Repositioning to prevent pressure sores--what is the evidence?

Engaging in the prevention of pressure injuries in spinal cord injury: A qualitative study of community-dwelling individuals' different styles of prevention in Switzerland

Context: Spinal cord injury (SCI) is a complex chronic condition with multiple self-management requirements and a high prevalence of complications. Pressure injuries (PIs) are among the most common ones and represent a frequent reason for re-hospitalization. This study aimed to identify styles of prevention that individuals with SCI adopt to deal with the risk of developing PIs.Design: Qualitative explorative interview study. Data was collected through semi-structured interviews, which were transcribed verbatim and analyzed following the principles of thematic analysis.Setting: Switzerland.Participants: The participants were a purposive sample of community-dwelling Swiss residents with SCI for at least five years.Interventions: Not applicable.Outcome measures: Not applicable.Results: Although all participants (N = 20) showed at least a basic knowledge of prevention of PIs by describing some preventive measures, they had different prevention styles characterized by different behavioral patterns (i.e. complying with all recommended measures, performing only a selection of them or delegating them to others) and different beliefs and attitudes towards prevention.Conclusion: By identifying the style of prevention of an individual, it is possible to develop tailored interventions that have an impact on the factors which seem to play a role in determining the adoption of preventive behaviors (i.e. perceived susceptibility to PIs, attitudes towards prevention, and self-efficacy). Such interventions would constitute a concrete effort to support individuals with SCI during their self-management. Besides alleviating a frequent and disabling medical complication and contributing to an enhanced quality of life, these interventions might also help decrease healthcare costs.

Two-Hourly Repositioning for Prevention of Pressure Ulcers in the Elderly: Patient Safety or Elder Abuse?

For decades, aged care facility residents at risk of pressure ulcers (PUs) have been repositioned at two-hour intervals, twenty-four-hours-a-day, seven-days-a-week (24/7). Yet, PUs still develop. We used a cross-sectional survey of eighty randomly selected medical records of residents aged ≥ 65 years from eight Australian Residential Aged Care Facilities (RACFs) to determine the number of residents at risk of PUs, the use of two-hourly repositioning, and the presence of PUs in the last week of life. Despite 91 per cent (73/80) of residents identified as being at risk of PUs and repositioned two-hourly 24/7, 34 per cent (25/73) died with one or more PUs. Behaviours of concern were noted in 72 per cent (58/80) of residents of whom 38 per cent (22/58) were restrained. Dementia was diagnosed in 70 per cent (56/80) of residents. The prevalence of behaviours of concern displayed by residents with dementia was significantly greater than by residents without dementia (82 per cent v 50 per cent, p = 0.028). The rate of restraining residents with dementia was similar to the rate in residents without dementia. Two-hourly repositioning failed to prevent PUs in a third of at-risk residents and may breach the rights of all residents who were repositioned two-hourly. Repositioning and restraining may be unlawful. Rather than only repositioning residents two-hourly, we recommend every resident be provided with an alternating pressure air mattress.

A pilot randomised controlled trial comparing reactive air and active alternating pressure mattresses in the prevention and treatment of pressure ulcers among medical ICU patients

BACKGROUND

Data on the prevention and treatment of pressure ulcers (PU's) among ICU patients is sparse.

OBJECTIVE

To compare PU outcomes in medial ICU patients nursed on either a reactive mattress overlay (ROHO, ROHO Inc, Belleville, IL, USA) or an active alternating pressure mattress (NIMBUS3, ArjoHuntleigh, Luton Bedfordshire, UK).

DESIGN

Pilot prospective single blind randomised controlled clinical trial.

INTERVENTION

Two types of pressure redistributing mattress.

PATIENTS

Two groups of eight patients.

METHODS

Patients included in the study were those at high risk (Norton scale <8) or with a PU on admission.

