Risk Factors Associated with Skin Tear Development in the Canadian Long-term Care Population.

BACKGROUND: Skin tears (STs) are prevalent wounds found in aging populations and in particular among those living in long-term care (LTC) settings. They are often misunderstood as expected outcomes of aging and as a result are frequently underrecognized and undertreated. Although many factors have been associated with ST development, there is little evidence to corroborate their roles as ST risks. OBJECTIVE: To examine the risk factors associated with ST development in the Ontario LTC population. METHODS: A prospective study design was used to explore the risk factors associated with ST development. A total of 380 individuals 65 years or older from four LTC facilities in Ontario were examined for STs at the beginning of the study and at week 4 to determine if STs had occurred. RESULTS: The study found an ST prevalence of 20.8% and an incidence of 18.9%. History of an ST at baseline (relative ratio [RR], 1.84; 95% confidence interval [CI], 1.25-2.70; P = .002); the presence of skin changes associated with aging, ecchymosis, and hematomas (RR, 1.60; 95% CI, 1.43-1.79; P < .001); chronic disease (RR, 1.17; 95% CI, 1.03-1.32; P = .018); requiring assistance with activities of daily living (RR, 1.13; 95% CI, 1.08-1.18; P < .001); and displaying aggressive behavior (RR, 1.06; 95% CI, 1.02-1.10; P = .001) were key risk factors associated with ST development. CONCLUSIONS: These results provide much needed Ontario data on the risk factors associated with ST development and can be used to support prevention programs mitigating ST risk.

Skin tear prevalence and incidence in the long-term care population: a prospective study.

OBJECTIVE: The World Health Organization estimates that between 2015 and 2050 the proportion of the world's population over 60 years old will nearly double from 12% to 22%. An often overlooked byproduct of ageing is the skin changes associated with it, which heighten the risk of developing skin tears. Despite this presumed increased risk, the true impact of skin tears across age groups and care settings is poorly understood. The purpose of the present study was to establish the prevalence and incidence of skin tears in the Ontario long-term care population. METHOD: A prospective study design was used to explore the prevalence and incidence of skin tears. Individuals from four long-term care facilities in Ontario were followed over four weeks. The participants were examined for skin tears at the beginning of the study and at week four to determine whether skin tears had occurred and to record the skin tear type and location. RESULTS: A total of 380 individuals, aged 65 years and over, took part. The study found a skin tear prevalence of 20.8% and an incidence of 18.9% within four weeks. These results provide much needed data on the burden of skin tears in the long-term care population. Conclusion: The present study is an important first step towards developing a prevention programme targeting individuals at risk for skin tears in long-term care.

OPTN/SRTR 2015 Annual Data Report: Kidney.

The first full year of data after implementation of the new kidney allocation system reveals an increase in deceased donor kidney transplants among black candidates and those with calculated panel-reactive antibodies 98%-100%, but a decrease among candidates aged 65 years or older. Data from 2015 also demonstrate ongoing positive trends in graft and patient survival for both deceased and living donor kidney transplants, but the challenges of a limited supply of kidneys in the setting of increasing demand remain evident. While the total number of patients on the waiting list decreased for the first time in a decade, this was due to a combination of a decrease in the number of candidates added to the list and an increase in the number of candidates removed from the list due to deteriorating medical condition, as well as an increase in total transplants. Deaths on the waiting list remained flat, but this was likely because of an increasing trend toward removing inactive candidates too sick to undergo transplant.

Diabetic foot risk assessment.

Diabetes is a serious chronic disease that results in foot complications for many people world-wide. In 2014, the World Health Organization estimated the global prevalence of diabetes in adults to be 9%. To ascertain the risk that an individual patient might develop a diabetic foot ulcer that could lead to an amputation, clinicians are strongly encouraged to perform a risk assessment. Monteiro-Soares and Dinis-Ribeiro have presented a new DIAbetic FOot Risk Assessment with the acronym DIAFORA. It is different from other risk assessments in that it predicts the risk of developing both diabetic foot ulcers and amputation specifically. The risk variables were derived by regression analysis based on a data set of 293 patients from a high-risk setting, a Hospital Diabetic Foot Clinic, who had diabetes and a diabetic foot ulcers. Clear descriptions of the risk variables are provided as well as sensitivity, specificity, positive and negative predictive values for the risk categories. As an added benefit, likelihood ratios are provided that will help clinicians determine the risk of amputation for individual patients. Having a risk assessment form is important for clinician use and examples exist. A question is raised about the effectiveness of risk assessment and how effectiveness might be determined.

