4/2/2010

EPIDEMIOLOGY: Prevention and Treatment Estimates

• Hospital Admissions: 7.7% will develop a pressure ulcer8

• 60% of all pressure ulcers develop in a hospital3
• 18% off all
ll pressure ulcers
l develop
d l in i nursing
i homes
h
• 18% of all pressure ulcers develop at home
• In Australia about 60,000 people have at least one
pressure ulcer5

Heel Pressure Ulcers

Denis B. Drennan, MD & Joseph W. Drennan, MIB

Definition & Etiology of Pressure Ulcers Heel Anatomy Contributes to PU Risk

Pressure ulcers are localized areas of tissue necrosis that tend to occur when soft
tissue is compressed between a bony prominence and an external surface for a
prolonged period of time.

Risk Factors:
• Immobility
• Peripheral Neuropathy
• Femur Fractures
• Vascular Disease
• Incontinence
• Dehydration/Malnutrition
• Diabetes
•Altered Consciousness
• Elderly
• Impaired tolerance to pressure—thin subcutaneous tissue
• Unrelieved Pressure
• Limited blood flow – end arterial plexus from the posterior tibial and peroneal arteries
• Friction/Shear • Marked prominence of the posterior tubercle of the calcaneous
• Moisture • Pressure mapping studies have shown the heel sustains intense pressures even on bed
pressure-redistribution surfaces!

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The Average Location Prevalence from 2005 - 2009 Prevalence Incidence & Hospital Acquired Prevalence

Prevalence
Defined as the number of patients with a PU in a specific population at a specific
• Sacrum 29% 1 time. It includes those who were and were not admitted to a facility with a PU.
• Heel 21 8%
21.8%
• Ischia 18.8%
• Ear 4.6%
• Foot 3.1% Incidence (including hospital acquired prevalence)
Defined as the number of patients who develop PU after admission to a facility.
(The 2009 heel PU Prevalence dropped to 20%) Patients were initially assessed as PU free, and developed one or more ulcers over
a specific period.

Prevalence & Incidence of Pressure Ulcers Pressure Ulcers Risk Assessment

Establish a risk assessment policy; educate the staff on assessment and documentation.

Common subscales include sensory-perceptual, moisture, activity, mobility, nutrition,

Prevalence of Pressure Ulcers
USA: 2005 – 2009 average
Canada: 2004
International Long Term Acute Care
Incidence of Pressure Ulcers
USA: 2005 – 2009 average
Australia: 2004
friction-shear, BMI, sex, age, and skin type.
15%1
24%3
22%4
Norton Scale12: at risk below 12
Sensitivity = 73% - 92%,
Specificity = 61% - 94%
6.1%
Braden Scale9: at risk below 17
16.6%2
Sensitivity = 83% - 100%
Specificity = 64% - 77%

Waterlow Scale10: at risk above 16

Sensitivity = 71%
Specificity = 67%

2

Other Risk Factors
• Are palpable pulses present? Is there large vessel disease?
• Diabetes -- presume there is neuropathy and microvascular disease7
• A past history of PU is the greatest indication of future PU.
• Immobility- Will the patient be immobile more than 4 hours?
• Can the patient straight leg raise? If not, person is high risk for HPU.
• Malnutrition or incontinence?
• Restraints?
• Is the patient on vasopressors, ventilation, or dialysis?
Prevention
• The most important treatment is prevention.
• Patients with multiple risk factors must have pressure transferred from the small
heel area to the larger calf
• The closing capillary pressure of small vessels about the heel is 32mm Hg. Heel
pressures on pressure reduction mattresses are well over 100mm of Hg.15
• The high risk patient must have pressure redistribution to prevent a heel ulcer.
• For this patient population, pillows and mattresses do not work!
4/2/2010
Avoidable versus Unavoidable
All Pressure Ulcers are NOT avoidable!
• If a PU occurs despite accurate risk assessment and an adequate plan of care.
• If a facility properly assessed and developed a plan of care, and
• Implemented the plan of care, and
• Evaluated resident outcome, and
• Revised the plan of care as conditions indicated
Under these conditions a PU may be considered unavoidable.
Repositioning
• Done to reduce the duration and magnitude of pressure over risk areas
• Frequency is influenced by individual tolerance, medical condition, and support surface.
• Avoid positioning over bony prominences or non-blanchable erythema.
• Avoid positioning over medical devices such as tubes or drainage systems.
• Use the 30 degree side-lying position.
• Avoid the 90 degree side-lying and bed elevation above thirty degrees
• Educate the staff on the importance of repositioning and documentation
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Heelift® Boot Plus Computers Save Heels Heelift® Boot Plus Computers Save Heels

Authors: Joan A. McInerney, MSN, RN, BC, CWOCN - Sandra K. Wheeler, BSN, RN, CWOCN - NCH Healthcare System, Naples, FL This chart compares the percentage of patients, both nationally and within the Southwest Florida studies,
who presented with hospital-acquired pressure ulcers over a time ranging from January 2002 to January
Problem: 2007. It also charts the percentage of patients presenting pressure ulcers on the heel.
Heel pressure ulcers accounted for >50% of all hospital-acquired pressure ulcers. From June 2000 though July 2003,
heel ulcers, with the exception of one survey, accounted for more than half of our hospital-acquired pressure ulcer
prevalence rate. We were inconsistently using a rigid, heavy, pressure-relieving boot that sometimes damaged the
dorsum of the foot, leaving the nurses and physicians reluctant to use them.

