MaryAnne Lewis RN, BSN, CWOCN - PowerPoint Presentation

MaryAnne Lewis RN, BSN, CWOCNCommunity Wound Ostomy, Continence Nurse Texas Children’s Hospital Pediatric Heel Pressure Injury Prevention

Pressure injuries are more common in children than in adults!Common site for injury : Occiput, Sacrum, Heels50 % pressure ulcers are device related Non- critical care 0.47%-13% Critical care 20-27% • Complex care patients: up to 43%Adults: 9.2-15% HAPI Risk: JWOCN Mar/Apr 2018 Background: Pediatric Pressure Injury

National Problem: The heel is most common site for DTI’s ( 41% of all DTI’s)and 2 nd most common site for Pressure injuries ( etiology : the anatomy)Heel injuries seen in both inpatient and outpatient setting ( orthopedic clinic; under casts and splints) Background

Elevation of the heel off the underlying support surface is considered the standard of care ( national guidelines : WOCN, NPUAP, NICE,) This can be done with pillow placed under the calf or with offloading heel device (boot)Patients often find the boot to be restrictive and hotThere is growing interest in the use of dressings to redistribute pressure and decrease shearing forces at the heel. Heel Injury Prevention

To develop an evidenced-based guideline that answers the following PICO question: PurposeIn patients at risk for heel pressure injury, does the use of a multilayered, prophylactic silicone/foam dressing compared to an offloading heel boot, provide better outcomes?

Setting: Texas Children's Hospital Evidence Based Practice ProgramMethodology: Databases searched: PubMed; CINAHL ; Medline Date Published 2005-2018 Keywords : Heel pressure ulcer/injury, heel offloading device/boot, prophylactic silicone foam dressing, multilayered foam dressing, heel dressing No head to head studies. Each preventative practice was looked at separately Heel Injury Prevention

4 RCT’s4 Nonrandomized studies5 Systematic Reviews 4 Eternal Guidelines Expert Consensus PanelRandomized Controlled trials : Santamaria (2013) Myers ( 2017) Donnelly ( (2011) Gilcreast (2005)Observational Studies: Forni ( (2011) Miller ( (2016) Santamaria( 2015) Myers ( 2010) Literature Appraisal

Santamaria (2013), The Border Trial (Melbourne, Australia) To explore the effectiveness of a multilayered soft silicone foam dressing in PU preventionN=440 trauma and critically ill pts. Pressure ulcer incidence with dressing 5/161 compared to no dressing 19/152 ( 10% difference in the intervention vs control group) Santamaria ( 2015) The Border II trial.Enrolled another 191 pts to further assess the dressings effectiveness using the same control group as previous study.Final sample size 150.None of the intervention group developed a heel ulcer compared to 19 from the previous studyLiterature Appraisal: Best Evidence (Dressing)

Pediatric Study ! (Bologna Italy)Forni ,(2011) (Research specialty Hospital)Tested the effectiveness of polyurethane foam in contact with the heel inside a plaster cast to decrease the rate of pressure ulcers in a very high risk population (N=156 pts) with orthopedic disease requiring lower limb casting, chemotherapy +/or heel stage 1 Intervention group (with dressing) 2/56 ( 3.6%) developed a heel ulcer while 21/49 ( 42%) in the control group (without the dressing) developed a heel ulcerLiterature Appraisal: Best Evidence dressing

Myers, 2010 (cohort), 2017 (RCT). To explore heel ulcer prevention and Plantar Flexion Contracture ( PFC) with use of offloading boot.2010 ( cohort) N= 53 ICU pts. Braden < 16. All received a boot and QOD ankle measurements: No HAPU’s. 55% reduction in prevalence of abnormal heels. Myers, 2017 (RCT) N=54 surgical ICU pts with 5 days of sedation. Intervention group (Boot) (N=37) 10 pts with improvement in angle of PFC and 0/37 with HAPI of heel.Control group (no boot) ( N=17) 7/17 with HAPI of heel. 3 pts experience an increase in angle of PFC. Literature Appraisal: Best Evidence Boot

Ramundo, Pike, Pittman ( 2018) • D o prophylactic foam dressings reduce heel pressure injuries?Review of 56 articles, of which 13 studies met inclusion criteria:• “ All studies identified suggest that use of prophylactic foam dressings reduces the development of pressure injuries on the heel when used in conjunction with a pressure injury prevention program” JWOCN Jan/Feb 2018 Literature Appraisal: Best evidence Systematic Review

A strong recommendation with moderate quality evidence to support the use of a soft silicone multilayered foam dressing applied to the heels, as part of an evidence-based pressure injury prevention program. Working with product committee and dressing manufacturers to develop pediatric size dressing. Recommendation

Results • The offloading heel boot is best for heel elevation off underlying support surface and prevention of plantar flexion contracture. • The clinical effectiveness of a prophylactic, multilayered soft silicone foam dressing to redistribute pressure and decrease shearing forces at the heel is fully supported by the literature. Evidence-based Practice

Conclusion An inclusive heel injury prevention program includes both the offloading boot and the soft silicone foam dressing. An Algorithm was developed to provide the bedside nurse with an organized process for decision making ( What prevention product to use and when) Implications: This should result in decreased HAPI’s! Evidence-Based Practice

Heel Injury Prevention Algorithm

Ramundo, J., Pike, C., Pittman, J., (2018) Do prophylactic foam dressings reduce heel pressue injuries? Journal of Wound Ostomy and Continence Nursing, Jan/Feb 45 (1) 75-82.Meyers, T.R.,(2017) Prevention of heel pressure Injuries and plantar flexion contractures in high-risk, neurotrauma, medical, and surgical intensive care units, a randomized controlled trial., Journal of Wound Ostomy and Continence Nursing, 44(5), 429-433. Tayyib, N., Coyer, F., (2016) Effectiveness of pressure ulcer prevention strategies for adult patients in intensive care units: A systematic review. Worldviews on Evidence –based nursing, Dec: 13 (6):432-444.Santamaria, N., Gerdtz, M., Sage, S., McCann, J., Freeman, A., Vassiliou, t., Knott, J., (2015). A randomized controlled trial of the effectiveness of soft silicone multilayered foam dressins in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: The border trial. International Wound Journal, 12(3), 302-308.Santamaria, N., Gerdtz, M., Liu, W., Rakis, S., Sage, S., Ng, A.W., Tudor, H., McCann, J., et al. (2015). Clinical effectiveness of a silicone foam dressing for the prevenetion of heel pressure ulcers in critically ill patients: Border II trial. Journal of Wound Care , 24(8). Miller, S.K., Sharma, N., Aberegg, L.C., et al., (2015) Analysis of the pressure distribution qualities of a silicone border foam dressing. Journal of Wound Ostomy and Continence Nursing .42(4) 346-351. Black, J., Clark, M., Dealy, C. Brindle, C.T., Alves, P., Santamaria, N., & Call, E., (2015). Dressings as an adjunct to pressure ulcer prevention: Consensus panel recommendations. International Wound Journal, 12(4), 484-488. King, A, Stellar J, Blevins A, Shah KN. Dressings and products in pediatric wound care. Adv. Wound Care 2014; 3, 324.). Clark, M., Black, J., Alves, P. et al. (2014). Systematic review of the use of prophylactic dresings in the prevention of pressure ulcers . International Wound Journal 11(5), 460-471. Forni C, Loro, L., Tremosini, M., et al. (2011) Use of polyurethane foam inside plaster casts to prevent the onset of heel sores in the population at risk. A controlled clinical study. Journal of Clinical Nursing, 20(5/6) References