Technology and product reviews References


16. Kelleher AD, Moorer A, Makic AB. Peer-to-peer nursing


rounds and hospital-acquired pressure ulcer prevalence in


a surgical intensive care unit. J Wound Ostomy Continence Nurs 2012; 39(2): 152–57.


17. Elliott R, McKinley S, Fox V. Quality improvement program to reduce the


prevalence of pressure ulcers


in an intensive care unit. Am J Crit Care 2008; 17(4): 328–34.


18. Clarke HF, Bradley C, Whytock S, Handfield S, van der Wal R, Gundry S. Pressure ulcers:


implementation of evidence- based nursing practice. J Adv Nurs 2005; 49(6): 578–90.


19. National Pressure Ulcer Advisory Panel and European


Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers: Clinical


Practice Guideline. Washington DC: National Pressure Ulcer Advisory Panel: 2009


20.Wound, Ostomy, and


Continence Nurses Society (WOCN). Guideline for


Prevention and Management of Pressure Ulcers. Mount


Laurel (NJ): WOCN; 2010 Jun. 21. Donnelly J, Winder J,


Kernahan WG, Stevenson,


M. An RCT to determine the effect of a heel elevation device in pressure ulcer


prevention post hip fracture. J Wound Care, 2011; 20(7): 309–18.


22. Cadue JF, Karloweicz S, Tardy C, et al. Prevention of pressure sores with a foam-body


support device. A randomized control trial in a medical


intensive care unit. Presse Med 2008; 37(1): 30–36.


23. Bales I. A comparison between the use of


intravenous bags and the


Heelift suspension boot to prevent pressure ulcers in orthopedic patients. Adv


Skin Wound Care 2012; 25(3): 125–31.


24. Tymec AC, Pieper B, Vollman K. A comparison of two


pressure relieving devices on the prevention of heel


pressure ulcers. Adv in Wound Care 1997; 10(1): 39–44.


Universal heel precautions All bedridden patients need to be considered at risk of pressure ulcers on the heels. A set of 'universal heel precautions', created by the author, is designed to identify early stages of heel ulceration [Table 1]. Patients who are bedridden for 12 hours or less are a group at moderate risk of heel ulceration. The universal heel precautions should be followed along with heel elevation. Several groups of patients, namely, those with impaired mobility, arterial inflow or sensation, are at high risk and additional assessments and interventions are required for prevention, classified as strict heel precautions[15]


.


Quality improvement processes Several quality improvement processes have been reported that can reduce pressure ulcer rates in general. Discussing the patient's skin status during hospital rounds has been shown to increase awareness of skin problems and decrease pressure ulcer development from 27% to 0%[16]


. One-on-


one clinical instruction, reminders and the presentation of raw data on pressure ulcer prevalence as a reminder of the importance of preventive measures was associated with a reduction in the number of pressure ulcers cases (from 50% to 8.3%) in one intensive care unit (ICU)[17]


. Also, the use of computerised decision-


support systems to assist the staff in selecting optimal, evidence-based care strategies improved understanding in one multi- disciplinary team[18]


.


Use of off-loading devices Off-loading devices should completely lift the heel from the bed[19,20]


Clinical experience Clinical experience suggests that boot-type devices are more likely to stay on the leg and support the foot in a neutral alignment to prevent prolonged plantar flexion[26]


.


Air-filled cells are lightweight, but may not hold the limb in place, allowing it to rotate. Foam boots tend to be warm and can cling to the bed linen. Furthermore, compressed foam does not have the ability to support the weight of the leg. Boots made from synthetic products wick away moisture and are not overly warm. Sheepskin vascular boots can be very warm but, until recently, did not suspend the heel from the bed. The WOCN guidelines recommend against


the use of synthetic sheepskin, bunny boots, rigid splints, IV bags, and rolled towels or sheets[20]


. Adejumo and Ingwu[27] reported


on the practice of nurses of using water- filled gloves for heel ulcer prevention in Nigeria, where resources are limited. While this practice is frowned upon in developed nations, the principles of pressure redistribution are fulfilled by the use of these water-filled gloves. A common clinical issue encountered is


whether a brace, often called an ankle-foot orthotic (AFO), can be an adequate substitute for a heel elevation boot. Clinical experience has shown that AFOs can lead to pressure ulcers on both legs/feet. These devices are rigid and while they maintain foot and ankle alignment, they do not seem to prevent pressure ulcers[26]


. Boots that reduce pressure


on the heels and maintain normal ankle- foot flexion were studied by Meyers[28]


in . The use of pillows


placed lengthwise under the calf, as well as boots to elevate the heel are common. Pillows can be used in patients who are not moving their legs, but boots are needed for those patients who move about in bed or who are at high risk for ulceration and/or delayed healing after ulceration. Boots can be made from plastic filled with air, foam, fibre or synthetic sheepskin. Several authors have reported reduced heel


ulcer incidence when off-loading boots are used, compared with when no heel elevation device[21]


is used[17,22] (IV) bags[23] along with intravenous


heel offloading devices[14,24,25] these appears to be superior.


60 Wounds International Vol 3 | Issue 2 | ©W ol 3 | Issue 3 | ©Wounds International 2012


. Many authors have compared and none of


patients who were sedated on ventilators. The application of heel protectors led to a 50% reduction in the prevalence of abnormal foot positioning and no patients developed plantar flexion contractures or new ulcers in this study. Aspects to be considered when choosing


an off-loading device include the ability of the device to suspend the heel from the bed surface, the ease at donning and doffing the device, the likelihood of the device coming off through movement in the bed, and the need for ambulation as none of the heel elevation devices can be worn during ambulation.


Support surfaces Nicosia and colleagues[29]


reported on a meta-


analysis of 14 studies examining the effect of support surfaces on heel ulcer development.


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