RESULTS

The two groups had similar patient characteristics. However, the NIMBUS 3 group presented with more ulcers per patient on admission (62.5%) and more severe ulcers (20% category 3) while four patients (50%) presented with a single superficial ulcer in the ROHO group. HEALING: The progress of the ulcers showed significant decreases in PU surface area (p=0.05), total PUSH tool score (p=0.01) in the NIMBUS 3 group compared to the ROHO group. In the NIMBUS 3 group 82% of the ulcers improved versus none in the ROHO group (p=0.002) and 18% remained stable versus 33%. None of the ulcers deteriorated in the NIMBUS 3 group versus 67% in the ROHO group (p=0.006). Full thickness wounds (Category 3) were present in 22% of the NIMBUS 3 group versus 0% of the ROHO group on admission and in 0% versus 66.7% (p=0.008) respectively at the end of the pilot study.

PREVENTION

Non-blanching erythema occurred equally in both arms at baseline; skin remained intact for the NIMBUS 3 group while 50% in the ROHO group worsened with superficial tissue loss.

CONCLUSION

This small pilot study suggests that 'active' alternating therapy is a useful adjunct in the care of highly vulnerable patients, while the outcomes may be less favourable when using 'reactive', constant low pressure devices.

Estimating the risk of pressure ulcer development: is it truly evidence based?

The aim of the current method of screening patients is to identify risk factors that are considered to cause, or contribute to, pressure ulcer (PU) development. Yet screening has not resulted in a reduction in pressure ulcer development. The literature was reviewed to identify the level of evidence for the inclusion of risk factors in six published pressure ulcer risk-screening tools. Evidence for each risk factor was ranked according to the National Health and Medical Research Council levels of evidence with a modification. Three of 19 risk factors (mobility, continence and nutrition) included in more than one screening tool have been tested for association with pressure ulcer development. While varying degrees of immobility and decreased serum albumin are reported to significantly increase the risk for PU development, the direction of the relationship, i.e. causal or resultant of PU, is not always clear. No publications reported a significant causal link between incontinence and PU development. Inclusion of risk factors for PU in screening tools must be evidence based. Until other risk factors have been tested for positive predictive value, the Ramstadius approach to screening is the only evidence-based tool.

Patient stories of living with a pressure ulcer

AIM

This paper reports the findings of a pilot study exploring the experience of older people living with pressure ulcers.

BACKGROUND

Pressure ulcers are known to be a significant health burden, but little is known of the impact on the quality of life of the sufferer. They mainly affect older people, and this is a neglected group in previous studies of this topic.

METHODS

A Heideggerian phenomenological approach was used and patients were recruited if they were over 65 years of age and had a grade 3 or 4 pressure ulcer that had been present for more than a month. Patients were recruited from multiple centres but the data were analysed centrally. The study took place in 2003-2004.

FINDINGS

Analysis of the transcripts revealed three main themes, all with associated subthemes: pressure ulcers produce endless pain; pressure ulcers produce a restricted life; coping with a pressure ulcer. The endless pain theme had four subthemes: constant presence, keeping still, equipment pain and treatment pain. Some patients found that keeping still reduced their pain. Several patients also reported that pain was exacerbated by their pressure relieving equipment and at dressing change. There were three subthemes for the restricted life theme: impact on self, impact on others and consequences. Patients found that the pressure ulcer restricted their activities and had an impact on their families. In addition, for some, the restrictions delayed their rehabilitation. To cope with their pressure ulcers, patients developed ways of accepting their situation or comparing themselves with others.

CONCLUSIONS

Although a pilot, this study has produced a wealth of data that demonstrates the impact of pressure ulcers on people. While a larger study is required to obtain a European perspective, it is still reasonable to conclude that the issues of pain and restrictions should be considered in the development of pressure ulcer treatment and prevention guidelines.

Assessment and management of chronic pressure ulcers in the elderly

Pressure ulcers remain a complex and costly problem to the health care system. As the population ages, a greater number of individuals will be at high risk for developing pressure ulcers. An understanding of the physiologic changes that occur with aging skin is important in preventing and treating chronic wounds. Risk factor assessment and modification, when possible, can help to reduce the development of pressure ulcerations. Although the goal continues to be prevention, once a pressure ulcer does occur, a systematic and comprehensive approach to assessment and treatment is necessary to reduce healing times.