Methodology:
gy
In September 2003, a Task Force was convened consisting of:
• Risk Manager • Chief Medical Officer
• Critical Care Physician • Chief Nursing Officer
• Podiatrist • Managers of Central Distribution,
• WOC (ET) Nurses • Education, Operating Room, &
• Clinical Informatics Analyst • Critical Care

Action:
We decided to switch to the Heelift Smooth Boot, a foam, lightweight, one-size-fits-all boot. Our IT Department was
able to link an automatic order for the boots as well as a consult to the WOC Nurses for all patients placed on a
ventilator or on hemodialysis. The WOC Nurses monitored compliance with the Boots’ use. We continued to monitor
prevalence every 6 months among all adult inpatients with our usual exceptions of new mothers and those admitted
to Behavioral Health.

Estimated Costs of Pressure Ulcers A Cost to Healing Projection

Australian General Hospital 10,000 discharges annual

Overall PU Prevalence 15% or 1500 total PU
Annual Australian costs A$350 Million5 If 76% of PU are Stage I & II 1140 stage I & II
Annual Netherland costs $362 Million - $2.8 Billion And if 22% are HPU 250 HPU
Annual United Kingdom costs £180-132 Million If the Stage I & II cost to healing is $3,000 A$750,000
Annual United States costs $11.6 Billion
If 24% of PU are Stage III & IV 360
If 22% are HPU 80 Stage III & IV HPU
If the Stage III & IV cost to healing is $60,000 A$4,800,000
Stage III cost three months Canada C$27,0006
Stage IV costs to healing estimated $61,230

