Take the pressure down: preventing pressure ulcers10 April 2018
Pressure ulcers, or bed sores, can be a chronic source of pain and discomfort for patients, but a new dressing could help improve their condition. Dave Callaghan gets an expert view on the matter from Carol Johnson of County Durham and Darlington NHS Foundation Trust, and Elaine Thorpe, from University College London Hospitals NHS Foundation Trust.
Known to patients as ‘bed sores’, pressure ulcers are a huge problem for bedridden people. Unlike other issues, pressure ulcers usually develop while a patient is in hospital, not before they are admitted. With the risk of serious complications if not treated effectively, pressure ulcers often present difficulties that add to a patient’s list of needs.
Pressure ulcers can develop easily, especially if a patient does not move regularly. Old age, poor general health or a lack of good nutrition can also be aggravating factors. Health problems such as diabetes can make the treatment of pressure ulcers particularly challenging, especially as healing is slower.
Serious conditions such as meningitis, cellulitis or endocarditis can result from a failure to adequately address pressure ulcers, leading to infection. In some cases, the muscle and bone are actually exposed as the pressure ulcers develop.
Apart from ensuring patients move themselves routinely, are moved by nursing staff, or helped using props such as alternating pressure beds, foam mattresses or cushions, and are keeping as well as possible with a balanced diet, there is a limit to what can be done to prevent pressure ulcers.
Now, a new type of preventative dressing has been examined by the National Institute for Health and Care Excellence (Nice). It can be applied to heels or the lower back or sacrum areas of the body, where pressure ulcers are most likely to develop, and no extra staff training is required. There are dressings for the treatment of pressure ulcers, but until now, not prevention.
The Mepilex dressings produced by Molnlycke are self-adherent, multilayer foam dressings that include soft silicone technology called ‘Safetac’. They come in different sizes and there are five layers that each perform a different function in protecting the skin.
The layer closest to the skin can be peeled back and reapplied with minimum discomfort to the patient, which allows the skin to be checked multiple times. This layer is designed to prevent friction between the skin and dressing. The other four layers are there to cushion, prevent stretching or tearing, absorb moisture and allow moisture to evaporate.
A briefing issued by Nice quoted three expert commentators, two of whom said they believed the dressings to be an innovative tool. They said the dressings helped patients who have sensory or motor impairments and those at high risk of developing pressure ulcers when they enter critical care. The third expert said they felt it would be a minor addition to current practice.
The Nice briefing is positive about the Mepilex dressings. According to the document, “Mepilex Border dressings would be used in patients of all ages in acute-care settings who are considered to be at risk of pressure ulcers. The dressings may also be used in the community in patients who are at risk of pressure ulcers through mobility issues. They would mainly be applied by nursing staff.
“The main points from the evidence summarised in this briefing are from two randomised controlled trials and one cohort study, including a total of 956 adults in critical-care and emergency-room settings. The studies show that standard care plus Mepilex Border dressings are more effective than standard care alone in preventing pressure ulcers.
Caution and cost
However, Nice does add some provisos. “Key uncertainties around the evidence or technology are the lack of evidence directly comparing Mepilex border dressings and standard care in patients at high risk of developing pressure ulcers in the NHS, and a lack of evidence of effectiveness in children,” the briefing reads.
– Elaine Thorpe
“The evidence included adults only, but the technology can be used in children, so further research evaluating the effectiveness of Mepilex Border dressings in children would be useful.”
Nice also points out that none of the evidence was from the UK, and so may not be generalisable to the NHS. “Using Mepilex Border dressings would represent an additional cost to standard care. This could be offset if using the dressings reduced the severity or incidence of pressure ulcers,” Nice concludes.
The dressings cost £3–7 each before VAT, are sold in packs of five and might need to be changed every three to five days. The Nice briefing says these costs should be considered against the savings in the treatment of pressure ulcers. Nice guidelines estimate the daily cost of treating pressure ulcers is between £43–374 in addition to normal care costs.
