Keeping Patients Under the Damage Threshold for Pressure Injury: Addressing Microclimate Through Allostasis.

BACKGROUND: Pressure injuries (PI) are an ongoing problem in health care. Current interventions, both from clinicians and support surface technologies, do not sufficiently address PI prevention. PROBLEM: Patient microclimate is a contributing risk factor for PI, one which can be more adequately addressed. However, the acceptable range for microclimate is unknown, in part because the body adapts to changing conditions. APPROACH: Two key concepts in allostasis are finite resources and responding to intrinsic and extrinsic demands. These concepts have not previously been applied to PI treatment or interventions. Addressing microclimate, when coupled with an increasing awareness of the cumulative effect of individual patient risk factors, can help resolve the risk of PI by lowering the cumulative inputs to keep patients under the threshold for tissue damage. CONCLUSION: This new approach, which places microclimate risk into the broader conceptual framework of allostasis, can produce more effective products and interventions to prevent PI.

Use of a Support Surface Standard to Test the Effects of a Turning and Positioning Device Versus Low-Air-Loss Therapy on Temperature and Humidity.

BACKGROUND: Turning and repositioning devices (TRDs) help to reduce strain on caregivers, but clinicians question their effects on humidity and temperature (microclimate) at the skin surface that may increase risk of pressure ulcers. OBJECTIVE: To pilot the use of a standard test for support surfaces to compare microclimate at the skin surface in three scenarios: (1) on a low-air-loss (LAL) surface, (2) on a representative TRD with a basic underpad (TRDU) placed on a LAL surface, and (3) on a negative control with full occlusion. The results are designed to inform clinical decision-making in using a TRD on a LAL surface and the viability of using this test to study TRDs. DESIGN: Measuring humidity and temperature at the device-surface interface using a heated moisture-exuding bronze thermodynamic human model in a laboratory setting. MAIN OUTCOME MEASURE: Humidity and temperature levels across 3 hours 15 minutes of continuous loading with a 45-second complete unloading to simulate a position change at 3 hours. MAIN RESULTS: Relative humidity on the TRDU was below that on the LAL surface for the first 110 minutes and was markedly lower than the negative control for the remainder of humidity testing. Temperature on the TRDU was well below the negative control and negligibly higher than the surface alone throughout testing. The position change enhanced the effects of the TRDU. CONCLUSIONS: The support surface standard test appears useful in evaluating TRDs. This TRD along with the basic underpad is more comparable to a LAL surface than to full occlusion in managing the microclimate of the skin and pressure ulcer risk.

Results of Laboratory Testing for Immersion, Envelopment, and Horizontal Stiffness on Turn and Position Devices to Manage Pressure Injury.

BACKGROUND: A continuing complication, pressure injuries are due to sustained mechanical loading and tissue deformations, which can then be exacerbated by additional intrinsic and extrinsic risk factors. Although support surfaces are designed to mitigate risk factors for pressure injuries, the presence of a turn and position device (TPD) between the patient and support surface may interfere with how support surfaces affect these risk factors. OBJECTIVE: Report the use of the NPIAP's S3I standard test methods to characterize the performance of a support surface when used in conjunction with three different TPDs. DESIGN: Laboratory testing compared three TPDs for Immersion, Envelopment, and Horizontal Stiffness in each of five surface combinations. MAIN OUTCOME MEASURE: Immersion test measures how far mannequin indenter immerses into surface. Envelopment test measures immersion and pressure distribution with hemispherical-indenter with mounted sensor rings. Horizontal Stiffness test measures the shear modulus of the support surface with epicondyle indenter. MAIN RESULTS: For the specific TPDs tested here, the one with an adjustable integrated air bladder improved rather than compromised both the envelopment and the immersion of the support surface alone. Additionally, this TPD provided potential protection against sliding and the associated frictional shear forces. CONCLUSIONS: This paper describes how TPDs should perform in order to help establish which features are needed in a new medical device of this type. Laboratory testing demonstrates it is possible to improve performance of a support surface by applying a TPD as an add-on, thus relieving tissue deformation exposure through more effective pressure redistribution.

Utility of a sensor-based technology to assist in the prevention of pressure ulcers: A clinical comparison.

