A review of the surgical management of heel pressure ulcers in the 21st century

Heel ulceration, most frequently the result of prolonged pressure because of patient immobility, can range from the trivial to the life threatening. Whilst the vast majority of heel pressure ulcers (PUs) are superficial and involve the skin (stages I and II) or underlying fat (stage III), between 10% and 20% will involve deeper tissues, either muscle, tendon or bone (stage IV). These stage IV heel PUs represent a major health and economic burden and can be difficult to treat. The worst outcomes are seen in those with large ulcers, compromised peripheral arterial supply, osteomyelitis and associated comorbidities. Whilst the mainstay of management of stage I‐III heel pressure ulceration centres on offloading and appropriate wound care, successful healing in stage IV PUs is often only possible with surgical intervention. Such intervention includes simple debridement, partial or total calcanectomy, arterial revascularisation in the context of coexisting peripheral vascular disease or using free tissue flaps. Amputation may be required for failed surgical intervention, or as a definitive first‐line procedure in certain high‐risk or poor prognosis patient groups. This review provides an overview of heel PUs, alongside a comprehensive literature review detailing the surgical interventions available when managing such patients.     

Peer-to-peer nursing rounds and hospital-acquired pressure ulcer prevalence in a surgical intensive care unit: a quality improvement project

We conducted a quality improvement project in order to evaluate the effect of nurse-to-nurse bedside "rounding" as a strategy to decrease hospital-acquired pressure ulcers (HAPU) in a surgical intensive care unit. We instituted weekly peer-to-peer bedside skin rounds in a 17-bed surgical intensive care unit. Two nurses were identified as skin champions and trained by the hospital's certified WOC nurse to conduct skin rounds. The skin champion nurses conducted weekly peer-to-peer rounds that included discussions about key elements of our patients' skin status including current Braden Scale for Pressure Sore Risk score, and implementation of specific interventions related to subscale risk assessment. If a pressure ulcer was present, the current action plan was reevaluated for effectiveness. Quarterly HAPU prevalence studies were conducted from January 2008 to December 2010. Nineteen patients experienced a HAPU: 17 were located on the coccyx and 2 on the heel. Ten ulcers were classified as stage II, 3 PU were stage IV, 5 were deemed unstageable, and 1 was classified as a deep tissue injury. The frequency of preventive interventions rose during our quality improvement project. Specifically, the use of prevention surfaces increased 92%, repositioning increased 30%, nutrition interventions increased 77%, and moisture management increased 100%. Prior to focused nursing rounds, the highest HAPU prevalence rate was 27%. After implementing focused nursing rounds, HAPU rates trended down and were 0% for 3 consecutive quarters.     

SCI health care provider attitudes about pressure ulcer management

BACKGROUND/OBJECTIVE: To evaluate the variability in clinical decisions about pressure ulcer management for persons with spinal cord injury (SCI) and expand understanding of the various factors influencing variability. METHODS: Eighty-one SCI physicians and nurses completed a survey on pressure ulcer management. Patient scenarios were used to assess the effect of patient characteristics on provider decisions regarding inpatient treatment of severe pressure ulcers, surgery vs medical management, and amount of healing before discharge. RESULTS: The availability of social support to facilitate bed rest appears to be a more important factor in deciding whether the patient is managed at home vs in the hospital than is the level of injury. Medical condition does not appear to influence surgical vs medical management of severe pressure ulcers. For patients with poor social support, more healing was required before discharge, regardless of their medical condition. Providers were queried about other issues that influence management, including inpatient resource availability, patient preferences, the availability and quality of local home care, and the availability and use of formal care protocols. Respondents were virtually unanimous in their agreement that patients who are compliant with prevention measures can avoid ulcer development. CONCLUSION: Like many health care providers, those who provide care to people with SCI are struggling to provide quality care to improve their patients' lives in the absence of good evidence to guide their treatment decisions. The results of the present study indicate that in situations in which there is no strong empirical evidence, variation in care provided is extensive.     

