The cost‐benefit of using soft silicone multilayered foam dressings to prevent sacral and heel pressure ulcers in trauma and critically ill patients: a within‐trial analysis of the Border Trial

Little is known about the cost‐benefit of soft silicone foam dressings in pressure ulcer (PU) prevention among critically ill patients in the emergency department (ED) and intensive care unit (ICU). A randomised controlled trial to assess the efficacy of soft silicone foam dressings in preventing sacral and heel PUs was undertaken among 440 critically ill patients in an acute care hospital. Participants were randomly allocated either to an intervention group with prophylactic dressings applied to the sacrum and heels in the ED and changed every 3 days in the ICU or to a control group with standard PU prevention care provided during their ED and ICU stay. The results showed a significant reduction of PU incidence rates in the intervention group (P = 0·001). The intervention cost was estimated to be AU$36·61 per person based on an intention‐to‐treat analysis, but this was offset by lower downstream costs associated with PU treatment (AU$1103·52). Therefore, the average net cost of the intervention was lower than that of the control (AU$70·82 versus AU$144·56). We conclude that the use of soft silicone multilayered foam dressings to prevent sacral and heel PUs among critically ill patients results in cost savings in the acute care hospital.     

Saudi Arabian adult intensive care unit pressure ulcer incidence and risk factors: a prospective cohort study

The purpose of this study was to identify pressure ulcer (PU) incidence and risk factors that are associated with PU development in patients in two adult intensive care units (ICU) in Saudi Arabia. A prospective cohort study design was used. A total of 84 participants were screened second daily basis until discharge or death, over a consecutive 30‐day period, out of which 33 participants with new PUs were identified giving a cumulative hospital‐acquired PU incidence of 39·3% (33/84 participants). The incidence of medical devices‐related PUs was 8·3% (7/84). Age, length of stay in the ICU, history of cardiovascular disease and kidney disease, infrequent repositioning, time of operation, emergency admission, mechanical ventilation and lower Braden Scale scores independently predicted the development of a PU. According to binary logistic regression analyses, age, longer stay in ICU and infrequent repositioning were significant predictors of all stages of PUs, while the length of stay in the ICU and infrequent repositioning were associated with the development of stages II–IV PUs. In conclusion, PU incidence rate was higher than that reported in other international studies. This indicates that urgent attention is required for PU prevention strategies in this setting.     

Use of wound dressings to enhance prevention of pressure ulcers caused by medical devices

Medical device related pressure ulcers (MDR PUs) are defined as pressure injuries associated with the use of devices applied for diagnostic or therapeutic purposes wherein the PU that develops has the same configuration as the device. Many institutions have reduced the incidence of traditional PUs (sacral, buttock and heel) and therefore the significance of MDR PU has become more apparent. The highest risk of MDR PU has been reported to be patients with impaired sensory perception, such as neuropathy, and an impaired ability for the patient to communicate discomfort, for example, oral intubation, language barriers, unconsciousness or non‐verbal state. Patients in critical care units typify the high‐risk patient and they often require more devices for monitoring and therapeutic purposes. An expert panel met to review the evidence on the prevention of MDR PUs and arrived at these conclusions: (i) consider applying dressings that demonstrate pressure redistribution and absorb moisture from body areas in contact with medical devices, tubing and fixators, (ii) in addition to dressings applied beneath medical devices, continue to lift and/or move the medical device to examine the skin beneath it and reposition for pressure relief and (iii) when simple repositioning does not relieve pressure, it is important not to create more pressure by placing dressings beneath tight devices.     

