A Review on Pressure Ulcer: Aetiology, Cost, Detection and Prevention Systems

Pressure ulcer (also known as pressure sore, bedsore, ischemia, decubitus ulcer) is a global challenge for today’s healthcare society. Found in several locations in the human body such as the sacrum, heel, back of the head, shoulder, knee caps, it occurs when soft tissues are under continuous loading and a subject’s mobility is restricted (bedbound/chair bound). Blood flow in soft tissues becomes insufficient leading to tissue necrosis (cell death) and pressure ulcer. The subject’s physiological parameters (age, body mass index) and types of body support surface materials (mattress) are also factors in the formation of pressure ulcer. The economic impacts of these are huge, and the subject’s quality of life is reduced in many ways. There are several methods of detecting and preventing ulceration in human body. Detection depends on assessing local pressure on tissue and prevention on scales of risk used to assess a subject prior to admission. There are also various types of mattresses (air cushioned/liquid filled/foam) available to prevent ulceration. But, despite this work, pressure ulcers remain common.This article reviews the aetiology, cost, detection and prevention of these ulcers

Alternative reactive support surfaces (non-foam and non-air-filled) for preventing pressure ulcers

Background Pressure ulcers (also known as injuries, pressure sores, decubitus ulcers and bed sores) are localised injuries to the skin or underlying soft tissue, or both, caused by unrelieved pressure, shear or friction. Reactive surfaces that are not made of foam or air cells can be used for preventing pressure ulcers. Objectives To assess the effects of non‐foam and non‐air‐filled reactive beds, mattresses or overlays compared with any other support surface on the incidence of pressure ulcers in any population in any setting. Search methods In November 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In‐Process & Other Non‐Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta‐analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. Selection criteria We included randomised controlled trials that allocated participants of any age to non‐foam or non‐air‐filled reactive beds, overlays or mattresses. Comparators were any beds, overlays or mattresses used. Data collection and analysis At least two review authors independently assessed studies using predetermined inclusion criteria. We carried out data extraction, 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool, and the certainty of the evidence assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology. If a non‐foam or non‐air‐filled surface was compared with surfaces that were not clearly specified, then the included study was recorded and described but not considered further in any data analyses. Main results We included 20 studies (4653 participants) in this review. Most studies were small (median study sample size: 198 participants). The average participant age ranged from 37.2 to 85.4 years (median: 72.5 years). Participants were recruited from a wide range of care settings but were mainly from acute care settings. Almost all studies were conducted in Europe and America. Of the 20 studies, 11 (2826 participants) included surfaces that were not well described and therefore could not be fully classified. We synthesised data for the following 12 comparisons: (1) reactive water surfaces versus alternating pressure (active) air surfaces (three studies with 414 participants), (2) reactive water surfaces versus foam surfaces (one study with 117 participants), (3) reactive water surfaces versus reactive air surfaces (one study with 37 participants), (4) reactive water surfaces versus reactive fibre surfaces (one study with 87 participants), (5) reactive fibre surfaces versus alternating pressure (active) air surfaces (four studies with 384 participants), (6) reactive fibre surfaces versus foam surfaces (two studies with 228 participants), (7) reactive gel surfaces on operating tables followed by foam surfaces on ward beds versus alternating pressure (active) air surfaces on operating tables and subsequently on ward beds (two studies with 415 participants), (8) reactive gel surfaces versus reactive air surfaces (one study with 74 participants), (9) reactive gel surfaces versus foam surfaces (one study with 135 participants), (10) reactive gel surfaces versus reactive gel surfaces (one study with 113 participants), (11) reactive foam and gel surfaces versus reactive gel surfaces (one study with 166 participants) and (12) reactive foam and gel surfaces versus foam surfaces (one study with 91 participants). Of the 20 studies, 16 (80%) presented findings which were considered to be at high overall risk of bias. Primary outcome: Pressure ulcer incidence We did not find analysable data for two comparisons: reactive water surfaces versus foam surfaces, and reactive water surfaces versus reactive fibre surfaces. Reactive gel surfaces used on operating tables followed by foam surfaces applied on hospital beds (14/205 (6.8%)) may increase the proportion of people developing a new pressure ulcer compared with alternating pressure (active) air surfaces applied on both operating tables and hospital beds (3/210 (1.4%) (risk ratio 4.53, 95% confidence interval 1.31 to 15.65; 2 studies, 415 participants; I2 = 0%; low‐certainty evidence). For all other comparisons, it is uncertain whether there is a difference in the proportion of participants developing new pressure ulcers as all data were of very low certainty. Included studies did not report time to pressure ulcer incidence for any comparison in this review. Secondary outcomes Support‐surface‐associated patient comfort: the included studies provide data on this outcome for one comparison. It is uncertain if there is a difference in patient comfort between alternating pressure (active) air surfaces and reactive fibre surfaces (one study with 187 participants; very low‐certainty evidence). All reported adverse events: there is evidence on this outcome for one comparison. It is uncertain if there is a difference in adverse events between reactive gel surfaces followed by foam surfaces and alternating pressure (active) air surfaces applied on both operating tables and hospital beds (one study with 198 participants; very low‐certainty evidence). We did not find any health‐related quality of life or cost‐effectiveness evidence for any comparison in this review. Authors' conclusions Current evidence is generally uncertain about the differences between non‐foam and non‐air‐filled reactive surfaces and other surfaces in terms of pressure ulcer incidence, patient comfort, adverse effects, health‐related quality of life and cost‐effectiveness. Reactive gel surfaces used on operating tables followed by foam surfaces applied on hospital beds may increase the risk of having new pressure ulcers compared with alternating pressure (active) air surfaces applied on both operating tables and hospital beds. Future research in this area should consider evaluation of the most important support surfaces from the perspective of decision‐makers. Time‐to‐event outcomes, careful assessment of adverse events and trial‐level cost‐effectiveness evaluation should be considered in future studies. Trials should be designed to minimise the risk of detection bias; for example, by using digital photography and adjudicators of the photographs being blinded to group allocation. Further review using network meta‐analysis will add to the findings reported here

