EUROPEAN PRESSURE ULCER ADVISORY PANEL

EDUCATIONAL PROGRAMME FOR ASSISTANT NURSES ACCORDING TO EPUAP GUIDELINES

Anna-Britta Tallberg R.N., Agneta Bergsten R.N.
Wound Healing Centre, Department of Surgery, University Hospital, Uppsala, Sweden.

Introduction

An educational programme for registered nurses was developed and implemented in 1998 and repeated in 2001. These pressure ulcer nurses have been active in pressure ulcer prevention in their own units. Since pressure ulcer prevention is a multidisciplinary teamwork it was important to include assistant nurses in this work.

Objectives

To conduct an educational programme for assistant nurses working in different units in the university hospital, in nursing homes and home care units.

Method

The educational programme was adjusted to assistant nurses and based on guidelines issued by the European Pressure Ulcer Advisory Panel. The course consisted of twelve hours of theory (three afternoons) and practical tasks. For example, the participants should perform an inventory of routines for pressure ulcer prevention and dressings in their own units. Two nurses from the wound healing centre were course leaders together with two pressure ulcer nurses.

Result

The educational programme was held twice with thirty participants in each course. An evaluation showed that the participants were very satisfied.

Conclusion

The educational programme was successful. The number of candidates who applied to the courses was twice as many as there were places.

INVESTIGATION OF THE MINIMUM SPATIAL RESOLUTION REQUIRED BY PRESSURE MAPPING SYSTEMS FOR SEATED PATIENTS

Nicholson G, Elhusseiny A, Bain D, and Ferguson-Pell M.
Centre for Disability Research and Innovation, University College London and ASPIRE, Brockley Hill, Stanmore Middlesex. HA7 4LP. g.nicholson@ucl.ac.uk

Introduction

Wheelchair users, particularly those with spinal injuries, are at significant risk of developing pressure sores. In order to assist clinicians in the evaluation and selection of suitable cushions the mapping of pressure distribution at the buttock/cushion interface is being increasingly used. The greater the number of sensors across the interface, or spatial resolution, the greater the chance of identifying changes in pressure, giving a more realistic representation of a person’s actual pressure distribution. Commercial pressure mapping systems vary greatly in the spatial resolution, and in order to make up for a lower spatial resolution manufacturers use interpolation. The aim of this study was to assess the influence of sensor spatial resolution on measured pressure values at a seated interface and a therapists’ ability to make subjective judgements from them.

Methods

Pressure distributions from ten spinal cord injured patients and ten able-bodied subjects were collected using a high-resolution pressure mapping system (Tekscan, Boston, MA). The spatial resolution of these pressure distributions was degraded mathematically, and cubic spline interpolation applied to the degraded pressure distributions to give three pseudo levels of spatial resolution; Resolution 1, 40 x 40 sensing elements (7 mm diameter) with 10mm spacing between their centres; Resolution 2, 20 x 20 sensing elements (7 mm diameter) with 20mm spacing between their centres and interpolated to 40 x 40; Resolution 3, 10 x 10 sensing elements (7 mm diameter) with 30mm spacing between their centres and interpolated to 40 x 40. The original and degraded–interpolated pressure distributions were scored by three occupational therapists and two rehabilitation engineers in terms of obliquity, rotation, pelvic tilt and localisation of pressure. The pressure distributions were quantified in terms of peak pressure, average pressure, peak pressure index, localisation of pressure, and index gradient at peak pressure.

Results

Sensor repeatability was 2–3% between 50–200 mmHg, linearity 2–5%, creep <10% over 5 minutes continuous loading and average hysteresis 7.5%. Spatial Resolution 1 was compared with 2 and 3 using McNemar’s test for qualitative results and paired t-test for quantitative results. In the patient group there were no significant differences for observed pelvic obliquity, rotation and tilt between spatial resolutions. In the able bodied group there was no significant difference for observed pelvic rotation and tilt but there was for pelvic obliquity between resolutions 1 and 3 (p < 0.05). In both patient and able-bodied groups there were significant differences in identification of unacceptable localisation of pressure between resolutions 1 and 3 (p < 0.01) and between peak and average pressure at all spatial resolutions for all patient groups (p < 0.01). The peak pressure values were underestimated at resolution 3 in patients by up to 33% and average pressures by up 18%. There was no evidence of a difference in peak pressure for able-bodied groups but there was for average pressure at all resolutions (p < 0.001). There were significant differences between peak pressure index, localisation of pressure and gradient at peak pressure between spatial resolution 1 and 3 that wasn’t evident between resolutions 1 and 2 for both patient and able-bodied groups.

