Many assessment tools have combined urinary incontinence and faecal incontinence, into one risk factor, ‘incontinence.’  It is therefore, difficult to objectively assess ‘incontinence’ as a causal risk factor, or an intervening variable coming after a predictive factor, prior to PI development. However bivariate analysis has shown UI to be associated with a significantly higher rate of PI development.[3] Berlowitz (2001) reported continent residents had a higher rate of PI 90 days after the initial screening than those coded as ‘usually continent’ or ‘incontinent’. This prospective study was carried out on 14,607 nursing home residents who were without a Stage 2 PI, or larger, although these Stages were not defined.

[1] Allman RM, Goode PS, Patrick MM, Burst N. & Bartolucci AA.  Pressure ulcer risk factors among hospitalized patients with activity limitation. JAMA 1995; 273(11): 865- 70; Fisher AR, Wells G. & Harrison MB. Factors Associated with Pressure Ulcers in Adults in Acute Care Hospitals. Advances in Skin & Wound Care 2004; 17(2): 80-90; Papanikolaou P. Lyne PA. & Lycett EJ. Pressure ulcer risk screening: application of logistic analysis. J Adv Nurs 2003; 44(2):128-36; Pase MN. Pressure relief devices, risk factors, and development of pressure ulcers in elderly patients with limited mobility. Adv Wound Care 1994; 7: 38–43;  Maklebust J, Siggreen MY. Pressure Ulcers. Guidelines for Prevention and Nursing Management. Springhouse PA: Springhouse Corporation, 1996, 24; Versluysen M. Pressure sores in elderly patients. The epidemiology related to hip operations. J Bone Joint Surg Br 1985; 67(1): 10-3; Brandeis GH, Morris JN, Nash DJ et al. The epidemiology and natural history of pressure ulcers in elderly nursing home residents. JAMA 1990; 264:2905–2909.

I can show you how to cut costs while still providing quality care and fulfilling criteria for Skin Care for Accreditation.

I can tell you which air mattresses will prevent pressure injuries (PI) and which won’t.

Why not give me a call on 0408121331 or email me at info@thewoundcentre.com

Kate ]]> http://thewoundcentre.com/a/490/wound-care-consults-for-your-frail-aged/feed/ 1 http://thewoundcentre.com/a/442/incontinence-causes-pressure-ulcers-but-does-it/ http://thewoundcentre.com/a/442/incontinence-causes-pressure-ulcers-but-does-it/#comments Sun, 18 Sep 2011 01:44:07 +0000 http://thewoundcentre.com/a/?p=442 Seriously though…how can incontinence cause a pressure injury (PI) /ulcer??
If you ‘micro-think’ about this you will see that it makes no sense whatsoever!When a patient is incontinent of urine and / or faeces the wettest, soggiest area is the perineum, vulva, penis and testicles….isn’t it?…not the sacrum and certainly not the heels!
Sure the sacrum might get wet and pooey.. BUT … it is not where the greatest concentration of gloop is found in the incontinentpatient; the sacrum might get damp…but so might the symphysis pubis…both are equidistant from the perineum but I have never seen a Stage 4 PI over the symphsis pubis or abdomen.

You don’t need to be critical of the methodology of its findings – just remember the Cochrane Review and the recommendations are based on RCTs only and did not take into account all the other papers that are not RCTs.

We already know that hydrocolloids, for example, prevent bacteria & water from entering the surgical site and they prevent self-contamination of the surgical site from the patient’s own fingers or staff hands; great Infection Control measures.

We know that tape used to secure gauze dressings may be contaminated. And bloody gauze dressings pose huge OH&S issues for nurses handling and removing them, ‘flick’ & ‘splash’ injuries for example. So despite spending forever researching this subject & co-authoring the Cochrane Review I will NOT put gauze on a surgical site nor will I leave the surgical site exposed. I won’t be persuaded by [perceived] cost savings either.

I look forward to your comments. What are your favourite dressings for surgical sites? Did any of you contemplate leaving a surgical site exposed after reading the Review?

Kate

Here is the recent Cochrane Review [summary & abstract only] that I had the pleasure of participating in. You can read the whole paper on www.cochrane.org

Plain Language Summary
No recommendations regarding type of wound dressing for the prevention of surgical site infection
Millions of surgical procedures are conducted globally each year. The majority of procedures result in wounds in which the edges are brought together to heal using stitches, staples, clips or glue – this is called ‘healing by primary intention’. Afterwards, wounds are often covered with a dressing that acts as a barrier between them and the outside environment.

