Evaluating adhesive foam wound care dressings in ... - Systagenix

Wounds UKEvaluating adhesive foam woundcare dressings in clinical practiceVictoria PeachThis article was published in the Wounds UK Journal 2012, Vol 8, No 3

Evaluating adhesive foamwound care dressings inclinical practiceAbstractBackground: Tissue viability nurses have an important role inensuring that product choice is cost effective and meets therequirements of the patient population, enabling quality care tobe provided. Identified as the most commonly used wound careproduct, foams account for a significant proportion of healthcareexpenditure (Bianchi et al, 2011). Aims: To evaluate foam adhesiveproducts in practice. Method: A group of tissue viability nursesdeveloped an evaluation form specifically designed to capturethe performance of foam adhesive dressings. The performanceexpectations of adhesive foams provided objectives for clinicalevaluation, agreed as exudate management, conformability,adherence, ease of application, ease of removal and condition ofsurrounding skin. This paper describes the evaluation process andcritiques the findings that enabled local decisions to be reached. Thefoam products chosen to be evaluated were pre-selected by cliniciansvia a table-top evaluation. Results: The evaluation results have beenused to choose which foam adhesives are on the local formulary. Theresults also identified that dressings were being changed on a routinebasis and education strategies were put in place to overcome this.Staff were involved with the formulary decisions and are happy withthe outcome as well as the decisions reached.Clinical Research/AuditKEY WORDS Adhesive foam dressings Evaluation FormularyIn the current financial climate, tissueviability nurses must demonstrate thatthey can use resources effectively, whilecontinuing to provide quality care andevidence that product selection decisionsare based on the needs of the patientrather than the preference of the clinician(Department of Health [DH], 2010). Oneway that this can be achieved is by robustlyreviewing wound care product usage andupdating local wound care formularies.FoamsFoams are considered to be the mostcommonly used wound care dressing(Bianchi et al, 2011), and evidence fromthe author’s area of practice indicates thatthe foams most often used are adhesives.Anecdotal evidence identified that thefoams on the formulary in the author’sarea were not meeting patients’ needs,for example, problems with skin strippingand maceration were reported. While costis an important element of any formularyprocess, it is imperative that the clinicalneeds of the patient are met. Only thencan cost-effectiveness be achieved.Foam products are versatile and can be usedas a primary or secondary dressing. Bianchiet al (2011) concluded that no evidence iscurrently available that identifies one foamdressing to be superior to another. Thiscombined with the availability of such awide variety of foam adhesive productsand supporting company literature can beconfusing for clinicians, potentially leadingto product choice being ritualistic or opento industry influence.As indicated by Gray et al (2011), it isimperative that clinicians are confidentthat the foam product they choose meetsthe needs of their patient population.VICTORIA PEACHTissue Viability Nurse Clinical Lead(Community), University Hospital of SouthManchesterWounds UK 2012, Vol 8, No 3 53

