Hydrocellular Foam Versus Hydrocolloid Plate in the Prevention of Pressure Injuries

Introduction. Pressure injury is one of the most prevalent skin injuries and a great challenge in the hospital environment. The implementation of preventive measures contributes to reducing its occurrence. Objective. This study compares the protective effect of 2 adhesive dressings used in the prevention of pressure injuries in at-risk patients. Materials and Methods. This case series was conducted at a university hospital in southeastern Brazil with 80 hospitalized adult patients at risk for pressure injuries, as per the Braden Scale for Predicting Pressure Sore Risk. Patients were randomized to preventive intervention with either hydrocellular foam (n = 40) or hydrocolloid plate (n = 40) dressing, which was applied to the intact skin over the sacrum and trochanters and changed weekly over 8 weeks. Results. Of the patients, 56.5% were women, 64.5% were 60 years of age or older, 58.1% were admitted to an intensive care unit, and 63.9% were at high risk for pressure injuries. None of the patients developed a pressure injury. However, the presence of blanchable erythema, desquamation, pruritus, discomfort during dressing removal, and skin damage caused by the strong adhesiveness of the dressings were observed in both groups. In the hydrocolloid plate group, patients reported significantly more discomfort during dressing removal due to its strong adhesion to the skin (P = .004) than those in the hydrocellular foam group. Conclusions. Standard preventive measures combined with the use of either hydrocellular foam or hydrocolloid plate contributed to the prevention of pressure injuries in at-risk patients, with hydrocolloid plate being associated with significantly more discomfort during dressing removal.

Early Detection of Pressure Injury Using a Forensic Alternate Light Source

Pressure Injury Prevention Practices in the Intensive Care Unit: Real-world Data Captured by a Wearable Patient Sensor

Introduction

Pressure injury is defined as a skin damage usually located over a bony prominence or under a medical or another device that occurs as a result of pressure or pressure in combination with shear.¹ It is a serious complication caused by multiple factors that has an important social and economic impact, negatively affecting a patient’s quality of life.^2-4 In the United States, the estimated cost of pressure injury treatment for the health care system is about $11 billion annually.⁵ Pressure injury is the second most prevalent lesion in the hospital environment.⁶ The incidence of pressure injuries ranges from 0.4% to 39.8%, and its prevalence ranges from 10% to 18% worldwide, with intensive care units (ICUs) showing the highest incidence rates.^6-9

International organizations focused on the study of skin injuries consider the early identification of the at-risk population, continuous assessment of the skin, and development and implementation of preventive measures to be the main pillars in preventing these injuries.¹⁰ Given the major impact of pressure injuries, other preventive alternatives have been developed, such as the use of topical agents and prophylactic dressings.^11-14 Several studies^14-20 on the use of essential fatty acids, foams, barrier creams, hydrocolloids, transparent films, and dressings containing ceramide 2, among others, to prevent pressure injuries are found in the literature.

Hydrocolloid and foam dressings have physical properties that help prevent pressure injuries.²¹ Modeling studies^21,22 showed these dressing materials redistribute mechanical forces, such as pressure, shear, and friction. Investigations using animal and human models also have identified the protective effects of prophylactic dressings applied to regions at risk for developing pressure injuries.^18,23,24 Another study²⁵ found foam dressings, in addition to preventing pressure injuries, have a protective effect against excessive moisture when applied to the sacral region. Other authors^26,27 also observed a reduction in the incidence of pressure injuries in ICUs after the implementation of standard preventive measures, training of the nursing team, and the application of silicone foam dressings in the sacral region. However, despite their use in clinical practice, few studies have assessed the efficacy of these products in Brazil.

Thus, the aim of this study was to compare the protective effect of hydrocellular foam and hydrocolloid plate dressings on the prevention of pressure injuries in at-risk patients.

Materials and Methods

This single-center case series was approved by the Research Ethics Committee of the Federal University of São Paulo (approval no. 0662/10; São Paulo, Brazil), authorized by the study institution, and performed in accordance with the ethical standards of the Declaration of Helsinki (1964) and its subsequent amendments. The study was conducted from April 2012 to July 2013 in a university hospital in São Paulo (Brazil) with patients admitted to hospital wards, ICUs, and semi-intensive care units (SICUs). Written informed consent was obtained from all patients or their representatives prior to their inclusion in the study; patient anonymity was assured.