Improving the quality of pressure ulcer management in a skilled nursing facility

Pressure ulcers (PUs) are a serious health care problem for nursing home residents and a key quality metric for regulators. Three initiatives were introduced at a 128‐bed facility to improve PU prevention. First, a Quality Assurance and Performance Improvement project and a Root Cause Analysis were conducted to improve the facility's wound care programme. Second, a digital wound care management solution was adopted to track wound management. Third, the role of skin integrity coordinator was created as a central point of accountability for wound care‐related activities and related performance metrics. Improvements in PU prevention were tracked using Centers of Medicare and Medicaid data, specifically (a) the percentage of long‐stay high‐risk residents with PUs and (b) the percentage of short‐stay residents with PUs that are new or have worsened. PU prevalence for long‐stay high‐risk residents was 12.99% (Q4 2016), and upon implementation of these initiatives, the facility saw continued reductions in PU prevalence to 2.9% (Q4 2017), while PUs for short‐stay residents were maintained at zero throughout this period. This study highlights the power of effective management combined with real‐time data analytics, as enabled by digital wound care management, to make significant improvements in health care delivery.     

The biomechanical protective effects of a treatment dressing on the soft tissues surrounding a non‐offloaded sacral pressure ulcer

Patients who are immobile endure prolonged bodyweight‐related compressive, tensional and shear loads at their body‐support contact areas that over time may lead to the onset of pressure ulcers (PUs). Approximately, one‐third of the common sacral PUs are severe and classified as category 3 or 4. If a PU has occurred, off‐loading is the basic, commonly accepted clinical intervention; however, in many situations, complete off‐loading of sacral PUs is not possible. Minimising the exposure of wounds and their surroundings to elevated mechanical loads is crucial for healing. Accordingly, in the present study, we aimed to investigate the biomechanical effects of the structural and mechanical properties of different treatment dressings on stresses in soft tissues surrounding a non‐offloaded sacral PU in a supine patient. Using a novel three‐dimensional anatomically realistic finite element modelling framework, we have compared performances of three dressing designs: (a) The Mepilex Border Sacrum (MBS) multilayer anisotropic silicone foam dressing (Mölnlycke Health Care), (b) an isotropic stiff dressing, and (c) an isotropic flexible dressing. Using our newly developed protective efficacy index (PEI) and aggravation index (AI) for assessing prophylactic and treatment dressings, we identified the anisotropic stiffness feature of the MBS dressing as a key design element.     

Cost‐effectiveness of multi‐layered silicone foam dressings for prevention of sacral and heel pressure ulcers in high‐risk intensive care unit patients: An economic analysis of a randomised controlled trial

Pressure ulcer incidence is high in intensive care units. This causes a serious financial burden to healthcare systems. We evaluated the cost‐effectiveness of multi‐layered silicone foam dressings for prevention of sacral and heel pressure ulcers in addition to standard prevention in high‐risk intensive care units patients. A randomised controlled trial to assess the efficacy of multi‐layered silicone foam dressings to prevent the development of pressure ulcers on heels and sacrum among 422 intensive care unit patients was conducted. Direct costs for preventive dressings in the intervention group and costs for treatment of incident pressure ulcers in both groups were measured using a bottom‐up approach. A cost‐effectiveness analysis by calculating the incremental cost‐effectiveness ratio using different assumptions was performed. Additional dressing and labour costs of €150.81 (€116.45 heels; €34.36 sacrum) per patient occurred in the intervention group. Treatment costs were €569.49 in the control group and €134.88 in the intervention group. The incremental cost‐effectiveness ratio was €1945.30 per PU avoided (€8144.72 on heels; €701.54 sacrum) in the intervention group. We conclude that application of preventive dressings is cost‐effective for the sacral area, but only marginal on heels for critically ill patients.     

An integrated experimental‐computational study of the microclimate under dressings applied to intact weight‐bearing skin

Pressure ulcers (PUs) are one of the most prevalent adverse events in acute and chronic care. The root aetiological cause of PUs is sustained cell and tissue deformations, which triggers a synergistic tissue damage cascade that accelerates over relatively short time periods. Changes in skin microclimate conditions are known to indirectly contribute to PU‐risk levels or to exacerbation of existing wounds. It is therefore surprising that information concerning heat accumulation under dressings is poor. Here, we aimed to investigate the effects of dressings on the microclimate of weight‐bearing buttocks skin in 1‐hour supine lying sessions. Using a novel and originally developed experimental‐computational approach, we compared the combined influence of the mechanical and thermal properties of a polymeric membrane dressing (PolyMem, Ferris Mfg. Corp., Fort Worth, TX) on skin microclimate under and near the dressings with those of a standard placebo foam dressing. We specifically identified the thermal conductivity properties of dressings as being highly important in the context of protective dressing performances, given its association with potential heat accumulation under dressings. Accordingly, this article highlights, for the first time in the literature, the relevance of thermal properties of a dressing in effectively mitigating the risk of developing PUs or aggravating an injury, and offers a systematic, methodological bioengineering process for assessing the thermal performances of dressings.     

