R E V I E W S & A N A LY S E S Improving the Safety of Negative-Pressure Wound Therapy ABSTRACT INTRODUCTION Negative-pressure wound therapy Acute and chronic wounds affect at least 1% of the population and represent a sig- (NPWT) is a noninvasive therapy that nificant risk factor for hospitalization, amputation, sepsis, and death.1 The technique uses negative pressure to treat acute of applying negative pressure to a wound to assist in healing has been in use since and chronic wounds. NPWT has the 1950s, and the practice has continued to evolve and gain in popularity. The tech- become a widely used option for treat- nique is referred to as negative-pressure wound therapy (NPWT), although several ing all types of wounds. When used other names exist for this technique, such as vacuum-assisted closure, vacuum-sealing safely as a component of a compre- techniques, sealed surface wound suction, subatmospheric pressure therapy, and vac- hensive wound treatment program, uum-pack technique. The technique typically involves inserting foam or gauze dressing NPWT has been associated with the into a wound, cavity, or surface; connecting an evacuation tube embedded in the foam promotion of wound healing. How- or gauze to a vacuum pump; and sealing the area with an adhesive film. The vacuum ever, while NPWT may be beneficial pump creates an intermittent or continuous subatmospheric pressure in the range to patients, complications have been of -50 mmHg to -125 mmHg. NPWT acts to reduce edema, promote granulation tissue associated with its use. Seventy-seven perfusion and formation, and remove exudate and infectious materials.2 patient injuries and six deaths associ- The popularity of NPWT as an adjunct to wound healing has been attributed to world- ated with NPWT in two years prompted wide marketing, assumed safety, and overall cost-effectiveness.2 NPWT is estimated to the U.S. Food and Drug Administration cost approximately $100 per day. This includes the cost of dressings ($25 to $60 per to issue an alert to healthcare providers. change), a canister ($8 to $15 per day), and rental of the vacuum pump ($55 to $58 per In 2008 and 2009, the Pennsylvania day). NPWT has higher material costs than traditional wound treatment therapies Patient Safety Authority received 419 (i.e., gauze); however, the cost may be offset by the benefits of reduced healing time, reports related to the application or reduced nursing staff time and expense, decreased length of hospital stay, and facilita- management of NPWT. Complications tion of patient transfer to lower-cost care settings.2 For example, Braakenburg et al. related to NPWT were described in 112 reported that NPWT is associated with significantly lower nursing staff expense due (27%) reports and included bleeding, to fewer effort hours than treatment with conventional wound dressings.3 Similarly, a evisceration of bowel, retained sponges, study of 51 patients in a long-term acute care facility demonstrated that despite a higher infection, maceration, and compromise product cost, the overall cost of NPWT was lower than topical advanced moist heat of tissue surrounding the wound. Clini- strategies.4 The study calculated that patients treated with NPWT showed a statistically cians can endeavor to prevent patient significantly higher average daily rate of volume reduction compared to an advanced harm associated with the use of NPWT moist wound healing group. The cost of wound reduction was $11.90/cm3 in the NPWT by employing risk reduction strategies group compared to $30.92/cm3 in the moist wound-healing group. The authors suggest such as appropriate patient selection, that when developing a wound-healing strategy, the cost decision should be based on proper device application, and frequent overall expense and not individual product cost. monitoring. (Pa Patient Saf Advis 2011 Mar;8[1]:18-25.) NPWT has been associated with serious complications. In 2009, the U.S. Food and Drug Administration (FDA) issued a warning to healthcare professionals and consum- ers regarding reports of 6 deaths and 77 injuries over a 2-year period related to NPWT.5 Bleeding was the most serious injury and occurred in all 6 reported deaths and in 17 of the reported injuries. Twenty-seven of the reports indicated that the patient developed an infection from the original open wound or from retention of dressing pieces in the wound. Foam dressing pieces, either adhering to tissues or embedded in the wound, were observed in 32 of the injury reports; the majority of these patients required sur- gical procedures to remove the retained pieces, wound debridement, and treatment of wound dehiscence, as well as additional hospitalization and antibiotics. Similarly, healthcare facilities have reported serious complications associated with NPWT to the Pennsylvania Patient Safety Authority, including bleeding, evisceration