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TEMPLATE FOR MANAGEMENT 

Developing a 

negative pressure 

wound therapy 

service 

THE IMPORTANCE OF AUDIT 

THE ROLE OF QUALITY IMPROVEMENT 

HOW TO MAKE THE CASE FOR A MANAGED 

SERVICE 

INTRODUCING A NPWT SERVICE IN DIFFERENT 

HEALTHCARE SYSTEMS

SUPPORTED BY AN 

EDUCATIONAL GRANT 

FROM KCI 

The views expressed in this 

publication are those of the authors 

and do not necessarily reflect those 

of KCI. 

© WOUNDS INTERNATIONAL 

2010 

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TO REFERENCE THIS DOCUMENT 

CITE THE FOLLOWING: 

Template for Management: Developing a 

negative pressure wound therapy service. 

London: Wounds International, 2010. 

WOUNDS INTERNATIONAL EDITOR 

Suzie Calne 

SENIOR EDITORIAL ADVISOR 

Keith Harding 

Professor of Rehabilitation Medicine (Wound Healing) 

Head of Department of Dermatology and Wound Healing 

Cardiff University, Cardiff, UK 

EDITORIAL BOARD 

Franco Bassetto 

Plastic Surgeon, Clinic of Plastic Surgery 

Department of Medical Surgical Specialties 

University Hospital of Padova 

Padova, Italy 

Andreas Bruhin 

Consultant, Department of Trauma and Visceral Surgery 

Kantonsspital Luzern 

Luzern, Switzerland 

Paul Trueman 

Director, Health Economics Research Group (HERG) 

Professor of Health Economics 

Brunel University, London, UK 

Stella Vig 

Consultant Vascular and General Surgeon 

Mayday University Hospital, Surrey, UK 

Kathryn Vowden 

Nurse Consultant, Acute and Chronic Wound Care 

Bradford Teaching Hospitals 

NHS Foundation Trust and University of Bradford, UK 

Kevin Williams 

Matron, Royal Devon and Exeter (Wonford) Hospital 

Exeter, UK 

Christian Willy 

Professor of Surgery 

Military Hospital Ulm, Germany 

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This practical document is a 

Template for management 

and is designed to support 

healthcare professionals and 

managers in developing and 

introducing a managed 

negative pressure wound 

therapy (NPWT) service. By 

providing clear guidance on 

how to secure funding and 

how to set up an effective 

service, this document aims 

to enhance provision of care 

and ensure all patients 

receive appropriate therapy 

when they need it and in the 

desired setting. 

1. Vascular Surgeon, Bradford 

Teaching Hospitals NHS 

Foundation Trust and University of 

Bradford, Bradford, UK; 

2. Nurse Consultant, Acute and 

Chronic Wound Care, Bradford 

Teaching Hospitals NHS 

Foundation Trust and University of 

Bradford, Bradford, UK; 

3. Professor of Rehabilitation 

Medicine (Wound Healing), Head 

of Department of Dermatology 

and Wound Healing, Cardiff 

University, Cardiff, UK 

The successful transition of innovative wound 

care products from concept to widespread 

clinical use is not only reliant upon their 

demonstrated clinical effectiveness proven by 

randomised clinical trials, but also on the 

product’s cost-effectiveness. 

Although cost-effectiveness is often inferred 

from clinical trial results, this does not always 

equate to true service costs where products are 

used across the healthcare system. Without careful 

management, and outside of the constraints of a 

clinical trial, products may be used less effectively 

and equipment downtime may be greater than 

anticipated. Controlling these variables is the key to 

the successful introduction of new therapies to the 

wider healthcare community. 

This series of articles looks at the development of 

a negative pressure wound therapy (NPWT) 

service, guiding both managers and practitioners 

through the process of establishing a business case 

and then introducing and managing a service across 

both community and hospital-based environments. 

The model described could apply equally well to the 

introduction of any advanced wound therapy. 

A number of synonyms are used to describe 

NPWT including topical negative pressure and 

vacuum therapy; the majority of the published 

research is, however, on the V.A.C.® Therapy 

(KCI Inc.) system. It is not known if alternative 

systems deliver equivalent results in terms of 

clinical or cost-effectiveness and the adoption of 

each system will therefore require separate 

modelling and business case development. 

Trueman, in the opening paper, outlines the 

economic data supporting the introduction of 

NPWT and shows how audit can be used to 

identify current practice, establish need, and 

evaluate effectiveness following introduction. 

Vig, in the second paper, looks at drivers for 

change and in particular the quality agenda and 

patient demand for new technology and 

improved outcomes, suggesting the use of the 

SIMPLE concept and audit to justify usage. 


Developing a negative pressure 

wound therapy service 

P Vowden 1 , K Vowden 2 , KG Harding 3 

Williams, in the third paper, outlines the 

strategic framework needed to develop a 

business case supporting the implementation of 

a managed service for NPWT, identifying 

stakeholders and the process of providing such a 

service. Long-term issues such as product 

maintenance, product evolution and redundancy 

and educational support need to be factored 

into such a programme and specific 

documentation, product ordering and tracking 

mechanisms established if such a service is to 

function across care divides. Certainly our 

experience establishing and monitoring such a 

service has allowed the controlled introduction 

of NPWT based on the V.A.C.® Therapy system 

across the local healthcare district with a 

planned discharge process and an established 

budgetary system straddling health providers. 

The final two papers by Willy and Bassetto et al, 

and the brief accounts by Bruhin and McGinnis 

(pp13-14), look at how NPWT has been introduced 

in different national healthcare systems, providing 

valuable insight into the different challenges facing 

healthcare professionals in Europe. Appropriate 

use of resources is an important consideration in 

the current economic climate and decisions about 

availability will often be based on the published 

scientific evidence. However, where this is lacking, 

patients should not be prevented from receiving 

therapy where it is deemed the best available 

treatment based on experience and clinical 

knowledge. Evidence of its clinical efficacy and 

cost-effectiveness using a robust system of audit is 

obviously the best way forward. Service 

development should be supported by formal 

training to ensure all clinicians are practised in 

equipment use and NPWT is used responsibly and 

effectively to improve clinical outcomes. By using 

NPWT in a more discriminating manner, it will 

improve the way it is delivered across acute and 

community settings and allow it to become an 

essential part of an integrated clinical care 

pathway. 

1

2 TEMPLATE FOR MANAGEMENT 

This paper addresses the 

issue of how audit can be 

used to contribute to the 

development of a business 

case for a negative pressure 

wound therapy (NPWT) 

service. It provides practical 

advice and examples of how 

clinicians have used audit to 

demonstrate cost savings 

using NPWT. 

Director of Health Economics 

Research Group (HERG) and 

Professor of Health Economics, 

Brunel University, London, UK 

The importance of audit in 

justifying the cost-effectiveness 

of NPWT 

P Trueman 

There is a growing body of evidence to support 

the clinical use of NPWT in the management of 

chronic wounds and some surgical wounds 1. The 

most robust studies are in chronic wounds, such 

as diabetic foot ulcers 2,3 and venous leg ulcers 4. 

However, studies have also shown NPWT to be 

effective in managing more complex wounds, 

including non-healing surgical wounds 5 and 

trauma wounds 6, although the quality of the 

evidence in these indications is often less robust 

due to the difficulties of adopting randomised 

controlled study designs in these wound types. 

ECONOMIC EVALUATION OF NPWT 

In addition to the data on clinical effectiveness, 

there is a growing body of evidence that supports 

the economic use of NPWT. Economic 

evaluations in the management of diabetic foot 

ulcers 7, surgical and traumatic wounds 8 and 

burns 9 have shown NPWT to be a cost-effective 

intervention when compared to standard 

practice. In some cases, the findings have 

suggested that NPWT may show superior clinical 

effectiveness and result in lower overall 

treatment costs, when the totality of treatment 

costs, including hospitalisations and 

complications such as amputations and 

infections, are taken into account. The quality of 

some of the economic evaluations published to 

date has been limited by the availability of high 

quality data on current treatment patterns and a 

lack of agreement on what constitutes current 

practice. In most cases, the authors of the studies 

have sought to acknowledge these limitations by 

reporting their findings in a transparent manner. 

Without a clear understanding of what 

constitutes current practice in a locality, the 

types of wounds treated and the outcomes of 

current practice, decision makers are unlikely to 

be able to determine whether NPWT can offer 

any incremental improvements in clinical and 

economic outcomes. 

