Support Surfaces for Pressure Ulcer Prevention

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Support Surfaces for Pressure Ulcer Prevention
John Bloomer, Livia Phillips, Justin Sword and
Lance Wheeler University of Oklahoma College of
Nursing EBP Symposium Spring 2009
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Pressure Ulcer Stages Normal and 1
(National Pressure Ulcer Advisory Panel, 2007)
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Pressure Ulcer Stages 2 and 3
(National Pressure Ulcer Advisory Panel, 2007)
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Pressure Ulcer Stages 4 and Unstageable
(National Pressure Ulcer Advisory Panel, 2007)
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Problem Identification

• Incidence Rates
• 0.4 to 38 Acute Care
• 2.2 to 23.9 Long Term Care
• 0 to 17 Home Care

(Duncan, 2007)
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Problem Identification

• Patient Implications
• 2.5 Million treated
• 60,000 Deaths

(Ayella, 2007)
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Problem Identification

• Fiscal Implications
• 11 Billion
• Up to 70,000
• Medicare - October 1, 2008

(Duncan, 2007) (American Journal of Nursing,
2009)
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PICO

• For patients at risk for developing pressure
  ulcers, does a
• static pressure relieving device compared to
  dynamic pressure relieving surfaces
• provide improved protection against pressure
  ulcer development?

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• Static Surfaces
• Ex foam over-lay, gel-filled overlay, static
  air overlay mattress
• Dynamic Surfaces
• Ex alternating air-filled overlay mattresses,
• air-fluidized beds, low air loss beds
• Standard Surfaces
• Ex study specific

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Literature Review

• Support Surfaces for Pressure Ulcer Prevention
  (Review)
• McInnes, E., Bell-Syer, SEM, Dumville, JC,
  Legood, R., Cullum, NA. (2008)

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Support Surfaces for Pressure Ulcer Prevention

• Sample Median size 100
• Settings Intensive care, orthopedic,
  emergency, and medical/surgical settings
• Independent Variable Alternating pressure
• Dependent Variable Constant low
  pressure/ standard foam mattress

(McInnes, et al., 2008)
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Support Surfaces for Pressure Ulcer Prevention

• Findings
• 3 RCTs
• 2 Statistically Insignificant
• 1- Significant but unreliable
• Overall Study Implications
• AP mattresses were associated with a high
  probability of reducing costs, resulting from a
  delay in the formation of pressure ulcers, and a
  reduction in the patients length of stay.

(McInnes, et al., 2008)
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Support Surfaces for Pressure Ulcer Prevention

• Threats to Validity
• Small sample sizes
• High attrition rates
• Type of AP device not defined
• AP settings not defined
• Not blinded
• Not independently verified

(McInnes, et al., 2008)
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Literature Review

• Preventing Pressure Ulcers A Systematic Review
• Reddy, M., Gill, S., Rochon, P. (2006)

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Preventing Pressure Ulcers A Systematic Review

• Sample
• Meta-analysis, 59 randomized, controlled trials.
• 14 studies were relevant to PICO
• Settings
• 67.9 were in acute care
• 17.1 were in long term care
• 2.4 in rehabilitation
• 12.6 in mixed settings

(Reddy, et al., 2006)
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Preventing Pressure Ulcers A Systematic Review

• Independent Variable
• Dynamic support surfaces
• Dependent Variable
• Static support surfaces

(Reddy, et al., 2006)
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Preventing Pressure Ulcers A Systematic Review

• Findings 
• Only 3 trials found that dynamic support
  surfaces were better than static support
  surfaces and 1 of these trials did not report
  statistical evidence.

(Reddy, et al., 2006)
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Preventing Pressure Ulcers A Systematic Review

• Implications
• Overall Preventive interventions should be
  instituted because reducing or eliminating risk
  factors can prevent pressure ulcer formation.
• Specific to RCTs Due to the small number of
  reliable studies there is a need for
• well- designed RCTs that follow standard
  criteria for reporting quantifiable data to
  support conclusions.

(Reddy, et al., 2006)
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Preventing Pressure Ulcers A Systematic Review

• Threats to Validity
• Small sample size
• Inadequate blinding
• Lack of statistical evidence to support a change
• of practice

(Reddy, et al., 2006)
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Literature Review

• Randomized Clinical Trial
• Comparing 2 Support Surfaces
• Results of the Prevention of
• Pressure Ulcers Study
• Russell, L., Reynolds, T., Park, C., Rithalia,
  S., Gonsalkorale, M., Birch, J., et al. (2003)

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Randomized Clinical Trial

• Sample
• 1168 Pts aged 65 or older with a score of
• 15-20 on the Waterlow assessment
• Settings
• Acute elderly, rehabilitation, and
• orthopedic wards

(Russell, et al., 2003)
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Randomized Clinical Trial

• Independent Variable
• 562 Pts on a visco-elastic foam mattress
• Dependent Variable
• 604 Pts on Standard hospital mattresses
• 2 Patients removed

(Russell, et al., 2003)
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Randomized Clinical Trial

• Findings
• Statistical significance was found for
  prevention of blanching erythema.
• Significance was not achieved for nonblanching
  erythema.