One advantage of this may be to protect the wound from micro-organisms, and thus infection. Many different dressing types are available for use on surgical wounds, however, it is not clear whether one type of dressing is better than any other at preventing surgical site infection, or, indeed, whether it is better not to use a dressing at all. We conducted a review of all available, relevant, evidence regarding the impact of dressings on the prevention of surgical site infections in surgical wounds healing by primary intention.

The review examined data from 16 randomised controlled trials and found no evidence to suggest either that one dressing type was better than any other, or that covering these wounds with dressings at all was better, at preventing surgical site infection, or that any dressing type improves scarring, pain control, patient acceptability or ease of removal.

It is important to note that many trials in this review were small and of poor quality, at high or unclear risk of bias. Decisions on wound dressing should be based on dressing costs and the need for management of specific symptoms e.g., absorption of exudate.

This is a Cochrane review abstract and plain language summary prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2011 Issue 7, Copyright © 2011 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).

This record should be cited as: Dumville JC, Walter CJ, Sharp CA, Page T. Dressings for the prevention of surgical site infection. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD003091. DOI: 10.1002/14651858.CD003091.pub2
Editorial Group: Wounds Group
This version first published online: July 6. 2011
Last assessed as up-to-date: May 10. 2011

Abstract
Background
Surgical wounds (incisions) heal by primary intention when the wound edges are brought together and secured – often with sutures, staples, clips or glue. Wound dressings, usually applied after wound closure, provide physical support, protection from bacterial contamination and absorb exudate. Surgical site infection (SSI) is a common complication of surgical wounds that may delay healing.

Objectives
To evaluate the effects of wound dressings for preventing SSI in people with surgical wounds healing by primary intention.

Search strategy
We searched the Cochrane Wounds Group Specialised Register (searched 10 May 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011 Issue 2); Ovid MEDLINE (1950 to April Week 4 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, May 9, 2011); Ovid EMBASE (1980 to 2011 Week 18); EBSCO CINAHL (1982 to 6 May 2011). There were no restrictions based on language or date of publication.

Selection criteria
Randomised controlled trials (RCTs) comparing alternative wound dressings or wound dressings with leaving wounds exposed for postoperative management of surgical wounds healing by primary intention.

Data collection and analysis
Two review authors performed study selection, risk of bias assessment and data extraction independently.

Main results
Sixteen RCTs were included (2578 participants). All trials were at unclear or high risk of bias. Nine trials included people with wounds resulting from surgical procedures with a contamination classification of ‘clean’, two trials included people with wounds resulting from surgical procedures with a ‘clean/contaminated’ contamination classification and the remaining trials evaluated people with wounds resulting from various surgical procedures with different contamination classifications. Two trials compared wound dressings with leaving wounds exposed. The remaining 14 trials compared two alternative dressing types. No evidence was identified to suggest that any dressing significantly reduced the risk of developing an SSI compared with leaving wounds exposed or compared with alternative dressings in people who had surgical wounds healing by secondary intention.

Authors’ conclusions
At present, there is no evidence to suggest that covering surgical wounds healing by primary intention with wound dressings reduces the risk of SSI or that any particular wound dressing is more effective than others in reducing the rates of SSI, improving scarring, pain control, patient acceptability or ease of dressing removal. Most trials in this review were small and of poor quality at high or unclear risk of bias. However, based on the current evidence, we conclude that decisions on wound dressing should be based on dressing costs and the symptom management properties offered by each dressing type e.g. exudate management.

I would like to thank Leonard for his dedication in writing this  - a significant contribution about Biofilm.

It’s contributions like these that helps to further knowledge in Wound Care.

If you have a contribution (papers, studies, feedback, comments, tips, ideas), please forward them to…

info(at)thewoundcentre.com
replace (at) with @ symbol

And together we’ll bring the world of Wound Care closer.

With the Wound Care newsletter going out to over 31 countries,
the information we can learn from each other is priceless.

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BIOFILM/S AND WOUNDS

Leonard Schembri S.N., R.N. (Aust.), B.Nsg. (Aust.), B.A., T.E.F.L.

Phytotherapeutical Studies (Brazil).

