Jacky Edwards, Burns Specialist Nurse, Wythenshawe Hospital
Louise O’Connor, Tissue Viability Nurse, Wythenshawe Hospital
VERSAJET™ is an effective means of achieving precise wound debridement. Like other treatment modalities, it is the
responsibility of the user in the ward, clinic or community setting to ensure competent, effective and safe practice.
This workbook has been designed for practitioners with little or no experience with VERSAJET. It can also be used
to update and refresh skills and knowledge. It is not intended as a stand-alone module and should be used in
conjunction with support from an appropriate trainer.
Guide to completing the workbook
The workbook is individual for each practitioner and represents a record of personal learning. Practitioners should
read the learning outcomes below and then describe what they hope to achieve and identify their learning needs.
They should then work through the sections and get the most out of the exercises by completing all the timeout
At the end of the workbook is an opportunity to record procedures observed or
performed. It is important that practitioners take time to reflect on practice and think about any learning points from
these procedures. This will help to determine what the practitioner could do to improve patient care.
In addition, utilisation of the workbook with the accompanying competencies should assist practitioners in
developing their learning needs and devising action plans to develop their clinical skills. They should work with a
suitably trained assessor.
At the end of this workbook the practitioner should be able to:
- Discuss methods of debridement
- Understand relevant underlying structures and how to identify them
- State and understand the concept of VERSAJET debridement
- Understand how to set up and operate the VERSAJET
- Identify the indications and precautions to be considered when using VERSAJET
- Identify how to trouble shoot VERSAJET
- Recognise their limitations in personal knowledge, skill and competence
- Acknowledge personal accountability
- Understand the importance of informed consent and be able to undertake it
- Document the wound assessment and VERSAJET procedures
Section 1 – Debridement
Section 2 – VERSAJET™
Section 3 – Precautions
Section 4 – Troubleshooting
Section 5 – Patient Assessment and competencies
Section 6 – Self Awareness and Accountability
Section 7 – Patient information and informed consent
Section 8 – Procedure Record
Section 9 – References and Further Reading
Section 1 – Debridement
Debridement is seen as essential to promote wound healing. Debridement is the
‘removal of devitalised or infected tissue or foreign material from a wound’ (National Institute for Clinical Excellence
NICE 2001). Although research is lacking to state categorically that debridement is necessary for wound healing, a
wealth of clinical experience over many years exists to indicate that in many cases healing progresses much more
rapidly following debridement and it is accepted practice in good wound care (NICE 2001).
Dead or devitalised tissue is known to inhibit wound healing by inhibiting the migration of epithelial cells across
the wound and therefore epithelialisation (Poston 1996). Wound assessment is difficult to undertake when slough
or necrotic tissue is present as the extent of the wound cannot be determined and any undermining of the wound
is not apparent. Debridement may also be necessary to prevent wound or systemic infection, as moist devitalised
tissue acts as a culture medium, promoting bacterial growth and inhibiting leukocyte phagocytosis of bacteria.
Once bacteria have colonised dead or foreign materials, they may be less susceptible to host defence
mechanisms and antibiotic therapy (Fowler 1995). Poston (1996) suggests that there are a number of varieties of
bacteria that thrive in devitalised tissue, but colonisation rarely leads to clinical infection. They are more likely to
cause exudate and odour. The exceptions to this are Staphylococcal and Streptococcal colonisation, which do
usually lead to clinical infection (Burton 1994).
Devitalised tissue is tissue that has been deprived of nutrients and oxygen for a period of time (Tong 1999). It
ranges from hard, dry black necrotic tissue to soft, stringy, yellow or green slough. It is important that practitioners
are able to identify the type of tissue present in the wound. A useful tool is the Red, Black & Yellow colour system
developed by Cuzzell in 1988. This system relates colour to tissue type. Red is related to granulation tissue, Black
to necrotic tissue and Yellow to slough. Removal of slough will enhance healing, eliminate the potential for infection
and reduce odour and exudate production (Tong 1999).
This is mostly yellow fat; there are some blood vessels but generally there is poor vascularity
Shiny/gleaming white. It is the ‘tough’ covering of muscles.
