The national incidence of facility-acquired pressure ulcers (FAPU) of the heel has steadily increased from 19% to 30% over the past decade.1 Heel ulcers account for 30.3% of total pressure ulcers and are the second most common site for skin breakdown.2 Complex heel pressure ulcers represent one of the most costly complications in the elderly.3 The quarterly prevalence monitoring at one Midwestern community hospital demonstrated an increasing rate in heel FAPU similar to national trends. However, the heel site accounted for 43% of the incidence of FAPU, higher than comparable national data. Many of the patients who developed heel FAPU were traditionally considered low risk for skin breakdown.
Pressure ulcers affect both the physical health and the psychosocial functioning of the individual. Physical health is affected by increased pain, prolonged treatments, and other morbid sequelae.4 Psychosocial functioning may be negatively impacted by the development of pressure ulcers resulting in depression and social isolation.5 In addition to the personal costs associated with FAPU, there are increased lengths of stay, inconvenience, and higher medical costs.4 Costs to treat pressure ulcers range from $2,000 to $30,000 and can be as high as $70,000 for a complex full-thickness pressure ulcer.6 The annual cost of treating FAPU is estimated at $2.2 to $3.6 billion.3
Purpose
The purposes of this study were to: (1) determine if assessment of comorbidities in addition to Braden Scale for predicting pressure sore risk (Braden Scale) would improve identification of patients at risk, (2) determine if early and aggressive implementation of pressure-reducing and pressure-relieving devices in concert with more frequent assessment and documentation of heel skin integrity would decrease the incidence at this hospital, and (3) compare products for patient and staff satisfaction and effectiveness in preventing heel FAPU.
Pressure ulcers are seen as quality indicators.7-9 Because preventing FAPU lies within the scope of nursing care, accurate identification of patients at risk is the first step in preventing the occurrence. With accurate identification, interventions that are tailored to the patient's needs have demonstrated improved patient outcomes.
Review of the Literature
The nursing professional practice model at the authors' hospital blends Jean Watson's caring theory,10 Madeleine Leininger's theory of cultural care diversity,11 Patricia Benner's novice to expert theory,12 and the relationship-based model of care.13 The patient/family and community are at the inner core of the model. Nurses are accountable for providing competent, compassionate, and culturally sensitive care. Establishing relationships and collaborating with the healthcare team, the patient/family, and the community to lead patients to their maximum level of health potential is another key component of the model. In addition, the authors' nursing model integrates the 14 forces of magnetism for professional nursing practice as outlined by the American Nurses Association.14
Risk factors for development of FAPU have been identified in the literature. The Braden scale is a research-based tool that has quantified skin characteristic risk factors but excludes comorbidities.15 It assesses 6 factors to predict pressure ulcer risk: (1) sensory perception, (2) moisture, (3) activity, (4) mobility, (5) nutrition, and (6) friction and shear. In addition to skin characteristics, there are additional risk factors associated with the development of heel pressure ulcers. Patients who are immobile are at greatest risk for developing heel pressure ulcers, with an associated incidence of nearly 87%.16,17 Immobility may be due to lower extremity injury,18,19 paraplegia,20 or weakness due to cerebrovascular accident (CVA).21 Patients with type 2 diabetes mellitus (T2DM) with peripheral neuropathy are also at great risk for developing heel pressure ulcers.22-24 Diseases such as peripheral vascular disease (PVD), which results in impaired peripheral circulation and ischemia, also place patients at risk.25,26 In critical care patients, vasopressor therapy that leads to decreased lower extremity perfusion is also a risk factor.27 In addition, malnutrition and low albumin may be risk factors in geriatric patients.28,29
The Braden Scale has been revised to reclassify patients who were originally considered low risk for FAPU.30 This risk category of scores ranging from 15-18 is now classified as "at risk." The updated national guideline for preventing pressure ulcers addresses protocols linked to Braden Scale risk categories. For the newly termed Braden Scale "at risk" category, the revised recommendations specifically include protection of the patients' heels.
The heel is one of the most difficult anatomical areas to be addressed by preventive products. Studies have demonstrated that support surfaces, including special beds, mattresses, and overlays, do not provide complete pressure relief in the heel region.31 Current research has not yet clearly defined which interventions are most efficient and cost effective in preventing the development of heel pressure ulcers. Therefore, nurses are instrumental in the reduction of FAPU by performing frequent assessments, early identification of risk factors, and planning care tailored to the individual patient needs.
Methods
The setting for this study was a 333-bed community hospital located in the Midwestern United States. A prospective intervention study with control group design was begun after chart audits helped determine an improved method for identifying patients at risk for heel FAPU. The 4-phase study began after Institutional Review Board (IRB) approval was obtained (Table 1).
The instrument used to evaluate the risks throughout the study was a confidential history and assessment questionnaire designed specifically for this study. It included age, gender, Braden scale score, and dichotomous questions concerning comorbidity risks of T2DM, current vasopressor therapy, PVD, CVA, paraplegia, paraparesis, low albumin, and lower extremity orthopedic surgery.