As the evidence on the clinical and costeffectiveness 

of NPWT improves, inevitably there 

are increased demands from healthcare 

professionals and patients for access to this 

advanced wound care technology, together with 

an increasing consensus on its clinical 

positioning 10. For healthcare commissioners and 

planners this creates some challenges. The 

acquisition costs of NPWT devices appear to be 

relatively high compared to traditional wound 

management modalities. Furthermore, while the 

evidence from published studies appears to make 

a convincing case for NPWT in the management 

of chronic wounds, the relevance of this evidence 

to local services needs to be considered. The 

findings generated within randomised controlled 

trials are unlikely to be reproducible in clinical 

practice and the heterogeneity of patients with 

chronic wounds and approaches to service delivery 

mean that additional local evaluations may be 

necessary to support widespread adoption. 

UNDERSTANDING CURRENT PRACTICE 

THROUGH CLINICAL AUDIT 

One of the limitations of published economic 

evaluations of NPWT is the availability of evidence 

on current practice relating to the management of 

chronic wounds. While clinicians in individual 

centres may have a good understanding of the 

effectiveness of their practice, quantitative evidence 

on patient characteristics, treatment modalities and 

outcomes are frequently absent or poorly 

documented due to the difficulties involved in data 

capture and management in wound care. As a 

result, business cases are often developed on the 

basis of expert knowledge and/or opinion on many 

parameters, which will be central to determining 

whether new treatments are an effective use of

BOX 2 Designing an audit 

● Select a topic, agree why it is 

worth doing and define aims 

and objectives, eg: 

– Improve wound healing 

rates 

– Reduce the prevalence of 

chronic wounds within the 

community 

– Reduce the cost of wound 

care dressings within the 

healthcare community 

● Decide who to involve and 

when to conduct the audit 

● Define criteria (ie the aspects 

of care that need to be 

measured) and set standards 

● Assess local practice 

– decide which patients and 

care setting should be 

included/excluded 

– decide what types of 

wounds to include (chronic 

and/or acute) 

– decide what data should be 

collected, how much and 

how this is collected 

local resources. For example, evidence may be 

missing on key parameters, including the number of 

chronic wounds treated in a region over a given 

period of time, admission rates to hospital, length of 

stay, specifics of the wound management 

treatments used, and most importantly, the 

outcomes associated with treatment. 

Establishing high-quality evidence on the effect of 

current practice on these parameters is vital if we are 

to determine whether novel wound management 

modalities, such as NPWT, can provide any 

incremental benefit over current treatment. 

Clinical audit is an essential tool in this 

process. Best practice guidelines for conducting 

clinical audits have been made available by 

numerous bodies with an interest in evidencebased 

medicine, including the National Institute 

for Health and Clinical Excellence 11 in the UK. 

There is increasing recognition of the value of 

audit to better understand the nature of wound 

care and the need to collate information on 

health status in order to evaluate innovative 

wound management practice 12. 

The study by Vowden and Vowden 13 

(summarised in Box 1) provides a detailed 

picture of treatment in a locality and offers 

valuable insights into how patients with acute 

and chronic wounds are currently managed. This 

example highlights how to capture detailed 

BOX 1 Audit used to better understand wound types and treatments in one health 

authority (Adapted from the abstract on acute wounds by Vowden and Vowden, 2009 13 ) 

A survey was undertaken in 2007 across all care providers serving Bradford, UK, to provide 

robust evidence on the types of wounds currently being managed in the region, as well as 

evidence on how these were being managed and the outcomes of treatment 

1735 completed questionnaires were returned, each marking the most severe wound 

experienced by a patient, which were subsequently divided into chronic and acute wounds 

for analysis 

A total of 826 acute wounds were identified, of which 303 were traumatic wounds and 237 

primary closures with smaller numbers of other acute wound types 

In a subgroup of 96 lower limb traumatic wounds, 25 patients had wounds of 6 weeks or 

longer duration, only 3 had undergone Doppler assessment and only 2 received 

compression bandaging. Typically these wounds were of recent origin and small in size; 

however 10 people had wounds over 25cm2 in area while 3 wounds had been present for 

over 5 years 

101 (12.2%) of the wounds were considered to be infected; 37.6% of all infected acute 

wounds were not swabbed and 97 non-infected wounds were swabbed. Where wounds 

were swabbed 4.5% were found to be MRSA positive 

Across all acute wound types (with the sole exception of primary closures) antimicrobial 

wound dressings were the most prevalent form of dressing and covered 56 (55.4%) of all 

infected wounds 

The authors concluded that this work provided a better understanding of current wound 

management practices in the region and gave detailed information on particular wound 

types against which novel treatments can be compared 


information. The key reasons for undertaking 

this audit were as follows: 

● To understand the current burden of wounds 

in a healthcare setting 

● To understand what resources are being 

consumed in managing wounds 

● To understand the types of wounds being 

treated 

● To provide a baseline for quality improvement 

initiatives. 

Audits of this type may be conducted 

prospectively or retrospectively. Adopting a 

retrospective approach, however, demands 

detailed and accurate patient records and as such 

may be more applicable to insurance-based 

health systems, where detailed patient records are 

available. Issues for consideration when designing 

an audit include which patients and care settings 

should be included and the most appropriate time 

to conduct the audit (Box 2). Attempts should 

also be made to ensure that the audits are 

designed to be naturalistic, providing a fair 

reflection of current practice. This means avoiding 

weekends or holiday periods that may reflect 

atypical patterns. In addition, consideration should 

be given to how the audit is to be used, eg as a 

comparative audit between sites, to monitor 

change before and after the introduction of new 

treatment practices, or to examine improvement 

over time. 

DETERMINING THE EFFECTIVENESS OF 

NOVEL THERAPIES 

Establishing the nature of current treatment 

provides a baseline against which novel therapies 

can be compared to determine whether the 

benefits presented in a business case are realised 

in practice. By conducting audits prior to and 

subsequent to the implementation of a new 

therapy, individual centres can generate a crude 

‘before-and-after’ evaluation. This type of study 

lends itself to interventions where randomised 

controlled trials may be difficult to conduct. This 

could be for any number of reasons, including 

difficulties in recruiting patients to a study, the 

ethics of randomisation or simply practical 

problems involved in conducting a trial, including 

the cost and time involved. 

Observational studies, such as before and 

after analyses using audits, inevitably generate 

weaker evidence than randomised controlled 

trials. Such studies are unable to control for the 

3


BOX 3 Impact of NPWT on 

pressure ulcer care (Adapted 

from Schwien et al, 2005 14 ) 

A retrospective study was 

conducted in the US to 

determine the prevalence of 

Stage III and Stage IV pressure 

ulcers in the home health 

population and to quantify the 

impact of NPWT in reducing 

acute care hospitalisations and 

emergent care in general, and 

wound infection or deteriorating 

wound status in particular 

Data from 1.94 million wound 

care assessments in 2003 and 

2004 were evaluated to 

estimate pressure ulcer 

prevalence and a retrospective 

matched group analysis 

compared patients using (n=60) 

and not using (n=2,288) NPWT 

In 2003, 6.9% and in 2004, 7% 

of patients had pressure ulcers 

at the start of care. Of these, 

23% were Stage III or Stage IV 

and 31% were ‘not healing’ 

In the matched analysis group, it 

was found that those receiving 

NPWT experienced lower rates 

of hospitalisation (35% versus 

48%, p

BOX 4 Two methods for 

assessing cost in relation to 

outcomes of treatment 

Cost-effectiveness analysis – 

outcomes are measured in 

clinical terms, such as time to 

heal a wound 

Cost utility analysis – outcomes 

are measured by the value 

placed by patients on alternative 

health states, such as living with 

a chronic wound 

BOX 5 Audit of NPWT usage in a UK hospital 

may be unaffordable within current budgets. Most 

often this arises due to difficulties in ‘moving’ 

money between budgets; for example, savings 

that result from reductions in hospitalisations or 

adverse events cannot be readily transferred to 

dressing budgets. In these cases, there may be a 

need to prioritise who can benefit the most from a 

treatment, acknowledging that it may be 

unaffordable to provide new treatments to all 

patients who could benefit. 

In extrapolating audit data to explore the 

economic impact of new technologies, attention 

should be paid to identifying financial impacts 

that may lead to realisable cash savings (eg 

reductions in co-medications or hospitalisations) 

as well as those that may lead to opportunity 

cost savings but no cash savings (eg marginal 

reductions in nurse visits). While opportunity 

cost savings may lead to improvements in 

efficiency they should not be presented as cash 

savings that can be offset against the acquisition 

cost of a new technology. 

There is an increasing demand for business 

cases to support the adoption of new wound 

care technologies 15. Box 5 provides an 

example of the use of audit to support the 

implementation of NPWT in a UK hospital. 

CONCLUSION 

Demands for improved evidence on the clinical 

and cost-effectiveness of new technologies are 

to be welcomed, as ultimately this should lead to 

An audit was carried out at Mayday University Hospital in the UK to collect data for 

submission of a wound care business case to implement NPWT 

A care pathway was introduced with a single point of contact to authorise NPWT usage. 

