Prevention of Heel Ulcers and Plantar Flexion Contractures in High-Risk Ventilated PatientsTina Meyers, BSN, RN, CWOCN, ACHRN – Conroe Regional Medical Center, Conroe TX

Patients in the intensive care unit (ICU) have a high risk of developing heel pressure ulcers (hPUs) and plantar flexion contractures (PFCs), with prevalence ranging from 14% to 41%, and incidence ranging from 1% to 56%.1 In one study, approximately 50% of ICU patients with severe sepsis experienced acutely acquired neuromuscular dysfunction,2 which is a complex process leading to myopathy in the critically-ill, the morphology of which is well described in Millers Anesthesia 6th Edition.3 In addition to the pathophysiological processes associated with high-risk critically-ill patients, such as polyneuropathy and myopathy, the new reimbursement policies of the Centers for Medicare & Medicaid Services (CMS) are a strong catalyst for refocusing efforts on preventing negative outcomes and hospital-acquired conditions such as pressure ulcers.4

An IRB-approved study (waiver received) was conducted to assess the impact of a heel protector* intervention on hPU rates and PFCs through the use of a heel protector in a high-risk, sedated, intensive care unit (ICU) population. Patients who did not receive the heel protector for off-loading the heel, received a pillow for heel offloading (per facility protocol).

Keller BP, Wille J, van Ramshorst B, van der Werken C. Pressure ulcers in intensive care patients: a review 1. of risks and prevention. Intensive Care Med. 2002;28:1379-1388.

Khan J, Harrison TB, Rich MM, et al: Early development of critical illness myopathy and neuropathy in 2. patients with severe sepsis. Neurology. 2006; 67:1421–1425.

Miller R. 3. Morphology. Miller’s Anesthesia, 6th ed. Orlando, FL:Churchill-Livingstone;2005.

Centers for Medicare and Medicaid Services. Federal Register Part II 42 CFR Parts 411, 412, 413, and 4. 489: Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates; Final Rule. Federal Register. 2007;72(162):47201-47205.

Whittington KT, Briones R. National prevalence and incidence study: 6-year sequential acute care data. 5. Adv Skin Wound Care. 2004;17:490-494.

Tourtual DM, Riesenbert LA, Korutz CJ, et al. Predictors of hospital acquired pressure ulcers. 6. Ostomy/Wound Manage. 1997;43(9):24-40.

Landi F, Onder G, Russo A, Bernabei R. Pressure ulcer and mortality in frail elderly people living in 7. community. Arch Gerontol Geriatr. 2007;44 Suppl 1:217-223.

Wong VK, Stolis NA. Physiology and prevention of heel ulcers: the state of science. 8. J Wound Ostomy Continence Nurse. 2003;30:191-198.

Hoppenfeld S. (1976). 9. Physical Examination of the Spine and Extremities. Norwalk, CT:Prentice-Hall;1976.

Kapandji IA. Ilustrated Physiology of Joints. 10. Med Biol Illus. 1964;14:72-81.

Kendall FP, McCreary EK, Provance PG, et al. 11. Muscles: Testing and Function with Posture and Pain. 5th ed. Baltimore, MD:Lippincott Williams and Wilkens;2005.

References

* Prevalon, Sage Products Inc.

Prevention of Heel Ulcers and Plantar Flexion Contractures in High-Risk Ventilated PatientsTina Meyers, BSN, RN, CWOCN, ACHRN – Conroe Regional Medical Center, Conroe TX

100% prevention of hospital-acquired hPUs

100% prevention of plantar flexion contractures

21202

NPUAP’s Biennial Conference, February 27-28, 2009

The study resulted in 100% prevention of hPU development, 100% prevention of PFC development, enhanced caregiver compliance with existing protocols, and several surprising secondary findings:

9.4% showed improvement in heel status from entry to discharge

11.3% of existing heel skin conditions stayed the same with no change and no worsening in status