There were 4 phases to the study to address the research questions. Phase 1 comprised a retrospective chart audit. The authors reviewed medical records over a 2-year period to determine risk factors of patients who were admitted with heel pressure ulcers or developed them during their hospital course. A total of 39.7% of these wounds were acquired outside the facility (n = 29), while the remaining occurred during the patient's hospital stay (n = 41).
Phase 2 began after the chart audit was completed. The first 10-day study period involved 2 hospital units, 1 critical care unit, and 1 medical/surgical unit. A second 10-day study was repeated on the critical care unit. A single nursing unit was selected due to the financial costs associated with the purchase of the trial product for evaluation. Hospital-wide interventions, including policy changes and educational programs, were implemented prior to initiating phase 2 (Table 2). During phase 2, in addition to usual and customary care, the nurses on the intervention units performed more frequent and improved risk assessment with use of comorbidities and Braden scale scores. The procedure was used in concert with tailored interventions (Table 3). Additional practice changes on the intervention units included assessment and documentation of heel skin integrity every 8 hours, application of lotion daily, and notification of the wound care nurse if any pressure ulcer developed.
The third phase of the study was conducted at the completion of the 10-day study periods. During this phase, the authors assessed the effectiveness of interventions as compared to patients on control nursing units.
The fourth phase of this research study compared products that could address deficiencies noted by the nursing staff. At the conclusion of the first 10-day intervention period, the nurses on one critical care unit completed an anonymous product evaluation questionnaire of the Foot Waffle Heel Elevator (EHOB Inc, Indianapolis, IN), the standard product used for high-risk patients. During the second 10-day intervention period, the study protocol questionnaire and interventions were repeated; however, a new heel pressure-relieving product, the Prevalon Pressure-Relieving Heel Protector (Sage Products, Cary, IL) was used. To compare and evaluate the established and new products, the nurses again completed an anonymous product evaluation questionnaire after a 10-day use period. Product characteristics were measured on a 1-4 scale and included the following criteria: "effectiveness in floating the heel for total pressure relief;" "not too warm;" "no hard, sharp or rough edges;" "ease of application; comfort of interior;" "compatibility with deep vein thrombosis compression devices;" "stays in place;" "does not twist on the patient's foot;" and "protects the heels from pressure, friction, and shear."
Results
For phase 1, baseline chart audit compared patients who acquired heel FAPU to those of patients admitted with skin breakdown. Of the patients who were hospitalized for lower extremity orthopedic surgery and developed a FAPU, 91% had Braden scale scores between 15-18, which was previously considered "low risk" (Figure 1). Patients with T2DM (65%) or with a history of CVA (63%) who developed FAPU were also more often in the previously categorized Braden scale "low risk" category. Of the 70 patients with heel ulcers, 50 had documented low albumin, 3 had normal albumin levels, and the remaining 17 had unknown levels. Statistical analysis of differences between patients with FAPU and those who developed heel pressure ulcers prior to their admission revealed 5 variables of significance. The level of skin breakdown by stage was less severe for patients with FAPU (t = 2.39(68), P = .02), and these patients also had higher Braden scale sores (t = 2.21(68), P = .03), were less likely to be diabetic ([chi]2 = 4.08, P = .04), or to have PVD ([chi]2 = 9.71, P < .01), and were less likely to have received a referral to the wound care nurse ([chi]2 = 10.13, P < .01) than were those admitted to hospital with heel pressure ulcers.
Phase 2 of the study was conducted over two 10-day study periods. The study protocol was followed on a total of 46 high-risk patients from the 2 intervention units. The mean age of the high-risk patients was 74.95 (range 49-94), and 59% were female. The average Braden scale score was 14.96 (range 10-18; mode 18).
From the high-risk group (met inclusion criteria), 4 heel ulcers developed during the two 10-day intervention periods. All subjects who developed heel FAPU were postoperative patients and had been transferred from other units and were not attributable to the intervention. Three had low albumin levels. Half of the FAPU were identified on each intervention unit, 50% of whom were women. There was no significant difference in skin breakdown by age (range: 65-85 years) or by Braden scale score. Seventy-five percent of patients with skin breakdowns had T2DM. One patient each with PVD or CVA experienced a heel FAPU. No one on vasopressor therapy, no patient with paraplegia or paraparesis, and no patient who underwent orthopedic surgery developed FAPU.
Phase 3 of the study compared FAPU occurrences on intervention units with similar units serving as controls. During the 2 prevalence days, 67 patients from the intervention floors were compared to 51 on the control group floors. There were no differences between units on high-risk characteristics of Braden scale scores of <=18, T2DM, vasopressor therapy, PVD, CVA, or paraplegia/paraparesis. Low albumin was more frequently identified in the control group ([chi]2 = 20.44, P < .01).