of bowel, retained sponges, infection, maceration, and compromise of tissue surrounding the wound. Authority reports also describe issues related to application and management of NPWT devices. Page 18 Pennsylvania Patient Safety Advisory Vol. 8, No. 1—March 2011 ©2011 Pennsylvania Patient Safety Authority AUTHORITY DATA The wound care nurse noted foam staff member found a 4 × 4 inch From January 2008 to December 2009, and bioclusive dressing were left on sponge packed into upper section of 419 events associated with NPWT were the wound after NPWT was removed. the wound behind a piece of black reported to the Authority. The event Protocol was not followed per proce- sponge. The sponges were bagged in reports are summarized as follows, accom- dure; the physician was notified, and hazardous package to bring to operat- panied by deidentified examples: a saline dressing was applied. ing room staff’s attention. — Events associated with assessment NPWT dressing was due to be changed; — Events associated with NPWT issues (5%) include issues related to physi- when the wound was examined by after the patient’s discharge from cian orders or patient assessment the doctor, the dressing was found to the acute care setting (7%) suggest before initiation of treatment. be applied incorrectly with the tubing that patient and/or family caregiver directly against the wound instead of on may not have received adequate The patient arrived on unit with the top of the sponge as directed. NPWT home care education before vacuum set at 90 mmHg intermittent. When changing the NPWT dressing, discharge. The report from the RN [registered nurse] was that the vacuum was set at staff noted that the foam had been A patient who had surgery several 120 mmHg continuous. There were covering intact skin and was not just months ago was admitted with an no orders noted on the chart for wound in the wound bed. The skin surround- open wound that was very deep with vacuum settings. The RN failed to ing the incision line was now very red tunneling. The patient had a NPWT pick this up at time of assessment. and abraded. until recently. The patient thinks he cleaned the wound with a vinegar The admitting physician has not — Events citing monitoring and ongo- solution. seen the patient since admission, nor ing assessment (47%) issues represent has he designated a hospitalist to the largest number of events related Per patient, he noticed that NPWT manage the patient medically. The to NPWT. suction was fluctuating while he patient also does not have a written The suction tubing for the NWPT was still an inpatient; pressure order for NPWT currently in use. device was dislodged, and assessment was not remaining constant at The patient does not have a wound of the site revealed a stage III pres- 120 mmHg as ordered by the physi- ostomy nurse consult. The NPWT sure ulcer where the tubing had been cian. The patient reported suction dressing has not been changed since positioned on the patient’s leg. Staff issue to staff prior to discharge; staff the patient was admitted. repositioned tubing, and physician were unable to troubleshoot and did was to be made aware at start of the not contact physician. Per patient, Patient came into the emergency staff stated visiting nurse would department with NPWT in place. shift to assess options for therapy. rectify the problem. When wound NPWT was not removed as per Nurse went to the bedside for NPWT and skin graft was assessed by visiting protocol to examine wound and then dressing change and noticed that nurse, [the patient’s tissue was] found dressed with a wet to dry dressing the sponge was not compressed, the to be macerated from the amount until seen by wound care. [There was machine was off, and the suction of drainage that built up under the a] delay in treatment. tubing connector not connected to the dressing. The patient was instructed — Events associated with application of canister. The nurse reconnected the on troubleshooting the unit and mea- NPWT (21%) include issues related machine and suction was established; sures to employ if needed. to a delay in application or incorrect it was not determined how long the machine was left off. The remainder of the reports (20%) application of NPWT. involve a combination of some or all of Blood was noted in [a patient’s] The patient was seen for a routine the above categories of events. NPWT tubing. Tubing found lying visit at a local wound clinic. A call directly on the patient’s wound with a was received that NPWT dressing PRINCIPLES OF NPWT sponge covering the tubing. The dress- was done poorly prior to patient’s dis- ing was removed, and the wound was charge with black foam overlapping How Does It Work? cleansed with normal saline. NPWT the intact skin, causing maceration of healthy tissue. NPWT is used in the three phases of was then placed as per manufacturer’s