis of exudate levels.  A foam dressing applied firmly can be beneficial in reducing overgranulation.

Other considerations 

• Avoid occlusive dressings.
• If overgranulation fails to respond to any of the above topical steroids may be of use - refer to Advance Practitioner Dermatology or Advanced Practitioner Tissue Viability.
• Eliminate malignancy. 
• Overgranulation is normally transient and will often resolve itself as the wound contracts (Dunford, 1999).  Adopting a “wait and see” policy may therefore carry fewer implications for the patient than some of the other options discussed. 
• Surgical excision:  re-traumatises the wound, re-initiating the wound healing cycle.  Undertaken in theatre as last resort. 

References

• Cooper, R., 2007. Steroid therapy in wound healing. In Free Paper. EWMA Conference. Glasgow.
• Dunford, C (1999) Hypergranulation Tissue. Journal of Wound Care 8 (10) 506-7.
• Stephen-Haynes, J. and Hampton, S., 2010. Achieving effective outcomes in patients with overgranulation. Wound Care Alliance UK, pp.1-10.
• Hampton,S (2007) Understanding over granulation in tissue viability practice.  British Journal of Community Nursing,September 2007, vol./is.1219 (S24-30), 1462 – 4753.

Fungating wounds are caused either by a local tumour infiltrating the skin, or by metastatic spread from the primary tumour.  Malignant fungating lesions are an immense challenge.  Management goals vary depending on the stage of the underlying cancer, the patient’s prognosis, and the individual’s own goals and wishes. In some cases, the aim is to arrest tumour growth, but in many situations fungating tumours occur at the end of life, and treatment is completed in a palliative setting that focuses on comfort and maintenance of the best possible quality of life for that patient and their family.  In either case it is important to remember that the symptoms produced by a fungating wound are often as distressing as the wound itself.  Management focuses on alleviation of distressing symptoms including pain, cutaneous irritation, exudate, bleeding and odour. 

Other considerations 

• Exudate  - In selected wounds with high exudate either stoma appliances or absorbent pads over a non-adherent contact layer may be the most appropriate dressing method.
• Bleeding - Bleeding may be controlled by careful removal of dressings moistened first with warmed normal saline.
• Skin irritation - Advice to the patient regarding the use of light, cool clothing and bathing may be of some benefit.   Irritation caused by radiotherapy may respond to topical hydrocortisone – seek specialist advice.
• Pain - Chemotherapy, radiotherapy, hormone therapy or a combination of these anti-cancer therapies may help to shrink the wound by destroying malignant cells, reducing pressure on nerves and other structures and decreasing the area of exposed tissue. This may have a significant effect on the level of pain experienced by the patient – seek specialist advice regarding appropriate analgesia.
• Dressing choice - Dressing choice for fungating wounds should not only be based on the wound characteristics but also should have minimum bulk, conform to the body to prevent leakage, conformable and cosmetically acceptable to the patient.

References: 

• Bergstrom, KJ. (2011). Assessment and Management of Fungating Wounds, J Wound Ostomy Continence Nurse, 38(1); 31-37
• Grocott, P et al (2012). Malignant Wound Management in Advanced Illness: New Insights. Current Opinion in Supportive and Palliative Care. Review, 7(1); 101-105.
• Da Costa Santos, CM et al (2010). A Systematic Review of Topical Treatments to Control the Odour of Malignant Fungating Wounds, Journal of Pain and Symptom Management, 39(6); 1065-1076.
• Graves, LM. (2013). Providing Quality Wound Care at the end of Life. Journal of Hospice and Palliative Nursing, 15(2); 66-74.
• Alexander, S. (2009). Malignant Fungating Wounds: Epidemiology, Aetiology, Presentation and Assessment. Journal of Wound Care,18(7); 273-280.
• Seaman, S. (2006). Management of Malignant Fungating Wounds in Advanced Cancer. Seminars in Oncology Nursing, 22(3); 185-193.
• Chrisman, CA. (2010). Care of Chronic Wounds in Palliative Care and End-of-Life Patients. International Wound Journal, 7(4); 214-235.
• Zeppetella G, Ribeiro MD. (2005). Morphine in intrasite gel applied topically to painful ulcer. J Pain Symptom Manag,29; 118-119.
• Healthcare Improvement Scotland Best Practice Statement: Skincare of Patients Receiving Radiotherapy (2010).

For Tissue Viability Referral form please click here (Copy and paste the link into a new browser window. NHS Highland intranet access required).

For Product Complaint form please click here (Copy and paste the link into a new browser window. NHS Highland intranet access required).

1. Why have a formulary for these products?

The WMG&F provides guidance on the prescription and application of preferred tissue viability products for use in NHS Highland.  In keeping with other NHS Boards, the NHS Highland Formulary is evidence based and takes into consideration patient acceptability as well as clinical and cost effectiveness.  This aims to support the Highland Quality Approach to person centred care by minimising harm, variation and waste in the management of wound care.