ReferencesBianchi J, Gray D, Timmons J, Meaume S(2011) Do all foam dressings have the sameefficacy in the treatment of chronic wounds?Wounds UK 7(1): 62–67DH (2010) Equity and Excellence: liberating theNHS. DH, LondonGray D, Cooper P, Russell F, Stringfellow S(2011) 3M TM Tegaderm HP TM Foam Adhesivedressing: a case report series. Wounds UK 7(3):60–66Payne WG, Posnett J, Alvarez O, et al (2009) Aprospective, randomised clinical trial to assessthe cost-effectiveness of a modern foam dressingversus a traditional saline gauze dressingin the treatment of Stage II pressure ulcers.Ostomy Wound Manage 55(2): 50–55Stephen-Haynes J, Bielby A, Searle R (2011)Putting patients first: reducing the human andeconomic costs of wounds. Wounds UK 7(3):47–5554 244 Wounds UK UK 2012, 2012, Vol Vol 8, 12, No No 3 12The studyAimsThis paper presents the process andresults of an evaluation of six adhesivefoam dressings in clinical practice. Foamadhesive products were reviewed bya group of clinicians who consideredthe properties of the individual foamdressings and selected the top sixproducts that they wished to take forwardfor clinical evaluation. The table topevaluation considered various aspects,such as packaging, range of sizes andshapes, absorption, conformability andadherence.Study design and methodsA group of tissue viability nursesdeveloped an evaluation form specificallydesigned to capture the performanceof foam adhesive dressings. Theperformance expectations of adhesivefoams provided the team with objectivesfor clinical evaluation. These were agreedto be: Exudate management Conformability Adherence Ease of application Ease of removal Condition of the surrounding skin.Additionally, the reason why a dressingchange was taking place; whether or notthe dressing could be left in place longer;and any reasons for a dressing beingdiscontinued, were also recorded.Due to the variance of wound types,differences in wound sizes, patient comorbidities,and differing reasons whya foam dressing could be used, suchas palliation or healing, as well as timerestrictions, it was agreed not to usehealing outcomes as a measure of success.Patient assessment and the criteria forselection of a wound dressing was not tochange from standard practice. To thisend, nurses were asked to select only oneof the foam dressings being evaluated (seeDressing Key above) after a foam dressinghad already been identified as the woundproduct of choice.The aim was to discover the optimal foamadhesive in line with current practice —this would include: Use as a secondary dressing with avariety of other wound care productsDRESSING KEYFoam A — PermaFoam ® (Hartmann)Foam B — Tegaderm Foam Adhesive(3M )Foam C — Biatain ® (Coloplast)Foam D — Tielle ® (Systagenix)Foam E — Allevyn Adhesive(Smith & Nephew)Foam F — Trufoam Self-adhesive(Unomedical) Use on a variety of wound types andanatomical locations presented bypatients on a community nursingcaseload.Patients were selected over a six-weekperiod and nurses were requested toselect the most appropriate size and shapeof foam dressing to correlate with the sizeand anatomical location of the woundbeing dressed.The nurses were asked to record sixconsecutive dressing changes for eachpatient — if six consecutive dressingchanges were not achieved, the reason forthis was to be recorded.Prior to commencement of theevaluation, each company representativewas invited to attend a meeting with amember from each nursing team. Theaim of the meeting was to ensure thatclinicians completing the evaluationwere familiar with the products andunderstood any specific individualproduct requirements, such as applicationor removal techniques.All nursing teams were also providedwith detailed written instructions of theevaluation process.It was decided that the evaluationshould not only incorporate clinicaldata captured at dressing changes, butshould also allow for nurses’ opinionsand patients’ experiences to be taken intoaccount. Nurse preference forms andpatient experience forms were devisedfor this purpose. For nurses’ opinions tobe regarded as valid it was important thateach had practical exposure to each ofthe six products. Therefore, each nursingteam evaluated all of the products.At the end of the evaluation period,

Clinical ReseaRch/audit‘All of the foamswere used totreat patientswith pressureulceration,leg ulceration,traumatic woundsand surgicalwounds’688075 63117Foam AFoam BFoam CFoam DFoam EFoam FFigure 1: Proportion of changes for eachdressing.nurses were sent a nurse preferenceform to complete. Patient experiencewas captured by completing a patientexperience form that asked simplequestions such as: Did you find your wound caredressing comfortable? Did your dressing stay in place? Did your dressing leak?There was also a comments box for freeexpression.After collation of the evaluationforms, the results were discussed withrepresentatives from the participatingnursing teams in order for a collectivedecision to be reached regarding productformulary inclusion. A maximum of twoproducts were to be chosen to be listedon the formulary — two foam adhesiveproducts provide clinicians with sufficientchoice to ensure that patient needs arebeing met; one foam may not be suitablefor all.86ResultsEighteen district nursing teams acrossthree geographical areas recorded a totalof 489 dressing changes — these rangedfrom 63–117 per foam product (Figure1). Eighty-nine percent of all dressingchanges were completed as routinepractice.A total of 34 evaluation forms, with apotential 204 dressing changes, werediscarded due to incomplete informationor obvious misinterpretation of theevaluation process. One recurringmisinterpretation related to entriesindicating that the size of the dressingselected was not suitable for the wounddimensions. The team had to reject theseforms as the use of too small or too largea dressing has the potential to negativelyaffect the performance of these dressings.The types of wounds selected for eachfoam group were consistent, althoughthe number of wound types differed foreach group as did the number of dressingchanges.All of the foams were used to treat patientswith pressure ulceration, leg ulceration,traumatic wounds and surgical wounds(Figure 2). Other wounds includedfungating ulcers, diabetic foot ulcers,burns, and donor graft sites, the number ofwhich differed between foam groups.The location of the wounds for all foamgroups was similar. One difference notedwas that Foam D was used for only threepatients presenting with lower limb/footulceration, whereas the other foams rangedin number from 9 (Foam F) to 15 (Foam B).Pressure ulcerTraumatic woundLeg ulcerSurgical woundOtherFigure 2: Wound types assigned to each foam.56 Wounds UK 2012, Vol 8, No 3

