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A strategic approach to maximize patient outcomes in relation to a formulary listed product

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A strategic approach to maximize patient outcomes in relation to a formulary listed product


Professor Jackie Stephen-Haynes and Moira Evans,

Worcestershire Health and Care NHS Trust, Tissue Viability Team





Implementing best practice in relation to a clinical formulary does not end at the time of the product listing. This poster will describe how an NHS organisation reviewed the implementation of a Silicone Medical Adhesive Remover (SMAR) to ensure that the clinicians were achieving the maximum clinical and financial outcomes.




Following the review of the organisation’s skin assessment guidelines (1), an audit of the use of a formulary listed product was undertaken within clinical practice across an NHS organisation with a 620,000 population. The aim was to determine whether clinicians assessed patients at risk of skin trauma following the removal of medical adhesive products.The strategy included:

  • Approval from the Area Prescribing Committee 
  • SMARS  algorithm use
  • SMARS use in Tissue Viability and continence care
  • Bespoke SMARS education power point presentation
  • Implementation  across the trust




The initial review highlighted that further work was required to broaden the educational awareness programme as evidence had been gathered from areas other than tissue viability.

The removal of urinary sheaths was one such area, where consideration could be given to the use of the SMAR to prevent post removal trauma. Following discussions with the continence team, a review was undertaken resulting in further awareness across clinicians which support the atraumatic removal of urinary sheaths by the use of the SMAR.(2)


12 months after the initial tissue viability educational events, nurses were surveyed to define the impact upon clinical practice and to assess whether the educational programme had been effective.  A patient focused survey (3) highlighted that nurses were assessing the patient’s skin type prior to the selection of a medical adhesive product. If the patient was identified at being of risk of post-removal trauma then a SMAR was used during the removal of the medical adhesive product, to maintain skin integrity.




The clinician needs to be aware of the importance of protecting fragile skin and protecting the peri-wound and peri-stoma area when removing adhesives. The removal of adhesive products will remove loosely bound epidermal cells and with repeated use of adhesive products can strip away varying amounts of the stratum corneum (superficial epidermis) layer (Dykes et al 2001 and Zillmer et al 2006.

The use of formulary listed SMARs should be given further consideration as to their potential use across other clinical specialities, as the maintenance of skin integrity is not a remit that is managed by tissue viability alone.



The evaluation of the formulary listed SMAR has identified a need for a wider inclusion of use across the Trust, which has been implemented and evaluated and a conclusion made that access to education and educational resources support the evidence based approach and can significantly affect patient outcomes. 




(1)  www.hacw.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=84166

(2)  www.wounds-uk.com/.../maintaining-skin-integrity-for-patients-using-urinary-sheaths

(3)  EP114http://ewma2016.org/fileadmin/user_upload/EWMA/pdf/EWMA_2016/361461_EWMA2016_Programme_ENG_low_Part1_NEW.pdf

(4)  Dykes PJ, Heggie R, Hill SA (2001) Effects of adhesive dressings on the stratum corneum of skin. J Wound Care 10(2): 7–10

(5)  Zillmer R, Agren MS, Gottrup F, Karlsmark T (2006) Biophysical effects of repetitive removal of adhesive dressings on peri-ulcer skin. J Wound Care 15(5): 187–91


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