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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. 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: For the longest time, Dr. Suzuki found the sacral ulcer to be the most prevalent of all pressure ulcers he observed. Now he cites data from the Symposium on Advanced Wound Care Spring/Wound Healing Society (SAWC Spring/WHS) and other national conferences that the posterior heel pressure ulcer may have become the number one most common pressure ulcer, closely followed by sacral ulcers.2,3 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. McGovern J, DiPerri J. Heel pressure ulcer prevention: a comparative effective evaluation. Presented at the 25th Annual Symposium on Advanced Wound Care Spring (SAWC Spring)/Wound Healing Society (WHS), April 19-22, 2012.

Pharmacy product

In his practice, Dr. Sage most often sees pressure ulcers on hospital patient consults, usually in seriously ill patients who have been on prolonged bed rest. He notes that he does not see nursing home patients or make house calls. Q: What kind of offloading boot or brace do you prescribe to your pressure ulcer patients? A: Kazu Suzuki, DPM, CWS, views treating pressure ulcers like treating any other wounds. He starts with a thorough history, figures out when and how the pressure ulcers started, and what kind of pressure formed the ulcers. Similarly, Martin Wendelken, DPM, emphasizes the importance of having a clear understanding of the patient’s activities of daily living and ability to perform those functions, and includes a Braden Scale assessment on the patient. 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. 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.

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 Maintaining 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 A cross-referral to the NICE guideline on sepsis: recognition, diagnosis and early management will be made from recommendation 1.4.18. A 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. 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 stakeholder queried why high-specification foam mattresses were specifically recommended during surgery for adults but not children. Recommendations on support surfaces for children are less specific on settings than the recommendations in adults and therefore cover using a high-specification mattress in surgery. 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 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. Individuals in bed who are completely immobile should have a care plan that includes the use of devices that totally relieve pressure on the heels, most commonly by raising the heels off the bed.” 2 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 peripheral arterial disease: diagnosis and management will be made from recommendation 1.4.26.the patient has limited mobility (i.e., the patient cannot independently make changes in body position significant enough to alleviate pressure and at least one of the conditions A-D below); or Stakeholders asked for the PURPOSE-T risk assessment tool to be added to the guideline. All evidence we have examined for this suggests further study is needed, therefore we will await further evidence before considering it as a recommended tool. 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.

Dr. Wendelken notes that in each case, the medical record must document the severity of the condition sufficiently to demonstrate the medical necessity for a pressure reducing support surface. If Dr. Sage anticipates that an inpatient is likely to have prolonged immobility, he will prescribe such protection prophylactically. If there is drainage from any wound, he has patients cleanse the area daily, apply a topical product such as Silvadene and use a light gauze and Kerlix dressing to cover the wound as necessary to absorb the drainage. He emphasizes the importance of offloading. 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: Another study published in JWOCN demonstrated a 100% prevention of both heel pressure injuries and plantar flexion contracture over a seven month period when using the heel protector device. 3

Prevalon® Heel Protectors – Reducing heel pressure ulcer risk

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. 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. 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. In one study, implementation of a heel pressure ulcer prevention protocol that included Prevalon Heel Protector resulted in a 28% decrease in facility- acquired heel pressure ulcers over a one-year period. Continued use of the Prevalon Heel Protector over four years, coupled with in-depth education, continuous monitoring of compliance, and continual reporting of outcomes to ensure accountability, resulted in a cumulative 72% decrease in heel pressure ulcers. 4 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.