Pressure ulcers prevention efficacy of an alternating pressure air mattress in elderly patients: E²MAO a randomised study.

OBJECTIVE: Our aim was to compare Axtair One, an alternating pressure air mattress (APAM), with a viscoelastic foam mattress (VFM) in elderly patients at moderate to high risk of developing pressure ulcers (PUs). METHOD: A randomised, controlled, superiority, parallel-group, open-label, multicentre study, was conducted, between February 2012 and March 2015, in nine French, medium- and long-term stay facilities. Eligible patients were aged 70 and over, had no PUs on enrolment, were bedridden for at least 15 hours per day, had reduced mobility, an absent or minimal positioning capability, a Braden score <14, a nutritional status score >12 and a Karnofsky score <40%. The primary endpoint was the appearance of PUs over a 30-day monitoring period. The primary objective was to demonstrate a 50% reduction in instantaneous risk of PUs in the APAM versus the VFM group. Secondary objectives were to determine if preventive care was less frequent in the APAM group, the instantaneous relative risk of PUs (hazard ratio) was constant over time and the comfort experienced was higher in the APAM group and to verify the uniformity of the preventive benefit of an APAM, regardless of the level of exposure to major risk factors for PUs. RESULTS: We randomised 76 patients (39 in the APAM group and 37 in the VFM group). The groups were comparable on enrolment and throughout the study. The cumulative risk of PUs was estimated at 6.46% [95% confidence interval (CI): 1.64; 23.66] in the APAM group and at 38.91% [95% CI: 24.66; 57.59] in the VFM group, p=0.001 (log-rank test). The adjusted hazard ratio according to the Cox model with four prognostic factors for the appearance of PUs was 7.57 [95% CI: 1.67; 34.38, p=0.009]. Preventive care proved to be equivalent in both groups. The only risk factor significantly associated with an increased risk of PUs was the type of mattress (VFM). The comfort and tolerance perceived by the patients were both high and similar in the two groups. The constancy over time of the preventive benefit of an APAM could not be verified because of the lack of a sufficient number of events (appearance of PUs) in the APAM group. CONCLUSION: The APAM was superior to a VFM for preventing PUs in elderly patients, bedridden for more than 15 hours per day, severely dependent, at moderate-to high-risk of PUs, with an instantaneous risk for the appearance of PUs 7.57 times greater in the VFM group than in the APAM group. This study provides descriptive information and evidence for practice.

As of 2012, what are the key predictive risk factors for pressure ulcers? Developing French guidelines for clinical practice.

INTRODUCTION: An evaluation of predictive risk factors for pressure ulcers is essential in development of a preventive strategy on admission to hospitals and/or nursing homes. OBJECTIVES: Identification of the predictive factors for pressure ulcers as of 2012. METHOD: Systematic review of the literature querying the databases PASCAL Biomed, Cochrane Library and PubMed from 2000 through 2010. RESULTS: Immobility should be considered as a predictive risk factor for pressure ulcers (grade B). Undernutrition/malnutrition may also be a predictive risk factor for pressure ulcers (grade C). DISCUSSION: Even if the level of evidence is low, once these risk factors have been detected, management is essential. Sensitizing and mobilizing health care teams requires training in ways of tracking and screening. According to the experts, risk scales should be used. As decision aids, they should always be balanced and complemented by the clinical judgment of the treatment team. CONCLUSION: According to experts, it is important to know and predictively evaluate risk of pressure ulcers at the time of hospital admission. The predictive risk factors found in this study are identical to those highlighted at the 2001 consensus conference of which was PERSE was the promoter.

Which medical devices and/or local drug should be curatively used, as of 2012, for PU patients? How can granulation and epidermidalization be promoted? Developing French guidelines for clinical practice.

INTRODUCTION: Management of a patient with pressure ulcer sore(s) must associate local and general treatment. OBJECTIVES: To determine which medical devices other than supports and which treatments may be used for pressure sore healing (granulation tissue and epithelization/epidermidalization) as of 2012. METHODS: Systematic review of the literature querying the databases: PASCAL Biomed, PubMed, and Cochrane library from 2000 through 2010. RESULTS: Data in the literature on granulation tissue and epithelisation/epidermidalization in pressure sore healing are poor. The level of evidence regarding the relative effectiveness of one modern dressing compared to another has remained low. However, the study data on the interest of hydrocolloid dressing compared with impregnated gases are more significant. DISCUSSION: Studies with heterogeneous results and populations have shown low power. Meta-analyses are difficult due to the wide range of therapeutic aims. Further clinical studies with adequate methodology are needed prior to elaboration of more specific recommendations. CONCLUSION: The use of hydrocolloid dressing may be recommended to improve granulation tissue development and epithelization/epidermidalization in pressure sore (Level B).