A biofilm is a collection of microbial cells that are attached to a surface and embedded in a self-produced extrapolymeric substance. (Davis et. al. 2008). Bacterial biofilms cause or complicate numerous medical conditions, including chronic wounds. (Wolcott & Rhoads 2008).

The biofilm has become a common occurrence in wounds and this poses a big challenge to all the Nurses and Doctors. Unfortunately, many Health Professionals still do not know how to manage a biofilmed wound.

There are different schools of thought of how and why a biofilm is formed. Be that as it may, this short article is not about the how and why. It is about different methods of “how to remove” the biofilm from wounds whether they’d be acute or chronic.

All the information below is from the author’s experience.

First method A biofilm could easily be removed with sterile plastic forceps. The procedure itself is, many a time, painless. However, with certain types of wounds, for example, an arterial leg ulcer (below the knee), this simple procedure could be painful.

The problem of pain could be overcome by either one of the following two methods explained below.

1. a. The application of Emla Cream (a local anaesthetic) on top of and around the wound. Then the Health Practioner has to wait an hour for the cream to absorbed. Waiting for two hours is better.
2. b. If the pain is excessive, in addition to the Emla Cream, the Nurse (or other Health Practioner), can apply Lignocaine 1% solution. The vial’s transparent solution is placed onto two layers of gauze and then the wet gauze is applied over the wound and its immediate and surrounding healthy tissue. This is left in place for 2 minutes or slightly longer. Soon afterwards, the Nurse can start to remove the biofilm with a sterile scoop or the edge of a sharp blade.

Second method Another method which is liked by some Health Practioners is the application of Negative Therapy Pressure (NPT) or Vacuum Assisted Closure (VAC).

This, we have found, could be applied over a stubborn biofilm where the Nurse finds it extremely difficult to remove. After one or two applications of this therapy, the biofilm is removed.

Unfortunately, the biofilm has the tendency of returning (recalcitrance) once the therapy is stopped. Thus it is important to apply a suitable dressing or to continue with the use of NPT or VAC to prevent the biofilm from reforming.

Third method Prontosan is a new solution for biofilms. This solution is first placed on a couple of sterile gauze swabs and then applied over the wound and left in situ for 15 minutes.

This is meant to break up the biofilm or eat away, as it were, at the film and the bacteria underneath. It ought to be mentioned at this stage, that the first method (mentioned above) is first carried out and is then followed by using this method. To compliment the Prontosan solution, B. Braun has come up with Prontosan Gel.

This gel is to prevent the formation of a further biofilm or to continue the action of breaking the biofilm, that is, killing the bacteria underneath. Once the wound is free from the biofilm, the gel enhances granulating tissue.

If, on the other hand, the biofilm is thick and stubborn and  the Health Practioner can still see the biofilm present on the wound, then s/he can remove the biofilm with either a scoop or a sharp blade some 2 to 3 weeks after the application of the solution and gel. The combination of these two products seems to dislodge easier the film from the surface of the wound bed.

Fourth method A super-oxygenated environment is good for healthy tissue and bad for biofilms. (Wolcott 2008). Thus, hyperbaric oxygen is one method of combating biofilms. Even though this idea might be a good idea for diabetic ulcers with recurring biofilms, it has not as yet been accepted by our peers.

Nurses still need to promote “research marketing”, so to speak, with surgical and medical staff; research marketing which is based on anecdotal research and further up the ladder of research.

Fifth method The Cutimed Sorbact dressing – This dressing, which could be left in situ for up to one week, is applied over the biofilmed wound. However, the secondary dressing is changed regularly, that is, when there is too much discharge. The dressing captures the bacteria and inactivates their activity (sequestration).

It is an easy dressing to apply and does not require any special technique of application. It ought to be mentioned, that the first method (mentioned above) is first carried out and is then followed with the use of this dressing. It has been observed that this dressing is better used once there is no biofilm as it prevents the formation of the biofilm.

Sixth method Another simple and straightforward method is to obtain a brand new sterile toothbrush. The Health Practitioner can clean the biofilmed wound with the toothbrush under running water. S/he can refer to the guidelines of the first method, referred to above, if the patient is in pain or experiences pain during the procedure.

This method is partially successful but it aids at removing the thickness of the biofilm. To check the efficacy of the procedure, it might be a good idea to do half of the wound at first and compare this with the rest of the wound. Either one of the methods referred to above can then be applied.

Future wound dressings Presently, it is common practice not to use any other anti biofilm agents. This is because there are no specific commercial wound dressings on the market for biofilms.