Detection of subcutaneous tissue damage before it is visible can trigger early intervention and decrease hospital-acquired pressure ulcer (HAPU) rates. The objective of this two-phase study was to evaluate the clinical utility of the Sub-Epidermal Moisture (SEM) Scanner (Bruin Biometrics (BBI), LLC), a hand-held device that assesses increases in interstitial fluid or subepidermal moisture, indicating early tissue damage. Phase 1: Patients were provided standard-of-care risk assessment and interventions and were scanned with the SEM Scanner, but the resulting SEM scores were not used to determine interventions. This gave a baseline pressure ulcer incidence rate. Phase 2: This phase is the same as Phase 1 except the resulting SEM scores were used in conjunction with risk assessment scores to determine appropriate interventions and care planning. In Phase 1, 12 of the 89 subjects or 13.5% developed visible pressure ulcers-4 Stage I's, 6 Stage II's, 1 Stage III, and 1 deep tissue injury. In Phase 2, 2 of the 195 subjects or 1.0% developed visible pressure ulcers-1 Stage I and 1 Stage II. Patients in Phase 2 were more incontinent, less mobile, and had longer lengths of stay than those in Phase 1. Use of the Scanner resulted in a 93% decrease in HAPU. No deep injuries developed in Phase 2.

The clinical relevance of treating chronic wounds with an enhanced near-physiological concentration of platelet-rich plasma gel.

OBJECTIVE: This study investigated clinical outcomes in chronic nonhealing wounds following the short-term use of an enhanced, near-physiological concentration of platelet-rich plasma (PRP) gel (AutoloGel System, Cytomedix, Inc, Gaithersburg, Maryland). DESIGN: Study design was a large, observational case series using a multicenter registry database (all wounds included), which compared different populations within the database. SETTING: Thirty-nine centers contributed to the registry, including long-term acute-care centers, outpatient clinics, a durable medical equipment company, a home health agency, and a long-term-care center. PATIENTS: The target population included 285 chronic wounds (patient n = 200). Wound etiologies included diabetic, pressure, or venous ulcer; dehisced, surgical, or traumatic wound; and wounds of other etiologies. INTERVENTION: Therapeutic, PRP gel is produced from patient blood utilizing autologous platelets and plasma that contribute growth factors, cytokines, and chemokines, in a fibrin matrix. MAIN MEASURES: Area and volume of the wound and the linear total of undermining and sinus tracts/tunneling were calculated. Clinical relevance was determined by analyzing outcomes in wounds that responded to treatment. MAIN RESULTS: A positive response occurred in 96.5% of wounds within 2.2 weeks with 2.8 treatments. In 86.3% of wounds, 47.5% area reduction occurred, and 90.5% of wounds had a 63.6% volume reduction. In 89.4% undermined and 85.7% of sinus tracts/tunneling wounds, 71.9% and 49.3% reductions in linear total were observed, respectively. CONCLUSION: In chronic wounds recalcitrant to other treatments, utilization of PRP gel can restart the healing process. Rapid treatment response was observed in 275 of 285 wounds, and the magnitude of response was consistently high, with statistically significant outcomes reported for various subgroups.

Effect of platelet rich plasma gel in a physiologically relevant platelet concentration on wounds in persons with spinal cord injury.

The objective of the study was to investigate the use of a 1·3 times normal platelet concentration platelet-rich plasma (PRP) gel to move chronic wounds towards healing in persons with spinal cord injury (SCI). The study design was a case series of 20 persons with SCI with non healing wounds. The outcome measures were, in wound area, volume, undermining and sinus tracts/tunnels (ST/Ts), calculated average, (i) percent of change from baseline, (ii) change per day from baseline, (iii) number of treatments and (iv) number of weeks. In a mean of 4·0, after treatments over 3·4 weeks, the wounds closed on an average of 47·9% in area and 56·0% in volume. Undermining closed on an average of 31·4% using 3·5 treatments over 2·6 weeks. ST/Ts closed on an average of 26·1% after 2·3 treatments over 1·5 weeks. Clinical relevance by percent of positive responders and their response: in area, 90·0% of the subjects responded positively, the average reduction was 53·8%. In volume, 90·0% responded, with an average reduction of 67·3%. Of four subjects with undermining, 75% closed 47·0% on average. Of the three with ST/Ts, 100% closed 26·1% on average. Average haemoglobin and haematocrit levels were below normal. To conclude, 1·3× PRP gel appears to progress chronic, non healing wounds in SCI patients into the granulation phase of healing quickly. Review of the literature shows these results may not be applied to all PRP preparations.

Chronic wounds treated with a physiologically relevant concentration of platelet-rich plasma gel: a prospective case series.