Foam surfaces for preventing pressure ulcers

Background Pressure ulcers (also known as pressure injuries) are localised injuries to the skin or underlying soft tissue, or both, caused by unrelieved pressure, shear or friction. Foam surfaces (beds, mattresses or overlays) are widely used with the aim of preventing pressure ulcers. Objectives To assess the effects of foam beds, mattresses or overlays compared with any support surface on the incidence of pressure ulcers in any population in any setting. Search methods In November 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In‐Process & Other Non‐Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta‐analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. Selection criteria We included randomised controlled trials that allocated participants of any age to foam beds, mattresses or overlays. Comparators were any beds, mattresses or overlays. Data collection and analysis At least two review authors independently assessed studies using predetermined inclusion criteria. We carried out data extraction, 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool, and the certainty of the evidence assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology. If a foam surface was compared with surfaces that were not clearly specified, then the included study was recorded and described but not considered further in any data analyses. Main results We included 29 studies (9566 participants) in the review. Most studies were small (median study sample size: 101 participants). The average age of participants ranged from 47.0 to 85.3 years (median: 76.0 years). Participants were mainly from acute care settings. We analysed data for seven comparisons in the review: foam surfaces compared with: (1) alternating pressure air surfaces, (2) reactive air surfaces, (3) reactive fibre surfaces, (4) reactive gel surfaces, (5) reactive foam and gel surfaces, (6) reactive water surfaces, and (7) another type of foam surface. Of the 29 included studies, 17 (58.6%) presented findings which were considered at high overall risk of bias. Primary outcome: pressure ulcer incidence Low‐certainty evidence suggests that foam surfaces may increase the risk of developing new pressure ulcers compared with (1) alternating pressure (active) air surfaces (risk ratio (RR) 1.59, 95% confidence interval (CI) 0.86 to 2.95; I2 = 63%; 4 studies, 2247 participants), and (2) reactive air surfaces (RR 2.40, 95% CI 1.04 to 5.54; I2 = 25%; 4 studies, 229 participants). We are uncertain regarding the difference in pressure ulcer incidence in people treated with foam surfaces and the following surfaces: (1) reactive fibre surfaces (1 study, 68 participants); (2) reactive gel surfaces (1 study, 135 participants); (3) reactive gel and foam surfaces (1 study, 91 participants); and (4) another type of foam surface (6 studies, 733 participants). These had very low‐certainty evidence. Included studies have data on time to pressure ulcer development for two comparisons. When time to ulcer development is considered using hazard ratios, the difference in the risk of having new pressure ulcers, over 90 days' follow‐up, between foam surfaces and alternating pressure air surfaces is uncertain (2 studies, 2105 participants; very low‐certainty evidence). Two further studies comparing different types of foam surfaces also reported time‐to‐event data, suggesting that viscoelastic foam surfaces with a density of 40 to 60 kg/m3 may decrease the risk of having new pressure ulcers over 11.5 days' follow‐up compared with foam surfaces with a density of 33 kg/m3 (1 study, 62 participants); and solid foam surfaces may decrease the risk of having new pressure ulcers over one month's follow‐up compared with convoluted foam surfaces (1 study, 84 participants). Both had low‐certainty evidence. There was no analysable data for the comparison of foam surfaces with reactive water surfaces (one study with 117 participants). Secondary outcomes Support‐surface‐associated patient comfort: the review contains data for three comparisons for this outcome. It is uncertain if there is a difference in patient comfort measure between foam surfaces and alternating pressure air surfaces (1 study, 76 participants; very low‐certainty evidence); foam surfaces and reactive air surfaces (1 study, 72 participants; very low‐certainty evidence); and different types of foam surfaces (4 studies, 669 participants; very low‐certainty evidence). All reported adverse events: the review contains data for two comparisons for this outcome. We are uncertain about differences in adverse effects between foam surfaces and alternating pressure (active) air surfaces (3 studies, 2181 participants; very low‐certainty evidence), and between foam surfaces and reactive air surfaces (1 study, 72 participants; very low‐certainty evidence). Health‐related quality of life: only one study reported data on this outcome. It is uncertain if there is a difference (low‐certainty evidence) between foam surfaces and alternating pressure (active) air surfaces in health‐related quality of life measured with two different questionnaires, the EQ‐5D‐5L (267 participants) and the PU‐QoL‐UI (233 participants). Cost‐effectiveness: one study reported trial‐based cost‐effectiveness evaluations. Alternating pressure (active) air surfaces are probably more cost‐effective than foam surfaces in preventing pressure ulcer incidence (2029 participants; moderate‐certainty evidence). Authors' conclusions Current evidence suggests uncertainty about the differences in pressure ulcer incidence, patient comfort, adverse events and health‐related quality of life between using foam surfaces and other surfaces (reactive fibre surfaces, reactive gel surfaces, reactive foam and gel surfaces, or reactive water surfaces). Foam surfaces may increase pressure ulcer incidence compared with alternating pressure (active) air surfaces and reactive air surfaces. Alternating pressure (active) air surfaces are probably more cost‐effective than foam surfaces in preventing new pressure ulcers. Future research in this area should consider evaluation of the most important support surfaces from the perspective of decision‐makers. Time‐to‐event outcomes, careful assessment of adverse events and trial‐level cost‐effectiveness evaluation should be considered in future studies. Trials should be designed to minimise the risk of detection bias; for example, by using digital photography and by blinding adjudicators of the photographs to group allocation. Further review using network meta‐analysis adds to the findings reported here