Prevention and Treatment of Pressure Ulcers

Pressure ulcers are complex chronic wounds for which no gold standard for prevention or treatment has yet been established. Several attempts at developing guidelines has been undertaken by different organizations. Pressure ulcers are devastating comorbidities for patients and difficult to prevent or manage. Whether or not pressure ulcers are preventable remains controversial. The strategy for prevention includes recognizing the risk, decreasing the effects of pressure, assessing nutritional status, avoiding excessive bed rest and prolonged sitting, and preserving the integrity of the skin. The principles of treatment of pressure ulcers include assessing severity, reducing pressure, friction and shear forces, optimizing local wound care, removing necrotic debris, managing bacterial contamination, and correcting nutritional deficits.

Wound cleansing for pressure ulcers

BACKGROUND

Pressure ulcers (also called pressure sores, bed sores and decubitus ulcers) are areas of tissue damage that occur in the very old, malnourished or acutely ill, who cannot reposition themselves. Pressure ulcers impose a significant financial burden on health care systems and negatively affect quality of life. Wound cleansing is considered an important component of pressure ulcer care.

OBJECTIVES

This systematic review seeks to answer the following question:What is the effect of wound cleansing solutions and wound cleansing techniques on the rate of healing of pressure ulcers?

SEARCH STRATEGY

We searched the Specialised Trials Register of the Cochrane Wounds Group (up to August 2005), and the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2005). We searched bibliographies of relevant publications retrieved. We contacted drug companies and experts in the field to identify studies missed by the primary search.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing wound cleansing with no wound cleansing, or different wound cleansing solutions, or different cleansing techniques, were eligible for inclusion if they reported an objective measure of pressure ulcer healing.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently and resolved disagreements through discussion and reference to the Cochrane Wounds Group editorial base. A structured narrative summary of the included studies was conducted. For dichotomous outcomes, relative risk (RR), plus 95% confidence intervals (CI) were calculated; for continuous outcomes, weighted mean difference (WMD), plus 95% CI were calculated. Meta analysis was not conducted, because of the small number of diverse RCTs identified.

MAIN RESULTS

No studies compared cleansing with no cleansing. Two studies compared different wound cleansing solutions: a statistically significant improvement in Pressure Sore Status Tool scores occurred for wounds cleansed with saline spray containing Aloe vera, silver chloride and decyl glucoside (Vulnopur) compared to isotonic saline (P value = 0.025), but no statistically significant change in healing was seen when water was compared to saline (RR 3.00, 95% CI 0.21, 41.89). One study compared cleansing techniques, but no statistically significant change in healing was seen for ulcers cleansed with, or without, a whirlpool (RR 2.10, 95% CI 0.93 to 4.76).

AUTHORS' CONCLUSIONS

We identified only three studies addressing cleansing of pressure ulcers. One noted a statistically significant improvement in pressure ulcer healing for wounds cleansed with saline spray containing Aloe vera, silver chloride and decyl glucoside (Vulnopur) when compared with isotonic saline solution. Overall, there is no good trial evidence to support use of any particular wound cleansing solution or technique for pressure ulcers.

The 30° tilt position vs the 90° lateral and supine positions in reducing the incidence of non- blanching erythema in a hospital inpatient population: a randomised controlled trial

Manual repositioning of patients by nursing staff is a recognised technique for preventing pressure ulcer formation. The 30 degree tilt is a method of positioning patients that, in the laboratory setting, reduced the contact pressure between the patient and the support surface. A randomised controlled trial was used to examine the effects of the 30 degree tilt position in reducing the incidence of non-blanching erythema (i.e. established pressure damage) in a hospital inpatient population (n=23) when compared to the use of the 90 degree lateral and supine position (n=23). The primary outcome of the trial was the incidence of pressure damage, defined as non-blanching erythema. In this study no subject developed pressure damage that presented with visible breaks in the epidermis, but all damage was restricted to areas of non-blanching erythema (five of the 39 subjects who completed the study exhibited such injury). The main findings of this study were that patient positioning using the 30 degree tilt method did not reduce the incidence of pressure damage compared with either the 90 degree lateral or supine positions. This study also investigated the feasibility of using the 30 degree tilt position with medical inpatients; it found that 78% of subjects experienced difficulty in adopting and maintaining the position. This finding seriously questions the practicality of using the 30 degree tilt method with a predominantly ill population.