Summary

There is evidence to suggest that 7 mm diameter sensors at 30mm spacing between their centres is inadequate for the measurement of peak pressure values under the ischial tuberosities or for evaluating the suitability of different wheelchair cushions for individual patients. At this resolution the observer’s ability to assess areas of unacceptable localisation of pressure is significantly reduced and pressure appears more evenly distributed at the buttock cushion interface, limiting the identification of pelvic pathologies. This study also indicates the potential variability in defining pathologies between observers.

PRACTICAL EXPERIENCE IN USING DRAFT ISO (CD 16840-2) TEST METHODS FOR WHEELCHAIR SEATING
Part 2 : Test methods for devices intended to manage tissue in practice

Nicholson G, Bain D, and Ferguson-Pell M.
Centre for Disability Research and Innovation, University College London and ASPIRE, Brockley Hill, Stanmore Middlesex. HA7 4LP. g.nicholson@ucl.ac.uk

Introduction

Pressure ulcers are a major secondary medical complication experienced by many people with physical impairments. Many new cushion designs for prevention of ulcers during wheelchair use have evolved and reached the market. There are also many methods used to characterise them but which yield results that are not comparable, leaving the user/carer with few guidelines on cushion selection and manufacturers with little data upon which to compare or improve their products. In the last few years the International Standards Organisation committee ISO/TC 173/SC 1/WG 11 has been developing standard test methods for testing and disclosing the characteristics of wheelchair cushions. As part of this development process it is imperative that the test methods are assessed for practicability and relevance, and this poster seeks to demonstrate some of these issues.

Methods

Five cushion types were evaluated. Two standard foam blocks with high resilience foam HR45 and 70, and three Varilite ‘air and foam floatation’ cushions (Evolution, Stratus and Solo). A cushion loading indentor (CLI) was used to characterise interface pressure distributions according to draft ISO specifications (ISO/TC 173/SC 1/WG11 Part 2). A RLG to which loads were applied was used to determine the load deflection of the cushion in square wave loading, 30 s per interval from 0 to 750 N to 0 N. The cushions were fatigued using the RLG to repeatedly apply load to the cushion between 0 and 750N at 1Hz for 20,000 cycles. The load deflection test applied was applied after each 20,000 cycles and pressure distribution measured after a total of 200,000 cycles.

Results

Pressure distribution was analysed in terms of max pressure, average pressure, dispersion index DI, 1st and 3rd quartiles, contact area and peak pressure index PPI. The resilience and restoration energy of the Varilite cushions was calculated before and after fatigue. In all pressure tests the indicated force was within 10% of the applied force. The pressure distributions showed significantly lower pressure values, DI and PPI in the Varilite cushions than the two standard foam blocks. There was no visible sign of physical deterioration in the cushions due to fatigue but there was a small but significant increase in maximum pressure and DI, and decrease in contact area. The PPI for Evolution and Stratus showed a significant increase and the Solo no change. The 1st and 3rd quartiles for Evolution and Solo were only slightly but significantly affected by fatigue. The stratus showed no change. Only the increase in DI for the Evolution could be explained by a 10% increase in measured force. There was a significant change in resilience and restoration energy in the Evolution and Stratus cushions after fatigue.

Conclusion

What do these results indicate? The pressure distributions using the standard buttock shape CLI indicate that the Varilite cushions give a more even distribution across the interface than standard foam blocks. The peak pressure, dispersion index, and contact area are definite indicators. However, the assessment of quartiles gives no information on localisation of pressure, i.e., possible high pressure areas, and have now been removed from the current draft standard. The assessment of resilience and restoration energy can give misleading results that may not be relevant to the different types of cushion assemblies now marketed. They were originally used for characterising foam slabs and cushions that may be used by many people. They do not take into account conformability of the cushion nor the custom fit to an individual. The “fatigue” test produced only small changes in the cushions, raising the question whether they were really fatigued at all. Had more cushions of a single type been tested for inter-cushion reproducibility such differences may no longer have been of significance.

AN EXAMINATION OF THE EFFICACY OF THE CONTRACTURAL PAD FOR PRESSURE ULCER

Makiko Tanaka, Miki Haruma, Maki Mimura and Kouji Kajiwara
Yamaguchi Prefectural University School of Nursing, Yamaguchi, Japan. Molten Corporation, Hiroshima, Japan

Introduction

Through the questionnaire administered to 404 nurses in Japan, it was made clear that many nurses experience difficulty with positioning of patients with pressure ulcer. It was particularly noteworthy that while 84% of the nurses felt the necessity of the positioning as a care for contractural patients, they did not possess any effective methods. A pad for contractural patients was therefore devised; its effects are described in this paper.