50% of abnormal heels showed improvement

hPUsHeel PUs are the second most common pressure ulcer in the clinical setting,5 and can result in serious complications such as osteomyelitis, cellulitis, septicemia, and limb amputation.6 Septicemia is reported as the cause of death in 40% of pressure ulcer patients, according to national multiple cause-coded death records.7 Fortunately, with appropriate preventative measures, hPUs can be prevented,8 and the clinical implications of a successful prevention protocol for hPUs in high-risk sedated patients can result in the following:

Decreased morbidity and mortality related to hPU Prevention of possible pain and discomfort related to hPUs Potential for indirect cost savings (decreased length of stay,

savings on cost of treatment, decreased nursing staff time, etc.) Prevention of a hospital-acquired condition

PFCsCentral nervous system disease or injury, and/or spinal cord disease or injury can lead to PFC.9-11 Damage to the peroneal nerve, myopathy due to critical illness, or immobility which results in shortening of the Achilles tendon (foot drop due to contracture) are all etiologic factors which can contribute to PFCs. Risk factors for PFCs include pharmacologic sedation or paralysis, coma, leg weakness, and/or heavy and tight bed linens which hold the foot in prolonged plantar flexion (extension). Physical therapy can reverse tendon contracture, but prevention is preferable as PFCs can become permanent deformities. Clinical implications of a successful PFC prevention protocol include:

Improved quality of life Prevention of potentially permanent deformities Potential for indirect cost savings (decreased length of stay,

savings on rehabilitation costs for PFC, etc.) Prevention of a hospital-acquired condition

Financial Benefits of hPU Prevention

[Avg census 260; 7.3%4 may develop PUs = 19; 28%4 may develop hPUs = 5; total hPU days (365) = 1825; avg LOS 4.6 (NIS Data) = 397 actual hPU days; 93% stage 1 or 2 4 = 369; 7% stage 3 or 4 4 = 28]

4 Whittington KT, Briones R. Adv Skin Wound Care. 2004;17:490-494; 9 Young ZF, Evans A, Davis J. J Nurs Adm. 2003;33:380-383.

Neutral (normal)

Secondary Goniometric Findings: Improvements in Plantar Flexion Contractures

50

60

70

80

90

100

110

120

130

Individual ankles

Ank

le a

ngle

at r

est

Entry Measurement Exit Measurement

Secondary Goniometric Findings: Improvements in Plantar

Flexion ContracturesSecondary Goniometric Findings:

Improvements in Plantar Flexion Contractures

50

60

70

80

90

100

110

120

130

Individual ankles

An

kle

ang

le a

t re

st

Entry Measurement Exit Measurement

n = 106= improvement

Individual ankles*

* Of the 106 ankles measured with goniometer, 20 showed improvement from entry to exit..

Ank

le a

t res

t (in

deg

rees

)

This intervention established hPU and PFC prevention protocols in a high-risk patient population in order to ensure earlier recognition of heel skin issues and prevent PFCs if possible.

In order to be treated with the intervention, the following inclusion criteria were met:

Patients were sedated in ICU >5 days

Patients may or may not have been intubated

Braden score of 16 or less

The intervention provided to these high-risk patients included the following:

On admission to ICU, heel skin assessment and Braden scale were administered to all patients

Initial ankle range of motion (ROM) was measured with a goniometer on admission and before application of the heel protector

Goniometric measurements were documented every other day

Heel assessments, Braden scale, and Ramsey sedation scale scores were recorded every shift, and recorded as part of study every other day

Measurements continued until patient was either transferred, heel protector boot was discontinued by the physician, or the patient had Braden scale greater than 16

Patients who were treated with the pillows for offloading received the same measurements and documentation as patients who received the intervention.

Change in Heel/Patient Status

New hPUs

Keller BP, Wille J, van Ramshorst B, van der Werken C. 1. Pressure ulcers in intensive care patients: a review of risks and prevention. Intensive Care Med. 2002;28:1379-1388.

Khan J, Harrison TB, Rich MM, et al: Early development of 2. critical illness myopathy and neuropathy in patients with severe sepsis. Neurology. 2006; 67:1421–1425.

Miller R. 3. Morphology. Miller’s Anesthesia, 6th ed. Orlando, FL:Churchill-Livingstone;2005.