However, there are potential anti biofilm agents which still need be explored and researched in the treatment for wound biofilms.

According to various authors, some of these chemical and natural agents are: Lactoferrin, Xylitol, Gallium, Dispersin B and Honey (Manuka)* (Percival et. al. 2010). In the author’s opinion, there are no anti biofilm wound dressings; at least, not in Malta.  We hope to witness, in the future, some new form of wound dressing with these agents.

This gives manufacturers the opportunity to explore and experiment with new products.

In the case of mouth biofilms, the author does not know whether there are any of the agents (mentioned above) which could be used against biofilms.

It would be interesting to find out what Dentists use when there is a biofilm in the mouth and the reason of using one agent over the other.

The methods and the chemical/natural agents used by Dentists could be adopted by Nurses and Doctors which might lead to a breakthrough in the treatment for wound biofilms.

* In some instances, Manuka Honey was used against MRSA in Mater Dei Hospital. This is not the case any longer as silver dressings have been introduced since then. There is a Honey dressing on the market but it does not specify that it is Manuka Honey. From the author’s experience, a commercial wound dressing is a sterile manufactured product where the Health Professional user opens the dressing and lays it over the wound to help/assist the wound to heal in the shortest time possible.

References: Davis S.C. et. al., Microscopic and physiologic evidence for biofilm-associated wound colonization in vivo. Wound Repair Regen. 2008 Jan-Feb; 16(1):23-9.

Percival S.L., Cutting K.F., Williams D., Biofilms: possible strategies for suppression in chronic wound. Nursing Standard Autumn 2010.

Wolcott R.D., Rhoads D.D., A study of biofilm-based wound management in subjects with critical limb ischaemia. J Wound Care. 2008 Apr;17(4):145-8, 150-2, 154-5. _______________________________________________________________________________________________

Please share your thoughts and comments.

This time Eileen’s passion for preventing pressure injury is brilliantly expressed in her paper from the heart…

You can either read the full article below or download the PDF here.

PREVENTING PRESSURE ULCERS 2010

Eileen Wilkins

ABSTRACT

Pressure ulcers, considered a preventable adverse event, continue to be a problem around the world, despite a plethora of instructive literature on prevention. In nearly every wound care journal I read, or at any conference I attend, pressure ulcers are still discussed as a major concern, by clinicians.

Yet preventing pressure ulcers is basic nursing care and it has been since I started my nursing career in 1970, so what are we doing wrong? The risk of pressure ulcer development hasn’t changed over the years so when will we get this right?

Could it be that nursing is now harder and heavier than it ever has been; an occupational health and safety concern when it comes to repositioning patients? Increased longevity, a positive factor in many ways, means that there are many more bedridden frail aged for whom pressure ulcers can be a common, serious and deadly condition. This along with the huge amount of paperwork and computer data entry nurses have to fit into their day means staff are struggling to meet the basic care needs of the patients.

It is clear that we are missing something so we need to get back to basics and rethink risk assessment and protocols for intervention to relegate pressure ulcers to history books.

INTRODUCTION

Pressure ulcers (PU) are a significant burden to all health care systems. Once a deep Stage 4 PU exposing muscle and bone develops, the cost associated with treatment of just one such PU has been estimated at $61,230.00 [1] and legal action as much as $632,500. [2] Patients may be admitted to, or

discharged from, any healthcare facility, with one or more PU [3,4,5,6]. Pressure ulcers result in an increased length of stay [7] increase morbidity and mortality [8] and are very painful, causing suffering for the poor patient.

There have been so many advancements in the prevention of PU so I question why they still occur, especially in this day and age. Should we be seeing any PU at all?

Most hospitals and facilities would have a protocol in place to prevent PU from occurring, along with a risk assessment tool to predict which patients are ‘at risk’ of developing a PU.

The aim of the risk assessment tool is to distinguish risk factors considered associated with the cause and to identify patients ‘at risk’ of a PU [9] then intervene immediately with appropriate equipment to reduce the incidence of these nasty ulcers.

Many numerical assessment tools have been used to assess the patient to determine whether they are ‘at risk;’ the Norton 1962, Waterlow 1962, Braden 1984 just to mention a few, but are they truly evidence-based? [9]

In 1992, Brenda Ramstadius, a clinical nurse consultant in wound care in Australia noticed that nurses were not using the available PU risk assessment tool (Norton) in her hospital, to identify “at risk” patients. Nurses said they found it time consuming evaluating the numerous variables. Ramstadius then designed an assessment tool that reflected pressure ulcer aetiology, which has more clinical relevance and was able to determine “not at risk” status earlier in the assessment process.