Pharmacokinetics and lung and muscle concentrations of tulathromycin following subcutaneous administration in white-tailed deer (Odocoileus virginianus).

Respiratory tract infections are common in farmed North American white-tailed deer (Odocoileus virginianus). Tulathromycin is approved for use in cattle but not deer but is often employed to treat deer. The pharmacokinetic properties and lung and muscle concentrations of tulathromycin in white-tailed deer were investigated. Tulathromycin was administered to 10 deer, and then, serum, lung, and muscle tulathromycin concentrations were measured using liquid chromatography-mass spectrometry (LC-MS). The mean maximal serum tulathromycin concentration in deer was 359 ng/mL at 1.3 h postinjection. The mean area under the serum concentration-time curve, apparent volume of distribution, apparent clearance, and half-life was 4883 ng·h/mL, 208 L/kg, 0.5 L/h/kg, and 281 h (11.7 days), respectively. The maximal tulathromycin concentration in lung and muscle homogenate from a single animal was 4657 ng/g (14 days) and 2264 ng/g (7 days), respectively. The minimum concentrations in lung and muscle were 39.4 ng/g (56 days) and 9.1 ng/g (56 days), respectively. Based on similarity in maximal serum concentrations between deer and cattle and high lung concentrations in deer, we suggest the recommended cattle dosage is effective in deer. Tissue concentrations persisted for 56 days, suggesting a need for longer withdrawal times in deer than cattle. Further tissue distribution and depletion studies are necessary to understand tulathromycin persistence in deer tissue; clinical efficacy studies are needed to confirm the appropriate dosage regimen in deer.

Tool for Rapid & Easy Identification of High Risk Diabetic Foot: Validation & Clinical Pilot of the Simplified 60 Second Diabetic Foot Screening Tool.

BACKGROUND: Most diabetic foot amputations are caused by ulcers on the skin of the foot i.e. diabetic foot ulcers. Early identification of patients at high risk for diabetic foot ulcers is crucial. The 'Simplified 60-Second Diabetic Foot Screening Tool' has been designed to rapidly detect high risk diabetic feet, allowing for timely identification and referral of patients needing treatment. This study aimed to determine the clinical performance and inter-rater reliability of 'Simplified 60 Second Diabetic Foot Screening Tool' in order to evaluate its applicability for routine screening. METHODS AND FINDINGS: The tool was independently tested by n=12 assessors with n=18 Guyanese patients with diabetes. Inter-rater reliability was assessed by calculating Cronbach's alpha for each of the assessment items. A minimum value of 0.60 was considered acceptable. Reliability scores of the screening tool assessment items were: 'monofilament test' 0.98; 'active ulcer' 0.97; 'previous amputation' 0.97; 'previous ulcer' 0.97; 'fixed ankle' 0.91; 'deformity' 0.87; 'callus' 0.87; 'absent pulses' 0.87; 'fixed toe' 0.80; 'blisters' 0.77; 'ingrown nail' 0.72; and 'fissures' 0.55. The item 'stiffness in the toe or ankle' was removed as it was observed in only 1.3% of patients. The item 'fissures' was also removed due to low inter-rater reliability. Clinical performance was assessed via a pilot study utilizing the screening tool on n=1,266 patients in an acute care setting in Georgetown, Guyana. In total, 48% of patients either had existing diabetic foot ulcers or were found to be at high risk for developing ulcers. CONCLUSIONS: Clinicians in low and middle income countries such as Guyana can use the Simplified 60-Second Diabetic Screening Tool to facilitate early detection and appropriate treatment of diabetic foot ulcers. Implementation of this screening tool has the potential to decrease diabetes related disability and mortality.

Pharmacokinetics of tulathromycin after subcutaneous injection in North American bison (Bison bison).

Tulathromycin is approved for the treatment of respiratory disease in cattle and swine. It is intended for long-acting, single-dose injection therapy (Draxxin), making it particularly desirable for use in bison due to the difficulty in handling and ease of creating stress in these animals. The pharmacokinetic properties of tulathromycin in bison were investigated. Ten wood bison received a single 2.5 mg/kg subcutaneous injection of Draxxin. Serum concentrations were measured by liquid chromatography-mass spectrometry (LC-MS) detection. Tulathromycin demonstrated early maximal serum concentrations, extensive distribution, and slow elimination characteristics. The mean maximum serum concentration (Cmax) was 195 ng/mL at 1.04 h (tmax) postinjection. The mean area under the serum concentration-time curve, extrapolated to infinity (AUC0-inf ), was 9341 ng · h/mL. The mean apparent volume of distribution (Vd /F) and clearance (Cls/F) was 111 L/kg and 0.4 L/h/kg, respectively, and the mean half-life (t1/2) was 214 h (8.9 days). Compared to values for cattle, Cmax and AUC0-inf were lower in bison, while the Vd /F was larger and the t1/2 longer. Tissue distribution and clinical efficacy studies in bison are needed to confirm the purported extensive distribution of tulathromycin into lung tissue and to determine whether a 2.5 mg/kg subcutaneous dosage is adequate for bison.