Centers for Medicare and Medicaid Services. Federal 4. Register Part II 42 CFR Parts 411, 412, 413, and 489: Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates; Final Rule. Federal Register. 2007;72(162):47201-47205.

Whittington KT, Briones R. National prevalence and 5. incidence study: 6-year sequential acute care data. Adv Skin Wound Care. 2004;17:490-494.

Tourtual DM, Riesenbert LA, Korutz CJ, et al. Predictors 6. of hospital acquired pressure ulcers. Ostomy/Wound Manage. 1997;43(9):24-40.

Landi F, Onder G, Russo A, Bernabei R. Pressure ulcer 7. and mortality in frail elderly people living in community. Arch Gerontol Geriatr. 2007;44 Suppl 1:217-223.

Wong VK, Stolis NA. Physiology and prevention of heel 8. ulcers: the state of science. J Wound Ostomy Continence Nurse. 2003;30:191-198.

Hoppenfeld S. (1976). 9. Physical Examination of the Spine and Extremities. Norwalk, CT:Prentice-Hall;1976.

Kapandji IA. Ilustrated Physiology of Joints. 10. Med Biol Illus. 1964;14:72-81.

Kendall FP, McCreary EK, Provance PG, et al. 11. Muscles: Testing and Function with Posture and Pain. 5th ed. Baltimore, MD:Lippincott Williams and Wilkens;2005.

ReferencesSource: Research Institute for Human Engineering for Quality Life, “Measurement and evaluation of the human dynamic characteristics,” Joint Passive Resistance Database a4, 2000. Available at: http://www.dh.aist.go.jp/bodyDB/a/HQL-00-04e.html

Goniometer used by trained and licensed clinicians to assess for

plantar flexion contracture6-8

Source: Research Institute for Human Engineering for Quality Life, “Measurement and evaluation of the human dynamic characteristics,” Joint Passive Resistance Database a4, 2000. Available at: http://www.dh.aist.go.jp/bodyDB/a/HQL-00-04e.html

Goniometer used by trained and licensed clinicians to assess for

plantar flexion contracture6-8

Source: Research Institute for Human Engineering for Quality Life, “Measurement and evaluation of the human dynamic characteristics,” Joint Passive Resistance Database a4, 2000. Available at: http://www.dh.aist.go.jp/bodyDB/a/HQL-00-04e.html

Goniometer used by trained and licensed clinicians to assess for

plantar flexion contracture6-8

NPUAP’s Biennial Conference, February 27-28, 2009 21202

* Prevalon, Sage Products Inc.

Patients in the intensive care unit (ICU) have a high risk of developing heel pressure ulcers (hPUs) and plantar flexion contractures (PFCs), with prevalence ranging from 14% to 41%, and incidence ranging from 1% to 56%.1 In one study, approximately 50% of ICU patients with severe sepsis experienced acutely acquired neuromuscular dysfunction,2 which is a complex process leading to myopathy in the critically-ill, the morphology of which is well described in Millers Anesthesia 6th Edition.3 In addition to the pathophysiological processes associated with high-risk critically-ill patients, such as polyneuropathy and myopathy, the new reimbursement policies of the Centers for Medicare & Medicaid Services (CMS) are a strong catalyst for refocusing efforts on preventing negative outcomes and hospital-acquired conditions such as pressure ulcers.4

An IRB-approved study (waiver received) was conducted to assess the impact of a heel protector* intervention on hPU rates and PFCs through the use of a heel protector in a high-risk, sedated, intensive care unit (ICU) population. Patients who did not receive the heel protector for off-loading the heel, received a pillow for heel offloading (per facility protocol).

Keller BP, Wille J, van Ramshorst B, van der Werken C. Pressure ulcers in intensive care patients: a review 1. of risks and prevention. Intensive Care Med. 2002;28:1379-1388.

Khan J, Harrison TB, Rich MM, et al: Early development of critical illness myopathy and neuropathy in 2. patients with severe sepsis. Neurology. 2006; 67:1421–1425.

Miller R. 3. Morphology. Miller’s Anesthesia, 6th ed. Orlando, FL:Churchill-Livingstone;2005.

