Campbell Noreen A, Campbell Donna L, Turner Andrea
Ostomy Wound Manage. 2015 Nov;61(11):44-52.
Offloading heel ulcers is a challenging task because strategies deemed to be most optimal from a medical perspective may be unacceptable to patients. Observed adverse dressing events and problems with offloading devices led to a pilot study and subsequent change in practice at the authors' Foot and Leg Ulcer Clinic. Starting in 2004, patients requiring offloading received a nonremovable padded heel dressing (PHD) that was changed twice a week by the visiting nurse. A retrospective quality improvement review was conducted to compare outcomes, nursing visits, and nursing visit costs for 40 consecutive patients with heel ulcers treated at this clinic with a nonremovable PHD (n = 20) or without a PHD (n = 20) between January 20, 2001 and December 31, 2006. Patient demographic data, relevant comorbidities, wound depth, weeks of care, adverse events, and treatment-related narrative comments were abstracted from patient records. Relevant comorbidities were similar in both groups. The PHD group was younger (average age of 74.6 [range 35-91] years) compared to PHD nonuse group (average age 79.5 [range 25-95] years; P less than 0.04). The PHD group required fewer total weeks of care compared to the nonuse group (368 versus 527 weeks, respectively; P less than 0.001), and average duration of clinic treatment in the PHD group was 18.40 (range 5-51) weeks versus 40.54 (range 6-88) weeks in the nonuse group. The PHD group had fewer total nursing visits (736 versus 1,581, P less than 0.001); the average number of nursing visits for the PHD was 36.80 (range 10-102) compared to 121.61 (range 18-264) for the nonuse group. Nursing visit costs were lower for PHD users ($114,080 versus $245,055, P less than 0.001), and the cost-efficiency ratio was less than one third (1:3.3) of PHD nonuse for the average heel ulcer. All 20 patients in the PHD use group had wound closure compared with the PHD nonuse group, in which 13 out of 20 wounds closed, 3 amputations were performed, and 4 patients were lost to review (P less than 0.000). No adverse events were reported in the records of the PHD use group; the PHD nonuse group reported periwound maceration, skin stripping, pressure injury, and sensitivity. Patient and nurse feedback identified pain relief, improved mobility, easy technique, low cost, and reduced workload as benefits of PHD. The results of this quality improvement review warrant a prospective clinical study to examine the efficacy, effectiveness, and cost-effectiveness of PHD for the care of patients with heel ulcers.
减轻足跟溃疡的压力是一项具有挑战性的任务，因为从医学角度来看被认为最优化的策略可能不为患者所接受。观察到的不良敷料事件和减压装置问题促使作者所在的足腿溃疡诊所开展了一项试点研究，并随后改变了实践方法。从2004年开始，需要减压的患者接受了一种不可拆卸的足跟软垫敷料（PHD），访视护士每周更换两次。进行了一项回顾性质量改进评估，以比较2001年1月20日至2006年12月31日期间在该诊所连续治疗的40例足跟溃疡患者使用不可拆卸PHD（n = 20）或未使用PHD（n = 20）的治疗结果、护理访视次数和护理访视成本。从患者记录中提取患者人口统计学数据、相关合并症、伤口深度、护理周数、不良事件以及与治疗相关的叙述性评论。两组的相关合并症相似。与未使用PHD组（平均年龄79.5岁[范围25 - 95岁]）相比，使用PHD组患者更年轻（平均年龄74.6岁[范围35 - 91岁]；P小于0.04）。与未使用组相比，使用PHD组所需的总护理周数更少（分别为368周和527周；P小于0.001），使用PHD组的门诊治疗平均时长为18.40周（范围5 - 51周），而未使用组为40.54周（范围6 - 88周）。使用PHD组的总护理访视次数更少（736次对1581次，P小于0.001）；使用PHD组的护理访视平均次数为36.80次（范围10 - 102次），而未使用组为121.61次（范围18 - 264次）。使用PHD患者的护理访视成本更低（114,080美元对245,055美元，P小于0.001），平均足跟溃疡的成本效益比不到未使用PHD的三分之一（1:3.3）。使用PHD组的20例患者伤口均愈合，而未使用PHD组中，20处伤口有13处愈合，进行了3次截肢手术，4例患者失访（P小于0.000）。使用PHD组的记录中未报告不良事件；未使用PHD组报告了伤口周围浸渍、皮肤剥脱、压力性损伤和敏感性问题。患者和护士的反馈表明，PHD的益处包括缓解疼痛、改善活动能力、操作简便、成本低以及减轻工作量。这项质量改进评估的结果值得开展一项前瞻性临床研究，以检验PHD治疗足跟溃疡患者的疗效、有效性和成本效益。
