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Setting up Wound Dressing Guidelines: Avoiding the Pitfalls.


Authors

David Morgan,
Director of Pharmaceutical Public Health,
North Wales Health Authority,
Preswylfa, Hendy Road,
Mold, Flintshire CH7 1PZ.

Contents


Published in World Wide Wounds: September 2000
Version: 1.0

Introduction

Wound dressings guidelines consist of an agreed, regularly revised, limited list of dressings (and associated products) and specific prescribing advice, which are used locally by a practice, directorate, trust or health authority. The aim of guidelines is to promote rational prescribing by encouraging the safe, effective, appropriate and economic use of dressings therapy. Familiarity with prescribing from a restricted list of products, promotes rational prescribing. This ensures that the right patient receives the right dressing, at the right time, in the right amount and in the right setting.

Getting Started

The use of the titles guide or guidelines is often more acceptable than formulary or protocol which may be too prescriptive for some practitioners. The guidelines should be sufficiently detailed to be clinically useful. Further information is always available in other publications and journals such as the British National Formulary (BNF), the Drug Tariff, model GP formularies [1] , the Drugs and Therapeutics Bulletin and national wound care journals. Guidelines should be written and agreed by the users of the guide. Thus, there should be wide consultation with a broad range of practitioners having an interest in wound care: in order to promote uninterrupted care and uniform prescribing across different agencies and throughout the healthcare system. The views of the prescriber are important and this not only includes the doctor but the patient (for over the counter products), the pharmacist (for pharmacy only products) and the nurse (for the nurse prescribing initiative). Occasionally, prescribing is restricted to a specialist prescriber or group eg consultant dermatologist. This approach gives a specialist the opportunity, over a defined period, to use new products and assess their efficacy.

Decisions about the use of a particular product are made after considering the efficacy, safety, patient acceptability and costs of the product or dressing. Treatment recommendations are selected on the grounds of current clinical opinion and clinical effectiveness about which there are many sources of useful information.

Gathering Data and Information

Information on current prescribing practice in primary care can be obtained by analysing manual prescribing records eg PACT/PARC and computerised prescribing and analysis systems eg PIAS (in Wales). Pharmaceutical advisers in health authorities have access to these manual and on-line sources of information. Similar information is available for hospitals but usually only at a local level. All hospital pharmacy departments have computerised prescribing systems. Most health authorities will have a drug information department which is usually associated with a pharmacy department in a hospital and the facilities are generally available to health professionals. Other sources of information have also recently been identified [2] , [3] .

The Cochrane Collaboration, founded in 1993, is an international network committed to preparing, maintaining and disseminating systematic reviews. The reviews cover research evidence (usually randomised controlled trials, RCTs) on prevention, treatment and rehabilitation of particular health problems, including wound care and treatment. Within the Collaboration, the UK Cochrane Centre (UKCC) supports people within the UK who contribute to the Collaboration's work. The main output of the UKCC, which is of relevance to all wound care advisers, is the Cochrane Library which consists of four related databases. These are regularly updated and issued four times a year as an electronic journal which is available on the Internet and also on disk and CD-ROM.

The NHS Centre for Reviews and Dissemination (CRD) was established in 1994 in the University of York and works closely with the Cochrane Centre. The CRD conducts systematic reviews in priority areas and commissions and supports experts to undertake reviews. It maintains databases of literature reviews and economic evaluations and maintains registers of reviews in progress. There is also an information and enquiry service. The CRD issues Effective Health Care Bulletins in collaboration with the Nuffield Institute and the Royal College of Physicians. To date, 26 bulletins have been published including the prevention and treatment of pressure sores [4] and implementing clinical practice guidelines [5] .

In addition, there is also a range of new clinical effectiveness bulletins eg Bandolier (Pain Relief Unit, the Churchill Hospital, Oxford), Evidence Based Purchasing (NHS Executive, South and West, Bristol) and Clinical Effectiveness News (Clinical Effectiveness Support Unit, Llandough Hospital, South Wales).