Surgical and reconstructive management of pressure ulcers

Despite significant advances in therapeutic options, pressure ulcers continue to pose a challenge to physicians and surgeons and frequently require multidisciplinary input. In addition, they place huge financial burdens on health care providers. Generally classified as grades I to IV depending on the extent and severity of the ulcer, grades I and II are usually amenable to conservative management. Grades III and IV may require surgical intervention, which could either be simple debridement or complex reconstructive microsurgery. Direct closure or skin grafting is useful in only a small number of early pressure ulcers. For non-healing and advanced pressure ulcers, reconstructive surgery is indicated, which consists of soft tissue flap coverage such as fasciocutaneous, musculocutaneous, perforator, or free flaps. The selection of a particular flap depends on a variety of factors, for instance, the location and grade of the ulcer, vascularity of the surrounding tissue, mobility of the patient, and the experience and expertise of the surgeon. There are no clear guidelines at present regarding the suitability of a particular flap in the management of pressure ulcers at different stages. This article aims to provide an overview of the etiology, pathophysiology, and management of pressure ulcers in various anatomical locations, with particular emphasis on current advances in reconstructive surgical procedures.     

Use of a sacral silicone border foam dressing as one component of a pressure ulcer prevention program in an intensive care unit setting

In 2008, patients in the intensive care unit (ICU) at Danbury Hospital, Danbury, Connecticut, experienced 79 pressure ulcers. As a result, pressure ulcer-prevention interventions were standardized in critical care and medical-surgical units and education was provided to all direct patient care staff about principles of skin care and prevention. Following these efforts, 53 ICU patients developed pressure ulcers in the sacral area in fiscal year 2009, representing a 12.5% incidence for the ICU as compared to a 3.4% overall pressure ulcer incidence for the total hospital. In order to achieve additional reduction in pressure ulcer incidence, we replicated an initiative that called for application of a silicone foam dressing every 3 days to determine its effect on sacral pressure ulcer incidence in the ICU. We found that the use of the dressing further diminished the incidence of sacral pressure ulcers in our patients.     

Improving stoma management in the low-vision patient

Teaching the low-vision patient with an ostomy to manage a stoma independently provides a significant challenge for the WOC nurse. Although guide strips, lighted mirrors, and other handheld devices are available to patients with impaired eyesight, these products, when used alone, may be inadequate for the patient with an ostomy. In addition, there is a paucity of literature available to the WOC nurse describing specific interventions for the low-vision patient with an ostomy. Common visual problems encountered when managing people with an ostomy are reviewed. Specific Interventions are discussed, including products designed to assist the low-vision patient with an ostomy with stoma care. A case study is provided that underscores the importance of consulting a low-vision specialist in the care of the patient with a new ostomy who has low vision as a result of albinism.     

Health economic benefits of cyanoacrylate skin protectants in the management of superficial skin lesions

Superficial skin damages, including stage II pressure ulcer, skin tears and moisture‐associated skin damages (MASDs) are common and constitute a significant disease burden to the health care system. A cost analysis was conducted by comparing a cyanoacrylate barrier film with routine care in the treatment of superficial skin damages in a chronic care facility. The analysis included 12 patients: four patients with stage II pressure ulcers, six with MASD and two with skin tears. Cost analysis was conducted comparing the cost of care 7 days before and 7 days after the acrylate barrier was used. The total cost took into consideration the time, products and supplies required to manage the skin problem.     

Changing perspectives in diabetic foot ulcer management

Diabetic foot ulceration is a serious complication of diabetes mellitus; it is the cause of more than half of nontraumatic lower limb amputations. Diabetic foot ulcers are the major cause of hospital admission for diabetic patients. Treatment costs are high. There have been advances in managing diabetic foot ulceration with the development of new dressings, growth factors, skin substitutes, and other novel approaches to stimulating wound healing. The management of vascular disease in the patient with diabetes mellitus is an essential and important consideration. However, the need for a multidisciplinary team to provide good foot care to diabetic patients is still vital for the prevention and treatment of diabetic foot ulceration.     