Pilot study compares scores of the Resident Assessment Instrument Minimum Data Set Version 2.0 (MDS 2.0) Pressure Ulcer Risk Scale with the Braden Pressure Ulcer Risk assessment for patients in complex continuing care.

OBJECTIVE: To determine if the Braden Scale for Predicting Pressure Sore Risk (Braden Scale) and the Resident Assessment Instrument Minimum Data Set Version 2.0 (MDS 2.0) Pressure Ulcer Risk Scale (PURS) provide a comparable assessment of the level of risk of developing a pressure ulcer at admission in complex continuing care. SETTING: Saint-Vincent Hospital, Bruyère Continuing Care, a 336-bed complex continuing care facility that provides restorative, complex, specialized, and supportive care to adults in Ottawa, Ontario, Canada. METHODS: A retrospective chart review was conducted from February 2012 to April 2012 on 51 patient charts that were chosen based on the completion of an admission Braden Scale assessment within a maximum of 4 weeks from admission and completed admission MDS 2.0. RESULTS: The Braden Scale categorized 63% of patients at risk when using scores between 15 and 23, compared with 33% for the MDS 2.0 PURS scores of 0-2 (low and very low risk). Both scales were comparable in identifying patients in the lower risk categories when data was reviewed using a cutoff point of 18 for the Braden. At the high risk end of the spectrum, the MDS 2.0 PURS categorized more patients, 45%, as high or very high risk, compared with 21% for using the Braden Scale. CONCLUSION: This preliminary study may provide some evidence that the MDS 2.0 PURS may be an alternative risk assessment tool option that utilizes mandatory collected data, reduces workload duplication, and would generate a Resident Assessment Protocol, when indicated, in complex continuing care.

The role of qualitative research in understanding diabetic foot ulcers and amputation.

PURPOSE: To enhance the learner's competence with knowledge about using qualitative methodologies to understand diabetic foot ulcers and amputations. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to:1. Analyze qualitative research methodologies.2. Summarize how conclusions from qualitative research relate to diabetes mellitus and its complications. Persons living with diabetes are at high risk for foot complications, lower extremity trauma, injury, ulceration, infection, and potential amputation. Qualitative health research helps to explore and understand more fully the complexities of diabetes. Qualitative health research seeks to understand what is happening and going on for the individual and his/her support persons. In addition, qualitative health research enables clinicians to appreciate how different qualitative research approaches can explore illness from the perspective of the individual living with the disease.

Effects of pipothiazine palmitate on handling stress and on the characteristics of semen collected by electroejaculation in bison (Bison bison) bulls.

Handling North American bison can pose risk to the handler and evoke stress in the animal. Moreover, this induced stress might affect qualities of semen collected by electroejaculation. The objective of this study was to investigate if a long acting neuroleptic tranquilizer (LAN) would reduce the stress of bison and thereby improve the quality of electroejaculated semen. Eight experimental replicates were conducted between May and November. In each replicate, the same six bison bulls were randomly assigned into LAN-treated (n=3) and non-treated control (n=3) groups. Pipothiazine palmitate (Piportil L4) was administered intramuscularly as a single dose of 100 mg in replicates 1-4 or 200 mg in replicates 5-8. Within each replicate, semen was collected by electroejaculation at 4, 6, 11 and 13 days post treatment. Behavioral parameters, sperm morphology and motility parameters were analyzed. A blood sample was collected before each electroejaculation and serum concentrations of testosterone, cortisol and corticosterone were determined. Treatment bulls with 100 mg of Piportil L4 reduced the restraint time and the struggling of bison bulls during handling compared to the control group (P<0.05). Semen motility parameters and serum concentrations of testosterone, cortisol and corticosterone were not significantly affected when 100mg of the LAN was administered (P>0.05). However, giving 200 mg of Piportil L4 reduced the restraint time of bison bulls and the duration of semen collection (P<0.05). Also, this treatment improved total and progressive sperm motilities when compared to the respective controls (P<0.05). Interestingly, serum concentration of corticosterone, as an endocrine stress indicator, was decreased after administration of 200mg of Pipothiazine palmitate, while testosterone concentrations were increased compared to those values in untreated control bulls (corticosterone: 0.10±0.01 compared with 0.15±0.02 ng/mL; testosterone: 9.11±1.68 compared with 5.33±0.74 ng/mL; P<0.05). In conclusion, this study demonstrated that a treatment dose of 200mg of Piportil L4 can decrease the behavioral and endocrine stress responses in bison bulls, which indirectly increasing testosterone concentrations and improving semen quality.

