Performing under pressure: Preventing pressure ulcers

Skin damage due to pressure is not a pretty sight. The smell can be worse. A pressure sore may start simply with a change in skin color or temperature (stage 1), then progress to an abrasion, blister, or skin crater (stage 2). By the time it reaches stage 3, there is a deep crater with loss of skin and damaged or dead subcutaneous tissue, possibly extending down to the underlying fascia. In stage 4, the damage extends to muscle, bone, or supporting structures such as tendons, possibly accompanied by sinus tracts.1  It’s amazing—and alarming—to think that what started out as just a little red spot on the derriere can result in the need to plan a funeral.

It has 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.  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, as is health status, such as diabetes or emaciation.

Prevention is always the best course and is the only option.  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."

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.  Cynthia Silva with Gaymar states, "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 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.  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.   Patients should be reassessed at least every 48 hour, or more frequently, as the patient’s status can change rapidly.

The changes in CMS reimbursement seem to be on everyone’s mind. It is important to know if the patient already has a pressure sore when admitted, and documentation of a pressure ulcer is imperative.

Harty touched more on how the patient’s medical condition prior to admission is a contributing factor. "There are two types of factors: intrinsic factors, 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, and extrinsic factors which are generally identifiable and controllable. They include pressure, shearing forces, heat, moisture, and friction."

Megadyne is in partnership with Action Products Inc., 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."

Harty offered 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.  STERIS FIT pads have welded seams that prevent fluid from penetrating the cover material." 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 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 . "One product introduced in the fall of 2007, is the Envision E700 wound surface," said Lauren Green-Caldwell, APR.  The Envision E700 has multiple layers of 3-D fabric encased in a shear liner shift that minimizes shear and friction during patient movement. It 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.  This product comes with the industry’s first software-based bedside user instructions and video demonstrations.  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 line includes 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.  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.  It comes with a clinical guarantee for successful outcomes. The Symmetric Aire family is also 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.                  by Susan Cantrell, ELS, HealthCare Purchasing News

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. 3. Fogerty, MD, Abumrad, NN , Nanney L , Arbogast, PG, Poulose B, Barbul A. Risk factors for pressure ulcers in acute care hospitals. Wound Repair Regen 2008;16:11-18.                                                                   Edited     Loyce J. McCullough