Download 01-2014-exit-site-management-in-the-community-using

WOUND CARE
Exit site management in the community
using Kendall™ AMD Antimicrobial
Foam Dressing with PHMB
Julie Evans
d
Lt
le
op
Pe
Exit sites are commonly encountered in the community setting as
a result of a shift in clinical practice that means more patients with
complex conditions are being managed at home. The management
of exit sites varies according to indication, but there are principles
of practice that are common to all sites, and these are outlined
in this article. Kendall™ AMD Antimicrobial Foam Dressing
with PHMB has been used to successfully prevent and manage
infection of exit sites, and to manage overgranulation, a common
complication of these wounds.
Percutaneous devices are widely
used in clinical practice and have a
variety of functions: from the shortterm use of orthopaedic pins to heal
a fracture, to the life-long delivery of
nutrition to patients who have lost
the ability to swallow due to diseases
such as cancer or stroke (Edward
Jones and Leahy-Gilmartin, 2012). The
management of exit sites, therefore,
is increasingly required within the
community setting.
KEYWORDS:
C
‘...care of percutaneous sites
is relatively straight-forward,
however, mismanagement
exposes the patient to
complications ranging from
pain and discomfort to lifethreatening illness...’
W
ou
nd
I
n recent years a high volume
of patient care has shifted into
the community setting, with
the needs of this patient group
becoming increasingly more complex
as medical advances enable patients
with multiple comorbidities to live
for longer (Royal College of Nursing
[RCN], 2012).
ar
e
Exit site management  Percutaneous devices  Overgranulation
 Kendall™ AMD Antimicrobial Foam Dressing with PHMB
©
20
14
Percutaneous devices, defined as
medical devices that pass through the
skin, are increasingly encountered in
the community, and, depending on
their indication, may require either
long- or short-term management.
The care of percutaneous sites is
relatively straightforward, however,
mismanagement exposes the patient
to complications ranging from pain
and discomfort to life-threatening
illness, with associated negative
impact on nursing time and costs of
care (Lynch and Fang, 2004; Wild and
Ansell, 2010; Walker, 2012).
Although exit sites have specific
guidelines on management depending
upon their indication, there are basic
common management principles
Julie Evans, Tissue Viability Nurse, Abertawe Bro
Morgannwg University Health Board, Swansea
MANAGEMENT PRINCIPLES
FOR EXIT SITES
The aim with exit sites is to prevent
complications before they occur by
keeping them open and healthy. By
minimising exudate production and
its detrimental effects on the skin, and
reducing the risk of infection, other
associated complications, such as
overgranulation, can be prevented.
for all percutaneous sites (Spruce
et al, 2012). This article discusses
these, and the role that Kendall™
AMD Antimicrobial Foam Dressing
with PHMB (Covidien) plays in the
management of this patient group.
Principles of management that are
common to all exit sites include:
 Maintaining the device
 Maintaining integrity of the
surrounding skin
 Prevention or management of
infection and other complications,
especially overgranulation.
PERCUTANEOUS DEVICES
Maintaining the device
Percutaneous devices are positioned
through a surgically created wound
in the skin to provide a link with
underlying tissues, structures and
organs, for the therapeutic benefit
of the patient (Spruce et al, 2012).
The place at which the device exits
the skin is known as the exit site.
The device may be held in position
using internal and/or external fixators
to prevent movement of the device
and damage to the surrounding skin
through friction, pressure or fluid
leakage (Best, 2009; Warriner and
Spruce, 2012).
Any external fixator used to secure
the percutaneous device should also
be examined to ensure it is securely
positioned and immobile. Patient
movement or poorly positioned devices
may result in damage to the surrounding
skin from pressure or friction.
All percutaneous devices should be
routinely checked during cleansing
of the exit site to ensure that they
are fit for purpose and not damaged
(McClave and Neff, 2006), which, in
some patients, e.g. those with suprapubic catheters, could result in leakage
of fluid, such as urine, onto the skin.
JCN
2014, Vol 28, No 1
55
WOUND CARE
W
14
20
©
It may be more appropriate for
patients to shower before or on the
day of dressing changes rather than
having a bath, depending on the
device in situ (RCN, 2010).
If a barrier cream is needed to
treat the surrounding skin, it is
important to ensure that it does not
damage the device or become runny,
thereby leaking into the opening of
the exit site.
Complications
A breach in the skin’s integrity puts
patients with exit sites at an increased
risk of wound infection (Table 1).