Which medical device and/or which local treatment for prevention in patients with risk factors for pressure sores in 2012? Developing French guidelines for clinical practice.

INTRODUCTION: Implementation of a prevention strategy after the identification of risk factors is essential at the entrance in a care unit or in a medical-social unit. OBJECTIVES: Determine which medical devices and which treatments may be used in order to prevent pressure sore in 2012. METHOD: Systematic review of the literature using databases: Pascal, Biomed, PubMed, and Cochrane library between 2000 and 2010. RESULTS: Nursing care including use of soft product, non-irritating for the cleaning, hydration of the skin with emollients, protection of fragile skin in case of incontinence by applying a skin protector and application of dressings in front of bony prominences to reduce shear forces, remain valid (level C). DISCUSSION: Nursing cares and use of dressing in patients with high risks of pressure sores are the responsibility of the nurses. The engagement of health care teams involves screening of risk factors and the knowledge of treatments and local devices. CONCLUSION: Local preventive treatment in a patient with risk factors of pressure sore is of great interest at entrance in a care unit or in a medical-social unit.

What is the role of TPE in management of patients at risk or with pressure ulcer as of 2012? Developing French guidelines for clinical practice.

INTRODUCTION: Pressure ulcer (PU) is a common complication in chronic affection, especially neurological disorders and diseases commonly diagnosed in the elderly. For a long period of time, the prevention of skin lesions was taught only in an empirical manner. The development of therapeutic patient education (TPE) sheds a new light on care management for patients with chronic pathologies. OBJECTIVES: Determine the place of TPE in persons at risk of and/or already suffering from pressure ulcer (PU) as of 2012. METHODS: The methodology used is the one promoted by SOFMER, including: a systematic review of the literature with a query of the PASCAL Biomed, PubMed and Cochrane Library databases for data from 2000 through 2010; a compendium of prevailing professional practices and advice from a committee of experts. RESULTS: The review of the literature found six studies including four controlled trials in patients with chronic neurological impairments (most of them with spinal cord injury). No studies were found regarding the elderly. The level of evidence for efficacy in persons with spinal cord injury (SCI) is moderate. The clinical practice study focuses on programs currently underway, dedicated to SCI patients or elderly populations. DISCUSSION: The approach proposed through TPE has its role in a strategy aimed at preventing PU in persons at chronic risk of developing PU. The educational objectives and techniques used must be adapted to the clinical and psychological context and are debated in this review. The co-construction of programs, recommended in the official texts on therapeutic education in France, should help to tailor these programs to the patients' needs. CONCLUSION: TPE is relevant in care management or prevention of PU in persons at chronic risk, patients with spinal cord injury (Grade B) or elderly subjects (Grade C).

Which medical device and/or which local treatment are to be used, as of 2012, in patients with infected pressure sore? Developing French guidelines for clinical practice.

INTRODUCTION: Taking care of a patient with an infected pressure sore necessitates a diagnosis allowing for a suitable treatment strategy. AIMS: To choose the dressings and topical antimicrobial agents that can be used as of 2012 in treatment of an infected pressure sore. METHODS: A systematic review of the literature with queries to the databases Pascal Biomed, PubMed and Cochrane Library from 2000 through 2010. RESULTS: Diagnosis of local infection is essentially clinical. It is subsequently difficult to destroy and/or permeabilize biofilm by means of mechanical wound debridement. Application of an antimicrobial product and a disinfectant solution are of utmost importance in this respect. DISCUSSION: The studies do not demonstrate that one topical product is better than another in wound cleaning. The papers recommending antimicrobial topics lead to the conclusion that they may be interesting, but show little clinical evidence of their beneficial effects. Dressings including silver, iodine, polyhexamethylene biguanide (PHMB) and negative pressure wound therapy could likewise be of interest, but once again, existing studies present only a low level of evidence (Grade C). CONCLUSION: Local antimicrobial treatment can be used when there are signs of local infection (Grade C). Systemic antibiotic treatment is to be used when there are general medical signs of infection (Grade B).