Method of Measurement

Because it is not possible to generalize contracture, the upper body muscular contracture (the shoulder’s incyclo-duction, adduction, and upper arm pronation) often seen in clinical settings, was used as the standard contractural position. The contractural pad was made of perforated urethane foam with the cover having a perforated honeycomb structure. The body pressure dispersion effect and the humidity of this pad were examined when the pad was placed under the arm and when it was not.

Conditions of Measurement

The contractural standard position was simulationally assumed. Then the body pressure sensor and the humidity sensor were placed and a measurement for each was taken five times with one subject (female, BMI 19.0). As for the humidity, a measurement was taken after over one hour of continuous usage.

Results

The average body pressure when the contracture pad was not used, was 51mmHg, while the average when it was used was 28.6 mmHg, indicating a lower body pressure when the contractural pad was in use. As for the humidity, an examination of an approximate linear line showing the humidity change showed a larger slope when the pad was not used, indicating a marked increase of humidity. The humidity one hour after the beginning of the measurement was 71% when the pad was not used and 30.7% when it was used.

Summary

It may be concluded that the contractural pad under discussion was effective as a cushioning device to the body pressure and humidity.

STUDY OF FIVE BED MATTRESSES USING PRESSURE MAPPING AT 500-BED LONG-TERM CARE FACILITY

Vern C. Taylor, P.T. Physical Therapist, Verg Inc., Winnipeg, Manitoba, Canada
Beth Kondratuk, R.N., B.N., M.S.A, Clinical Nurse Specialist, Deer Lodge Centre, Winnipeg, Manitoba, Canada

Introduction

In North America, over 1.8 Million people develop ulcers annually,1 which cost up to $1.3 Billion/year.2 Prevalence is estimated at 11% in skilled-care and nursing homes, 10% in acute care, and 4.4% in home care.3,4,5 Causes of these ulcers is multifactorial and include lowered sensory perception, immobility, incontinence/moisture, altered level of consciousness, poor circulation, severity of disease, and poor nutritional status.6,7,8,4,9 Wound Care is expensive. The cost of treating one ulcer is reported to be from $5,000 to $60,000 depending on stage of ulcer and patient condition.10,11,12,13 Long Term Care facilities have the challenge of caring for the chronically ill on a continuing basis. This group of patients is subject to pressure ulcers associated with their disabling condition. Nursing at these facilities must provide preventative management and heal existing wounds within a very limited budget.

Methods

This study assesses five bed mattress surfaces that range in cost from least expensive to the highest affordable price within the institutional budget. A multi-layered single case study design was used with a healthy 81-year-old volunteer that closely matched the average (age, gender, weight) of the patient population. The volunteer was positioned in four standard nursing positions used routinely in care at the facility. A Standard Hospital mattress was used first and last for each test series to provide a control. Multiple pressure maps were taken of each position, using a calibrated Force Sensing Array (FSA) pressure mapping system.[*] Results were collected and pressure distribution was compared for each position and all mattress surfaces using three methods:

Sensor Count: defined as total number of sensors reading above a minimum threshold. This measure indicates how much contact is occurring with the patient in each position and each mattress type. This would indicate the amount of envelopment for each bed mattress.

Peak Pelvic Pressure Row: the cross-sectional row of highest pressures identified at the pelvis region in each position for each surface was graphed and compared. This allowed the different surfaces to be compared on a single graph for the pressure row at the highest pressure point through the pelvis.

Pressure Map Comparisons: the complete pressure map images were blinded to the type of surface and the readings for each nursing position were presented to the care-giving nurses for ranking (best to worst) in their judgment. The nurses were also asked to rate the comparative value of the pressure map based on the nurse’s perception of usefulness to their patient using a 0–5 scale. Five skilled wound care nurses and five regular duty nurses were used and these results were then graphed separately and together for comparison.

Results

Presented results demonstrate: Sensor Count, the most objective measure, showed Standard hospital mattress to be poorest in all positions but did not demonstrate much differentiation for other surfaces. Peak Pelvic Pressure Row graphing clearly demonstrated relative differences well which allowed good comparison of different surfaces for each position. Pressure Map comparisons by nursing staff showed good correlation amongst assessors and allowed for ranking and valuation of the surfaces under consideration.

