Pressure Ulcers in the Intensive Care Unit: the 'Forgotten' Enemy

OPUS 12 Scientist 2007 Vol. 1, No. 2 E. F. Reilly et al. Submitted 04/2006 – Accepted 09/2007 – Published 11/2007

Pressure ulcers in the intensive care unit: The ‘forgotten’ enemy

Eugene F. Reilly, MD 1, Giorgos C. Karakousis, MD 2, Sherwin P. Schrag, MD 3, S. P. Stawicki, MD 4 1 Department of Surgery, Section of Trauma and Surgical Critical Care, The Reading Hospital and Medical Center, W. Reading, PA, USA 2 Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA 3 Department of Surgery, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA 4 Principal Scientist, OPUS 12 Foundation, King of Prussia, PA, USA

ABSTRACT consensus conferences clearly established the preferred use of the term pressure ulcer rather than synonyms such as “decubitus Pressure ulcers (PU) have plagued critically ill and debilitated 5 patients since the dawn of recorded medicine. Pressure ulcers are ulcer” or “bed sore”. There is also consensus that four ulcer stages are useful for reporting the prevalence and guiding the associated with adverse patient outcomes, and contribute to 1 patient pain, depression, loss of function and independence, therapy of PU. These stages can be briefly summarized as increased incidence of infection and sepsis, additional surgical follows: interventions, and prolonged hospital stays. Therefore, the best • Stage 1 is defined as nonblanchable erythema with intact treatment for pressure ulcers is to prevent their development. skin. Relatively little has been written about PU in the intensive care • unit (ICU) setting, making this topic relatively ‘forgotten’ not Stage 2 is defined as partial-thickness skin loss of epidermis, only from clinical standpoint but also from research standpoint. dermis, or both. The ulcer is a superficial abrasion, blister, or For the intensivist, the concern for total welfare of the sickest and shallow crater. most dependent persons requires an excellent understanding of • Stage 3 is characterized by full-thickness skin loss with the epidemiology, causes, and effective methods for the prevention subcutaneous tissue damage or necrosis that may extend and treatment of PU in the context of a multidisciplinary team. down to but not through underlying fascia. The ulcer is a This review focuses on PU prevention, diagnosis and treatment in deep crater with or without undermining of adjacent tissue. the intensive care setting. • Stage 4 entails full-thickness skin loss with extensive tissue Cite as: Reilly EF, Karakousis GC, Schrag SP, Stawicki SP. OPUS 12 destruction, tissue necrosis, or damage to muscle, bone, or Scientist 2007;1(2):17-30. supporting structures (tendon, joint capsule, etc.) Correspondence to: S. P. Stawicki, MD. OPUS 12 Foundation, 304 Monroe Undermining and sinus tracts may be seen concurrently. Blvd, King or Prussia, PA, 19406 USA.

Keywords: Decubitus ulcers, Pressure ulcers, Risk factors, Assessment, Management, Pathophysiology. INTRODUCTION Pressure ulcers (PU) have plagued critically ill and debilitated patients since the dawn of recorded medicine. 1 Pressure ulcers are associated with adverse patient outcomes, and contribute to patient pain, depression, loss of function and independence, increased incidence of infection and sepsis, additional surgical interventions, significant economic costs and prolonged hospital stays. 1 Therefore, the most effective treatment for pressure ulcers is to prevent their development. 2 Relatively little has been written about PU in the intensive care unit (ICU) setting, making this topic relatively ‘forgotten’ not only from clinical but also from research standpoint. 3 For the Figure 1 . Schematic representation of pressure ulcer staging. In stage 1 intensivist, the concern for the total welfare of the sickest and (left upper window) there is nonblanchable erythema with intact skin. In most dependent persons implies an excellent understanding of the stage 2 (left lower window) there is partial-thickness skin loss of epidemiology, causes, and effective methods for the prevention epidermis, dermis, or both. In stage 3, there is full-thickness skin loss (right upper window) that may extend down, but not through the and treatment of PU in the context of a multidisciplinary team. underlying fascia. In stage 4 (right lower window) the ulcer penetrates This review focuses on PU prevention, diagnosis and treatment in through the full thickness of the skin, with associated damage to the the intensive care setting. underlying muscle and/or bone. Mainly historical in importance, an older PU classification existed DEFINITIONS that included Stage 5 , where the wound was said to involve Pressure ulcers are localized areas of tissue necrosis that develop underlying organs and deeper structures. Of note, the when soft tissue is compressed between a bony prominence and nonblanchable erythema associated with Stage 1 pressure ulcer 4 an external surface for a prolonged period of time. Numerous differs from reactive hyperemia associated with pressure by the

Copyright 2007 OPUS 12 Foundation, Inc. 17 OPUS 12 Scientist 2007 Vol. 1, No. 2 E. F. Reilly et al. Submitted 04/2006 – Accepted 09/2007 – Published 11/2007 complete disappearance of reactive hyperemia within 24 hours of surfaces to become particularly pronounced. 1 In paralyzed or relief of pressure, although some believe that this distinction may chronically supine patients, sacral or ischial ulcers are most likely be made within 2 hours of relief of pressure. 6 the result of long-term pressure on these areas. 1 At times, pressure ulcers in the occipital scalp area can also be seen. Less commonly, PATHOPHYSIOLOGY OF PRESSURE pressure ulcers due to improper placement of cervical collars and other orthotic/prosthetic devices can occur. In nonambulatory ULCERS patients, especially those with impaired peripheral perfusion, The amount and duration of pressure are the primary contributors calcaneal ulcers may also develop. 1 to development of PU. In a canine model, ulcers developed with 500 mmHg of pressure applied for only 2 hours or 150 mmHg applied for 10 hours. However, microscopic changes occurred in tissues after they were subjected to as little as 60 mmHg of pressure for only 1 hour. 7 These pressures are clinically relevant, and healthy persons seated on a flat board generate pressures of 300 to 500 mmHg under their buttocks. A 2-inch-deep foam pad reduces this pressure only to 160 mmHg. 8 Simply resting in a hospital bed generates heel-to-bed pressures of 50 to 94 mmHg when the patient is positioned supine 9-11 and femoral trochanter- to-bed pressure in the range of 55 to 95 mmHg when the patient is positioned on one side. 10-13 These pressures exceed the normal intra-capillary pressures of 12 to 32 mmHg and thus are sufficient to produce local capillary occlusion, ischemia, and tissue 14 Figure 3 . Example of shearing forces and friction contributing to the hypoxia. Direct pressure on the sacrum or femoral trochanter can development of a presarcral pressure ulcer. decrease the transcutaneous oxygen tension from 80 mmHg to 13 mmHg. 15 Thus, the amount of pressure needed to produce tissue Other etiologic factors include shearing force and friction. Friction damage and pressure ulcers is readily present in all patients occurs when the patient is moved across the bed and may result in confined to a bed or chair. an abrasion or skin tear. Shear is the stress from applied force that causes two parts of a body to slide on each other, and can be generated when the skin remains stationary and the underlying tissue moves. Shear occurs when the head of the bed is raised and the patient slips down or when the patient slides down in a chair. In elderly patients, the sitting mechanics result in shear that is on average three times that generated in healthy young adults. 16 The stretching or bending of blood vessels may also contribute to ischemia. In fact, it has been demonstrated that with shearing forces, less pressure is needed to produce ischemic occlusion. 17-18 Acute illness, systemic and local circulatory conditions may also contribute to the development of PU. For example, blood flow recovery time was delayed in elderly patients who developed PU compared with those without ulcers, and PU development was associated with lower diastolic blood pressures in a cohort of nursing home residents. 6, 19 This is consistent with the concept that the effective tissue perfusion pressure (TPP) can be thought of as a difference between the diastolic blood pressure and the overall pressure within the tissue in question – with the optimal TPP being above 40 mmHg. In addition, among a cohort of patients admitted to an intensive care unit, the Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were found to be markers of a high risk for developing pressure ulcers. 20 In APACHE II, 12 routine physiologic measurements and previous health status are used to provide a general measure of disease severity. 21 Thus, acute illness and associated hemodynamic factors may play a role in PU development.

