PORTSMOUTH HOSPITALS NHS TRUST

VACCUM ASSISTED CLOSURE THERAPY GUIDELINES

MANAGEMENT OF VACUUM ASSISTED CLOSURE THERAPY. Issue 1. 28.12.2006

TITLE /

Management of Vacuum Assisted Closure Therapy

MANAGER / COMMITTEE RESPONSIBLE / Tissue Viability Clinical Nurse Specialist
Mr Mark Pemberton, Vascular Consultant
NMCEC
DATE ISSUED / 28.12.2006
VERSION / 1
REVIEW DATE / December 2007
Equality Impact Assessment has been applied to this policy / B. Topley. Tissue Viability Clinical Nurse Specialist
AUTHOR / Barbara Topley Tissue Viability – Clinical Nurse Specialist
RATIFIED BY / PROFESSIONAL ADVISORY COMMITTEE – 05.12.2006
CONTENTS:
1.INTRODUCTION
2.STATUS
3.PURPOSE
4.SCOPE/AUDIENCE
5.DEFINITIONS
6.CLINICAL PRACTICE GUIDANCE
7.SUPPORTING EVIDENCE
8.ASSOCIATED DOCUMENTATION
9.DUTIES AND RESPONSIBILITIES and Audit Standards/Audit Tool
10.TRAINING
APPENDICES:
1.FLOW CHART FOR VAC THERAPY
2.INDICATIONS FOR USE OF VAC THERAPY
3.THE DIFFERENT TYPES OF VAC DEVICES, CANISTERS AND DRESSINGS
4.PRESSURE SETTINGS
5.SAFE DISCHARGE
6.COMPETENCY LEVELS
  1. INTRODUCTION
Vacuum Assisted Closure (VAC) is a therapy that can be used on a variety of acute and chronic wounds to achieve either wound closure or prepare the wound bed for further surgical interventions. It has the potential to reduce morbidity and mortality associated with chronic wounds, is an alternative treatment modality when other conventional treatments fail or if patients are unable to undergo surgery. Appropriate use of this therapy has the potential to reduce length of hospital stay, reduce the risk of healthcare associated infections and improve patients’ quality of life.
  1. STATUS
Clinical Guideline
  1. PURPOSE
This guideline has been developed to support nurses to manage a wide variety of wounds using VAC therapy appropriately and safely at all Competency Levels.
  1. SCOPE/AUDIENCE
This guideline applies to all healthcare professionals who have been deemed competent to apply VAC therapy on the QA site within the Surgical division, Dept of Critical Care, Renal Unit. It may be applied on the RHH site but only with the support of Senior Nursing Staff in Plastics. A practitioner who can demonstrate detailed knowledge of the device; its application and uses as well as its side effects must only prescribe VAC therapy.
Patients requiring VAC therapy outside of the above departments must be discussed with Tissue Viability and the surgical division prior to commencing treatment.
  1. DEFINITIONS
Chronic wounds can be described as wounds that have not responded to surgical or medical treatment and are more likely to be present in the elderly or in people with multi-system failure1. Chronic wounds include pressure ulcers, venous and arterial leg ulcers, diabetic foot ulcers and fungating wounds. Acute wounds are those that usually heal without complications, for example: surgical incisions on a healthy patient. However any wound can develop complications that can lead to delays in wound healing2. Patients with complex wounds invariably have complicated, underlying health problems with multi-factorial clinical signs and symptoms that will deal wound healing3.
  1. CLINICAL PRACTICE GUIDANCE