healing in acute and chronic wounds: suggestions. The physician and the When staff removed a NPWT the inflammation phase, the prolifera- nursing director were notified. dressing for dressing change, the tive phase, and the maturation phase. Vol. 8, No. 1—March 2011 Pennsylvania Patient Safety Advisory Page 19 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S The inflammatory phase is characterized wound treatments, such as gel products, Appropriate patient selection is impor- by hemostasis and inflammation and bolster dressings, and hydrocolloids.6 An tant to the success of NPWT. As with lasts two to five days.6,7 The proliferative Agency for Healthcare Research and Qual- any wound care regime, optimizing the phase is characterized by the formation of ity (AHRQ) evidence report by the ECRI patient’s ability to heal is essential and granulation tissue and epithelialization. Institute Evidence-Based Practice Center requires assessment and management of The duration of this phase depends on identified 22 systematic reviews published underlying diseases (e.g., diabetes mel- the size of the wound. The maturation between 2000 and 2008 that covered litus) and oversight of any anticoagulation phase is characterized by increased col- NPWT.6 The review included studies and immunosuppressive therapy.14 Other lagen production and breakdown. Tissue reporting data on the use of NPWT on a factors affecting wound healing include contraction occurs during this phase, in number of wound types (e.g., diabetic foot hemodynamic stability, nutritional status, which tissue strength reaches 80% of the ulcers, pressure ulcers, vascular ulcers, burn blood glucose, fluid balance, and the pres- strength of normal tissue. wounds, surgical wounds, trauma-induced ence of infection.15 NPWT is thought to act by several wounds) and studies comparing NPWT to Bleeding and infection are serious com- fluid-based and mechanical processes, other wound treatments (e.g., gauze, plications associated with the use of including the following:8-10 bolster dressings, wound gels, alginates, NPWT.16,17 Careful consideration must be other topical therapies). AHRQ assessed given to patients receiving anticoagulants Stimulation of wound edge retraction. three systematic reviews as high-quality Negative pressure draws the edges of the and heparin, since these medications may based on criteria that included duplicate increase the risk of bleeding. Frequent wound together. study selection, the likelihood of pub- monitoring of activated partial thrombo- Stimulation of granulation tissue formation. lication bias, and conflict of interest. plastin time and/or prothrombin time Application of mechanical force is None concluded that NPWT provided with international ratio levels is neces- thought to slowly deform skin over time additional benefit when compared to other sary for these patients. Bleeding may because skin and most tissues are visco- conventional wound treatment. However, occur with the removal of dressing that elastic. Stretching of the skin stimulates the systematic reviews all noted the lack of has adhered to the wound. Bleeding can an increased rate of new cell growth and high-quality clinical evidence supporting also occur if the dressing is placed over increases the formation of granulation the advantages of NPWT compared to exposed vessels in or around the wound tissue, which is thought to reapproximate other wound treatments. Another concern that have not been covered and protected wound edges. was the large number of prematurely termi- during the application of NPWT as rec- nated and unpublished trials of NPWT.11 ommended by the manufacturer.16 Wound Increased local blood flow. Adequate Nevertheless, AHRQ concluded that infection may develop if pieces of dressing perfusion is essential to proper wound NPWT is a safe alternative treatment to are retained in the wound. Desiccation, healing in order to provide nutrients and other traditional wound treatments.6 pain, erosion, odor, and maceration are inflammatory mediators and to remove local edema. Increased blood flow also additional complications associated helps to remove bacteria from the wound. Which Patients Are Candidates? with NPWT.10 NPWT is used in healing both chronic Continuous removal of exudate. Optimal patient selection includes and acute wounds. Chronic wounds are evaluation for the factors that may place Reduced interstitial edema. Removal of wounds that have not completed the pro- a patient at risk for complications during excess interstitial fluid around the wound cess of healing in the expected amount of NPWT, including the following:5,18 margins increases capillary blood flow to time, generally 30 days, or have not pro- the wound bed. gressed through the healing process with — Friable vessels and infected blood the expected results.12 Diabetic foot ulcers, vessels Reduced