Five‐layer border dressings as part of a quality improvement bundle to prevent pressure injuries in US skilled nursing facilities and Australian nursing homes: A cost‐effectiveness analysis

The BORDER III trial found that five‐layer silicone border dressings effectively prevented pressure injuries in long‐term care, but the value of this approach is unknown. Our objective was to analyse the cost‐effectiveness of preventing facility‐acquired pressure injuries with a quality improvement bundle, including prophylactic five‐layer dressings in US and Australian long‐term care. Markov models analysed the cost utility for pressure injuries acquired during long‐term care from US and Australian perspectives. Models calibrated outcomes for standard care compared with a dressing‐inclusive bundle over 18 monthly cycles or until death based on BORDER III outcomes. Patients who developed a pressure injury simulated advancement through stages 1 to 4. Univariate and multivariate probabilistic sensitivity analyses tested modelling uncertainty. Costs in 2017 USD and quality‐adjusted life years (QALYs) were used to calculate an incremental cost‐effectiveness ratio (ICER). Dressing use yielded greater QALYs at slightly higher costs from perspectives. The US ICER was $36 652/QALY, while the Australian ICER was $15 898/QALY, both of which fell below a willingness‐to‐pay threshold of $100 000/QALY. Probabilistic sensitivity analysis favoured dressings as cost‐effective for most simulations. A quality improvement bundle, including prophylactic five‐layer dressings, is a cost‐effective approach for pressure injury prevention in all US and Australia long‐term care residents.     

The prevalence of pressure ulcers in community‐dwelling older adults: A study in an Indonesian city

The objectives of this study were to investigate the prevalence and the characteristics of pressure ulcers (PU) in community‐dwelling older adults in Indonesia, including specific characteristics of the PU patients and their use of formal and informal care. A cross‐sectional design was used for the study, with 325 participants aged 60 years or older, randomly chosen from the general community. The overall PU prevalence and the PU prevalence excluding category 1 were 10.8% (95% confidence interval [CI], 5.8‐15.8) and 5.2% (95% CI 0.2‐10.2), respectively. Category 1 PUs were mostly (34.3%) located on knees and toes, while category 2 and higher PUs were mostly (70.4%) located on the shoulder, sacrum, and hip. The main factors that contributed strongly to PUs among older adults in the community were the degree of physical activity, problems with sensory perception, and having a history of stroke. None of the participants with a PU received wound care or information about PUs from formal caregivers and only 11.4% received wound care from family caregivers. This study shows that pressure ulcers in community‐dwelling older adults in Indonesia are a relevant and largely unaddressed problem. Developing an intervention program to manage the PU problem in the community is recommended.     

Pressure ulcers’ incidence,preventive measures,and risk factors in neonatal intensive care and intermediate care units