Action / Rationale
A Competent Level 3 trained staff should carry out a thorough wound assessment on all identified patients2 / The outcome of the assessment should be documented in the Trust’s Wound Assessment and Care Plan
Wound selection criteria4, 5
Refer to (Appendix 1) / To identify suitability for VAC therapy as some wounds are contra-indicated for Vac therapy
Explain to patient reasons why VAC therapy was chosen and document in the patient’s medical records. Give patient leaflet information about VAC Therapy / VAC therapy should only commence with the agreement of the patient and their consultant
VAC therapy may be used in certain circumstances when it is contra-indicated although only with the approval of a Tissue Viability Nurse. This will need to be discussed with the patient and their relatives (Appendix 2) and documented
In these circumstances, the prescriber is accountable and responsible for the outcome of the therapy
Notify Tissue Viability Team when commencing VAC therapy but complex wounds must be referred / Tissue Viability Team will guide and support ward staff to ensure safe application of VAC therapy for all patients with complex wounds
Action / Rationale
Applying the dressings6
Refer to (Appendix 3) / PHT currently have available 3 types of pumps and 2 types of foam that can be used for applying VAC therapy
All healthcare professionals must be able to identify the differences and choose the appropriate dressings and device
Foam should not be placed directly over exposed blood vessels or organs. This should be covered with natural tissues (membranes or muscle), mesh or multiple layers of non-adherent dressings
White foam may be placed directly over Vicryl/prolene mesh, or intact peritoneum.
If there are large volumes of exudate, increase pressures by 25 – 75 mmHg until it reduces except in the management of Diabetic Feet
Vac therapy can still be applied if deep tension sutures are in situ but it is easier to dress and maintain seal if they are removed with the Consultant’s approval
If patients experience discomfort, use continuous therapy and follow Pain Assessment guidelines
If patients are on anticoagulants, ensure INR is stable and, if no evidence of active bleeding, start with lower pressure and slowly titrate to 125mmHg
Using more than one piece of foam or a combination of foams and silicone dressings / This should be recorded in the patients notes to ensure safe removal of all pieces of foam and silicone dressing if used to line the wound bed
Care should be taken when inserting foam into areas of undermining and tunnelling6 / The undermining and tunnelled areas must be measured before inserting foam into these areas
Foam should be cut 1- 2 cm longer than the tunnel measures, should be placed in the distal part of the tunnel and the end of the foam should be in contact with foam in the wound bed. This allows the distribution of higher pressures to collapse the edges of the wound together allowing the wound to granulate
Foam should be gently placed into the distal areas of undermining and not forced in. This allows the distribution of higher pressures to collapse the free areas of undermining together allowing the wound to granulate together from the distal portion
Multiple wounds / It is possible to use a bridging technique to apply VAC therapy. A Y-connector can be used if the patient has more than one wound that requires VAC therapy
Optimal therapy 4,6,7 (Appendix 4) / To optimize the benefits of VAC therapy, it should remain active
Pressure settings range between 50mmHg – 200mmHg and are set according to the wound type
It can be applied either continuously or intermittently depending on the site, volume of exudate and patient’s level of pain
If the therapy is turned off for more than 2 hours in a 24 hour period, the therapy must be discontinued and replaced with conventional dressings
Dressing changes4, 8 / The first dressings should be removed out after the first 48 hours
Subsequent dressing changes: 2 or 3 times weekly depending on foam used and if interface dressing is used
Use non-adherent dressing to protect underlying structures
In the presence of significant infection, dressings should be changed every 12-24 hours
Changing the disposable canister / The VAC device will alarm when the canister is full and it should be changed immediately. As the canister is a single use item, it should be changed at each dressing change or if exudates is low once a week.
Action / Rationale
Monitoring the wounds9 / Wounds must be monitored for signs of complications including: bleeding, maceration, pain, odour, skin reaction, pressure damage from tubing
If there is a marked deterioration in the wound, or the surrounding skin or if the wound becomes very dry, VAC therapy should be discontinued and medical staff informed
The therapy should be discontinued immediately if there is rapid bleeding and medical staff informed
The wound must be monitored to ensure that the therapy is maintained
The Tissue Viability Team should be contacted for further advice
Management of fistula6 / VAC therapy can assist in the healing of enteric fistula although results cannot be guaranteed. Refer to the Tissue Viability Team or a Level 4 Practitioner and the patient’s Consultant before applying VAC therapy
Infected wounds10 / More frequent dressings changes may be necessary
Observe and report clinical signs of infection to medical staff
Odour6, 8 / Interaction between foam and exudate may cause odour and dressings may need to be changed more frequently
Increasing odour could indicate infection and medical staff should be informed
Pain2, 4,9 / All patients to undergo a pain assessment as analgesics will be required at dressing changes or when VAC therapy is applied
There are also rare occasions when patients may have to go to Theatre initially to have the dressings changed
Consult with Acute Pain Team as necessary
If patients report continuous pain, not controlled by analgesia, VAC therapy can be reduced in increments of 25mmHg until pain is relieved
This can be titrated up as the pain improves or is controlled
Increased pain may indicate infection in the wound therefore medical staff should be informed. VAC therapy may need to be discontinued if pain is not controlled
Bleeding9 / Blood stained exudates is common as a wound heals as granulation tissue is well vascularised and easily traumatised .
If rapid bleeding (haemorrhaging) into canister, VAC therapy must be discontinued immediately and medical team informed
Rapid granulation tissue formation may result in ingress of tissue into foam and cause bleeding on removal. To reduce the risk a silicone interface dressing (Mepitel) can be used
If foam adheres to the wound bed, to avoid trauma and bleeding, saline can be used to soak the foam dressing prior to its removal
Skin reaction / Occasionally patients may experience a skin reaction to the drape. Cavilon Film or Duoderm Thin can be used to protect the peri-wound skin
Prevention of pressure damage from tubing4 / The tubing from the dressing can potentially cause pressure damage. Care should be taken to avoid this when placing the tube into the foam. To minimise pressure from tubing over areas of skin/bony prominences, spare foam can be used to cushion the tubing
Discontinuation of therapy4, 9 / VAC therapy should be discontinued:
  • When the aim of the therapy has been met
  • If no improvement in wound after 2 applications of therapy
  • If ward staff are unable to maintain therapy
  • If there is active bleeding
  • If there is a deterioration in the wound