Evidence-Based Protocol: Prevention of Pressure Ulcers

Those who provide direct care to older individuals who are functionally impaired and immobilized must be constantly vigilant for the potential development of pressure ulcers. Use of the evidence-based guideline "Prevention of Pressure Ulcers" (Folkedahl et al., 2002) can provide a template for identification of patients at risk and implementation of interventions to prevent their occurrence.

Pressure ulcer prevention and treatment: transforming research findings into consensus based clinical guidelines

The translation of research findings into practice guidelines is an important aspect in maintaining the currency of practice and adding value to research. While there has been a large amount of published literature regarding the treatment and prevention of pressure ulcers, very few studies have attempted to provide clear clinical guidelines. The present study proposes a model to transform research into clinical guidelines whilst developing a series of guidelines that can be applied to a variety of clinical settings.

Risk, prevention and treatment of pressure ulcers--nursing staff knowledge and documentation

The aims were to investigate (i) registered nurses' and nursing assistants' knowledge of risk, prevention and treatment of pressure ulcer before implementing a system for risk assessment and pressure ulcer classification for patients with hip fracture (ii) interventions documented in the patient's records by registered nurses, and (iii) to what extent reported and documented interventions accord with the Swedish quality guidelines. Nursing staff (n=85) completed a questionnaire, and patient's records (n=55) were audited retrospectively. The majority of the nursing staff reported that they performed risk assessment when caring for a patient with hip fracture. These risk assessments were, however, not comprehensive. The most frequently reported preventive interventions were repositioning, use of lotion, mattresses/overlays and cushions for the heels. These interventions were to some extent documented in the patient's records. Nutritional support, reduction of shear and friction, hygiene and skin moisture, and patient's education were reported to a small extent and not documented at all. The Swedish quality guidelines regarding prevention and treatment of pressure ulcers were not fully implemented in clinical practice. It was concluded that nursing staff's knowledge and documentation of risk, prevention and treatment of pressure ulcers for patients with hip fractures could be improved.

Introducing the pressure support surfaces from Kaymed

The range of support surfaces available is quite varied. It is important that both the purchaser and the users are satisfied with the quality, comfort and the pressure-reducing properties of the mattress. The mattress needs to be versatile, in that it can be used both in a patient's home or in a hospital or nursing home and also on profiling beds. The Kaymed range of mattresses offers increased comfort with low interface pressures for patients up to and including high risk. This product focus examines the Kaymed mattress and looks at the design and results of tests performed on the visco-elastic foam used in the manufacturing of the mattresses.

Debating the relative unimportance of pressure-reducing equipment

This article examines some assumptions underlying the provision of pressure-reducing equipment, and argues that failure to 'act first and ask questions later' may be a key source of pressure damage. Indeed, it is argued that prevention of pressure damage can be simplified by identifying three groups of patients: those who have pressure ulcers; those who will develop them in faction is not taken; and those who will not get them. The linkage of risk assessment scores and guidelines is challenge as erroneous and misleading.

Hospital-acquired heel ulcers: a common but neglected problem

The development of hospital-acquired pressure ulcers on the heel is a growing problem. The best way of preventing this is to ensure the heel is completely free from pressure.

How effective are prevention strategies in reducing the prevalence of pressure ulcers?

The prevalence of pressure ulcers has remained constant at about 7% over the past 20 years, even though considerable time and money has been invested in various prevention strategies. This literature review explores whether pressure-prevention programmes can reduce the prevalence rate still lower or whether they are working but are limited by an increasingly aged population and rising patient acuity.