- 1 - Welcome to the first issue of the Dressings Times a new pub- lication which will be produced two or three times a year providing information on changes and developments in the field of surgical dressings and wound management. The "Times" will contain technical information and advice relating to the use of particular wound management materials together with more general information on the purchasing and contracting arrangements for dressings which are made cen- trally on behalf of the Health Authorities in Wales. If suf- ficient interest is shown in this first issue it is hoped it may eventually develop into a Welsh Wound Management Journal which will be distributed free to hospital and community staff throughout the Principality. The success of any publication can only be judged by the in- terest which it generates among its readership. If you feel that there is a place for such a journal or have any views, letters or short articles on any dressings' related topic which you would like to have included in a future edition, please write to the editor at the address shown overleaf. Any user comments relating to the performance of new con- tract items favourable or otherwise would be particularly welcome as these may help to influence future purchasing de- cisions. If you are dissatisfied with the quality or perfor- mance of any of the materials you use daily within your wards and departments this is your opportunity to make your views known. CONTRACTING ARRANGEMENTS FOR DRESSINGS As this is the first issue of the Dressings Times, it was thought that it might be appropriate to give a brief outline of the mechanisms by which dressings are selected for pur- chase within Wales. Many hospital staff believe that con- tracts for dressings are awarded based entirely upon finan- cial considerations. Obviously although cost is a major fac- tor, quality and performance are equally important in the decision making process. To this end a multi-disciplinary contracting committee has been set up which is composed of representatives of interested parties including CSSD, Medi- cal, Nursing, Pharmaceutical and Supplies personnel. The role of this committee is to ensure that the dressings which are placed on contract represent the best value for money available. The dressings contract runs for a twelve month period from March 1st to the end of the following February. This year a total of 18 companies supplying nearly 120 items are included in the contract schedule representing a total spend of some 1.67 million. It is estimated that as a re- sult of this years contracting process, financial savings in the order of 1.2 million (41%) have been achieved compared with normal hospital list prices. Each November, tender documents are sent out by the Welsh Health Common Services Authority (WHCSA) to all companies on an approved list. These documents include copies of product specifications and other more general requirements relating to the contract. Any company wishing to supply one or more products under the terms of the contract completes a copy of the tender which is returned to WHCSA for examination and collation. At the same time samples are sent for testing and examination to the laboratory based in East Glamorgan Hospi- tal. The results of these tests together with the price analysis prepared by WHCSA are considered by the contracting committee and used as a basis for the selection of the prod- ucts concerned. In the past, dressings were purchased against standard structural specifications laid down in the British Pharma- copoeia (BP) or the British Pharmaceutical Codex (BPC) but in recent years developments in the dressings field have been so rapid that many of the new materials are not subject to such specifications. Products such as gauze swabs, ribbon gauze, cotton wool etc are still purchased against specifi- cations which have been in use for many years but other products such as bandages and synthetic casting materials have to be assessed using specially devised tests. A consid- erable amount of work is carried out within the laboratory to ensure that the tests which are developed are relevant to the normal clinical usage of the materials concerned. Ef- forts are also made to obtain the views of potential users on the performance of new dressings particularly where a change in supplier is contemplated. It is acknowledged that the background to many of these pur- chasing decisions is not always properly made known to users and it is partly in an attempt to overcome this problem that this news sheet has been produced. The Contracting Committee at Work "Heads it's Smith and Johnson, tails it's ...." PRINCIPAL CHANGES ON THE 1988-89 DRESSINGS CONTRACT. Orthopaedic Casting Materials. This year for the first time, a contract has been awarded for a synthetic splinting material. A number of these prod- ucts are now available and all the manufacturers concerned have worked hard to try to ensure that their individual brands get used in theatres and plaster rooms etc. Although a number of local purchasing arrangements have been made in the past, it was evident that an `All Wales' contract for these items would bring about a degree of rationalization and result in significant cost savings without having to place large orders in order to obtain worthwhile financial discounts. From all the products submitted for tender, two were select- ed for contract, Scotchflex (3M Health Care) and Deltal- ite`S' (Johnson and Johnson Orthopaedic). Although