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by Susan Cantrell, ELS

In times past, pressure ulcers most often have been associated with long-term care, but it’s come to light in recent years that pressure ulcers often have their beginnings in the operating room (OR), particularly with operations that may take a long time, such as heart surgery. The patient, anesthetized, is unable to speak up and tell the doctor that pressure on tissue has become uncomfortable. Shifting the patient on the OR table can cause shearing, aggravating the problem. The next thing you know, there’s that little red spot on the behind or the heel or some other bony spot on the body. It could turn out to be a case of "the operation was a success, but the patient died," that tired, old, not-so-funny joke.

As with so many things, the coming Centers for Medicare and Medicaid Services (CMS) changes are creating more awareness of the need to stop pressure ulcers in their tracks. Just where should that process start in the scheme of patient care?

Prevention is always the best course. Zak Harty, product manager, Surgical and Critical Care Technologies, STERIS Corporation, Mentor, OH, expressed strong feelings on the subject: "From the perspective of the OR staff, prevention is the only option. If a hospital subscribes to this philosophy, the potential for pressure ulcers should be addressed before a patient arrives at the hospital. The potential for OR-acquired pressure ulcers should not exist. There are technologies available today that minimize the risk of OR-acquired pressure ulcers."

Cynthia Sylvia, program manager for educational development, Gaymar Industries, Orchard Park, NY, explained that, upon admission to the hospital, the patient’s skin should be examined to determine the patient’s risk for developing a pressure ulcer; then a plan for prevention can be developed. "The etiology of pressure ulcers is a complex interplay of intrinsic and extrinsic factors. Thorough assessment of skin and risk reveals strengths and weaknesses upon which a comprehensive patient-centered plan of care is built. Skin and risk assessment, tied to prevention protocols, are keys to increasing quality and improving outcomes."

Screening of newly admitted patients should be performed with a tool such as the Braden Scale². The Braden Scale predicts the risk of a patient’s likelihood for developing a pressure sore. The prediction is based on evaluations in six categories: (1) sensory perception, the patient’s ability to respond to pressure-related discomfort; (2) moisture, the degree to which his or her skin is exposed to moisture; (3) activity, the degree of the patient’s physical activity; (4) mobility, the patient’s ability to change and control body position; (5) nutrition, the patient’s normal food intake pattern; and (6) friction and shear. When it comes to scoring, more is not better: the lower the score the higher the risk. Scores range from 6 to 20. A score of 10 to 12 places a patient at high risk; a score below 9 indicates that patients are at very high risk of developing a pressure ulcer. Determining the level of risk helps to identify how aggressively preventive measures should be taken for that particular patient.

STERIS FIT Table Pad Set on a 3085 table

The looming changes in CMS reimbursement seem to be on everyone’s mind. It’s more important than ever to know if the patient already has a pressure sore when admitted or if the patient has a greater potential for developing a sore. Melissa K. Fischer, RN, MSN, CNOR, clinical specialist, product manager, Megadyne Medical Products, Draper, UT, told Healthcare Purchasing News: "Since Medicare soon will not be paying for these types of things, if the patient has a pressure ulcer already started at the point of admission, it would behoove the hospital to find it or to put things in place to prevent a pressure ulcer from forming."

Penny Gilbert, MBA, RN, CPHQ, director, clinical outcomes, Clinical Outcomes Team, Hill-Rom, Batesville, IN, agreed: "Identification and documentation of the presence of pressure ulcers upon admission is imperative to assure full-market reimbursement from third-party payers such as CMS. Beginning October 1, 2008, hospitals will no longer receive Medicare reimbursement for eight preventable adverse events. The move is a cost-cutting measure, and its list of conditions includes pressure ulcers."

The possibility of not being reimbursed provides yet another reason to create more awareness of the potential for pressure ulcers. Sylvia believes that hospitals need to campaign for prevention. "To meet the expectations of the new value-based purchasing approach by CMS, hospitals, but more precisely the professional caregivers that are the organization, must take up the banner and champion for prevention of pressure ulcers."

Assessment on admission is only the beginning. Follow-up is crucial, noted Gilbert. "According to Barbara Braden, creator of the Braden risk assessment tool, acute-care patients should be reassessed at least every 48 hours. Many acute-care facilities do so more often, because patient status can change rapidly. Intensive care unit patients whose condition is stable should be reassessed daily; those whose condition is unstable should be reassessed every shift.