Can interface conditions be modified by support surfaces to minimise the risk of pressure ulcer development?

PhDThe characteristics of a patient support interface can influence the susceptibility of subjects, particularly there who are immobilised and insensate, to pressure ulcer development. Accordingly, externally powered alternating pressure air mattresses (APAM) are utilised to produce intermittent pressure relief and control of the interface microclimate. These conditions will permit adequate blood and lymph flow within the soft tissues and favourable conditions at the loaded skin surface and thus minimise the risk of ulcer formation. Two sets of measurements were performed. Tissue viability was estimated, from a measure of transcutaneous gas tensions and sweat content, from healthy volunteers subjected to various alternating pressure regimens. The latter was achieved by two different strategies a) a custom–made controller which imposes the pressure profile on the subject and b) a prototype APAMs incorporating a novel sensor, which adjusts the profile according to individual subject characteristics. The latter prototype was placed on an articulated hospital bed, with an adjustable Head of Bed (HOB) angle. The second set of measurements involved monitoring the microclimate, namely temperature and humidity, at the interface loaded with a human analogue model supported on an APAM system. The interface was saturated with moisture to simulate sweating. The human studies, involving healthy subjects with BMI values ranging from 18.9 to 42.5 kg/m2, revealed significant differences in soft tissue response under various support surface profile by both strategies. In many cases, the TcPO2 levels either remained fairly stable during the loaded period or fluctuated at a periodicity equivalent to the cycle period of the APAM system, with the corresponding TcPCO2 levels remaining within the normal basal range. These findings were associated with II maximum interface pressures generally not exceeding 50 mmHg (6.67 kPa). By contrast in some cases, there was a significant compromise to the TcPO2 levels during the loaded period, which was often associated with an increase in TcPCO2 levels. These cases generally corresponded with the internal pressures in the mattress prescribed at a maximum amplitude of 100 / 0 mmHg or when the Head of Bed angle was raised to 45º or above. Changes in prototype covering sheet and air flow rates of the APAM system were found to influence both interface temperature and humidity. These results revealed enhanced levels of humidity often reaching 100% RH at the high simulated sweat rates. By contrast, at the lower sweat rate of 1.5 ml/min, the nature of the prototype covering sheets had an effect on the interface humidity profile, with values considerably reduced in the latter stages of the monitoring period. These results were compared with a compartmental model, which predicted the transport of moisture and heat using various mattress support systems. The results offer the potential for the development of intelligent APAM systems, whose characteristics can be adjusted to an individual morphology. These systems will need to be designed to ensure adequate tissue viability and maintain appropriate microclimate at the loaded interface. Such an approach will be directed at those subjects considered to be at high/medium risk of developing pressure ulcers

