European Pressure Ulcer Advisory Panel : Review 4,2

FINAL ABSTRACTS FROM THE FIFTH EPUAP OPEN MEETING
Le Mans, France, 2001 (continued from EPUAP Review, Volume 4, Number 1)

CAN PATIENTS' INTERFACE PRESSURE PREDICT PRESSURE ULCER DEVELOPMENT DURING BEDREST?

J.T.M. Westrate, R.H.M. Goossens, F. Heule, W.C.J. Hop, H.A. Bruining
Local Pressure Ulcer Advisory Panel, Rotterdam, The Netherlands.

Introduction

Studies under laboratory conditions of the relationship between interface pressure (IP) on different support surfaces and the possible development of pressure ulcers have assumed that the lower the (IP), the smaller the risk of developing a pressure ulcer. Our aim was to investigate whether the magnitude of the IP can be used to predict pressure ulcer development in patients undergoing at least four days of bedrest. Such a predictive model has very rarely been studied previously. In order to do the study we needed to discover whether the IP remained stable during a patient's admission to hospital.

Method

After approval of the Medical Ethical Committee patients could be asked to participate in the study. Besides bedrest, the following entry criteria were applicable; no existing pressure ulcer (grade 2 or higher), nursing on a standard hospital mattress, no longer than 48 hours bedrest prior to entering the study, Caucasian, minimum age 18, informed consent. The IP (measurement 1) was measured at the patient's sacrum and buttocks using Talley's Oxford Pressure Monitor. IP was measured during ten minutes and patients were asked to move as little as possible during this period. The procedure was repeated between one and five day's later (measurement 2). During and after this period the patient's sacrum and buttocks were checked daily for the development of pressure sores until he/she was fully mobilised or discharged.

Results

In total 97 patients were evaluated. The mean age was 60 years (±15), the mean weight was 74 kg (±15). The mean height was 172 cm (±19) and the mean BSA was 1.86 m2 (±0.2). Table 1 shows the mean results of the first and second measurements of the IP.

