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Several stakeholders supplied new evidence, however none was suitable for inclusion in the surveillance review for various reasons (unpublished research, unsuitable evidence type, not in scope, outside search dates). A cross-referral to the NICE guideline on nutrition support for adults will be made from recommendation 1.4.5. Multiple guidelines recommend the use of a heel protection device that completely offloads the heel to help prevent the development of heel pressure injuries. 1,2 Prevalon ® Heel Protectors are the number one brand of heel protection. 3 They offer continuous heel offloading to protect your patients’ heels. START A TRIAL Choose the optimal heel protector Oftentimes, Dr. Suzuki sees pressure ulcers starting with a period of immobility, such as when patients are acutely ill and hospitalized for a period of time. Sometimes, Dr. Suzuki notes pressure ulcers may develop slowly at home if patients have inappropriately hard bedding surfaces, poor dental condition (which is extremely common in older patients) and gradual malnutrition, which he notes may cause a slow deterioration of their skin. A cross-referral to the NICE guideline on antimicrobial stewardship: systems and processes for effective antimicrobial medicine use will be made from recommendations 1.4.21, 1.4.22, 1.5.18 and 1.5.19.
A stakeholder requested we consider new evidence about the association between moisture-associated skin damage and pressure ulcers. However no new evidence was supplied. The evidence already identified by the surveillance review on incontinence and pressure ulcers was consistent with the guideline. Multiple guidelines recommend the use of a heel protection device that completely offloads the heel to help prevent the development of heel pressure ulcers. Prevalon® Heel Protectors are the number one brand of heel protection. They offer continuous heel offloading to protect your patients’ heels. Choose the optimal heel protector Additionally, Dr. Wendelken finds pressure ulcers in areas such as the medial first and lateral fifth metatarsal heads. Other less common areas where pressure ulcers form are the proximal fibula head and the anterior ankle, according to Dr. Wendelken. He notes the anterior ankle ulcer is commonly caused by a dressing that one did not properly apply and is usually too tight. In his practice, Dr. Wendelken most often finds pressure ulcers on the heel, typically the retrocalcaneal surface and the lateral heel. He also encounters numerous pressure ulcers on the ankle over the malleolus as well as pressure ulcers along the lateral aspect of the foot (base of the fifth metatarsal at the styloid process). In his clinic, Dr. Suzuki has seen quite a few “ankle” pressure ulcers over the lateral malleolus or even the medial malleolus as some of his patients sleep on their sides. This may turn the ulcer into a chronic ulceration at the tip of the malleolus, according to Dr. Suzuki. A study published in JWOCN found the use of Prevalon and a heel ulcer prevention protocol led to a 95% decrease in heel pressure ulcers. 2
Dr. Wendelken notes a group 1 mattress overlay may be indicated and is covered by the Centers for Medicare and Medicaid Services (CMS) if the mattress meets the following conditions: Dr. Sage evaluates the wound for signs of infection and evaluates the foot for signs of ischemia. If infection is present, he says debridement and/or antibiotics may be necessary, but he does not debride stable, non-infected blisters or eschars. When a new patient presents with what appears to be a pressure ulcer on the lower extremity, Dr. Wendelken proceeds with a vascular assessment that includes an ankle/brachial index, a neuropathy assessment that utilizes the Semmes Weinstein test, and an assessment of mobility and range of motion. A stakeholder queried if frail older people should be a separate category in the guideline. No evidence was found about this issue by the current surveillance review. The Waterlow score (1 of 3 tools the guideline recommends considering for assessing ulcer risk) includes items for age, and skin type (for example tissue paper - thin/fragile). No impact on the guideline is currently expected. This is a randomised controlled study (RCT) to investigate the effectiveness of Prevalon Boots when used to prevent heel pressure injury among orthopaedic hospital patients. Orthopaedic in-patients with either no visible heel pressure damage or category I heel damage will be identified by their health care provider and willing patients, meeting the inclusion and exclusion criteria, will be consented.
A study published in JWOCN found the use of Prevalon and a heel pressure injury prevention protocol led to a 95% decrease in heel pressure injuries. 2 A cross-referral to the NICE guideline on peripheral arterial disease: diagnosis and management will be made from recommendation 1.4.26. I despise those heel cradle cushions,” says Dr. Suzuki. “They are widely used pillow boots that are attached directly to the heel itself. They add bulk to the heel and do nothing to prevent or offload heel pressure ulcers.” Q: Do you recommend or prescribe a bed or mattress for their pressure issues? A: Integrated Anti-Rotation Wedge helps prevent lateral rotation, reducing risk of peroneal nerve damageMaintaining alignment [with a pillow] may be difficult if the patient moves. In addition, pillows do not prevent plantar flexion contracture or lateral leg and foot rotation.” 1 NICE guideline CG179 recommendations 1.4.3 and 1.5.3 refer to the International NPUAP‑EPUAP [2009] Pressure Ulcer Classification System. This has had 2 revisions since 2009, therefore the reference to a specific year will be deleted. Stakeholders requested a definition of a high-specification foam mattress be added to the guideline. It was noted that the guideline examined evidence on a variety of different high-specification mattress types, and the guideline committee were therefore unable to be highly specific about the nature of mattresses and so used the term 'high-specification foam mattress' (which is also used by the NPUAP/EPUAP/PPPIA guideline). The primary outcome measures will be (i) incidence of new pressure ulcers at the heel and (ii) resolution of category I heel pressure ulcers. Secondary endpoints will be patient comfort along with patient and staff acceptance of the heel protectors. Calf Cradles completely elevate the heels and distribute pressure over the lower leg without creating undue pressure on the Achilles tendon
A stakeholder wanted to draw attention to limitations of moist wound care. However the current surveillance review identified 2 RCTs showing benefit of moist dressings, which agrees with the guideline recommendation to consider using a dressing that promotes a warm, moist wound healing environment. A cross-referral to the NICE guideline on sepsis: recognition, diagnosis and early management will be made from recommendation 1.4.18. the patient is completely immobile (i.e., the patient cannot make changes in body position without assistance); orA stakeholder drew attention to one of their products which prevents pressure ulcers in the operating theatre. The product is a high-specification foam mattress and is therefore covered by the recommendations for high-specification foam mattresses in the guideline. We found no evidence in the current surveillance review specifically concerning this product.
Dr. Sage is a Professor and the Chief of the Section of Podiatry at the Department of Orthopaedic Surgery and Rehabilitation at the Loyola University Stritch School of Medicine in Maywood, Ill. b) Distribute or display publicly the Training Video or any derivative works, in whole or in part, in any medium and for any purpose other than for internal training and educational purposes. Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles, and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo.Dr. Sage adds that ischemic extremities may require vascular intervention if the patient is a suitable candidate and he emphasizes the importance of offloading. Q: Where do you see the pressure ulcer in the lower extremity in your practice? A: Forty patients will be randomised, 20 to receive Prevalon boots and 20 to receive the standard pressure ulcer prevention method used by the ward they are on, to be used whilst in bed. Patients will be assessed daily for 10 days and at each assessment their heels will be photographed using a high resolution digital camera. A blinded assessor will assess all of the photographs to determine whether pressure damage has occurred at the heels.
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