Any patient with a difficult or complex wound was referred to the vascular team during an 

18-month period 

86 patients were referred from 23 different consultants and 9 different departments. The 

case mix of wounds referred was variable from Grade 3/4 pressure ulcers, diabetic foot 

wounds, dehisced surgical and obstetric wounds, arterial and venous ulcers 

21 patients were discharged early with NPWT at home. This resulted in 679 bed days saved 

for the trust and 788 for the primary care trust (PCT). The reduction in spend by the PCT 

for the extra bed days was £166,045 

75% of bed days saved were within acute and elective orthopaedic and surgical beds. It was 

estimated that 6 surgical beds could be decommissioned (saving £168,142 over the 18 

months), with a redeployment of nursing headcount to more pressured areas. In addition, a 

clear reduction of length of stay of complex patients was achieved 

The increase in productivity covered the costs of the NPWT budget for both the PCT and 

the trust, allowing the business plan to be approved 

The additional benefits of this pathway have been patient satisfaction and reduction in 

major amputations 


more efficient use of scarce healthcare resources 

allocated to wound care. However, very often 

business cases are built on assumptions and 

hypotheses that remain untested. Audit of 

current practice and the impact of new 

technologies is an effective means of testing the 

value proposition presented in a business case 

and should be more widely adopted among 

wound care specialists. 

Audit and evaluation activities should be seen 

as integral to the business case for adoption of a 

novel technology. Without them there is a danger 

that the business case is accepted without any 

form of validation to determine whether the 

benefits presented can actually be realised. 

Manufacturers of new technologies should be 

encouraged to be actively engaged in supporting 

audits by providing audit templates and supporting 

resources, including staff time where appropriate. 

REFERENCES 

1. Hammond C, Clift M. Evidence Review: Vacuum assisted closure 

therapy. NHS Purchasing and Supplies Agency, Centre for Evidence 

Based Purchasing. London, June 2008. 

2. Blume PA, Walters J, Payne W, et al. Comparison of negative 

pressure wound therapy utilizing vacuum-assisted closure to 

advanced moist wound therapy in the treatment of diabetic 

foot ulcers. A multicenter, randomized controlled trial. Diabetes 

Care 2008; 31(4): 631-6. 

3. Armstrong DG, Lavery LA. Negative pressure wound therapy 

after partial diabetic foot amputation: A multi-centre 

randomised controlled trial. Lancet 2005; 366(9498): 1704-10. 

4. Vuerstaek J, Vainas T, Wuite J, et al. State-of-the-art treatment 

of chronic leg ulcers: A randomized controlled trial comparing 

vacuum-assisted closure (V.A.C.) with modern wound 

dressings. J Vasc Surg 2006; 44(5): 1029-37. 

5. Batacchi S, Matano S, Nella A, et al. Vacuum-assisted closure 

device enhances recovery of critically ill patients following 

emergency surgical procedures. Crit Care 2009; 13(6): R194. 

6. Kanakaris N, Thanasas C, Keramaris N, et al. The efficacy of 

negative pressure wound therapy in the management of lower 

extremity trauma: review of clinical evidence. Injury 2007; 

38(5): S9-18. 

7. Flack S, Apelqvist J, Keith M, et al. An economic evaluation of 

VAC therapy compared with wound dressings in the treatment. 

J Wound Care 2008; 17(2): 71-8. 

8. Trueman P, Flack S, Loonstra A, Hauser T. The feasibility of using 

V.A.C. Therapy in home care patients with surgical and traumatic 

wounds in the Netherlands. Int Wound J 2008; 5(2): 225-31. 

9. Mouës CM, van den Bemd GJ, Meerding WJ, Hovius SE. An 

economic evaluation of the use of TNP on full-thickness 

wounds. J Wound Care 2005; 14(5): 224–7. 

10. Armstrong DG, Attinger CE, Boulton AJ, et al. Guidelines 

regarding negative wound therapy (NPWT) in the diabetic foot. 

Ostomy Wound Manage 2004; 50(4B Suppl): 3S-27S. 

11. National Institute for Health and Clinical Excellence. Principles of 

Best Practice in Clinical Audit. London: NICE, 2002. 

12. Haworth M. Wound care teams: redesigning community nursing 

services. Br J Community Nurs 2009; 14(9 Suppl): S16-22. 

13. Vowden KR, Vowden P. A survey of wound care provision 

within one English health care district. J Tissue Viability 2009; 

18(1): 2-6. 

14. Schwien T, Gilbert J, Lang C. Pressure ulcer prevalence and the 

role of negative pressure wound therapy in home health quality 

outcomes. Ostomy Wound Manage 2005; 51(9): 47-60. 

15. Sorenson C. The procurement landscape for medical 

developments and applications to wound care. Eurohealth 

2009; 14(3): 4-6. 

5


This paper draws on the 

introduction of quality 

improvement in the UK to 

demonstrate how this 

framework can be used to 

build a successful business 

case for negative pressure 

wound therapy (NPWT). 

Economic constraints on 

healthcare spending require 

clinicians to deliver highquality 

services with more 

effective targeting of 

resources and better 

outcomes for patients. 

Consultant Vascular and 

General Surgeon, 

Mayday University Hospital, 

Surrey, UK 

Developing a business case 

for NPWT as a value-added 

service 

S Vig 

Within the National Health Service (NHS) in 

the UK there is a drive towards Quality, 

Innovation and Productivity (QUIP) with the 

intention of delivering higher standards of 

service 1. The anticipated benefits will be 

dependent on the following: 

● efficient use of resources 

● effective partnerships 

● best practice. 

The NHS has to respond to the six 

challenges faced by all modern healthcare 

systems: ever higher patient expectations; an 

ageing society; the dawn of the information age; 

the changing nature of disease; advances in 

treatments; and a changing workforce. Globally, 

clinicians have a vital role in driving clinically 

effective and efficient treatment that recognises 

the value of clear patient pathways and 

integrated care. The challenge in the current 

financial climate is to ensure that clinicians and 

managers develop robust business plans that 

encourage both innovation and appropriate 

early adoption of new technology. 

EFFICIENT USE OF RESOURCES 

Evidence suggests that faster healing rates in 

both chronic and acute wounds can be achieved 

using advanced wound care products 2. This 

may lead to a reduction in nursing time with 

less frequent dressing changes, shorter hospital 

stays and in fewer wounds failing to heal or 

developing wound-related complications. 

The global market for advanced wound 

management was valued at US$3.6 billion in 

2008 and is forecasted to reach US$5 billion by 

2015 3. This market is dominated by the US 

(valued at more than US$1 billion in 2008), 

with a market share of 45%, which is expected 

to rise to 48% by 2015 3. Emerging markets 

include countries such as South Africa where 

the advanced wound care market was US$48 

million in 2008 and is estimated to reach 

US$117.1 million in 2015 (Figure 1) 4. 

The major drivers for the rise in healthcare 

spending will be an increase in the incidence of 

chronic wounds, including venous leg ulcers, 

diabetic foot ulcers and pressure ulcers, 

exacerbated by an ageing population 3 (Figure 2, 

see p8). Raised awareness of new treatments 

such as NPWT will add to patient expectations 

and demand for services 3,5. 

Increases in revenue or increased spend by 

the healthcare sector need to be set against the 

current challenging financial climate and, in 

particular, the reduction in the gross domestic 

product (GDP) in the UK. For the NHS, the 

Treasury has stated that ‘each primary care trust 

will have a 5.5% increase in allocations, but that 

this will be the last year of growth’. However, 

standing still will not be an option. By 2013–14 

approximately £15–20 billion will need to be 

generated from existing resources to keep pace 

with the demands of the system. In 2010–11, 

radical and innovative approaches will be 

needed to deliver the priorities set out in the 

operating framework for the NHS and these will 

need to be clinically driven 6. 

It is therefore increasingly important that any 

business case is based on an audit of current 

practice and that this provides evidence for costeffectiveness 

and efficiency (see Trueman P, 

pp2–5). For wound care, the benefits may be 

delivered over a longer time period and only 

within a clinically driven patient care pathway. 

Against the backdrop of increasing economic 

demands and the drive to do more with the 

same level of expenditure, there are many 

opportunities for clinicians to take the initiative 

and prove when and how NPWT can provide 

cost-effective wound care.