(Russell, et al., 2003)
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Randomized Clinical Trial

• Implications
• While the experimental equipment did show a
  statistical difference in reducing blanching
  erythema we must remember that statistical
  significance ?
• clinical significance

(Russell, et al., 2006)
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Randomized Clinical Trial

• Threats to Validity
• Identifying blanching and nonblanching erythema
  is difficult.
• The technique for identifying blanching erythema
  is not standardized.
• Eliminating the risk of bias is impossible
  because it was impossible to blind the research
  nurses to mattress assignment

(Russell, et al., 2003)
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Literature Review

• Pressure Ulcer Prevention in Intensive Care-a
  Randomised Control Trial of Two
• Pressure-Relieving Devices
• Theaker, C., Kuper, M., Soni, N. (2005)

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Pressure Ulcer Prevention in

• Sample
• 62 high risk patients, over 18 admitted
  without current pressure sores
• Setting
• Intensive Care

(Theaker, et al., 2005)
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Pressure Ulcer Prevention in

• Independent Variable
• 30 Pts on KCI TheraPulse bed
• Dependent Variable
• 32 Pts on Hill-Rom Duo mattress

(Theaker, et al., 2005)
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Pressure Ulcer Prevention in

• Findings
• 3 pts on KCI TheraPulse developed a PU
• 6 pts on Hill-Rom Duo developed a PU
• No significant difference was found between the
  surface types.

(Theaker, et al., 2005)
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Pressure Ulcer Prevention in

• Implications
• These results do not have a significant
  implication for practice.
• A study using a greater number of
  participants may possibly yield a significant
  difference.
• Additional research is be needed to say for
  certain if one of the two pressure relieving
  devices is better at preventing pressure ulcers.
•  

(Theaker, et al., 2005)
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Pressure Ulcer Prevention in

• Threats to Validity
• Small Sample Size
• Nursing care may have been influenced by
  awareness of research

(Theaker, et al., 2005)
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Recommendations for Further Study

• More Independent Studies using RCTs
• Larger Sample Sizes
• Blind Trials
• Standardized Inclusion Criteria
• Domestic Studies

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Unaddressed Questions

• Why hasnt more research been conducted on
  pressure relieving surfaces?
• Why hasnt research been conducted in the US?

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Recommended Interventions

• Increase frequency of assessment for PU presence
  and risk
• Universal technique for pressure ulcer risk
  evaluation
• Turning schedule pressure relieving surface

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References

• American Journal of Nursing (2009). On October 1,
  2008, Medicare Stopped Paying Hospitals.
• American Journal of Nursing. 109(1), 22.
• Ayella, E. (2007). Protecting patients from harm
  preventing pressure ulcers. Nursing , 36-40.
• Duncan, K. (2007). 5 Million Lives Campaign.
  Preventing pressure ulcers the goal is zero.
  Joint Commission Journal of Quality and Patient
  Safety, 33(10), 605-610. Retrieved March 8,
  2009 from CINHAL Plus with Full Text database.
•   
• McInnes, E., Bell-Syer, SEM, Dumville, JC,
  Legood, R., Cullum, NA. (2008). Support
  surfaces for
• pressure ulcer prevention (Review). Cochrane
  Database of Systematic Reviews, 4(3).
• National Pressure Ulcer Advisory Panel. (2007).
  Updated Staging System. Retrieved April 15,
  2009, from National Pressure Ulcer Advisory
  Panel http//www.npuap.org/resources.htm
• Reddy, M., Gill, S., Rochon, P. (2006).
  Preventing pressure ulcers A systematic review.
  The Journal of the American Medical Association,
  296, 974-948.
• Russell, L., Reynolds, T., Park, C., Rithalia,
  S., Gonsalkorale, M., Birch, J., et al. (2003).
  Randomized Clinical Trial Comparing 2 Support
  Surfaces Results of the Prevention of Pressure
  Ulcers Study. Advances in Skin Wound Care ,
  317-327.
• Theaker, C., Kuper, M., Soni, N. (2005).
  Pressure ulcer prevention in intensive care-a
  randomised control trial of two
  pressure-relieving devices. Anaesthesia ,
  395-399.