EUROPEAN PRESSURE ULCER ADVISORY PANEL

LIFETIME ACHIEVEMENT AWARD - DR MARY BLISS

Thank you very much. I don’t need to tell you how much I appreciate this presentation. I like to think of it as a recognition of what I have tried to do for patients in my medical career, and, although I think they often don’t think so, for nurses.

I regard nursing as being more important than medicine. One of my aims has been to free nurses from some almost impossible tasks such as routine repositioning of enormous numbers of patients, so as to give them time to attend to other equally important aspects of care, like ensuring that patients are clean and comfortable, properly fed and listening to their needs.

Sadly, with increasing precedence given to technological nursing – in which we must include pressure relieving supports – I don’t think this is working; but that is what I hoped.

My other aim, which I don’t think has been much more successful, has been to interest doctors in peripheral tissue necrosis in sick patients. After nearly forty years of examining patients who develop pressure sores, I have not the least doubt that they only occur in sick patients. Paralysis, and even sensory loss, by themselves, do not cause pressure sores in a healthy person. The precipitating illness may not be obvious, because by the time the patient has developed the sore, even only a day later, they may have recovered from their acute illness, and only have the tissue injury to show how ill they have been.

Virtually all pressure sores occur during or immediately following an intercurrent illness or period of stress. An operation, or even severe fatigue, or dehydration, may be sufficient to cause peripheral circulatory failure in a vulnerable person. Pressure injuries are the peripheral manifestation of similar tissue dysfunction which occurs in internal organs, such as the lungs or kidneys, and form part of the syndrome of multiorgan failure.

In future, instead of studies of interface pressure and tissue oxygen levels in healthy volunteers, we should be doing Laser Doppler studies of vasomotion and reactive hyperaemia in non-pressurised areas in sick patients to see what is happening to the microcirculation.

Understanding why peripheral tissue necrosis occurs gives us a chance of preventing it before it is too late. Just as a doctor routinely puts up an intravenous infusion to prevent and treat dehydration when he admits an ill or injured patient, so he need to be prepared to provide an alternating pressure mattress overlay to prevent peripheral tissue death. This should be standard treatment for every very ill or unconscious patient, and for all those with neurological or vascular disease who are likely to develop microcirculatory failure with less severe illness, including postoperatively. I suggest an alternating pressure mattress overlay because, after many years carrying out randomised controlled trials of moderate priced, static low pressure and alternating pressure supports, large celled (diameter 10 cm.) alternating pressure mattresses were the only type which my co-researchers and I found were worth having. They prevented almost all pressure sores in intensive care patients1 and in geriatric patients with terminal illness.2 This meant that they were probably adequate for most other patients as well. All the other types of low priced supports allowed pressure sores to develop in the sicker patients – which then meant that they were likely to need more expensive supports to heal them (although I have found that large celled alternating pressure overlays heal sores also).2 As a patient’s condition may deteriorate rapidly, we think all pressure relieving supports should be capable of preventing sores in all types of patient.

Yesterday, several people asked if I felt happy because of my award, and I realised that I did not. The reason was that in the manufacturer’s exhibition at this conference, I had not seen one single, simple alternating pressure overlay. It made me wonder why I was here!

The reason why there are no overlays is because manufacturers find it more profitable to sell or rent more expensive pressure relieving mattress replacements and beds. They claim that the latter are necessary to prevent sores in high risk patients, and for healing. But they are less portable, and therefore less easy to install for an acutely ill patient on admission to hospital – and we can not afford them for all our patients who need them. We need to realise that it is not we, but the manufacturers who are telling us what we think we need. They have their job, but we also have ours, which is to carry out – and heed – independent research.

I do not know if there are other designs of low priced supports which I have not tried which work, but alternating pressure overlays, specifically Large Cell Ripplebeds (Talley Medical) and Alpha X Cell (Huntleigh Technology) overlays which were used in our trials, are the only ones which I know which prevent sores in at least 85% of really ill, at risk patients. It seems that movement is required to stimulate reactive hyperaemia and maintain the circulation in the deep tissues. However, these machines will only work if they are properly serviced – a very important point which has not been touched on at this meeting.

The vulnerable patient needs to be nursed mainly in bed on their pressure relieving overlay, not sitting in a chair beside it, for the first critical few days until they have recovered from their acute illness and begun to regain their former level of mobility. Then, like the intravenous infusion, the pressure relieving support can be removed.

I think only when the vital link between acute illness and peripheral circulatory failure is understood can we hope to reduce the incidence of pressure injuries.

References

1. Gebhardt KS, Bliss MR, Winwright PL, Thomas JM. Pressure-relieving supports in an ICU. Journal of Wound Care 1996; 5(3): 116–121
2. Bliss MR. Preventing sores in elderly patients: a comparison of seven mattress overlays. Age and Ageing 1995; 24: 297 – 302