Setting up Wound Dressing Guidelines: Avoiding the Pitfalls.

Introduction

Getting Started

• staff in a GP practice;
• staff in a particular locality eg community hospital/clinic;
• directorate staff;
• acute or community trust committee;
• drugs and therapeutics committee;
• pressure or leg ulcer or burns group;
• health authority prescribing committee;
• joint hospital/GP group

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

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

• product group (Table 1). Products are selected from each of the groups and advice is given on their use for wounds;
• by particular wound (Table 2). The care and management of particular wounds is detailed;
• by wound type (Table 3). The care and management of particular wound types is detailed;
• by colour classification (Table 4). This is similar to wound types (above) but uses colour to identify different wounds.

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:

• first and second line recommendations;
• brief information about selected products (table 5);
• availability of products in both primary and secondary care;
• use of secondary dressings;
• product costs (unit costs or costs per day);
• products to be avoided (table 6).
• treatment protocols. Subject areas could be the use of anti-microbial agents, the use of pressure relieving devices, the use of compression, or the management of leg ulcers ^[15] .

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

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

Structure:

• have management arrangements been implemented?
• is computerised prescribing information available?
• is there a drugs and therapeutics committee?
• has a guide been implemented?
• are there prescribing policies or protocols?

Process:

• is there a broad range of representation on the committee?
• are regular meetings and assessments held?
• how are new products added to the guide?
• is there a policy for considering the resources required for using new products?
• is there a policy for the use of non-guide products?
• is there a mechanism for obtaining user feedback?

Outcome:

• is rational prescribing achieved?
• what are the budgetary issues?
• are quality indicators used to monitor the outcome of guide recommendations?

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

• the use of the title formulary like protocol, may be too prescriptive for some practitioners. Guide or guidelines may be more acceptable;
• the guide should be more than a list of products but should also contain specific guidelines eg treatment of infected wounds;
• inadequate consultation in producing guidelines may result in lack of ownership or commitment to using them;
• guidelines limit drug/product choices, thereby affecting the prescribers clinical freedom and commitment to the guidelines. Clinical responsibility, however, is also a consideration as no prescriber has the right to spend resources inefficiently;
• the availability of products in primary care should be considered when making decisions about their use in secondary care (and vice versa);
• guidelines have to be continually managed to be effective. This requires a local infrastructure and resources. Otherwise, the guidelines quickly become out of date;
• financial considerations should consider total treatment costs and cost effectiveness rather than just the products unit cost;

Conclusion

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.