Letters to the Editor

Dear Editor,

    The paper by Anderson and Rappl (Lateral rotation mattresses for wound healing. Ostomy Wound Manage. 2004;50(4):50-62) that describes the effect of a rotating surface on pressure ulcer healing is particularly important in light of the mounting evidence that pressure ulcers occur because immobile patients are not repositioned, not because of comorbidities such as anemia, cardiovascular disease, renal failure and diabetes.¹

    In a related study,² an electronic monitor was used to record the actual frequency of turning of nursing home residents at high risk of developing pressure ulcers — individuals who should have been turned at least every 2 hours. Of those residents, 70% were turned less often than every 3 hours. The average longest time without turning was 5 to 6 hours; some patients were not turned for 11 hours. Another study³ of ICU patients where 2-hour turning also was the standard of care found that 97% of the time patients were not turned every 2 hours; 23% of the time they were not turned for more than 8 hours. These studies and the repeated demonstration that focused educational efforts can, at least temporarily, sharply diminish the rate of occurrence of pressure ulcers in nursing home residents^4,5 indicate that patients frequently do not get appropriate repositioning. In the electronic-monitor study, the chart record and the actuality of repositioning were sharply variant. An overburdened staff must prioritize — repositioning seemingly sinks to the bottom of an over-long list of things to be done.

    The system described by Anderson and Rappl, where patients are turned automatically, may provide a partial answer to the problem. A similar system that used a bed that tilted 15 degrees laterally at 15-minute intervals was described in a Japanese study⁶ that compared 19 study patients and 12 control patients (turned manually every 2 hours). After 3 months, a statistically significant improvement was noted in the grade of the pressure ulcer in the patients turned automatically while no improvement was seen in patients turned manually. Although the Japanese study was limited by small numbers and absence of randomization and blinding, the potential for automated turning to accelerate the healing of pressure ulcers, as well as minimize their occurrence, is clear.

    Cost savings potential for automated turning also is evident. The extra cost of caring for a nursing home resident with pressure ulcers was estimated to be $270 a month ($3,240/year) 9 years ago⁷; assuming a 7% per annum inflation in medical costs, the current cost is approximately $6,000 a year. The device described by Anderson and Rappl costs about $5,000 and has a useful life of approximately 8 to 9 years. Thus, spending about $600 per patient per year on patients whose Braden scores predicted imminent pressure ulcer development would save about $5,400 per patient per year if the device were 100% effective.

    Other systems that could be useful for automated turning are also available.^8,9 Although they are more complex and expensive than the $5,000 device, they have the potential to be reengineered to meet the more limited requirements of nursing home residents and, subsequently, the cost would be less prohibitive. However, the manufacturers of these devices seem unenthusiastic about reengineering — perhaps, in part, because nursing homes are deemed too impoverished to pay for new technology. This reluctance to reengineer might change if an automatic device became the standard of care. A convincing double-blind study proving that automatic turning reduces or eliminates pressure ulcers is sorely needed.

    Simeon Pollack, MD
    Albert Einstein College of Medicine
    Bronx NY

References
1. Allmann RM, Laprade CA, Noel LB, et al. Pressure sores among hospitalized patients. Ann Int Med. 1986;105:337–342.
2. Bates-Jensen BM, Cadogan M, Jorge J, et al. Standardized quality-assessment system to evaluate pressure ulcer care in the nursing home. JAGS. 2003;51:1194–1201.
3. Krishnagopalan S, Johnson WE, Low LL, et al. Body positioning of intensive care patients: clinical practice versus standard. Crit Care Med. 2002;30: 2588–2592.
4. Lyder CH, Shannon R, Empleo-Frazier O, et al. A comprehensive program to prevent pressure ulcers in long-term care: exploring costs and outcomes. Ostomy Wound Manage. 2002;48(4):52–62.
5. Moody BL, Fanale JE, Thompson M, et al. Impact of staff education on pressure sore development in elderly hospitalized patients. Arch Int Med. 1988;148:2241–2243.
6. Izutsu T, Toshifumi T, Satoh T, et al. Effect of rolling bed on decubitus in bedridden nursing home patients. Tohoku J Exp Med. 1998;184:153–157.
7. Ferrell BA, Keeler E, Siu A, et al. Cost effectiveness of low-air-loss beds for treatment of pressure ulcers. J Gerontol: Med Sci. 1995;50A:M141–M146.
8. Raoof S, Chowdhrey N, Raoof S, et al. Effect of combined kinetic therapy and percussion therapy on the resolution of atelectasis in critically ill patients. Chest. 1999; 115: 1658–1666.
9. Melland HI, Langemo D, Hanson D. Clinical evaluation of an automated turning bed. Orthopaedic Nursing. 1999;18:65–70.

Reply

    The use of lateral rotation mattresses is an answer — albeit a partial one — to the problem of inadequate turning frequency because fully repositioning a patient always will remain the best means of preventing or treating skin breakdown. The skin must be allowed to breathe, evaporating heat and moisture by moving it off of the support surface at regular intervals. In addition, other parts of the body such as joints, muscles, lungs, inner ear, bladder, and brain respond to the effects of repositioning.

    Reputable manufacturers of lateral rotation mattresses have been careful to instruct customers that these mattresses do not take the place of standard every-2-hour repositioning. The reality, as Dr. Pollack points out, is that repositioning simply is not happening every 2 hours. As funding to nursing homes decreases, the situation may only get worse, despite education and threats of financial or regulatory penalties.
Dr. Pollack has overestimated the financial costs to the facility. The $5,000 mattress that Dr. Pollack mentions actually costs less than $2,000.

    Carol Anderson, RN, MSN
    Laurie M. Rappl, PT, CWS