Policy and Procedure for NPWT
NPWT has a rich history. It’s one of the oldest forms of medicinal therapy and dates back centuries. Wound drainage has been implemented for even longer – reported cases trace back to 600 BC in Assyria and Babylon – and vacuuming via heated copper bowls began in 400 BC by the Greeks. The technique and design began to advance as cupping spread west over the centuries, and in 1907, Dr. E. Klapp first used a suction pump on a wound. By the 1970’s, doctors were using drainage canisters help with tissue repair.
In 1985, Dr. Katherine Jeter developed a unique system of products to apply negative pressure to a patient’s wound bed. She pioneered the use of suction to treat wounds utilizing a gauze dressing and wall suction. Dr. Mark Chariker aided in a clinical study and furthered this new revolutionary healing process. They understood that the application of negative pressure to a wound bed had extraordinary effects on a patient’s ability to heal, and they published their findings and advanced the art of wound care in 1989.
Today, NPWT is a widely adopted treatment helping to heal wounds around the world. NPWT offers a new approach to this healing therapy. The lightweight device allows patients to experience wound healing while being mobile and living more normally without being bedridden.
Negative pressure wound therapy (NPWT) is a treatment for acute and chronic wounds. The treatment requires a vacuum source to create a continuous or intermittent form of negative pressure inside the wound. Doing so removes fluid, exudates, and infectious materials which may promote wound healing and closure.
Ulcers and Wounds in the Home Setting:
- Chronic Stage III or IV pressure ulcer
- Partial Thickness Wounds
- Neuropathic (for example, diabetic) ulcer
- Venous or arterial insufficiency ulcer
- Chronic (being present for at least 30 days) ulcer of mixed etiology)
- Traumatic or surgical wounds where there has been a failure of immediate or delayed primary closure
- Grafts and Flaps
- Acute wounds
- Sub-acute and Dehisced wound
The Negative Wound Therapy Pump System is a portable, battery-powered pump intended to generate negative pressure or suction to remove wound exudates, infectious material, and tissue debris from the wound bed which may promote wound healing. Negative Pressure Wound Therapy is meant for continuous use (at least 22-24 hours per day).
Contraindications for Use of NPWT
- Exposed vessels, organs, or nerves.
- Anastomotic sites.
- Exposed arteries or veins in a wound. All exposed vessels and organs in and around the wound must be completely covered prior to initiation of NPWT. Note: A thick layer of natural tissue is preferred.
- Several layers of fine meshed non-adherent material or bio-engineered tissue may be an alternative.
- Ensure that protective materials will maintain their position throughout therapy.
- Fistulas, unexplored or non-enteric.
- Untreated osteomyelitis.
- Malignancy in the wound. The system may be used after excision of malignancy if all margins are clear.
- Excess amount of necrotic tissue with eschar. Note: The system may be used with a minimal amount of slough or after debridement of necrotic tissue.
- Wounds which are too large or too deep to be accommodated by the dressing.
- Inability to be followed by a medical professional or to keep scheduled appointments.
- Allergy to urethane dressings and adhesives.
- Use of topical products which must be applied more frequently than the dressing change schedule allows.
- Don’t use wound care pump around explosives or flammable material
- Large capacity Canister should be used in a closely monitored environment (i.e. Hospital, LTC)
- Negative pressure wound care has not been cleared for children
- Do not place this device in temperatures over 170* for more than 2 hours (may cause battery fire)
- If battery swells, gets hot, or smokes while charging disconnect immediately
- Bleeding: Patients that are at a high risk for bleeding should be treated in an inpatient setting.
- If heavy bleeding starts during treatment:
- Clamp of tubing to dressing
- Remove NPWT pump
- Leave dressing in place and apply direct pressure
- Seek medical attention immediately
- Vessel and Bone Protection
- Precautionary measure should be taken if any bones, vessels, ligaments, or tendons are exposed
- Bone and sharp edges requiring special attention as prescribed by the attending clinician.
- Defibrillation: Remove pump and dressing if necessary for defibrillation
- Don’t wear in MRI however clamping dressing will be safe during MRI
- Hyperbaric Oxygen Therapy (HBO) Do Not take extri-Care device or dressing into the Hyperbaric Chamber. Dressing should be replaced with HBO compatible material. NEVER LEAVE WOUND CARE DRESSING IN PLACE FOR MORE THAN TWO HOURS WITHOUT AN ACTICE EXTRI-CARE PUMP
- Infection: Infected wounds and osteomyelitis pose a significate risk for NPWT.
- Patient Size and Weight should be taken into consideration when prescribing therapy.
- Spinal Cord Injury: If patient experiences a sudden change in blood pressure or heart rate because of sympathetic nervous system stimulation. Discontinue NPWT and give immediate medical assistance.
- Mode: In unstable anatomical structures, continuous rather than intermittent therapy is recommended.
- Continuous is recommended with an increased bleeding risk, profusely exuded wounds, fresh grafts, and/or flaps, and wounds with acute enteric fistulae.
- Enteric Fistulas: Wounds with enteric fistulas require special consideration to be effective in NPWT
- Circumferential Dressings: DO NOT USE CIRCUMFERENTIAL DRESSINGS.