No silver bullet
One of the expert commentators is Elaine Thorpe, a critical care matron with University College London Hospitals NHS Foundation Trust. She is keen to stress that the dressings are not the answer to pressure ulcers. “Using the dressing is part of our pressure ulcer prevention strategy. Using the dressing alone would not prevent pressure ulcers occurring – that's very important to clarify,” she points out.
However, she does believe the dressings can play an important role. “[In] critical care, we use a proactive prevention strategy to do all we can to prevent the pressure damage occurring. We use SSKIN [an approach to preventing ulcers] that ensures patients have the right mattress, turning frequency and so on. Despite using the SSKIN bundle very well, we still had a few pressure ulcers, especially in low-BMI patients, that were initially caused by friction or shear,” she says.
“Using the Mepilex Border dressing as part of a preventative strategy seemed like the last piece of the jigsaw. The dressing goes on to the patient's sacrum as soon as they arrive [at] critical care and it can be left on for several days, but has the ability to be pulled back and reapplied every shift, or more frequently, to check the condition of the patient's skin. We take it off before the patient is discharged to the ward. The dressings can be applied to other areas such as elbows and heels, but we generally only put it on the sacrum.”
The dressings could also be very useful in other hospital settings, Thorpe says. “I do believe that there is a place for the use of a preventive dressing outside of critical care, [including] areas where patients have a higher risk, such as elderly care, cancer care, end-of-life care and patients who are having very long operations. The difficulty lies in ensuring that staff are checking what's going on underneath the dressing and it's not just left [there]. On critical care, we have higher nurse-to-patient ratios, so it's easier to do that,” she says.
“The dressings practically are very easy to use and so [have] no issues. Patients and staff new to critical care sometimes wonder why we are putting a dressing on 'when something’s not broken', but when we explain the reason, we easily overcome that hurdle. As with any piece of equipment, it costs money, but the price of a dressing versus the cost of a pressure ulcer – financially for the trust, and emotionally and psychologically for the patient – is easily outweighed,” she says.
More study needed
Another of the experts consulted by Nice was Carol Johnson, who is tissue viability matron at County Durham and Darlington NHS Foundation Trust (CDDFT). She agrees the dressings have a valuable contribution to make.“Within our experience, the Mepilex Border heel dressings are effective, as they decrease the skin interface pressure, decrease shear and friction, and aid in the prevention of heel blistering. Within our organisation, we have used them with patients who have had spinal or epidural anaesthesia pre and post-operatively, until the patient’s sensation has fully returned, with excellent results.”
She also agrees that they are not a solution on their own. “The dressings themselves are not the sole answer to preventing pressure ulcers,” she says. “However, I do believe that they have a place in the overall ‘toolbox’ of pressure ulcer prevention and, when used in conjunction with excellent nursing care, skin assessments and other prevention strategies, they complement the care delivery, and assist in the prevention of friction and shear tissue damage.
“Within CDDFT, we use them routinely for all hip surgery patients from the point of admission. We are currently undertaking a pilot study using them in paediatrics. I do feel that there is potential for wider use; however, this requires scoping, investigating, evaluation and further research of the use of [the dressings] in various clinical practices. We are currently undertaking this as a scoping exercise in CDDFT.”
Johnson does not see any major issues with the dressings. “Since the relaunch of the newer dressing, which has higher aspects covering the malleolus, we have found little drawback or issues with using the dressing,” she explains. “Patients find them comfortable and they don’t inhibit any clinical needs the patients may have. The skin can be seen and examined, and the dressing replaced without the need to change it.”
The dressings are also a good investment from a financial point of view. “The obvious drawback for organisations is the initial cost outlay. However, when reviewed against the economic costs of treating pressure ulcers attributed to friction and shear forces, we found the dressings extremely cost-effective, with over 150% return on investment for its implementation,” Johnson says. The dressings can also help to reduce care costs for cash-strapped medical services.
So while they may not be the magic wand to make pressure ulcers disappear, the Mepilex dressings can clearly be an important part of a care package for hospital patients.