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	Interface Pressure Measurement 1 (n = 101)	Interface Pressure Measurement 2 (n = 97)	Significance
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Sacrum	47(117-17)	45(18-135)	Ns
Buttock right	38 (22-76)	35 (21-71)	P = 0.037
Buttock left	44 (19-81)	41(23-93)	P = 0.029
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Above: Table 1 Mean Interface Pressure (mmHG)(range) measured during a period of bedrest. Further analysis of the relationship between the first and second measurement reveals weak correlation's of only 0.26 at the sacrum, 0.21 and 0.19 at both the buttocks indicating large day to day variations. Eight patients developed one pressure ulcer at the sacrum or buttocks on a standard hospital mattress. Except for the first measurement on the right buttocks (P = 0.41) there was no significant difference between the IP measurements of the patients that did and did not develop a pressure ulcer Summary This study shows that the IP cannot be used as a single factor to predict pressure ulcer development in patients on bedrest. There is no clinical significant difference between the IP of patients who did or did not develop pressure sores and therefore it is uncertain whether the magnitude of the pressure plays a decisive role in the development of pressure ulcers. WOCN ACCREDITATION STANDARDS FOR EVALUATING WOUND, OSTOMY, AND CONTINENCE EDUCATION PROGRAMS WOCN Accreditation Committee Members: Elizabeth A. Avello, (Co-Chair) New York University; Patricia A. Slachta, (Co-Chair) Technical College of the Lowcountry; Ioan Iunkin, Bryan LGH Medical Center; Susan D. Stelton, Memorial Hospital, Evelyn M. Cofone, Kent Hospital, Zoe I. New, Janet E. Cuddigan,University of Nebraska Medical Center. Introduction The Wound, Ostomy, and Continence Nurses Society (WOCN) is a professional nursing society which supports its members by promoting educational, clinical, and research opportunities to advance practice and guide delivery of expert care to individuals with wounds, ostomies, and incontinence. Methods The accreditation of educational programs for WOC(ET) Nursing Education Programs is one way in which the WOCN fosters the development of WOC(ET) nursing education to assure quality patient care. Accreditation of Nursing Education Programs by WOCN is a voluntary and rigorous process. The focus of the accreditation process is the systematic review of the WOC(ET) Program using the WOCN Accreditation Policy and Procedure manual. A WOC(ET) Program seeking WOCN accreditation writes a self-study report following the accreditation criteria in the WOCN manual. By this process of systematic self-study, each program will assure continuous evaluation and improvement as well as provide evidence with respect to each of the 12 criteria. Two members of the WOCN Accreditation Committee read the program's self-study report and make a site visit to evaluate compliance with the WOCN criteria. The 12 criteria were developed by the WOCN Accreditation Committee in collaboration with the Program Directors of WOC(ET) Programs and approved by the WOCN Board. The criteria covers such areas as program director, faculty, and clinical preceptor qualifications, clinical facilities and resources needed to support a WOC(ET) program, curriculum and instruction, student evaluation, program evaluation, program records, administrative support, student admission, integrity and professionalism of program practices, and challenge options. Results The achievement of WOCN accreditation for either one or five years indicates that a WOC(ET) program has met the criteria. There are seven WOCN accredited professional education programs and one accredited specialty wound course. Applications for several new programs seeking initial WOCN accreditation are in progress. Summary By a process of criterion-based accreditation, the WOCN promotes high standards of education. A baccalaureate degree with a nursing major or an equivalent is the entry level for WOC(ET) Nursing Education Programs and for specialty education programs in wound, ostomy, or continence management. CLINICAL OPEN EVALUATION OF THE EFFECT OF A COLLAGEN DRESSING IN THE TREATMENT OF PRESSURE ULCERS *J.E.* Torra i Bou, Rueda López, J.F. Martinez Cuervo, J.J. Soldevilla Agreda. Interdisciplinary Chronic Wounds Unit, Consorci Sanitari de Terrassa and Grupo Nacional para el Estudio y Asesorameinto en Úceras por Presión y Heridas Crónicas (Spanish Pressure Ulcers and Chronic Wound Panel), Terrassa, Barcelona. Introduction Collagen is the most abundant protein in the human body. The synthesis of collagen plays a very important role in the early phases of the process of healing and formation of granulation tissues, which afterwards will form a healing tissue. Inside this process the collagen formation is due to the action of cytokines and the interaction between extracelular mould and fibroblasts. The macrophages control the liberation of collagen by fibroblasts by means of so called growth factors PDGF, (Platelet Derived Growth Factor), EGF (Epidermic Growth Factor), FGF (Fibroblasts Growth Factor) and TGF-beta (Transformer Growth Factor). From 1976 the collagen was typified as a sanitary product by American FDA (Food and Drug Administration) and has been used in this country as a dressing in the healing of chronic wounds. Exogenic collagen facilitates a fast healing of the wound, induces wound excision and new tissues' development and afterwards is absorbed by the native collagen in the bed of lesion. In the United States there are presentations of exogenic collagen in the form of micronized powder, gels, dressings and bans. PU (Pressure Ulcer) is a problem which usually appears in patients of an elderly age. Various contradictory versions exist about the relation between this variable and presence of collagen, although according to the experimental models the elder age supposes the lesser presence of collagen and, therefore, the greater difficulty in the healing. Materials and Methods Clinical evaluation study, open and non-controlled, for the evaluation of the effectiveness of Catrix®, a bovine trachea collagen powder dressing, in the healing of pressure ulcers in patients admitted to nursing homes and home care programmes. Patients with PU in stage II and III are included in the study. The collagen powder dressing is a component of micronized bovine trachea cartilage powder which includes growth factors and because of the size of particles, 35 micros, allows embrace all the surface of the bed of lesion. Results We have included 65 wounds from 53 patients. The average age of the patients was 81.6 ±9.4 (SD) years. The median of evolution of the pressure ulcers was 103 days. 39 (60% of the wounds) had a surface of less than 10 cm2, 16 (24.6% between 10 and 20 cm2, and 14 (21.5%) more than 20 cm2. 13 pressure ulcers (20.7%) were Stage II, 31 (47.7%) of stage III, and 21 (32.3%) of stage IV. The three most frequent localizations were heels (33.8% of wounds), sacrum (32.3%) and trochanters (15.4%). At the seven weeks of being treated with the collagen dressing, the evolution of ulcers were as follows: ______________________________________________________________________________________________________ Stage II - 9 (69.2% of the ulcers of this stage) healed, 3 (23.1%) improved (reducing its severity index), and 1 (7.7%) worsened. ______________________________________________________________________________________________________ Stage III -14 (45.2%) healed, 14 (45.2%) improved, 2 (6.5%) equal, and 1 (3.2%) worsened. ______________________________________________________________________________________________________ Stage IV - 4 (19%) healed, 16 (76.2%) improved, and 1 (4.8%) got worse. ______________________________________________________________________________________________________ In the case of the ulcers that had not healed completely during the seven weeks of inclussion: in the Stage II ones, the Severity Index (SI) changed from 6.87 to 3.85, in the Stage III from 11 to 6.75, and in the Stage IV ones from 16 to 10. In all the cases there was statistical difference. According with the cost-effectiveness dimension, we needed a median of 4.09 days for healing a initial centimetre square of surface of stage II ulcers, 4.78 for stage III ones and 7.88 for stage IV group. Discussion According with our results, Catrix® has shown a very good performance in the full healing or improvement of pressure ulcers in an elderly group of the population, with a very good cost/effectiveness relation. It has also a good acceptance from patients and professionals. At the time of the presentation of this summary the work of research is underway and the data related to the first fifteen patients will be presented depending on: The evolution of the lesion surfaces after the utilisation of the dressing - the object of the study The evolution of the index of severity of these lesions As well as professionals' opinion after the utilisation of the dressing - the object of the study. Discussion Our preliminary results suggest that the collagen powder dressing evaluated is effective in the evolution of the pressure ulcers healing rate, and has a good acceptance from patients.