Prevention Of Heel Pressure Ulcers Research Articles

A realist evaluation of devices used for the prevention of heel pressure ulcers: An ethnographic study of clinical practice

BackgroundIt is known that heel offloading devices are widely used in clinical practice for the prevention of heel pressure ulcers, even though there is a lack of robust, good quality evidence to inform their use. ObjectiveTo explore how and why heel offloading devices are used (or not used) and reasoning behind their use in population at high risk of developing heel pressure ulcers. MethodsAn ethnographic study was conducted as part of a realist evaluation in three orthopaedic wards in a large English hospital. Twelve observations took place, with 49 h and 35 min of patient care observed. A total of 32 patients were observed and 19 members of the nursing team were interviewed and in-depth interviews with the three ward managers were conducted. ResultsAlthough the focus of the study was on offloading devices, constant low pressure heel specific devices were also observed in use for pressure ulcer prevention, whilst offloading devices were perceived to be for higher risk patients or those already with a heel pressure ulcer. Nursing staff viewed leadership from the ward manager and the influence of the Tissue Viability Nurse Specialists as key mechanisms for the proactive use of devices. ConclusionsThis study informs trial design as it has identified that a controlled clinical trial of both types of heel specific devices is required to inform evidence-based practice. Involving the ward managers and Tissue Viability Nurse Specialists during set up phase for clinical equipoise could improve recruitment.Tweetable abstractHow, for whom, and in what circumstances do devices work to prevent heel pressure ulcers? Observations of clinical practice.

Impact of material properties in the simulated tissue response in heel pressure ulcer prevention: a preliminary study

Impact of material properties in the simulated tissue response in heel pressure ulcer prevention: a preliminary study

Offloading devices for the prevention of heel pressure ulcers: A realist evaluation

BackgroundHeel pressure ulcers can cause pain, reduce mobility, lead to longer hospital stays and in severe cases can lead to sepsis, amputation, and death. Offloading boots are marketed as heel pressure ulcer prevention devices, working by removing pressure to the heel, yet there is little good quality evidence about their clinical effectiveness. Given that evidence is not guiding use of these devices, this study aims to explore, how, when, and why these devices are used in hospital settings. ObjectiveTo explore how offloading devices are used to prevent heel pressure ulcers, for whom and in what circumstances. MethodsA realist evaluation was undertaken to explore the contexts, mechanisms, and outcomes that might influence how offloading devices are implemented and used in clinical practice for the prevention of heel pressure ulcers in hospitals. Eight Tissue Viability Nurse Specialists from across the UK (England, Wales, and Northern Ireland) were interviewed. Questions sought to elicit whether, and in what ways, initial theories about the use of heel pressure ulcers fitted with interviewee's experiences. ResultsThirteen initial theories were refined into three programme theories about how offloading devices are used by nurses ‘proactively’ to prevent heel pressure ulcers, ‘reactively’ to treat and minimise deterioration of early-stage pressure ulcers, and patient factors that influence how these devices are used. ConclusionsOffloading devices were used in clinical practice by all the interviewees. It was viewed that they were not suitable to be used by every patient, at every point in their inpatient journey, nor was it financially viable. However, the interviewees thought that identifying suitable ‘at risk’ patient groups that can maintain use of the devices could lead to proactive and cost-effective use of the devices.This understanding of the contexts and mechanisms that influence the effective use of offloading devices has implications for clinical practice and design of clinical trials of offloading devices. Tweetable abstractHow, for whom, and in what circumstances do offloading devices work to prevent heel pressure ulcers? Tissue viability nurses' perspectives.

