Pressure Promise

Options for treating pressure ulcers in LTC proliferate, from improved existing products to entirely new therapies

by Matt Mahady

Pressure ulcers pose particularly daunting challenges for long-term care professionals and facilities. "Pressure ulcers are a big problem in long-term care as they can affect three percent to 29 percent of residents," reported Diane Langemo, PhD, RN, president, National Pressure Ulcer Advisory Panel (NPUAP), Reston, Va. "The optimal approach is always total prevention, but total prevention is impossible. We live in a real world and this is not reality."

Despite proactive tactics, attentive staff members, clinically sound interventions, and high-quality facilities, the fight against pressure ulcers continues, and the price of losing can be high. Last year, a California jury mandated that a long-term care facility pay $3 million to the family of an elderly woman who died of bedsores while residing at the institution.¹ According to NPUAP data, pressure ulcers afflict more than 1.8 million people annually and cost an estimated $1.3 billion per year. "With health-care costs continuing to escalate, the role of products, such as dressings and support surfaces, will become increasingly important to promote healing of pressure ulcers in a more cost-effective, research-based manner," predicted Catherine R. Ratliff, PhD, GNP, MS, CWOCN, geriatric nurse practitioner, Department of Plastic and Maxillofacial Surgery, University of Virginia Health System, Charlottesville.

Increasing Treatment Choices

Fortunately, the tools available to long-term care practitioners and providers are steadily increasing due to new research, improved technology, and intensified investments in product development. "The current state of pressure ulcer treatment is very good with many advances now available for health-care providers" according to Dr. Langemo.

According to Courtney Lyder, ND, GNP, FAAN, professor of nursing, internal medicine and geriatrics, Division of Acute and Specialty Care for Adults, University of Virginia Medical Center, Charlottesville, "Continued advancement [in pressure ulcer-related products] will aid clinicians in diagnosing pressure ulcers in their earliest stages."

This, in turn, may one day help decrease the progression of patients' pressure ulcers, alleviate patients' pain and suffering, and lower the cost of burdens associated with pressure ulcer care.

A number of currently available products aim to provide support for or increase the ease, simplicity, or convenience of standard pressure ulcer prevention strategies. These products include pressure-reducing seat cushions, pillows, foam wedges, protective padding for vulnerable body parts, slippers, nutritional supplements, lubricants, topical wound care dressings, trapeze-style lifting devices to minimize friction when patients are turned or otherwise moved, special mattresses and beds (i.e., low-air-loss beds, alternating pressure mattresses, and air-fluidized beds), and sheepskin blankets.

One nonprofit group, the National Decubitus Foundation, recently praised air-fluidized beds as "the only engineering solution that removes the cause of the pressure wound." Air-fluidized beds are inflated by air that's pumped through an area with ceramic-type beads. A patient lying on an air-fluidized bed feels supported by liquid.

With the exception of nutritional supplements, all of these products are designed to minimize or eliminate pressure and friction between skin and potentially abrasive surfaces. A recent study on seat cushions found interface pressure between bare skin and other surfaces to be a significant predictor of pressure ulcers.²

Once a pressure ulcer develops, many of the same products employed for pressure ulcer prevention can prove useful in their treatment. As an example, nutritional supplement manufacturers state that adequate nutritional support is just as important for treating pressure ulcers as it is for preventing them. Supplement manufacturers claim that numerous studies have linked poor hydration, declining body weight, and low serum protein concentrations to compromised tissue strength.

Nestle S.A., a subsidiary of Nestle Clinical Nutrition based in Deerfield, Ill., claims that current research supports the "essential" importance of nutrients, such as vitamin A, zinc, and iron in wound healing (www.woundnutrition.com/about_wm/importance.asp).

Besides nutritional considerations, it's also crucial that long-term care staff members facilitate pressure relief by constantly turning and repositioning patients, and by utilizing proper pressure relief devices. Additional wound care products may be required based on the severity and characteristics of the patient's wound.

More Research Required

Any advance in the field of pressure ulcer prevention and treatment is a welcome one. Still, no product is a magic bullet.

"Despite wound care and treatment advances," noted Lisa Cantrell, RNC, co-founder and president, National Association of Geriatric Nursing Assistants, "pressure ulcers remain difficult to treat." Much of the promise of new technologies and treatments remains unsupported by sound data and clinical evidence.

Dan R. Berlowitz, MD, MPH, associate professor of medicine, Boston University School of Medicine, and associate director, Veterans Administration Center for Health Quality, Outcomes and Economic Research at the VA New England Health Care System, Boston, echoed the sentiments of many long-term care practitioners. "While many new products continue to be developed that may be of benefit in the prevention and treatment of pressure ulcers, their precise role in long-term care in many cases must still be defined through well-designed randomized clinical trials," he said.

Richard G. Bennett, MD, Raymond and Anna Lublin professor in geriatric medicine, Johns Hopkins University School of Medicine, vice-president, Medical Affairs, Johns Hopkins Bayview Medical Center, Baltimore, concurred.

"The continued lack of rigorous research with respect to pressure ulcer prevention and treatment continues to make patient treatment a challenge," he explained, noting that clinicians usually have to rely on small trials or anecdotal evidence to support the use of new products.

"The inadequacy of current funding for such research was recently documented and revealed only $16 million in awarded grants--a minute fraction of the annual expenditures for treatment,"³ observed Dr. Bennett. "Even the ability of a clinician to accurately diagnose the extent of pressure-related cutaneous damage and correctly 'stage' a lesion is problematic and needs further study. Full-thickness damage under intact skin--sometimes termed deep tissue injury--is regularly seen in the long-term care setting, and no diagnostic methods are currently available to accurately predict the extent of subcutaneous necrosis. So, a nursing home patient who returns from the hospital with a bruise over the sacrum might already have a Stage IV lesion that will take many days to evolve. Research projects are needed to address this problem."

Conclusion

According to many pressure ulcer experts, guidelines represent a possible first step toward the establishment of an evidence-based standard of clinical practice. "Guidelines significantly ease the care of these individuals and provide clinicians with universal standards upon which to base care," reiterated Dr. Langemo.

Toward that end, AMDA's Pressure Ulcers Clinical Practice Guideline "is probably the best tool I have seen," noted Cantrell. For more information on that guideline and its accompanying Pressure Ulcer Therapy Companion, visit www.amda.com/info/cpg/.

Contributing Writer Matt Mahady is based in Florida.

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