The specialist products section should only be used where there is no suitable product for a particular wound type/clinical condition available from the standard primary and secondary product sections.

2. Where can the formulary and product list be found?

The WMG&F can be found on TAM under Formularies (and the Pink One), other formularies, Wound Management Guidelines and Formulary.

3. What benefits will adhering to these formularies bring?

Formularies are a standard tool for ensuring that product selection decisions are informed by best available evidence and are focussed on reducing clinical variation whilst ensuring best value is obtained from medicines and appliances, building clinical experience with a limited number of products.  Adhering to formularies generates significant and recurrent savings that are needed to preserve other clinical services.

4. What if a product is not available on the formulary to meet the clinical needs of an individual patient?

A product from the formulary should meet clinical needs in the majority of cases; we are aiming for 90% of all wound products used to be formulary products.

Non formulary products should only be used when there is a good and justifiable clinical reason to do so.  If, after a suitable trial of formulary products or the individual has a particular clinical need, there is no suitable formulary product then agreement should be sought from the Senior Charge Nurse/Team lead in conjunction with advice from an NHS Highland Tissue Viability Advanced Practice Nurse.

5. Should the updated product list be applied to the selection of products for people with new wounds or should it be applied to review products in use for people with existing wounds?

The new product list applies to the selection of products for all wounds and people who are being treated with non-formulary products should be switched to the formulary products as soon as is reasonably possible.

Where possible, make sure to use up any non-formulary products before switching to avoid waste.

6. What if a person is unhappy with a switch to a formulary product?

Listen to the person’s concern and try to understand their reasoning and provide an explanation of the rationale for the product change as part of NHS Highland policy.  If the product meets the person’s need and they agree with the change, then proceed with use of the product.  If however, the person remains concerned, share their concerns with the Senior Charge Nurse/Team Leader for resolution.

People who wish to make a complaint can do so via the NHS Highland Feedback Team.

7. Will the product list be reviewed?

Yes, the formulary products will be subject to regular review by the Tissue Viability Group. If you would like to suggest a product be added to/removed from the product list then refer to the Wound Formulary & Tissue Viability Section of the NHS Highland intranet.

8. District nursing teams are being encouraged to order wound management products they use from PECOS.  Why is this? 

There are a number of benefits to ordering products on PECOS:

1. Pecos ordering provides nurses with a readily available supply of formulary products.  Often there can be a delay in getting the right product to the individual when a prescription has to be written and dispensed.
2. Community based nurses who are not prescribers themselves do not have to wait for a prescription to be issued by a GP or another prescriber.
3. Generally, the same product is cheaper when supplied on PECOS compared to being supplied by issuing a primary care prescription.
4. Products ordered via PECOS belong to the NHS whereas products prescribed for individuals become their property.  So, a box of dressings can be split and used by a community nurse for different people rather than prescribing a separate whole box for each person.  Prescribing whole boxes of products for individuals leads to considerable waste, especially if products are changed.  Similar principles apply to all appliances.

9. How do I order products from PECOS?

The process is no different to ordering any other product via PECOS.  PECOS catalogues have been updated to reflect formulary products.  Local teams should order products in a way that suits their way of working eg setting up a system in your own team to monitor product use and stock levels and adjust quantities in future orders to reflect product usage and delivery schedules.  Setting up a recurring requisition can speed up the ordering process.

10. Does this mean nurse or other prescribers can’t issue prescriptions for these products?

No, definitely not.  There will be circumstances when there is a clinical need to use a non formulary product.  If a product is required before the next delivery is due to your base, it may be necessary to have a prescription dispensed.  Additionally, some products are not available via PECOS – these are highlighted in the product list.

11. Will all individuals have their wound management products supplied via PECOS?

Because of the advantages of ordering from PECOS for district nurse teams we recommend that all products being used by district nurses are ordered from PECOS.  This includes people in residential homes that are having their wound managed by the district nursing team.   People who are having their wound managed by someone other than a district nurse eg self care, by a nurse in a care home or by a practice nurse will still require to have their products supplied on prescription.

12. Will our team budget be affected?

Yes and No.  Yes in that more cost will be recorded against your cost centre.  And no because, at the end of an accounting period, costs will be reconciled and appropriately balanced with savings made on primary care prescribing.

13. I am a Senior Charge Nurse/Nurse Team Lead and am required to monitor my team’s compliance with the Formulary.  How will I do this?

Monitoring of products ordered on PECOS can be reviewed from your team’s monthly finance reports.  Reports detailing products that have been issued on prescription and formulary compliance are available at a district/locality level from your primary care lead pharmacist.

Click here to access form (intranet access required).