Pressure ulcers affect both physical health and psychosocial functioning. Heel pressure ulcers account for 30 percent of facility-acquired pressure ulcers (FAPUs) nationwide.1 Furthermore, complex heel pressure ulcers represent one of the most costly complications in the elderly.
The heel is one of the most difficult anatomical areas to be addressed with preventive products. Studies have demonstrated that support surfaces, including special beds, mattresses and overlays, do not provide complete pressure relief in the heel region.2 Current literature has not yet clearly defined which interventions are most efficient and cost-effective in preventing the development of heel pressure ulcers.
The Braden Scale was recently revised to identify patients in the risk category of 18-15 as "at risk" instead of the previous classification of "low risk." The National Guideline Clearinghouse's guideline for "Preventing Pressure Ulcers and Skin Tears" addresses prevention protocols linked to Braden Scale risk categories. For the Braden "at risk" category score of 18-15, the recommendation is to "protect the patient's heels."3
The prevalence rate of FAPUs at one Midwestern community hospital had steadily increased, with heels as the most common site identified. Many of the patients who developed FAPUs had Braden scores in the 18-15 range.
A practice change was needed to address the prevention of FAPUs. The goal of this practice change was to use the tenets of the nursing professional practice model as a guide. Prevention strategies would need to produce quality outcomes, result in patient and staff satisfaction, and remain cost-effective.
Pressure ulcers are seen as quality indicators within the scope of professional nursing practice. Accurate patient assessment and the determination of which patients are most at risk for developing FAPUs is the first step toward prevention. Several risk factors for the development of FAPUs have been identified in the literature. The Braden Scale is a research-based tool that has quantified many of these risk factors.
staff satisfaction.
The nursing professional practice model was used to guide the nurse researchers as they revised heel pressure ulcer prevention strategies, including a combination of accurate assessment of risk, more frequent heel assessment, education, increasing staff awareness and appropriate balance among different prevention products.
Patient-Centered Outcomes
In addition to their place as a key tenet of the nursing professional practice model, patient-centered quality outcomes are supported by professional bodies across healthcare. For example, pressure ulcers are seen as quality indicators by the American Nurses Association's Nurse-Sensitive Indicators project. In addition, accreditation and regulatory agencies such as JCAHO and the Centers for Medicare and Medicaid Services have identified pressure ulcers as quality indicators. Preventing FAPUs lies within the scope of nursing care and begins with the accurate identification of patients at risk.
Nurses are accountable and responsible for their clinical practice and the outcomes of their nursing care. Early, aggressive implementation of pressure-relieving and pressure-reducing devices impacts this nurse-sensitive outcome measure. Frequent assessment and documentation of heel skin integrity is a quality standard of care.
Evidence-Based Practice
As part of the nursing professional practice model, nurses view themselves as continuous learners, consistently striving to increase their scientific knowledge of health and illness.
Staff education was one of the first strategies employed for this practice change. Competency assessment for use of heel pressure-reduction and pressure-relief products was required for nursing staff. In addition, pressure ulcer dressings and product inservices were provided by a wound care specialist.
Although the Braden Scale was already in use at the hospital, two new process changes were implemented. First, based on a review of the literature, the hospital's skin risk assessment and intervention protocol was updated to classify the Braden Scale score of 18-15 as "at risk" rather than "low risk." Second, standardized timing of the daily Braden Scale risk assessments to the first hours of the day shift for all units, based on validation study results, was implemented by the wound care specialist.
Pressure-relief protocols should demonstrate efficient and cost-effective use of resources. In the past, the strategy to prevent heel FAPUs was to elevate the heels off the bed using pillows. Although inexpensive, this strategy was not effective because the pillows needed to be frequently repositioned to keep the heels off the bed, particularly for patients who move about in bed.
Now, some new hospital beds have a heel-pressure relief mechanism that can be activated by the nurse. In addition, pressure-reduction and pressure-relief devices are available for prevention of heel ulcers.