Centers for Medicare and Medicaid Services. Federal Register Part II 42 CFR Parts 411, 412, 413, and 4. 489: Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates; Final Rule. Federal Register. 2007;72(162):47201-47205.

Whittington KT, Briones R. National prevalence and incidence study: 6-year sequential acute care data. 5. Adv Skin Wound Care. 2004;17:490-494.

Tourtual DM, Riesenbert LA, Korutz CJ, et al. Predictors of hospital acquired pressure ulcers. 6. Ostomy/Wound Manage. 1997;43(9):24-40.

Landi F, Onder G, Russo A, Bernabei R. Pressure ulcer and mortality in frail elderly people living in 7. community. Arch Gerontol Geriatr. 2007;44 Suppl 1:217-223.

Wong VK, Stolis NA. Physiology and prevention of heel ulcers: the state of science. 8. J Wound Ostomy Continence Nurse. 2003;30:191-198.

Hoppenfeld S. (1976). 9. Physical Examination of the Spine and Extremities. Norwalk, CT:Prentice-Hall;1976.

Kapandji IA. Ilustrated Physiology of Joints. 10. Med Biol Illus. 1964;14:72-81.

Kendall FP, McCreary EK, Provance PG, et al. 11. Muscles: Testing and Function with Posture and Pain. 5th ed. Baltimore, MD:Lippincott Williams and Wilkens;2005.

References

* Prevalon, Sage Products Inc.

Prevention of Heel Ulcers and Plantar Flexion Contractures in High-Risk Ventilated PatientsTina Meyers, BSN, RN, CWOCN, ACHRN – Conroe Regional Medical Center, Conroe TX

100% prevention of hospital-acquired hPUs

100% prevention of plantar flexion contractures

21202

NPUAP’s Biennial Conference, February 27-28, 2009

The study resulted in 100% prevention of hPU development, 100% prevention of PFC development, enhanced caregiver compliance with existing protocols, and several surprising secondary findings:

9.4% showed improvement in heel status from entry to discharge

11.3% of existing heel skin conditions stayed the same with no change and no worsening in status

50% of abnormal heels showed improvement

hPUsHeel PUs are the second most common pressure ulcer in the clinical setting,5 and can result in serious complications such as osteomyelitis, cellulitis, septicemia, and limb amputation.6 Septicemia is reported as the cause of death in 40% of pressure ulcer patients, according to national multiple cause-coded death records.7 Fortunately, with appropriate preventative measures, hPUs can be prevented,8 and the clinical implications of a successful prevention protocol for hPUs in high-risk sedated patients can result in the following:

Decreased morbidity and mortality related to hPU Prevention of possible pain and discomfort related to hPUs Potential for indirect cost savings (decreased length of stay,

savings on cost of treatment, decreased nursing staff time, etc.) Prevention of a hospital-acquired condition

PFCsCentral nervous system disease or injury, and/or spinal cord disease or injury can lead to PFC.9-11 Damage to the peroneal nerve, myopathy due to critical illness, or immobility which results in shortening of the Achilles tendon (foot drop due to contracture) are all etiologic factors which can contribute to PFCs. Risk factors for PFCs include pharmacologic sedation or paralysis, coma, leg weakness, and/or heavy and tight bed linens which hold the foot in prolonged plantar flexion (extension). Physical therapy can reverse tendon contracture, but prevention is preferable as PFCs can become permanent deformities. Clinical implications of a successful PFC prevention protocol include:

Improved quality of life Prevention of potentially permanent deformities Potential for indirect cost savings (decreased length of stay,

savings on rehabilitation costs for PFC, etc.) Prevention of a hospital-acquired condition

Financial Benefits of hPU Prevention

[Avg census 260; 7.3%4 may develop PUs = 19; 28%4 may develop hPUs = 5; total hPU days (365) = 1825; avg LOS 4.6 (NIS Data) = 397 actual hPU days; 93% stage 1 or 2 4 = 369; 7% stage 3 or 4 4 = 28]

4 Whittington KT, Briones R. Adv Skin Wound Care. 2004;17:490-494; 9 Young ZF, Evans A, Davis J. J Nurs Adm. 2003;33:380-383.