There was a statistically significant difference between the incidence of heel FAPU noted on the Prevalence days, with 3 occurring on the control unit and 1 occurring on the intervention unit ([chi]2 = 86.37, P < .01). The one patient from the unit involved in the intervention who developed the FAPU had not been following the protocol. Among the 4 patients with hip fractures on the intervention unit using the pressure-relieving product, no FAPU developed, in contrast to a similar patient with an FAPU on the control group. This patient would have met inclusion criteria on the intervention unit.
The focus of phase 4 of the study was a comparison of the current product used for heel pressure relief and a new pressure-relieving product. Evaluation of the product for patient and nursing satisfaction was a key component to product decision making. The critical care nurses on all 3 shifts completed the product evaluation survey voluntarily. Twenty-four product evaluations were evaluated-16 for the standard product and 8 for the trial pressure- relieving device. Both products received high scores on recommend the product for use: 3.18 (current product) mean score vs 3.49 (trial product) mean score (on a 1-4 scale). Overall, the products were both highly ranked. Only 2 mean scores were ranked less than 3.0 (on a 1-4 scale). Both of these were evaluations of the current product related to the characteristics: "stays in place" and "not too warm."
Overall, the evaluators ranked the trial product, the Prevalon Pressure-Relieving Heel Protector, at a higher level that was statistically significant (t = 2.19(2,22), P = .04). The trial product was higher ranked on all measures except for ease of removal, but not at a statistically significant level. There were statistically significant higher scores for the trial product on: "comfortable interior"; "not too warm"; "no hard, sharp, or rough edges"; "protects heels from pressure, friction, and sheer"; "DVT prevention compression devices compatibility"; and "floats the heel for total pressure relief."
Discussion
Key findings of this study include the systematic use of comorbidities, along with the Braden scale in the study questionnaire to accurately determine the risk status of patients for developing heel FAPU. Individualized risk factor assessment for patients in the Braden scale range of 15-18 as part of the daily nursing assessment was effective in reducing the risk of developing heel FAPU. Assessment of comorbidities in patients with Braden scale scores of 17-18 effectively stratified patients at greater risk to develop heel FAPU. Patients with Braden scale scores of 15-16 and below were assessed to be at risk for development of heel FAPU, regardless of comorbidities. The use of tailored prevention interventions, as part of the individualized care planning process, was effective in reducing the risk of developing heel FAPU.
There were a few recognized limitations to the study. The success of the study was dependent on product use. For 2 days during the study, the supply of trial product was delayed. Additionally, the skin resource nurses on the units were not present every day of the study, so some questions may have been postponed until their return. These factors may have contributed to the patient not following protocol for the study and at the end of phase 3 having developed a heel FAPU. Data collection created a heightened awareness of FAPU assessment throughout the hospital, and this may have reduced the incidence on the control units. Finally, the low numbers of FAPU identified in phases 2 and 3 of the study limited the ability of some aspects of the research to reach statistical significance.
The nursing professional practice model framed the key concepts of this research namely, patient-centered and competent care, which maximized the patient's health status. The nurses used autonomy and accountability to develop and maintain relationships and collaboration to develop, implement, and evaluate the research study. The strategies demonstrated evidence-based translation of research into practice with a cost-effective quality outcome. From onset to the presentation of the results, the staff was involved in all phases of the research. To develop a research-oriented culture in the hospital, involvement in the process is crucial.
Next Steps
The next steps will be to revise the hospital's protocol to standardize these interventions across departments. The early and aggressive implementation of the pressure-relieving and pressure-reducing devices and more frequent assessment of heel skin integrity based on the study criteria were effective on 2 units and now will be translated into use across the hospital. Specific protocols will be developed for the hip fracture and lower extremity orthopedic patient populations. Also, a protocol for prevention of heel FAPU in critical care patients receiving vasopressor therapy is under development.
The relationship of malnutrition and low albumin levels as a major indicator of risk for the development of heel FAPU warrants further study. Although it was identified in the baseline chart audit, it was not a factor in the patients in the intervention groups. Additionally, interest has been generated and further study is recommended for risk stratification that includes the patient's age.
Conclusion
This study demonstrated that consistent use of a standardized pressure ulcer prevention protocol that incorporates early aggressive implementation of pressure-reducing and pressure-relieving devices based on accurate assessment of Braden scale scores and specific comorbidities is effective in reducing the risk of developing heel FAPU. Frequent assessment and documentation of heel skin integrity as a standard of care impacts this important nursing sensitive outcome.
KEY POINTS
[check mark] Heel pressure ulcers result in significant physical, psychosocial, and financial costs.
[check mark] Use of the Braden scale for predicting pressure sore risk in conjunction with assessment of individual comorbidities is effective in reducing the risk of developing heel facility-acquired pressure ulcers.
[check mark] Early and aggressive implementation of pressure-relief and pressure-reduction products as part of the individual care planning process is effective in prevention of heel facility-acquired pressure ulcers.
References