Per capita spending (US$) 

7,000 

6,000 

5,000 

4,000 

3,000 

2,000 

1,000 

0 

3517 

2884 

United States 

717 

3647 

Norway 

FIGURE 1 Healthcare spending 

in 2007, selected countries 

(Source: Frost & Sullivan 4 ) 

1684 

2403 

Switzerland 

Austria 

Belgium 

Healthcare spending, selected countries (2007) 

Private per capita spending 

Spending as % of GDP in 2007 

854 

2665 

914 

2451 

630 

2693 

France 

989 

2337 

Canada 

760 

2527 

Germany 

1018 

2110 

Australia 

Denmark 

The Netherlands 

Clinical responsibility 

It is a clinical responsibility to ensure that NPWT 

is used responsibly and effectively to improve 

clinical outcomes. It should only be authorised 

for appropriate patients, rather than using it for 

all wounds irrespective of outcomes. This 

approach would not only bankrupt any 

healthcare system, but also would not benefit 

patients. Healthcare commissioners, who are 

responsible for funding healthcare provision in 

the UK, are now discussing payment for 

integrated care within a structured framework. 

High standards of governance are expected with 

clear pathways of clinical responsibility and 

treatment goals. This is fundamental in wound 

care as the clinical pathways are only effective 

when a multidisciplinary approach is adopted. 

DEVELOPING AN EFFECTIVE PATHWAY 

FOR NPWT 

Efforts have been made to provide robust 

international consensus guidelines to identify 

TABLE 1 Incidence of acute wounds within a variety of healthcare settings 

494 

2614 

Location Patients Overall Incidence acute 

(n) wounds (%) wounds (%) 

Hurd and Posnett 8 Canada: acute care 3099 41.2 31.1 

McDermott-Scales et al 9 Ireland: community 1854 15.6 1.7 

Vowden and Vowden 10 UK: all settings 1735 100 47.6 

Santamaria et al 11 Australia: acute care 5800 49 31 

Srinivasaiah et al 12 UK: all settings 1644 12 48 

Sweden 


Public per capita spending 

Spending as % of GDP in 2050 

1165 

1927 

449 

2409 

352 

United Kingdom 

593 

2371 1938 

Italy 

431 514 

1927 

Japan 

1829 

New Zealand 

646 

1609 

Spain 

30.0 

25.0 

20.0 

15.0 

10.0 

5.0 

0.0 

% of GDP 

appropriate wound-specific criteria for NPWT. 

For example, the World Union of Wound 

Healing Societies’ consensus document 

provides guidance for clinicians wishing to 

develop integrated care pathways for NPWT 7. 

However, further work needs to specify the 

expected length of time of application and to 

describe how to develop treatment goals for 

individual patients. 

Introducing the SIMPLE concept 

When deciding whether to implement any 

advanced wound care technology, a SIMPLE 

concept can be used to ascertain its efficacy in 

individual patients. This is an acronym 

designed to facilitate sensible decision making 

and may involve asking a number of questions 

to assess whether the intervention is Safe and 

sensible, is Indicated, achieves a Measurable 

difference, offers a Patient advantage, as well 

as the Length of time to review required and 

the desired treatment Endpoint (Box 1, p8). 

Effective partnerships 

Any business case that seeks to implement a 

‘high cost’ advanced wound care technology 

needs to consider carefully the opportunities 

for the overall community; cost savings should 

be explored across all healthcare settings 

rather than simply presenting the budget for 

the setting in which the business case is to be 

submitted. As Table 1 shows, multiple studies 

7

8 


FIGURE 2 Worldwide 

prevalence of wounds (Source: 

MedMarket Diligence. Available 

at: www.mediligence.com/ 

rpt/rpt-s245.htm) 

Prevalence (millions) 

20 

15 

10 

5 

0 

102.8M 

Surgical wounds 

Traumatic wounds 

Lacerations 

BOX 1 Using the SIMPLE concept as an aid to decision-making 

Burn wounds 

(outpatient) 

Burn wounds 

(medically treated) 

Burn wounds 

(hospitalised) 

Pressure ulcers 

Patient history 

84-year-old war veteran lives independently at home and has an excellent quality of life. 

He developed a surgical site infection, resulting in a superficial dehiscence of the 

laparotomy wound, measuring 10x20cm and extending down to the fascia. 

Options 

1. Manage conservatively with a hydrocolloid dressing; superficial dressing changed 

every 24 hours 

2. Manage using NPWT; interface dressing changed every 72 hours 

S Is the intervention Safe and sensible? 

Both options are safe and sensible 

I Is it Indicated in this patient? 

Both options are indicated 

M Will it achieve a Measurable difference compared to traditional interventions? 

Both options allow wound healing and there are no randomised controlled studies 

that allow an evidence-based approach. Option 2 allows a safe and early discharge of 

a large complex wound, which is not possible with Option 1 

P Is there a Patient advantage? 

Patient wishes to maintain his independence. Option 1 does not allow the patient to 

go home. In addition, he is unable to tolerate the odour from the wound and the 

feeling that he is not in control. As the patient is slightly overweight, when he stands 

up, and if the dressing is soaked with exudate (especially towards the end of the 

day), he feels as if the dressing will fall off and it needs to be changed. This also 

limits the patient’s mobility. The patient feels more comfortable being managed with 

Option 2 and describes it as if ‘he is wearing a corset’ 

L What is the Length of time to review the wound? 

The use of Option 2 is agreed with review of the wound every 48–72 hours 

E What is the treatment Endpoint? 

The endpoint will be the safe transition to a simple wound care dressing such as a 

hydrocolloid. This will be indicated when the wound shows evidence of granulation 

tissue formation and becomes more superficial 

Worldwide wound prevalence by aetiology (2007) 

Worldwide prevalence (millions) 

CAGR 2005-14 

Venous ulcers 

Diabetic ulcers 

Amputations 

Carcinomas 

Melanoma 

Complicated skin 

cancer 

10.0 

9.0 

8.0 

7.0 

6.0 

5.0 

4.0 

3.0 

2.0 

1.0 

0.0 

Compound annual growth rate (CAGR) (%) 

have demonstrated that up to one half of all 

acute wounds may be treated within the hospital 

setting. This point stresses the need to look at 

opportunity cost savings across all healthcare 

settings. 

Within a business case, integrated care 

pathways for NPWT should be agreed by all 

stakeholders or decision makers so that the right 

treatment is made available for the right patient 

at the right time, regardless of where the patient 

is within the healthcare system 13. The 

stakeholder group should be diverse, including 

both providers and commissioners as well as 

patient groups, who are ultimately the focus of 

care. Identification of the key stakeholders is an 

important step as this also identifies the clinical 

champions, who will lead the wound care 

workforce (see Williams K, pp11–14). 

Providers will be based in both the acute 

and home care settings, but increasingly also 

the private and commercial sector. NPWT and 

consumables are often funded within 

pharmaceutical budgets, which are set by 

advisors who demand high levels of 

evidence. It is therefore important to engage 

with this group of individuals when making a 

business case.

BOX 2 Whole systems 

approach for complex wounds 

For complex wounds, such as the 

diabetic foot ulcer, there is a 

need to deliver a continuum of 

wound care in both the hospital 

and the community. Members of 

the mulitdisciplinary team will 

be involved in the following: 

● urgent debridement 

● infection control 

● offloading of the foot 

● vascular and endocrinology 

input 

● dietetic and diabetic advice 

If care is costed within a single 

budget then any benefit with 

regard to a cost saving may not 

be seen. A reduction in 

amputation rates due to such an 

intensive approach will reduce 

the overall healthcare spend 

across sectors. 

BOX 3 An example of using 

clinical audit 

The National Institute for Health 

and Clinical Excellence (NICE) in 

the UK has recently appraised 

NPWT and the open abdomen. 

As the body of evidence is 

considered inadequate to make a 

decision to withdraw or 

recommend treatment, it is 

conducting a clinical audit using 

an online data collection tool 

See www.nice.org.uk/IPG322 for 

further information and 

supporting materials for data 

collection 

Clinical care pathways are also necessary 

when adopting a whole systems approach (Box 

2). This considers all the factors and elements 

involved in managing complex wounds, 

including how the multidisciplinary team 

relates to each other and work together as a 

whole. Issues such as accountability and 

shared resources also need to be considered 14. 

Every clinician from any healthcare setting 

who signs up to the integrated care pathway 

for NPWT should be able to stop therapy once 

an appropriate treatment goal has been 

achieved. Clinicians providing care need 

educational support to ensure that the clinical 

guidelines and pathways are followed. Any 

business model should therefore also discuss 

education/training needs and clinical 

governance of clinicians. This will guarantee a 

systematic approach to maintaining and 

improving the quality of patient care. 

Manufacturers of NPWT devices need to 

demonstrate committed educational and 

clinical support 7. In addition, in-house rolling 

educational programmes should be in place to 

ensure safe and appropriate practice. 