Neutral (normal)

Secondary Goniometric Findings: Improvements in Plantar Flexion Contractures

50

60

70

80

90

100

110

120

130

Individual ankles

Ank

le a

ngle

at r

est

Entry Measurement Exit Measurement

Secondary Goniometric Findings: Improvements in Plantar

Flexion ContracturesSecondary Goniometric Findings:

Improvements in Plantar Flexion Contractures

50

60

70

80

90

100

110

120

130

Individual ankles

An

kle

ang

le a

t re

st

Entry Measurement Exit Measurement

n = 106= improvement

Individual ankles*

* Of the 106 ankles measured with goniometer, 20 showed improvement from entry to exit..

Ank

le a

t res

t (in

deg

rees

)

This intervention established hPU and PFC prevention protocols in a high-risk patient population in order to ensure earlier recognition of heel skin issues and prevent PFCs if possible.

In order to be treated with the intervention, the following inclusion criteria were met:

Patients were sedated in ICU >5 days

Patients may or may not have been intubated

Braden score of 16 or less

The intervention provided to these high-risk patients included the following:

On admission to ICU, heel skin assessment and Braden scale were administered to all patients

Initial ankle range of motion (ROM) was measured with a goniometer on admission and before application of the heel protector

Goniometric measurements were documented every other day

Heel assessments, Braden scale, and Ramsey sedation scale scores were recorded every shift, and recorded as part of study every other day

Measurements continued until patient was either transferred, heel protector boot was discontinued by the physician, or the patient had Braden scale greater than 16

Patients who were treated with the pillows for offloading received the same measurements and documentation as patients who received the intervention.

Change in Heel/Patient Status

New hPUs

Patients in the intensive care unit (ICU) have a high risk of developing heel pressure ulcers (hPUs) and plantar flexion contractures (PFCs), with prevalence ranging from 14% to 41%, and incidence ranging from 1% to 56%.1 In one study, approximately 50% of ICU patients with severe sepsis experienced acutely acquired neuromuscular dysfunction,2 which is a complex process leading to myopathy in the critically-ill, the morphology of which is well described in Millers Anesthesia 6th Edition.3 In addition to the pathophysiological processes associated with high-risk critically-ill patients, such as polyneuropathy and myopathy, the new reimbursement policies of the Centers for Medicare & Medicaid Services (CMS) are a strong catalyst for refocusing efforts on preventing negative outcomes and hospital-acquired conditions such as pressure ulcers.4

An IRB-approved study (waiver received) was conducted to assess the impact of a heel protector* intervention on hPU rates and PFCs through the use of a heel protector in a high-risk, sedated, intensive care unit (ICU) population. Patients who did not receive the heel protector for off-loading the heel, received a pillow for heel offloading (per facility protocol).

Keller BP, Wille J, van Ramshorst B, van der Werken C. Pressure ulcers in intensive care patients: a review 1. of risks and prevention. Intensive Care Med. 2002;28:1379-1388.

Khan J, Harrison TB, Rich MM, et al: Early development of critical illness myopathy and neuropathy in 2. patients with severe sepsis. Neurology. 2006; 67:1421–1425.

Miller R. 3. Morphology. Miller’s Anesthesia, 6th ed. Orlando, FL:Churchill-Livingstone;2005.

Centers for Medicare and Medicaid Services. Federal Register Part II 42 CFR Parts 411, 412, 413, and 4. 489: Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates; Final Rule. Federal Register. 2007;72(162):47201-47205.

Whittington KT, Briones R. National prevalence and incidence study: 6-year sequential acute care data. 5. Adv Skin Wound Care. 2004;17:490-494.

Tourtual DM, Riesenbert LA, Korutz CJ, et al. Predictors of hospital acquired pressure ulcers. 6. Ostomy/Wound Manage. 1997;43(9):24-40.

Landi F, Onder G, Russo A, Bernabei R. Pressure ulcer and mortality in frail elderly people living in 7. community. Arch Gerontol Geriatr. 2007;44 Suppl 1:217-223.

Wong VK, Stolis NA. Physiology and prevention of heel ulcers: the state of science. 8. J Wound Ostomy Continence Nurse. 2003;30:191-198.