A number of factors can predispose a patient to developing a decubitus ulcer. Fischer outlined a few: "Pressure over time, particularly in the OR, where there’s unrelieved pressure, can contribute to developing an ulcer. Often bedsores are thought of in connection with older, bedridden patients, but frequently the operating room is where a sore starts. An anesthetized patient can’t tell you if a bony prominence, like their bottom, is going numb. Shearing occurs when a patient is repositioned intraoperatively, and the muscle layer slides over a bony prominence. Other things that contribute to the risk of developing a pressure ulcer are the patient’s health and age. The older the patient the higher the risk. Health status, such as diabetes or emaciation, can contribute to the risk."

Harty touched more on how the patient’s medical condition prior to admission is a contributing factor. "There are two types of factors: intrinsic and extrinsic. Intrinsic factors are those already present in the patient and are related to how well the circulatory system and the skin can cope with demands of the surgical environment. They include age, weight, length of time immobile, medications, and nutrition, among others. Extrinsic factors exist outside of the body and are generally identifiable and controllable. They include pressure, shearing forces, heat, moisture, and friction."

"Severity of illness and setting can directly affect the formation of pressure ulcers," agreed Gilbert, adding that any of the following elements can lead to formation of an ulcer: the patient’s inability to respond to pressure-related discomfort or painful stimulus; skin exposure to moisture from perspiration, urine, fecal incontinence, etc; inability to change or control body position; and/or poor nutritional status. "It is imperative that best-practice methodology, which includes risk assessment and proper mobility and surface selection, be implemented. Depending upon the underlying risk factor, appropriate interventions must be implemented and maintained to assure prevention."

A pressure ulcer could form despite staff’s best efforts, noted Sylvia. "It is evident that there is a subset of individuals who, for a variety of reasons, may develop pressure ulcers. Gaymar Industries has established an initiative called ‘Skin Changes at Life’s End’ and tasked a panel to investigate and come to consensus on recommendations for care of individuals who experience these skin changes, which may be unavoidable. Proceedings from the panel will be forthcoming, along with conference presentations."

(For more information, contact Cynthia Sylvia at csylvia@gaymar.com).

"Once a sore has developed," said Fischer, "depending on the severity, it’s an injury that can cause loss of function, increased length of stay, and increased need for treatment. It can create a secondary infection that can lead to loss of life, which is what happened to actor Christopher Reeve. He died of an infection from a pressure ulcer."

Gilbert explained in further detail: "When the integrity of the skin is disrupted, an open portal for infection exists; therefore, infection is one of the greatest risks associated with pressure ulcer formation. Sepsis is a systemic response to infection, which can lead to organ failure and death in severe cases. Other risks include deformity, related to degree or severity of the pressure ulcer; body fluid loss or dehydration; and increased length of hospitalization and costs. A true reduction in the quality of life can result with the formation of a pressure ulcer."

Megadyne’s Mega Soft is an easy-to-use return electrode combined with an effective OR-table pressure-reduction pad

There are an abundance of tools on the market that can help to prevent development of decubitus ulcers. Understanding and using good technique is a necessary partner to tools. Nursing knowledge is what’s needed to prevent pressure ulcers, according to Fischer. "If they know which patients are at high risk, there are some simple steps they can implement to take care of patients, including proper positioning of patients and making sure there’s adequate padding. There are tools available such as mattresses with overlays and padding for bony prominences. It’s a combination of nursing intervention and having the proper tools available to protect the patient."

Megadyne is in partnership with Action Products Inc. (Hagerstown, MD), which designs overlays to settle over the existing OR mattresses. "The Mega Soft pad combines Megadyne’s electrosurgical grounding pad with Action’s AKTON Polymer, a dry, viscoelastic polymer semi-solid gel, which helps to distribute weight, preventing bottoming out, and to distribute heat evenly, preventing hot spots," explained Fischer. "The urethane on the outside of the pad prevents shearing from occurring."

Gilbert cited an interesting study by Fogerty et al that focused on the importance of using pressure-reducing surfaces. "There are identified best-practices for preventing and treating pressure ulcers. As discussed earlier, interventions of frequent turning and repositioning, nutritional supplementation, and the use of pressure-relieving devices are considered important in the prevention of pressure ulcers. However, of these three broad categories, only the use of pressure-reducing surfaces have been found to significantly reduce the incidence of pressure ulcer development, by as much as 60%.3"

Sylvia referred to "recent work by the Support Surface Standards Initiative, now a working group of the International Standards Organization (ISO), which highlights the importance of support surfaces as an integral part of the care planning process. Based upon a thorough patient assessment, it is a matter of matching patient needs to support surfaces that incorporate features that address the identified needs."

