EUROPEAN PRESSURE ULCER ADVISORY PANEL

A RANDOMISED CONTROLLED STUDY TO COMPARE A SEQUENTIAL TREATMENT USING ALGINATE-CMC AND HYDRO-COLLOID DRESSING TO HYDROCOLLOID DRESSING ALONE IN PRESSURE ULCERS

Meaume, S.1, Faucher, N.2, Henry, O.3 and Belmin, J.4

1Charles Foix Hospital, 2Sainte Périne Hospital, 3Charles Richel Hospital, 4René Muret Hospital, Paris, France.

Introduction
Calcium alginate and hydrocolloid dressings are now widely used in the management of pressure ulcers. Whereas alginates are most indicated in debridcment and/or exudative wounds, hydrocolloid dressings are usually used from debridement till epithelialisation in moderate exudative wounds. While not supported by clinical evidence, wound care professionals often use a sequential approach based on first alginate for few weeks and followed by hydrocolloids better than hydrocolloids alone from debridement to complete healing .

Objectives
We carried out a multicentric, randomised controlled trial to compare the efficacy and safety of sequential treatment (alginate-carboxymethylcellulosis (alginate-CMC)/hydrocolloid) versus hydrocolloid alone, in the management of full thickness pressure ulcers (stage III and IV of Yarkony’s classification), in elderly patients.

Patients and Methods
One hundred and ten patients of twenty French geriatric hospital wards were randomised in two treatment groups: alginate-CMC dressings for four weeks followed by hydro-colloids for four weeks (sequential group) or eight week-hydrocolloid dressings (control group). Clinical, planimetric and photographic evaluation were recorded weekly during the trial, using standardised protocol. Statistical analysis was performed on all the patients randomised, according to intention to treat principle.

Results
Baseline, characteristics of the patients (demographic data. history, nutritional status and nursing procedures) and lesion’s characteristics (stage, location...) were similar in the two groups. The primary objective, the relative rate of healing, determined by the pressure ulcer area reduction, was significantly greater at the end of the eight-week treatment (p < 0.05) in the sequential group than in the controlled group. That difference was already significant in favour of sequential treatment at the fourth week. The two alternative treatments were well-tolerated.

Conclusion
This study is the first controlled trial which clearly demonstrates the efficacy of a sequential approach of the healing process, using alginate-CMC followed by hydrocolloid dressings.

DISSEMENATION AND QUALITY OF DUTCH GUIDELINES ON PRESSURE ULCER PRE-VENTION

Dr J. Leytens, Nivel
(Netherlands Institute of Primary Health Care) Utrecht, and

Dr P. C. Grijns, NIGZ (Netherlands Institute for Health Promotion and Disease Prevention) Woerderi, The Netherlands.

Content
Since 1992 there exists a National Guideline - the so-called CBO- guideline on pressure-ulcer prevention in The Netherlands. This guideline has been published in the form of a booklet and has been spread among all relevant healthcare institutions.

However, the prevalence of pressure ulcers is still high. An average of 22 % is not uncommon. The reasons for this fact are diverse. One of the supposed reasons why we still have a serious pressure sore problem might be caused by the fact that the guidelines are not sufficiently disseminated. At this very moment there is no clear understanding of the amount of institutions that actually know about the existence of this booklet. It is very important to gain insight into the state of the art concerning the dissemination of the National Guideline, to be able to guarantee that at the end nurses are capable to apply these guidelines in practice.

Though we suppose that dissemination of the official guideline is poor, it does not mean that when it comes to prevention of pressure ulcer, institutions have been passive. They developed in past years a great amount of well-designed ‘protocols’. It is interesting to know if these protocols meet the quality of the National Guidelines. If they do this might give us an indication that as we know, enough knowledge doesn’t automatically influence actual behaviour. At the other hand, if the quality of the protocols do not meet the National Guideline, an intensive re-implementation offensive is needed.

People who are interested to know more about how this investigation has been set up and the state of the art on dissemination and quality on knowledge of prevention of pressure ulcers in The Netherlands, are kindly invited to participate in this workshop.

