Fifteen years ago there were few decisions to be made when choosing negative pressure wound therapy (NPWT) for your patients. There was one company, one wound filler and one device type on the market. Today there are numerous NPWT manufacturers, multiple wound filler types and several different device types to choose from. This trend may lead to confusing the already complicated process of determining the right NWPT option for your patients. In order to simplify the decision, it is important to:

1. Know what NPWT is, its benefits and advantages, and the indications and contraindications for the therapy.
2. Know the product/NPWT system: ensure it works on/in multiple wound types and healing stages.
3. Know the provider: a) Do they offer a simple solution for getting the patient on the therapy, including distribution and reimbursement? b) Do they provide consistent quality customer care and patient/caregiver education?
4. Know the patient: Understand wound specifics, pain level and mobility requirements.

What Is Negative Pressure Wound Therapy?

NPWT is best described by Malmsajo and Borgquist in the article “NPWT Made Easy” when they state, “NPWT uses a closed drainage system to apply controlled suction (vacuum) to a wound bed.” The system consists of a vacuum source (the NPWT device), a fill material (normally foam or gauze) to fill the dead space and evenly distribute the vacuum, and a semi-occlusive, clear adhesive film (transparent film) to cover the wound and seal in the vacuum. The vacuum then pulls the drainage from the wound and deposits it in the accompanied canister.
What are the benefits and advantages of the therapy?

The benefits of NPWT many. They include:

1. Drainage can be contained to a canister, keeping the patient clean, dry and comfortable and decreasing the number of dressing changes per week. The dressing change frequency is typically two to three times per week.
2. Swelling or edema in and around the wound is decreased. This will reduce discomfort for the patient and allow greater blood flow to the wound.
3. Suction draws more blood to the area, also increasing blood flow to the wound. The improved blood flow brings nutrients and oxygen to the wound, increasing its potential for healing.
4. A stretching or pulling effect on the wound tissue by the vacuum and the wound filler has been found to cause the cells in the wound tissue to divide and multiply, filling in the deficit.

Secondary benefits of NPWT are contraction of the wound edges caused by the vacuum drawing all areas of the wound together and protection of the wound from outside contaminants via the semi-occlusive film. The film is waterproof, protecting the area from the external environment while its semi-occlusive nature allows gases produced by the wound to evaporate to the outside of the dressing.

Advantages of using NPWT include:

• Fewer dressing changes.
• Everything is contained. The dressing is under the waterproof film and the drainage is contained to the canister.
• Increase in the rate of healing.
• The waterproof nature of the dressing will allow the patient to shower without fear of compromising the dressing.

Wound Types Indicated for NPWT

NPWT can be used on a variety of wounds. Wounds indicated include: pressure ulcers (normally stage III and IV), diabetic ulcers, chronic, acute or traumatic wounds, sub-acute or dehisced (reopened surgical incisions) wounds, and skin flaps and grafts.

Contraindications for the Therapy

1. Malignancy in the wound bed, except in the event of palliative care.
2. Presence of necrotic tissue with eschar (black/brown/gray necrotic tissue).
3. Untreated osteomyelitis (inflammation of the bone related to infection).
4. Exposed organs, blood vessels and nerves.
5. Unexplored fistulas.

Considerations for Choosing the Right Product

Wound Fillers. Primarily there are two choices for wound fillers: foam and gauze. Foam has a proven track record for the past decade or so, as it was the only choice. Early use of gauze was documented in the 1980s when Dr. Mark Chariker and Katherine Jeter, RN, ET, successfully used gauze-based negative pressure while treating incisional and cutaneous fistulae. Gauze has gained momentum during the past few years with the market entry of Smith & Nephew (St. Petersburg, Fla.) and other gauze-based systems.

Advantages of gauze, according to Hurd, et al., include decreased pain during dressing changes and ease of use for the clinician. Gauze has also been shown to provide comparable healing rates to that of foam. Providing the flexibility to choose either foam or gauze has provided greater convenience for both the patient and the clinician.