Infection can spread along the plane (necrotising fasciitis)
Dull red in colour, highly vascular and tears easily protects bones, joints, nerves and vessels
Hard, bright white. Desiccates rapidly if exposed and turns yellow.
No vascular flow to the joint, fluid will leak if entry into joint.
Connective tissue with poor vascularity. Covers the bone at the joint.
Type 1 – White fibrous, inelastic, Type 2 – Yellow elastic tissue
Strong, gleaming white, shiny elastic fibrous tissue. They attach muscle to bone, poor
Observe for pulsation
Time Out 1
List the different approaches to debriding a wound
Surgical or sharp debridement is a fast method of debriding hard necrotic wounds. There are two methods of sharp
debridement, the first is excision or wide resection of all dead or devitalised tissue, possibly including excision of the
viable wound margin. This is usually carried out in theatre under anaesthetic by a surgeon. It is sometimes referred to
as “Surgical toilet”. The second is the removal of dead or foreign material just above the level of viable tissue, and is
carried out without anaesthetic by a doctor or a nurse (Poston 1996). The method used can depend on the anatomical
position of the wound and amount of tissue requiring debridement (Bale 1997). Debridement is one area of overlap
between nursing and medicine.
Enzymatic debridement involves the use of proteolytic enzymes. These enzymes are said to digest slough and
necrosis whilst leaving healthy tissue intact (Bale, 1997). It works by breaking down fibrin, denatured collagen and
This is the debridement of soft necrosis and slough by the application of certain
chemicals. The most commonly used chemicals include hypochlorite solutions,
hydrogen peroxide and iodine solutions.
This was a common method of debridement in the past, however, evidence supporting their use is poor and there
is some evidence that these preparations damage healthy granulation tissue (Vowden 1999).
Autolysis is the process by which the body is facilitated to break down dead tissue using its own enzymes. In
moist conditions it has been demonstrated that enzymes soften and liquefy dead tissue which then separates
spontaneously from the healthy tissue (Bale, 1997).
Many modern dressing products support the body in this process and assist in the removal of waste products from
this process. In order for this to occur the wound must be sealed or occluded which promotes fluid retention, which
in turn re-hydrates the desiccated devitalised tissue and aids its separation from the healthy tissue (Tong, 1999).
This process obviously takes longer than sharp debridement and therefore there is a potential for toxins to
continue to be produced and for infection to occur. However, Bale (1997) contends that it is a gentle, non-traumatic
and easy to use method of wound debridement. It is non-invasive and can be utilised by any practising nurse. It
also causes minimal pain and discomfort to the patient.
Larval therapy has become a popular method of debridement in the UK in the past four years. The larvae have the
ability to internally and externally digest large amounts of necrotic tissue and are an extremely effective form of
wound debridement. Vowden & Vowden (1999) suggest that debridement is rapid and selective and is a means of
debriding both large and small wounds. Larvae may also have a role in preventing or controlling infection (Bale, 1997).
Section 2 – VERSAJET™
Time Out 2
Write down your understanding of how VERSAJET achieves wound
debridement and why this helps the wound as it progresses to healing
VERSAJET is a powered instrument for debridement of wounds. It utilises a high-speed stream of saline to create a
localised vacuum which simultaneously holds, cuts and removes tissue. This allows for a highly controlled means
of removing sloughy, infected or devitalised tissue debris and foreign matter from acute, chronic and traumatic
wounds. It facilitates the ideal balance between effective debridement and tissue preservation.
This is a close up diagram of the tip of the device. Saline is travelling parallel
across the operating window and back into the evacuation tube. This
creates a vacuum via the Venturi Effect which brings tissue and contaminants
up into the stream of saline. The fluid stream then ablates the tissue which
the jet and vacuum carry into the evacuation tube and from there to the
waste collection pot.
The VERSAJET Hydrosurgery System consists of three main components:
Hand piece - The hand piece is a sterile, disposable unit that can be used
to debride and clean wounds. The hand pieces come with operating
windows in two sizes, either 8mm or 14 mm in length.
