Journal of Tissue Viability

Editorial

Michael Clark — 2010-02-01

As we start a new decade and thoughts turn to the next stage of development for the rapidly growing field of tissue viability, two perennial issues remain to be fully resolved. The value of tissue viability services (including the role of the specialist tissue viability nurse) has not been clearly demonstrated either in terms of improved patient outcomes or reduced expenditure on wound prevention and treatment. Without such evidence continued services in these times of health service expenditure reductions cannot be guaranteed. Obtaining such evidence will not be easy given the widespread diffusion of dedicated wound healing services within most health care organisations! Let us hope that it is not too late to formally investigate the impact tissue viability services can have!

Laboratory measurement of the interface pressures applied by active therapy support surfaces: A consensus document

Tissue Viability Society — 2010-01-25

Abstract: A key element in pressure ulcer prevention and management is the selection of appropriate pressure redistributing (PR) patient support surfaces for use while seated and in bed. However little explicit guidance exists allowing standardised quantitative comparison of different PR surfaces based upon their ability to redistribute pressure from anatomical landmarks such as the heels and sacrum. In 2008 a working group was established in Europe through the US National Pressure Ulcer Advisory Panel (NPUAP) support surface standardisation initiative (S3I) and under the aegis of the European Pressure Ulcer Advisory Panel with the specific remit of developing test methods for the evaluation of active therapy support surfaces (alternating pressure air mattresses). This report describes a consensus development process to agree test methods appropriate to compare active therapy surfaces based upon their ability to redistribute pressure from the sacrum and the heels.

A pilot randomised controlled trial comparing reactive air and active alternating pressure mattresses in the prevention and treatment of pressure ulcers among medical ICU patients

2010-01-15

Abstract: Background: Data on the prevention and treatment of pressure ulcers (PU's) among ICU patients is sparse.Objective: To compare PU outcomes in medial ICU patients nursed on either a reactive mattress overlay (ROHO®, ROHO Inc, Belleville, IL, USA) or an active alternating pressure mattress (NIMBUS®3, ArjoHuntleigh, Luton Bedfordshire, UK).Design: Pilot prospective single blind randomised controlled clinical trial.Intervention: Two types of pressure redistributing mattress.Patients: Two groups of eight patients.Methods: Patients included in the study were those at high risk (Norton scale <8) or with a PU on admission.Results: The two groups had similar patient characteristics. However, the NIMBUS 3 group presented with more ulcers per patient on admission (62.5%) and more severe ulcers (20% category 3) while four patients (50%) presented with a single superficial ulcer in the ROHO group.Healing: The progress of the ulcers showed significant decreases in PU surface area (p=0.05), total PUSH tool score (p=0.01) in the NIMBUS 3 group compared to the ROHO group. In the NIMBUS 3 group 82% of the ulcers improved versus none in the ROHO group (p=0.002) and 18% remained stable versus 33%. None of the ulcers deteriorated in the NIMBUS 3 group versus 67% in the ROHO group (p=0.006). Full thickness wounds (Category 3) were present in 22% of the NIMBUS 3 group versus 0% of the ROHO group on admission and in 0% versus 66.7% (p=0.008) respectively at the end of the pilot study.Prevention: Non-blanching erythema occurred equally in both arms at baseline; skin remained intact for the NIMBUS 3 group while 50% in the ROHO group worsened with superficial tissue loss.Conclusion: This small pilot study suggests that ‘active’ alternating therapy is a useful adjunct in the care of highly vulnerable patients, while the outcomes may be less favourable when using ‘reactive’, constant low pressure devices.

Clinical and economic consequences of discharge from hospital with on-going TNP therapy: A pilot study

Gill Hiskett — 2010-02-01

Abstract: Despite practical advantages (such as exudate management and reduced dressing changes) the adoption of topical negative pressure therapy (TNP) in home care may be restricted through logistical issues and a perception that the intervention is more expensive than the more traditionally utilised wound management products. This pilot study followed the experiences of 20 subjects with a variety of acute and chronic wounds who received TNP either in hospital (n=10), at home (n=5) or in both care settings (n=5). All except one subject showed both reductions in wound surface area and improved appearance of the wound bed during the course of treatment ranging from 2 to 74 days. The single subject, where a deterioration in their wound was noted, had presented with an unclear wound diagnosis thus highlighting the absolute need for accurate diagnosis of wound aetiology prior to commencement of any treatment regime. The cost of treatment was lower where subjects were treated at home (mean cost per day £45.9 SD: 17.0) and highest where care was delivered exclusively in hospital (mean cost per day £259.1 SD: 2.8). Direct comparison of these data with other published studies on the use of TNP therapies is obviously restricted through regional differences in the cost of nursing care, patterns of use of the TNP consumables and the wound outcomes followed in individual cases, however, there would appear to be a qualitative and economic benefit from home care.

The value of systematic evaluation in determining the effectiveness and practical utility of a pressure-redistributing support surface

Corinne Ward — 2010-01-28

Abstract: Introduction: Up to 20% of hospital patients will have pressure ulcers; more than half will be nosocomial and are associated with high treatment cost, increased morbidity, complaints and litigation. Consequently, patient safety programmes may include the provision of pressure-redistributing mattress replacements (PRM). However, despite the different functionality of PRMs, there is often little information to support clinical prescription; with some mattresses potentially unsuitable for a busy acute care environment: this is particularly true for mattresses which require manual adjustment each time the patient changes position.Methods: A systematic prospective investigation of a new PRM was conducted over a 5-month period; following a convenience sample of high-risk hospital patients. The device automatically detects the angle of back rest, optimises cell inflation and reduces the risk of user error and sub-optimal support. Outcomes reported: ulcer prevention, healing, usability.Results: A convenience sample of 60 patients were included; 39 (65%) had existing wounds. A single patient developed erythema to the sacrum (1.6%) while the majority of existing wounds (69%), including full thickness injury, improved or healed. The utility of the device was well received by staff and patients.Conclusion: Although ideal, effectiveness studies (such as RCTs) are difficult to control in wound care and seldom reflect the natural challenges encountered in a busy hospital. By contrast the data arising from this pragmatic evaluation showed the mattress to be compatible with the care setting and also suitable for the vulnerability of the population and so provided the necessary information to inform subsequent clinical practice.

Can meaningful quality benchmarks be derived from pressure ulcer prevalence data?

Lyn Phillips, Michael Clark — 2010-01-21

Abstract: The burdensome process of collecting, analysing and reporting pressure ulcer outcome data has changed very little since its introduction some years ago; simply growing in complexity and frequency. Typically, prevalence audit has focused on the scale of negative outcomes i.e. number, severity, size, location and origin of the wound, while missing the opportunity to measure other critical metrics such as concordance with key measures within preventative care protocols. As a result, pressure ulcer assessment remains largely disconnected from patient safety or quality improvement programmes and thus may have little impact on overall outcomes.The data itself is also problematic, with healthcare providers increasingly expected to publish performance against healthcare targets. It is necessary to consider the ramifications of reporting outcome data which has not been normalised against important variations in risk exposure, particularly when more than half of all wounds may be occurring during an episode of supervised care. It is recommended that outcome measures are mathematically adjusted in order to account for population differences over time and between facilities; this will enable accurate trend analysis, ‘hot spot’ identification and reliable comparison.If pressure ulcer data collection is to have a place in contemporary healthcare systems it must meet the robust standards required for clinical benchmarking. There will be a need to refocus the assessment process to reflect upon the quality of the preventative care delivered in order to improve patient safety.