Prevention of Heel Pressure Ulcers in
Fractured Hip Patients
Lena McCubbin, RN, MS, CWOCN, CNS
Columbus Regional Hospital, Columbus, Indiana Donna Smith, RN, UBCM
Kathy Jackson, RN, MSN, CRRN
1.Misra, SK, Elasy, T, Holcomb, J, Powers, JS. The frequency of heel pressure ulcers in Pressure ulcers of the heel are a devastating event for the fragile elderly who fracture
VA patients undergoing a hip or knee-related orthopedic procedure. J Am Geriatrics their hip. This population is especially vulnerable due to age, malnutrition, and functional
Soc. 49(4) April 2001 pS29. decline.
2. Gunningberg L, Lindholm C, Carlsson M, Sjoden PO. Reduced incidence of pres- In spite of standard prevention practices including the use of pillows to elevate the heel
sure ulcers in patients with hip fractures: a 2-year follow-up of quality indicators. Int off the bed, our fractured hip population (FHP) continued to suffer heel ulcers. We found
J Qual Health Care 2001 Oct; 13(5):399-407. the pillows were used inconsistently, usually the human element: patient and family
moved them, the pillow was placed under the heel instead of suspending it, staff placed
pillows in the chair for patient comfort, or during daily linen changes, the pillows were not
replaced to suspend the heels.
By proactive use of the ventilated static air mattress (VSAM), all areas of the body were
protected and pressure ulcers in the FHP went to zero (0). This is now standard practice
on the orthopedic unit. The auditing of heel ulcers has become the standard by which
new hospital replacement mattress (HMR) evaluation is measured. All new evaluation
mattresses are trialed on the ortho unit with close follow up by the wound, ostomy, and
continence nurse. Thus far, trial mattresses have not matched the performance of the
VSAM in prevention of heel ulcers.
• Prevention of Heel Pressure Ulcers in Fractured Hip Patients • Conference
Lena McCubbin, RN, MS, CWOCN, CNS • Donna Smith, RN, UBCM • Kathy Jackson, RN, MSN, CRRN Columbus Regional Hospital Columbus, Indiana
Purpose/Rationale Method Pressure Ulcer Pressure Ulcer Prevention Implementation Results 2002 vs Statistical
To examine whether a ventilated This was a quasi-experimental
Prevention for for “After” Group 2003 Analysis
static air mattress (VSAM) could study with before/after design. RN Case Manager (CM) explained
prevent nosocomial heel ulcers in
“Before” Group • Static air mattress overlay* with ventilation holes the importance of the static air mat- Sample Heel Percent • Fisher’s exact test:
the fractured hip population (FHP) Convenience sampling of the Standard Care was placed on the bed before patient reached tress to staff and obtained education
unit from Emergency Department or within 8 hours size N= Ulcers P-Value = 0.038
if applied early in the hospital entire Fractured Hip Population on •Hospital replacement mattress for staff on proper use of mattress
(HRM) plus heel elevation of admission. Before Suggests significance
admission. the Ortho Unit was obtained for overlay.
one year before intervention and with pillows. group
• No boots or pillows were use to elevate the heels. (Stage II- 72 4 5.6% • Compare with published
The authors hypothesize there one year after intervention to CM monitored:
• Skin inspection each shift IV) 2002 studies on HFP.
would be a decrease in the compare rates of pressure ulcers. • All admissions and time frame in
incidence of post-fracture heel • Skin inspection each shift. which the patient was placed on After
• Turning, repositioning and group – McCubbin, Smith,
ulcers with the use of this VSAM the overlay. 84 0 0.0%
early mobilization. • Turning,repositioning (Stage I- Jackson 0.0%
and early mobilization. • Condition of heels and other bony
– Misra, et al. 5.6%
prominences at discharge. No sacral ulcers were indentified
in the after group. – Gunningberg, et al. 27%
• The presence of overlay and time
frame of implementation became
a standard shift change report
1. 2. 3. 4. 5. 6. 7.
Why Does This Does Shear Does the Timing Do Our Hip Fracture Patients What About Financial Conclusion
Protocol Work? Reduction Matter? Make it Work? Still Get Heel Ulcers? Finances? Statement
Static air mattress provides increased Most were placed on the The results suggest that heel ulcers
Should we routinely place patients This study was supported by can be prevented in FHP using this
Do the holes matter? support area, and reduces shear and ventilated static air overlay upon After study was completed, a patient went from on a prevention overlay? Columbus Regional Hospital as protocol.
pressure - AHCPR No. 15 p. 38. admission. surgery to Intensive Care Unit (ICU) due to
part of an ongoing
• Casual observation during and unstable vital signs (dropping blood pressure). 84 patients were protected with a
Static air produces “normal” or Clinical Process and Quality
The 8 hour time frame was hospital material cost of approxi-
after the study suggests the Improvement Projects.
perpendicular force on the skin, chosen based on how long the Patient was placed on prevention HRM. No air References
ventilation holes may have some mately $3000.
reducing shear. storeroom could re-supply if the mattress was implemented. Patient received vol- See handouts for references.
influence. EHOB, Inc., provided poster and
floor had no overlay. This alerts ume support, vasopressors, and blood Compare with:
We used a flat bed sheet instead handout printing.
• The majority of the time, the the nurse to intervene by a transfusions. • Cost of treating pressure ulcers
of a fitted sheet. specific deadline.
heels are observed resting in the loss of patient or family Financial Disclosure
ventilation holes. Patient was transferred to the floor in 48 hours. • Confidence in the hospital.
• The loose flat sheet moves with the No other financial support was
Prevention interventions should
patient. received for this study.
• Patients with Buck’s Traction are be applied early in the hospital Four days post-op he was discovered to have
also observed with the heel in a stay -- Lyder, et al. Arch Intern large bilateral heel blisters.
• The sheet takes the friction, not the Med 2001;161:1549-1554
skin. The exact cause cannot be known: pressure vs.
low blood flow or the combination of both.
• Less friction means less shear on
8. the skin and underlying soft tissue. 9. 10. 11. 12. 13. 14.
* W A F F L E® B r a n d O v e r l a y