Figure 2 . Most common locations of pressure ulcers according to patient PRESSURE ULCER EPIDEMIOLOGY IN positioning. GENERAL HOSPITALIZED POPULATION Whereas most of PU develop as a result of chronic pressure, Considerable research is available on the effective prevention of sometimes a short-term exposure to a noxious surface can lead to and therapy for PU. In one large study of hospitalized patients skin breakdown. 1 Poor nutrition leads to muscle wasting and soft with PU, the overall incidence was 8.4%, and 3.2% of patients tissue loss and allows the impact of bony prominences on external had PU present at the time of admission. 24 Although it would

Copyright 2007 OPUS 12 Foundation, Inc. 18 OPUS 12 Scientist 2007 Vol. 1, No. 2 E. F. Reilly et al. Submitted 04/2006 – Accepted 09/2007 – Published 11/2007 logically follow that the application of modern knowledge and Among other factors, the constant increase in the elderly ICU skills would lead to reduced incidence and prevalence of PU, data population, as well as the increasing number of emergent indicate that the incidence of pressure ulcers remains relatively admissions and patients with high illness acuity (sepsis or severe constant ( Figure 4 ). 22-23 This trend may be due to several factors, trauma), may also be contributory. 1 including (a) coding changes when the prospective payment Unfortunately, the overall incidence of PU is likely to increase in system was implemented in 1983; (b) an increased proportion of the future. 29 This trend will have a major impact on healthcare the oldest segment of population, (c) a greater number of invasive expenditures because the cost of managing PU is projected to procedures performed in older persons at high overall risk for increase significantly. 30 Moreover, PU are a major precipitant of complications; (d) the ineffectiveness of preventive and medical malpractice litigation. 31-33 They can also lead to life- therapeutic interventions for pressure ulcers; and (e) the lack of threatening infectious complications that may require numerous implementation of effective interventions. Regardless of the 31- debridements and tissue transfer procedures for wound closure. reason, existing data do not provide evidence for a reduction in 33 22-23 The often complex surgical procedures associated with PU PU prevalence in hospitals. generally require prolonged hospitalization and forced immobility Encouraging is the fact that prevalence of pressure ulcers has for wound and/or graft healing and therefore predispose to other remained stable in nursing homes over a 10-year period despite life-threatening complications such as venous thromboembolic the increasing acuity of admissions, indicating that the application disease, sepsis, and pneumonia. 1, 34-35 of current knowledge and skills may be having an impact. 25 With the development of large institutional databases 26 , more data on EPIDEMIOLOGY OF PRESSURE ULCERS PU prevalence should become available. IN THE INTENSIVE CARE UNIT Although some patients are admitted to hospitals with preexisting Data on the epidemiology of pressure ulcers in the ICU ulcers and others develop them during their stay, pressure sores demonstrate the magnitude of the problem and help guide are a significant and increasing source of suffering and financial prevention and therapy. Prevalence studies from Europe, South 27 burden. In one study, approximately 60% of PU were hospital- Africa, South America and Canada show that anywhere between acquired, with the remaining 40% already present at the time of 5% and over 40% of all hospitalized patients in major series suffer 24 hospital admission. Hospital-acquired PU tended to be of lesser from pressure ulcerations at some point during their hospital 24 severity than those present on admission. There was an average stay. 34, 36-39 Over 31% of patients who are identified to be at high of 1.6 ulcers per patient, with approximately 56% of ulcers being risk for PU develop such ulcers. 39 Stage I and 36% being stage II. 24 The most common PU sites were coccyx-sacral area, heels, and elbows ( Figure 2, Figure 9 ). 24

Figure 4 . Postacute and chronic care nursing home residents with pressure ulcers, by type of resident, 1999-2004. Postacute care incidence is represented by the red line. The light green line represents high-risk chronic care patients. Low-risk chronic care patients are represented by the yellow line. Source: www.ahrq.gov/qual/nhqr06/report/Chap2.htm . Previously, the most important factor believed to contribute to PU 28 formation was the nonambulatory patient status. In the ICU, nonambulatory patients often suffer from acute or chronic illness, or may harbor other conditions predisposing to bedrest such as Figure 5 . Incidence of pressure ulcers in major reported ICU series. Note the wide range of incidences, from 5% to over 40%. stroke, traumatic brain injury, or prolonged respiratory 1 insufficiency. Moreover, these patients are more difficult to Even at the lower range of prevalence, pressure ulcers are one of mobilize by the nursing staff, whose time for patient care has been the more common problems facing physicians in the ICU. Among 1 increasingly constrained. In fact, the observation of decreased patients with PU, the average prevalence of each stage is relatively nursing presence in the patient room and increased charting predictable. 26 The combined prevalence of stage 1 and stage 2 1 responsibility for the nurses was noted in at least one study. ulcers is approximately 65%. In one study of PU incidence in the Inability to turn or mobilize those patients at highest risk for PU ICU, close observation showed that as many as 98% of the potentially contributes to the formation of additional ulcers.