Hoppenfeld S. (1976). 9. Physical Examination of the Spine and Extremities. Norwalk, CT:Prentice-Hall;1976.

Kapandji IA. Ilustrated Physiology of Joints. 10. Med Biol Illus. 1964;14:72-81.

Kendall FP, McCreary EK, Provance PG, et al. 11. Muscles: Testing and Function with Posture and Pain. 5th ed. Baltimore, MD:Lippincott Williams and Wilkens;2005.

References

* Prevalon, Sage Products Inc.

Prevention of Heel Ulcers and Plantar Flexion Contractures in High-Risk Ventilated PatientsTina Meyers, BSN, RN, CWOCN, ACHRN – Conroe Regional Medical Center, Conroe TX

100% prevention of hospital-acquired hPUs

100% prevention of plantar flexion contractures

21202

NPUAP’s Biennial Conference, February 27-28, 2009

The study resulted in 100% prevention of hPU development, 100% prevention of PFC development, enhanced caregiver compliance with existing protocols, and several surprising secondary findings:

9.4% showed improvement in heel status from entry to discharge

11.3% of existing heel skin conditions stayed the same with no change and no worsening in status

50% of abnormal heels showed improvement

hPUsHeel PUs are the second most common pressure ulcer in the clinical setting,5 and can result in serious complications such as osteomyelitis, cellulitis, septicemia, and limb amputation.6 Septicemia is reported as the cause of death in 40% of pressure ulcer patients, according to national multiple cause-coded death records.7 Fortunately, with appropriate preventative measures, hPUs can be prevented,8 and the clinical implications of a successful prevention protocol for hPUs in high-risk sedated patients can result in the following:

Decreased morbidity and mortality related to hPU Prevention of possible pain and discomfort related to hPUs Potential for indirect cost savings (decreased length of stay,

savings on cost of treatment, decreased nursing staff time, etc.) Prevention of a hospital-acquired condition

PFCsCentral nervous system disease or injury, and/or spinal cord disease or injury can lead to PFC.9-11 Damage to the peroneal nerve, myopathy due to critical illness, or immobility which results in shortening of the Achilles tendon (foot drop due to contracture) are all etiologic factors which can contribute to PFCs. Risk factors for PFCs include pharmacologic sedation or paralysis, coma, leg weakness, and/or heavy and tight bed linens which hold the foot in prolonged plantar flexion (extension). Physical therapy can reverse tendon contracture, but prevention is preferable as PFCs can become permanent deformities. Clinical implications of a successful PFC prevention protocol include:

Improved quality of life Prevention of potentially permanent deformities Potential for indirect cost savings (decreased length of stay,

savings on rehabilitation costs for PFC, etc.) Prevention of a hospital-acquired condition

Financial Benefits of hPU Prevention

[Avg census 260; 7.3%4 may develop PUs = 19; 28%4 may develop hPUs = 5; total hPU days (365) = 1825; avg LOS 4.6 (NIS Data) = 397 actual hPU days; 93% stage 1 or 2 4 = 369; 7% stage 3 or 4 4 = 28]

4 Whittington KT, Briones R. Adv Skin Wound Care. 2004;17:490-494; 9 Young ZF, Evans A, Davis J. J Nurs Adm. 2003;33:380-383.

Neutral (normal)

Secondary Goniometric Findings: Improvements in Plantar Flexion Contractures

50

60

70

80

90

100

110

120

130

Individual ankles

Ank

le a

ngle

at r

est

Entry Measurement Exit Measurement

Secondary Goniometric Findings: Improvements in Plantar

Flexion ContracturesSecondary Goniometric Findings:

Improvements in Plantar Flexion Contractures

50

60

70

80

90

100

110

120

130

Individual ankles

An

kle

ang

le a

t re

st

Entry Measurement Exit Measurement

n = 106= improvement

Individual ankles*

* Of the 106 ankles measured with goniometer, 20 showed improvement from entry to exit..

Ank

le a

t res

t (in

deg

rees

)

This intervention established hPU and PFC prevention protocols in a high-risk patient population in order to ensure earlier recognition of heel skin issues and prevent PFCs if possible.