Summary

Using a standardized assessment with a healthy volunteer, representative of patient population, with three review methods derived from pressure mapping proved very useful in understanding the relative value of the bed mattress surfaces under consideration by nursing. From this assessment a recommendation was compiled for mattress purchases for prevention and management of ulcers in the facility. It is hoped that this evidence based recommendation forwarded to administration for future mattress purchases would aid nursing to provide improved quality of care within a limited budget including prevention and healing of Pressure Ulcers in this Long Term Care Facility.

[*]Verg Inc. manufactures the FSA Pressure Mapping System used in this study. The second author is a co-owner of the company and provided the technical equipment and assistance for this study.

References

1. POV Inc.(1998), Long term care: Evolving business opportunities and threats. Cedar Grove, NJ.
2. Miller, H. and Delozier, J.(1994) Cost implications of pressure ulcer treatment guideline (pp. 1–17). Columbia, MD: Center for Health Policy Studies. CNo. 282–91–0070. Sponsored by HCP&R
3. Barczak, C.A. et al(1997), Fourth National Pressure Ulcer Prevalence Survey. Advances in Wound Care, 10(4), 18–26.
4. Brandeis, G.H., Berlowitz, D.R., Hossain, M., and Morris, J.N. (1995). Pressure ulcers: The minimum data set and the resident assessment protocol. Advances in Wound Care 8(6), 18–25
5. Hallet, A.(1996), Managing pressure sores in the community. Journal of Wound Care 5(3), 105–107.
References 6–13 were provided at the conference.

STUDY ON PRESSURE ULCERS (PU), THEIR LOCATIONS AND PROTECTION MEASURES ON THREE INTENSIVE CARE UNITS OF THE ACADEMIC MEDICAL CENTER IN AMSTERDAM

J.A. Tutuarima 1, M.J. Lubbers 2, J. Vorstermans 3
1. Nurse researcher, Department of Neurosciences,
2. Surgeon intensivist, Department of Surgery,
3. Intensive care nurse, The Academic Medical Center, University of Amsterdam in Amsterdam, The Netherlands

Introduction

On the Intensive care units PU are a serious problem. High percentage is usual.1 The Dutch Institute for Healthcare Improvement (CBO) in Utrecht started a multi-center project to improve risk assessment, prevention, diagnosis and treatment of existing pressure ulcers. This study is part of the CBO project. The objective of this study is to determine the prevalence of pressure ulcers (PU) and of post surgical onset of PU as well as factors associated with PU and to assess the specific protection measures.

Methods

We designed an observational cohort study on 130 consecutively admitted patients in three adult intensive care units of a Dutch university hospital. The primary nurse daily inspected the presence of PU and assessed the protection measures with regard to prevention and healing of PU over a period of two months.

Main results

Of the patients 31% suffered from hospital acquired PU. Sacrum, ears and heels were most involved (15, 12 and 12% respectively), buttocks, mouth and back were affected in 5, 4 and 4% respectively. All other nine locations were less involved. Post surgical assessment showed PU of the lip and fingers in one patient each, of the back of head in two cases, of the nose and mouth in three patients each, of the buttocks in five cases, and of the sacrum in nine patients. Cross tabulation on PU showed no association with gender age, post surgery and Apache II. All patients are positioned on active pressure relief mattresses. Extra protection measures were practised to 80% of the patients. Protection of heels and ears each to 60% of the patients, multiple turning position and protection of the skin to 43 and 38% respectively.

Summary

This observational study showed evidence based figures of PU and detailed locations and protection measures of an highly risk population of patients for PU in an acute care setting.

Reference

1. Bours GJ, De Laat E, Halfens RJ, Lubbers. M. Prevalence, risk factors and prevention of pressure ulcers in Dutch intensive care units. Results of a cross-sectional survey. Intensive Care Med. 2001 Oct;27(10):1599–1605.

MEASURING THE PRESSURE AT ‘THICKENED EDGES’ AND ‘NORMAL EDGES’ OF A WOUND

Mayumi Okuwa1, Hiromi Sanada1, Junko Sugama1, Chizuko Konya1, Atsuko Kitagawa1, Yumiko Fujimoto2 and Nao Tamai3
1. School of Health Sciences, Faculty of medicine, Kanazawa University, Japan. 2. Kobe City General Hospital, 3. St Luke’s International Hospital.