Information will also be produced by the national demonstration projects (when they report). In Wales, there are five of these including one on pressure damage care (in Dyfed/Powys Health Authority). In promoting action on clinical effectiveness, in England, the Kings Fund are looking at both leg ulcers and pressure sores.

The Surgical Materials Testing Laboratory (Bridgend) and the Welsh Value for Money Unit have established a World Wide Web site on the internet. This is called the Wound Management Practice Resource Centre and is a source of free, independent information on dressings and medical devices. The address of the web site is http://www.smtl.co.uk.

Clinical guidelines are available from many national sources. They have been produced by the DoH (tel: 01937 840250) on pressure sores, venous insufficiency and wound care and by the Scottish Intercollegiate Guideline Network, SIGN, (Tel: 0131 2257324). A consensus committee has classified pressure sores [6] and a literature review is available on a strategy for major clinical guidelines on the prevention and management of pressure sores [7] .

Policies and guidelines are available from many local trusts. Bolton Hospital Trust have reviewed wound care and produced guidelines for practice [8] . Other nursing led guidelines are in production for leg ulcers [9] and pressure sores [10] .

The pharmaceutical industry already produces algorithms, clinical pathways and care maps. There is a challenge here to the national organisations, the Tissue Viability Society, the Wound Care Society, the European Wound Management Association and the European Tissue Repair Society, to produce independently evaluated information based on evidence based practice.

Format and Content of a Guide

The guide should be printed in a size which can be carried in a pocket, or incorporated into an existing handbook, and regularly consulted. It must be readily updatable and have an index.

The development of wound management guidelines has been discussed in previous articles [11] [12] [13] [14] . The format of the guide can be constructed by

Table 1. Product groups
  • traditional dressings (gauze, cotton wool, lint, gamgee etc.);
  • low-adherent dressings (13 products);
  • vapour permeable films/membranes (20 products);
  • hydrogels (10 products including 6 gels);
  • hydrocolloids (13 products);
  • polysaccharide dressings (6 products);
  • alginates (16 products);
  • foams (10 products);
  • de-odorisers (10 products);
  • paste bandages (10 products);
  • tulles, plain and medicated (11 products);
  • desloughing agents (15 products);
  • anti-microbials (many products):

Table 2. Particular wounds:
  • venous ulcers;
  • arterial ulcers;
  • pressure ulcers;
  • diabetic ulcers;
  • burns/scalds.

Table 3. Wound types
  • unbroken skin;
  • epithelialising;
  • open, superficial, granulating;
  • deep, granulating;
  • exuding - low, medium, high;
  • sloughy;
  • infected;
  • necrotic;
  • fungating;
  • malodorous;
  • oedematous.

Table 4. Colour classification format:
  • pink - epithelisation;
  • red - granulating;
  • yellow - sloughy;
  • green - infected;
  • black - necrotic.

The guide should not just consist of a list of products but should contain prescribing guidelines and other useful information eg:

Table 5. Brief information about products:
  • name and manufacturer;
  • classification, FP10 status;
  • product description/constituents;
  • indications/contra-indications;
  • method of use;
  • application;
  • side effects/adverse reactions;
  • warnings and precautions;
  • prescribing points.

Table 6. Examples of products to be avoided:
  • alcoholic solutions - fix skin cells and delay healing;
  • antiseptics - doubtful value;
  • cetrimide products - toxic at low concentrations;
  • chlorinated solutions - better alternatives available;
  • Crystal Violet - carcinogenic dye;
  • eggs - prohibited by the Department of Health;
  • Fucidin Intertulle - topical antibiotic, contains lanolin;
  • Sofra-Tulle - topical antibiotic, contains lanolin;
  • topical antibiotics - induce resistance and sensitisation.

Managing the Guidelines System

The guide has to be continually managed for it to be useful and effective. This requires a local infrastructure and resources. Otherwise, the guide quickly falls out of date and is relegated to gathering dust on the bookshelf. Thus, the guide must be regularly monitored, reviewed and updated. This should be carried out by the local group of practitioners who have an interest in prescribing and applying dressings.