Epidemiological studies on pressure ulcers (PUs) in hospitalised infants are scarce. Spain lacks comprehensive research studies providing data on the prevalence or incidence in this population. This work was developed to determine the incidence of PUs in hospitalised infants admitted to intensive and intermediate care units, along with relevant risk factors and preventive measures. A prospective study appraising the incidence of PUs in infants was performed. The risk factors and preventive measures were evaluated using a multivariate logistic regression model. A sample of 268 infants was included. The cumulative incidence of PUs was 12.70% (95% confidence interval, CI_95% = [8.95%‐17.28%]). The cumulative incidence in the intermediate care units was 1.90% (CI_95% = [0.39%‐5.45%]), while it was 28.18% (CI_95% = [20.02%‐37.56%]) in the intensive care units. The PUs were categorised as stage I, 57.10%; stage II, 31.70%; and stage III, 11.10%. The multivariate analysis found the following to be risk factors: low scores in the Spanish version of the Neonatal Skin Risk Assessment Scale (e‐NSRAS) (Relative Risk (RR) 0.80; CI_95% = [0.66‐0.97]), the use of non‐invasive mechanical ventilation (RR 12.24; CI_95% = [4.02‐37.32]), and the length of stay (RR 1.08; CI_95% = [1.02‐1.15]), suggesting a direct impact of these factors on PU development in infants. Kangaroo care influenced the prevention of PUs (RR 0.26; CI_95% = [0.09‐0.71]). The infants admitted in intermediate care units suffered PUs. In the case of intensive care units, the incidence is even higher. The risk increases with the length of stay, while the presence of medical devices, particularly non‐invasive mechanical ventilation, is the main causal relationship. Kangaroo care has been shown to be an important preventive measure.     

Cost–utility analysis of an advanced pressure ulcer management protocol followed by trained wound,ostomy, and continence nurses

The high prevalence of severe pressure ulcers (PUs) is an important issue that requires to be highlighted in Japan. In a previous study, we devised an advanced PU management protocol to enable early detection of and intervention for deep tissue injury and critical colonization. This protocol was effective for preventing more severe PUs. The present study aimed to compare the cost‐effectiveness of the care provided using an advanced PU management protocol, from a medical provider's perspective, implemented by trained wound, ostomy, and continence nurses (WOCNs), with that of conventional care provided by a control group of WOCNs. A Markov model was constructed for a 1‐year time horizon to determine the incremental cost‐effectiveness ratio of advanced PU management compared with conventional care. The number of quality‐adjusted life‐years gained, and the cost in Japanese yen (¥) ($US1 = ¥120; 2015) was used as the outcome. Model inputs for clinical probabilities and related costs were based on our previous clinical trial results. Univariate sensitivity analyses were performed. Furthermore, a Bayesian multivariate probability sensitivity analysis was performed using Monte Carlo simulations with advanced PU management. Two different models were created for initial cohort distribution. For both models, the expected effectiveness for the intervention group using advanced PU management techniques was high, with a low expected cost value. The sensitivity analyses suggested that the results were robust. Intervention by WOCNs using advanced PU management techniques was more effective and cost‐effective than conventional care.     

Independent risk factors for pressure ulcer development in a high‐risk nursing home population receiving evidence‐based pressure ulcer prevention: Results from a study in 26 nursing homes in Belgium

The aim of this study was to identify independent risk factors for pressure ulcer (PU) development in a high‐risk nursing home population receiving evidence‐based PU prevention. This study was part of a randomised controlled trial examining the (cost‐)effectiveness of static air support surfaces compared with alternating pressure air mattresses. The sample consisted of 308 residents at a high risk of PU development (presence of non‐blanchable erythema, Braden score ≤ 12 or Braden subscale “mobility” ≤ 2). PU incidence was monitored for 14 days. Demographic variables; functional, physical, and psychological characteristics; and data on skin assessment were collected. Independent risk factors were identified using multiple logistic regression analysis. The overall PU incidence (category II‐IV) was 8.4% (n = 26), and 1.9% (n = 6) of the residents developed a deep PU (category III‐IV). PUs (category II‐IV) were significantly associated with non‐blanchable erythema, a lower Braden score, and pressure area‐related pain in high‐risk residents even if preventive care was provided. These results highlight the need of a systematic risk assessment, including pain assessment and skin observations, in order to determine and tailor preventive care to the needs of high‐risk individuals.     

Pressure ulcers in cardiac surgery: Few clinical studies,difficult risk assessment,and profound clinical implications

Pressure ulcers (PUs) are a common complication after cardiac surgery, with almost one third of patients suffering from PUs during hospitalisation. Because of the burden that PUs exert on both the patients and the health care system, prevention is of utmost importance. The first step in successful prevention, however, includes the identification of the main features that render patients prone to PU development. Cardiac surgery population is not adequately addressed in current clinical trials and studies. Few studies focused specifically on cardiac surgery patients, but the majority included cardiac surgery patients within a heterogeneous population of acute or critical care patients. Therefore, additional research is warranted to understand the unique risk profile of patients undergoing cardiac surgery. Intraoperative risk factors that affect tissue tolerance have not been thoroughly investigated but are likely to play an important role, which might explain the epidemiology of a PU. Further research is also needed to better comprehend the risk of PUs among cardiac surgery patients and to design effective and tailored preventative measures with the help of newer tools for risk assessment.     

