Keeping It Heeled – Heel Pressure Ulcer Prevention and Treatment in Long-Term Care

Problem: A significant rise in heel pressure injury (PI) incidence was noted with a peak rate of 15% in our 168-bed long-term care facility. A heel boot was in use for prevention, but compliance was poor as patients felt that it was hot, heavy, and uncomfortable. Additionally, the heel device did not support neutral body alignment and the strap occasionally caused superficial pressure injuries.

Method: The wound care team conducted a test of change utilizing the Plan, Do, Study, Act (PDSA) cycle. The prevention protocol was altered to add a heel dressing for high-risk patients and the heel boot for patients with existing PI was changed to a device incorporating Z-flex technology.

A root cause analysis of our previous facility-acquired pressure injuries indicated the following risk factors: a pressure ulcer risk score of 15 or below, recent surgical procedure, recent admission within 24 hours, and/or those needing total assistance for mobility.

The test of change ran four consecutive weeks with 10 patients participating. The four patients with an existing heel pressure injury had the five-layer heel dressing and the Z-flex boot applied. The six high-risk patients had the five-layer heel dressing applied and the heels suspended on pillows.

Results: Quality measure of long-stay patients with pressure ulcers decreased from a peak of 15% to a current of 4.2%.

Over four weeks, the six high-risk patients who received the prophylactic heel dressing experienced no breakdown. Of the four patients receiving the treatment bundle, two heel injuries, one unstageable and one stage 1, resolved completely. The remaining two treatment patients experienced 50% healing within the four weeks and had no further or new skin breakdown.

No pain or discomfort was conveyed. All patients reported that the new device was comfortable, and compliance with wearing the device increased.