THE INFLUENCE OF 30 DEGREE LATERALLY INCLINED POSITION ON THE HAEMO-DYNAMIC CONDITION OF 1C- PATIENTS, FOLLOWING CORONARY ARTERY SURGERY

E de Laat
Department of Intensive Care,
University Hospital ‘St Radboud’ Nijmegen,
The Netherlands

Intensive care nurses are generally reluctant to initiate turning of the patient in the immediate post-operative period to prevent pressure sores, because they consider that this will have a negative haemodynamic influence. The purpose of this study was to establish whether changes in position in the immediate post-operative period had a negative influence on the haemodynamic condition of patients following coronary artery surgery. Additionally, it was explored whether discontinuation of the lateral position earlier than planned occurs for practical reasons.

Methods
Fifty-five patients were positioned, starting two or four hours after surgery in a scheme of two hours in a lateral position, two hours in a supine position and two hours in the opposite lateral position. In each group, half of the patients were positioned first 30 degrees laterally on their right side, while the other half were positioned first on their left side. In each group, there was at least one patient who was dependent on an intra-aortic balloon pump (IABP) or had received a high dose of a positive inotropic medication. In a third group of patients whose position was not changed, the comparison group, data were obtained solely in the supine position. The cardiac output (CO) was measured and the cardiac index (CI) was calculated. Besides measuring the CO, the MAP, RAP, PAWP and PAP were constantly monitored, and any changes in the medication were recorded. The mean CI of the two turning groups while they were in the supine position was compared to their mean CI while they were in the lateral position. Then the mean CI values of all the patients in the turning groups were compared to the mean values of all the patients in the comparison group. In addition, the absolute number of decreases in the CI in the lateral position and the number of increases in the subsequent supine period in the turning groups were compared to changes in the corresponding CI values in the comparison group.

Results
The results of this study indicates that lateral position in the immediate post-operative period in patients who have undergone coronary artery surgery:

• did not lead to any unacceptable increase or decrease from the pre-established parameters for the MAP, PAWP, RAP and PAP values;
• was not experienced as uncomfortable;
• and did not lead to any practical problems.     Furthermore no significant difference were found in the CIs:
• between the supine position and the 30 degree lateral position (left and right);
• between the patients who were turned and those who were not;
• between the supine position and lateral position in patients who were treated with the intra-aortic balloon pump or high doses of a positive inotropic medication.

Implications for nursing practice
The findings indicate that there are no contraindications to changing the position of a patient to prevent decubitus in the immediate post-operative period after coronary artery surgery. Changing a patients position for the treatment of stage I decubitus is the treatment of choice until effective, alternative methods are found. Further, the results of this study form an important basis for future (experimental) research of the effects of positioning in the prevention of decubitus in intensive care patients.

THE USE OF A LOW-PRESSURE INFLATABLE FOOT PROTECTOR IN THE MANAGEMENT OF PATIENTS WITH PRESSURE SORE DAMAGE TO THE HEEL

S. Rees-Mathews, H. Crook and S. Bale
Wound Healing Research Unit,
University of Wales,
College of Medicine,
Heath Park, Cardiff, UK

Many resources are utilised in both the prevention and treatment of pressure sores. Although most pressure sores have been reported to occur on the trunk, around 20% develop on the heel of the foot. Whilst being nursed on specialised beds, provision for additional pressure relief to the heel zone can sometimes be provided. However, there are certain situations where provision of such equipment is not feasible.

Three patient case studies are reported where patients are nursed in different settings without access to high technology beds. These patients were provided with low-pressure inflatable Foot Protectors designed to protect the lower limb from both trauma and further tissue damage.

Patient 1 underwent a prolonged surgical procedure in the operating theatre and used the Foot Protectors pre and peri-operatively. The practicality of using such a device in theatres is discussed together with infection control issues pertinent to the use of pressure relieving devices in operating theatres. The patient continued to use the device post-operatively.

Patient 2 was nursed in a nursing home, had developed a grade 3 pressure sore to the heel and was nursed for much of the day seated in a chair. Due to her improved physical condition and reduction in Waterlow score she was not considered at high risk of further tissue damage. However, the problem of providing pressure relief to the heel area was present. This patient was provided with a Foot Protector which was used throughout the healing phase.

Patient 3 had experienced blistering to the heel area whilst nursed in hospital as an acute medical admission causing unrelieved discomfort. The use of the Foot Protectors in this situation relieved the discomfort and improved the patient’s sleep pattern.

Although not formally evaluated as yet data collected on over 100 patients using this device and the experience of these 3 patients suggest that there is value in further evaluating the use of this product in the management of tissue damage to the heel area.