Copyright 2007 OPUS 12 Foundation, Inc. 19 OPUS 12 Scientist 2007 Vol. 1, No. 2 E. F. Reilly et al. Submitted 04/2006 – Accepted 09/2007 – Published 11/2007 developing ulcers are first detected at stages I and II. 6 Thus, most factor. Healthy, active people can develop PU when anesthesia, ulcers can be identified in early stages, when they can be treated sedation, disease, or injury renders them immobile and causes most easily. decreased pain perception. 49 Although all patients who are bed- or chair-bound have some degree of mobility impairment, the Several reports on the incidence of pressure ulcers from 26, 40 severity ranges from complete immobility to the ability to administrative databases are available. The computed reposition independently. Patients may not reposition themselves incidence from these studies of 0.20 to 0.56/1000 patient-days because they cannot move or cannot sense the discomfort may be low because stage 1 ulcers were not included. Some associated with immobility. Patients who cannot move include investigators exclude stage 1 pressure ulcers from their studies those with spinal cord injury, various fractures, Parkinson’s because of the potential difficulty of reliable identification for 22, 26 disease, stroke, and deconditioning associated with severe illness. research purposes. In a 2-week prospective cohort study of Physical restraints, used in the bed or chair, contribute to impaired patients at risk (Braden Scale score less than 17), the incidence of 47 6 movement and also may directly cause pressure. Examples of pressure ulcers (including stage 1) was 14/1000 patient-days. For sensory loss that impair sensing the need to reposition include comparison purposes, the incidence among all admissions to an peripheral neuropathy, spinal cord injury, stroke, and coma from adult ICU was 28/1000 patient-days 41 ; high-risk patients any cause (including medically-induced sedation and/or (APACHE II score greater than 15) admitted to an ICU had an 20 paralysis). Although inability to move and inability to sense the incidence of 52/1000 patient-days. It is imperative that patients need to move are separated in these examples, it is more common at risk are recognized at the time of ICU admission and that to find patients who have both immobility and sensory loss, such preventive interventions are started as soon as is feasible. as a ventilated patient with a hip fracture who is receiving intravenous analgesia and sedation. PRESSURE ULCERS: RISK FACTORS Malnutrition has been also been associated with the development Previous studies have identified the following factors as of pressure ulcers. In prospective cohorts with multivariate increasing the likelihood of developing a pressure ulcer: analyses, lower dietary protein intake 6, 41, 44, 50 and inability to immobility, admission to the ICU, malnutrition, incontinence, feed oneself 26, 40 have been found to be independently predictive hypoalbuminemia, spinal cord injury, stroke, hypertension, of PU development. In one study of PU present on admission, the reduced level of consciousness (impaired mentation), fractures majority of patients had stage 3 sacral ulcers, were below their and/or major orthopedic procedure, advanced age, trauma, usual body weight, and had a low prealbumin level. 51 With decreased perfusion, poor wound healing, inadequate nursing continued poor dietary intake, deterioration in other markers of care, and chronic illness (including being bed-bound). 1, 42-43 Risk malnutrition (hypoalbuminemia, low prealbumin, low vitamin C factors derived from cohort studies are displayed in Figure 6 . 6, 26, level) may later occur. This observation is supported by the 40, 44-48 Each risk factor has varying levels of severity, and many relationship of hypoalbuminemia to the presence of PU that was patients have more than one risk factor. Thus, both the severity of noted in several cross-sectional studies. 36, 45, 52-55 However, low a risk factor and the number of risk factors are taken into account albumin has not been found to be an independent predictor of PU when determining the overall risk. Significant associations with development in several longitudinal cohort investigations. 6, 41, 44-45, age and gender have been variably reported depending on the 50, 54-55 Therefore, it may be preferable that when identifying population under study and how the multi-institutional data are patients at risk for developing pressure ulcers, physicians should pooled. 44, 49-50 Relative risk ratios for PU occurrence between 2.5 concentrate on assessing the overall nutritional intake rather than and 4.2 have been identified for factors such as coma, traditional serum markers. Aggressive nutritional therapy is unresponsiveness, paralysis, sedation, and cardiovascular certainly warranted in these situations. 51 instability. 37 An estimated 50% to 80% of patients with spinal cord injuries develop pressure ulcers at least once in their lives. 36 Urinary and fecal incontinence are considered to be predictive of PU development, at least since the validation of the early predictive instruments. 56 However, the independent contribution of incontinence in predicting pressure ulcers has not been consistent in several large cohort studies. 6, 26, 40-41, 44-45, 50, 54-55 Urinary incontinence was not found to be a significant risk factor in these studies except as a component of ‘skin moisture’ in the Braden Scale, which includes five other factors. 6, 41, 44, 50 Fecal incontinence was significant in only one of the three studies. 26, 40 The lack of consistency may be related to the use of different measures of fecal incontinence or confounding with mobility measures. 26, 40, 45, 54-55 Despite that, it seems reasonable to consider patients with mobility problems and fecal incontinence as being at higher risk for development of PU than patients not exposed to such contamination. The risk of PU in the intensive care unit has been shown to Figure 6 . Multiple intrinsic and extrinsic factors contribute to pressure increase as a function of time. In one study, the cumulative risk ulcer formation and progression. of developing PU was found to be 50% at 20 days in the ICU. 37 In another study, almost all PU developed in patients with an ICU Because the development of pressure ulcers depends on the length stay >7 days. 1, 29 The greatest risk factors for the decubitus ulcers of time that pressure is applied, immobility is the major risk