IMPORTANCE OF AUDIT 

New adopters of NPWT should collect robust 

data on wound types, wound healing rates and 

overall outcomes to provide a comparison with 

previous wound care practice. 

This data can help providers articulate to 

commissioners the wider value of their activities. 

This is especially relevant in wound care where 

large numbers of patients develop complex 

wound-related problems that require high-cost 

hospital care and are potentially avoidable. 

A robust system of audit can therefore allow 

clinicians to collect data rapidly to add to a 

body of evidence (Box 3). This will ensure 

that this treatment is widely recommended if 

the data supports this indication. 

Telemedicine and audit 

A business case may also need to discuss 

telemedicine, which would allow a ‘specialist’ 

in wound care to assess and monitor wound 

outcomes remotely or give advice to ensure 

that a treatment outcome is achieved. This 

would also permit interrogation of a database 

to quantify types of wounds treated and wound 

healing rates (outcomes). 


A database attached to telemedicine would 

contribute to a national or international audit 

tool and does not have to be product or 

industry specific, but rather wound care 

specific. This would also provide a 

comparison of international data where 

reimbursements and indications for therapy 

remain so variable. 

NEW NHS QUALITY FRAMEWORKS 

In the UK the NHS has introduced new 

frameworks to strengthen the focus on quality. 

These both have implications for making a 

convincing business case for NPWT. 

High Quality Care for All 

The recent publication in the UK, High Quality 

Care for All, examined the delivery of high 

quality care by frontline staff. Quality of care is 

defined as clinically effective, personal and 

safe 15. This report has helped to unite clinicians 

and managers on the principle of quality and to 

focus efforts on using innovation to drive up 

both the quality of patient care and 

productivity of healthcare services. The use of 

NPWT meets these principles on a number of 

levels, allowing: 

● Safe discharge of patients with complex 

wounds, who would otherwise occupy acute 

sector beds 

● Increased efficiency of bed usage, which can 

lead to reduced bed stock and head count 

● Reduction in the number of dressings per 

week with associated time efficiencies and 

increased independence of the patient 

● Earlier discharge, which can cause less 

disruption to the patient and family/carers, 

protection from redundancy due to time off 

work and more rapid return to normal life. 

Transforming Community Services 

The Transforming Community Services agenda 16 

provides a framework for the development of 

new and innovative ways to deliver services. 

This reviews how providers can best meet the 

future needs of patients and local 

communities and how change can be 

managed when transforming these services 

for patients. 

The Transforming Community Services agenda 

has reportable indicators that allows providers 

to ‘measure what we value’. Of these, there are 

9


two quality targets that may be directly 

affected by the usage of NPWT: 

● Effectiveness in reducing complications – 

reduced incidence of grade 2 or higher 

pressure ulcers in older people treated in a 

community setting 

● Effectiveness in reducing healing times – 

increased percentage of wounds that heal in 

a specified time. 

These targets can only be achieved using a 

whole systems approach (Box 2). For example, 

a reduction in pressure ulcer development can 

only be maintained through an education 

programme for carers, enhanced nutrition 

input, management of comorbidities and 

appropriate pressure-relieving mattresses as 

well as excellence in wound care using 

appropriate dressings. 

One marker of effectiveness will be the 

percentage of wounds that heal within a 

specified time. Current users of NPWT need to 

collect data on all wounds to demonstrate 

compliance with this target. This will also add 

to a body of evidence to demonstrate the 

effectiveness of NPWT in reducing time to 

healing. 

CONCLUSION 

A business case that incorporates the clinical 

benefits and financial savings of NPWT will 

have an advantage where the costs are financed 

by a single payer across a whole system. An 

insurer-based system where home care is 

funded separately or not funded at all may not 

see this advantage. For hospitals the discharge 

of a patient to a home care setting may allow 

increased revenue return through an efficient 

use of hospital beds and reduction or 

reallocation of numbers of patients treated. 

The strengthening of focus on quality will 

help to change the way in which an integrated 

NPWT service is delivered across acute and 

community settings. This can be measured 

using performance measurement criteria with a 

greater emphasis on audit to show costefficiencies 

and allow improved access to 

higher quality care. 

Those who use and provide current NPWT 

services are best placed to design services that 

work well for patients and staff and to know 

what needs to change. The business case also 

has to demonstrate clinical and corporate 

responsibility across the sector. This requires 

identification of clinical champions who will 

lead the teams to deliver on quality, patient 

outcomes and financial governance. 

REFERENCES 

1. Department of Health. NHS 2010–2015: from good to great. 

Preventative, people-centred, productive, CM 7775. London, 

UK: The Stationery Office; 2009. Available from: 

www.dh.gov.uk/en/Publicationsandstatistics/ 

Publications/PublicationsPolicyAndGuidance/DH_109876 

(Accessed 10 March 2010). 

2. Lavery LA, Boulton AJ, Niezgoda JA, Sheehan P. A 

comparison of diabetic foot ulcer outcomes using negative 

pressure wound therapy versus historical standard of care. 

Int Wound J 2007; 4(2): 103-13. 

3. Global Advanced Wound Management: Market Analysis and 

Opportunity Assessment. GlobalData; 2009. GBDT2508721. 

4. Health spending projections through 2015: Changes on the 

horizon. San Jose, CA: Frost & Sullivan, 2009. 

5. US Markets for Current and Emerging Wound Closure 

Technologies. Irvine, CA: Medtech Insight, 2009. 

6. Department of Health. The NHS operating framework for 

England for 2010/11. London: COI; 2009. Available from: 

http://www.dh.gov.uk/en/Publicationsandstatistics/Publica 

tions/PublicationsPolicyAndGuidance/DH_110107 


7. World Union of Wound Healing Societies. Principles of best 

practice: Vacuum assisted closure: recommendations for use. A 

consensus document. London: MEP Ltd, 2008. 

8. Hurd T, Posnett J. Point prevalence of wounds in a sample 

of acute hospitals in Canada. Int Wound J 2009; 6(4): 

287-93. 

9. McDermott-Scales L, Cowman S, Gethin G. Prevalence of 

wounds in a community care setting in Ireland. J Wound 

Care 2009; 18(10): 405-17. 

10. Vowden KR, Vowden P. A survey of wound care provision 

within one English health care district. J Tissue Viability 

2009; 18(1): 2-6. 

11. Santamaria N, Carville K, Prentice J. WoundsWest: 

Identifying the prevalence of wounds within Western 

Australia’s public health system. EWMA J 2009; 9(3): 

13-9. 

12. Srinivasaiah N, Dugdall H, Barrett S, Drew PJ. A point 

prevalence survey of wounds in north-east England. J 

Wound Care 2007; 16(10): 413-6, 418-9. 

13. Welsh Assembly Government. Healthcare Quality 

Improvement Plan. Designed to Deliver. 2006. 

14. Department of Health. Working in Partnership: Developing a 

whole systems approach – self-assessment toolkit. London: 

COI, 2000. Available from: 




15. Department of Health. High Quality Care for All. NHS Next 

Stage Review Final Report. London: The Stationery Office; 

2008. Available from: 

http://www.dh.gov.uk/en/Publicationsandstatistics/ 

Publications/PublicationsPolicyAndGuidance/ 

DH_085825 (Accessed 10 March 2010). 

16. Department of Health. Transforming Community Services: 

enabling new patterns of provision. London: COI; 2009. 

Available from: 



(Accessed 10 March 2010).

This paper describes how 

to develop a business case 

for the implementation of a 

negative pressure wound 

therapy (NPWT) service. 

Successful integration of 

an advanced therapy into 

day-to-day practice 

requires a strategically 

managed approach to 

service provision. 

Matron, Royal Devon and Exeter 

(Wonford) Hospital, Exeter, UK 

Developing a strategic 

framework to implement a 

managed service for NPWT 

K Williams 

IDENTIFYING THE NEED FOR CHANGE 

Developments in the scope and use of NPWT 1-3 

have led to high demand in many specialties and 

settings. It is becoming increasingly necessary 

therefore to make NPWT available when it is 

required and for it to remain in situ as patients 

move from one healthcare setting to another. 

However, the change in responsibility during a 

transition of care often causes interruptions in 

treatment and delays in hospital discharges, 

especially when discussions around funding or 

resource application are involved 4. To ensure 

consistent, high-quality patient care there needs 

to be a robust system in place that is sufficiently 

flexible to meet the needs of individual patients 

and be effective in providing cost-effective 

treatment across different healthcare settings. 

For many hospitals this will involve adopting a 

strategic and formal framework for implementing 

NPWT. The reasons for adopting a managed 

approach to service delivery are outlined in Box 1. 

ASSESSMENT OF CURRENT PRACTICE 

A written proposal or business case is often 

essential to secure funding for a managed 

service. Box 2 outlines the key factors that need 

to be considered when preparing a business case. 

