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5 year experience with low friction bootees intergrated into standard of care for heel pressure ulcer prevention in a uk nhs teaching hospital

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5-year experience with low-friction bootees integrated into standard of care for heel PU prevention in a UK NHS Trust teaching hospital
Debbie Gleeson, Lead TVN, St Helens and Knowsley NHS Trust.

Standard care, Low-friction Bootees, training, and an assessment tool focused on heels reduced the incidence of heel PU by 84% over 5 years

Cumulative cost savings over the 4 years were over £558,000 compared with baseline


Ø~25% of all PU occur on the heel
ØThe incidence of hospital acquired heel PU may be up to 30%1 even with standard care
ØThe heel is at-risk because of the weight of the foot; the anatomy of the calcaneus; lack of protective padding; poor blood supply2
ØIt is important to minimise the risk of skin injury through pressure, friction, and shear
ØFriction and shear are increased when the patient is moved leading to tissue deformation and the potential for damage3
ØThe standard care for the management of pressure is mattresses and foot elevation. The standard care for the management of friction is dressings. However, heel PU still form because of shear forces
ØMore effective friction management needed
ØLow friction bootees (LFB) and undergarments (APA Parafricta) have a coefficient of friction of 0.2, lower than other technologies which protects the heel from friction and shear
ØSt Helen and Knowlsey NHS Trust conducted an analysis of the incidence of heel PU over 5 years during which LFB and other improvements to the management of the risk of PU were introduced4
ØBaseline data from 2011 were analysed for admissions to the hospital and the incidence of all PU and the subset of heel PU
ØLFB were introduced for all at-risk patients in 2012. Risk assessment was conducted using the Maelor risk assessment tool5,6
ØEducation and training on the management of PU were introduced for all staff in 2013. Over 1800 staff were trained by 2 TVNs in weekly sessions of 1 hour each over a year.
ØA new risk assessment (RA) tool was introduced in mid-2014. The tool was an enhanced version of the Maelor risk assessment tool that ensured focus on assessment of the risk of heel PU. The enhanced tool included 11 risk categories reported to increase the risk for heel PU formation6
ØAny patient identified as having 1 or more risk(s) for heel PU formation was allocated LFB
ØHeels were regularly assessed as part of routine skin inspection. The presence of heel injury was monitored monthly. Annual data for 2012 to 2015 were compared with admissions and PU incidence data from the 2011 baseline
ØRoot cause analysis (RCA) was conducted for any Gr 2, 3 or 4 PU reported
ØHealth economic analysis was conducted using assumptions based on:
ØCost of healing a grade 2 PU (£5241.009)
ØCumulative cost of LFB and laundering
ØChange in heel PU incidence


ØAdmissions 2011 to 2015 were between ~212,000 and 220,000, (+3.7%). In 2011, 125 PU of all types were reported. hPU accounted for 40%.

ØIn 2012 (LFB introduced), 117 PU of all types (-6.4% versus 2011) and 34 hPU were recorded (29% of all PU; - 32% versus 2011).
ØAfter the introduction of compulsory staff education and training (2013) 56 PUs of all types (-52% versus  2012) and 11 hPUs (19.6% of the total; - 67.6% versus 2012) were reported. In 2014, after the new hPU risk assessment tool was introduced, 39 PU of all types (-30.4% versus 2013) and 11 hPU (no change versus 2013; 28% of the total  PU) were recorded.
ØIn 2015 hPU reduced to 8 (-27.3% versus 2014). During the five-year initiative the number of PU of all types reduced by 67% and the number of hPU reduced by 84%.
Ø19 Grade 2 hPU were reported in 2014 and 2015. Of these 3 had initially been assessed as at risk from friction and shear injury. For 2/3, RCAs identified poor patient adherence to LFB; both patients were removing the LFB, interrupting the management of friction and shear

DISCUSSION:ØFriction at the skin surface can cause damaging shear stresses in dermis or muscle3 (Reger et al, 2010). Friction prevents the skin moving easily over a support surface while the patients’ body moves relative to it. This is known as static friction or “stiction”.

ØA patient moving on the bed or to the edge of a seat causes shear in soft tissue over bony prominences such as the heel. Profiling beds can increase friction and shearing when the sections move; the heels may drag 15-20cm across the bed surface9. Patients may develop skin damage from the movement of the heel on bed linen when pushing themselves up the bed or by involuntary repetitive movements and/or as a result of poor manual handling techniques.
ØUnresolved friction and shear are widely recognised as a factor in PU formation10-13. Managing and avoiding friction can protect deeper tissues from damage3, 5, 14. NICE recommends using friction-reducing products15
ØMost hPU reported in this initiative were pressure-related. In 2/3 shear-related hPU, RCA identified non-concordance with LFB as the primary cause and with the reduction in hPU in 2012 LFB appear to have contributed significantly to the reduction in hPU. These findings agree with a previous study on low friction garments16
ØAdditional factors including the education and training programme and the new RA tool contributed to the reduction in all PU and hPU.
ØThe cost savings estimated for the Trust arising from this initiative imply the potential for significant economic benefit for the NHS if a similar programme is widely adopted

CONCLUSION: Low friction materials included in a standard of care that includes management of pressure and moisture has the potential to minimise the risk of tissue damage and save costs. These outcomes from targeting friction and shear with LFB for hPU prevention indicate the potential benefits. The 84% reduction in hPU by 2015 and associated cost savings were achieved by an integrated pathway that included pressure relief, LFB, moisture management, nutrition, staff education and training, and a specific risk assessment tool.

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