Action / Rationale
Discharge planning
(Appendix 5) / The Tissue Viability Team must be informed of patients being discharged on VAC therapy.
Staff to ensure competency of community staff who will continue therapy post discharge.
Teaching to be organised if deficit in knowledge base identified. This may result in a delayed discharge
District Nurses must be contacted and there consent obtained for continuing VAC therapy on patients at home
Staff must ensure patient’s will be safe at home whilst continuing VAC therapy. i.e. risk of trips, falls etc.
Check list to be completed and returned to Tissue Viability Office
Patients can be reviewed in Tissue Viability Outpatient Clinic or as a ward attendee
Transferring patients to other hospitals / Ward staff must contact the Tissue Viability Department before a patient is transferred outside PHT with VAC therapy. If unable to contact the Department out of hours or at weekends, VAC therapy should be removed and conventional dressings applied. This is to ensure PHT equipment is not lost and always accounted for.
It is the ward staff responsibility to communicate recommended ongoing care to the receiving hospital.
  1. SUPPORTING EVIDENCE
Specific references
Specific references
  1. BENBOW M (1995), Intrinsic factors affecting the management of chronic wounds, British Journal of Nursing 4 (7) pp 407-410
  2. Flanagan M (1997) Wound management Churchill Livingstone
  3. BUTCHER M (1999) A systematic approach to complex wounds, Nursing Standard 15 (29) pp58-64
  4. Argenta L C & Morykwas MJ (1997) Vacuum-Assisted Closure: A New Method for Wound Control and Treatment: Clinical Experience Annals of Plastic Surgery 38 (6) pp563-576
  5. Thomas S (2001), An introduction to the use of vacuum assisted closure, World Wide Wounds http//
  6. KCI Medical (2003), VAC Therapy Clinical guidelines, Oxfordshire
  7. Morykwas M J, Argenta L C, Shelton-Brown E I et al (1997), Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation, Annals of Plastic Surgery 38 pp 553-562
  8. DeFranzo A J, Argenta L C, Marks M W, Molnar J A, David L R, Webb L X, Ward W G, MCCALLON S K, Knight C A, Valiulus J P, Cunningham M W, McCulloch J M, Farinas L P (2000) Vacuum-Assisted Closure versus Saline-Moistened Gauze in the Healing of Postoperative Diabetic Foot Wounds Ostomy/Wound Management 46 (8) pp 28-34
  9. Banwell P E & Teot L (2003), Topical negative pressure (TNP): the evolution of a novel wound therapy Journal of Wound Care 12(1) pp22- 28
  10. Tang A T M, OKRI S K, Haw M P (2000) Vacuum-assisted closure to treat deep sternal wound infection following cardiac surgery Journal of Wound Care 9 (5) pp 229-231
  11. Medical Devices Agency (2000) Equipped to Care: The safe use of medical devices in the 21st century Medical Devices Agency London
  12. Nursing & Midwifery Council (2004) The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics NMC

8. ASSOCIATED DOCUMENTATION
Competencies for VAC therapy – Levels 1 – 4
Wound Assessment and Care Plan
Flow chart
Discharge protocol
General information leaflet
Further reading
Collier M (2003), Topical negative pressure Nursing Times 99(5) pp54
Evans L& Land L (2004), Topical negative pressure for treating chronic wounds
Cochrane Database of Systematic Reviews 3

Higgins S (2003), The effectiveness of vacuum assisted closure (VAC) in wound healing
Centre for Clinical Effectiveness, MONASHUniversity