To produce a business case that involves a 

change in practice, there first needs to be an 

assessment of current practice. This will involve 

gathering data on previous practices, usage and 

costs. It is important that the data collected is 

robust and reflects previous, current and future 

predicted usage. This can be extrapolated from 

rental records from the manufacturer, patientspecific 

records, or in some cases a retrospective 

audit trail from available documentation or a 

combination of several methods. Ideally data 

should be collated from the longest available time 

prior to implementation to faciliate a credible 


comparison and to help identify the benefits of 

using NPWT in practice. This will provide a solid 

foundation for establishing what is being 

achieved and what needs to be changed. 

BOX 1 Making the case – the potential benefits 

of a managed service 

● Uses a centralised system for rental, maintenance 

and purchasing – reduction in rental costs; single 

maintenance contract paid quarterly and known 

in advance; reduced waste with all consumables 

purchased from one supplier 

● Produces accurate records, including numbers of 

patients treated, specialty, wound type, length of 

treatment and outcome 

● Eliminates delay in treatment 

● Makes transition from secondary to community care 

seamless, with more patients being treated at home 

● Reduces inappropriate use by limiting 

authorisation to those who are experienced and 

knowledgeable in the use of NPWT 

● Units are futureproof to enable technological 

advances in products to be implemented effectively 

(ie replacement of older units with newer models) 

● Supports integration of all wound treatment 

options in addition to NPWT 

BOX 2 A check list for planning a business case 

● What is your vision for the new service and what 

needs to change? 

● What are the aims of your proposal? 

● Who are your champions? 

● How would your proposal improve patient care? 

● What criteria are to be measured? Set standards 

and define how the service will be monitored to 

ensure planned benefits are realised 

● What evidence (local, national or international) 

supports this development? 

● How will costs be funded? 

● What risks are identified? 

11


BOX 3 Possible 

organisational stakeholders 

Tissue viability nurses (TVNs) 

Medical staff – eg consultants 

(trauma, plastic surgery, 

vascular, colorectal and 

orthopaedics) 

Nursing staff – eg matrons and 

lead nurses 

Medical electronics technicians 

Community representatives – eg 

nurses and general practitioners 

Company representatives 

Operating theatre staff 

Finance and procurement staff 

Portering services 

BOX 4 Factors to consider 

when planning a managed 

service 

● Who will need to be involved 

in the planning phase 

● Who will manage, monitor 

and review the implemented 

service 

● What documentation is 

needed to support the service 

● Associated considerations, eg 

who will authorise equipment 

use, provide finance etc 

An assessment of current practice should include: 

● Current and previous usage broken down into 

specialties, costs, wound types treated and 

length of stay 

● How the NPWT is currently authorised, 

accessed and applied 

● Current process of transition from hospital to 

home care (and vice versa) 

● Where the consumables and any current units 

are stored and their value 

● Evaluation of delays in discharges due to 

problems transferring patients to a home care 

setting with NPWT. 

By formulating accurate data around current 

usage and costs, wound types treated etc, it is 

possible to document supporting evidence for 

the implementation of a structured service and to 

show the consequences of doing nothing. 

A strong business case will demonstrate 

improvements in quality of care for patients and 

staff, combined with better use of time, cost 

efficiencies and potential financial savings. 

Once current practice has been assessed and 

formally documented, the next step is to look at 

what is required to resolve any current problems 

within the existing system. 

THE PLANNING TEAM 

In the planning stages, it is important that key 

organisational stakeholders (Box 3) are consulted 

to help shape what is needed and identify 

appropriate people for the planning team, who 

can assist in making the required changes to the 

service. Success will be dependent on engaging a 

limited number of people who have the required 

enthusiasm and drive, and who will act as 

‘champions’. 

This will ensure that the service is developed 

and successfully implemented in a timely and 

effective manner 5. Ideally, the individuals 

involved will be from procurement and medical 

electronics, and involve wound care specialists 

and a representative from the community. 

It is important to work within a planned and 

manageable timeframe; this will depend on many 

factors including the commitment and 

enthusiasm of those involved. 

Identifying a leader with the required 

experience and skills in change and project 

management will ensure a structured and 

considered approach. The advantage of good 

leadership during this phase will help to inspire 

others, while subsequent good management 

will ensure ongoing sustainability 6. 

DEFINING THE DESIRED SERIVICE 

By consulting with other stakeholders, the 

planning team can start to work with those who 

will be required to carry out various aspects of 

the new service, which may help to resolve any 

anticipated issues prior to implementation. 

Although healthcare settings share many 

similar structures and demands, each will have 

its own specific requirements. Therefore, before 

embarking upon setting up a managed service for 

NPWT, it is important to have a clear idea of 

what is needed and how it will be managed on a 

day-to-day basis (Box 4). 

Who will manage, monitor and review the 

implemented service? 

Responsibility for managing and overseeing the 

service on a day-to-day basis will often be 

decided by the structure within the organisation 

and how similar systems are currently managed. 

A shared responsibility between the tissue 

viability service and the medical equipment 

department can provide the optimum team for 

effective service delivery. 

The more streamlined the structure of the 

service, the less waste will be generated in time, 

money and other resources. Ideally, NPWT units 

should be maintained and issued via the current 

equipment library within the hospital. This requires 

close cooperation with the manufacturers. 

A central source will help to eliminate the ad 

hoc usage that may have previously existed, with 

all usage recorded in real time. This can prevent 

inappropriate use and facilitate more accurate 

record keeping, allowing the tissue viability team 

to monitor and review the usage of NPWT more 

easily. In addition, a retrospective audit can be 

used to identify efficacy and usage trends. 

Authorising treatment 

To ensure that NPWT is used appropriately and 

cost-effectively, it is important to identify the 

members of staff who are most qualified in its 

use and to limit the requests only to those who 

are sufficiently experienced and knowledgeable. 

The identity of the person who is responsible for 

authorising NPWT use should be known and 

issuing of the equipment withheld if its use is not 

authorised by a recognised professional. Staff

who may be considered suitable authorisers may 

include trauma and plastic surgeons, vascular 

surgeons, tissue viability nurses, orthopaedic 

surgeons, colorectal consultants and other 

specialist wound care professionals. 

Some healthcare purchasing authorities in the 

UK, however, provide a list of wound types for which 

NPWT is indicated, thus limiting individual decisionmaking. 

This may prevent some patients from 

receiving NPWT, who may benefit from treatment 7. 

In addition, it is important to assess the existing 

core competencies of staff and to meet their 

continuing education and training needs. This will 

ensure correct application by experienced and 

qualified practitioners and help to provide a 

consistent standard of service for patients. 

Documentation to support the system 

To support the single point of access, it is 

important to develop appropriate documentation 

at the outset. The use of an electronic database, 

stored on a shared network drive, combined with a 

paper ordering system can be an effective way of 

managing this, although the actual documentation 

system used will be dependent upon individual 

organisations and current methods. 

An electronic database is useful to log unit 

loans and distribution of consumables. This can 

be bespoke or part of the existing medical device 

CHALLENGES AND SOLUTIONS TO THE INTRODUCTION OF 

NPWT: A SWISS PERSPECTIVE 

Andreas Bruhin, Consultant, Department of Trauma and Visceral Surgery, Kantonsspital 

Luzern, Switzerland 

The use of experimental vacuum sealing techniques in the 1990s were seen as a 

revolution in wound care treatments. Inspired by these advances, the hospital in Luzern 

developed its own system. We experimented with different drainage systems and 

improvised using old mattresses and vacuum wall suction to carry out the first 

treatments. With time, we gained greater experience and better results within the 

hospital setting. 

In 2003, following the introduction of the first commercially available negative pressure 

wound therapy (NPWT) system, the hospital acquired a contract for leasing the 

equipment for use on inpatients. This lead to a wider use of NPWT and there was a need 

for improved understanding of its possibilities and limitations. 

Since this time, there has been a move to use vacuum assisted closure techniques in the 

outpatient clinic. However, this highlighted a lack of experience among the staff when 

using NPWT and led to the setting up of a national school to train doctors and nurses on 

the use of vacuum assisted closure. They are taught how to use the system and 

encouraged to discuss particular cases to identify problems and how to improve their 

practice. This has resulted in better use and understanding of NPWT. Today, the 

hospital is able to treat greater numbers of patients in the outpatient clinic and on an 

increasing range of complex wound types. For us, this is a new era that has only just 

begun. 


system. A paper trail for ward or unit use is 

needed to allow usage to be recorded within 

patient records and/or ward records. This will 

enable cross-charging and provides the means to 

pay for the managed service. 