2. Power Console - This creates the fluid jet that enables the hand piece to work.
3. Pedal - A pedal switch allows single-handed usage.
The innovative VERSAJET Hydrosurgery system is a specialised powered
surgical tool designed to improve care for patients undergoing wound
debridement. This unique system can reduce the number of procedures
some patients may have to undergo (Granick 2006). This is not only better
for the patient and clinician it can also reduce the cost of debridement.
It is also possible to use the 45° hand pieces outside of the theatre
environment allowing the benefits of VERSAJET to be experienced outside
of theatre. This allows for surgical debridement to be carried out by
experienced clinicians of all levels in the ward, outpatient or community
setting (Smith and Nephew Wound Management).
Operating the System
• The unit is activated by using the pedal
• Sterile saline flows through low-pressure tubing to the power console
where it is pressurised
• Pressurised saline is forced under very high pressure through a tiny jet
nozzle at the end of the hand piece as described previously
• This saline stream is directed backwards across the operating window and
into the evacuation collector tube in the hand piece, which also collects any
debris or contaminants created by the procedure
Application set up
Before inserting pump cartridge, move the console knob to the open position (4
o’clock) as shown. Insert the pump cartridge fully into the user interface being sure to
align the orange post on the pump cartridge with the receiving hole on the interface.
To lock the pump cartridge, user must move the console knob to the closed position.
DO NOT push pump cartridge while closing the console knob
VERSAJET™ pump cartridge is in locked position as verified by a click. Console knob is
in the 6 o’clock position
Connect hand piece waste line to a gravity feed waste container.
Ensure at least one part is left open for ventilation. If using a vacuum container do
not connect to vacuum. If using a container with a filtered port, ensure you do not
connect the tube to this port.
Insert footswitch plug by aligning red dot on plug with red dot on console. Turn
console on using power switch. If door and/or pedal light are illuminated, refer to
Spike saline bag and release white clip. To prime the system, increase the power
to setting 10, depress foot pedal and listen for the change in sound as the saline
reaches the tip. Once system is primed, lift foot from pedal and turn console back
down to power level 1.
The system is now ready to use
- Position hand piece over area to be debrided (hold like a pen)
- Ensure that the hand piece is in contact with the tissue and move rapidly across the tissue
- Start on a low setting and increase as appropriate
- Raise tip of hand piece before taking foot off pedal to prevent dripping
Additional design attributes allow the user to finely control excision. Orienting the operating window parallel to
the tissue optimises the VERSAJET™ performance for tissue excision. Alternatively, orienting the operating window
obliquely (at an angle) to the tissue optimises the VERSAJET’s performance for fluid removal.
Care should always be taken when using near sensitive tissues at all settings
The system is highly controllable and has 10 power settings. In addition pressure can be modified by adjusting the
hand piece direction and pressure.
the lowest power levels (1-3), VERSAJET will function mainly as a vacuum and removes little tissue with each
pass. At this level the main action is suction, irrigation and scrubbing
the power is increased, tissue ablation increases, as does the ability to remove harder, tougher tissue types
the highest power levels (7- 10), the VERSAJET system will remove nonviable tissue very rapidly and cut all but
the hardest tissues including bone
Disconnecting and cleaning the equipment
- Hard surface medical wipe (as per Trust Guidelines)
- Disposable gloves
- Disconnect console from mains and remove power cord and foot pedal cable
- Put on disposable gloves
- Dispose of hand piece as per Trust Guidelines
- Extract a hard surface medical wipe from container
- Wipe over all surfaces with the wipe ensuring all surfaces have been wetted
- Dispose of the wipe and gloves via the hospital clinical waste system
- The foot pedal and cables should also be cleaned in a similar manner
Equipment required to use VERSAJET
- VERSAJET Console
- VERSAJET Hand piece
- Saline (both Intravenous saline and Saline for Irrigation are suitable)
- Waste canister for collection of fluid (Suction pots are useful for this)
- Protective equipment as per Trust procedure
The unique properties of VERSAJET enable clinicians to debride traumatic wounds, chronic wounds, or other soft
tissue lesions or remove contaminants from a wound quickly and efficiently.