What is the best support surface in prevention and treatment, as of 2012, for a patient at risk and/or suffering from pressure ulcer sore? Developing French guidelines for clinical practice.

INTRODUCTION: The use of support surfaces in the prevention and treatment of pressure ulcers prevention is an important part of care for a patient at risk and/or suffering from sore(s). OBJECTIVES: Define which support surfaces to use in prevention and treatment of at-risk and/or pressure sore patients. METHODOLOGY: A systematic review of the literature querying the several Pascal Biomed, PubMed and Cochrane Library databases from 2000 through 2010. RESULTS (GRADE A): In prevention, a structured foam mattress is more efficient than a standard hospital mattress. An alternating pressure mattress is more effective than a visco-elastic mattress limiting the occurrence heel pressure ulcers, but those that do occur are more serious. A low-air-loss bed is more efficient than a mixed pulsating air mattress in prevention of heel pressure ulcers. Some types of sheepskin can reduce sacral pressure ulcer incidence in orthopedic patients. Use of an overlay on an operating table limits the occurrence of peroperative and postoperative pressure ulcers. An air-fluidized bed improves pressure ulcer healing. DISCUSSION: The data in the literature are not always relevant and do not suffice to dictate a clinician's choices. We are compelled to recognize the methodological limitations of many studies, the lack of corporate interest in conducting such studies and the relatively small number of available trials. However, the effectiveness of some support surfaces reaches a sufficient level of evidence, especially when they are associated with postural, hydration and nutritional measures. CONCLUSION: Support surfaces are recommended in prevention and treatment of patients at risk and/or already suffering from pressure ulcer, and their use should constitute part of an overall preventive or curative strategy.

Which medical technology and/or local treatment is most conducive, as of 2012, to pressure sore debridement ? Developing French guidelines for clinical practice.

INTRODUCTION: Implementation of a curative strategy at the debridement stage associates systemic therapy with local therapy. OBJECTIVES: To determine which medical devices and technology other than support surfaces and what kinds of drugs to use in order to cleanse a pressure ulcer in 2012. METHOD: A systematic review of the literature querying the databases PASCAL Biomed, Cochrane Library and PubMed from 2000 to 2010 along with a compendium of prevailing professional practices. RESULTS: Pressure sore debridement is based on local care and on the use of alginates, hydrogels and hydrocolloids. DISCUSSION: The analyzed articles do not take into account any specific stage of pressure ulcer debridement. Data that might favor some kinds of dressings show a low level of evidence. Were it possible to decide on the dressing to be used for a given indication, professionals would be better able to orient and narrow down their choices. CONCLUSION: Use of alginates and hydrogels in pressure ulcer debridement is of real interest. According to expert opinion, other dressings (irrigo-absorbents, for instance) seem promising, but have yet to receive adequate scientific validation.

Urinary retention in the elderly: a study of 100 hospitalized patients.

OBJECTIVE: To estimate the prevalence of incomplete bladder emptying by the elderly and to determine its significance and its relationship to overflow incontinence. DESIGN: Survey comparing groups with and without incomplete bladder emptying. SETTING: A geriatric hospital ward. PATIENTS: One hundred patients who were consecutively admitted, with an average age of 82.6 years. MEASUREMENTS: A physical examination, perineal examination, micturition assessment, and evaluation of the post-voiding residual urine volume (PRUV) by ultrasonography at day 1 and day 8 following admission. One-channel cystometry and urine cultures were also done. Between-group comparison was performed between groups R (ie, PRUV greater than 50 mL) and C (ie, PRUV less than 50 mL). MAIN RESULTS: The prevalence of PRUV greater than 50 mL was 34%. Group R patients presented with greater dependency; death was the final outcome of hospitalization in 36% of these cases (vs only 9% in group C). A high PRUV was not correlated with urinary tract infection or renal failure, but there was a strong, almost significant trend toward incontinence being more prevalent in R (57%) than in C (38%) (P = 0.06). Group R presented a hypotonic bladder in 45% of cases, evidenced by cystometry, versus 6% in group C. CONCLUSIONS: In cases with a high PRUV, the utmost caution is necessary both in the diagnosis of overflow incontinence and in establishing a therapeutic approach. Incomplete bladder emptying is associated with a poor prognosis.