By highlighting the reduction in costs and the 

ability to access the service when it is needed, 

thereby reducing the time previously spent 

sourcing equipment, should provide a strong 

argument for the implementation of a managed 

service for NPWT. 

FUNDING THE SERVICE 

In making a business case, it is important to 

agree the required funding and predict future 

funding to protect the service. Identifying specific 

cost savings is often difficult despite the fact that 

increased efficiency will save costs. There may be 

initial capital costs and add-on costs in terms of 

needing additional staff to manage the system. 

These costs may be offset by the projected 

savings in implementing a managed service as 

well as the more nebulous potential savings of 

reducing inappropriate NPWT use, eliminating 

delays in discharge, and simplifying access to 

NPWT and consumables. 

One aspect of implementing a managed 

service is that it should address the possibility 

that equipment usage will increase once access is 

made easier and more efficient. It may be 

necessary in some instances to set up a negative 

budget line in anticipation of the predicted 

income and offsetting this over a 12-month 

period. Alternatively, initial investment could be 

used, which would then create an end-of-year 

surplus to offset this. 

CONCLUSION 

Regular evaluation of healthcare services is 

increasingly important as demand and 

expectations rise and more pressure is placed on 

available resources. A centralised managed service 

allows controls to be put in place that can lead to 

more appropriate and cost-effective use of NPWT 

and inform future improvements in service 

delivery. The ethos behind this is in keeping with 

the Productive Series initiative 8, while centralising 

the service management creates consistency and 

efficiencies in this element of service provision. 

This system can also be adapted for other areas of 

service provision as the systematic approach is 

based upon lean principles. 

13

14 


It is important in planning a business case to 

have a clear idea of what is required and to be 

able to implement this in a strategic and 

managed way. The success of all aspects of this 

service is highly dependent upon identifying the 

individual who has the necessary skills to lead 

this change, including credibility and a driving 

passion to make a positive difference for patients; 

ideally this individual will also have the skills and 

abilities to drive the process from the outset, and 

to improve the pathway of patient care. 

REFERENCES 

1. Schimp VL, Worley C, Brunello S, et al. Vacuum-assisted 

closure in the treatment of gynaecologic oncologic wound 

failures. Gynecol Oncol 2004; 92(2): 586-91. 

2. Greene AK, Puder M, Roy R, et al. Microdeformational wound 

A GOOD PRACTICE EXAMPLE OF HOW TO IMPLEMENT NPWT IN THE UK 

therapy: effects on angiogenesis and matrix metalloproteinases 

in chronic wounds of 3 debilitated patients. Ann Plast Surg 

2006; 56(4): 418-22. 

3. Kilpadi DV, Stechmiller JK, Childress B, et al. Composition of 

wound fluid from pressure ulcers treated with negative 

pressure wound therapy using V.A.C ® Therapy in home health. 

Wounds 2006 18(5): 119-26. 

4. Stevens P. Vacuum-assisted closure of laparostomy wounds: 

a critical review of the literature. Int Wound J 2009; 6(4): 

259-66. 

5. Newton H, Benbow M, Hampton S, et al. TNP therapy in the 

community: findings of a national survey. Wounds UK 2006; 

2(4): 31-5. 

6. Belbin MR. Management Teams: why they succeed or fail, 3rd ed. 

Oxford: Butterworth Heinemann, 2010. 

7. Cunningham JB, Kempling JS. Implementing change in public 

sector organizations. Manage Decis 2009; 47(2): 330-44. 

8. NHS Institute for Innovation & Improvement. Helping the NHS 

to Fulfil its Potential. Warwick, UK: NHS Institute for 

Innovation and Improvement, 2009. Available at: 

http://www.institute.nhs.uk/images//documents/Quality_an 

d_value/productiveseries/productiveleaflet%20final.pdf?sou 

rce=newsletter5 (Accessed 15 March 2010). 

Elizabeth McGinnis, Tissue Viability Consultant, Leeds Teaching Hospitals NHS Trust, Leeds, UK 

Leeds Teaching Hospitals NHS Trust is one of the largest trusts in the UK. Several years ago, following the appointment of a nurse consultant for 

tissue viability, a number of issues relating to the use of NPWT were identified. These included: 

● Training, both at the implementation stage and as part of the ongoing support for staff, was inadequate. Clinical support was provided by a 

company representative, but a robust training process was lacking 

● There were no trust-approved procedural guidelines 

● There had been an almost exponential increase in the use of NPWT over the last few years within the trust 

● NPWT use had become an added cost pressure for the clinical management teams (CMTs) 

● There had been no previous audit of practice 

● Cost-effectiveness of the rental process was dependent on the timely ordering and cancellation and transfer between wards of the equipment, 

which was not apparent 

● There was a question of potential conflict of interest, ethical practice and commercial advantage when clinical staff used a company 

representative to advise on patient selection and management 

● There was no clear process for the cleaning, decontamination, maintenance and repair of the therapy unit pumps etc. 

Due to these concerns a working group was convened, which was led by the nurse consultant. Other members of the team included senior medical 

and nursing staff, business managers, supplies and health service managers and commissioner representatives. 

The group were active in producing clinical guidelines on NPWT, which were approved by the trust. In addition, an audit of practice was carried out 

that identified current use of NPWT, associated costs and described patient outcomes. This was used to develop a business case for the trust to 

ensure cost-effective use of NPWT and clinically effective care for patients. The business case included details on the use of NPWT and the risks as 

stated above; the evidence base for NPWT; and the impact of this technique on the patient experience and the trust finances. The financial 

information included details of the previous year’s expenditure and proposed future spend. At this time an allocation of capital expenditure was used 

to purchase several new NPWT devices. 

The business case also included an appraisal of the options to distribute NPWT devices to key clinical areas or to maintain these centrally and charge 

the wards a fee (30% less than the manufacturer’s rental price). The revenue from this would be used to fund a clinical nurse specialist (CNS) and the 

maintenance costs for the equipment. The CNS would be responsible for providing an equitable service for staff and patients through the training and 

support for nursing and medical staff in the trust. The business case was approved with the appointment of the CNS and all NPWT controlled 

centrally through the equipment library. 

Through the inclusion in the working group of local management and commissioning staff and the close working relationship built up by tissue 

viability services between the trusts, an agreement was reached to ensure the seamless continuation of therapy in the community following 

discharge of patients from hospital on reaching appropriate evidence-based criteria. 

Since the implementation of the business plan and appointment of the NPWT specialist nurse, an audit of patients in the local community trust has 

shown that 54 patients were discharged home with NPWT and continued therapy for an average of 23.5 days. It is estimated that there has been a 

saving on the number of inpatient days of at least two weeks for each patient. Over a year, this equates to 756 days. There have also been reports of 

increased patient satisfaction with early discharge and smooth transition of care following discharge from hospital.

In Germany the decisions 

about what treatments are 

recommended for outpatient 

and inpatient care are made 

in different ways, which has 

led to variations in the uptake 

of negative pressure wound 

therapy (NPWT) in the 

different sectors. 

FUTURE PROVISION OF 

NPWT IN GERMANY 

If NPWT is used in a more 

discriminating way and it 

becomes recognised as an 

essential part of the treatment 

algorithm for complicated 

wounds, the health insurance 

schemes will start paying for 

both hospital and outpatient 

use. This does, however, 

require separate consideration 

to be given to each indication 

and every wound, including 

when NPWT should be used, 

the therapy settings used 

(target pressure, intermittent 

or continuous cycle) frequency 

of dressing changes, type of 

foam and whether this should 

be combined with the 

instillation of fluids, the 

duration of treatment and 

expected outcome. 

Professor of Surgery, Department 

of Surgery, Military Hospital Ulm, 

Ulm, Germany 

Integrating NPWT into the 

German healthcare system 

C Willy 

In Germany, clinicians have the freedom to 

make treatment decisions for inpatients 

without restrictions. Payments are made on 

the basis of ‘diagnosis-related groups’ and 

clinicians can choose whether to prescribe 

expensive or low-cost therapies for patients. 

This has led to a high uptake in the use of 

NPWT in hospitals, with this treatment 

now considered an essential part of modern 

wound care in hospitals in Germany 1-3. 

In the outpatient sector, the range of services 

provided under the statutory health insurance 

(SHI) scheme (which covers more than 70 

million people) is determined by The Federal 

Joint Committee (G-BA). This influential 

decision-making body provides a legal 

framework for the reimbursement of medical 

treatment costs. In addition, the G-BA decides 

on the quality assurance measures to apply to 

the outpatient and inpatient sectors of the 

public health service. 

An important area of G-BA’s responsibility is 

the assessment of new methods of medical 

diagnosis and treatment. New treatments must 

receive a positive evaluation before they can be 

reimbursed by the SHI. A major obstacle to the 

inclusion of NPWT in the official catalogue of 

services for the health insurance scheme to 

date relates to a lack of documented evidence 

for the benefits of NPWT in the scientific 

literature 4. 

