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Using the BNF to guide product choice

Una Adderley
Specialist Nurse
Team Leader
North Yorkshire
and York Primary
Care Trust

Nurses who care for patients with wounds require a reliable, unbiased source of information when deciding which dressing to use, and the British National Formulary aims to be such a resource. Una Adderley reviews Appendix 8 covering wound care products, which has recently been completely revised and updated.

One of the fundamental questions facing nurses who care for patients with wounds is which dressing to use. There is a bewildering array of wound management products available in the UK, most of which are available on prescription. Choosing an appropriate dressing is a challenging task. Many community nurses work within organisations that have devised their own "formulary" or short list of dressings to help clinicians select a dressing that is both clinically appropriate and cost-effective.

The British National Formulary (BNF)1 is recognised as the authoritative source of information for healthcare professionals. It provides up-to-date information about medicines, as well as selected medical devices and clinical appliances that are prescribable in the UK. Appendix 8 for wound management products has been included in the BNF for many years, but recently this appendix has been completely revised and updated (September 2009) to make it easier
to use.

The prompt for reviewing Appendix 8 came from the Nurse Prescribers' Advisory Group (NPAG), which meets three times a year to provide the BNF with advice and guidance regarding the needs of prescribing nurses. The NPAG pointed out that while Appendix 8 in the BNF included a useful list of available wound care products, the appendix could be improved to facilitate the selection of the most appropriate wound management product for each patient. The BNF is ideally placed to provide nurses with a source of unbiased information using evidence-based guidance to support clinical decision-making and for the creation of local formularies.

For BNF 58 (September 2009), Appendix 8 has been completely reorganised and the guidance notes have been updated. The new layout takes into consideration other recent wound product publications, such as the NHS Purchasing and Supply Agency (PASA) buyers' guide, published in 2008,2 as the BNF editorial team recognised that clinicians would prefer the key publications that guide their decision-making to have similar formats. The changes are based on the evidence-based recommendations in the PASA guide, consultation with prescribing nurses, and product information provided by manufacturers.

Appendix 8 now includes introductory notes describing the stages of wound healing and the principles of moist wound healing. These notes are followed by a new table intended as an aid to the selection of an appropriate wound contact dressing based on the appearance and condition of the wound.
Wound dressings have been classified into five separate categories:

  • Basic wound contact materials (A8.1).
  • Advanced wound dressings (A8.2).
  • Antimicrobial dressings (A8.3).
  • Specialised dressings (A8.4).
  • Adjunct dressings and appliances (A8.5).

The basic wound contact materials and the advanced wound dressings categories contain sub-sections for different types of dressings, listed in order of increasing absorbency. Adhesive dressings are listed separately from non-adhesive dressings.

The Advanced wound dressings section includes moisture donating hydrogel dressings (A8.2.1) and vapour-permeable films and membranes (A8.2.2) before the more absorbent dressings such as alginates (A8.2.6) with greater ability to absorb wound exudate. Also within each category, dressings may be further subdivided; for example, in section A8.2.5, different foams are categorised in terms of their absorbency, so there is a group of foams for "lightly to moderately exuding wounds" and another group of foams for "moderately to heavily exuding wounds". Each of these groups is further subdivided to differentiate between adhesive dressings and non-adhesive dressings. These groupings are designed to follow more closely the clinical decision-making process and to aid comparison of similar products based on dressing sizes, prices etc.

Antimicrobial dressings now have their own section (A8.3), which is subdivided according to the different active agents such as honey (A8.3.1), iodine (A8.3.2) and silver (A8.3.3). The Specialised dressings section (A8.4) includes those regarded as interactive dressings, such as protease modulating matrix dressings and silicone keloid dressings. The Adjunct dressings and appliances section (A8.5) includes products such as surgical absorbents used as secondary dressings or appliances, such as wound drainage bags used in place of dressings. Another new section, Complex adjunct therapies (A8.6), includes those products used for topical negative pressure therapy. The products necessary to carry out wound care, such as dressing packs, tapes, swabs, have all been grouped together in the Wound care accessories section (A8.7).

In addition to dressings and dressing packs, Appendix 8 also includes categories for different types of bandages and compression hosiery and garments that form a fundamental part of tissue viability practice. The bandage section (A8.8), which previously included adhesives, now only lists bandages and these are presented in order of increasing levels of compression. Compression hosiery and garments now have their own section (A8.9) with guidance notes and a table that clearly differentiates between the British standard compression for compression hosiery and the European classification for lymphoedema garments. It is hoped that this will more clearly explain the differences between the different levels of compression offered by these two different classification systems.  

Appendix 8 is included in the BNF, published twice yearly, and in the smaller Nurse Prescribers Formulary (NPF), which is published every two years and distributed to all community nurses who have the nurse prescriber qualification. As the range of wound care products changes relatively frequently in terms of what is available, size and price, a more up-to-date source of information for nurse prescribers can be found on the BNF website (www.bnf.org).

Although considerable work and consultation has gone into revising Appendix 8, the BNF editorial team recognises that further improvements may be necessary and welcomes feedback (both on Appendix 8 and any other parts of the BNF).
Comments and constructive criticism should be sent to: British National Formulary, Royal Pharmaceutical Society of Great Britain, 1 Lambeth High Street, London SE1 7JN or by email to: editor@bnf.org

References
1. Joint Formulary Committee. British National Formulary 58. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; 2009.
2. NHS Purchasing and Supply Agency (PASA). Buyers' Guide: Advanced wound dressings. London: PASA; 2008.

Your comments (terms and conditions apply):

"The Lothian Joint Formulary for Adults has a section on Wound Dressings & Bandages 13.13 and is available to all by logging on to www.ljf.scot.nhs.uk
Dressing conversion chart (LJF Dressing Choices)can be printed off advising the best choices" - Patricia Willis