Utilizing International Consensus Panel Recommendations and a Clinical Decision Tree to Guide Selection of Negative Pressure Wound Therapy

Amanda Loney, BScN, RN, NSWOC, WOCC(C), IIWCC; Rafael J. Diaz-Garcia, MD, FACS; Julie M. Murdoch, PhD; Mandy Spitzer, MBA, RN, CWOCN, CFCN

Disclosures

Wounds. 2023;35(7):E209-E217.

Abstract and Introduction

Abstract

Introduction: A variety of NPWT products have become commercially available in the last 30 years. Utilizing advanced wound therapies appropriately can improve patient outcomes and decrease health care expenditures. Due to the increasing number of available product options, Hurd and colleagues published 10 Consensus Statements and a clinical decision tree to provide guidance on how and when to use NPWT and when to transition between device types.

Objective: To demonstrate the applicability of the consensus panel's statements and the clinical decision tree, 2 clinicians in the United States and Canada explored the benefits of applying these recommendations into their routine wound management practice.

Materials and Methods: Case studies were collected and reviewed in accordance with the Consensus Statements and clinical decision tree.

Results: Case presentations illustrate the application of the consensus panel's guidance through the prescribing of the NPWT products utilized as standard of care within both facilities.

Conclusion: Utilizing NPWT devices according to the consensus panel recommendations and the clinical decision tree may assist in optimizing care delivery to patients and address logistical and economic efficiencies.

Introduction

Acute and chronic wounds create a substantial burden for patients, providers, and health care systems. In the United States in 2014, approximately 8.2 million people (roughly 15% of the Medicare population) suffered from chronic wounds.^[1] Treatment of these wounds carried an estimated annual cost of between $28.1 billion and $96.8 billion to the US health care system.^[1] In Canada, 50% of nursing visits in the community setting involve wound care delivery, and 35% of persons receiving community care have a chronic wound.^[2,3] Because of this, Canadian provinces developed focused initiatives to improve patient outcomes, reduce hospitalizations and readmissions, and cut health care costs related to wounds. It has been estimated that adoption of these best practices could reduce Canadian community wound care costs by up to 50%.^[4]

Ensuring that advanced wound therapies are utilized appropriately can improve patient outcomes and decrease health care expenditures. In the time since NPWT became commercially available in the late 20th century, it has been embraced by the medical community as a standard treatment modality for complex wounds. NPWT was initially prescribed by clinicians for the management of large, complex wounds with high levels of exudate.^[5] However, a developing understanding of the multimodal mechanism of action of NPWT has expanded its application to address a range of acute and chronic wound types, regardless of their size or level of exudate.^[6]

Two main categories of NPWT exist: tNPWT and sNPWT. The original systems, now categorized as tNPWT, utilize a non-disposable pump that delivers subatmospheric pressure to the wound bed. This is accomplished by the creation of an airtight seal on the periwound area with a clear, adhesive drape. Negative pressure is delivered via tubing from the pump to the wound bed through a wound filler, typically gauze or foam, and a disposable canister collects exudate from the wound. It is understood that a wide range of pressure settings deliver therapeutic outcomes, and tNPWT pumps typically provide a range of therapy modes, therapy set points, and cycle times that allow individualized care of wounds and patients.^[7] sNPWT emerged on the market in the early 2000s and applies subatmospheric pressure to the wound through a smaller and more portable single-use pump. Various sNPWT systems are now commercially available and may function with or without an associated canister and integrated dressing.

In response to the numerous NPWT product options that now exist, the need arose for expert guidance on the appropriate product use to optimize clinical, economic, and logistical outcomes, as well as patient experience. In 2020, an international consensus panel of 8 experts from Canada, Spain, the United Kingdom, and the United States convened virtually with the aim of establishing a consensus on how and when to use NPWT, as well as when to transition between tNPWT and sNPWT devices.^[7] Ten Consensus Statements (Table 1) were agreed upon by the panel in the following categories: therapeutic goals, wound-related factors, patient satisfaction and quality of life, care setting-related factors, economic-related factors, and NPWT system-related factors.

In addition, the consensus panel created a clinical decision tree to guide the selection of tNPWT and/or sNPWT (Figure 1). Both tNPWT and sNPWT operate with unique characteristics and the consensus panel recommendations, along with the clinical decision tree, guide clinicians to utilize the most appropriate therapy type.

(Enlarge Image)

Figure 1.

NPWT clinical decision tree for the treatment of open wounds.⁷
Abbreviation: NPWT, negative pressure wound therapy.