Chronic wounds are characterized by a long inflammatory phase that hinders regenerative wound healing. The purpose of this prospective case series was to evaluate how a physiologically relevant concentration of an autologous platelet-rich plasma (PRP) gel affects initial wound healing trajectories of chronic, nonhealing wounds of various etiologies and in different care settings. Using convenience sampling methods, 49 patients (average age: 60.6 years, SD 14.7) with 65 nonhealing wounds (mean duration 47.8 weeks, range 3 to 260) at eight long-term acute care (LTAC) hospitals and three outpatient foot or wound clinics who were prescribed PRP gel for their nonhealing wound were enrolled. The majority of patients had low albumin, hematocrit, and/or hemoglobin levels. After wound assessments and measurements were obtained and the gel prepared, a skin barrier was applied to the periwound skin and the gel applied and protected with cover dressings. The most common wounds were pressure ulcers (n = 21), venous ulcers (n = 16) and diabetic foot ulcers (n = 14). Mean wound area and volume were 19 cm2 (SD 29.4) and 36.2 cm3 (SD 77.7), respectively. Following a mean of 2.8 (SD 2.4) weeks with 3.2 (SD 2.2) applications, reductions in wound volume (mean 51%, SD 43.1), area (39.5%, SD 41.2), undermining (77.8%, SD 28.9), and sinus tract/tunneling (45.8%, SD 40.2) were observed. For all wound etiologies, 97% of wounds improved. The results of this study suggest the application of this PRP gel can reverse nonhealing trends in chronic wounds.

Use of alternatives to air-fluidized support surfaces in the care of complex wounds in postflap and postgraft patients.

Air-fluidized support surface therapy has many drawbacks, such as dehydration, in an already difficult recovery for those wound patients who have undergone flap and graft surgery. In addition, patient care and handling are also problematic. Patients complain of discomfort, and the instability of the surface interferes with patient stability in side lying and semi-Fowler's positions. Alternative support surfaces can be considered for postflap or postgraft patients. Such technologies as alternating pressure, low-air-loss, and therapeutic nonpowered, advanced, and lateral rotation surfaces are widely used for pressure management in high-risk patients and those with existing pressure ulcers. These surfaces must be used within a total pressure ulcer management program that includes frequent turning and repositioning, skin and ulcer care according to evidence-based protocols, patient and caregiver instruction, nutrition, and offloading and positioning. The proposed recommendations require more research on the relative effectiveness of less expensive and more user-friendly support surfaces such as low-air-loss and nonpowered advanced support surfaces and is necessary in order to conclusively recommend one type of surface over another. However, at this time the available clinical studies and opinions remain positive.

Physiological changes in tissues denervated by spinal cord injury tissues and possible effects on wound healing.

There are many metabolic and physiological changes that happen to the tissues below the level of a spinal cord injury. These deficits are examined in relation to the series of events that has to take place for wound healing - the "wound healing cascade". The conclusion is that every step of the wound healing process is impaired by the physiological deficits inherent post-spinal cord injury. This may explain, in part, why pressure ulcers on these patients are so difficult to close and to maintain closed.

Wound care organizations, programs, and certifications: an overview.

The number and variety of wound care organizations and certification programs have increased considerably in recent years. Many healthcare professionals interested in pursuing certification, employers who want to hire them, and the public at large are confused about the plethora of certification designations, program names, and requirements. Some of the largest wound care organizations in the US support or develop educational programs and meetings or support credentialing programs. Two of the four largest credentialing organizations are accredited. Information about the effect of credentialing on healthcare provider knowledge and clinical skills is not available and standards are needed to help healthcare providers and employers decide which program best serves their needs. Most importantly, research to ascertain the effects of educational programs and credentialing on patient outcomes must be conducted to help improve the quality of care and substantiate the goals of the credentialing programs.

Lateral rotation mattresses for wound healing.

Continuous lateral rotation therapy utilizes mattresses and beds that move the patient in a regular pattern around a longitudinal axis. Although these devices have been used for several decades for other medical purposes, literature is scant regarding their role in the treatment of skin breakdown in the bedridden, difficult-to-reposition patient. A descriptive study was undertaken to ascertain the rate of wound healing and number of weeks to achieve wound closure when continuous lateral rotation therapy was employed in patients with partial-thickness (n=10) and full-thickness (n=20) ulcers on the trunk or pelvis. Patients receiving the services of Advanced Therapy Surfaces in home or long-term care between March 15, 2002 and April 1, 2003 were enrolled. Partial-thickness wounds healed at an average rate of 16.68% per week, with an average time for continuous lateral rotation therapy of 9.25 weeks. Full-thickness wounds healed at an average rate of 14.38% per week (time to healing 11.25 weeks). No additional areas of skin breakdown were observed. These encouraging results suggest that additional research is warranted.