The first skin assessment was conducted at hospital admission and those who met eligibility criteria were included in the study.

The sample size (n = 80) was defined based on the supply of hydrocellular foam and hydrocolloid plate dressings available for the study. Thus, 80 hospitalized adult patients at risk for pressure injuries, according to the Braden Scale for Predicting Pressure Sore Risk (Braden Scale),²⁸ who had intact skin over the sacrum and trochanters randomly were selected to participate in the study.

Patients with scars, changes in skin color, or desquamation in the sacral and trochanteric regions were not included in the study. Patients who died and those discharged from the hospital or transferred to other institutions before the second skin assessment (ie, before the first dressing change) were removed from the sample.

Because the use of prophylactic dressings in the prevention of pressure injuries is supported by the literature,^10,14,27,29 the Institutional Ethics Committee considered that a control group receiving standard preventive care alone without the use of prophylactic dressings would represent an unnecessary risk of harm to a cohort of frail patients.

Patients were randomly allocated to 2 groups and received preventive intervention with either hydrocellular foam (foam group; n = 40) or hydrocolloid plate (hydrocolloid group; n = 40) applied to the intact skin over the sacrum and trochanters. The allocation sequence was generated using a computer-generated randomization chart (www.randomization.com). The patients and nursing team were blinded to group assignment until the moment of intervention.

Dressings were changed weekly or when they became damp, loosened, or soiled. Patients remained in the study while at risk for pressure injury until the end of the 8-week study period or the development of pressure injury in the sacral or trochanteric region.

Data collection
Two instruments were used for data collection: a questionnaire assessing patients’ sociodemographic and clinical characteristics, level of risk for pressure injury, and presence of risk factors and the Braden Scale.²⁸

A 2-part questionnaire was created for data collection. The first part assessed sociodemographic characteristics (eg, sex, age, marital status, and level of education) and clinical characteristics (eg, reason for hospitalization, medical conditions, use of medications, smoking history, and allergies) of patients at the beginning of the study. The second part of the instrument was used at all patient assessments to record the level of risk for pressure injury development, according to the Braden Scale, and presence of risk factors, such as level of consciousness, mobility, changes in vital signs, prolonged fasting, fecal or urinary incontinence, and use of mechanical ventilation, sedatives, and vasoactive drugs. Changes in color, texture, and integrity of the skin also were recorded.

Skin assessments were performed weekly at every dressing change (after dressing removal) by the study investigators, who are experienced in pressure injury management. The investigators were not blinded to group assignment because patient assessments were conducted simultaneously to dressing changes. Alterations in skin color, such as the occurrence of reddish/purplish spots, were evaluated and classified as either stage 1 (nonblanchable) pressure injuries or blanchable erythema. Skin texture was assessed by palpating the skin area protected by the dressings to detect tender and hardened regions. Skin integrity was evaluated by visual inspection for the presence or absence of desquamation, maceration, and rupture of the skin. In cases of desquamation, the skin was examined for the presence or absence of dermis exposure to differentiate a stage 2 pressure injury from a superficial skin flaking caused by the use of the prophylactic dressing. Skin ruptures were assessed using the National Pressure Ulcer Advisory Panel (NPUAP) guidelines to distinguish pressure injuries from other lesions.¹

The Braden Scale is a pressure injury risk assessment tool composed of 6 subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.²⁸ The sum of ratings on the subscales gives a total score (possible range, 6–23), which indicates the level of risk as follows: 19 to 23 = no risk, 15 to 18 = at risk, 13 to 14 = moderate risk, 10 to 12 = high risk, and 9 or below = very high risk for pressure injury.³⁰ The Braden Scale was applied at all patient assessments.

Prophylactic dressings
Hydrocellular foam (Allevyn Adhesive; Smith & Nephew, Hull, United Kingdom) is a hydrophilic polyurethane dressing composed of a triple-layer structure, having a nonadherent, nonsilicone-based skin-contacting layer, an intermediate absorbent layer of hydrophilic polyurethane foam, and an outer layer of polyurethane adhesive film, which adheres to the surrounding skin.²⁹ The pads of hydrocellular foam dressing used in the study had square shapes (12.5 cm x 12.5 cm and 17.5 cm x 17.5 cm).