Care of chronic wounds in palliative care and end‐of‐life patients

The aim of this paper was to provide a literature synthesis on current wound care practices for the management of chronic wounds in palliative care and end‐of‐life patients, focusing on the control of wound‐related symptoms for comfort and improved quality of life. These wounds included pressure ulcers, venous and arterial leg ulcers, diabetic ulcers and fungating malignant wounds. Wound‐related symptoms included pain, exudate, malodour, infection, bleeding, dressing comfort and negative psychological and social functioning. Best care wound practices were formulated for each wound type to ease suffering based on the literature review. Although symptom management strategies for comfort may work in tandem with healing interventions, it is important to recognise when efforts towards wound closure may become unrealistic or burdensome for the patient at end of life. Thus, unique aspects of palliative wound care feature clinical indicators for early recognition of delayed healing, quality of life measurement tools related to chronic wounds, and comfort care strategies that align with patient wishes and realistic expectations for wound improvement.     

Facial skin breakdown in patients with non‐invasive ventilation devices: report of two cases and indications for treatment and prevention

Non‐invasive ventilation (NIV) provides an effective ventilatory support in patients with respiratory failure without endotracheal intubation. However, there are potential problems with its clinical application and the development of pressure ulcers represents a common complication. Often several intensive care units treat facial skin breakdown related to NIV. In this article, we report our experience in treatment and prevention of these lesions, emphasising the higher risk of certain age groups to develop them, such as preterm infants and elderly patients with comorbidities. We performed daily disinfection of the lesions followed by application of topical cream containing hyaluronic acid (HA) sodium salt. In addition, in order to prevent worsening of injury, we applied a cushion made of gauze pad containing HA sodium salt between the skin and the masks, so as to reduce friction between the NIV devices and the skin. Local medical treatment allowed complete reepithelialisation of the injured skin areas. Systematic monitoring of patients' faces is essential to detect early damages and to intervene with appropriate therapy, especially in preterm infants and elderly. Moreover, refining the devices with the proposed protective cushion can reduce pressure ulcers and increase comfort for the patients.     

Factors affecting outcome of diabetic patients with foot ulcers or gangrene

This paper reports the outcome in 205 diabetic patients with foot ulcers or gangrene. The circulation to the foot was assessed using a radioisotope clearance test to measure the skin perfusion pressure (SPP) and skin vascular resistance (SVR) in the foot. Factors important in predicting initial healing were the age of the patient, SPP and SVR but not the ankle pressure index. The factors predicting death during 6-42 months follow-up were age and initial SPP; half the patients had died or under-gone amputation at 22 months. The information from the radioisotope clearance test is important in helping determine appropriate management for these patients and provides information not available from other methods, such as the ankle pressure measurement.     

High-voltage electrical stimulation for the management of stage III and IV pressure ulcers among adults with spinal cord injury: demonstration of its utility for recalcitrant wounds below the level of injury

Context

Patients with spinal cord injury (SCI) have many factors that are associated with pressure ulcer formation, including paralysis, loss of sensation, poor nutrition, anemia, and skin maceration related to incontinence. Treatment of these ulcers involves relieving pressure, improving nutrition and skin hygiene, treating infections, removing necrotic tissues, and applying the appropriate dressings. However, some cases are not responsive to the above treatment. Electrical stimulation (ES) is thought to enhance soft tissue healing through promotion of protein synthesis, inhibition of bacterial growth, facilitation of epithelial tissue migration, improvement of blood flow, and tensile strength. This data is mainly based on evidence from animal studies and very few rigorously controlled studies conducted in humans.

Objective

To demonstrate the effectiveness of ES in the treatment of recalcitrant pressure ulcers.

Methods

Retrospective case series describing the care of adults with SCI and recalcitrant pressure ulcers. ES was applied directly into the wound bed: 60 minutes per session, 3–5 times per week; with an intensity of 100 milliamperes and a frequency of 100 pulses per second. Polarity was negative initially and was switched weekly. The amplitude and wave form were maintained throughout.

Results

The long-standing (11–14 months) pressure ulcers were completely healed after 7 to 22 weeks of treatment with high-voltage ES.