A three constituent mixture theory model of cutaneous and subcutaneous tissue in the context of neonatal pressure ulcer etiology and prevention

Localized ischemia, impaired interstitial fluid flow, and sustained mechanical loading of cells have all been hypothesized as mechanisms of pressure ulcer (PrU) etiology. Time-varying loading has experimentally been shown to increase fluid flow in human skin in vivo. Towards the design of prophylactic protocols and treatment modalities for PrU management there is a need for an analytical model to investigate the local fluid flow characteristics of skin tissue under time-varying loading. In this study, a triphasic mixture theory model with constituents of extracellular matrix, interstitial fluid, and blood was calibrated and validated and used to investigate stress and fluid velocity under quasi-static and time-varying loading conditions, respectively. Four input strain profiles were considered, including uniform, geometric circular segment, Gaussian, and Hertz-type strain profiles. Calibrated bulk and shear modulus (κ;=227.7kPa, µ=1.04kPa) were on the same order of magnitude as literature. Fluid velocities were investigated for apparent strain amplitudes of 100-700μϵ and frequencies of 10-80Hz. At the lowest amplitude and frequency, interstitial fluid velocities were on the same order of magnitude as literature values, 1 micrometers/s and 1 mm/s, respectively. Interstitial fluid and blood velocity both experienced significant increases with increasing amplitude and frequency. The study demonstrated the ability to analytically predict quasi-static stress profiles as well as predict fluid velocity increases in cyclically loaded soft tissues by employing quasi-static mechanics and mixture theory models. Consequently, this study builds a strong foundation for use in the development of vibrational support surfaces for use in prophylactic protocols and adjunctive treatment modalities for PrU managemen

Flexible Sensor for Measurement of Skin Pressure and Temperature for the Prevention of Pressure Ulcers

With the prolonged lifespan of the average person, the number of hospital stays have increased. Currently, pressure ulcers are one of the most severe complications associated with prolonged hospital stay. The protocol in today€™s hospital is to rotate bedridden patients once every two hours to prevent pressure ulcers. This puts a strain on attending nurses as the risk of a pressure ulcer for a patient is not universal and therefore, a universal preventative protocol is not the most effective solution. This thesis describes the circuit design and physical implementation of a device to address the issue of pressure ulcers. The device has the form factor of a patch to be placed on specific, at risk areas of the human body. The device was designed and prototyped first on a rigid structure and then on a flexible printed circuit board substrate. A calibration procedure was developed to reduce part to part variability inherent to the pressure sensor. The resistance measurement was achieved through a novel approach including the use of a timer removing the need for an analog-to-digital converter. A seven hour experiment was conducted with live, animal subjects to measure the pressure and temperature of at risk areas of the body. The results of the experiment successfully prove the fundamental approach outlined in this thesis and justify continued research and refinement into the product design

A REVIEW OF FACTORS, SEATING DESIGN, AND SHAPE CAPTURE METHODS FOR REDUCING PRESSURE INJURY RISK

This dissertation in the form of three papers ready for submission to peer-reviewed journals is submitted toward the requirements of the PhD in Health Related Sciences program at Virginia Commonwealth University. Chapter One provides an introductory overview of the project, including: (a) an overview of pressure injuries, (b) the impact of seating as an intervention, and (c) aims of the three-paper dissertation in addressing various aspects of pressure injury prevention. Each paper is unique and singular in its focus, yet all share the overlying aim of addressing pressure injury risk associated with wheelchair seating. Paper One describes the unique facilitators and barriers associated with pressure injury prevention practices among individuals with upper motor neuron lesions. Paper Two consists of a systematic review of the literature on the comparative effectiveness of various wheelchair seat cushions in reducing pressure injuries. Paper Three presents the results of a pilot study of a unique shape-capture method for custom-fitted wheelchair cushions conducted by the student researcher