both products are based upon a polyurethane resin applied to a glass fibre fabric, they are very different and can be said to have separate and distinct applications. Scotchflex is a lightweight material which is well suited for the production of upper limb casts and for use in paediatrics and for older people where it may be important to keep cast weight to a minimum. Delta-Lite `S' is essentially a much heavier fab- ric and is probably one of the strongest materials avail- able. Casts which are manufactured from Delta-Lite `S' are capable of withstanding the maximum loads which are ever likely to be met in use. In addition, the bandage contains a silicone additive which has the effect of reducing the "tackiness" normally associated with polyurethane casting materials resulting in a product which is easy to apply and which forms a cast with a smooth surface, comparable with that of a standard plaster cast. More detailed information on both of these materials may be found in the Surgical Dressing Information Sheets. Changes have also been made to the Plaster of Paris bandages which are on contract. In addition to Gypsona (plaster of Paris Bandage BP from Smith and Nephew), a contract has been awarded to Lohmann to supply an alternative material, Cel- lona SR. Although similar to Gypsona in appearance, it dif- fers from it in the structure of the base fabric and more importantly the composition of the plaster itself. Both Gyp- sona and Cellona SR are manufactured from a blend of two different crystalline forms of calcium sulphate but the rel- ative proportions differ in the two products. The plaster mass on Cellona SR contains mainly alpha crystals and re- quires a shorter dip time than the plaster mass on Gypsona which has a higher content of beta crystals. It is also claimed that a plaster high in alpha crystals becomes weight bearing earlier and forms a slightly harder cast than a plaster rich in the beta form. These differences mean that users may require to make minor modifications to their tech- nique when changing from one brand to another and it is im- portant that the instructions for the use of this alterna- tive material are followed carefully. There is a significant financial advantage to using the Cellona SR material and plaster room staff may wish to try this new product as an alternative to the material they are currently using. Orthopaedic Wadding Bandages Also in the field of orthopaedics, this year the contract for a cellulose based under cast padding has changed from Velband (Johnson and Johnson Orthopaedic) to Soffban Natural (Smith and Nephew Ltd). Soffban Natural is similar in struc- ture and performance to Velband and user comments to date have been very favourable. The bandage may be autoclaved prior to use and will not become stiff or hard to unwind. Extensible Bandages This year there is a new addition to the range of bandages which are available on contract, K Crepe from Parema is a lightweight knitted bandage which contains polymeric yarns which make the product much more elastic in use than the traditional crepe bandages. Laboratory tests have shown that this new material is able to apply and maintain levels of pressure which are considerably higher than those achieved by Crepe BP or Cotton Stretch Bandage BP (Grip). These characteristics make the bandage well suited for controlling mild oedema in average sized limbs. It is not suitable for application to very large legs which are grossly swollen. In these situations a much heavier product is required such as Bilastic, Rowden Foote or Blue Line Webbing BP although the latter is hard and uncomfortable and generally disliked by patients. When used with a suitable dressing, K Crepe may be of value for the treatment of venous ulcers within the con- straints outlined above. Because the bandage has a tendency to `neck' or become narrower when under tension, it is rec- ommended that a 10 cm width is used routinely. Even using this larger size, the bandage is still more economical in use than a 7.5cm wide crepe bandage. It is important not to confuse K Crepe with other lightweight woven or knitted ban- dages which are available for dressing retention purposes as these are definitely not suitable for the application of pressure. However, because the fabric used in the manufac- ture of K Crepe is lighter than that used in the all cotton bandages it may not be as effective as the crepe materials in providing support for a sprain for example. Like all ex- tensible bandages K Crepe should not be applied at full stretch or with excessive tension. A more detailed account of the performance of different bandages will appear in a later edition of the Dressings Times. Wound Management Products Another new product to appear on the contract this year is Biofilm from CliniMed. Biofilm is one of the family of hy- drocolloid dressings which have made a big impact in wound management in the last couple of years. The first product to come on the scene was Granuflex from Squibb which has proved to be extremely effective in the treatment of many different times of exuding wounds including leg ulcers and pressure areas. Although Biofilm is similar to Granuflex in the com- position of the adhesive base it has a different backing ma- terial. Granuflex is made from a thin foam sheet covered with an impermeable plastic membrane but Biofilm has a non woven fabric backing which is permeable to water vapour but impermeable to liquid water under normal conditions