Hydrocolloid plates (DuoDERM CGF; ConvaTec, Deeside, UK) are composed of carboxymethylcellulose, gelatin, and pectin with a thin outer layer impermeable to contaminants; the dressings had square shapes (10 cm x 10 cm and 15 cm x 15 cm).³¹

The size of the dressings was chosen according to the size of the area to be covered and patient size. Both dressings were water resistant, served as a bacterial barrier, allowed gas exchanges, and provided protection against excessive pressure, friction, and shear.^21-23

Preventive interventions
Preventive interventions followed the study institution’s prevention protocol for pressure injuries, which is based on the European Pressure Ulcer Advisory Panel (EPUAP) and NPUAP guidelines,¹⁰ and included repositioning of bedridden patients every 2 hours, use of viscoelastic foam mattresses, skin moisturizing with emollients once daily, frequent diaper monitoring and change, care of urine collection devices, heel elevation by cushions, and use of industrialized enteral formulas for patients on enteral nutrition. Members of the nursing team received updated information on prevention of pressure injuries 4 months prior to data collection and were encouraged to participate in the institution’s online permanent education program, which has a module for prevention and treatment of pressure injuries.

Statistical analysis
Data were entered into an Excel spreadsheet (Microsoft Corporation, Redwood, WA) and SPSS for Windows, version 20.2 (IBM Corp, Armonk, NY), was used for data analysis.

Intention-to-treat analysis was carried out using the last assessment information for patients with missing data (last observation carried forward). Only patients who died and those discharged from the hospital or transferred to other institutions before the second skin assessment (ie, before the first dressing change) were removed from the sample.

Student’s t test, a chi-square test, the Mann-Whitney U test, and the Kolmogorov-Smirnov test were used for comparisons between groups. All statistical tests were performed at a significance level of α = 0.05 (P < .05).

Results

Of the 80 patients selected for the study, 18 were excluded from the sample because they were discharged from the hospital or died before the second skin assessment (ie, before the first dressing change). Sixty-two patients remained in the study, with 31 in the foam group and 31 in the hydrocolloid group.

At the beginning of the study, 36 (58.1%) patients were admitted to ICUs, 8 (12.9%) were admitted to SICUs, and 18 (29.0%) to inpatient wards. Three (4.8%) patients completed the 8-week study period and 59 (95.2%) remained in the study from 6 to 50 days (mean, 17.9 days) until hospital discharge (n = 23; 37.1%), showing skin alterations (n = 17; 27.4%), death (n = 10; 16.1%), or showing no risk for pressure injury according to the Braden Scale (n = 9; 14.5%).

Among the 62 patients, 35 (56.5%) were women and 40 (64.5%) were 60 years of age or older (mean, 62.2 years) (Table 1). Regarding clinical characteristics, 14 (22.6%) patients were hospitalized due to respiratory problems, 10 (16.1%) due to changes in consciousness level, 27 (43.5%) received mechanical ventilation, 18 (29.0%) were on continuous sedation, and 10 (16.1%) received vasoactive drugs at some point in the study. In addition, 29 (46.8%) patients had both fecal and urinary incontinence and only 1 (1.6%) patient remained continent during the entire study period. With regard to medical conditions, 31 (50.0%) patients had cardiovascular diseases, 17 (27.4%) had nervous system diseases, and 16 (25.8%) had respiratory diseases, with arterial hypertension (n = 31; 50.0%) and diabetes mellitus (n = 12; 19.4%) being the most prevalent. The medications most used at admission were antihypertensive drugs (n = 22; 35.5%). According to the Braden Scale scores, 3 (4.8%) patients were at low risk, 19 (30.7%) at moderate risk, 39 (62.9%) at high risk, and 1 (1.6%) was at a very high risk for pressure injury development at admission (Table 2).

The groups were comparable with regard to all variables, except age (P = .030), with patients in the foam group having a mean age of 67.4 years, which was higher than that of patients in the hydrocolloid group (mean age, 57.1 years).

In both groups, prophylactic dressings were changed every 5 to 8 days. The participants received between 1 and 11 dressing changes, proportional to the length of time the patient remained in the study. No significant difference in the number of dressing changes was found between groups.