Harty offered good advice on what to look for in equipment and tools that can help to prevent pressure ulcers. "OR table pads should be lightweight, conformable to the patient’s anatomy, flame retardant, and resistant to stains and cross-contamination. The table pad must conform to the patient’s anatomy to ensure the maximum amount of pad surface is supporting the patient’s weight. A pad should be fluid-resistant in critical areas. If fluid penetrates the cover material, the chance of cross-contamination increases dramatically. STERIS FIT pads have welded seams that prevent fluid from penetrating the cover material."

"A patient positioner should conform to the patient’s anatomy and support the weight of the patient without contributing to skin breakdown," continued Harty. "STERIS FIT table pads are designed to minimize interface pressures between the patient and the support surface. Pressure is, by definition, force divided by area. The patient’s weight exerts a force on the table pad which, in turn, applies an equal and opposite force. Since the weight of the patient is fixed, there remains only one option to reduce the pressure between the patient’s body and the supporting surface: the skin-to-pad contact area must be increased. After the patient’s body weight settles into the pad and the air valve is closed, the pad maintains the profile of the patient’s anatomy, redistributing pressure evenly and supportively over the entire body surface, not just bony prominences. The FIT pads effectively "immerse" the patient in the pad, mimicking the weightless buoyancy of floating, thus providing the ultimate protection against pressure sores."

Hill-Rom also offers a variety of products that work to mitigate existing pressure sores and prevent them from developing. "One of our newest products, introduced in the fall of 2007, is the Envision E700 wound surface," said Lauren Green-Caldwell, APR, director, Corporate Communications and Public Relations, Hill-Rom. The Envision E700 has multiple layers of 3-D fabric encased in a shear liner shift that minimizes shear and friction during patient movement. Its microclimate management system delivers low air loss through multiple layers of breathable fabric with crush-resistant channels that increase air circulation and flow. The PressureSmart sensing technology senses the patient’s position in real time, allowing optimal pressure redistribution as the patient sleeps, sits up, or moves within the bed. An easy-to-use color graphic indicates head-of-bed angle above or below 30 degrees, so the caregiver can raise or lower the head to optimize pressure redistribution.

"Key to any technology is that it be easy to use," said Green-Caldwell. "You can have the best technology on the market, but if caregivers are not sure how to use it, then the value will not be realized. This product comes with the industry’s first software-based bedside user instructions and video demonstrations to help caregivers quickly understand the technology. A user-friendly touch screen controls most of the Envision E700 wound-surface functions, making ongoing use more intuitive and easy to use."

Gaymar Industries also has a wide range of pressure-management products that redistribute pressure to prevent and treat pressure ulcers. "Our breadth of line includes clinically and cost-effective overlays and therapeutic support surfaces that offer a variety of feature sets including alternating pressure, low air loss, turning options, and active sensor technology to ensure continuous, optimal inflation," said June Brennan, senior product manager. The SofCare family uses a three-layer air-channeling technology to immerse and envelop the patient for maximum protection and comfort. It’s single-use to reduce cross-contamination. The Plexus family offers deep air-cell technology. The ISOFLEX family has a gelastic honeycomb technology, with 100% memory, that redistributes the patient’s weight. ISOFLEX is a nonpowered support surface that is both therapeutic and comfortable. It comes with a clinical guarantee for successful outcomes. The Symmetric Aire family is a nonpowered, closed system using foam/air cell technology to redistribute air within the mattress. The Pressure Pedic line consists of multiple foam configurations as the first line of defense against pressure ulcers. To extend the life of the product, select Pressure Pedic mattresses come with a replaceable center zone. The Contour and Contour Plus feature a memory-foam topper for additional protection and comfort.

References:

1. National Pressure Ulcer Advisory Panel. 1989 NPUAP Pressure Ulcer Stages. Updated staging system. http://www.npuap.org/positn6.htm. Last update 11/03.

2. Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden Scale for predicting pressure sore risk. Nurs Res 1987;36:205-210. http://www.bradenscale.com/braden.PDF.