Evaluating the Efficacy of a Uniquely Delivered Skin Protectant and Its Effect on the Formation of Sacral/Buttock Pressure Ulcer

  • Wed, 9/3/08 - 10:25am
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Author(s): 
Kimberly Clever, RN; Gloria Smith, RN; Carol Bowser, RN; and Kurt Monroe, MA, ABD

T he development of pressure ulcers is a common adverse occurrence in healthcare, affecting 2.3% to 28% of patients in long-term care (LTC) facilities.1 Although the highest prevalence (total number of people affected within the population at any time) is seen in LTC facilities, the highest incidence (number of people with new ulcers formed within a specific period of time) is in acute care.1 The perception that all pressure ulcers are a marker of poor care and neglect provokes litigation that mostly affects nursing homes.2,3 More than 75% of pressure ulcers represent superficial tissue damage (Stage I - 37% and Stage II - 39%).4 Almost half of all pressure ulcers form on the sacrum or ischium; patients over the age of 70 are affected the majority of the time.4

Once a pressure ulcer develops, longer hospitalization and more nursing time are required, resulting in higher costs.5 Pressure ulcers tracked across multiple healthcare settings cost, on average, between $1,119 and $10,185 to treat6 while the management of severe wounds may cost as much as $55,000.7 In the current decade, pressure ulcer prevention has become a national goal, as healthcare facilities seek to reduce pressure ulcer prevalence in nursing home residents from 16 per 1,000 residents (1997 baseline National Nursing Home Survey to 8 per 1,000 residents.8 More recently, the Centers for Medicare and Medicaid Services (CMS) have designated pressure ulcers as a quality measure in the Nursing Home Quality Initiative.

Risk factors that may compromise the ability of tissue to tolerate the forces of pressure, friction, or shear include: Age, mobility, nutrition, continence, concurrent disease, medication, and a history of previous pressure ulcer formation.5,10-12 Unfortunately, none of these risk factors operates independently. The presence of one factor often accompanies at least two others, making pressure ulcer prevention strategies complex and interrelated.9,11,13 Efforts to prevent pressure ulcers focus on managing the risk factors that are amiable to manipulation.

Urinary and fecal incontinence have been cited as risk factors, with fecal incontinence the better predictor of ulcer formation.9-13 Fecal incontinence provides an environment where physical and chemical trauma compromise the skin's normal barrier function, which compromises tissue integrity and increases a patient's chance of developing a pressure ulcer up to 22 times higher than continent patients.12 In addition, patients with incontinence require frequent cleansing of the perineal and buttock areas, which can dry the skin and alter its pH, especially when soap and water are used; thus, compromising the skin's ability to withstand physical and chemical trauma.14-20

Products designed to cleanse, moisturize, and protect the skin abound on the market in the form of sprays, foams, lotions, creams, and ointments. The Agency for Healthcare Research and Quality (AHRQ) developed a guideline in 1992 that advocates the use of protectant moisture barriers. However, the guideline was derived from usual practice and standards developed by professional organizations, not on research evidence.21 The Wound Ostomy and Continence Nurses Society (WOCN) has formed a Clinical Practice Committee that is currently developing four evidence-based wound guidelines; the second in the series will address pressure ulcers. This guideline is expected to be completed in 2003.

References: 

1. Cuddigan J, Berlowitz D, Ayello E. Pressure ulcers in America: prevalence, incidence and implications for the future. Advances in Skin and Wound Care. 2001;14(4):208-215.
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22. Food and Drug Administration, Department of Health and Human Services. 21 CFR Part 347 Skin Protectant Drug Products for Over-the-Counter Human Use; Diaper Rash Products; Proposed Rule. Federal Register 55(119), June 20, 1990.
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