Additional websites




9. DUTIES AND RESPONSIBILITIES
Members of the Tissue Viability Team are responsible for developing, implementing and monitoring this guideline.
Audit Standards/Audit Tool
Aspect of Care/outcomes / Expected Standard/Target / Source of Data Collection
All patients should undergo an holistic assessment prior to the application of VAC therapy
1. A wound assessment and care plan is completed / 100% / Patient records and Wound Assessment and Care Plan
2.The wound is evaluated at each dressing change / 100% / Patient records and Wound Assessment and Care Plan
3.All patients receive general information leaflet / 100% / Patient records and patient satisfaction survey
4. Patients discharged with VAC therapy have a discharge plan and will be followed up in the Tissue Viability Outpatient Clinic / 100% / Patient records, checklist and Tissue Viability Database
All healthcare professionals are responsible for using any medical device safely and staff applying VAC therapy must be competent (Appendix 6). The Tissue Viability Department will be responsible for maintaining a list of competent staff. The Medical Devices Training Team will be responsible for training staff at Competency Levels 1 and 2. The Tissue Viability Team will be responsible for assessing staff at Competency Levels 3 -4.
10. TRAINING
All staff using VAC therapy must have received appropriate training by attending a recognised training programme provided by either the Trust or KCI Medical11, 12. They should also have received training in wound assessment, wound management and complete the appropriate documentation. Staff must attend a training update at least every 2 years.
Staff must be assessed in clinical practice to achieve competencies from Level 1-4

APPENDIX 1

Flow Chart for VAC Therapy
APPENDIX 2

Indications for use

Indications for use5,6
Mains Powered Device / Portable Device
Acute/ traumatic wounds / Venous stasis ulcers
Sub-acute / Lower extremity diabetic ulcers
Pressure ulcers / Pressure ulcers
Chronic wounds / Lower extremity flaps
Meshed grafts / Dehisced incisions
Rotational/ free flaps
/ Grafts
Partial thickness burns
Contraindications and precautions for VAC Therapy
Fistula to organs/body cavities
Dry eschar
Untreated osteomyelitis
Malignancy in wounds
Exposed blood vessels or organs
Long term anticoagulant therapy
Haemophilia
Haemoglobinopathies, i.e. sickle cell disease

APPENDIX 3

The different types of VAC devices, canisters and dressings6

Type of pump
Classic pump:
  • 300 ml canisters
  • Must be switched on to battery manually when disconnected from the mains
  • Battery lasts 2 hours

Mini VAC pump
  • Portable
  • Uses 50 ml canisters
  • Battery operated and lasts up to 12 hours
  • Battery must be recharged
  • Facility to attach to mains

ATS pump
  • Different connection to Classic and Mini VAC
  • Uses 500 ml canisters
  • Battery lasts up to 4 hours
  • Automatic transfer to battery when disconnected from the mains

Freedom pump
  • Only available on rental
  • Not available within PHT
  • Portable pump
  • Uses 300 ml canisters
  • Has battery life of 12 hours

Recommended guidelines for foam use6

Type of wound / Black Foam / White foam (PVA) / Either
Deep, acute wounds with moderate granulation tissue present / x
Deep pressure ulcers / x
Flaps / x
Painful wounds / x
Superficial wounds / x
Tunnelling/sinus tracts/undermining / x
Deep trauma wounds / x
Wounds which require controlled growth of granulation tissue / x
Diabetic ulcers / x
Post graft placement (including bioengineered tissues) / x
Shallow chronic ulcers / x

APPENDIX 4

Optimal settings for:

Acute traumatic wounds6

Surgical wound dehiscence6

Pressure ulcers6

Initial cycle / Subsequent cycle / Target pressure (Black foam) / Target pressure
(White foam) / Dressing change interval
Continuous first 48 hours / Intermittent
5 min ON/ 2 min OFF for remaining therapy / 125 mmHg / 125-175 mmHg
Titrate up if more drainage / Every 48- 96 hours (every 12 -24 hours with infection)

Chronic ulcers

Initial cycle / Subsequent cycle / Target pressure (Black foam) / Target pressure
(White foam) / Dressing change interval
Continuous for first 48 hours / Intermittent
5 min ON/ 2 min OFF for remaining therapy / 50-125 mmHg / 125-175 mmHg
Titrate up if more drainage / Every 48- 96 hours (every 12 -24 hours with infection)

Diabetic and Peripheral Vascular Foot Wounds