EUROPEAN PRESSURE ULCER ADVISORY PANEL

THE LIMITS OF PRESSURE SORE PREVENTION
Analysis and Questions:  Is there a limit to pressure ulcer prevention?

This article shows how intensive preventive care does result in the prevention of most pressure ulcers. The study presented the fate of 275 patients: of whom 36 were assessed to be at risk of developing pressure ulcers (Braden Score of greater or less than sixteen). The 36 at-risk patients were given the most intensive preventive care the staff could provide: in fact the described care seems to be almost ideal (turning every two hours, using a special mattress, keeping the skin dry and clean, evaluating hydration and nutritional status and avoiding friction).

The first important result is that none of the 239 patients with a Braden Score of at least 17 developed any pressure ulcers. The second important result is that amongst the 36 at-risk patients only 33.3% developed one or more pressure ulcers. So in this case preventive care avoided 66.6% of at risk patients developing pressure ulcers.

Nevertheless, there are two questions we must ask. Were the 33.3% of at-risk patients who developed ulcers the group that scored lowest on the Braden Scale? We only know that eight of these patients died during their stay in hospital. There is also one comment regarding the preventive care allocated in this study. Why did skin inspections occur only at least once per day? Generally the accepted ‘best’ practice would be to inspect the skin at the time of each planned change of position.

In conclusion, the article is very interesting for it can help nurses from feeling guilty if their preventive care is unsuccessful.

Brigitte Barrois, France

It has been claimed that 95% of pressure sore are preventable1. The corollary being that 5% of sores cannot be prevented. Whilst the former statement has been regularly quoted, there has been little evidence to substantiate it. The researchers in this study consider that they have provided some of the necessary evidence.

The study was undertaken in a teaching hospital in Japan on a medical ward with 50 beds. Prevalence and incidence of pressure ulcers was measured on the ward over a 12-month period. Short stay patients were excluded. Most of the patients included in the study suffered from impaired mobility, neurological deficit or multiorgan failure. Braden scores were measured on admission and then weekly for those at risk. Care was taken to ensure inter-rater reliability amongst the nurses when using the risk calculator. Prevention strategies were implemented according to level of risk following an agreed protocol. Those with Braden scores of 16 or less were provided with an alternating air mattress and repositioned every two hours. Care was taken to prevent friction when transferring patients. Pressure areas were inspected at least once daily, skin care given and nutritional status monitored. All preventative measures were recorded by the nursing staff and checked by the research nurse.

The overall prevalence for the year was 5.1% with an incidence of 4.4%. None of the patients who were considered not to be at risk developed a sore. A number of those who developed sores were very ill. Of the 275 patients studied, 22 died. Eight of the patients who died had pressure sores, seven developing them in hospital. The authors conclude that not all pressure sores can be prevented in very ill patients despite good preventative care. They also suggest that their incidence levels are possibly the lowest that can be achieved in this type of patient, thus, supporting the premise that 5% of pressure sores cannot be prevented.

This study provides a good example of a study which has been meticulously planned and undertaken. However, the major flaw in the researchers reasoning is the assumption that their prevention protocol was, in fact, effective practice. At present, the prevention protocol used in the study is considered to be good practice, but we have limited evidence to be certain that this is the case. Thus, although I have considerable sympathy with the conclusions of the researchers, I do not think they provide us with all the evidence we need to support it.

Reference:

1. Waterlow, J. ‘Prevention is cheaper than cure.’ Nursing Times, 1988, 84 (25) 69–70.