A non‐randomised,controlled clinical trial of an innovative device for negative pressure wound therapy of pressure ulcers in traumatic paraplegia patients

The conventional methods of treatment of pressure ulcers (PUs) by serial debridement and daily dressings require prolonged hospitalisation, associated with considerable morbidity. There is, however, recent evidence to suggest that negative pressure wound therapy (NPWT) accelerates healing. The commercial devices for NPWT are costly, cumbersome, and electricity dependent. We compared PU wound healing in traumatic paraplegia patients by conventional dressing and by an innovative negative pressure device (NPD). In this prospective, non‐randomised trial, 48 traumatic paraplegia patients with PUs of stages 3 and 4 were recruited. Patients were divided into two groups: group A (n = 24) received NPWT with our NPD, and group B (n = 24) received conventional methods of dressing. All patients were followed up for 9 weeks. At week 9, all patients on NPD showed a statistically significant improvement in PU healing in terms of slough clearance, granulation tissue formation, wound discharge and culture. A significant reduction in wound size and ulcer depth was observed in NPD as compared with conventional methods at all follow‐up time points (P = 0·0001). NPWT by the innovative device heals PUs at a significantly higher rate than conventional treatment. The device is safe, easy to apply and cost‐effective.     

Microclimate is an independent risk factor for the development of intraoperatively acquired pressure ulcers in the park‐bench position: A prospective observational study

Preventing pressure ulcers is important in patients undergoing procedures in the park‐bench position. We hypothesized that the microclimate around the skin is a significant risk factor for developing pressure ulcers. This research continuously assessed factors of the microclimate in terms of skin temperature and perspiration as well as the interface pressure in order to determine whether the microclimate is an independent risk factor for the development of park‐bench position‐related pressure ulcers (PBP‐PUs). A prospective observational study was conducted among patients undergoing elective surgery in the park‐bench position at a general hospital in the metropolitan area of Japan between April and November 2014. Factors of the microclimate, including skin temperature and perspiration, in addition to the interface pressure were continuously measured throughout surgery. Twenty‐nine patients were analyzed (mean age 44.4 ± 13.2 years, male 44.8%). Of these 29 patients, seven (24.1%) developed Category I PBP‐PUs. The change in skin temperature from baseline to the end of surgery (2.7 ± 0.3 °C vs. 1.9 ± 0.8 °C) and the average peak pressure (119.1 ± 36.8 mmHg vs. 94.5 ± 23.1 mmHg) were significantly higher in the patients with PBP‐PUs than in those without PBP‐PUs. There were no significant differences in the amount of perspiration between the two groups. A hierarchical logistic regression analysis showed that the change in skin temperature was significantly related to the development of PBP‐PUs (unit = 0.1 °C: odds ratio 1.44, 95% confidential interval 1.09–2.33) when adjusted for the average peak pressure and length of surgery. Our results suggest that a change in skin temperature toward a higher value is an independent risk factor for the development of PBP‐PUs. Proper intraoperative management of skin temperature may therefore be a promising candidate as a preventive method against PBP‐PU development.     

