A pressure ulcer is a wound that occurs when skin or underlying tissue, usually over a bony prominence, suffers injury due to direct pressure or pressure with shear forces . The mechanism of injury is due to localized pressure exceeding capillary blood flow pressure. This then leads to ischemia with edema, cell necrosis, and tissue injury . There are other factors, such as decreased sensation, difficult moisture management, and nutritional compromise, which contribute to pressure ulcers, but their importance has yet to be defined . The goal in prevention of pressure ulcers is to reduce pressure and shear forces over bony prominences.
Regulating agencies assert that the development of pressure ulcers are a serious reportable event and thus are largely preventable. Since 2008, the Centers of Medicare and Medicaid Services in the USA have chosen to no longer reimburse for certain hospital-acquired pressure ulcers . In contrast, many wound care experts believe that despite all prevention strategies, there are situations (such as in some advanced illnesses) when skin can no longer maintain its integrity . The European and National Pressure Ulcer Advisory Panels (EPUAP and NPUAP respectively) stated in 2011 that not all pressure ulcers are avoidable. They stated that there are clinical conditions such as critical illness and untreatable malnourishment, when pressure ulcers cannot be prevented [5▪].
It can be challenging to prevent pressure ulcers in with advanced illness. In this article, we summarize the relevant recent literature.
MEDLINE and CINAHL databases were searched from January 1, 2011 to June 1, 2012 to identify relevant abstracts. Pressure ulcer and prevention were the search terms used. Our purpose was to review current literature, so search dates were limited between January 1, 2011 and June 1, 2012. The abstracts were then reviewed by one author (F.W-C.). We included articles that addressed patients with advanced illness, which are defined as patients transitioning from curative to supportive and palliative care. These patients may be in various clinical settings, such as acute care, intensive care, long-term care, palliative care or hospice care . There were four articles that specifically addressed patients with advanced illness. We decided to broaden the search to also include those articles that addressed patients who were in the various clinical settings but did not specify whether a transition from curative to supportive care had occurred.
In total, 231 articles were found. Twenty articles were non-English articles and were not included due to lack of translation. After reviewing the abstracts for the specific parameters as outlined above, there were 14 remaining articles. The articles and the prevention strategies they address are listed in Table 1.
One systematic review evaluated the use of any support surfaces, mattress or wheelchair, for the prevention of pressure ulcers [7▪▪]. The trials selected were randomized controlled trials and quasi-randomised trials – published or unpublished – that evaluated support surface interventions for pressure ulcer prevention. The trials were for patients in multiple settings – ICUs, hospital wards, nursing home facilities – and were not necessarily in the stages of advanced illness. The authors concluded that a higher specification mattress is more likely to prevent a pressure ulcer rather than a standard hospital mattress. Alternating pressure mattresses may be more cost–effective, and comfortable, for the patient, as compared with alternating pressure overlays. Medical grade sheepskins in general and use of operating room overlays may prevent pressure ulcers. It remains unclear as to whether constant low-pressure or alternating-pressure ulcer supports are more effective in pressure ulcer prevention. These observations have been corroborated in another systematic review published in 2006 . Because this current review looked at a broad population of patients, the findings do not necessarily generalize to those patients in advanced illness. When making a decision to change the support surface in those frail patients, based on these findings, the provider will also need to factor in cost and patient comfort.
RANDOMIZED CONTROLLED TRIAL
One randomized controlled trial (RCT) evaluated frequent repositioning in a long-term care setting as a method of preventing pressure ulcers . Repositioning every 3 h and including a 30° tilt reduced the pressure ulcer incidence compared with usual care (90° tilt every 6 h). This RCT did not reach its participant enrollment target due to several extraneous reasons that the authors do not specify. The authors also cite variation in cluster sizes as a limitation. Despite variance in cluster size limitations, there was significant clustering effect. The RCT methods were considered reflective of everyday clinical practice. The intervention was a simple change in repositioning technique and usual plan of care (e.g. nutritional support, hygiene, toileting) were continued through the day. Depending on the patient's comfort level, instituting a 30° tilt may reduce their risk of pressure ulcers. A better-powered study may further strengthen, or weaken, this recommendation.
