Practice Innovations
Since heels are a high risk area for hospitalized patients to develop pressure ulcers, determining effective offloading capabilities for the hospital’s new heel boots*** on formulary as applied by therapists was our objective. There have been many articles and guidelines(EPUP/NPUAP/NICE/AORN) written in order to investigate methods to decrease heel pressure ulcers.1 Some methods studied use of- staff education 2, dressings3, support surfaces and offloading devices-wedges, pillows, and boots 4.
Recommendations to maintain heels off the underlying surface are repeatedly noted. Citations regarding use of hospital pillows being used under the calves to float the heels note that they can be of low quality, making them ineffective over time, that they don’t stay where placed and that they are not designed to reduce friction/shear when there is patient movement 5. Boots were noted to allow improvement in movement and improved ease of application/removal 6.
Normal capillary filling pressure is in the range of 25-32 mmHg hence pressure above that can lead to occlusion followed by ischemia/necrosis. A standard non-specialized hospital bed generates heel-to-bed pressure of 50-94 mmHg in supine-exceeding the range where tissue damage occurs7. Hospital products are often part of a larger contract so that prior clinically-chosen products are replaced by other products as part of an overall contract change in order to facilitate expense reductions.
Methods:
Therapists were given verbal instructions to ”offload the right heel” of a mannequin with a hospital pillow and then with the new boot. There was no product education provided. A pressure monitor was then utilized under the heel and measurements recorded.
Results:
100% of the six therapists participated and all produced 0mmHg during both point in time trials.
Discussion:
We recommend more research using various sized patients with a variety of medical conditions and pressure measurements taken intermittently-especially since research has shown that pillows are not effective over time for offloading heels. Additionally, consideration of clinical evaluation of formulary product changes by the multidisciplinary team prior to implementation may be useful.