Consistent pressure ulcer prevention practice: The effect on PU prevalence and PU stages,and impact on PU prevention—A quasi-experimental intervention study

This study evaluates the effect of nursing staff's renewed consistent pressure ulcer (PU) prevention practice on PU prevalence and the PU prevention implemented for residents. A quasi-experimental intervention study was conducted. The data were collected from 232 residents (n = 115 in intervention and 117 in comparison group) in two public long-term older people care (LOPC) facilities in Finland using the Pressure Ulcer Patient instrument (PUP-Instrument). The facilities were chosen with convenience sampling, after which they were randomly allocated as either intervention or comparison facility. Based on international guidelines for PU prevention, the renewed, consistent PU prevention practice with six areas was developed and implemented using the operational model for evidence-based practices (OMEBP). After the intervention, a significant difference between the intervention and the comparison facility was seen in the prevalence of PUs and in the residents’ highest stage of PUs in the sacrum, buttock and hip areas, and heels. Between the facilities, a significant difference was seen in the use of PU and nutrition risk assessment instruments and nutritional supplements, time used for repositioning in the daytime and at night-time, lifting belt use, and avoiding shearing or stretching residents’ skin. The successful intervention improved skin integrity in LOPC facilities.     

Effects of loading and prophylactic dressings on the sacral and heel skin: An exploratory cross‐over trial

Pressure ulcers/injuries are caused by sustained loading and deformation of skin and underlying soft tissues. Prophylactic dressings are recommended as an adjunct to other preventive measures such as repositioning and offloading. The aim of this study was to investigate the effects of prophylactic soft silicone multi‐layered foam dressings on the skin structure and function of the two most common pressure areas, sacrum and heel, with and without loading. An exploratory randomised cross‐over trial using intra‐individual comparisons was conducted. Eight healthy volunteers (mean age 27.5 years) were assigned to three groups and either spent 2.5 hours on a standard hospital mattress lying in supine position with and without dressings or spent 2.5 hours with dressings applied but without loading. Skin temperature, stratum corneum, and epidermal hydration increased in all groups irrespective of wearing a dressing and/or loading. Mean roughness decreased at the heels. Reactive hyperaemia and the release of interleukin 1 alpha were associated with loading only. Results suggest that the occlusive effects of dressings are similar or only slightly greater than those observed with non‐loading or loading without dressings. Thus, a dressing does not cause additional irritation or skin changes during loading but it may reduce the inflammatory response.     

Personality and Behavioral Predictors of Pressure Ulcer History

PURPOSE: To assess the relationship of psychological, environmental, and behavioral factors with pressure ulcers (PUs) in persons with spinal cord injury (SCI). METHODS: A total of 1,549 participants from a large rehabilitation hospital in the southeast United States answered questions regarding outcomes after SCI. Variables from each set of factors were entered sequentially into the model: (1) psychological and environmental, and (2) behavioral. RESULTS: Forty-eight percent of participants reported having a PU in the past year. After entering behavioral variables into the model, all environmental and psychological variables became nonsignificant. Odds of having a PU increased 28% with each psychotropic medication taken weekly. Persons who smoked one or more packs of cigarettes daily had 2.82 times the odds of having a PU than persons who did not smoke. Increased hours out of bed were protective against PUs. CONCLUSION: This study demonstrated the importance of health behaviors in the occurrence of PUs after SCI. These health behaviors provide important targets for intervention for health care providers.     

Non‐adherence to treatment of chronic wounds: patient versus professional perspectives

The reasons for the non‐adherence to treatment for wound healing are complex and fall into unintentional and intentional categories. This study explored intentional and unintentional non‐adherence to treatment from patient/carer and health care professional perspectives. Patients with wounds receiving ALLEVYN Life dressings (n = 20) and patients not receiving ALLEVYN Life dressings who were deemed to be non‐adherent to treatment regimes (n = 6) took part in semi‐structured interviews to explore their experiences of living with a wound, treatment and intentional and unintentional non‐adherence. Three focus groups of health care professionals explored issues surrounding non‐adherence to treatment regimes. Groups included nurses and doctors (n = 25). We found that relationships between participants and health care professionals varied in character across the groups. All participants expressed reasons for both intentional and unintentional adherence. Many reasons for intentional non‐adherence are related to comfort and working the regime around patients' lives. Health care professionals considered the most common form of non‐adherence to be unintentional. However, patients describe the most common form of non‐adherence as being intentional. The relationship between patients and health care professionals varied in character between the groups. Discrepancies between professional and patient perspectives need to be reconciled and addressed to improve adherence to treatment regimes.