1 2 3 4 5 6

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Table 1. NPWT Consensus Statements by Category ⁷
THERAPEUTIC GOALS
Consensus Statement 1	Initiation of NPWT should be considered when there is a need to: 1) promote granulation tissue; 2) prepare a wound for closure—whether through use of an autograft, use of other advanced wound care modalities, delayed primary closure, or secondary intention; 3) control edema; 4) manage exudate, 5) achieve wound stabilization; and 6) assist in stabilization of patients with complex, traumatic, open wounds.
WOUND-RELATED FACTORS
Consensus Statement 2	Wounds appropriate for consideration of sNPWT are those that meet device IFU based on wound size, depth, and exudate amount. The clinician must be familiar with the IFU of the sNPWT system utilized, as these factors can considerably vary between sNPWT devices.
Consensus Statement 3	Wounds appropriate for consideration of tNPWT are those in which the size, depth, and volume of exudate are beyond the management capacity of an sNPWT system.
Consensus Statement 4	The sNPWT system can be considered as a bolster dressing for wounds in which closure is being obtained via a split-thickness skin graft or application of a skin substitute.
Consensus Statement 5	The wound should be reassessed at regular intervals (ideally every 2 weeks) to determine if NPWT treatment should be continued or discontinued and for the appropriateness of transition from tNPWT to sNPWT. Consideration should be made for reassessment of NPWT use if therapeutic goals have not been met or there is minimal or no change in wound size, amount of granulation tissue, or reduction in edema and exudate volume. Transition from tNPWT to sNPWT should be considered when the wound size, depth, and exudate amount are within the management capacity of the sNPWT system that is being considered for use.
PATIENT SATISFACTION AND QUALITY OF LIFE
Consensus Statement 6	When NPWT is deemed an appropriate treatment modality for acute and chronic wounds, sNPWT should be the first-line modality utilized to increase patient satisfaction and quality of life. Patient education on NPWT as a treatment modality, the benefits of its use, and the advantages of sNPWT over tNPWT can improve patient satisfaction and treatment compliance.
Consensus Statement 7	sNPWT use may be an optimal choice for ambulatory patients with wounds eligible for sNPWT use who must return to work or face barriers to access follow-up medical appointments.
CARE SETTING-RELATED FACTORS
Consensus Statement 8	tNPWT is a valuable treatment option for patients with acute or chronic wounds that are large and complex. Benefits of tNPWT include stabilization of the wound and patient, patient mobility, more rapid transition from critical care units to step-down units, and reduced hospital length of stay. Initial use of sNPWT or early conversion to sNPWT from tNPWT in eligible wounds should be considered to assist in transitioning patients from inpatient to outpatient care.
ECONOMIC-RELATED FACTORS
Consensus Statement 9	The application of sNPWT as the initial NPWT modality or as conversion from tNPWT can reduce overall health care costs as well as assist in the transition of patients from inpatient to outpatient care.
NPWT DEVICE-RELATED FACTORS
Consensus Statement 10	The decision on which NPWT system to utilize should be based on factors such as: 1) published evidence demonstrating the effect on wound management and healing, 2) system ease of use, 3) ease of system device and supply procurement, 4) logistical and technical support provided, 5) cost effectiveness of individual systems, and 6) user/patient acceptability.

Abbreviations: NPWT, negative pressure wound therapy; sNPWT, single-use negative pressure wound therapy; IFU, instructions for use; tNPWT, traditional negative pressure wound therapy.

Table 2. Summary of Cases 1–4 With Key Outcome Measures
	CASE 1	CASE 2	CASE 3	CASE 4
Wound type	Foot abscess in patient with type 2 diabetes	ANCA vasculitis with pyoderma gangrenosum	Medial gastrocnemius flap with skin graft	Revision of nonhealing APR wound
Management goals at assessment 1	Stabilize wound and increase granulation tissue	Stabilize wound and increase granulation tissue	Support closed surgical incision and graft take	Support closed surgical incision
Consensus statements applied	1, 3, 8, 10	1, 3, 8, 10	1, 2, 4, 5, 6, 7, 8, 9, 10	1, 2, 4, 5, 6, 7, 8, 9, 10
Initial NPWT device selection	tNPWT	tNPWT	sNPWT	sNPWT
Management goals at assessment 2	Bolster full-thickness skin graft	Increase epithelialization and support patient QoL	Increase granulation tissue and fill tunnels
Consensus statements applied	1, 2, 4, 5, 6, 7, 8, 9, 10	1, 2, 5, 6, 7, 8, 9, 10		1, 3, 5, 8, 10
Second NPWT device selection	sNPWT	sNPWT		tNPWT
Management goals at assessment 3				Continue prior goals while supporting patient QoL
Consensus statements applied				1, 2, 5, 6, 7, 8, 9, 10
Third NPWT device selection				sNPWT
Did the wound achieve full closure?	Yes	Yes	Yes	Yes

Abbreviations: ANCA, anti-neutrophil cytoplasmic autoantibody; APR, abdominal perineal resection; NPWT, negative pressure wound therapy; tNPWT, traditional negative pressure wound therapy; sNPWT, single-use negative pressure wound therapy; QoL, quality of life.