PROSPECTIVE COHORT TRIALS
We found three prospective trials [10,11▪,12]. None of the trials specified whether the patients were in advanced illness. The trials did enroll patients who were either in intensive care or long-term care setting. The three trials evaluated three different prevention modalities: repositioning, support surfaces, and skin integrity maintenance.
One of the trials investigated pressure ulcer occurrence in critically ill patients, who were either on a low air loss mattress with microclimate features or an integrated power pressure redistribution bed . The pressure ulcer incidence in patients on a low air loss mattress was 0%, whereas it was 18% for patients on an integrated power pressure redistribution bed (P = 0.046). One flaw of this trial was that the integrated power pressure redistribution beds were 7 years old and the low air loss beds were brand new. Optimizing the microclimate has become a topic of interest in support surface technology. The NPUAP recommends optimizing the microclimate in order to prevent pressure ulcers, which means minimizing friction and shear, moisture, and optimizing temperature control .
An additional prospective trial found that pressure ulcer prevalence in an ICU could be reduced from 13.6 to 1.8% in a 6-month period [11▪]. The intervention was application of a silicone border foam dressing over the sacrum. Providers may want to consider the use of such a dressing for prevention of sacral pressure ulcers in those high-risk patients.
Another prospective trial evaluated oxygen flow characteristics in long-term care patients with turning . This pilot trial, comprised of nine patients, concluded that turning did not necessarily enhance oxygen flow to skin over boney prominences. Limitations of this trial were that it did not look closely at patient confounders. It called into question the current turning schedule guidelines of every 2–4 h. Given the poor quality of this trial, providers should continue to follow the recommended turning guidelines, provided they are within the goals of care for a patient in advanced illness.
RETROSPECTIVE COHORT TRIALS
We found two retrospective cohort trials [13,14▪▪]. One trial evaluated repositioning techniques while the other trial investigated risk assessment.
One trial of bedbound hip fracture patients found that repositioning every 2 h did not decrease the incidence of pressure ulcers . Nonbedbound patients were excluded. The trial did not evaluate why the hip fracture patients were bedbound the first 5 days of hospitalization. It is probable that these bedbound patients had severe comorbidities that increased their risk of pressure ulcer formation and thus confounded the results.
A large trial of the Braden Scale did not pertain specifically to patients with advanced illness, but it did include patients in an ICU setting [14▪▪]. This study suggested that the friction/shear score on the Braden Scale was the most powerful positive predictor of pressure ulcer, as was surgery greater than 5 days after hospitalization and acute respiratory failure. The authors highlight that the Joint Commission on the Accreditation of Healthcare Organizations’ recommendation of all ventilated patients having the bed elevated more than 30° increases shear forces on the sacrum and coccyx. Prevention strategies in these critically ill patients may be best focused on how to reconcile two competing guidelines.
One cost–effectiveness analysis investigated multiple interventions for pressure ulcer prevention in long-term care patients . Interventions implemented included pressure redistribution mattress, oral nutritional supplementation in those patients with recent weight loss, skin emollients for those high-risk patients with dry skin, and foam cleansing for those high-risk patients, who suffered from incontinence. This study found that higher-specification foam mattress both improved pressure ulcer prevention outcomes and were costeffective. These findings corroborate with the findings of the systematic review previously mentioned.
Nutritional supplements were not shown to be costeffective in these patients in long-term care. Previous data from other trials published prior to January, 2011 do not support the routine use of supplemental nutrition to prevent pressure ulcers in general, regardless of advanced illness status .
Skin emollients to hydrate skin were found to be costeffective. There was no intention-to-treat analysis, however. The authors decided to recommend skin emollients because current guidelines recommend skin hydration to prevent skin damage. The use of foam cleansers on patients who suffered from incontinence was found to be both valuable in pressure ulcer prevention and costeffective in this analysis.
As healthcare costs continue to rise, providers will need to be mindful of quality pressure-reduction strategies as well as the cost–effectiveness of care plan elements.