Comparative effectiveness of heel-specific medical devices for the prevention of heel pressure ulcers: A systematic review

BackgroundPressure ulcers (PUs) impact on patient's quality of life and are costly for healthcare providers. Heels are a particular concern due to specific risk factors. Relative effectiveness of medical devices, e.g., dressings, off-loading devices, heel cushioning devices, to reduce PU development is unknown. MethodsSystematic review of the effectiveness of heel-specific medical devices for the prevention of heel PU (HPU)s. Database searches were performed from inception to June 2021 for RCTs. The primary outcome was incidence of new HPUs. Trials were assessed for risk of bias and data analysed with risk ratios, mean difference or hazard ratios as appropriate. ResultsFifteen RCTs (4724 participants) were identified.Dressings, as constant low pressure (CLP) devices vs standard care: eight trials (very low quality) showed no-significant difference in effectiveness (RR 0.31, 95%CI 0.10 to 1.01).Off-loading devices vs standard care: three trials (low quality), showed significant reduction in development of Category≥1 HPUs (RR 0.20, 95%CI 0.05 to 0.80) two trials (medium quality), showed significant reduction in development of Category≥2 HPUs (RR 0.08, 95%CI 0.01 to 0.67).Comparisons between off-loading devices: two trials (low quality) showed no clear difference in HPU incidence.In a paediatric post-surgical population, one trial of off-loading device and one of a dressing (CLP device), both versus standard care, showed no clear difference in HPU incidence (RR 0.19 95%CI 0.02 to 1.55 and RR 0.89 95%CI 0.56 to 1.42 respectively). ConclusionsOff-loading devices may reduce HPU incidence, from low-quality evidence. There is insufficient evidence to suggest that dressings reduce HPU incidence.

Offloading Devices for the Prevention of Heel Pressure Ulcers: A Realist Evaluation

Offloading Devices for the Prevention of Heel Pressure Ulcers: A Realist Evaluation

Clinical effectiveness of a silicone foam dressing for the prevention of heel pressure ulcers in critically ill patients: Border II Trial

Critically ill patients are at high risk of developing pressure ulcers (PU), with the sacrum and heels being highly susceptible to pressure injuries. The objective of our study was to evaluate the clinical effectiveness of a new multi-layer, self-adhesive soft silicone foam heel dressing to prevent PU development in trauma and critically ill patients in the intensive care unit (ICU). A cohort of critically ill patients were enrolled at the Royal Melbourne Hospital. Each patient had the multi-layer soft silicone foam dressing applied to each heel on admission to the emergency department. The dressings were retained with a tubular bandage for the duration of the patients' stay in the ICU. The skin under the dressings was examined daily and the dressings were replaced every three days. The comparator for our cohort study was the control group from the recently completed Border Trial. Of the 191 patients in the initial cohort, excluding deaths, loss to follow-up and transfers to another ward, 150 patients were included in the final analysis. There was no difference in key demographic or physiological variables between the cohorts, apart from a longer ICU length of stay for our current cohort. No PUs developed in any of our intervention cohort patients compared with 14 patients in the control cohort (n=152; p<0.001) who developed a total of 19 heel PUs. We conclude, based on our results, that the multi-layer soft silicone foam dressing under investigation was clinically effective in reducing ICU-acquired heel PUs. The findings also support previous research on the clinical effectiveness of multi-layer soft silicone foam dressings for PU prevention in the ICU.

Prevention of heel pressure ulcers among adult patients in orthopaedic wards: an evidence-based implementation project

BackgroundImmobility and prolonged bed rest often lead to heel pressure ulcers in patients. A point prevalence audit undertaken in the orthopaedic wards of a Singapore tertiary hospital reported that 6 out of 30 patients who were audited had mild to blanching redness on their heels. AimsThe evidence-based project sought to achieve 80% compliance from nurses to perform heel off-loading practice and a 50% reduction in the occurrence of heel pressure ulcers. MethodsThe project, lasting two years, was undertaken in two orthopaedic wards and utilized a pre- and post-implementation audit strategy using the Joanna Briggs Institute on-line 'Practical Application of Clinical Evidence System' and 'Getting Research into Practice' programs. Implementation occurred in four phases and involved a sample consisting of 30 adult patients. ResultsNurses’ compliance with performing heel off-loading techniques increased. The post-implementation audit showed 93.3% compliance of nurses undertaking heel off-loading techniques in the subsequent four follow-up audits. Meanwhile, the compliance with documentation increased from 63.3% to 86.7%. The project resulted in more than 50% reduction in stage one heel pressure ulcers. ConclusionThe implementation of heel off-loading techniques significantly reduced the incidences of heel pressure ulcers in orthopaedic wards.