bacterial loads in the wound. Reduction in the number of dressing pressure ulcers, venous leg ulcers, and — Vascular anastomosis changes decreases damage to delicate infected sternal wounds are common types — Infected wounds new tissue and decreases exposure of the of chronic wounds treated with NPWT. — Malignancy in the wound margins wound to nosocomial infection. Acute wounds are those lasting less than — Untreated osteomyelitis 30 days. Surgical wounds, burn wounds, and trauma wounds are common wounds — Exposed vessels, nerves, tendons, Is It Clinically Effective? and ligaments (Direct contact with treated with NPWT. It can also be used as Despite widespread use, the evidence is NPWT creates risk of desiccation an adjunct to surgery for skin grafts, flap unclear that NPWT provides additional ben- or injury.) surgery, and wound bed preparation.12,13 efit when compared to other conventional Page 20 Pennsylvania Patient Safety Advisory Vol. 8, No. 1—March 2011 ©2011 Pennsylvania Patient Safety Authority — Sharp edges in the wound (Bone in-servicing and competency updates are — Consider using 0.9% sodium chlo- fragments or sharp edges in the essential to ensure safe and successful use ride solution instead of antiseptic or wound could puncture protective of NPWT. Although a number of NPWT antibacterial preparations.12,18,20 barriers, vessels, or organs, causing devices are available, the basic steps of — Clean the periwound, and protect injury or bleeding.) NPWT are similar: accurate assessment the intact skin around the wound — Spinal cord injury of the patient and wound before initia- to prevent breakdown. Skin — Hemostatic agents applied at the tion of NPWT, appropriate wound-bed preparation products provide a wound site (Certain nonsutured preparation, application of the NPWT protective barrier between the skin homeostatic agents [e.g., bone wax, unit, and monitoring of progress during and the adhesive dressing, remove absorbable gelatin sponge, spray NPWT, which includes dressing changes skin oils to promote a better seal, wound sealant] may, if dislodged, and wound reassessment. Education of and help minimize trauma when the increase the risk of bleeding.) staff, patients, and caregivers is also essen- dressing is removed.12,18,20 tial. The Authority has received reports — Magnetic resonance imaging of events occurring during each step of Application — Hyperbaric chamber treatment the process. For each step, risk reduction — In acute or long-term care, a reg- — Defibrillation strategies can promote the safe use of the istered nurse who is certified as a — Application near vagus nerve device and facilitate wound healing. wound care specialist may perform because of risk of bradycardia the majority of NPWT applications. — Circumferential dressing application Assessment For all staff, particularly nursing, — Review the physician’s order. Orders conduct regular in-servicing and When to Stop NPWT should include the wound cleansing competency updates to troubleshoot In the absence of complications, base the agent, type of vacuum and dressing alarms, repair leaks, and observe for duration of NPWT on regular evaluation (i.e., foam or gauze), therapy settings complications.12,18,20,21 of wound progress and/or a predeter- (i.e., intermittent or continuous suc- — Select and prepare the dressing type mined treatment goal. Accurate and tion, negative-pressure setting), and and size appropriate for the wound reproducible measurement of the wound frequency of dressing changes.12,18,20 as directed by facility policy and should be recorded weekly.13 A 50% — Obtain a physician’s order if an manufacturers’ instructions. Two improvement in wound size over four order is not present when the patient types of sponges are typically avail- weeks is a good indication that the wound is admitted.12,18,20 able: black polyurethane and white will heal. In some cases, NPWT can be — Assess the patient for factors that soft foam. Gauze dressing may also used until wound closure, although gen- may place the patient at risk for any be used with some NPWT systems. erally it is used until the wound is filled complications, such as preexisting The dressing is used to fill all open with granulation tissue and ready for skin bleeding disorders and use of anti- areas of the wound while avoiding graft, flap, or standard wound therapy.19 coagulants or other medications or overpacking of the wound.12,18,20 After initiation of NPWT, evaluate the herbs that prolong bleeding times — Document the dressing applied, wound at each dressing change for signs (e.g., nonsteroidal anti-inflammatory including the type and number of deterioration, which include erythema, drugs, aspirin, gingko biloba).12,18,20 of dressing pieces as well as any pain, discharge or infection, tissue necro- — Assess the wound before initiat- additional measures used to create