A prospective, descriptive study to assess the reliability and usability of a rapid foot screen for patients with diabetes mellitus in a complex continuing care setting.

Inlow's 60-second Diabetic Foot Screen is a paper-pencil tool developed to guide professionals in the completion of a quick foot assessment of persons with diabetes mellitus to determine recommended frequency of assessments. The tool has been used in various healthcare settings and its reliability and validity previously tested in acute and long-term care settings. The purpose of this study was to assess content, time to complete assessment, ease of use, and reliability of the tool in a complex continuing care setting. The tool includes questions about 10 variables; skin, nails, deformities, footwear, temperature, range of motion, sensation, pulses, dependent rubor, and erythema. Answers convert to a score ranging from 0 (low risk, yearly screenings) to 23 (high risk, weekly screenings). Using the tool, the study questionnaire, and a watch, three nurse assessors experienced in assessing the feet of persons with diabetes completed 70 assessments on 35 patients during a period of 30 days. Content areas assessed included significance of comorbidities and interval screening times. Mean time to complete the assessment was 7 minutes (range 2 to 21 minutes); 39% of assessments took 6 to 7 minutes. Times to perform assessment varied widely due to the functional and cognitive well-being of the patient. Inter-rater reliability was low (ICC 0.608 [95% confidence interval 0.349-0.781]), perhaps due to varying interpretations of assessment parameters related to the complexity of the study patient population. Comments suggest that some tool revisions may increase ease of use as well as tool validity and reliability, especially for complex care patients with multiple comorbidities.

Evaluation of a peer-led self-management education programme PEP Talk: Diabetes, Healthy Feet and You.

PEP (Peer Education Programme) Talk: Diabetes, Healthy Feet and You is a peer-led self-management programme developed to address the problems of growing prevalence of diabetes and its complications, and limited health care dollars. An evaluation of the programme, how it might be situated within a public health perspective and potential bridges for its implementation in communities throughout Canada and worldwide, are presented. The programme consisted of workshops that were conducted by volunteer peer leaders and health care professionals in 12 communities in 10 Canadian provinces; the volunteers were supported through monthly mentoring teleconferences, on-line tips and discussion board conversations. A web portal was developed to be used by the team, volunteers and community participants. Workshop curriculum was developed based on diabetes footcare and self-management best practise guidelines. Community participants answered pre-and post-workshop statements that indicated that learning occurred, as indicated by an increase in the number of statements answered correctly. Participants' feedback about the workshops was positive. In telephone follow-up interviews, 97% of respondents reported having changed their foot self-management behaviours. The portal was commonly used according to website visits, but not as much as expected for registration of community participants. It is recommended that this programme be made widely available and tailored to the specific needs of the communities and that further evaluation be conducted.

Reliability and predictive validity of Inlow's 60-Second Diabetic Foot Screen Tool.

OBJECTIVE: : The purpose of this study was to assess Inlow's 60-Second Diabetic Foot Screen Tool to ascertain consistency of risk recognition for development of ulceration independent of specific assessor and practice setting. Screening tools that assist clinicians in identifying risk require validation. The objectives were to determine the intrarater reliability, interrater reliability, and predictive validity of Inlow's 60-Second Diabetic Foot Screen Tool in 2 healthcare settings. DESIGN: : Following ethics board approval, a prospective observational study was completed. SETTING AND PARTICIPANTS: : A convenience sample of 69 persons with diabetes was recruited: n = 26 from an acute care setting (dialysis) and n = 43 from long-term-care (LTC) setting. MAIN OUTCOME MEASURES: : The screening tool was administered by 2 assessors independently to determine interrater reliability and later the same day by one of the assessors to determine intrarater reliability. Occurrence of foot ulcers or amputation was noted 1 to 5 months later to determine predictive validity. MAIN RESULTS: : Reliability is reported per setting using the intraclass correlation coefficient (2.1) and 95% confidence intervals. Intrarater reliability: LTC 0.96 (0.93-0.98) right foot, 0.97 (0.95-0.98) left foot; dialysis 1.00 right and 1.00 left foot. Interrater reliability: LTC 0.92 (0.86-0.96) right foot, 0.93 (0.87-0.96) left foot; dialysis 0.83 (0.65-0.92) right foot and left foot. Predictive validity: Two subjects had events-1 ulcer and 1 amputation-that were associated with high Inlow's screening tool scores. CONCLUSION: : This study demonstrates excellent interrater and intrarater reliability and provides preliminary information about predictive validity.