Prevention of heel pressure ulcers among older patients – from ambulance care to hospital discharge: A multi-centre randomized controlled trial

The aim was to investigate the effect of an early intervention, a heel suspension device boot, on the incidence of heel pressure ulcers among older patients (aged 70+). BackgroundPressure ulcers are a global healthcare issue; furthermore, the heel is an exposed location. Research indicates that preventive nursing interventions starting during the ambulance care and used across the acute care delivery chain are seldom used. MethodsA multi-centre randomized control study design was used. Five ambulance stations, two emergency departments and 16 wards at two Swedish hospitals participated. Altogether, 183 patients were transferred by ambulance to the emergency department and were thereafter admitted to one of the participating wards. ResultsSignificantly fewer patients in the intervention group (n=15 of 103; 14.6%) than the control group (n=24 of 80; 30%) developed heel pressure ulcers during their hospital stay (p=0.017). ConclusionsPressure ulcer prevention should start early in the acute care delivery chain to increase patient safety.

Relieving the pressure at LNS 2015.

British Journal of NursingVol. 24, No. Sup15 London Nurse Show 2015Relieving the pressure at LNS 2015Rachel WebbRachel WebbSearch for more papers by this authorRachel WebbPublished Online:12 Aug 2015https://doi.org/10.12968/bjon.2015.24.Sup15.S10AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Brindle CT (2010) Outliers to the Braden scale: identifying high-risk ICU patients and the results of prophylactic dressing use. World Council of Enterostomal Therapists Journal 30(1): 11–8 Google ScholarNational Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance (2014a) Prevention and Treatment of Pressure Ulcers: Clinical Practice Guide. http://www.epuap.org/guidelines/ (accessed 28 July 2015) Google ScholarNational Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance (2014b) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. http://tinyurl.com/os6qyar (accessed 28 July 2015) Google ScholarSantamaria N, Gerdtz M, Sage S et al. (2015a) A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial. Int Wound J 12(3): 302–8 Crossref, Medline, Google ScholarSantamaria N, Gerdtz M, Liu W et al. (2015b) Clinical effectiveness of a silicone foam dressing for the prevention of heel pressure ulcers in critically ill patients: Border II Trial. J Wound Care (in press) Medline, Google Scholar FiguresReferencesRelatedDetails 12 August 2015Volume 24Issue Sup15ISSN (print): 0966-0461ISSN (online): 2052-2819 Metrics History Published online 12 August 2015 Published in print 12 August 2015 Information© MA Healthcare LimitedPDF download

Elevation devices for the prevention of heel pressure ulcers: a review.

The objective of this systematic literature review was to gain insight into the effectiveness of off-loading devices to prevent heel pressure ulcers within the acute hospital setting. Heels have been identified as the second most common site for pressure ulcers. Devices which off-load pressure can include pillows, wedges and boots. It is unclear as to which method or device is best at preventing pressure ulcers. A systematic review was carried out through the search of electronic databases and bibliographies of relevant publications. Randomised controlled trials (RCTs) and systematic reviews that compared devices which off-load heels to prevent pressure ulcers were identified. A total of five studies were included in the review. The methodological quality of the studies was generally poor. The studies reported that heel-boot elevation devices appeared more beneficial. However, poor compliance with wearing the devices was identified, as well as a perceived increased risk of falls. There were little data on cost-effectiveness. There is little high-quality trial evidence to support the routine use of heel devices to prevent pressure ulcers. However, they may have a role to play within a multifaceted programme of pressure-ulcer prevention.

Prevention of pressure ulcers in nursing home residents

Pressure ulcer prevention strategies are applicable to all anatomical sites; however, the main focus of this article is heel ulceration in the nursing home setting. The thinness of the subcutaneous tissue between the skin and bone, and the propensity for lower limb diseases, makes the heel the second most common site for pressure ulcer development. This article provides a review of the effect of education and knowledge on the prevention of heel pressure ulcers in nursing home residents. Where there is paucity of evidence, pressure ulcers in general will be examined.