56 JCN
2014, Vol 28, No 1
Device
Risks
Central venous
catheters (CVC)
Bloodstream infections
(Altman, 2006)
Peritoneal dialysis
Peritonitis (Johnson et
al, 2009)
Fixations
Pin tract infections
(Temple and Santy,
2004)
Lt
d
Percutaneous
Local infection (Zopf
endoscopic gastrostomy
et al, 2008)
(PEG) sites
le
2011), so measures to prevent its
development will improve patient
comfort and wellbeing.
op
In addition, infection may result
in the exit wound becoming enlarged,
as a result of the surrounding skin
breaking down (McClave and
Neff, 2006). The longer the breach
in the skin is present, the greater
the risk of infection, with the most
common causative organisms being
Staphylococcus aureus, Candida
species and Pseudomonas aeruginosa
(Rolston et al, 2011).
If overgranulation is not managed
appropriately, complications may
develop around the exit site that result
in the device having to be replaced or
removed. Indeed, If overgranulation
occurs in wounds around or near
devices, raised tissue can physically
obstruct device placement. For example,
if there is overgranulation around
a stoma wound, this will prevent
stoma flanges, gastrostomy tubes and
tracheostomy tubes from fitting closely,
resulting in exudate and effluent being
able to come into intimate contact with
the peristomal skin and leading it to
breakdown (McGrath, 2011).
Pe
Biofilm formation is a particular
risk for patients with exit sites, and
is recognised as a major factor in
contributing to bacterial infection and
chronic inflammation (Best Practice
Statement, 2013). Biofilms develop
when bacteria multiply at a very slow
rate and colonise the exit site (EdwardJones, 2012). Certain bacteria commonly
found on the skin can adhere to
percutaneous devices, particularly those
made from latex or silicone, where they
establish a biofilm. If left untreated, this
can result in a prolonged inflammatory
process that can lead to overgranulation
(Edward-Jones, 2012).
ou
Cleansing also gives the patient
or carer the opportunity to monitor
the site, so that any complications
can be identified and treated early.
It is important to thoroughly dry the
exit site and device using a soft clean
cloth, as this will help to prevent
maceration to the surrounding skin
(Wild and Ansell, 2010). Materials,
such as gauze or cotton wool, that
might leave fibres in the area and
increase the risk of irritation or
inflammation, should not be used.
The signs and symptoms of exit
site infections include:
 Pain
 Increased volumes of exudate
 Erythema
 Heat.
ar
e
The wound and device should be
cleansed regularly to prevent bacterial
growth. Mild soap and warm water,
rather than shower gels or shampoo
which might irritate the exit site
(Wood, 2001), can be used to remove
exudate, blood and wound debris from
the site and device. Povidone-iodine
has also been suggested as a cleansing
agent (Piraino et al, 2005), although
there is no uniform consensus on
which solution is best to use to reduce
the risk of infection (Twardowski
and Nichols, 2009) and so the most
appropriate agent for the patient’s
situation should be chosen (Wild and
Ansell, 2010), in accordance with the
manufacturer’s guidance.
Table 1: Increased risks
associated with exit sites
C
Maintaining integrity
of the surrounding skin
Furthermore, the presence of any
comorbidities will also increase the
infection risk (WUWHS, 2008) and
so must be considered in vulnerable
patient groups, such as those with
renal disease undergoing dialysis.
nd
All devices need to be positioned,
immobilised and secured. Dressings
can be used to hold the device in
position in some therapies (RCN,
2010). When used, dressings should
not cause any additional trauma to the
site, and as soon as they become wet
or soiled, they should be changed to
reduce the risk of infection.
Overgranulation
Repeated infection and friction
between the skin and poorly-fitting
or badly-secured devices can also
lead to overgranulation (Warriner
and Spruce, 2012; Edward-Jones and
Leahy-Gilmartin, 2013).
Overgranulation, also known
as hypergranulation, exuberant
granulation tissue, or proud flesh, is
caused by an excess of granulation
tissue, and presents as friable red, often
shiny and soft tissue that is above the
level of the surrounding skin. Although
it is not a life-threatening condition, it
can cause bleeding, exudate and odour,
all of which negatively affect patient
quality of life (Johnson, 2007; McGrath,
Thus, using dressings that protect
the moist tissue around exit sites can
help both to prevent and manage
complications such as infection and
overgranulation. Such dressings
include antimicrobial agents such
as silver, iodine, polyhexamethylene
biguanide (PHMB), chlorhexidine
and honey.
Foam dressings, in particular,
offer a non-traumatic way to reduce
overgranulation, as they apply local
pressure to the wound, helping to
reduce oedema and flatten any raised
affected tissue (Harris and Rolstad, 1994;
Stephen-Haynes and Hampton, 2010).