In 1996 this brought about a collaborative clinical research study between University academics and nurse clinicians in Australia, comparing the “Ramstadius Tool with the “Waterlow scale” in four nursing homes. [10] The Waterlow scale was chosen as the comparison tool as nurses said they thought it the most suitable for all patients.

In 1999 Annette Hoskins, a senior lecturer at Wollongong University, Australia, decided to conduct further study to assess the validity and reliability of the Ramstadius Pressure Ulcer Risk Assessment Tool, as well as to explore if mobility is the primary factor for PU formation.

This is when I first became excited by the idea that PU could be prevented. I came across an article in the Nursing Times that was asking for hospitals to participate in research comparing tools that predict who was ‘at risk’ of PU. I applied and my hospital Port Macquarie Private, in Port Macquarie, New South Wales, was accepted along with three other hospitals in Australia; Townsville Hospital in Queensland, Queen Elizabeth Hospital in South Australia and Dubbo Base Hospital in New South Wales..

The purpose of the descriptive study was to validate by comparison the recently developed “Ramstadius” PU risk assessment tool with an already existing tool, the “Waterlow” scale and explore the most significant factors in PU formation.

Each hospital was asked to assess 100 patients to see if they were ‘at risk’ of a PU comparing the “Ramstadius Tool” with the “Waterlow” scale. At that time the hospital was not interested in making any changes so they offered no assistance. I did the assessments in my own time mostly at the end of my shifts. I can remember wondering why I had bothered to take the project on, BUT it has actually been one of best projects that I have ever done as it is embedded in my head that if a patient cannot move then it is my job as a nurse to do something about it.

After a few assessments comparing the two tools, it became very clear that the ‘Waterlow’ scale was over predicting as there were too many variables to take into account and it was very time consuming to use. But what I found was that the “Ramstadius” tool was simple and easy to use. It had more clinical relevance and was able to determine “not at risk” status earlier in the assessment process.

Even though that research by Annette Hoskins was never published it changed my life as a nurse. It taught me about ‘best practice;’ improving patient outcomes and since participating in the study I have made a commitment to fight to prevent PU from ever occurring again in my hospital.

WATERLOW RISK ASSESSMENT SCALE

The Waterlow tool was designed for both medical and surgical patients. Risk factors for build/weight for height, continence, skin types, visual risk areas and appetite are categorised and scored from 0-3, sex and age from 1-5. Mobility is categorised into fully mobile, restless/fidgety; apathetic; restricted; inert/traction and chair bound each of which is scored from 1 -5 Special risk medication, can be scored 1 – 8 with more than one risk factor being scored in each subsection. A Score > 10 = the patient is at risk, > 15 = high risk and > 20 = very high risk.

Ramstadius Pressure Ulcer Risk Assessment

This is a non-numerical tool and begins with the assessment of mobility as yes/no. If the patients can reposition themselves independently, such as rolling over in bed and/or are fully mobile, the assessment is complete with the patient classified as not being at-risk of PU. If patients cannot reposition themselves without assistance they are at risk of a PU and guidance is provided for suitable preventative equipment, such as an alternating pressure air mattress (APAM). The Ramstadius tool has the advantage of requiring one factor only to be assessed – mobility and until other risk factors have been tested for positive predictive value, Sharp and McLaws [9] suggest the Ramstadius approach is evidence-based and may be very cost-effective.

If a patient walks into hospital for elective surgery they are not at risk at that moment but as soon as they are anaesthetized they are immediately at risk, because of their immobility, and the intervention should focus on a support surface that will prevent the development of a PU.

Patients that cannot roll from side to side or lift their limbs and pelvis off the bed unassisted are at risk, [11] irrespective of age, of developing a PU. [9]

This risk applies to patients who are bed- or chair-bound, on operating theatre tables, on trolleys in the emergency department, radiology, or whilst being transported in an ambulance, or in a ward or community setting.

Patients who have a disease or disorder which interferes with their ability to reposition or leads to failure of sensation (feeling) or of appreciation of pressure, places them at risk of PU, as they may not reposition in a timely or effective manner. For example: patients with fractured hips peripheral, neuropathy, (diabetes), Parkinson’s disease, Multiple sclerosis, Cerebro-vascular accident (CVA), loss of sensation (spinal injury/spinal anaesthesia) may be at risk if immobile or if their mobility is decreased.