The total annual costs to healing for one facility’s HPU could be A$5,550,000

PREVENTION IS CONSIDERABLY LESS EXPENSIVE

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Treatment
The treatment of the HPU is directly dependent on the severity of the injury.
The International NPUAP – EPUAP Classification System includes four Categories/Stages.7
Category/Stage I:
Non-blanchable Erythema-
y Intact skin with non-blanchable
redness of a localized area usually over a bony prominence.
Category/Stage II:
Partial Thickness Skin Loss- Presenting as a shallow open
ulcer with a red pink wound bed, without slough. May also
present as an intact or open/ruptured serum filled blister.
Treatment: Two Subgroups
Unstageable:
Depth Unknown- Full thickness tissue loss in which the base
of the ulcer is covered by slough and/or eschar. The
Category/Stage cannot be determined until enough
slough/eschar is removed to show the base.
Deep Tissue Injury:
Depth Unknown- Purple or maroon localized area of
discolored intact skin or blood-filled blister caused by
damage of underlying soft tissue from pressure and /or shear.7
4/2/2010
Treatment
Category/Stage III:
Full thickness Skin/tissue loss- Subcutaneous fat may be
visible but does not obscure the depth of tissue loss. May
include undermining and tunneling.
Category/Stage IV:
Full thickness tissue loss- Exposed bone, tendon or muscle.
Slough or eschar may be present on some parts of the wound
bed. Undermining and tunneling are common.
Pressure/Shear Relief: Category/Stage I & II Heel Pressure Ulcers7
• Pillows are appropriate for short term use in low-risk, alert
and cooperative individuals.
• Heel suspension devices are preferable for long term use or
with uncooperative patients.
• Beware of metal suspension devices that can cause injury
to either leg.
• Relieve pressure under the heel by using
pressure-reducing devices with heel suspension.
• Patient maintains mobility – Device remains in
postion
• Forefoot Support prevents heel cord contracture
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Pressure/Shear Relief: Category/Stage III & IV Heel Pressure Ulcers7
• Elevate the heel in a device that completely offloads the PU.
• Elevation on a pillow is inadequate!
• Because of time required to healing, a device completely offloading the ulcer
area and preventing foot drop is necessary.
• The device should be removed frequently for skin checks to avoid edema or
device related pressure.
Think Achilles Tendon!
Wound Bed Preparation
Infection:
Wounds exhibiting signs of infection culture using -
• The biopsy method for C&S
• The Levine quantitative method for C&S
Superficial swab techniques are rarely useful
Exposed bone – biopsy for C&S; osteomyelitis is probably present
Antibiotics:
• Topical antibiotics for >105 CFU/g of tissue bioburdens
• Systemic antibiotics for systemic infection or osteomyelitis
Surgery:
Consider skin grafts for large clean granulating HPU
Non-healing HPU:
Consider –vascularity -anaerobic infection –osteomyelitis
• Better pressure, friction, or shear control
• Malnutrition extends the odds of healing by 2.6 times
4/2/2010
Wound Bed Preparation
Cleansing:
• If clean, use saline or potable water
• Debris or bacterial colonization- consider surfactants/antibacterial agents
• Hydrotherapy or wound irrigation between 4-15# sq inch
• Cleansing surrounding skin before/after is useful
• HPU with hard dry eschar—DO NOT DEBRIDE
Debridement:
• Necrotic devitalized tissues should be debrided
• Select the method most appropriate to the wound and patient
• Sharp surgical debridement most rapidly converts to an acute clean wound
• Slower methods include mechanical (moist dressings), enzymatic, or biosurgical
(Maggot therapy).
Dressings:
• Keep the wound bed moist and the peripheral skin dry.
• Consider Negative Pressure Wound Therapy for large wide HPU
• All Stage III & IV wounds require a heel pressure redistribution device.
The Problem: Heel Pressure Ulcers
The Solution: Heelift® Suspension Boots
The Heelift Suspension Boot suspends the small area of the heel in space by transferring
all pressure to the larger calf area. This decreases the pressure per square cm.
• The Heelift supports the forefoot to prevent contracture of the heel cord
(Achilles Tendon) and subsequent foot drop.
• The opening under the heel gives more open space to protect the heel or for
dressings, or suction drainage devices. It allows palpation or direct
visualization of the heel.
• The low-friction Tricot backing allows the Heelift to glide easily
over most surfaces
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Customization References
1) KCI National P&I Study with permission 2009
2) Jolley DJ, Wright R, et al. Preventing Pressure Ulcers
with the Australian Medical Sheepskin. Medical Journal
Australia 2004; 324-327
• The latex-free, open cell, hypo-allergenic, polyeurthane
3) Woodbury et al: Prevalence of Pressure Ulcers. Ostomy
foam can be customized to address any patient’s Wound Mgt. 2004; 22-38
specific exigencies 4) VanGilder et al: Results of the 2008-2009 Int’l PU
prevalence survey. OWM Nov.2009, 39-45
5) Sharp CA, McLaws ML, et al. A Discourse on Pressure
Ulcer Physiology:
http://www.worldwidewounds.com/2005/October
6) Allen J, Houghton P, et al: A case study for Electrical
Stimulation on Stage
g III Pressure Ulcer. Wound Care
• Every Heelift comes with a Spare Pad that can be used Canada 2004; 2(1); 34-36
7) National (US) & European Pressure Ulcer Advisory
to provide additional support to address foot drop,
Panels. Pressure Ulcer Prevention and Treatment Clinical
external rotation, erythema over the Achilles, etc. Practice Guideline. Washington, DC: National Pressure
Ulcer Advisory Panel 2009; http://www.npuap.org
8) Whittington, K, Briones R, et al. National Prevalence and
Incidence Study: 6-Year Sequential Acute Care Data. Adv
Skin Wound Care 2004; 17(9); 490-494.
9) Magnan M, Maklebust J, et al. Braden Scale Risk
Assessments and Pressure Ulcer Prevention Planning. J
Wound Ostomy Continence Nurs 2009; 36(6); 622-634.
10) Serpa LF, Santos VLC, et al. Predictive Validity of
Waterlow Scale for Pressure Ulcer Development Risk in
Hospitalized Patients. J Wound Ostomy Continence Nurs
2009; 36(6); 640-646.
11) McInerney JA, DJ, et al. Reducing Hospital Acquired
Pressure Ulcer Prevalence. Adv Skin Wound Care 2004;
21(2); 75-78
12) Defloor T, Grypdonck M, et al. Pressure Ulcers:
Validation of Two Risk Assessment Scales. J Clin Nurs
March 2005, 14(3) 373-382
13) Banks M, Bauer J, et al. Malnutrition and Pressure Ulcer
Risk in Adults in Australian HC Facilities. Clin Nutr
2009, doi: 10.1016/j.clnu.2009.08.006.
14) Fowler E, Scott-Williams S, et al: Practice
Recommendations for Preventing Heel. Ostomy Wound
Mgt. 2008; 54(10)
15) Drennan D. Heel Pressure Mapping Study Aug 2003.
http://webtransfer.dmsystems.com/webpublic/Seating%20Dynamics
%20Heelift%20Materials/Clinical%20Resources/

• Pretibial venous ulcers, ulcers over the malleoli, over

the top of the foot, or sides of the calf are unusual, but
can be treated by cutting the boot or extra pad. Thank you very much!

02 9620 9641 0011.1.847.328.9540

www.seatingdynamics.com.au © 2010, DM Systems, Inc. All rights reserved. www.heelift.com