THE ROLE OF KENDALL™ AMD
ANTIMICROBIAL FOAM DRESSING
WITH PHMB
A product that has been shown to
effectively manage the complications
of moisture and infection around exit
Lt
d
WOUND CARE
Clinical efficacy
A recent audit of 24 patients with
overgranulation who were referred
to a home enteral nursing service
over a 6-week period evaluated the
use of Kendall AMD Antimicrobial
Foam Dressing within a care pathway
(Warriner and Spruce, 2012).
Indications
ar
e
Pe
op
wicking effect (Spruce et al, 2012).
At the foam’s core, the honeycomb
structure is denser to retain fluid and
give greater wear time. Its polyurethane
back sheet prevents strikethrough
when under compression and provides
protection against bacteria. Also, being
a double-sided dressing helps to
prevent confusion during application.
le
Figure 1.
Opening and cutting Kendall™ AMD Antimicrobial Foam Dressing with PHMB.
ou
Figure 2.
Kendall™ AMD Antimicrobial Foam
Dressing with PHMB applied to exit site.
nd
C
Kendall™ AMD Antimicrobial Foam
Dressing with PHMB can be used to
prevent and manage infection and
overgranulation around a variety of
exit sites, including:
 Catheter insertions (e.g. central
venous catheters and periperally
inserted central catheters)
 Tracheostomy sites
 External fixator pin entry sites
 Penrose drains
 G-tubes or J-tubes
 Chest drains
 Nephrostomy sites
 Central venous lines
 Suprapubic catheters.
©
20
14
W
sites is Kendall™ AMD Antimicrobial
Foam Dressing with PHMB. The
dressings are impregnated with 0.5%
polyhexamethylene biguanide (PHMB),
an effective antimicrobial agent
(Johnson and Leak, 2011) with broad
spectrum activity against gram positive
and negative bacteria, including:
 Meticillin-resistant Staphylococcus
aureus (MRSA)
 Vancomycin-resistant Enterococcus
(VRE)
 Pseudomonas aeruginosa
 Klebsiellas
 Candida albicans (Kirker et al,
2009; McGhee et al, 2009; Spruce
et al, 2012).
The PHMB activity helps to reduce
bioburden at the exit site, which
reduces the risk of infection occurring.
The foam base of the dressing
has been especially designed with a
loose ‘honeycomb’ structure to absorb
exudate from the wound with a vertical
Application
The appropriate sized double-sided
dressing should be opened and cut
to fit (Figure 1), and applied to the
exit site, ensuring that the device
is correctly positioned (Figure 2). If
overgranulation tissue is present,
a secondary foam dressing can be
used to increase localised pressure
if appropriate for the device. It is
important to observe the patient 72
hours after inserting the device for
signs of:
 Prolonged or severe pain, e.g.
associated with feeding
 External leakage
 Tube displacement.
The dressing was chosen as a result
of a thorough literature search which
provided evidence of its clinical
efficacy. From reviewing the evidence,
PHMB was also the preferred choice
of antimicrobial agent, due to its safety
profile (Hubner and Kramer, 2010)
and effectiveness (Moore and Gray,
2007; Sibbald et al, 2011). In addition,
as PHMB is not deactivated in the
presence of organic substances, such
as exudate or blood (Hubner and
Kramer, 2010), it is appropriate for
highly-exuding gastrostomy sites with
overgranulation tissue.
During the six-week evaluation the
dressing was applied and covered with
a standard polyurethane dressing to
apply pressure to the overgranulation
tissue. Daily cleansing, dressing
changes and inspection of the device
was carried out, with a review at week
two and at the end of the six-week
treatment period. At week two it was
found that the overgranulation tissue
had resolved in 33% of patients, but by
the six-week review overgranulation
had completely resolved in 16 out of
the 24 patients. The authors concluded
that adopting a strategic approach
to managing overgranulation by
following a care pathway and using a
foam dressing with PHMB improved
both patient outcomes and clinical
practice (Warriner and Spruce, 2012).
JCN
2014, Vol 28, No 1
57
WOUND CARE
20
14
W
Kendall AMD Antimicrobial Foam
Dressing with PHMB offers both
clinical (Ciprandi, 2011; Warriner and
Spruce, 2012) and cost-effectiveness
(Spruce et al, 2012) and, being
available in a variety of sizes and
shapes, offer a versatile solution for
managing exit sites. JCN
REFERENCES
©
Altman S (2006) Showering with central
venous catheters: experience using the
CD-1000 composite dressing. Dial Transpl
35(5): 320–27
Best C (2009) Percutaneous endoscopic
gastrostomy feeding in the adult patient.