Introduction

The 30-degree lateral and 30-degree head-elevated positions are widely used in a clinical setting for patients with pressure ulcers to relieve the localized pressure on bony-prominent areas. A result of this positioning sometimes causes the perimeter regions of the pressure ulcer to thicken. This phenomenon is believed to be caused by increased pressured on the perimeter of the wound. However, a new affixed sensor (by DENSO Ltd.) was developed to quantitatively measure the localized pressure around a wound. The purpose of this study was to use this device to measure the pressure on this thickened perimeter region and compare it with other local regions of a wound.

Methods

SENSOR SPECIFICATIONS
Pad Material: 3 Polyethylene naphthalate (waterproof) sensor pads
Pad Dimensions: diameter x thickness (5 mm x 0.3 mm)
Recording Interval: 0.16 sec. (simultaneous recording of all three sensors) The reliability and validity of the sensor were confirmed.

SUBJECTS
The informed consent was received by the five bedfast patients (mean age 78.6) with pressure ulcer who participated in this study. In the perimeter of each wound thickened parts and normal (thickening-free) parts existed. The wounds were located at sacrum or coccyx.

CONDITIONS AND MEASURING PROCEDURE
The pressure of specific areas around the wound region for each patient was measured at thirty-minute intervals with the patients lying in both the 30° lateral and 30° head-elevated positions. We measured the pressure of visibly thickened edges and normal edges of each wound.

ANALYSIS
We categorized our data into two groups. One representing ‘thickened edges’ and the other representing ‘normal edges’. We then compared both the maximum pressure values as well as the average pressure values for each group by using the Wilcoxon test.

Results

Both the 30-degree lateral position and 30-degree head-elevated position showed that the maximum pressure as well as the average pressure of the ‘thickened edges’ was significantly greater than that of the ‘normal edges’.
Conclusion
Based on our results, we found that the pressure at the ‘thickened edges’ was greater than at the ‘normal edges’. Furthermore, we found that positioning patients in the 30° lateral or 30° head-elevated position may not decrease the local pressure of these areas. We need future research to confirm a relationship between the positioning and the physical characteristics in Japanese elderly.

CLASSIFICATION OF HEALING PROCESS PATTERNS OF PRESSURE ULCERS WITH UNDERMINING FOR JAPANESE ELDERLY

Chizuko Konya, Hiromi Sanada, Junko Sugama, Mayumi Okuwa and Atsuko Kitagawa
School of Health Sciences, Faculty of Medicine, Kanazawa University, Japan

Introduction

Since there has been no reported research on the healing process for the conservative treatment of pressure ulcers with undermining, the healing process of this type of pressure ulcer is unknown. The purpose of this study was to categorize pressure ulcers with undermining into patterns and to examine the healing process of each pattern. We also attempted to determine what type of nursing care and physical factors influenced the healing process of each pattern.

Method

This study involved 69 elderly patients (65 years old, or older) with Stage III or IV pressure ulcers. We examined a total of 79 pressure ulcers. Informed consent was obtained from all patients. Photographs of the pressure ulcers were taken and hand-sketched on a weekly basis. Based on these sketches, we described the healing process of each pressure ulcer. We then inductively classified and statistically compared the following criteria of each healing process pattern: the healing period, wound surface area, type of nursing care and various physical factors.

Results

Of the 79 pressure ulcers, 57% were undermining. Based on the pressure ulcer healing process (undermining and epithelialization), ten healing patterns were inductively categorized. We discovered two phenomena: 1) When undermining was present with no necrotic tissue, the undermining spread inversely to wound contraction, a phenomenon we termed as ‘Undermining-spread-partial wound margin’, (hereafter referred to as ‘Us’). 2) Some epithelialized wounds closed only by contraction, a phenomenon we termed as ‘Epithelialization-contraction’, (hereafter referred to as ‘Ec’).Our results show the wound-healing period for general epithelialization was longer than for ‘Ec’ type wounds (p = 0.008). The physical factors that influenced undermining were external bony prominence (p = 0.003), urinary incontinence (p = 0.011), contracture (p = 0.023), and loose skin in the buttock area (p = 0.020). Similarly, the physical factors that influenced ‘Ec’ were external bony prominence (p = 0.0016), urinary incontinence (p = 0.001), shear (p = 0.032), and contracture (p = 0.025).

Summary

Based on the healing process for Stage III or IV pressure ulcers, we discovered the phenomenon referred to as ‘Us’ and ‘Ec’ and inductively categorized ten healing process patterns. The results show these categories of undermining and ‘Ec’ to have a significant relationship with external bony prominence, urinary incontinence and contracture.

The remaining Poster Abstracts from Tampere will appear in the next issue of the EPUAP Review.