Can using a dressing prophylactically reduce heel pressure ulceration?
Carol Johnson, Tissue Viability Matron, Darlington Memorial Hospital
Background to the study
A retrospective review of cases in the orthopaedic unit demonstrated that patients were developing blistering to the heel of the affected limb within the first 24 hours post operatively. In addition:
- all patients had sustained a of fractured neck of femur
- all patients reviewed were aged between 55-95 years of age
- length of time between injury and admission to the trauma ward varied
- fracture repair was performed under spinal anaesthesia
- the grade 2 tissue damage occurred despite full strategic prevention strategies being in place (Box 1)
- patients reported minor pain after sustaining the pressure damage
- routine blood analysis on and mission and post-operatively showed that none of the patients who developed an ulcer were deficient in albumin,
- all patients who developed an ulcer were referred to tissue viability to exclude vascular insufficiency (none present) and wound management advice
Given that ulcers were developing despite full prevention strategies being in place, we decided to undertake a study to determine if the prophylactic application of a five-layer silicone dressing (Mepilex Heel, Mölnlycke Health Care UK) would reduce the incidence of the development of grade 2 heel blisters caused by post-operative shear and in acute trauma patients who undergo spinal anaesthesia.
In this study, patients in the trauma unit will have Mepilex heel applied in addition to the routine prevention strategies (Box 1). Any patients who develop pressure area damage will have a tissue viability review and care plan management as per trust protocol.
- pressure ulcer risk assessment (Waterlow) within 4 hours of admission
- pressure reducing foam mattress as standard
- dynamic pressure relieving alternating mattress for ‘very high risk’ patients
- high quality nursing care interventions from identified pressure area champions
- 1 – 2 hourly rounding by the wider health care team
- ensuring patients are aware of need to change positions (were appropriate)
Box 1: Standard pressure ulcer prevention strategies
Previous studies have demonstrated the effectiveness of using a dressing prophylactically [1,2]. It is envisaged that incorporating the heel dressing into this prevention package will decrease shear and friction potential to the heel whilst the patients are in the initial recovery phase. It is during this phase whilst the spinal anaesthesia is ‘wearing off’ that the patient’s regains motor movement prior to the sensory perception. It is thought that this phase is a major impact in the development of the blister formation on the patient’s heel, hence leaving the heel dressing in place for 72 hours post-operatively.
The study will include any patient who presents to the trauma ward with a traumatic fracture of neck of femur and who does not already have a differential diagnosis which may be a causative factor for the formation of blisters.
Data collection will demonstrate if a reduction in incidence is shown when analysed against previously collected data when only strategic prevention strategies were in place.
If the product is successful in preventing heel pressure ulcers, recommendations for a wider study to include patients with a disease related deficit such as:
- stroke patients as they are often irritable and restless on admission and thus sustain friction episodes
- patients with peripheral neuropathy and are unaware of their sensory deficit
The prevention of hospital acquired pressure ulcers in all patients remains a critical challenge once all known preventative strategies have been used. We also need to recognise that deeper analysis into the specific causative factors of pressure area damage which are specialist to the patient and/or the patients presenting condition should also be addressed.
The hypothesis for testing is that the application of a five layer silicone dressing within the principles discussed by Santamaria et al’s study  can be applied in a setting where moisture is not present but where a sensory deficit results in shear and friction being a principle causative factor, will result in a decrease of incidence from previous acknowledged data statistics.