sis, requirement of repeated debridement, ing NPWT. If the periwound skin an adequate seal. Document the surgical interventions, or increased wound shows signs of compromise, such as number of dressing pieces on the size.16 Stop NPWT if any complication or breakdown or maceration, address outside of the adhesive film dressing deterioration of the wound occurs. these conditions before initiating and in the patient’s medical record NPWT.12,18,20 to prevent any retained gauze or PROMOTING THE SAFE USE sponge.12,18,20 OF NPWT Wound Preparation — Avoid pulling or stretching the trans- Cleanse the wound according to physician parent adhesive dressing used to seal Before initiating NPWT, healthcare prac- order and facility policy before each dress- the wound to prevent trauma to the titioners should refer to facility policy and ing application.12,18,20 periwound.12,18,20 be knowledgeable about the manufac- turer’s instructions for the device. Regular — Apply minimal mechanical force dur- — Implement and document the ing each cleaning.12,18,20 ordered amount of negative pressure Vol. 8, No. 1—March 2011 Pennsylvania Patient Safety Advisory Page 21 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S and the suction cycle. Continuous vein thrombosis and compro- from the device manufacturer or therapy provides sustained tension mised pulmonary function and at specific to the device.) on the cells of the wound, causing increased risk for infection and/or — Troubleshooting audio and visual mechanical stretch and removal of sepsis.12,16,19,22 alarms fluids. Intermittent therapy applies — Avoid any new areas of pressure by — Applying or reinforcing dressing greater mechanical stretch through- ensuring that the tubing is not press- application out the treatment as the unit is ing against the patient’s skin.12,16,18,20 — Recognizing signs and symptoms of cycled on and off.12,18,20 — Closely monitor infants, children, complications to report small adults, the elderly, and patients — Contacting appropriate healthcare Ongoing Monitoring and with highly exudating wounds for Assessment providers, especially in an emergency fluid loss and dehydration.16 situation — Dressing changes are generally per- — Troubleshoot and resolve NPWT formed every 48 hours or according — Responding to emergency situations, alarms according to manufacturer’s such as the observation of bright red to manufacturer’s guidelines. At each recommendations. For example, the dressing change, assess for wound blood in the tubing or collection Table contains examples of system canister deterioration, erythema, pain, puru- alarms and recommended action/ lent drainage, tissue necrosis, and In emergency situations, teach the resolution related to the V.A.C.® increase in wound size. The dress- patient/caregiver to immediately stop Therapy unit.16,18 ing may need to be changed more NPWT, apply direct manual pressure frequently in infected wounds; the Patient and Family Caregiver to the dressing, and activate emergency dressing change will be based on con- medical services. Education tinuing evaluation of the wound and The education of patients who will be Reports to the Authority indicate that the patient’s clinical status.12,16-18,20 discharged with an NPWT device and the patients have been readmitted because of — During each shift or per facility complications of NPWT. These reports patients’ caregivers ideally should begin policy, ensure that the sponge is indicate that the education of patients upon initiation of therapy and continue collapsed in the wound and the unit and caregivers regarding NPWT use may throughout the patients’ hospitalization. is on and functioning appropriately. have been a factor in the development of Return demonstrations are a good way A sponge that is not compressed may complications that resulted in readmis- to assess the patient and/or caregiver’s indicate a break in the seal.12,16,18,20 sion. Ongoing education and discharge understanding and skills. — If NPWT use is interrupted for more instructions for patients and caregivers on than two hours, remove the old NPWT and the use of the device includes CONCLUSION dressing and irrigate the wound. the following:17 By following the general principles of Disconnection from NPWT for wound care and implementing best — Safe operation of the device (Provide more than two hours places patients practices related to NPWT, healthcare printed patient instructions either at risk for development of deep providers can safely facilitate wound Table. Troubleshooting Negative Pressure Wound Therapy Alarms SYSTEM ALARM ACTION/RESOLUTION Low-pressure alarm Check tubing for blockages, crimps, closed clamps. Ensure dressing/drape has not shifted and blocked tubing. Lower therapy unit and tubing to or below wound level. Leakage alarm Use leak-detection procedures/tools to help find and repair leak. Lower