• Effective in debriding damaged and necrotic tissue in traumatic wounds, chronic
wounds, surgical incisions and burns
debris and foreign matter from acute and traumatic wounds
Use on infected wounds
VERSAJET can be used on infected wounds and clinical evidence shows that VERSAJET can dramatically reduce
the bacterial burden on the wound (Mosti 2005)
wounds promote more rapid wound healing
can be used by all suitably experienced clinicians to debride wounds
• The ability to debride outside of theatre means significant saving in materials and personnel costs
• Being able to carry out procedures in the ward or outpatient setting has significant benefits for patients
• Ability to precisely target damaged tissue and avoid viable tissue
• Enables rapid debridement, likely resulting in shorter procedure times
• Single step technique combining debridement, cleansing and aspiration
Section 3 – Precautions
Time Out 3
Given that VERSAJET™ is able to debride a wound to achieve punctate
(pin-prick) bleeding, list any indications or situations where caution
should be taken during use.
Care should be taken around vessels, organs and other anatomical structures that do not need debriding
Care should be taken if using VERSAJET on patients who are on anticoagulant therapy or have clotting disorders
Time Out 4
Some patients may have a lower pain threshold and it may be appropriate
to consider anaesthesia of some kind when treating their wound. List the
possible approaches to pain management in this situation.
It is important to prepare the patient carefully before any debridement procedure as explanations are more likely
to result in a relaxed patient, which makes sharp procedures much acceptable. Some practitioners don’t use any
analgesia until they are through the necrotic or sloughy tissue as there is little or no pain until viable tissue is
reached. Also, by dropping the power setting when the wound is almost debrided and angling the hand piece, the
wound can often be debrided to viable tissue with minimal discomfort. If any pain is experienced the procedure
should be stopped immediately and analgesia reviewed before re-commencement, if appropriate. A number of
options are available.
Section 4 – Troubleshooting
Obstruction of evacuation tube
(grit, stick, wire, or other foreign
Remove hand piece from surgical
field, take foot off foot pedal
and remove obstruction from
Waste evacuation tube is not
Raise waste evacuation tube so
collector end of waste tubing is at
lowest point of entire tube
Waste evacuation tube is:
Waste evacuation tube is
incorrectly connected to waste
Connect waste evacuation tube to
“PATIENT” port on waste container
Waste container is sealed
Open large drain port on waste
Misaligned jet (striking edge
of tube or shooting outside
Stop! Do not use
Replace hand piece
No fluid supply
Attach saline bag or replace
saline bag if empty
Air in supply tube
Pump fluid on high setting until
system is purged of all air in
Power cord not attached
Ensure power cord is attached to
back of console and wall outlet
Power switch in off position
Foot pedal is not attached
Attach footswitch securely
Footswitch is damaged
Console is running, no fluidjet is
visible in hand piece
Console does not run, power
indicator light is off
Console does not run, power
indicator light is on, Pedal light is
Remove object causing pinch
Section 5 – Patient Assessment and
Delivering the Modernisation Agenda within the Health Service requires clinical staff to deliver care based on
patient need. Rethinking the patient journey gives nurses the opportunity to break down professional boundaries
and speed the delivery of care to patients. However, a number of areas of law should be considered when making
decisions to undertake new roles
Obligations and liabilities arise from three key areas and underpin how any new role is developed and managed:
Professional Regulation of the appropriate regulatory body, e.g., The Nursing and Midwifery Council. The
professional who is undertaking the new role must be fully conversant with the requirements of registration and
work within these confines. In summary, in taking on new work, nurses (for example) must acknowledge any limits
in their competence and decline duties unless able to perform them in a safe and skilled manner. New service
protocols must acknowledge this principle, and therefore ensure practitioners can practice in a safe manner.
The law on civil wrongs to patients. The areas of concern are those relating to negligence and battery. Although
civil action would normally be directed against the NHS employer rather than the individual professional, and the
Trust would normally be responsible for paying any damages, a finding of negligence against a nurse or other
professional is harmful professionally and personally.
The nurse or other professional undertaking the activity could be held, for the purposes of negligence, to the
standard of the performance of a doctor for that task.
Employment law covering the relationship between employers and employees. While employees must be prepared
to adapt to new practices, an employer should provide the means for this, including the necessary training,
professional and managerial support.