The Wound CARE Instrument: the process for developing standards for wound management education and programming.

This article describes the collaborative process undertaken by the Canadian Association for Enterostomal Therapy and the Canadian Association of Wound Care in an effort to improve the quality of wound prevention and management education and programming. The end result of this process is the Wound CARE Instrument which promotes an interprofessional, collaborative appraisal process to support the development, adoption or adaption of wound management educational events and programs.

Development of the interRAI Pressure Ulcer Risk Scale (PURS) for use in long-term care and home care settings.

BACKGROUND: In long-term care (LTC) homes in the province of Ontario, implementation of the Minimum Data Set (MDS) assessment and The Braden Scale for predicting pressure ulcer risk were occurring simultaneously. The purpose of this study was, using available data sources, to develop a bedside MDS-based scale to identify individuals under care at various levels of risk for developing pressure ulcers in order to facilitate targeting risk factors for prevention. METHODS: Data for developing the interRAI Pressure Ulcer Risk Scale (interRAI PURS) were available from 2 Ontario sources: three LTC homes with 257 residents assessed during the same time frame with the MDS and Braden Scale for Predicting Pressure Sore Risk, and eighty-nine Ontario LTC homes with 12,896 residents with baseline/reassessment MDS data (median time 91 days), between 2005-2007. All assessments were done by trained clinical staff, and baseline assessments were restricted to those with no recorded pressure ulcer. MDS baseline/reassessment samples used in further testing included 13,062 patients of Ontario Complex Continuing Care Hospitals (CCC) and 73,183 Ontario long-stay home care (HC) clients. RESULTS: A data-informed Braden Scale cross-walk scale using MDS items was devised from the 3-facility dataset, and tested in the larger longitudinal LTC homes data for its association with a future new pressure ulcer, giving a c-statistic of 0.676. Informed by this, LTC homes data along with evidence from the clinical literature was used to create an alternate-form 7-item additive scale, the interRAI PURS, with good distributional characteristics and c-statistic of 0.708. Testing of the scale in CCC and HC longitudinal data showed strong association with development of a new pressure ulcer. CONCLUSIONS: interRAI PURS differentiates risk of developing pressure ulcers among facility-based residents and home care recipients. As an output from an MDS assessment, it eliminates duplicated effort required for separate pressure ulcer risk scoring. Moreover, it can be done manually at the bedside during critical early days in an admission when the full MDS has yet to be completed. It can be calculated with established MDS instruments as well as with the newer interRAI suite instruments designed to follow persons across various care settings (interRAI Long-Term Care Facilities, interRAI Home Care, interRAI Palliative Care).

Electrical stimulation therapy increases rate of healing of pressure ulcers in community-dwelling people with spinal cord injury.

OBJECTIVE: To investigate whether electric stimulation therapy (EST) administered as part of a community-based, interdisciplinary wound care program accelerates healing of pressure ulcers in people with spinal cord injury (SCI). DESIGN: Single-blind, parallel-group, randomized, controlled, clinical trial. SETTING: Community-based home care setting, Ontario, Canada. PARTICIPANTS: Adults (N=34; mean age +/- SD, 51+/-14y) with SCI and stage II to IV pressure ulcers. INTERVENTIONS: Subjects were stratified based on wound severity and duration and randomly assigned to receive either a customized, community-based standard wound care (SWC) program that included pressure management or the wound care program plus high-voltage pulsed current applied to the wound bed (EST+SWC). MAIN OUTCOME MEASURES: Wound healing measured by reduction in wound size and improvement in wound appearance at 3 months of treatment with EST+SWC or SWC. RESULTS: The percentage decrease in wound surface area (WSA) at the end of the intervention period was significantly greater in the EST+SWC group (mean +/- SD, 70+/-25%) than in the SWC group (36+/-61%; P=.048). The proportion of stage III, IV, or X pressure ulcers improving by at least 50% WSA was significantly greater in the EST+SWC group than in the SWC group (P=.02). Wound appearance assessed using the photographic wound assessment tool was improved in wounds treated with EST+SWC but not SWC alone. CONCLUSIONS: These results demonstrate that EST can stimulate healing of pressure ulcers of people with SCI. EST can be incorporated successfully into an interdisciplinary wound care program in the community.