Br J Nurs 18(12): 724–9
Best Practice Statement (2013) The use
of topical antimicrobial agents in wound
management. 3rd edn. Wounds UK, London
Ciprandi G (2011) Palliative wound care
in pediatric patients. 21st Conference
of the European Wound Management
Association, EWMA 25–27 May
58 JCN
2014, Vol 28, No 1
Royal College of Nursing (2010) Guidance on
pin site care. Report and recommendations
from the 2010 Consensus Project on Pin Site
Care. RCN, London
Royal College Nursing (2012) The
Community Nursing Workforce in England.
RCN, London
le
Lt
d
Sibbald RG, Coutts P, Woo KY (2011)
Reduction of bacterial burden and
pain in chronic wounds using a
new polyhexamethylene biguanide
antimicrobial foam dressing — clinical
trial results. Adv Skin Wound Care 24(2):
78–83
Spruce P, Warriner L, Keast D, Kennedy
A (2012) Exit site wounds Made Easy.
Wounds International 3(2). Available online
at: www.woundsinternational.com
Pe
Johnson S (2007) Haelan Tape for the
treatment of overgranulation tissue.
Wounds UK 3: 70–4
gastrostomy tube (PEG tube) insertion
site infections in patients with cancer.
Support Care Cancer 19(8): 1267–71
op
Johnson DW, Clark C, Isbel NM, et al
(2009) The honeypot study protocol: a
randomized controlled trial of exit-site
application of medihoney antibacterial
wound gel for the prevention of catheterassociated infections in peritoneal dialysis
patients. Perit Dial Int 29(3): 303–9
Johnson S, Leak K (2011) Evaluating a dressing
impregnated with polyhexamethylene
biguanide. Wounds UK 7(2): 20–5
Stephen-Haynes J, Hampton S (2010)
Achieving effective outcomes in patients with
overgranulation. Available online at: http://
tiny.cc/egdjt [accessed 16 January, 2014]
Kirker KR, Fisher ST, James G (2009)
Efficacy of Kendal™ AMD Antimicrobial
Foam Dressings against MRSA. Wounds
21(9): 229–33
Temple J, Santy J (2004) Pin site care for
preventing infections associated with
external bone fixators and pins. Cochrane
Database Syst Rev (1): CD004551.7
Lynch CR, Fang JC (2004) Prevention and
management of complications of percutaneous endoscopic gastrostomy (PEG)
tubes. Pract Gastroent, November: 66–72
ou
This is particularly true in the case
of patients in the community, many of
whom will have been discharged with
an exit site wound from a tracheostomy
or suprapubic catheter, for example,
which needs to be maintained. Products
that make it easier for patients and
community staff to manage these
wounds locally and with a minimum
amount of training, are to be welcomed.
Hubner NO, Kramer A (2010) Review on the
efficacy, safety and clinical applications of
polihexanide, a modern wound antiseptic.
Skin Pharmacol Physiol 23(suppl 1): 17–27
ar
e
By following basic principles that
involve routine cleansing of the site and
device, and using products that help to
prevent infection from occurring, further
complications around exit sites, such
as overgranulation, can be prevented.
This, in turn, results in clinical and
cost-effectiveness, which can be further
enhanced by educating patients and
carers in how to look after their wound
and device (Warriner and Spruce, 2012).
Harris A, Rolstad, BS (1994) Hypergranulation tissue: a non-traumatic
method of management. Ostomy Wound
Manage 40(5): 20–3
C
CONCLUSIONS
Edwards-Jones V, Leahy-Gilmartin A (2013)
Gastrostomy site infections: dealing with
a common problem. Br J Comm Nurs
18(5-Suppl): S8–S13
nd
Sibbald et al (2011) also found in
a randomised controlled trial (RCT)
involving 40 patients with leg and foot
ulcers across two sites, that PHMB
foam dressings helped to reduce pain
and bacterial burden. Again, in this
study, both the patients and healthcare
professionals were very satisfied with
the dressing’s performance.
McClave SA, Neff RL (2006) Care and
long-term maintenance of percutaneous
endoscopic gastrostomy tubes. J Parenter
Enteral Nutr 30(1): S27–S38
McGrath A (2011) Overcoming the challenge
of overgranulation. Wounds UK 7(1): 42–49
McGhee D, Bade D, Shah C, et al (2009)
Activity of antimicrobial dressings using
clinically relevant organisms MRSA, VRE,
and P. aeruginosa. Mansfield, MA (USA):
Covidien, 2009. Available online at: www.
kendallhq.com/imageServer.aspx?conten
tID=14302&contenttype=application/pdf
[last accessed 12 January 2014]
Moore K, Gray D (2007) Using PHMB
antimicrobial to prevent wound infection.
