Can We Talk?: Embrace the Future

    Skin fails like any other organ system when stressed beyond its ability to endure. The question is, how much stress is required? Human beings are dynamic organisms. In situations such as critical care and end-of-life, very little tissue/surface interface pressure is required to produce tissue ischemia and ultimate ulceration.

In these severe situations, skin — just like the heart, lung, kidney, and liver — failure becomes almost inevitable. That pressure ulcer incidence and prevalence rates have not significantly changed over the last two decades despite advances in support surface technology and every other healthcare technology leads me to believe that we often are dealing with a pathologic process rather than a simple “failure to turn.”

    Pressure ulcer prevention follows two paths: repositioning and the use of pressure distributing surfaces. Unfortunately, little hard evidence justifies the use of either one. The alleged standard of care of “Turn q 2” is based on obscure and outdated evidence. As medical and nursing professionals, we would never use one single number to make decisions about patients, yet we admonish staff, “Turn patients every 2 hours no matter what their condition and they will never develop pressure ulcers.” That is magical thinking.

    The amount of tissue/surface interface pressure that ultimately leads to ischemia and ulceration also has been debated for decades. Again we work with a single number — ie, keep pressure above 32 mm of mercury and you will never develop a pressure ulcer. If I have learned anything in my nursing career, it is that the only absolute in medicine is that there are no absolutes. That is why we practice the “art” of medicine and nursing.

    Now that I have addressed the need for science to answer certain questions, I must turn face. I believe many nursing professionals have become too reliant on guidelines, tools, and scales to make decisions that should be based on knowledge and clinical judgment (ie, the things we are paid for). The absence of a scientifically proven answer does not necessarily justify falling back on habit and outdated research. We need to open our eyes and minds and think critically about what we have observed and what appears to work, using personal experience when accepted science offers little help.

    In this vein, my personal belief is that every — yes, every — non-ambulatory patient admitted to any healthcare facility should have, at minimum, a dynamic, air-filled overlay mattress (ie, low-air-loss) on top of the standard foam core mattress. The technology exists and the cost is quite reasonable. Whether used in critical care, med/surg, or long-term care, a simple dynamic air overlay — of any type or manufacturer — in my experience significantly reduces the incidence of pressure ulcers. The pressure ulcers that develop under these circumstances are truly unavoidable.

    Healthcare facilities have made the move from old-style innerspring mattresses to much more effective foam-core mattresses. The next logical step is to use dynamic air surfaces for all immobilized patients. A simple before-and-after study at a few facilities around the nation would be a real eye-opener. Who is ready to embrace the future?