- Bradycardia: Avoid placing wound care dressing next to vagus nerve to minimize risk of bradycardia.
Prior to Therapy:
- Patient should be assessed, measurements taken, and pictures taken to document baseline to begin treatment
- Nutrition, medication, and blood glucose should be discussed with the patient
- Wound should have been recently debrided
- Issues of infection should be addressed
- Ensure that the skin that will be under the dressing is clean, dry, and free of surfactants and oil. (Any hair should be clipped away.)
- Peri-wound area should be cleaned and allowed to air dry. The use of skim preparation wipe is also recommended.
- Monitor skin for signs of breakdown or irritation. Treatment may be discontinued if this occurs and cannot be managed.
- Remove dressing as suggested by manufacturer. Make sure all pieces of the dressing are removed.
- Clean and debride wound as needed. Any bleeding should be controlled. Follow sterile technique when preparing and applying the dressing.
- Be careful not to stretch the dressing
- Avoid pleating the dressing
- Additional wrap dressing may be applied over the wound dressing
- For anatomically challenging areas a small amount of ostomy paste may be applied
- Refer to instruction of applying wound care dressing.
Assess the Wound
If you know what your patient’s wound needs, you can take proactive measures. What is the wound “telling” you? With adept assessment, you can become a “wound whisperer”—a clinician who understands wound-healing dynamics and can interpret what the wound is “saying.” This allows you to see the wound as a whole rather than just maintaining it as a “hole.”
- If the wound tells you it's too wet, take steps to absorb fluid or consider increasing negative pressure, as ordered.
- If it’s telling you it’s dry, consider decreasing negative pressure, as ordered. If the wound bed remains dry, you might want to take a NPWT “time out”. Apply a moisture dressing for several days and assess the patient’s hydration status before restarting NPWT.
- If the wound says it’s moist, maintain the negative pressure.
- If it tells you it’s infected, treat the infection.
- If it tells you it’s dirty, debride it.
- If it says it’s malnourished, feed it.
Ongoing Patient Assessment and Monitoring
Follow these guidelines to help ensure safe and effective NPWT:
- Follow the device manufacturer’s instructions and your facility’s NPWT protocol, policy, and procedures.
- Identify and eliminate factors that can impede wound healing, poor nutritional status, limited oxygen supply, poor circulation, diabetes, smoking, obesity, foreign bodies, infection, and low blood counts.
- Evaluate the patient’s nutritional status to ensure protein stores are adequate for healing.
- Assess and manage the patient’s pain accordingly.
- Protect the peri-wound from direct contact with foam or gauze.
- Prevent stretching or pulling of the transparent drape to secure the seal and avoid shear trauma to surrounding tissue.
- Prevent stripping of fragile skin by minimizing shear forces from repetitive or forceful removal of transparent drapes.
- Use protective barriers, such as multiple layers of non-adherent or petrolatum gauze, to protect sutured blood vessels or organs near areas being treated with NPWT.
- Don’t overpack the wound too tightly with foam. Compressing the foam prevents negative pressure from reaching the wound bed, causing exudate to accumulate.
- Position drainage tubing to avoid bony prominences, skinfolds, creases, and weight-bearing surfaces. Otherwise, a drainage tubing related pressure wound may develop.
- Bridge posterior wounds to the lateral or anterior surface to minimize drainage tubing related pressure wounds to the surrounding tissue.
- Count and document all pieces of foam, gauze, or adjunctive materials on the outer dressing and in the medical record, to help prevent retention of materials in the wound.
- Ensure the foam is collapsed and the NPWT device is maintaining the prescribed therapy and pressure at the time of initial patient assessment and when rounding.
- Address and resolve alarm issues. If you can’t resolve these issues and the device needs to be turned off, don’t let it stay off more than 2 hours. While the device is off, apply a moist-to-dry dressing.
- With a heavily colonized or infected wound, consider changing the dressing every 12 to 24 hours.
- Monitor the patient frequently for signs and symptoms of complications.
Evaluate Patient Comprehension of Teaching
A proactive approach to education can ease the patient’s anxiety about NPWT. Unfamiliar sounds and alarms may heighten anxiety and cause unwarranted concerns, so inform patients in advance that the device may make noise and cause some discomfort. An educated and empowered patient can participate actively in treatment. Improved communication may enhance outcomes and help identify errors in technique before they cause complications.
Be prepared to answer patients’ questions, which may include:
- Am I using the device correctly?
- How long will I have to use it?
- What serious complications could occur?
- What should I do if a complication occurs? Whom should I contact?
- How do I recognize bleeding?
- How do I recognize a serious infection?
- How do I tell if the wound’s condition is worsening?
- Do I need to stop taking aspirin or other medicines that affect my bleeding system or platelet function? What are the possible risks of stopping or avoiding these medicines?
- Can you give me written patient instructions or tell me where I can find them?
ANY SHOULD BE ADDRESSED WITH YOUR REPRESENTATIVE BEFORE STARTING TREATMENT.
Sharon Furr LPN, CCT