Heel Pressure Ulcers

The heel is a frequent site of pressure ulcer formation, in particular, the development of suspected deep tissue injury. This article reviews the epidemiology, pathophysiology and prevention of heel pressure ulcers. Also, the related concept of purple heel, a not-well-recognized entity, is introduced.

Implementation of best practice in the prevention of heel pressure ulcers in the acute orthopedic population

To implement and evaluate a heel pressure ulcer prevention program (HPUPP) for orthopaedic patients. Program development of HPUPP involved input from administrators, staff and adult patients on an orthopaedic service in an academic tertiary care facility, located in a small urban centre in Canada. Prospective evaluation was conducted. Consensus exercises with clinical staff and administrators (Delphi and Nominal group) were used to, evaluate current practices, select a heel protective device, and develop key aspects of the HPUPP. HPUPP involved an individualised, bedside, staff education program, a team approach to improve patient mobility and use of a heel protective device. A 2-inch foam wedge covered in washable vinyl was placed at the foot of all beds on the orthopedic service. After the program was implemented, the incidence of heel pressure ulcers was 0%, which was a significant reduction compared with pre-implementation levels [13.8% (95% confidence interval 8-18%)]. Key components of the program success were initial and ongoing support from administration and surgeons, incorporation of feedback from clinical staff and patients, and keeping the program simple. Heel PU can be prevented in most orthopaedic patients using a universal heel PU prevention program.

Effectiveness of Two Cushions in the Prevention of Heel Pressure Ulcers

The aim of the study was to determine the effectiveness of two cushions in the prevention of heel pressure ulcers in a geriatric population. Heel pressure ulcers are a major problem in nursing practice. Several measures for the prevention of heel pressure ulcers are discussed in the literature, but the effectiveness of the different types of cushions in the prevention of heel pressure ulcers is poorly studied. In this comparative study, two different cushions to prevent heel pressure ulcers were investigated: a wedge-shaped, bedwide, viscoelastic foam cushion and an ordinary pillow. All patients were lying on a viscoelastic foam mattress and were repositioned every 4 hours. One hundred sixty-two patients over 75 years of age. The incidence of heel pressure ulcers grades 2-4 was 1.9% in the wedge-shaped cushion group and was 10.2% in the pillow group. The patients in the wedge-shaped cushion group developed significantly fewer heel pressure ulcers (p = 0.03). Patients with a wedge-shaped cushion under the lower legs had an 85% less chance in developing a heel pressure ulcer (p = 0.02). The median time to develop a heel pressure ulcer was 4.0 days (IQR = 3.0-5.0) in the wedge-shaped cushion group and 3.5 days (IQR = 1.0-5.8) in the pillow group (p = 0.61). The probability to remain pressure ulcer-free at the heels was significantly higher in the wedge-shaped cushion group (p = 0.008). The study provides evidence that a wedge-shaped, bedwide, viscoelastic foam cushion decreases the risk of developing a heel pressure ulcer compared with the use of a pillow.

Reduced heel pressure damage when using the Repose® Foot Protector

An evaluation of the Repose® heel pressure ulcer prevention system was conducted in an orthopaedic setting to establish its clinical efficacy in reducing the incidence of heel pressure damage, following a literature review of appropriate pressure-reducing devices. The study involved patients from a 24-bed orthopaedic ward over a six-month period. The results showed that the use of the heel protector led to a significant reduction in the incidence of heel pressure ulceration from more than 6% to 0%. A significant reduction in cost was also identified. The results indicate that the use of a heel protector alongside individualized pressure ulcer prevention has a significant impact on preventing heel pressure damage.