Copyright 2007 OPUS 12 Foundation, Inc. 20 OPUS 12 Scientist 2007 Vol. 1, No. 2 E. F. Reilly et al. Submitted 04/2006 – Accepted 09/2007 – Published 11/2007 in that study were increased age, nonambulatory status, prolonged provide a systematic method for quantitative risk assessment and a time without any nutrition, and especially an emergent ICU method for interdisciplinary team communication. admission. Research performed by Fife et al , indicates that risk of a Stage II PRESSURE ULCERS: RISK ASSESSMENT pressure ulcer increases significantly with a Braden score of <13. If 13 is the score that triggers preventive care, this would decrease In order to determine which patients might be at increased risk of the population considered to be at risk to approximately 41% of developing a pressure ulcer, various pressure ulcer risk (PUR) neuro-ICU admissions in that study. No cutoff score can truly scales have been developed.57 Several of these scales have been guarantee that it will separate all of the at-risk patients from those implemented over the past 20-30 years, with the Norton scale not at risk in a large population, so some measure of risk must be being used most frequently ( Figure 7 ). 56 Other pressure ulcer risk accepted if a cutoff score is used. 27 Because dissipating the scales include the Waterlow scale ( Figure 9 ) 58-59 , the preventive care resources over all admissions is an impractical Jackson/Cubbin risk scale 57 and the Skin Ulcer Risk Evaluation solution, the alternative suggested by Fife et al , is to focus on (SURE). 20, 60 The Cornell Ulcer Risk Score (CURS) appears to those patients with Braden scores <13, regardless of body mass, correlate well with PU formation at least in one clinical study, but but expect a higher ulcer incidence among the low body mass it remains to be validated more widely. 1, 29 subgroup. 27 Fife et al , demonstrated that length of stay (LOS) in the neurologic ICU (NICU) does not correlate with new ulcer development but is highly correlated with the Braden score. Their results suggested that causal factors influence the Braden score, and the Braden score, in turn, can be used to predict both the incidence of new pressure ulcers and the LOS in the NICU.

Figure 7 . Norton scale for pressure ulcer risk assessment. This scale was created in England in 1962. The total sum of individual scores is added to produce the Norton Rating score for each patient. Source: http://www.lumetra.com/resource-center/index.aspx?id=486 . Figure 8 . Simplified representation of the Braden Scale. Please note the Standardized risk assessment instruments for PU development risk-predicting score of 16 points or less. Source: http://www.medscape.com/viewarticle/450041 . have received acceptance in some ICU settings. 6, 41, 44, 50, 56 The 6, 41, 44, 50 Braden Scale has six items (sensory perception, activity, When used in cohorts of high-risk patients in hospitals (in whom mobility, skin moisture, friction, and nutrition) that contain three the incidence of developing ulcers is about 20% over 10 to 14 to four grades each ( Figure 8 ). Scores are continuous; those of 16 days or about 14/1000 patient-days), the sensitivity of both or 17 indicate mild risk, and those of 12 or below indicate high Braden and Norton scales was 83%, the specificity was 63%-64%, 6, 41, 44, 50 risk. The Braden Scale has been previously compared and the positive predictive value was 36%-37%. 22 When used with the Norton Scale in the same population, with a kappa alone, these scales may not be helpful in populations at much 56, 61 statistic for agreement being fairy high, at 0.73. These scales lower risk. For example, among the nursing home population, the

Copyright 2007 OPUS 12 Foundation, Inc. 21 OPUS 12 Scientist 2007 Vol. 1, No. 2 E. F. Reilly et al. Submitted 04/2006 – Accepted 09/2007 – Published 11/2007 incidence of patients developing ulcers may average 0.5/1000 serve as a clinical warning device. 58 The primary purpose of such patient-days, or about 1% over 14 days. If the same sensitivity and scales is to provide the health care staff with a summary measure specificity are employed, the positive predictive value would be which reflects the risk a patient has of developing a PU. 2%. Thus, the information gained from using these scales in low- risk populations (all residents) is limited. For this reason, many PRESSURE ULCER PREVENTION physicians choose to use these scales only for higher-risk While previous reports have addressed the problem of PU in populations, such as bed-bound ICU patients. chronic care institutions, very few articles involved the prevention of PU in the ICU. 27 The development of PU confers substantial morbidity to the critically ill and debilitated patient. 1, 29 The incidence of PU in hospitalized patients is as high as 10% and may be even higher in the intensive care setting. 62 It follows logically that the best treatment for PU is the prevention of their development. 2 There is good evidence to support the notion that many pressure ulcers are preventable. Three general guidelines for PU prevention involve: (a) Identification of patients at higher risk for developing ulcers; (b) Implementation of preventive measures appropriate for the level of risk; and (c) Close follow-up of high-risk patients with reassessment whenever functional status deteriorates. Choosing the number and intensity of preventive measures appropriate for the level of risk requires good clinical judgment. Preventive measures involve reducing or eliminating factors contributing to the development of PU, including time and amount of pressure, friction, shear forces, malnutrition, and fecal incontinence. These measures most commonly include patient turning, special mattresses, and special skin care products. 24 After the development of PU, the most frequently used treatment modalities include specialized bed or mattress utilization, continued frequent turning, and special ointments and dressings. 24 From a healthcare system’s standpoint, the most important steps aimed at reducing the incidence of PU include (a) continuous reassessment and application of protocol-driven preventive and treatment measures, (b) creation of quality improvement groups where preventive and treatment strategies are utilized and discussed, (c) institution of educational courses, (d) clearly visible notices and reminders aimed at healthcare workers, and (e) ubiquitous availability of clinical instruments that serve to decrease PU incidence (cushions, pillows, etc). 39 Quality improvement programs employing a combination of education and technology are effective in decreasing PU formation. 61 Pressure ulcer reduction strategies include systematic turning regimens for immobilized patients. 1, 29 Innovations in rehabilitation engineering can now increase mobility in certain disabled patients. 1, 29 One of these techniques has been called “passive standing” and can counteract many of the negative effects of chronic immobilization, including bone demineralization, urinary calculi, cardiovascular instability, and reduced range of motion. 63

Physicians treating patients with mobility problems need to fully assess the medical conditions that limit the patients' ability to Figure 9 . Waterlow pressure ulcer risk assessment tool. Source: reposition or to sense the need for repositioning. This includes http://www.herhis.nhs.uk/RMCNP/content/mars47.htm . obtaining relevant history, physical examination, and laboratory

As noted above for the Braden scale, most PUR scales make use data and then treating identified conditions and/or addressing of a threshold score, which is meant to predict the development of specific risk factors. Although the process of complete evaluation a pressure ulcer in the near future. However, it should be noted and management of medical conditions is important, any that some authors have stressed that PUR scales are not designed prolonged pressure must be relieved immediately. The choice of to predict the inevitable development of PU but should mainly methods to relieve prolonged pressure depends on the extent of sensory loss and immobility. For patients with severe sensory