Wounds UK 3(2): 96–102
Piraino B, Bailie GR, Bernardini J, et al (2005)
Peritoneal dialysis-related infections
recommendations: 2005 update. Perit Dial
Int 25: 107–31
Rolston K, Mihu C, Tarrand J (2011) Current
microbiology of percutaneous endoscopic
Twardowski ZJ, Nichols WK (2009)
Peritoneal dialysis access and exit-site
care including surgical aspects. In: Nolph
and Gokal’s Textbook of Peritoneal Dialysis.
3rd edn. Springer, US: 307–61
Walker J (2012) Pin site infection in
orthopaedic external fixation devices. Br J
Nurs 21(3): 148–51
Warriner L, Spruce P (2012) Managing
overgranulation around gastrotomy
sites. Br J Nurs (Tissue Viability
Supplement)21(5): S14–24
Wild J, Ansell T (2010) Caring for patients
with peritoneal dialysis catheters and exit
sites. J Renal Nurs 2(1): 28–31
Wood M (2001) A protocol for care of
skeletal pin sites. Nurs Times 97(24): 66
World Union of Wound Healing Societies
(WUWHS) (2008) Principles of Best
Practice: Wound Infection in Clinical
Practice. An International Consensus. MEP
Ltd, London
Zopf Y, Konturek P, Nuernberger A, et al
(2008) Local infection after placement of
percutaneous endoscopic gastrostomy
tubes: a prospective study evaluating risk
factors. Can J Gastroenterol 22(12): 987–91
Tissue Viability and Lymphoedema
WCAUK 4th Annual Conference
Programme
Friday 11 April 2014 • 9.00am– 4.00pm
Friday 11 April 2014
Pe
Chair for the morning, Louise Toner, Associate Dean, Birmingham City University and Trustee WCAUK
0900 – 0930
Coffee and registration
op
Liberty Stadium, Swansea SA1 2FA
le
Lt
d
A Shared Goal
0930 – 0945
0945 – 1010
1010 – 1030
Introduction and welcome
The Vision from Lymphoedema
The Vision from Tissue Viability
1030 – 1100
Coffee and exhibition viewing
1100 – 1130
1130 – 1200
Lymphoedema Essentials
Tissue Viability Essentials
1200 – 1230
1230 – 1300
Managing Complexities in Lymphoedema
Managing Complexities in Tissue Viability
C
ar
e
Mark Drakeford, Health Minister for Wales
Melanie Thomas MBE, National Lymphoedema Clinical Lead
Michelle Greenwood, Consultant Nurse Tissue Viability,
Walsall Healthcare NHS Trust and Chair of WCAUK
ou
nd
Pat Roberts, Macmillan Lymphoedema Clinical Nurse Specialist
Jackie Stephen-Haynes, Professor and Consultant Nurse, Tissue
Viability, Birmingham City University and Worcester Health and Care Trust
Karen Morgan, National Lymphoedema Education and Research Specialist
Lorraine Grothier, Clinical Nurse Specialist Tissue Viability/
Lymphoedema Manager, Central Essex Community Services
©
20
14
W
1300 – 1350
Lunch and exhibition viewing
Chair for the afternoon, Jackie Griffin, Tissue Viability Clinical Nurse Specialist, Newtown Hospital
1350 – 1415
Choir
1415 – 1500
Patients’ stories – Lymphoedema, Leg Ulceration and Pressure Ulcers
1500 – 1515
Improving Patient Information
1515 – 1545
Expert panel with:
Jackie Stephen-Haynes, Professor and Consultant Nurse in Tissue
Viability, Birmingham City University and Worcestershire Health and Care Trust
Karen Morgan, National Lymphoedema Education and Research Specialist
Karen Kembery, Tissue Viability Nurse, Abertawe Bro Morgannwg University Health Board
Rosie Callaghan, Tissue Viability Nurse, Worcestershire Health and Care Trust
Delia Keen, Tissue Viability Clinical Nurse Specialist, North Powys Teaching Health Board/
Lymphoedema Clinical Lead, Powys
1545 – 1600
Quiz, prizes and close
In association with:
Wound Healing Practice Development Unit
Birmingham City University, Faculty of Health
Conference fee £5.00 for all members
Already a member? Book your place via [email protected]
Not a member? Book your place and register to become a member via [email protected]
or ring 07938 556066