In order to be treated with the intervention, the following inclusion criteria were met:

Patients were sedated in ICU >5 days

Patients may or may not have been intubated

Braden score of 16 or less

The intervention provided to these high-risk patients included the following:

On admission to ICU, heel skin assessment and Braden scale were administered to all patients

Initial ankle range of motion (ROM) was measured with a goniometer on admission and before application of the heel protector

Goniometric measurements were documented every other day

Heel assessments, Braden scale, and Ramsey sedation scale scores were recorded every shift, and recorded as part of study every other day

Measurements continued until patient was either transferred, heel protector boot was discontinued by the physician, or the patient had Braden scale greater than 16

Patients who were treated with the pillows for offloading received the same measurements and documentation as patients who received the intervention.

Change in Heel/Patient Status

New hPUs

Patients in the intensive care unit (ICU) have a high risk of developing heel pressure ulcers (hPUs) and plantar flexion contractures (PFCs), with prevalence ranging from 14% to 41%, and incidence ranging from 1% to 56%.1 In one study, approximately 50% of ICU patients with severe sepsis experienced acutely acquired neuromuscular dysfunction,2 which is a complex process leading to myopathy in the critically-ill, the morphology of which is well described in Millers Anesthesia 6th Edition.3 In addition to the pathophysiological processes associated with high-risk critically-ill patients, such as polyneuropathy and myopathy, the new reimbursement policies of the Centers for Medicare & Medicaid Services (CMS) are a strong catalyst for refocusing efforts on preventing negative outcomes and hospital-acquired conditions such as pressure ulcers.4

An IRB-approved study (waiver received) was conducted to assess the impact of a heel protector* intervention on hPU rates and PFCs through the use of a heel protector in a high-risk, sedated, intensive care unit (ICU) population. Patients who did not receive the heel protector for off-loading the heel, received a pillow for heel offloading (per facility protocol).

Keller BP, Wille J, van Ramshorst B, van der Werken C. Pressure ulcers in intensive care patients: a review 1. of risks and prevention. Intensive Care Med. 2002;28:1379-1388.

Khan J, Harrison TB, Rich MM, et al: Early development of critical illness myopathy and neuropathy in 2. patients with severe sepsis. Neurology. 2006; 67:1421–1425.

Miller R. 3. Morphology. Miller’s Anesthesia, 6th ed. Orlando, FL:Churchill-Livingstone;2005.

Centers for Medicare and Medicaid Services. Federal Register Part II 42 CFR Parts 411, 412, 413, and 4. 489: Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates; Final Rule. Federal Register. 2007;72(162):47201-47205.

Whittington KT, Briones R. National prevalence and incidence study: 6-year sequential acute care data. 5. Adv Skin Wound Care. 2004;17:490-494.

Tourtual DM, Riesenbert LA, Korutz CJ, et al. Predictors of hospital acquired pressure ulcers. 6. Ostomy/Wound Manage. 1997;43(9):24-40.

Landi F, Onder G, Russo A, Bernabei R. Pressure ulcer and mortality in frail elderly people living in 7. community. Arch Gerontol Geriatr. 2007;44 Suppl 1:217-223.

Wong VK, Stolis NA. Physiology and prevention of heel ulcers: the state of science. 8. J Wound Ostomy Continence Nurse. 2003;30:191-198.

Hoppenfeld S. (1976). 9. Physical Examination of the Spine and Extremities. Norwalk, CT:Prentice-Hall;1976.

Kapandji IA. Ilustrated Physiology of Joints. 10. Med Biol Illus. 1964;14:72-81.

Kendall FP, McCreary EK, Provance PG, et al. 11. Muscles: Testing and Function with Posture and Pain. 5th ed. Baltimore, MD:Lippincott Williams and Wilkens;2005.

References

* Prevalon, Sage Products Inc.