Copyright 2007 OPUS 12 Foundation, Inc. 22 OPUS 12 Scientist 2007 Vol. 1, No. 2 E. F. Reilly et al. Submitted 04/2006 – Accepted 09/2007 – Published 11/2007 losses, a standard method is turning the patient at least every 2 to but are more expensive. 10-12 Unfortunately, little information on 3 hours. 15, 22-23, 32 The objective is to prevent the patient from lying their efficacy in actual prevention of ulcers is available. supine (a position in which the sacrum and heels bear weight) and Still other technologies aimed at modifying the immobilized on one side (a position in which the femoral trochanter bears patient’s support surface or in the development of special beds or weight). Pillows are used to prop the patient at a 30-degree lateral mattresses and suspension devices designed to hold patients off position, and the patient is turned from side to side every 2 to 3 hard surfaces have been introduced. 70-71 A strategy called hours, or more frequently, if possible. Although protecting the “fluidization” utilizes warm air passing through small solid sacrum and hips, 30-degree lateral turning places pressure on the microspheres, and is postulated to decrease PU formation on the knees and the medial and lateral malleoli. To protect these areas, 72 surface of potential pressure areas. Beds utilizing fluidization pillows should be inserted between the ankles and knees, which technology have been effective in minimizing exacerbations of prevents prolonged pressure and relieves the amount of pressure. pressure ulcers once found, but they are very expensive and not practical for primary prevention in all high-risk patients. 1 Moreover, some patients may find the beds uncomfortable and nurses may consider them an annoyance. 1, 29 Dynamic (alternating air) mattresses relieve pressure by the use of multiple air cushions with alternating air pressure areas. These mattresses are more costly than static mattresses and are more complex to operate, but those with 6-inch-diameter air tubes were shown to be effective in preventing PU. 22 Kinetic or oscillating beds can rotate the patient in a complete circle and are used for high-risk patients with spinal cord injury. Low-air-loss beds provide pressure relief using air cushions that allow air to escape through multiple pores. These beds reduced the incidence of PU among patients admitted to an ICU but have not been compared with solid foam mattresses. 20 The bony prominences of the heels are vulnerable, frequently neglected areas. When the patient is in the 30-degree lateral position, the heels can be protected with pillows. When the patient

Figure 10 . Common locations for pressure ulcer formation. Over 95% of is supine, pillows can be placed under the legs to elevate the heels pressure ulcers form in these anatomic areas. Source: and relieve pressure. Special heel protectors and other pressure- http://www.herhis.nhs.uk/RMCNP/content/mars47.htm . relieving devices are appropriate for patients who cannot change the position of their lower extremities. Some of these heel Ulcers develop over the ischial tuberosities more frequently in protectors are constructed of foam and are inexpensive, but their patients who are chair-bound. The other bony prominences are effectiveness in PU prevention is not clear. More expensive heel subjected to pressure when patients are lying supine or on their protectors (or boots) have posterior splints for the leg that lift the side. Previous studies indicate that about 80% of PU develop over heel off contact surfaces, and are more appropriate for PU the sacrum or coccyx, hips (femoral trochanter), buttocks treatment or prevention in very-high-risk patients. (ischium), and heels. 64-65 Thus, for bed- and chair-bound patients, it is important to examine all pertinent sites below the waist. The Chair-bound patients who cannot sense the need for repositioning average number of ulcers reported per patient ranged from 1.6 to require intensive efforts for pressure relief. The pressures located 2.5, further emphasizing the importance of active surveillance. 64-65 over ischial prominences are significant, and the potential area for

distributing weight is relatively small. Measures of pressure Pillows are one example of devices that relieve pressure over reduction of cushions vary so widely among patients that specific prominent bony surfaces by distributing the weight over a wider 73 recommendations cannot be made. Thus, cushions need to be area using the principle of displacement. The wider the area of 22-23, 32 selected and prescribed individually for each patient. Most weight distribution, the less pressure will be exerted on one point. rehabilitation therapists and nurse specialists have been trained to Thus, the best pressure-relieving device may be a water bed, but evaluate patients and prescribe these devices. Doughnut-type this is impractical in most health care settings. Examples of 66-67 devices or ring cushions should be avoided because they pressure-relieving devices are shown in Figure 13 . Static compromise blood flow to areas of bony prominence. Seated overlays and pressure-reducing mattresses are made of or contain patients should be repositioned frequently (optimally every hour) gel material, foam, water, or air. While a 2-inch-deep foam or, if feasible, trained to shift weight every 15 minutes. mattress does not significantly reduce pressure over the trochanter, a 4-inch-deep foam mattress reduces pressure by 30% compared Preventive measures for shear and friction include maintaining the with regular hospital beds. 10, 12 Among elderly patients in three head of the bed at the lowest elevation consistent with medical different settings, a 4-inch-deep solid foam mattress reduced the conditions, using a trapeze or bed linen (lift sheet) for moving the incidence of PU compared with 3- or 4-inch-deep convoluted patient, and paying careful attention when the patient is being foam mattresses. 68 In addition, compared with a regular hospital positioned. The use of skin moisturizers for dry skin may be bed, a 6.5-inch-deep foam mattress reduced the incidence of PU considered. Advances have been made in ways to assess and from 68% to 24% among elderly patients with femoral neck manage fecal incontinence and malnutrition. Still other efforts fractures. 69 Other static mattresses reduce pressure by 40% to 70% have focused on strategies to relieve or redistribute pressure for those patients confined to a bed or wheelchair. 1, 29 A study from