of use. At the present time there is some controversy about the rel- ative merits of these two dressings and the question of the permeability of the CliniMed product has been discussed at length in the pharmaceutical press. Like Granuflex Biofilm is indicated for the management of ulcers and further infor- mation upon the use of the product is given in the Dressings Information Sheet. Other changes to the contract. Two new surgical tapes, Leukopor a nonwoven paper tape and Leukosilk a finely woven rayon taffeta tape from BDF replace Micropore and Durapore respectively on the contract. Both these tapes comply with the relevant BP specifications and should be well accepted by users. First aid dressings such as Elastoplast and Band Aid have been replaced by a new fabric range from BDF a large multi- national German company. The dressings, called Coverlet, are available in a wide range of shapes and sizes and adhere and conform extremely well. Complaints on dressings Despite all the care taken to ensure product quality, from time to time problems with dressings do occur. Although these are usually relatively minor, occasionally dressings are received which are obviously substandard or contaminated with oil or some other material which makes them totally un- suitable for use. When such problems occur, no matter how minor, we want to know about them. Please do not just throw the offending material into the bin but send it to the Qual- ity Control Department in East Glamorgan Hospital together with the packaging and a description of the problem. PRODUCT PROFILE It is the intention of the Dressing Times to include in each issue, a profile of one of the new wound management products which will provide information on the structure and composi- tion of the material concerned, together with the indica- tions for its use and the method of application. The subject of the first profile is Scherisorb gel which is manufactured and distributed by Smith and Nephew Medical Ltd. Scherisorb consists of a colourless to pale yellow transparent aqueous gel manufactured from chemically modi- fied corn starch. The gel is presented in aluminium lami- nate sachets and contains 2% of the basic copolymer with 78% water and 20% polyethylene glycol as a preservative and humectant. Originally introduced as a treatment for leg ul- cers, it has been found that Scherisorb is a useful alterna- tive to hypochlorite solutions for aiding the debridement of necrotic or sloughy wounds such as pressure sores and burns. As the gel itself does not contain any enzymes or have any intrinsic proteolytic activity, it is believed that its un- doubted success in this area is simply due to its ability to rehydrate the necrotic material which is subsequently re- moved by autolysis (a natural process by which the body breaks down and removes dead tissue.) When used for this purpose, the gel should be applied liber- ally to the surface of the wound and covered with a suitable pad. In the early stages of debridement, a perforated plas- tic film dressing such as Telfa or Melolin may be desirable to help conserve moisture but as the slough begins to soften and liquefy, a plain dressing pad may be all that is re- quired. It is unfortunately the case that some wounds pro- duce a very unpleasant odour as the slough breaks down due to the presence of bacteria. The application of a dressing containing activated charcoal may help to control this odour but if the wound is particularly unpleasant due to contami- nation with an anaerobic organisms such as Bacteroides for example, more positive measures may be required. Scherisorb gel to which has been added 0.8% metronidazole powder has proved to be extremely effective in killing the organisms which actually causes the odour in pressure areas and cer- tain forms of fungating carcinomas but this treatment should only be used under the direction of the medical officer in charge of the patient Scherisorb gel has also been used alone or in conjunction with ribbon gauze for packing cavities and sinuses although the gel should not be introduced into any sinus the full ex- tent of which is not known. An additional application for the use of Scherisorb is in the treatment of extravasation injuries in young infants. In this technique the affected limb is placed in a sterile plastic bag forming a "glove" or "boot" and a quantity of gel introduced onto the wound using a syringe and quill. The bag is then sealed and changed daily or on alternate days as appropriate. A wound dressed in this way will not dry out and remains visible at all times. The quality of healing ob- tained using this method appears to be superior to that ob- tained using conventional methods of management. A more de- tailed account of the use of Scherisorb for this application may be found in the Pharmaceutical Journal 1987;239:584. Cost of Scherisorb. The hospital list price of Scherisorb is 1.30 per sachet but small discounts are available for bulk purchases. Further information on Scherisorb gel and other wound man- agement materials can be found in the Dressings Information Sheets, supplies of which should be available through your local hospital pharmacy department. Any comments or contributions for future editions of the Dressings Times should be sent to the address below. The Dressing Times is produced by the Welsh Centre for the Quality Control of Surgical Dressings, East Glamorgan Hospi- tal, Church Village, Pontypridd, Mid Glamorgan. Telephone No. (0443) 202641.