A decision about whether NPWT should be 

included was deferred with the result that 

NPWT has not yet become established in the 

outpatient sector. During this period, the G-BA 

agreed that there would be a project to collect 

valid scientific data for separate indications on 

patient-relevant endpoints (in particular the 

stable healing of hard-to-heal and deep 

wounds) based on a suitable number of 

cases 4. The first results will be expected from 

2011 to 2012. 

TEMPLATE FOR MANAGEMENT 15 

APPROPRIATE USE OF RESOURCES 

It is now more important than ever for NPWT to 

be used in a more discriminating way using 

local protocols and manufacturers’ guidelines to 

decide when to start and stop therapy. The 

application of NPWT has increased greatly over 

the past decade and the spectrum of its 

indications for use has been continuously 

expanded. However, this has led to the 

inappropriate use of NPWT in a number of 

cases, either because the duration of treatment 

was inadequate or other measures, such as 

plastic surgical procedures, were unnecessarily 

delayed. 

In many cases, debridement, followed by 

NPWT and a period of wound bed preparation, 

is required prior to definitive wound closure. 

The literature, as well as clinical experience, has 

shown that there have been cases where a 

change in therapy was indicated, but that this 

change was only made after a delay, if at all 5. 

For this reason, it is important to emphasise 

that a change in the wound management 

regimen should be considered if the aims of 

NPWT (promoting new granulation tissue 

formation, increasing perfusion, reducing 

oedema and removing exudate and infectious 

materials) are not achievable after two or three 

dressing changes. This will help to guide future 

use of NPWT. 

REFERENCES 

1. Horch RE. [Changing paradigms in reconstructive surgery 

by vacuum therapy?] Zentralbl Chir 2006; 131(Suppl 1): 

44-9. 

2. Willy C, von Thun-Hohenstein H, von Lubken F, et al. 

[Experimental principles of the V.A.C.-therapy – Pressure 

values in superficial soft tissue and the applied foam]. 

Zentralbl Chir 2006; 131(Suppl 1): S50-61. 

3. Willy C, Völker HU, Engelhardt M. Literature on the subject 

of vacuum therapy – review and update. Eur J Trauma Emerg 

Surg 2007; 33(1): 33-9. 

4. G-BA. The Federal Joint Committee: 2008. Available from: 

http://www.g-ba.de/informationen/beschluesse/510/ 

(Accessed 18 Mar 2010). 

5. Dieu T, Leung M, Leong J, et al. Too much vacuum-assisted 

closure. ANZ J Surg 2003; 73(12): 1057-60.


This paper provides an 

example of how a negative 

pressure wound therapy 

(NPWT) service was 

implemented in a university 

hospital in Italy and the 

surrounding area. This 

required the introduction of a 

centralised service with 

appropriately trained staff 

and minimisation of 

treatment costs with many 

patients being treated in the 

home care setting. 

1. Associate Professor of Plastic 

Surgery; 2. Plastic Surgery Resident; 

3. Health Technology Assessment 

Unit Chief; Clinic of Plastic Surgery, 

University Hospital of Padova, 

Padova, Italy 

Introducing a NPWT service 

at Padova Hospital and 

surrounding area 

F Bassetto 1 , L Lancerotto 2 , M Castoro 3 

The successful introduction of a new therapy in 

clinical practice depends on a number of factors: 

the solidity of the clinical and experimental 

scientific background supporting its efficacy; the 

social and healthcare characteristics of the area 

in which it is introduced; and the correct timing 

in relation to overall patient needs and 

knowledge development. If these points are not 

appropriately addressed, it can lead to the 

abandonment of the new therapy, with the loss 

of the potential opportunities the new approach 

may offer. 

The introduction of NPWT at Padova 

Hospital first required approval by the Health 

Technologies Evaluation Unit, an independent 

unit within the hospital that evaluates the costeffectiveness 

of each treatment with possible 

alternatives. Approval was preliminarily granted 

after a review of the published literature on 

NPWT demonstrated its efficacy both in the 

laboratory and in clinical practice. However, to 

obtain definitive approval for its widespread 

use, hospital staff had to carry out ‘trial cases’, 

which needed to support the theoretical costeffectiveness 

of NPWT. The most significant of 

these involved a number of patients with sternal 

wound dehiscence. These wounds carry a high 

risk of infection and are slow to heal, requiring a 

prolonged hospital stay. The use of NPWT 

resulted in shorter healing times, with the ability 

to manage the patients in the outpatient clinic 

after a short hospitalisation. Following the 

success of these ‘trials’, a strategy was needed 

for the implementation of NPWT at the 

hospital. 

DEVELOPING A STRATEGY FOR NPWT 

In Italy, health care is primarily a public service 

that provides all the required services at no cost 

or with minor financial participation by the 

patient. It is organised on a regional basis, with 

the coexistence of a network of minor and 

major public hospitals and of an independently 

managed territorial service (‘socio-sanitary 

districts’). This raised a number of critical issues 

when introducing a new wound care technology 

that can be used for a wide range of clinical 

applications across multiple specialties. These 

included the need to have a uniform approach 

with sufficient numbers of trained staff in each 

unit and to guarantee a quick transition from 

hospital to home care, minimising the social 

and economic costs of hospitalisation and 

optimising the cost-effectiveness of the device. 

Our strategy was to address these issues on 

multiple levels while maintaining an overall 

perspective of what needed to be achieved, 

centred around three key areas (Figure 1), as 

outlined below. 

Centralised control 

The plastic surgery clinic was identified as the 

centre of referral and all potential NPWT cases 

underwent evaluation by a plastic surgeon (on 

call 24 hours a day). For NPWT to be 

implemented it had to be considered as ‘the 

best possible option’. If the indication was 

confirmed, the device was applied by the 

requesting unit, after further approval of the 

Health Technologies Evaluation Unit. Periodical 

evaluation by the plastic surgery clinic was 

performed to decide when NPWT should be 

stopped and to plan the post-therapy strategy. 

A uniform level of dedicated staff training 

A selected number of people in each unit were 

given full responsibility for the care of all patients 

receiving NPWT. Specific workshops were set up 

for members of staff to receive intensive training 

in the practical application of NPWT.

FIGURE 1 Strategy for 

implementation of NPWT 

service at Padova Hospital and 

the surrounding area 

Selection of patients for NPWT 

Assessment by consultant plastic surgeon Is NPWT indicated/safe? 

Reduction in use of hospital beds 

Patients undergoing NPWT were discharged to 

home care whenever possible. This required 

close collaboration with the territorial health 

case districts with training of selected staff using 

practical workshops. Patients were transferred to 

low daily cost units if they lived more than 60km 

from hospital or did not have adequate family 

support and could not be discharged. 

MEASURING SUCCESS 

The success of this strategy was evident 

through the following outcomes: 

● Quick uptake of NPWT by many specialties. 

In the first 12 months, plastic surgeons were 

the primary route for referral with requests 

for its use in the following departments: 

orthopaedic, cardiac surgery, intensive care 

and chronic patient units. Reports of its 

efficacy created interest in other hospital 

departments, with request for its use in 

metabolic disorders, spinal, hand surgery, 

neurology, infectious diseases units, medical 

and general surgery clinics and geriatrics 

departments. 

● Progressive reduction in inappropriate 

requests. Evaluation by experienced plastic 

surgery specialists was effective in 

Seek approval from Health Technologies Evaluation Unit 

Padova Sanitary District 

inhabitants 

Adequate family support 

Transfer to the care of the 

Territorial Sanitary District 


CENTRALISED CONTROL 

Patient residing >60km 

Transfer to a Chronic Patient 

Unit (low daily cost) 

preventing inappropriate use of NPWT. This 

helped to justify the role of plastic surgery 

as the primary referral centre, where many 

patients were often followed up for 

definitive closure. 

● Good optimisation of costs with early 

discharge home. More patients were able 

to be treated in the home care setting, with 

staff well trained in the use of NPWT. An 

essential aspect of the strategy was the 24hour 

patient helpline for technical and 

medical enquires. This meant that patients 

could be managed successfully in both the 

hospital and home care setting. 

CONCLUSION 

The introduction of a centralised system for 

NPWT at Padova Hospital has provided many 

benefits and the Health Technologies 

Evaluation Unit has been able to evaluate the 

number of patients treated, costs and patient 

outcomes. The positive results indicate an 

improved patient service. The data collected 

will lead to further research that has the 

potential to optimise the provision of NPWT 

with possible extension to a larger number of 

units and different specialties within the 

hospital. 

17

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