Significantly the Scope of Professional Practice document (UKCC 1992) appeared at the same time that the hours
of junior doctors were reduced by the ‘New Deal’. The scope made it possible to take on tasks and competencies
that were generally thought to be ‘medical’. More recently, the NMC has supported government led initiatives,
within the modernisation of the NHS that have placed nurses at the centre of care delivery. This has led to nurses
undertaking many roles that traditionally have been seen as outside their remit. Therefore in order to undertake
these roles there needs to be evidence of appropriate training and assessment.
The Tissue Viability Nurses Association (TVNA) suggest that ideally nurses wishing to undertake any form of
debridement should take into consideration the following:
Recommendations outlined within the UKCC, Midwifery and Health Visiting document ‘The Scope of Professional
Practice’ (1992) and the NMC, Code of Professional Conduct: Standards for Conduct Performance and Ethics (2004).
Accepting responsibility only if he/she is confident that the appropriate level of knowledge and understanding of
the procedure has been achieved (UKCC 1992, NMC 2004)
Being anatomically aware of the underlying structures within the area to be debrided
Having the ability to stop if they become uncomfortable, uneasy or uncertain at any time during the procedure
Awareness of local policies and guidelines relating to wound management (e.g. infection control, wound care)
Having approval from their employers to perform the task
Undertake the task as part of a treatment plan agreed with the multidisciplinary team managing the patients care
Time Out 5
What do you expect you will need to know about the patient and the
wound before considering the use of VERSAJET™?
In addition to considering the use of VERSAJET™ to benefit the patient and the wound, the practitioner must first
undertake a holistic assessment of the patient and consider the following points:
- Is the therapy appropriate for the wound and also for the patient? The practitioner should consider the
general wellbeing, product indications and precautions, concomitant therapies/medication and the
psychological state of the patient
- What type of wound is to be treated, where is the wound located and what type of tissue is present?
These assessments will affect the power setting chosen, the decision on whether to use anaesthesia and
the appropriate hand piece to select.
- Does the practitioner fully understand the capabilities of the VERSAJET Hydrosurgery System and its
abilities to achieve the desired outcome?
- Does the practitioner have an understanding of sharp debridement and the underlying structures in
the skin? Does the practitioner feel competent to use a sharp instrument and the power settings to
carefully debride tissue in this area?
- Is the practitioner able to fully communicate with the patient, their family and with the multi-disciplinary
team about their decision to use the VERSAJET system?
Section 6 – Self awareness and
UKCC’s Code of Professional Conduct,  states that practitioners are personally accountable for their
practice and the Scope of Professional Practice document [UKCC 1992] reiterates that they must recognise and
honour personal accountability borne for aspects of professional practice. According to the UKCC, professional
accountability rests on the two interrelated concepts of ability and competence. Ability is understanding the
relevant knowledge, skills and values to make decisions and act upon them. Competence is described as the
ability to perform a task with appropriate knowledge and skill.
There is now clear support for the individual practitioner to make decisions to widen her role within the context
of the changing environment. The UKCC states that practice “must be sensitive, relevant and responsive to the
needs of individual patients or clients and have the capacity to adjust, where and when appropriate, to changing
circumstances”. This approach has been endorsed by the Department of Health who state that “each practitioner
is personally accountable for his/her own practice and for maintenance and development of her knowledge and
As accountable practitioners, nurses retain responsibility for all actions and omissions.
Time Out 6
Why do you think accountability is important when considering the use of
an advanced therapy?
In addition, record keeping is of paramount importance when taking on an expanded skill. Documentation must
consist of patient consent, tissues debrided and appearance of wound pre and post debridement. In addition the
handset used, power setting and label from the handset should all be documented in the patient’s case notes.
Section 7 – Patient information and
Nurses in the UK have a professional responsibility to ensure that patients in their care are given information about
their conditions and understand the risks and implications of any interventions given (NMC 2004). They also
have a responsibility to gain the consent of patients for whom they have a duty of care, before they carry out any
procedure or intervention.
It is vital that the patient understands what he or she has consented to, and it is an important role of the nurse to
check and ensure that this happens. (Cable 2003). Effective communication is vital in gaining consent. The nurse
needs to be able to provide information in a form that is appropriate to each individual.