therapy unit and tubing to or below wound level. Blockage alarm Ensure dressing/drape has not shifted and blocked tubing. Ensure dressing/drape is located on a flat area of the body, avoiding a skin fold. Source: Kinetic Concepts, Inc. V.A.C. Therapy. Clinical guidelines: a reference source for clinicians [online]. San Antonio (TX): KCI; 2010 Aug [cited 2010 Oct 29]. Available from Internet: http://www.kci1.com. Page 22 Pennsylvania Patient Safety Advisory Vol. 8, No. 1—March 2011 ©2011 Pennsylvania Patient Safety Authority healing. Widespread use of NPWT sug- Clinical staff must be prepared to appro- must also be prepared to apply, monitor, gests that a healthcare provider is very priately apply, monitor, and effectively and respond appropriately to issues that likely to encounter a patient undergoing troubleshoot problems with the device. may arise if the patient continues NPWT NPWT. Safe and effective implementa- Staff must also be able to recognize and at home. tion of NPWT requires regular staff respond to complications related to in-servicing and competency evaluation. NPWT. Patients and family caregivers NOTES 1. Graham ID, Harrison MB, Nelson EA, et 1]. Available from Internet: http://www. J Wound Ostomy Continence Nurs 2009 al. Prevalence of lower-limb ulceration: a ahrq.gov/clinic/ta/negpresswtd/index. Mar-Apr;36(2):202-11. systematic review of prevalence studies. Adv html. 15. Brace JA. Commentary: negative pressure Skin Wound Care 2003 Nov;16(6):305-16. 7. Ueno C, Hunt TK, Hopf HW. Using wound therapy for abdominal wounds. J 2. ECRI Institute. Negative-pressure wound physiology to improve surgical wound out- Wound Ostomy Continence Nurs 2007 Jul- therapy for chronic wounds [Emerging comes. Plast Reconstr Surg 2006 Jun;117(7 Aug;34(4):428-30. Technology Report]. Plymouth Meeting Suppl):59S-71S. 16. Shirikawa M, Isseroff RR. Topical nega- (PA): ECRI Institute; 2009 Jun. 8. Plikaitis CM, Molnar JA. Subatmospheric tive pressure devices: use for enhancement 3. Braakenburg A, Obdeijn MC, Feitz R, pressure wound therapy and the vacuum- of healing chronic wounds. Arch Dermatol et al. The clinical efficacy and cost effec- assisted closure device: basic science and 2005 Nov;141(11):1449-53. tiveness of the vacuum-assisted closure current clinical successes. Expert Rev Med 17. Mirsaidi N. Negative pressure wound technique in the management of acute Devices 2006 Mar;3(2):175-84. therapy: Use with care. Nursing 2010 and chronic wounds: a randomized 9. Morykwas MJ, Simpson J, Punger K, et Sep;40(9):64, 66. controlled trial. Plast Reconstr Surg 2006 al. Vacuum-assisted closure: state of basic 18. Kinetic Concepts, Inc. V.A.C.Therapy. Aug;118(2):390-7; discussion 398-400. research and physiologic foundation. Plast Clinical guidelines a reference source for 4. de Leon JM, Barnes S, Nagel M, Reconstr Surg 2006 Jun;117(7 Suppl):121S-6S. clinicians. [online] 2010 Aug [cited 29 Oct et al. Cost-effectiveness of negative pres- 10. Gasbarro R. Negative pressure wound 2010]. Available from Internet: http:// sure wound therapy for postsurgical therapy: a clinical review. Wounds 2007 www.kci1.com. patients in long-term acute care. Adv Skin Dec;19(12 Suppl):2-7. 19. Gupta S. Differentiating negative pressure Wound Care 2009 Mar;22(3):122-7. 11. Gregor S, Maegele M, Sauerland S, wound therapy devices: an illustrative case 5. U.S. Food and Drug Administration et al. Negative pressure wound therapy: series. Wounds 2007 Jan;19(1 Supp):1-9. (FDA). Center for Devices and Radio- a vacuum of evidence? Arch Surg 2008 20. Malli S. Keep a close eye on vacuum- logical Health. Serious complications Feb;143(2):189-196. assisted wound closure. Nursing 2005 associated with negative pressure wound 12. Mendez-Eastman S. New treatment for Jul;35(7):25. therapy systems [online]. FDA Prelim an old problem: negative pressure wound 21. Fife C, Wei D. The challenges of negative Public Health Notific 2009 Nov 13 [cited therapy. Nursing 2002 May;32(5):58-63. pressure wound therapy in clinical prac- 2010 Oct 13]. Available from Internet: http://www.fda.gov/MedicalDevices/ 13. World Union of Wound Healing tice. Today’s Wound Clin [online] 2010 Safety/AlertsandNotices/PublicHealth Societies. Principles of best practice: vac- Jun 7 [cited 2010 Sep 9] Available from Notifications/ucm190658.htm. uum-assisted closure: recommendations Internet: http://www.todayswoundclinic. for use. A consensus document.