To address these issues and assist members of The Wound Care Association of New South Wales (WCANSW) Inc. a small passionate group got together to write the first State Pressure Ulcer Prevention Guidelines released in 2000; [12]. These Guidelines, revised in 2007 [13] are based on the ‘Ramstadius tool’ along with clinical judgement so that it is easy and simple for clinicians to follow. The WCANSW Inc. Guidelines also advise that the prevention of pressure injury is best achieved by prioritizing management in the following order:

1. Identifying and documenting patients ‘at risk’ of pressure injury immediately on admission to all wards, units, facilities and services.

2. Selecting pressure relieving equipment.

3. Implementing regular repositioning regimes, consistent with the efficacy of the equipment.

4. Assessing ‘risk’ status following any change in the clinical condition of the patient.

The main message is that any patient that cannot change their position, or chooses not to, either knowingly or not, irrespective of age, is ‘at risk’ of developing a PU.

They need to be placed on an APAM immediately unless contraindicated i.e. unstable spinal fractures. When this is the case the medical officer in charge must be consulted.

In 2004 at the Port Macquarie Base Hospital, where I work, we were also seeing too many PU. The “Ramstadius Tool” was implemented to see if it would make a difference. The hospital has been fantastic making sure that APAMs are always available for the patients deemed ‘at risk’ of PU development.

The hospital mattresses were all very basic, a standard single piece of foam covered with a hard plastic which then felt like a hard board or rock. Patients lying on the mattresses for long periods nearly always sustained a PU. Management agreed to replace all the sub standard mattresses. This action has greatly reduced the incidence of PU and thankfully with ongoing education we intend to continue working to improve patient outcomes.

Understanding the pathophysiology of PU development [14] will make the clinician aware of the damage to tissue if a patient has been lying on the floor at home for hours then brought into hospital. The frequent repositioning required to prevent a PU [14] is simply impractical and near impossible to do. Unless carried out every few minutes throughout the 24 hours Sharp and McLaws hypothesise that repositioning can cause ischaemia-reperfusion injury resulting in more damage to tissue and contribute to PU. [14] Clinicians know patients need pressure relief to prevent tissue injury as well as avoiding pulmonary complications. By placing the ‘at risk’ patient on an APAM the pressure is off the clinician as well as the patient.

CONCLUSION

Pressure ulcers are a problem for all health care workers. We know that immobility resulting in unrelieved pressure is the cause of PU development and judicious screening to identify those at risk of developing a PU is the cornerstone of PU prevention.]

So knowing that immobility and unrelieved pressure can cause PU it is clear that policies need to change immediately to reflect this. Patients need to be assessed as soon as they arrive at a hospital or facility and if the patient is found to be ‘at risk’ appropriate equipment supplied immediately. We may still see the odd PU but until we change our practice things will continue to remain the same.

Research is a fundamental part of our nursing practice and is necessary to improve best practice. Wound clinicians may be happy to read and implement guidelines relevant to their practice, but the cold hard facts are that other clinicians not as interested in wound care will not spend time reading long screeds of information they feel is not relevant to their practice.

With nursing workloads increasing assessment tools should be kept easy and simple for compliance to occur. Assessing risk and supplying APAM must be mandatory so that everyone knows their part

Finally as registered nurses we are personally accountable for our practice and actions. We are taught to promote health and healing, and prevent harm and complications so for our patients’ sake we have to keep fighting for best practice to improve patient outcomes; no pressure ulcers!

I would like to acknowledge the assistance of Kate Sharp, Wound Care / Infection Control Consultant. Founder & CEO The Wound Centre, Sydney Australia www.thewoundcentre.com She has happily given of her time to proofread this paper and offer advice.