Patients have a right to know exactly what it is they are consenting to, and information should enable and empower
them to make a decision about a proposed intervention. This requires that the nurse gives a balanced perspective
on whatever the patient is asked to consent to.
Time Out 7
What information should you provide to the patient and their family to help
them to make an informed decision about the use of VERSAJET™ for wound
As has been demonstrated, there are many methods of debriding wounds and it is important that patients are
involved in the decision so that they are able to give
informed consent. To make effective clinical decisions and ensure patients are fully informed it is essential
that nurses are aware of the different methods of debriding wounds. The nurse should also be aware of the
professional requirements for competence and the risks and benefits of each method.
In order to make an informed decision, the patient should know:
- What equipment is proposed for use
- How the equipment works
- What the objective of the treatment is
- The likely impact on the progression to wound healing
- The likely outcome if the treatment is not given
- What alternatives are available
- Any possible side effects (including pain) and how these will be managed
- Any possible impact of the therapy on the patient’s quality of life, length of stay etc.
- How long the procedure is likely to take
Some patients may be particularly interested in the mode of action of the treatment and how their wound is
progressing. Patients should be encouraged to be as involved as possible in their treatment and the journey to
Nurses are accountable for their actions. Nurses should always therefore ensure that they are competent to obtain
consent. This entails ensuring that they have the appropriate skills to undertake an assessment of the person’s
capacity to give consent and the communications skills to ensure that the person is informed.
Section 8 – Procedure record
This section is for you to keep a record of VERSAJET™ uses in the clinical setting and to note any learning points or
Section 9 – References and further
Anderson, I. Debridement methods in wound care. Nursing Standard 2006; 20 (24): 65-70
Bale S. A guide to wound debridement. Journal of Wound Care 1997; 6 (4): 179 – 182
Burton, C.S. A Symposium: wound infection and occlusion – separating fact from fiction. Venous ulcers.
American Journal of Surgery 1994; 167: 37S – 41S.
Cable S, Lumsdaine J, Semple M. Informed Consent. Nursing Standard 2003; 18 (12): 47-53
Cuzzell J. The new RYB Code. American Journal of Nursing 1988; 10: 1342-1346
Edwards J. Non-sharp debridement of devitalised wound tissue. Journal of Community Nursing 2000; 14: 8
Fowler E, van Rijswijk L. Using wound debridement to help achieve the goals of care. Ostomy Wound Management
1995; 41 (7A Suppl.): 23S – 36S
Granick MS, Jacoby M, Noruthrun S, Datiashvili RO, Ganchi PA. Clinical and economic impact of hydrosurgical
debridement on chronic wounds. Wounds: A Compendium of Clinical Research and Practice 2006; 18(2): 35-9
Mosti G, Iabichella ML, Picerni P, Magliaro A, Mattaliano V. The debridement of hard to heal leg ulcers by means of
a new device based on fluidjet technology. International Wound Journal 2005; 2: 307-314
NICE (2001) Guidance on the use of debriding agents and specialist wound care clinics for difficult to heal surgical
wounds. Technology appraisal guidance No. 24
Nursing and Midwifery Council (2004) The NMC Code of Professional Conduct:
standards for conduct, performance and ethics. London, NMC.
Poston, J. Sharp debridement of devitalised tissue: the nurse’s role. British Journal of Nursing 1996; 5(11): 655-662
Smith & Nephew Wound Management. Splatter and Aerosol Generation during use of VERSAJET hand pieces Data
on File ref. WMP/06/275-6
Tong, A. The identification and treatment of slough. Journal of Wound Care 1999; 8(7): 338 – 339
TVNA. Conservative Sharp Debridement: Procedure, Competencies and Training. Tissue Viability Nurses
United Kingdom Central Council (1992) The Scope of Professional Practice. London, UKCC.
United Kingdom Central Council (1992) Code of Professional Conduct for the Nurse, Midwife and Health Visitor (3rd
Ed). London. UKCC
Vowden KR. Vowden P. Wound debridement, Part 1: non-sharp techniques Journal of Wound Care 1999; 8(5):
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