TO THE EDITOR:

I read with great interest "Pressure Ulcers and Lateral Rotation Beds: A Case Study" by Teresa Russell, RN, CWOCN, MPH, and Angela Logsdon, RN, BSN, CWOCN, CCRN, in the May 2003 issue of the Journal of WOCN. I am concerned that several flaws in the study can lead the reader to false conclusions.

This study compares ulcer rates (prevalence and incidence are both used) in two situations (the overall hospital and, specifically, the ICU), on two different support surfaces (an unspecified mattress style in med/surg and lateral rotation in ICU), at two different 6-month intervals, before and after an intensive nursing education program that included instruction in the importance of q2hr skin checks, q2hr turning, offloading the heels, and systematic use of the Braden Scale.

An initial reading will lead the reader to conclude that lateral rotation mattresses are dangerous for patients and should not be used for preventing skin breakdown. In fact, the first Key Point says, "Forty-degree lateral rotation is not sufficient to off-load capillary closing pressure and places patients at risk for the development of pressure ulcers," although the text of the article makes no mention of studying the effects of lateral rotation on capillary closing pressure.

However, the only thing that this article proves is that education helps to reduce the incidence of skin breakdown. After implementing an intensive education program, the WOC nurses note that reported pressure ulcers (incidence?) decreased from 21 in 6 months to 10. In ICU alone, their reported pressure ulcers (incidence?) decreased from 11 in 6 months to 5. Therefore, education alone made a difference of a 52% decrease in their overall ulcer rate, and a 50% decrease in their ICU ulcer rate.

One-half of all of their ulcers occurred in ICU and, therefore, on lateral rotation mattresses. At first, this sounds like lateral rotation mattresses are dangerous. However, ICUs consistently have the highest incidence of skin breakdown due to the unique pressure ulcer risk factors among the ICU population, including hemodynamic instability, higher APACHE scores, respiratory involvement, and a host of other factors that often occur in multiples in a single patient.1 They are the sickest of the sick. Couldn't the "high proportion" of ulcers in ICU simply be a result of the kinds of patient, not the kinds of mattress?

In addition, "one-half" sound like a lot more than 5 ulcers out of 10 over six-months.

The way the numbers are reported is misleading. There is no indication of how many patients were included in this study. The facility is noted as a 500-bed military hospital, but the size of the ICU is not indicated. In a facility that size, a 20-bed ICU would be a conservative estimate. With incidence rates of pressure ulcers in ICUs reported to be between 22% and 40%,1 5 ulcers in 6 months is a number to be proud of. Perhaps these mattresses are working better than should be expected.

Their conclusion that "WOC nurses[horizontal ellipsis]should work with manufacturers to develop best practice guidelines that are product-specific in the prevention of nosocomial pressure ulcers" is more than appropriate, especially for the manufacturer of these particular mattresses. The manufacturer's instructions that patients are not to be turned and that the bed "does the turning" are completely out of line. None of my colleagues that I have surveyed who work for any mattress manufacturer would support that recommendation. We consistently tell our sales people and customers that nothing takes the place of manually repositioning the patient. Not only does the skin need to breathe off of the mattress surface, but joints and organs require regular position changes for stimulation and function.

There is no mention of how the lateral rotation mattress was programmed. This can make a dramatic difference in outcomes. Turning 40 degrees sounds good, but if the mattress is also told to keep the patient turned left for 2 hours, then at center for 2 hours, then to the right for 2 hours, these changes are not as aggressive as manual repositioning, or turning every hour, or skipping the center mode and only using left and right. For very sick patients, such as are found in ICUs, I often recommend initially programming a lateral rotation mattress to turn as far as possible, as often as possible, e.g. left and right every 30-minutes if the patient can tolerate that. This is not based on randomized controlled trials but on experience, reason, and outcomes.

The use of lateral rotation for skin management has been successful anecdotally, and it is hoped that more nurses will take the time that Ms. Russell and Ms. Logsdon did to examine and report the results of their clinical usage of this modality. Although lateral rotation is not perfect for every patient (what is?), and some may incur skin breakdown on this modality, many have benefited over the years. I would hate to see nurses discount lateral rotation based on this article alone.

I commend the authors for undertaking a rigorous examination of their skin issues, and implementing an aggressive education program to combat the problem. I hope they will be able to fill in some of the missing data explained above. I believe this will give a more accurate picture of the effects of lateral rotation in ICUs.

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