Feedback should be actively sought from users of the guide. Raw data and changes in clinical practice can be obtained from computerised prescribing systems. Recommendations are required about the use of new dressings and products as they are launched and consequent resource implications. This may involve the completion of a new product proforma, outside assessment and a probationary period of clinical assessment. Discontinued products will need to be excluded from the guide. Only products listed in the guide will be stocked in the hospital pharmacy or stores; non-formulary products are not stocked.

The minimum standard for any workplace is that there is a guide which is regularly reviewed and updated. Where there is good practice, the guide contains specific in-house wound care guidelines and restricted prescribing for certain products. A computerised prescribing system is used to monitor the guide against specific prescribers.

Audit

The guide should be subject to audit and this may be done by asking questions using a structure, process and outcome model:

Structure:

Process:

Outcome:

The guidelines can be used for clinical prescribing audit purposes. This will continually improve prescribing performance and result in better wound care and management.

Pitfalls

Conclusion

A wound dressings guide is an agreed, regularly revised, limited list of dressings (and associated products) which is used locally. The aim of guidelines is to promote rational prescribing.

All treatment recommendations are selected on the grounds of current clinical opinion and clinical effectiveness. Randomised controlled trials are the gold standard [15]! There should be wide consultation with a broad range of practitioners. Decisions are made after considering the efficacy, safety, patient acceptability and costs of the dressings.

Guidelines must be regularly monitored, reviewed and updated by local groups of practitioners. Recommendations are required about the use of new dressings and products as they are launched and consequent resource implications. The guidelines should be subject to clinical audit, for example, by using a structure, process, outcome method.

These arrangements will ensure that pitfalls are avoided in developing and using guidelines. If local practitioners are not involved in the production of the guidelines, there will be no ownership or commitment to using them. Thus, they will quickly fall out of date and become redundant.

References

1 - Grampian Medicines Committee Grampian Formulary. Aberdeen: the Committee, 1995

2 - Yeoh, J. Finding information in tissue viability. Journal of Tissue Viability 1996; 6(3): 79-81.

3 - Medicines Resource Centre. Sources of evaluated information on clinical effectiveness. MeReC Briefing. Liverpool: Liverpool Health Authority, 1997; 11: 1-12.

4 - Cullen V, Deeks J, Fletcher A, Long A, Mouneinne H, Sheldon T et al. The prevention and treatment of pressure sores. Effective Health Care 1995; 2(1).

5 - Davis J, Freemantle N, Grimshaw J, Hunvitz B, Long A, Russell I, et al. Implementing clinical practice guidelines. Effective Health Care 1994; 1(8).

6 - Consensus Committee. Towards a consensus classification of pressure sores. Journal of Wound Care 1994; 3(3): 157-160.

7 - Hitch S. NHS Executive Nursing Directorate. Strategy for major clinical guidelines. Prevention and management of pressure sores - a literature review. Journal of Tissue Viability 1995; 5(1): 3-25.

8 - Davey L, Solomon JM, Freeborn SF. A multi-disciplinary approach to wound care. An examination of the process by which a health-care team reviewed wound care and produced guidelines for practice. Journal of Wound Care 1994; 3(5): 249-252.

9 - Royal College of Nursing. Management of leg ulcers. In press.

10 - Royal College of Nursing. Pressure sores. In press.

11 - Morgan DA. Development of a wound management policy: Part 1. Pharmaceutical Journal 1990; 244: 295-7.

12 - Morgan DA. Development of a wound management policy: Part 2. Pharmaceutical Journal 1990; 244: 358-9.

13 - Morgan DA. Wound management: which dressing?. Pharmaceutical Journal 1993; 250: 738-743.

14 - Morgan DA. Establishing a dressings formulary. British Journal of Nursing 1994; 3(8): 387-392.

15 - Cullum N. Evaluation of treatments for wounds in clinical trials. Journal of Wound Care 1996; 5(1): 8-9.


This article was originally published in the Journal of Tissue Viability 1998, Vol 8, No 3, pages 5-8. The copyright of this article remains with the Tissue Viability Society.


All materials copyright © 1992-Feb 2001 by SMTL, March 2001 et seq by SMTL unless otherwise stated.

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