FOURTEENTH ANNUAL EUROPEAN PRESSURE ULCER ...

Thursday September 1st
Proceedings of the 14th Annual European Pressure Ulcer Meeting
Oporto, Portugal
Heel Pressure Ulcers: a study of wound healing
Elizabeth McGinnis
Leeds Teaching Hospitals NHS Trust, England. Elizabeth.mcginnis@leedsth.nhs.uk
Introduction
Pressure ulcers result in suffering and morbidity to
patients and are costly to the healthcare provider.
Heels are a common location for pressure ulcers
(PUs) [1]. Heel PUs are considered separate entities
to other body sites as the physiology of the heel is very
different: the epidermis is thicker, the dermis has no
sebaceous glands and contains fatty pockets within
the fascia; they are more prone to arterial disease,
neuropathy and oedema. Interventions for healing all
PUs include offloading the pressure, wound treatments
and correcting intrinsic factors e.g. nutritional deficits.
A systematic review of the evidence for effectiveness
of support surfaces for offloading the pressure did not
show efficacy of any specific type of support surface
[2]. No studies have been identified which provide
sufficient evidence for other healing interventions. This
study aims to identify prognostic factors for healing
heel PUs and offer insights that will inform future
intervention studies.
Methods
A prospective cohort study was performed. Patients
with heel PUs ≥ Category 2 were recruited from an
acute hospital, in specific inpatients areas where heel
ulcers were known to occur. Patients were followed up
weekly while in hospital then monthly following
discharge until healing or 18 months. Data was
collected on factors thought to be prognostic for
healing and included demographics, intrinsic factors,
patient and ulcer characteristics, treatments both
systemic and ulcer specific. Analysis was based on
time to healing of each ulcer, this was performed using
Cox proportional hazards (PH) models [3] with robust
standard errors (SE) to allow for clustering.
Results
140 patients with 183 PUs were recruited. 77 (42%)
ulcers healed, 88 (48%) did not heal as the patients
died, 5 (3%) were on limbs which were amputated, 11
(6%) had not healed after 18 months and 2 (1%) were
lost to follow-up. Univariate analysis using a Cox
proportional hazards model identified 12 variables
which reached significance at the p≤0.2 level. Eight
variables were entered into a multivariate model of
which two emerged that reached significance at the
p≤0.1 level: severity of the ulcer and the presence of
peripheral vascular disease.
Discussion
This study is the first known of its kind.
82
More than half of the ulcers did not progress to healing
as a consequence of the death of the patient.
Several factors emerged from the univariate model
which affected the probability of healing but not all of
these reached the p≥0.2 level of significance, these
could have occurred by chance or were due to the
small sample size.
This cohort consisted of a specific patient population
where heel PU were known to occur, results may not
be generalisable to other hospital populations however
as two thirds of the data collection occurred in the
community it seems reasonable to apply cautionary
generalisability to this care setting too.
Data on recruitment rates, duration and outcomes from
this study can be used inform future intervention
studies.
Clinical relevance
As severe pressure ulcers are likely to take longer to
heal than superficial ulcers thus long term care plans
should reflect their needs for ongoing ulcer
management. The presence of PVD is also likely to
delay healing; all heel pressure ulcer patients should
have their peripheral arterial status established to
inform ongoing ulcer management.
Acknowledgements
This study was supported by a Charitable Trustees
Fellowship from LTHT and a Smith & Nephew/ Multiple
Sclerosis Society Studentship
Academic supervisors: Prof EA Nelson, Prof JE Nixon,
Dr D Greenwood
Conflict of Interest
None.
References
[1] Dealey C. The size of the pressure ulcer problem in
a teaching hospital. Journal of Advanced Nursing 16:
633-70, 1991
[2] McGinnis E. Support surfaces for healing pressure
ulcers: A Cochrane Systematic Review. Proceedings
of the 12 th Annual European Pressure Ulcer Advisory
Panel Meeting. Amsterdam, Holland. 2009
[3] Cox DR. Regression models and life tables (with
discussion). Journal of the Royal Statistical Society.
Series B 34:187-220, 1972
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