Devices. Most full-service NPWT providers will give options for addressing multiple wound types. There will be a larger, more robust device to handle the large heavily draining wound and a small, more portable unit, if mobility is a priority. In the case of Smith & Nephew’s RENASYS™ NPWT System, the larger unit that addresses the more heavily draining wounds is call RENASYS EZ and the smaller more portable device is the RENASYS GO. Some NPWT providers may require the use of the larger device in the hospital and the portable device is limited to home use only. Others, like Smith & Nephew, allow both devices to be used in any care setting.

An advantage of consistency in NPWT therapy when used in multiple care settings is that the patient and caregiver are able to become more accustomed to the device and the dressing change procedure before they are sent home to manage the system more independently. This ease of care transition will also decrease the risk of errors and unnecessary home care visits due to unfamiliarity with the system.

Other considerations concerning device choice is ensuring the device can accommodate multiple stages of wound healing. There are small, ultra-portable devices on the market that will only serve the smaller, more superficial wound with limited ability to manage exudate.

When deciding on a specific NPWT system, the patient is best served when you have a system that allows the wound filler to be chosen for the specific wound being treated, as well as multiple device types that can provide proper exudate management and meet patient mobility needs.

Choosing the Right NPWT Provider

Not only should your NPWT source provide multiple wound fillers and devices that cross the continuum of wound healing, they should also provide consistent customer care. Customer care considerations relating to the NPWT system should include:

1. Can the provider get the patient the product in a timely manner? The provider must have a distribution network in place that provides timely delivery of the device and disposables.
2. Does the provider have clinical support 24/7 for the patient/caregiver and clinician? It is important that the provider has sufficient clinical support available to support educating both the patient and clinician on appropriate operation of the NPWT system and dressing application so that resources are available if questions arise.
3. Eligibility for reimbursement may vary by insurance provider and requires specific documentation of the patient’s medical history and wound progress. It is advantageous if the provider has a help line or online information concerning reimbursement of NPWT.
4. Product education is important when choosing an NPWT provider. Educational resources for device operation and dressing application are required to ensure appropriate utilization of NPWT and achieving the desired outcomes. Education on the product is important to the patient, caregiver and clinician.

Considerations for Ensuring a Positive Outcome

Lastly and most important, know your patient. There are a few things that a case manager should know when considering discharge for a patient with NPWT.

1. What are the dimensions of the wound? This will provide the wound care staff the ability to order an appropriately sized dressing kit.
2. How much drainage is the wound producing? This will ensure that the appropriate device and the correct canister size are ordered.
3. Is the patient having pain with the therapy in general or during dressing changes? This will inform the clinician’s expectations during dressing changes and support effective pain management as it relates to pharmaceuticals and NPWT wound fill material choice.
4. Make sure the admitting facility is familiar with NPWT and has staff available for education on the product being used. NPWT is not something that necessarily requires the presence of a wound specialist, however the nurses caring for the patient do need to understand how to operate the device and change the dressing.
5. Know the expected outcomes. A wound should make progress in 14 days. If the wound has not made progress within a 14-day period the treatment regime should be assessed.

In summary, ensuring that you are directing your patient to the right source for NPWT is a matter of following a few general guidelines: 1) Know the wound: what are the dimensions, drainage and pain levels? 2) Know the patient: indications for NPWT, contraindications for NWPT, level of compliance; 3) Know the care provider: familiarity with the chosen NPWT system, availability for education/training; and 4) Know your NWPT provider: level of clinical and customer support, ability to deliver and support the product.

As advances are made in NPWT therapy and new devices and wound fillers are introduced into market, the need for ongoing education will continue to be important in helping you make the right choice in NPWT therapy for your patient.

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Penny E. Campbell is a physical therapist and has been a board certified wound specialist for the past 10 years. She is a medical education manager for Smith & Nephew. (penny.campbell@smith-nephew.com)