[online] com/NPWT. 6. Agency for Healthcare Research and 2008 [cited 15 October 2010]. Available Quality. Negative Pressure Wound 22. Lambert KV, Hayes P, McCarthy M. from Internet: http://www.wuwhs.org/ Vacuum assisted closure: a review of devel- Therapy Devices [technology assessment datas/2_1/11/VAC_English_WEB.pdf. report]. ECRI Institute; Plymouth Meet- opment and current applications. Eur J ing (PA): 2009 May 26 [cited 2011 Feb 14. Long MA, Blevins A. Options in negative Vasc Endovasc Surg 2005 Mar;29(3):219-26. pressure wound therapy: five case studies. (See Self-Assessment Questions on next page.) Vol. 8, No. 1—March 2011 Pennsylvania Patient Safety Advisory Page 23 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S LEARNING OBJECTIVES SELF-ASSESSMENT QUESTIONS — Recall the mechanisms of action of The following questions about this article may be useful for internal education and negative-pressure wound therapy assessment. You may use the following examples or come up with your own. (NPWT). Case 1 — Recognize the risk factors for compli- An 82-year-old patient presents to the emergency department with a soft-tissue lower-extremity cations associated with NPWT. avulsion injury and an open fracture of his humerus as a result of a motor vehicle accident. — Assess potential strategies to manage The patient is taken to the operating room for debridement of his wounds and external fixa- NPWT using available evidence. tion of the open fracture. A foam dressing is applied over the avulsion wound of the patient’s — Select appropriate nursing interven- lower extremity, and NPWT is initiated. tions for a patient whose NPWT is 1. All of the following are considered mechanisms of action of NPWT in promoting interrupted. the healing of this patient’s wound EXCEPT: — Recall components of patient and a. Stimulation of wound-edge retraction as a result of negative pressure caregiver education about NPWT. b. Decreased capillary perfusion, which decreases interstitial edema c. Stimulation of granulation tissue formation caused by mechanical force applied to the tissues d. Reduction of the bacterial load in the wound 2. Which of the following factors, if present, is least likely to place this patient at risk for complications associated with NPWT? a. A sacral pressure ulcer with granulation tissue b. A medical history of poorly managed diabetes mellitus c. Anticoagulation therapy d. Exposed vessels in or around the wound edge 3. Assess the following statements about strategies for the patient discussed in case 1, using the literature about management of NPWT. Which statement is NOT accurate? a. At each dressing change, assess for deterioration of the wound as evidenced by erythema, pain, purulent drainage, tissue necrosis, or an increase in the wound’s size. b. If NPWT is interrupted for more than two hours, do not disturb the existing dressing because this may contaminate the wound. c. Closely monitor the patient for signs of dehydration if the wound has a large amount of exudate. d. At least once during each shift change, ensure that the sponge is collapsed in the wound. Case 2 A patient is admitted to the hospital from an extended care facility for surgical management of a sacral pressure ulcer. During the admission assessment, a nurse observes that a NWPT dressing covers the sacral pressure ulcer, but the dressing is not attached to a NPWT device. 4. Assess the following statements about strategies for the patient discussed in case 2, using the literature about management of NPWT. Which statement is inaccurate? a. Attach a NPWT device to the dressing to initiate therapy immediately because NPWT should not be interrupted for more than two hours. b. Obtain a physician’s order for NPWT if an order is not present when the patient is admitted. c. Assess the patient for preexisting bleeding disorders before initiating NPWT. d. Assess the wound before initiating NPWT; if the periwound skin is compro- mised, address it before initiating therapy. Page 24 Pennsylvania Patient Safety Advisory Vol. 8, No. 1—March 2011 ©2011 Pennsylvania Patient Safety Authority SELF-ASSESSMENT QUESTIONS (CONTINUED) 5. The patient in case 2 undergoes a magnetic resonance imaging (MRI) scan, which results in interruption of NPWT for more than two hours. Select the appropriate nursing intervention to be implemented when the patient returns from the MRI suite. a. Wait for a physician’s order before reinitiating NPWT. b. Reinitiate NPWT without removing the dressing. c. Remove the dressing, and cover the wound with sterile gauze while waiting for a physician or wound care practitioner to assess the wound. d. Remove the dressing, and irrigate the wound according to facility policy. 6. NPWT education for all patients and caregivers about the management of NPWT after discharge includes all of the following EXCEPT: a. How to respond to audio and visual alarms b. How to perform dressing changes c. How to contact the manufacturer if the device malfunctions d. How to respond to emergency situations, such as bright red blood in the tubing Vol. 8, No. 1—March 2011 Pennsylvania Patient Safety Advisory Page 25 ©2011 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 8, No. 1—March 2011. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2011 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.