Title: A case study approach to the evaluation of two polyabsorbant fibre dressings, one with TLC-NOSF and the other with TLC-Ag
Processes Required for Implementing Evidenced Based Practice into a Trust
It is recognised that the prevalence for leg ulcers is a financial burden to the NHS (1). These wound types require specialist intervention and a plan of care with the patients agreement. Healing challenging wounds is often multifaceted, even when the patient is 100% concordant. Therefore patients who become disheartened due to the length of time their leg wound is present, often leads to appointments being missed and patient non-concordance with the agreed planned care. Recently the National Institute for Health and Care Excellence (NICE) have engendered a new medical technologies guidance [MTG42] for treating leg ulcers, therefore, for the Trust the NICE resources evidenced based leg ulcer pathway is being adapted for use. Recommendations from MTG42 discusses adopting a range of treatments that are associated with increased wound healing for leg ulcers due to the Technology-Lipidocolloid, Nano Oligosaccharide Factor (TLC-NOSF) technology. Within the resources pathway additional dressings are included such as a poly-absorbent fibre with silver dressing.
Although the TLC-NOSF contact layer was already on the local formulary the TLC-NOSF with poly-absorbent fibres and the poly-absorbent fibre with silver was not. As these additional dressings were not available on the local formulary evaluations commenced to meet the formulary inclusion process. The silver poly-absorbent fibre dressing had not previously been evaluated for formulary inclusion within the Trust, so patients with suitable wounds were selected to allow the clinicians to determine the desloughing actions as well as to have experience with and evaluate these new dressings.
Case Study 1:
A 59 year old lady with bilateral venous leg ulcers had discoloured and friable granulation tissue, peri-wound erythema and localised pain, all recognised signs of local infection. The wound bed had 50% slough and 50% unhealthy granulation tissue present. The combined poly-absorbent fibres with silver has been shown to remove wound debris and biofilms and by day 11 the signs of local infection had minimised. Due to the patient’s previous experiences of recurring wound infections, no change in care was made and the treatment continued for 4 weeks prior to progressing away from the antimicrobial dressing. At this time, the wounds had improved to 60% healthy granulation tissue, 10% slough and 30% epithelialisation, which were positive changes for this lady as ‘there hadn’t been any progress for many months’. The clinic staff recorded the overall performance as excellent for non-adherence to the wound bed and ease of removal; very good for reduction in signs of infection, ability to clean the wound bed and patient comfort during dressing removal and good for patient comfort during wear. Due to the historical wound infections the patient was reluctant to move away from this successful treatment however, it is planned at the next dressing change to progress onto the TLC-NOSF treatment.
Case Study 2:
An 80 year old female patient with venous leg ulcers of more than 12 months was initiated on the silver poly-absorbent fibre dressing. Her lateral ulcer with 100% granulation tissue measured 3cm x 3cm and the medial wound with 80% slough and 20% granulation tissue measured 6.5cm x 4cm. Pain, malodour, local warmth, friable granulation tissue and high exudate levels were all clear indications of local infection. After 2 weeks the lateral wound showed no signs of infection and therefore treatment progressed onto the protease inhibitor with poly-absorbent fibres and was healed at the first planned dressing change.
The medial wound, continued to be treated within the leg ulcer clinic twice weekly until there were no signs of infection when the protease inhibitory treatment commenced. The clinic staff have recorded that this treatment met the evaluation objectives but sadly a wound recurrence has ensued and therefore, treatment has recommenced.
Case Study 3:
A 64-year-old male patient attended Leg Ulcer clinic presenting with a Venous Leg Ulcer. He had 3 ulcers that had appeared 3 months earlier, measuring 2cm x 3cm, 4cm x 2.5cm and 1cm x 0.5cm. This gentleman was determined to be self-managing therefore a leg ulcer hosiery kit was used to provide his compression therapy. He returned to clinic at 6 weeks by which time all 3 ulcers were fully healed.
Discussion and Conclusion:
The Clinicians state that both treatments were easy to use, conform to the wound area, can be removed with ease, with no adherence noted. The patients have not reported any discomfort from the dressings or increase of pain but have commented on the positive progress of their ulcers.
The next step is that the wound care formulary group will consider the TLC-NOSF poly-absorbent fibre treatment and poly-absorbent fibre dressing with silver for formulary inclusion, allowing other clinicians involved in the care of leg ulcers to provide their patients with equity of care.
The Leg Ulcer pathway is currently going through the Trust governance process and it is hoped that the NICE associated pathway will be fully implemented for all patients with a leg ulceration in the near future.