Implementation of best practice in the prevention of heel pressure ulcers in the acute orthopedic population.

To implement and evaluate a heel pressure ulcer prevention program (HPUPP) for orthopaedic patients. Program development of HPUPP involved input from administrators, staff and adult patients on an orthopaedic service in an academic tertiary care facility, located in a small urban centre in Canada. Prospective evaluation was conducted. Consensus exercises with clinical staff and administrators (Delphi and Nominal group) were used to, evaluate current practices, select a heel protective device, and develop key aspects of the HPUPP. HPUPP involved an individualised, bedside, staff education program, a team approach to improve patient mobility and use of a heel protective device. A 2-inch foam wedge covered in washable vinyl was placed at the foot of all beds on the orthopedic service. After the program was implemented, the incidence of heel pressure ulcers was 0%, which was a significant reduction compared with pre-implementation levels [13.8% (95% confidence interval 8-18%)]. Key components of the program success were initial and ongoing support from administration and surgeons, incorporation of feedback from clinical staff and patients, and keeping the program simple. Heel PU can be prevented in most orthopaedic patients using a universal heel PU prevention program.

A prospective, multicenter study to validate use of the PUSH in patients with diabetic, venous, and pressure ulcers.

Monitoring wound progress is essential for evaluating and documenting treatment outcomes. The Pressure Ulcer Scale for Healing (PUSH) was developed to track pressure ulcer (PU) progress but information about its utility for other types of chronic wounds is limited. A 10-month, descriptive, multicenter study was conducted to examine the responsiveness and concurrent validity of the PUSH when used to monitor wound changes in diabetic foot (DFU), venous leg (VLU), and PU. Using a convenience sample of participants (n = 98, mean age 60 [range 20 to 89] years, the majority [85%] male), PUSH score and acetate wound surface area tracings were obtained at baseline and approximately 4 weeks later from 47 Stage II to Stage IV PU, 23 VLU, and 28 patients with a DFU. After an average of 32 days, wound surface area, total PUSH scores, and individual PUSH component scores decreased significantly between baseline and follow-up (P = 0.000). The mean PUSH score change was significantly different between healing and nonhealing wounds (P = 0.000). A strong relationship (r = .66) was found between total PUSH score and surface area. Results suggest the PUSH tool is a valid, responsive, evaluative tool to monitor and document wound progress of PU, VLU, and DFU. Additional studies to assess use of this tool for DFU and to ascertain the predictive validity of the PUSH tool are warranted.

Heel pressure ulcers in orthopedic patients: a prospective study of incidence and risk factors in an acute care hospital.

Heel pressure ulcers (PU) are a major concern in orthopedic patients. A prospective 6-month study was conducted in an acute care hospital in Canada to determine the incidence of heel PU in an orthopedic population, evaluate the effect of patient and care variables on heel PU incidence, and describe the natural history/sequelae of Stage I heel PU. One hundred and fifty (150) patients (average age 70.6 years) admitted for elective orthopedic surgery or treatment of a fractured hip participated in the study. A direct heel skin assessment was performed following admission and before discharge. Patients with a Stage I ulcer were assessed or contacted 1 week following discharge. The incidence of heel PU in this population was 13.3% CI (range 8% to 19%). Incidence was 16% in the hip fracture and 13% in the elective surgery group. PU incidence in the hip fracture group was significantly lower (P = 0.016) for patients receiving heel pressure relief measures (pillows, rolled sheets). In the elective surgery group, PU incidence rates were higher for patients with respiratory disease, lower hemoglobin, low pulse rate, and altered mental status (P <0.05). When both patient groups were combined, only the presence or absence of respiratory disease significantly affected PU incidence. Length of stay was an average of 3 days longer in all groups with a heel PU but the difference was not statistically significant. One week following discharge, 13 of the 17 (76%) Stage I heel PU had resolved, one remained unchanged, and two were assessed as deep tissue injury (11%) and one as Stage II. These incidence rates are similar to those reported in other countries and confirm that efforts to reduce heel PU incidence rates are needed.