Cornell University showed that patients with intensive care unit While many stage 2 pressure ulcers and even larger ulcers will length of stay greater than seven days, who were still not mobile heal, a significant proportion will not. Only 72% of patients with after that time, were nearly always destined to develop PU. 1, 29 Stage 2 ulcers, 45.2% of patients with Stage 3 ulcers and 30.6% of those with Stage 4 ulcers were ulcer-free at 6 months. PRESSURE ULCERS: FOLLOW-UP AND Independent predictors of healing included PU size, older age, and receiving rehabilitation services. Both immobility and REASSESSMENT 45, 54-55, 74 Patients should be examined frequently to determine whether PU incontinence were associated with poor healing of PU. are developing or progressing. In high-risk patients, pressure points should be monitored daily. If pressure ulcers develop and Stage 1: Nonblanchable Erythema. Perhaps the most important are recognized early (stage 1 and 2), aggressive interventions can facet of therapy is shifting the healthcare team attitude from be instituted immediately, with expectations that ulcerations will minimalistic to that highlighting the eminence of soon-to-appear resolve within days. The objective is to avoid advanced stage advanced pressure ulcer stages. Interventions initiated early may ulcers that are associated with major morbidity. produce a cure within days, whereas delay may result in progression to advanced stages within the same period, with cure Some studies demonstrate that initiating PU preventive measures taking months. Thus, careful examination of patients to detect on the basis of the patient’s skin assessment does not prevent the early stages of disease is imperative. On the basis of the development of pressure sores but often only confines the area of epidemiology of pressure ulcers, the careful examination process damage. 59 Others demonstrated that point prevalence should start on the day of admission to the intensive care unit. measurement does not give reliable information about the PU problem in an ICU and that daily assessment of PU development For stage 1 ulcers, risk factors and current preventive measures with an established risk measuring tool better helps nurses to should be reassessed. When preventive measures are in place, the indicate specific risk factors and assists them with decisions on intensity or number of measures for prevention should be the frequency and method of PU precautions to be taken. 59 increased (for example, increased frequency of turning, a more Changes in patients' medical condition may affect their level of potent pressure-relieving device, increased mobility through risk for developing PU. Thus, risk factors for PU have to be trapeze bars or physical therapy, or increased nutritional reassessed after any change in condition to decide whether the repletion). These measures alone may be sufficient for stage 1 intensity of preventive measures should be increased or decreased. ulcers. As an alternative, polyurethane dressings applied every 1 Even patients not previously at risk should be periodically to 10 days can protect the area from additional friction. The assessed for the presence of risk factors for PU. This is a routine transparent polyurethane dressings are evenly coated on one side procedure performed in all modern health care institutions. with a synthetic adhesive. These semipermeable films are permeable to water vapor, oxygen, and other gases and are PRESSURE ULCERS: TREATMENT impermeable to water and bacteria. They maintain a moist Therapeutic measures should be appropriate for each PU stage and interface for healing but allow some exudate to be lost by should be consistent with the therapeutic goals for the patient. transmission of water vapor. With appropriate treatment, most Many therapeutic interventions follow the same principles as nonblanchable erythema lesions can be expected to heal by 2 preventive interventions. weeks.

Stage 2: Partial-Thickness Skin Loss. All therapeutic interventions for nonblanchable erythema are also appropriate for stage 2 pressure ulcers. Because a defect is present in this stage ulcers, the wound should be inspected and monitored for signs of secondary infection (surrounding erythema, warmth). For stage 2 ulcers, polyurethane dressings are more effective and less costly than saline wet-to-dry dressings. 76 Further, saline wet-to-dry dressings (debridement-type dressings) are rarely indicated for this stage.

Stages 3 and 4: Full-Thickness Skin Loss and Full-Thickness Skin Loss with Extensive Tissue Destruction. A difficulty with stage 3 and stage 4 lesions is that the extent of disease may not be evident because of the overlying necrotic material or eschar. To establish the true extent of disease and promote healing, the necrotic material must be removed and surgical consultation should be considered. Because physical debridement can be associated with peri-procedural bacteremia 77 , prophylactic antibiotic agents should be used for patients with implanted prosthetic devices. For smaller eschars, topical application of Figure 11 . The Stirling Pressure Sore Severity Scale. Source: Reid J, 78 Morison M. Towards a consensus classification of pressure sores. J enzymatic debriding agents is effective. The eschar should be

Wound Care 1994;3:157-159. scored so that the penetration and effectiveness of topical debriding agents are increased. These enzymes must be kept from

Copyright 2007 OPUS 12 Foundation, Inc. 24 OPUS 12 Scientist 2007 Vol. 1, No. 2 E. F. Reilly et al. Submitted 04/2006 – Accepted 09/2007 – Published 11/2007 touching the surrounding area because they irritate healthy skin. impregnated gauze are indicated for packing. Packing should be Applications should be stopped when the eschar sloughs. changed daily. Also, vacuum-assisted wound therapy should be considered for these lesions. Loose material can be effectively debrided by applying wet-to-dry saline dressings (debridement dressings) every 8 hours. Although Stage 4 ulcers usually require surgical consultation for initial ulcers may heal with this treatment, the dry dressing may remove physical debridement. Completion of debridement can be done or disrupt the granulation tissue and delay healing when the lesion with wet-to-dry dressings or repeated debridement. For some is clean with a granulating base. Polyurethane and hydrocolloid patients, whirlpool baths may help facilitate debridement. Clean, dressings are more effective for healing stage 3 pressure ulcers. 76, deep ulcers require packing, as discussed for stage 3 ulcers. 79-80 Hydrocolloid dressings are impermeable to gas and moisture. Vacuum-assisted wound therapy should be considered for these In contrast to polyurethane, hydrocolloid dressings absorb exudate lesions. and are changed more frequently, that is, every 1 to 4 days. Hydrocolloid dressings are overall less costly and more effective than wet-to-dry dressings. 79-80

Figure 12B . Selected mechanical methods used for relieving chronic pressure and for pressure ulcer treatment and prevention (continued). Source: http://www.herhis.nhs.uk/RMCNP/content/mars47.htm .

PRESSURE ULCERS: OTHER THREAPEUTIC CONSIDERATIONS The selection of patients for surgical procedures to close pressure ulcers is difficult. In elderly patients with severe cognitive dysfunction and other chronic disabilities, the rates of surgical complications, recurrences, and new ulcer formation can outweigh benefits of surgery. 22-23, 32 Moreover, aggressive treatment of advanced pressure ulcers may often be inconsistent with the overall therapeutic goals for the patient. 80 Because elderly patients with advanced pressure ulcers are often terminally ill, it is important to define the overall goals of therapy for the patient among many competing goals (prolongation of life, restoration of normal function, avoidance of burdensome therapies, relief of Figure 12A . Selected mechanical methods used for relieving chronic pain and suffering). 81 In patients with mild to moderate overall pressure as well as for pressure ulcer treatment and prevention. Source: http://www.herhis.nhs.uk/RMCNP/content/mars47.htm . dysfunction and comorbid conditions, surgical treatment may be preferred if it is compatible with treatment goals and the patient's 82 In the deeper stage 3 and stage 4 wounds, hyrodrocolloid ability to tolerate surgery. dressings alone are not appropriate. These deeper wounds need to If patients with large defects are candidates for surgery, and the be packed with materials according to the amount of exudate. For wounds are clean with healthy granulation tissue, consultation dry wounds with minimal exudate, the less absorptive hydrogels with plastic surgeons for consideration of skin grafting is are recommended. Continuous moist soaks with normal saline appropriate, depending on the goals for the patient and response to may be used, with care taken to ensure that the dressing does not conservative therapy. Patients with large defects in the sacral area become dry because healthy tissue is removed when dried and urinary incontinence may require chronic catheterization. dressing is changed. For wounds with significant exudate, the Those with fecal incontinence may need fecal stream diversion via more absorptive dressings, hydrophilic foam, alginates, or saline-