Prevention of Heel Ulcers and Plantar Flexion Contractures in High-Risk Ventilated PatientsTina Meyers, BSN, RN, CWOCN, ACHRN – Conroe Regional Medical Center, Conroe TX

100% prevention of hospital-acquired hPUs

100% prevention of plantar flexion contractures

21202

NPUAP’s Biennial Conference, February 27-28, 2009

The study resulted in 100% prevention of hPU development, 100% prevention of PFC development, enhanced caregiver compliance with existing protocols, and several surprising secondary findings:

9.4% showed improvement in heel status from entry to discharge

11.3% of existing heel skin conditions stayed the same with no change and no worsening in status

50% of abnormal heels showed improvement

hPUsHeel PUs are the second most common pressure ulcer in the clinical setting,5 and can result in serious complications such as osteomyelitis, cellulitis, septicemia, and limb amputation.6 Septicemia is reported as the cause of death in 40% of pressure ulcer patients, according to national multiple cause-coded death records.7 Fortunately, with appropriate preventative measures, hPUs can be prevented,8 and the clinical implications of a successful prevention protocol for hPUs in high-risk sedated patients can result in the following:

Decreased morbidity and mortality related to hPU Prevention of possible pain and discomfort related to hPUs Potential for indirect cost savings (decreased length of stay,

savings on cost of treatment, decreased nursing staff time, etc.) Prevention of a hospital-acquired condition

PFCsCentral nervous system disease or injury, and/or spinal cord disease or injury can lead to PFC.9-11 Damage to the peroneal nerve, myopathy due to critical illness, or immobility which results in shortening of the Achilles tendon (foot drop due to contracture) are all etiologic factors which can contribute to PFCs. Risk factors for PFCs include pharmacologic sedation or paralysis, coma, leg weakness, and/or heavy and tight bed linens which hold the foot in prolonged plantar flexion (extension). Physical therapy can reverse tendon contracture, but prevention is preferable as PFCs can become permanent deformities. Clinical implications of a successful PFC prevention protocol include:

Improved quality of life Prevention of potentially permanent deformities Potential for indirect cost savings (decreased length of stay,

savings on rehabilitation costs for PFC, etc.) Prevention of a hospital-acquired condition

Financial Benefits of hPU Prevention

[Avg census 260; 7.3%4 may develop PUs = 19; 28%4 may develop hPUs = 5; total hPU days (365) = 1825; avg LOS 4.6 (NIS Data) = 397 actual hPU days; 93% stage 1 or 2 4 = 369; 7% stage 3 or 4 4 = 28]

4 Whittington KT, Briones R. Adv Skin Wound Care. 2004;17:490-494; 9 Young ZF, Evans A, Davis J. J Nurs Adm. 2003;33:380-383.

Neutral (normal)

Secondary Goniometric Findings: Improvements in Plantar Flexion Contractures

50

60

70

80

90

100

110

120

130

Individual ankles

Ank

le a

ngle

at r

est

Entry Measurement Exit Measurement

Secondary Goniometric Findings: Improvements in Plantar

Flexion ContracturesSecondary Goniometric Findings:

Improvements in Plantar Flexion Contractures

50

60

70

80

90

100

110

120

130

Individual ankles

An

kle

ang

le a

t re

st

Entry Measurement Exit Measurement

n = 106= improvement

Individual ankles*

* Of the 106 ankles measured with goniometer, 20 showed improvement from entry to exit..

Ank

le a

t res

t (in

deg

rees

)

This intervention established hPU and PFC prevention protocols in a high-risk patient population in order to ensure earlier recognition of heel skin issues and prevent PFCs if possible.

In order to be treated with the intervention, the following inclusion criteria were met:

Patients were sedated in ICU >5 days

Patients may or may not have been intubated

Braden score of 16 or less

The intervention provided to these high-risk patients included the following:

On admission to ICU, heel skin assessment and Braden scale were administered to all patients

Initial ankle range of motion (ROM) was measured with a goniometer on admission and before application of the heel protector

Goniometric measurements were documented every other day

Heel assessments, Braden scale, and Ramsey sedation scale scores were recorded every shift, and recorded as part of study every other day

Measurements continued until patient was either transferred, heel protector boot was discontinued by the physician, or the patient had Braden scale greater than 16

Patients who were treated with the pillows for offloading received the same measurements and documentation as patients who received the intervention.

Change in Heel/Patient Status

New hPUs