Conclusion/clinical relevance

This case series demonstrates the effectiveness of ES for enhanced healing of Stage III–IV ulcers otherwise unresponsive to standard wound care. Further study is needed to identify the most effective protocol for ES therapy in the treatment of recalcitrant pressure ulcers.     

Developing and implementing a wound care program in long-term care.

Pressure ulcers in residents of long-term care facilities cause avoidable pain and suffering, and they place an additional burden on budgets that are already quite lean. To laypersons, these "bedsores" inaccurately enhance a widely held belief that nursing homes provide inferior care. Although most long-term care administrators recognize the need for better prevention and management of pressure ulcers, they lack specialized knowledge in the field of wound prevention and treatment and lack the necessary time to devote to such an effort. A systematic approach using prevention and treatment protocols and a wound care team and staff education, has proved highly effective in reducing the incidence of pressure ulcerations. This article provides a detailed guide for the development and implementation of a wound prevention and care program and defines the critical role played by the WOC nurse within such a program.     

Clinical and epidemiologic evaluation of pressure ulcers in patients at a university hospital in Turkey.

OBJECTIVE: We sought to measure the incidence of pressure ulcer development at a university health center in Turkey, and to determine whether the Waterlow Pressure Sore Risk (PSR) Scale score predicted pressure ulcer development, stage, or number of ulcers. DESIGN: We prospectively evaluated patients who were hospitalized at our university-based medical center. SETTING AND SUBJECTS: We analyzed data from 22,834 patients hospitalized at the Baskent University Adana Teaching and Medical Research Center in Ankara, Turkey from January 1, 2004 to December 31, 2004, including 360 patients who developed pressure ulcers. INSTRUMENTS: The Waterlow PSR Scale was used to assess pressure ulcer risk. In addition, age, sex, the ward or unit in which the patient was hospitalized, reason for hospitalization, and location and stage of ulcers were collected on a data form designed specifically for this study. METHODS: A single nurse physiotherapist assessed all patients daily during their hospitalization. When a pressure ulcer was diagnosed by the nurse physiotherapist, a physician staged the pressure ulcers based on the US National Pressure Ulcer Advisory Panel (NPUAP) staging system. RESULTS: Three hundred sixty out of 22,834 patients developed 1 or more pressure ulcers, resulting in an incidence rate of 1.6%. Most ulcers (59.2%) occurred in patients hospitalized in the intensive care unit (n = 213). A positive correlation between the Waterlow PSR Scale score and number of ulcers per patient (r: 0.178, P < .01) was identified. No significant correlation was found linking Waterlow PSR Scale score and ulcer stage or the development of a single ulcer. CONCLUSION: We found significantly lower pressure ulcer incidence rates than those commonly reported in the literature, which we believe is principally attributable to short hospital stays and a strong emphasis on preventive nursing care. While high Waterlow PSR scale Scores correlated positively with development of multiple ulcers, this did not predict ulcer stage or the presence of a single pressure ulcer.     

Risk factors associated with pressure ulcers in the pediatric intensive care unit.

OBJECTIVE: To identify risk factors that are associated with the development of pressure ulcers in children admitted to the pediatric intensive care unit (PICU). DESIGN: Case control study with no interventions held in a 30-bed PICU of Texas Children's Hospital, Houston. SETTING AND SUBJECTS: The study included 59 patients who developed pressure ulcers in the PICU and 59 patients who were critically ill who did not develop pressure ulcers during the same time period. INSTRUMENTS: Risk assessment data collection tool and Braden scale. METHODS: A comparison was done to identify risk factors between 2 groups of pediatric patients with and without pressure ulcers. A 45-indicator assessment tool was used. Physical assessment including staging of pressure ulcers was performed. RESULTS: Risk factors associated with pressure ulcers include edema (P = .0016), length of stay > 96 hours (P = .001), increasing positive end expiratory pressure (P = .002), not turning the patient or use of a specialty bed in the turning mode (P = .0001), and weight loss (P < .0001). CONCLUSIONS: The presence of edema, increasing length of stay, patients on increasing positive-end expiratory pressure, not turning the patient, use of a specialty bed in the turning mode, and weight loss are associated with the increased risk of development of pressure ulcers in patients in the PICU.