Nurses are empowered to make decisions about care delivery and recommend changes. There were patient and staff satisfaction concerns related to the current heel pressure-relieving product.
The nurse researcher and the wound care specialist felt a change in product from a heel elevator to a heel elevator boot for heel pressure relief might improve the outcomes and be well accepted by patients and the staff. Patients complained the heel elevator was too warm, had rough edges and did not stay in position. Nurses were frustrated the device frequently needed to be re-inflated, and because of this, were not using the heel elevator as per protocol. The heel protector was promoted to have a comfortable interior; no hard, sharp or rough edges; and stays in place on the patient's foot.
Research Study
Over the past 2 years, prevalence study results revealed many of the patients who developed heel FAPUs had Braden Scale scores in the "low risk" range of 18-15. To establish an evidence-based protocol for prevention of FAPUs in this risk category, a research study approved by the institutional review board was conducted.
The study included individualized risk factor assessment for patients in the Braden Scale "low risk" category. In addition, nurses assessed comorbidity risk factors including type 2 diabetes, PVD, stroke, paraplegia/paraparesis, low albumin and current vasopressor therapy, as well as orthopedic surgeries for hip fractures and knee replacements.
This expanded evaluation was used to assess patients on two hospital units on a daily basis.
Nurses implemented tailored interventions as part of the individualized care plan. These included use of pressure-reduction and pressure-relief products, heel assessment every shift, application of lotion to the heels at least daily and documentation of heel skin integrity.
Results of the study showed that no heel pressure ulcers developed on the patients who were wearing the pressure-reducing and pressure-relieving products on the intervention units. These findings demonstrate that using evidence-based interventions as part of practice was effective in reducing the prevalence of FAPUs of the heel.
Several factors impacted this significant outcome. Patients were consistently assessed by the nurses for risk of developing heel pressure ulcers during every shift. In addition to traditional Braden Scale scoring, nurses assessed risk factors specific to heel pressure ulcer development. Based on Braden scores and comorbidity assessment, nurses developed individualized care plans with tailored prevention interventions.
Additional factors were important to the success of this study. The pressure-relieving and pressure-reducing products were used consistently. The products were easy to obtain. During the study, the unit-based skin resource nurse helped answer staff questions about the assessments and interventions.
There also was a heightened awareness by the staff of pressure ulcer risk assessment and interventions. Additionally, the staff was involved in selecting the most effective intervention products, thereby taking ownership of this important nurse sensitive quality outcome.
Consistency Key
The consistent use of a standardized protocol that incorporates early, aggressive implementation of pressure-reducing and pressure-relieving devices in conjunction with assessment of comorbidities is effective in reducing the risk of developing heel FAPUs. Frequent assessment and documentation of heel skin integrity as a standard of care impacts this important nursing-sensitive outcome.
The nursing professional practice model was a valuable guide in determining cost-effective prevention strategies that produced quality outcomes, and resulted in patient and staff satisfaction.
References
1. Amlung, S.R., Miller, W.I., & Bosley L.M. (2001). The 1999 national pressure ulcer prevalence survey: A benchmarking approach. Advances in Skin & Wound Care, 14(6), 297-301.
2. Wong, V.K., & Stotts, N.A. (2003). Physiology and prevention of heel ulcers: The state of the science. Journal of Wound, Ostomy and Continence Nursing, 30(4), 191-198.
3. National Guideline Clearinghouse. (2003). Preventing pressure ulcers and skin tears. Retrieved March 10, 2006 from the World Wide Web: http://www.guideline.gov/summary/summary.aspx?doc_id=3511&nbr=002737&string=pressure+AND+sore
4. Black, J. (2004). Preventing heel pressure ulcers. Nursing 2004, 34(11), 17.
Resource
National Pressure Ulcer Advisory Panel. (2001). Pressure ulcers in America: Prevalence incidence and implications for the future. Advances in Skin & Wound Care, 14(4), 208-215.
Jill Walsh is house director at Adventist La Grange Memorial Hospital, La Grange, IL.