The effect of pressure‐relieving surfaces on the prevention of heel ulcers in a variety of settings: a meta‐analysis

This meta-analysis investigated the effectiveness of a pressure-relieving intervention on the incidence of heel pressure ulcers in a variety of settings. Literature searches of Cumulative Index to Nursing and Allied Health Literature, MEDLINE, PubMed, EMBASE and Cochrane databases were conducted for English-language articles that investigated the effect of pressure relief interventions with or without concurrent prevention programs on the number of heel ulcers occurring on adult humans in a controlled clinical design. Full articles were selected from citations based upon consensus between at least two independent reviewers. Methodological quality of each study was assessed using the Jadad and PEDro scales. A quantitative analysis was performed to determine and compare relative risk (RR) between pressure relief programs/devices that were classified according to similarity of interventions. Fourteen studies that involved a total of 1457 subjects were selected from a total of 105 full articles reviewed. Pressure-reducing/relieving surfaces were associated with a significantly lower incidence of heel ulcers compared with standard hospital mattresses (RR = 0.50, 95% CI = 0.26-0.93, P < 0.03). Foam mattresses also significantly reduced the risk of developing heel ulcers. There is evidence to support the use of certain air or foam mattresses/overlays in the prevention of heel pressure ulcers when compared with a standard hospital mattress. There is insufficient research available at this time to determine if heel-protective devices can prevent heel pressure ulcers. These results need to be interpreted with caution given the relatively low number and poor quality of research articles available to date.

The prevention of heel pressure ulcers using a hydropolymer dressing in surgical patients

A trial of a self-adhesive hydropolymer foam dressing (Tielle, Johnson & Johnson) demonstrated that it prevented the development of friction-generated pressure ulcers on the heels of ICU patients. Following the trial, use of the foam dressing became a standard preventive measure in the ICU and the prevalence of heel ulcers decreased by 72% in two years. This follow-up study evaluated the foam's effectiveness in preventing heel pressure ulcers in surgical patients. A total of 140 surgical patients were screened over a four-month period. They were assigned to one of two groups, depending on their pressure ulcer risk score and the anticipated length of the surgical procedure. The foam dressing was used as a barrier on the heels, depending on the patient's risk status, which was assessed using a modified Norton scale, and the duration of their surgery. Heels were inspected on a daily basis for up to 10 days. All 23 patients in the group whose surgery lasted less than 90 minutes dropped out of the study as they were discharged with insufficient data. A 76.7% reduction in heel pressure ulcers was achieved with this preventive measure. Use of an adhesive foam dressing on surgical patients can prevent heel ulcers. Research is needed on the effects of friction on the heel during the transfer and movement of surgical patients. This study was sponsored by Johnson & Johnson Medical.

Physiology and Prevention of Heel Ulcers

In Brief The prevalence of heel ulcers across settings is high and is increasing. Prevention of ulcers requires knowledge of their etiology and the scientific basis for preventive care. The interaction between external pressure and the heel vasculature is central to the prevention of heel ulcers. This article focuses on the prevention of heel pressure ulcers. The physiology of heel tissue perfusion, the effect of external pressure on heel perfusion, as well as what is known about strategies to reduce external pressure and approaches to improve heel skin blood flow will be discussed. It is only through understanding of the physiology of heel tissue perfusion and its relation to external pressure that effective preventive measures to reduce heel skin breakdown can be adapted in clinical practice. The physiology of heel tissue perfusion, the effect of external pressure on heel perfusion, as well as what is known about strategies to reduce external pressure and approaches to improve heel skin blood flow are considered, pursuant to providing effective preventive measures to reduce heel skin breakdown in clinical practice.

Physiology and prevention of heel ulcers: The state of science

The prevalence of heel ulcers across settings is high and is increasing. Prevention of ulcers requires knowledge of their etiology and the scientific basis for preventive care. The interaction between external pressure and the heel vasculature is central to the prevention of heel ulcers. This article focuses on the prevention of heel pressure ulcers. The physiology of heel tissue perfusion, the effect of external pressure on heel perfusion, as well as what is known about strategies to reduce external pressure and approaches to improve heel skin blood flow will be discussed. It is only through understanding of the physiology of heel tissue perfusion and its relation to external pressure that effective preventive measures to reduce heel skin breakdown can be adapted in clinical practice. (J WOCN 2003;30:191-8.)