Copyright 2007 OPUS 12 Foundation, Inc. 25 OPUS 12 Scientist 2007 Vol. 1, No. 2 E. F. Reilly et al. Submitted 04/2006 – Accepted 09/2007 – Published 11/2007 ostomy. Both venous and arterial insufficiency need to be assessed intensive but conservative therapy, specialized beds should be in the setting of PU of the lower extremity. considered. The constraint for not prescribing specialized beds earlier is the expense ($50 to $100 per day). 86 The degree to Among patients with very large or multiple ulcers, there is no which these costs can be offset by potential benefits of avoiding consensus on the use of costly but effective specialized beds (low- surgery, reducing ICU/hospital stay, or shortening subsequent air-loss or air-fluidized beds) for treatment of PU in the nursing nursing home stay requires further clinical trials with long follow- home setting. In hospitalized patients, the relative odds for up periods. showing improvement were 5.6-fold greater with air-fluidized beds compared with air mattresses covered with a 1.9-cm-deep Close attention to extensive wounds should not detract from foam pad after a follow-up of nearly 2 weeks. 83 In nursing home continued assessment and management of the other risk factors, residents, low-air-loss beds compared with 10-cm-deep including general medical condition, immobility, fecal corrugated foam pads resulted in a three-fold reduction in the incontinence, and malnutrition. Aggressive therapeutic ulcer area during a follow-up of 37.5 days. 84 Among patients interventions are frequently used without attention to basic care, receiving home care, air-fluidized beds did not improve healing such as nutritional assessment. 22-23, 32 Evidence shows that a compared with usual care (that is, various pressure-reducing higher protein intake is related to more rapid healing of PU. 83 In mattresses), but the costs of the beds were offset by reduced addition, ascorbic acid supplements have been shown in a hospital days. 85 randomized, double-blind clinical trial to significantly improve PU healing. 87

NEWER FORMS OF THERAPY Recent clinical trials of low-intensity direct current for treating pressure ulcer in stages 2 and 3 and of topical growth factor for treating ulcers in stages 3 and 4 have shown increased healing rates. 22-23, 32, 88-89 These studies suggest promising new areas for clinical investigation. In the future, very high-risk patients may be referred to zero-gravity “space clinics” to recuperate from their PU. 90

OUTCOMES AND OUTCOME- DETERMINING FACTORS Local Infection. Pressure ulcers are considered to be chronically contaminated wounds. Local infection is usually well controlled by relief of pressure, debridement, dressings, and other general

measures of care. Although higher bacterial counts per gram of tissue are associated with delayed healing, unproven antiseptic or

Figure 13 . Examples of various protective surfaces designed for antibiotic topical applications should be avoided because they prevention and treatment of pressure ulcers. A ‘fluidized’ surface bed (left may be toxic to fibroblasts and impair formation of granulation upper); Low-air-loss unit used for pressure relief and skin moisture tissue. 91 Few studies have shown efficacy of topical antibiotic management in high-risk patients (right upper); Specialized wheelchair agents. One study reported that gentamicin cream applied to ulcers cushion (center); Specialized boot for prevention of contractures, pressure reduced bacterial counts and improved healing. 92 Ulcers with a ulcers, and shielding of hypersensitive toes (left lower); Low-air-loss foul odor are probably infected with anaerobic organisms. Topical mattress for pressure ulcer prevention and therapy (right lower). metronidazole may be effective in reducing the foul odor and 93 bacterial counts of these ulcers. However, until efficacy is better In settings not using low-air-loss beds, only 20% to 30% of stage shown, topical antibiotic agents should have limited role. 91 3 and stage 4 ulcers heal completely. 26 Some advocate not prescribing specialized beds for most patients within the first 30 Sepsis. Among hospitalized patients, the combination of days of admission, as many patients who are prescribed special bacteremia and pressure ulcers has been associated with a beds shortly after admission are extremely ill and die of unrelated mortality rate of 50%. 94 If sepsis is suspected in patient on general conditions during the first 30 days, without discernible benefit of ward, the patient should be transferred to the ICU when this move 86 this therapy. Further, if specialized beds are prescribed, they is consistent with the patient's treatment goals. In patients with should be used for at least 60 days before their use is discontinued stage 3 and 4 pressure ulcers and clinical manifestations of sepsis 86 because of a lack of therapeutic response. A trial of intensive (fever, chills, confusion, and hypotension) without a definable total-patient therapy with close monitoring (weekly linear cause, it must be assumed that the wound is the primary source of measurements of wound size and depth) would provide objective infection. Because swab specimens frequently reflect surface evidence of healing, nonhealing, or worsening and the need or colonization, a deep-tissue biopsy specimen for culture should be absence of need for special beds. obtained when feasible, in addition to blood cultures. 95 Blood cultures frequently grow multiple microbial organisms 91 and have If aggressive therapy is consistent with the overall treatment goals included Pseudomonas aeruginosa, Bacteroides fragilis, and for the patient, and if the severe ulcers do not heal or worsen with Staphylococcus aureus. Thus, when sepsis is thought to be related