REFERENCES
1. Young C. What cost a pressure ulcer? Primary Intention 1997; 5(4): 24-25.
2. Dean A. Patient’s hospital care ‘inferior.’ 1994 Sydney Morning Herald;  Thursday August 25th
3. Cullum N. & Clark M. Intrinsic factors associated with pressure sores in elderly people. Journal of Advance Nursing 1992; 17: 427-431
4. Taler G. What do prevalence studies of pressure ulcers in nursing homes really tell us? Journal of the American Geriatrics Society 2002; 50: 773-774
5. Bliss M. & Simini B. When are the seeds of postoperative pressure sores sown? Often during surgery. British Medical Journal 1999; 319(7214): 863-4.
6. Van Marum RJ, Ooms ME, Ribbe MW. & Van Eijk JT. The Dutch pressure sore assessment score or the Norton scale for identifying at-risk nursing home patients? Age and Ageing 2000; 29: 63-68
7. Graves N, Birrell F. & Whitby M. Effect of pressure ulcers on length of hospital stay. Infection Control and Hospital Epidemiology 2005; 26: 293-297
8. Redelings MD, Lee NE and Sorvillo F. Pressure Ulcers: More Lethal Than We Thought? Advances in Skin & Wound Care: September 2005  Volume 18 Issue 7 pp 367-372
9. Sharp CA and McLaws M-L. Estimating the risk of pressure ulcer development: is it truly evidence-based? International Wound Journal December 2006 Volume 3 Issue 4 Page 344 – 353
10. Hoskins A, Ramstadius B, Risk assessment for pressure sores: A Comparison of two tools Primary Intention (Journal of the Australian Wound Management Association) December 1998. 6 (4)  pg 161.
11. Mino, Y, Morimoto S, Okaishi K, Sakurai S, Onishi M, Okuro M, Matsuo A. & Ogihara T. Risk factors for pressure ulcers in bedridden elderly subjects: Importance of turning over in bed and serum albumin level. Geriatrics Gerontology International 2001; 1(1-2): 38–44
12. Ramstadius B, Sharp CA, Carter R & Cavanagh J. Wound Care Association of NSW Inc. 2000 Pressure Ulcer Prevention Guidelines An Expert Consensus Statement www.wcansw.com.au
13. Ramstadius B, Sharp CA, Blanchfield D, Wilkins E, 2007 Pressure Ulcer Prevention Guidelines  (Revised Edition) An Expert Consensus Statement WCANSW.
14   Sharp CA & McLaws M-L. A discourse on pressure ulcer physiology: the implications of repositioning and staging. World Wide Wounds http://www.worldwidewounds.com/2005/october/ Sharp/Discourse-On-Pressure-Ulcer-Physiology.html

IF THEY ARE THIS WOULD NEVER HAPPEN!!

This patient was being nursed on an air mattress overlay so why did he develop these huge pressure ulcers on the left hip and foot? They are shockers aren’t they!

I was asked to see him because of the pressure ulcers and told that he was on an ‘air mattress’. He was—but just look at it! A deflated overlay ripple style mattress…but nobody was aware that it was deflated! The motor was face down under the bed and not plugged in….

Who is checking the mattresses when making the beds; not that this mattress will ever prevent pressure ulcers?

On top of the mattress there was a thick, green plastic macintosh, a pillow, a kylie (thick incontinence draw sheet, with quilted padding) and several ‘blueys.’

All these extra layers add to the pressure placed on the tissues sandwiched between the mattress and the bony skeleton, causing tissue ischaemia which results in pressure ulcers.

You only need a sheet between the mattress and the patient; don’t use anything more.

So what should you look for in an alternating pressure air mattress?

• Ask to try before you buy / lease / rent;
• Choose fully automatic; don’t use anything that needs to be ‘set’ by nurses;
• A loud audible alarm in case it is unplugged;
• Cells that deflate to atmospheric pressure at the very least; preferably zero pressure;
• A visible CPR pull at the foot of the bed; not one that is hidden under the mattress at the head of the bed…imagine looking for that in an emergency!!
• Alternating pressure (unless contra-indicated e.g. unstable fracture) every few minutes;
• Wipe-clean cover, impermeable to water and bacteria;
• Side-formers so patients cannot roll off the mattress & land on the floor and/ or get stuck between the edge of the mattress and bed rails. Side-formers will also prevent the edge of the mattress from collapsing when nurses are trying to get the patient in and out of bed. Nurses have been known to really hurt their backs trying to hang on to patients who slip, unexpectedly, off the edge of the bed.

And hey… the mattresses are not expensive… compare the cost of wound dressings for a pressure ulcer and nursing time to care for pressure ulcers once they develop, then talk to the companies about the daily cost to eventually own the mattress.. a rent and buy plan..YOU WILL BE AMAZED!!

