Pressure Ulcer Management

©2016 American Association of Critical-Care Nurses doi:

Pressure Ulcer Management

Background Patients in intensive care units are likely to have limited mobility owing to hemodynamic instability and activity orders for bed rest. Bed rest is indicated because of the severity of the disease process, which often involves intubation, sedation, paralysis, surgical procedures, poor nutrition, low flow states, and poor cir- culation. These patients are predisposed to the develop- ment and/or the progression of pressure ulcers not only because of their underlying diseases, but also because of limited mobility and deconditioned states of health. Objective To assess whether treating high-risk patients with a prophylactic sacral dressing decreases the inci- dence of unit-acquired sacral pressure ulcers. Methods An evidence-based tool for identifying patients at high risk for pressure ulcers was used in 3 intensive care units at an urban tertiary care hospital and academic medical center. Those patients deemed at high risk had a prophylactic sacral dressing applied. Incidence rates were collected and compared for the 7 months preced- ing use of the dressings and for 7 months during the trial period when the dressing was used. Results After the sacral dressing began being used, the number of unit-acquired sacral pressure ulcers decreased by 3.4 to 7.6 per 1000 patient days depending on the unit. Conclusions A prophylactic sacral dressing may help prevent unit-acquired sacral pressure ulcers. Implemen- tation of an involved care team with heightened aware- ness and increased education along with a prophylactic sacral dressing in patients deemed high risk for skin breakdown are all essential for success. (American Jour- nal of Critical Care. 2016;25:228-234)

PROPHYLACTIC SACRAL DRESSING FOR PRESSURE ULCER PREVENTION IN HIGH-RISK PATIENTS By Jaime Byrne, RN, MSN, CCRN, Patricia Nichols, RN, MSN, CCRN, Marzena Sroczynski, RN, BSN, CWOCN, Laurie Stelmaski, RN, BSN, CWON, Molly Stetzer, RN, BSN, CWOCN, Cynthia Line, PhD, and Kristen Carlin, MPH


P atients in intensive care units (ICUs) are predisposed to pressure ulcers because of limited mobility and the severity of their disease processes. Pressure ulcers result from pressure or a combination of pressure and shear, usually over bony promi- nences, and cause localized injury to the skin and underlying tissues.1 The prevalence of pressure ulcers in acute care settings is estimated at 12% to 19.7%, of which 20%

occur on the sacrum or coccyx.2 In ICUs, pressure ulcers rates can occur in 14% to 42% of patients.3 For patients, pressure ulcers can be painful, embarrassing, isolating, and, in some cases, life-threatening.4

The standard of care to prevent pressure ulcers includes routine repositioning to offload pressure points, moisture management, use of support sur- faces, and assessment of nutritional requirements by registered dietitians. Despite these practices designed to mitigate risk, pressure ulcers continue to develop in many high-risk ICU patients. In practice, pressure ulcers are indicators of quality of care.5 The Joint Commission considers prevention of health care– associated pressure ulcers a National Patient Safety Goal.6 The Institute for Healthcare Improvement included pressure ulcer prevention in its 5 Million Lives Campaign.7 More recently, the federal govern- ment identified pressure ulcers as one of the hospi- tal-acquired conditions included in the Agency for Healthcare Research and Quality composite mea- sure PSI-90.8 Hospital-acquired conditions are included in 2 pay-for-performance programs under the Patient Protection and Affordable Care Act that have great implications for hospital finances: pen- alties for hospital-acquired conditions and val- ue-based purchasing incentives.9

Treatment of pressure ulcers is expensive, with estimates of the cost at a mean of $1200 to $1600 per day.10 The Centers for Medicare and Medicaid Services no longer reimburses facilities for pressure ulcer care when the ulcers are acquired in the hospi- tal.11 Starting in 2015, hospitals that rank among

the worst 25% for hospital-acquired conditions, including pressure ulcers, will see their reimburse- ment rates decline.12 Reducing the incidence of pressure ulcers would not only reduce the negative physical and psychological impact on patients and improve patients’ outcomes, it might also reduce costs and increase reim- bursement for hospitals. Yet, despite the widespread recognition of the need to prevent pressure ulcers in critical care patients, chal- lenges remain in the ability to prevent them. Recent studies indicate that silicone dressings may hold promise for prevention of pressure ulcers. ICU patients who received a soft silicone multilayered foam dressing on the sacrum showed significantly fewer pressure ulcers.13-15

This study sought to evaluate the effects of a prophylactic silicone adhesive hydrocellular sacral foam dressing on incidence of sacral pressure ulcers among high-risk ICU patients. The product for the trial was chosen because the facility already used Allevyn (Smith & Nephew) dressings of various sizes and shapes for care of skin tears with good results and the nurses were already familiar with this type of product. The particular dressing used in this trial is specifically designed for use on the difficult-to-fit coccyx area.

Methods Setting

This study was conducted in an urban tertiary care academic medical center that is also a level I trauma center with 951 licensed acute care beds. Three ICUs at the institution participated in the study: the surgical coronary care unit (SCCU), a 9-bed surgical cardiac ICU; the medical coronary care unit (MCCU), a 9-bed medical cardiac ICU; and a 25-bed medical ICU (MICU). The SCCU generally provides care for patients after coronary artery bypass surgery, valve replacement or repair,

About the Authors Jaime Byrne is an intensive care clinical nurse specialist, Marzena Sroczynski is a certified wound ostomy conti- nence nurse specialist, and Laurie Stelmaski is a certified wound ostomy nurse at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. Patricia Nichols is director of nursing education at Aria Health, Philadelphia, Pennsylvania. Molly Stetzer is a certified wound ostomy continence nurse specialist, Children’s Hospital of Phila- delphia, Philadelphia, Pennsylvania. Cynthia Line is a proj- ect manager and Kristen Carlin is a biostatistician, Office of Nursing Research, Thomas Jefferson University Hospital.