QUALITY IMPROVEMENT PROJECT
We found one quality improvement study in pressure ulcer prevention in long-term care patients . The study focused on skin integrity and incontinence issues. The authors instituted an intensive staff educational intervention in pressure ulcer prevention as well as implementing a new barrier product for incontinence. Other interventions included applying an aqueous cream instead of soap for cleansing and dermal pads over previous pressure ulcer sites or areas of contracture. They were able to reduce their pressure ulcer prevalence from 14 to 1.28% in 6 months. This project did not analyze the statistical significance.
COMPARATIVE DESCRIPTIVE DESIGN TRIAL
One comparative descriptive designed trial evaluated the impact of repositioning on blood flow . This pilot trial of 20 patients aged 65 or older evaluated tissue blood flow and skin temperature on boney prominences in various positions. The blood flow to boney prominences significantly decreased when the patient was in the 30° lateral position as opposed to supine position. This trial, similar to the pilot prospective trial, suggested that turning did not enhance blood flow to skin over boney prominences. The trial was limited in that it did not adjust for patient confounders. If within the goals of care of the patient in advanced illness, providers should continue to follow the recommended turning guidelines for pressure ulcer reduction.
We found four review articles [18–21]. Three of them discussed comprehensive strategies of risk assessment, repositioning, mattress and cushion support surface selections, nutritional supplementation, and skin integrity/incontinence issues [18,20]. The remaining review did not incorporate mattress or cushion support surface into the discussion .
The NPUAP pressure ulcer prevention guidelines recommend the use of a structured risk assessment to identify patients at risk of pressure ulcers . The review authors supported the use of the Braden Scale or Pressure Sore Risk Assessment Scale for Palliative Care as quality predictors for pressure ulcer development in the advanced illness population . Highly predictive factors of pressure ulcer development were physical activity, mobility, and age.
The Palliative Performance Scale (PPSv2) score is a global assessment for those patients with advanced illness and who are transitioning to supportive and palliative care. The PPSv2 is considered an important assessment and prognostication tool for survival . One study found a positive correlation between the PPSv2 and the Braden scale . The PPSv2 may be used as a proxy for the Braden Scale in these patients in advanced illness.
The review authors agreed that for patients in advanced illness repositioning is not always feasible [18,20,21]. In these patients, repositioning may be contraindicated in the setting of hemodynamic instability, may cause increased pain, or may worsen nausea and vomiting. The clinician needs to discuss with the patient and family the goals of care. Comfort may be the predominant goal, even if this goal goes against national guidelines .
The review authors recommended either air mattress or overlay for pressure ulcer prevention [18–20]. They also advocated for individualized assessment on what mattress or wheelchair cushion would be best.
Two of the review authors emphasized that maintaining nutrition, weight, and a healthy diet are not realistic goals at the end of life [18,20]. If the patient has severe diarrhea or malabsorption, then oral intake may make this worse. Families often ask about intravenous fluids. They must be educated on the consequences of hypoalbuminemia or diuretic-resistant congestive heart failure, including total body anasarca . Small frequent meals and liberalization of the diet and supplements may be done to maintain adequate nutrition .
Basic skin care and incontinence management continue to be important aspects of maintaining skin integrity. Although incontinence does not cause pressure ulcers, it does compromise the pH balance, leading to excoriation and moisture-associated dermatitis . The change in the pH balance also allows for bacterial overgrowth and increasing the risk of infection . Two review authors emphasized the use of a low pH foam or soap cleanser to maintain skin integrity in patients in advanced illness [20,21].
Few original trials were published in the past 18 months on prevention of pressure ulcers in advanced illness. In those patients with advanced illness and multiple organ dysfunctions, skin may change as a result of end-of-life physiology. There is a growing recognition of this within the wound care community . Animal models have shown that some pressure ulcers may form in the midst of an ischemia-reperfusion cycle, in which during reperfusion there is a free-radical release leading to swelling and inflammation. More research is needed to elucidate how pressure ulcers form in patients with advanced illness. For now, optimizing patient comfort and goals of care when implementing pressure ulcer prevention strategies is essential to the care plan of these fragile patients.
The authors would like to thank Dr David Osterbur, Dr Anne Fabiny, and Ms Patricia Redd for assistance in the literature search and acquiring these articles.
Conflicts of interest
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
- ▪▪ of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 127–128).
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