How to not only treat wounds that won’t heal, but how to prevent them… While potentially saving a small fortune in the process

You are so busy, running your facility, looking after your staff and in the blink of an eye a PCA tells you that a resident has a pressure ulcer…You are devastated …because you simply do not know how this could have happened!

You know that you will now have to not only spend extra money on wound dressings, but that your staff, who hardly have time to fit all their work in, will now have even more work.

How do you find your way through the maze of dressings, alternating pressure air mattresses and ways of treating wounds? Well meaning, but misinformed sales reps. and undertrained staff (these days wound care is a specialist field) all have an opinion.

Almost every day I get a new residents with pressure ulcers that have developed because of lack of knowledge, misdiagnosis or faulty equipment. And as you’re probably aware, a pressure ulcer that is left to run away can lead to serious consequences. .. from opening right up into a full blown infection, to amputation of a leg and even death.

The biggest challenge in the industry is finding the time to not only run your facility and look after your staff but to try to keep on top of wounds like this. A recipe for stress, wasted funds and resources and in today’s world, potential lawsuits.

LET ME HELP

Hello! My name is Kate Sharp. I’ve been a top Wound Care Consultant in Sydney, Australia, for many years. I am the Founder & CEO of the amazingly successful Wound Centre®

And I can help you prevent and treat Pressure Ulcers in your RACF.

I can show you the best and easiest ways to not only treat pressure ulcers (even the ones that won’t heal)… but to prevent them before they tie up your resources.

Methods backed by EVIDENCE, case studies and results.

I am willing to share my knowledge with you. I have helped many RACFs become PRESSURE ULCER FREE over the past 13 years & I can do it for you too….

Just PICK UP THE PHONE & CALL ME on my mobile 0408121331 between 9am & 6pm (AEDST) if You LIVE IN AUSTRALIA…there is no charge to talk to me.

Or email me, if you are overseas, at info@thewoundcentre.com

Who am I and why should you believe me?

My passion for pressure ulcer prevention has almost taken over my life for 20 years.

I have had years of University education and even more practical bedside nursing.

Two of my Masters degrees are on the subject of pressure ulcers:

1996   Master of Clinical Nursing (USyd) ‘Assessment of Pressure Ulcer Risk and Guidelines for Prevention; and

2006  Master of Public Health (Research) (UNSW) Pressure Ulcers: risk, physiology and the magnitude of the problem in a Sydney home nursing service. (full thesis available on Google)

Other publications include

Sharp CA, Burr G, Broadbent M, Cummins M, Casey H and Merriman A. Pressure Ulcer Prevention and Care: a survey of current practice. Journal of Quality in Clinical Practice. 20: 150-157 2000

Sharp CA, Burr G, Broadbent M, Cummins M, Casey H and Merriman A. Clinical variance in assessing risk of pressure ulcer development. British Journal of Nursing 2005 14(6) pp. S4-S12

Sharp CA and McLaws M-L. A discourse on pressure ulcer physiology: the implications of repositioning and staging.  World Wide Wounds http://www.worldwidewounds.com/2005/october/Sharp/Discourse-On-Pressure-Ulcer-Physiology.html

Sharp CA, Burr G, Broadbent M, Cummins M, Casey H and Merriman A. 2006 Clinical variance in assessing risk of pressure ulcer development. In: Cutting K. ed. Trends in Wound Care Quay Books. London Vol. IV: 67-79

Sharp CA and McLaws M-L. Estimating the risk of pressure ulcer development: is it truly evidence-based? International Wound Journal December 2006 Volume 3 Issue 4 Page 344 – 353

Sharp C. and McLaws, ML. An Hypothesis of the “Middle Model” Concept Annals of Plastic Surgery: June 2010 – Volume 64 – Issue 6 – p 807.Letters to the Editor

Ramstadius B, Sharp CA, Carter R and Cavanagh J. Wound Care Association of NSW Inc. 2000 Pressure Ulcer Prevention Guidelines an Expert Consensus Statement www.ciap.health.nsw.gov.au/wcansw

Sharp CA, Ramstadius B, Blanchfield D. & Wilkins E. Pressure Ulcer Prevention Guidelines Second Edition 2007 – Wound Care Association NSW www.wcansw.com.au

References

[1] Young C. What cost a pressure ulcer? Primary Intention 1997; 5(4): 24-25.

[2] Dean A. Patient’s hospital care ‘inferior.’ 1994 Sydney Morning Herald; Thursday August 25th