Figure 3: Ease of application.All foam types were used both as aprimary and secondary dressing withhydrogel sheets and ribbons, alginates,barrier creams and films, and povidoneiodine commonly being used under thefoam dressings. Foam A and E were notused in conjunction with silver alginates— all other foam groups were.Foam B, D, and E had comparative resultsfor ease of application, achieving over 55%for the ‘excellent’ and 30% for the ‘good’category (Figure 3). Five of the six foamgroups achieved over 80% for combined‘excellent’ and ‘good’ categories for easeof removal (Figure 4). There was minimaldifference between foam A and B — bothgroups achieving ‘excellent’ for more thanhalf of dressings removals.The conformability of a foam dressing canimprove patient comfort and thus have apositive impact on concordance. Althoughthere were some differences in how thefoam dressings performed, there was littledifference between foam B and E, withboth achieving a 90% or greater score forthe way the pad and the adhesive edgecontoured to the wound and surroundingskin (Figure 5). Foam D achieved a highpercentage of both pad and adhesivecontouring with no negative reportsthat neither the pad nor the adhesivecontoured. Foam B was considered to bethe most adherent (Figure 6).A key function of foam dressings is theirability to manage exudate and reducenegative issues such as maceration.Foams A, B, D and E had comparablygood responses from clinicians regardingexudate management (Figure 7).Similarly, nurses recording the condition ofthe surrounding skin noted fewer problemswith issues such as maceration andredness in Foams A, B, and D. The levelsof discontinuation noted concurred withthese findings, with less frequent reports ofdressings being withdrawn due to negativeoutcomes in foams A, B and D, comparedwith the other foams (Figure 8).Only Foam B was recorded as improvingwear times (in over 50% of cases) withFoam D reaching 40%. Foams A, C, andF were considered less likely to remain‘A key function offoam dressingsis their ability tomanage exudateand reducenegative issues,such as maceration’PoorAverageGoodExcellentFoamAFoamBFoamCFoamDFoamEFoamFFigure 4: Ease of removal.Wounds UK 2012, Vol 8, No 3 57

Clinical ReseaRch/audit‘The outcomecan be used todetermine the mostsuitable adhesivefoam productsused to serve thelocal population’FoamAFoamBFoamCFigure 5: Conformability of foams.in place longer than the planned intervalbetween dressing changes (Figure 9).A total of 49 nurse preference forms werereturned. Of these, 24 were disregardeddue to nurses not confirming that theyhad experienced practical exposure to allof the foam dressings used in the study.Overall, Foams B, D and E were identifiedto be the foams of choice.Comments on the nurse preference formsreflected those on the clinical evaluations.For example, comments on Foam B and Dincluded: ‘This dressing appears much better incomparison with our usual dressing’ ‘Good dressing that remained in placeand did the job’ ‘Adherence good; removal difficult’ ‘Patient and staff very impressed withthis dressing’.Some foam dressings attracted morenegative comments such as: ‘A bit bulky’ ‘It wouldn’t stay in place’ ‘Initially good, then skin reactionoccurred’FoamDFoamEFoamF ‘Not the best at staying in place yetdifficult to remove’.The comments on the patient experienceforms often related to pain or comfortsuch as, ‘Wouldn’t use it again as notcomfortable,’ and, ‘Very happy withdressing and nurse’.Often, the patient experience forms werecompleted by the nurse on the patientsbehalf, with comments such as, ‘Patientdid not like dressing,’ or, ‘Patient found itpainful on removal.’discussioNThis evaluation aimed to capture dressingperformance in wounds assessed byregistered nurses as suitable for treatmentwith adhesive foam products. However,each foam did not have an equal numberof allocated wound types or anatomicallocations, nor were the wounds of equaldimension or producing an equal amountof exudate. The commonality in this studywas that the suitability of the adhesivefoam dressing, either as a primary orsecondary wound product, was assessedFoamAFoamBFoamCFoamDFoamEFoamFFigure 6: Adherence of foams.58 Wounds UK 2012, Vol 8, No 3