Copyright 2007 OPUS 12 Foundation, Inc. 26 OPUS 12 Scientist 2007 Vol. 1, No. 2 E. F. Reilly et al. Submitted 04/2006 – Accepted 09/2007 – Published 11/2007 to the pressure ulcer before culture results are obtained, antibiotic Patients in the ICU are at high risk of developing PU and the use therapy should cover anaerobic organisms, gram-negative bacilli, of PUR tools has been advocated as a means of identifying and gram-positive cocci. Therapy can be narrowed upon definitive patients in the highest risk groups. 37 Preventive care has to focus cultures and sensitivities. on decreasing the incidence of new ulcers, but can constitute an expensive use of hospital resources. 27 Therefore, it is important to Osteomyelitis. Because PU develop over bony prominences, have the best possible definition of an “at risk” population so that osteomyelitis is a potential complication. 96 The diagnosis is more these resources can be appropriately channeled. 27 likely when the ulcer involves bone surface or when healing is delayed. However, clinical evaluation for osteomyelitis is often In an acute-care facility, the average variable costs (additional inaccurate. Appropriate diagnostic procedures, which may include costs incurred to treat pressure ulcers) have been estimated to be pathologic examination of bone tissue, should be pursued to $1300 per patient or $80 per day. 98 If the patient was admitted justify a prolonged course of antibiotic therapy. 22-23, 32 Ulcers specifically for treatment of pressure ulcers and room costs were located over joints merit close attention for potential development included, the average variable costs increased to $3746 per of septic arthritis. patient. In the nursing home, the average variable costs were estimated to be $751 per patient and $5.35 per day (range, $0 to Mortality. Data on pressure ulcer-related mortality in the ICU is $128 per day). 99 For some individual nursing home residents, scarce. However, ample data exist to exemplify the morbid overall costs may range from $4255 to $23,300 per patient. 100 character of pressure ulcers in other settings. Patients admitted to These costs were estimated from the institutional perspective and nursing homes with pressure ulcers have a mortality rate of 50% at therefore underestimate the costs from the patient’s perspective. 1 year compared with a 27% mortality rate in those without ulcers. Costs not directly related to pressure ulcer treatment, such as costs Thirty-five percent of patients developing an ulcer within 3 of physical therapy to improve mobility, or the cost of the months of admission die within 1 year compared with 25% who prolonged stay because of the PU, were not included nor were do not develop ulcers. 26 An 180-day mortality rate of 69% was costs associated with pressure-relieving devices. 99 Thus, from the noted in patients who developed stage 4 pressure ulcers, with an patient’s perspective, treatment costs can be significantly higher, average of 47 days from ulcer onset to death.45, 54-55, 74 In one providing further incentive for early prevention and treatment. Veterans Administration study, pressure ulcers were found to be a significant marker for mortality in long-term care patients, with a In a prospective cohort study of post-discharge health care prevalence of approximately 10%. 45, 54-55 In fact, the relative risk utilization among patients 65 years of age or older whose activity of dying was 2.4 for patients with PU, and the depth of the ulcer was limited to bed or chair at the time of hospital admission, did not appear to correlate with increased mortality. 45, 54-55 Still, comparison of health care resource consumption was made in patients with pressure ulcers, death is more likely to be related between patients who did (11%) and those who did not develop a to cardiovascular disease, respiratory disease, or cancer than a PU during the hospital stay. 52 Patients with PU incurred Medicare complication of the pressure ulcer. 65 Majority of literature data payments during the 12-month post-discharge period that were demonstrate the overall frailty of patients with or developing approximately $13 higher per day of follow-up than those of pressure ulcers and the need for comprehensive patient care plan. patients who had been at risk for, but did not develop PU. 52 It is estimated that the average incremental cost of hospitalization due THE COST OF PRESSURE ULCERS to PU, adjusted for other admission predictors, is approximately $15,000 and is associated with lengthening of hospital stay of The yearly costs of prevention and treatment of PU are over 8 days. 36 In the United Kingdom, the cost of PU care is astronomically high, leading to the dictum of preventive therapy estimated to have nearly tripled from 1973 to 1982.101 being not only beneficial to the patient but also to the health care system as a secondary economic benefit. 38 Extended In another study, the cost of preventive surface patient assignment hospitalization is particularly deleterious for elderly patients was compared between rental and purchase strategies. 20, 60 That because they may lose their independence, rehabilitation may be study found a strategy based on purchased as opposed to rented delayed, and normal social networks of support may weaken, products to be economically more viable. 20, 60 making it more difficult for them to return home. 97 MULTIDISCIPLINARY CARE AND Table 1. Estimated treatment cost associated with pressure ulcers (PU) OTHER RESOURCES Patients who developed PU during hospitalization $6 billion/year Pressure ulcers are a multidisciplinary care problem. Before-and-

Average added Medicare hospital days due to PU 2.2 million days/year after studies have shown effective prevention with multidisciplinary teams for systematic risk assessment,

Estimated treatment cost per PU (stage-dependent) $2,000-$40,000 implementation of preventive and therapeutic measures, education of patients and healthcare staff, and monitoring of incidence. 22-23, Cost of reconstructive surgery for PU $25,000/patient 32, 102 These multidisciplinary teams include critical care trained physicians, surgeons, nurses, rehabilitation/therapy specialists, Additional variable costs associated with PU in acute care $1,300/patient dieticians, and various other surgical and medical subspecialists. or $80/day Nurses play a major role in coordinating systematic preventive

Source : Salcido R, Popescu A. Pressure ulcers and wound care. Available online at: interventions. Many intensive care units have established http://www.emedicine.com/pmr/topic179.htm . Last accessed November 4, 2007. protocols for such interventions. Some interventions require

Copyright 2007 OPUS 12 Foundation, Inc. 27 OPUS 12 Scientist 2007 Vol. 1, No. 2 E. F. Reilly et al. Submitted 04/2006 – Accepted 09/2007 – Published 11/2007 physician orders, whereas others are automatically implemented. Enterostomal Ther 1986;13:85-89. Dietitians offer nutritional assessments and recommendations for [11] Thompson-Bishop JY, Mottola CM. Tissue interface pressure and estimated supplements and methods for providing nutrition. Rehabilitation subcutaneous pressures of 11 different pressure reducing support surfaces. therapists help to improve mobility and devise or recommend Decubitus 1992;5:42-48. protective and pressure-relieving devices. Intensivist physicians [12] Krouskop TA, Williams R, Krebs M, et al. Effectiveness of mattress overlays in should be familiar with team function and organization, and with reducing interface pressures during recumbency. J Rehabil Res Dev 1985;22:7- established protocols. This will help facilitate their roles as team 10. participants, effective communicators, and leaders. [13] Stewart TP, McKay MG, Magnano S. Pressure relief characteristics of an alternating pressure system. Decubitus 1990;3:26-29. CONCLUSIONS [14] Landis EM. Micro-injection studies of capillary blood pressure in human skin. Heart 1930;15:209-228. The incidence of PU is likely to increase in the future. This condition is associated with significant morbidity, mortality and [15] Seiler WO, Allen S, Stahelin HB. Influence of the 30 degree laterally inclined position and the ‘super-soft’ 3-piece mattress on skin oxygen tension on areas health care costs. The best method of addressing PU in the of maximum pressure—implications for pressure sore prevention. Gerontology intensive care setting is through institution of preventive measures 1986;32:158-166. that target patients at greatest risk. Pressure ulcer risk (PUR) [16] Bennett L, Kavner D, Lee B, et al. 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