Heel pressure ulcer prevention: a 5-year initiative using low-friction bootees in a hospital setting

Pressure, particularly over bony prominences such as the ischium, trochanter, elbows, heels and other anatomic sites, leading directly to tissue damage and restricting blood flow creating areas of cell death and ischaemia, has been widely recognised as a risk factor for pressure ulcers (PU) (Grey et al, 2006; Gefen et al, 2008; National Institute for Health and Care Excellence [NICE], 2014). The National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA) (2014) and other expert PU guideline developers further recognise friction that causes shear as a critical risk factor. Friction, caused by the interaction of a surface material such as a bed sheet with skin, which may also be affected by moisture, leads to tangential forces in the tissue when the surface of the skin is prevented from sliding as a patient moves on the surface. The resulting shear, where two layers of skin move excessively in relation to each other, leads to deformation of the skin and underlying tissues that may damage tissue directly (Reger et al, 2010) or cause injury to superficial skin structures when a patient moves on a bed surface (Dealey et al, 2015). In an at-risk patient the outcome may be tissue injury. Friction and shear are predictive for the development of PU in adult critical care patients (Cox, 2011) and friction is a significant risk factor in critically ill patients (de Laat et al, 2006). Along with moisture, pressure and friction/shear account for most tissue damage in vulnerable sites. Heels are at risk because of the weight of the foot, the shape of the calcaneus, lack of padding and relatively poor blood supply (Langemo, 2014). The incidence of hospital-acquired hPU may be as high as 30% of patients (Bååth et al, 2016), demonstrating the need for interventions to minimise the risk of skin breakdown caused by pressure and other factors including friction and shear. Many patients are susceptible to hPU and in many cases this may be related to friction and shear. Susceptible patients include those with reduced lower limb mobility as a result of other conditions (e.g. fractured hips, joint replacement surgery, spinal cord injury, Guillian Barré Syndrome or stroke); those with diabetic neuropathy; those with leg spasms; patients who frequently reposition by pushing their heels on a mattress (Fletcher, 2015). In the period 2011 to 2015, St Helens and Knowsley Teaching Hospitals NHS Trust evaluated low-friction bootees (LFB) integrated into the care path for patients at-risk of heel pressure ulceration (hPU) in an initiative to reduce hospital acquired hPU related to friction and shear. In 2012, LFB were introduced and hPU reduced by 32% from 50 to 34 compared with 2011. In 2013, mandatory education and training was introduced. A further reduction to 11 hPU from 34 was recorded. In 2014 a new risk assessment tool was introduced. Thereafter the incidence of friction/shear associated hPU, identified by the depth of tissue injury, stabilised. Over the initiative, the overall reduction in all PU was 67% and for hPU, 84%. No grade 3 or 4 hPU were reported. The incidence of all PU reported was, and remains, below the national average. The five-year initiative substantially impacted on achieving zero harm targets, and led to estimated savings calculated from the reduced cost of managing hPU and the cost of acquisition and laundering of LFB versus 2011 of £53,371 in 2012 and £196,116 in 2013.