FoamAFoamBFoamCFoamDFoamEFoamFFigure 7: Exudate management performance.by a registered nurse and that the patientwas on a community nursing caseload.The evaluation process replicated clinicalpractice — therefore, the outcome canbe used to determine the most suitableadhesive foam products used to serve thelocal population.The most common reason fordressing change was routine practice(for instance, dressing changeswere performed according to a predeterminedplan, three times a weekperhaps, rather than when exudatelevelsdictated), despite a largeproportion of reports at dressing changeidentifying that the dressing could haveremained in place for a longer period oftime. Extra wear time can reduce overallcosts, particularly when managingchronic wounds, hence it should playa role in any decision regardingformulary choice.Failure to maximise the benefitsof modern foam dressings, asdemonstrated by Payne et al (2009),could result in unnecessary cost, forexample, if a dressing was changedmore often than clinically needed.If clinicians do not maximise theuse of modern dressing technologythere is also the potential for clinicalconsiderations to be overridden byprocurement strategies based onpurchasing cheaper dressings, whichmay not have the same patient benefits.Foam D was selected for use on fewerlower limbs than all other the foams. Bothfoam D and F were chosen for use on asmaller proportion of pressure ulcers thanthe other four foams. As each nursingteam were unaware of each other’s productselection this occurred by chance.However, this had minimal relevanceto the overall findings as objectives formeasuring success did not include healingand all parameters were based uponnursing assessment and judgment.Likewise, the categorisation of pressureulceration and chronicity of wounds wasnot recorded. Exudate management wassubjective according to the assessingnurses’ opinion and all products wereopen to the same subjectivity.Nurse preference and free expression onthe clinical evaluation forms proved tobe valuable when qualifying the findings.The comments enabled discussionpoints to be raised and enabled a greaterunderstanding of the practicalitiesof using these dressings. This wasparticularly important due to the largeamount of nurse preference forms thatwere disregarded due to some nurses’lack of experience with all products.Patient experience forms did not produceany additional information, but insteadseemed to broadly support the findings ofthe other information-gathering methods.The majority of the forms were completedby the nurse on behalf of the patient —this may account for the similarities in theresponses provided.To overcome this in the future, patientexperience could be assessed in‘The commentsenableddiscussionpoints to beraised andenabled a greaterunderstanding ofthe practicalitiesof using thesedressings’Wounds UK 2012, Vol 8, No 3 59

Clinical ReseaRch/auditFoamAFoamBFoamCFoamDFigure 8: Amount of foam dressings discontinued.‘This evaluationenabled theperformanceof six adhesivefoam dressingsto be comparedfor use withina communitypopulation’FoamEFoamFFoam AFoam BFoam CFoam DFoam EFoam Fdifferent ways, for instance, a telephonequestionnaire could result in differentfindings.After the results were collated the groupof nurses involved in the evaluation helda meeting. The results were analysed anddiscussed, including comments made bynurses, patients or on the patients’ behalf.Following this group discussion, foamsB, D and E were found to be the mostpopular products.A collective decision was reached forfoam B and D to be included on theformulary as both had fewer reports ofdiscontinuation (Figure 8).Additionally, foam B and D had uniquedifferences, particularly in relation to theiradhesive actions, whereas foam B and Ewere similar.Including two foams on the formularyprovides choice for both the nurse andthe patient.coNcLusioNThis evaluation enabled the performanceof six adhesive foam dressings to becompared for use within a communitypopulation. Nurse preference and patientexperience supported the clinical findingsand a collective decision was reachedabout which of the foams to include in thelocal product formulary.For patients with wounds, product choiceis only one element of their journey, withthe provision of high-quality care beingdependent upon a number of other factors,such as the use of concise decision-makingtools, correct product usage, educated andappropriately trained clinicians, effectivemeasuring and monitoring of wound caresystems, and a collaborative approachbetween public, health care and industry(Stephen-Hayes et al, 2011).Developing a local formulary based uponevidence that the needs of the patientpopulation are being met and ensuringthat collective decisions are reached hasassisted with achieving the above factors.Findings from this evaluation have informededucation and training strategies, ensuringthat nurses have increased their knowledgeof formulary products, that decision toolsare designed with reference to the specificbenefits of particular products, and thatcollaboration with companies can identifyhow to maximise wear time and ensure thatproducts are used effectively.It is important that formulary selection isreviewed on a regular basis to ensure thatlocal patients reap the benefits, especiallyas products are upgraded and newproducts become available. WUKNoneOne dayOver one dayFoamAFoamBFoamCFoamDFoamEFoamFFigure 9: Extra day wear time.244 60 Wounds UK UK 2012, Vol Vol 8, 12, No No 3 12