None of the patients in either group developed a pressure injury. However, alterations in the skin, such as blanchable erythema (n = 19; 30.6%), desquamation (n = 28; 45.2%), pruritus (n = 7; 11.3%), and skin damage caused by the strong adhesion between the dressing and the skin (n = 14; 22.6%) were observed in the sacral and trochanteric regions in both groups, with no significant differences between groups (Table 3). No significant differences in skin alterations and medical adhesive-related skin injuries were found between severely ill and not severely ill patients. Fifteen patients in the hydrocolloid group and 4 patients in the foam group complained of discomfort or pain during dressing removal due to the strong adhesiveness of the dressings, with a significant difference (P = .004) between groups (Table 3).

Discussion

Pressure injuries are present in all health institutions, affect individuals of all ages, are associated with prolonged treatment time and high treatment costs, and cause great suffering to the patients and their families.^2-4,32 Most pressure injuries are preventable, though preventive measures require time and trained personnel for patient care. The development of new techniques and technologies is of fundamental importance to aid in the prevention of these injuries.^10-14,33 The use of prophylactic dressings in areas of risk for pressure injury development exerts a protective effect by reducing shear and friction forces, forming a barrier against excessive moisture, and acting in the redistribution of pressure.^{10,21-23,25,32} However, only a few studies address the efficacy of prophylactic dressings in the prevention of pressure injuries.^18,34-36

The use of a prevention protocol for pressure injuries, based on the EPUAP/NPUAP guidelines, combined with the application of hydrocellular foam or hydrocolloid plate dressings in regions at risk for pressure injury development provided adequate skin protection. This is in agreement with the findings of a previous meta-analysis,²⁴ which indicated the use of standard preventive measures combined with the application of dressings in regions at risk for pressure injuries is more effective than the use of standard preventive measures alone, such as early identification of the at-risk population, skin examination, maintenance of adequate nutrition and hydration, use of support surfaces, regular repositioning, and skin care.^10,24

In this study, most patients were older women (≥ 60 years), had urinary or fecal incontinence, and were at high risk for pressure injuries, according to the Braden Scale. This patient profile is similar to those found in other studies on the use of hydrocellular foam applied to the intact skin over the sacral region to prevent pressure injuries.^26,36,37 Severely ill patients receiving mechanical ventilation, vasoactive drugs, or sedatives are at a high risk of developing pressure injuries. However, in the present study, no significant differences in skin alterations and medical adhesive-related skin injuries were found between severely ill and not severely ill patients.

No patient developed pressure injuries in the sacral and trochanteric regions, although patients in both groups were at risk for pressure injuries. In a Cochrane review, Moore and Webster³⁸ observed the incidence of pressure injuries reduced with the use of prophylactic dressings or essential fatty acids, although the quality of the included trials were questioned in the study. Nakagami et al¹⁸ verified the effectiveness of a hydrocolloid dressing containing ceramide 2 by randomly applying the dressing on the right or left trochanteric region of bedridden older patients (n = 37) and using the contralateral side as a control. Though a study by Cortés et al³⁹ (n = 170) showed standard preventive care was more effective in preventing pressure injuries than the use of a hydrocolloid plaque in regions at risk.³⁹ Santamaria et al³⁶ assessed the impact of hydrocolloid and foam dressings on the prevention of pressure injuries in critically ill patients (n = 90) and reported that none of the patients in the foam dressing group developed pressure injuries, whereas 13.3% of patients in the hydrocolloid dressing group and 23.3% in the control group developed stage 1 and 2 pressure injuries.

Other authors^25,35,37,40 have reported the positive effect of foam dressings on the prevention of pressure injuries in at-risk patients. Jing et al³⁴observed that spinal surgery patients (n = 100) who received foam dressings combined with transparent film on vulnerable skin areas developed fewer pressure injuries than the control group (P = .05). In a sample of 100 patients who underwent cardiac surgery, Brindle and Wegelin³⁸ found that controls had a 3.6-fold greater chance of developing pressure injuries than those who received foam dressings in the sacral region. Park²⁵ assessed 102 patients in ICUs with intact skin over the sacral region and discovered the use of foam dressings reduced the development of pressure injuries (P < .033) and incontinence-associated dermatitis (P < .001) in the study group compared with the control group. Similar results were found by Walker et al,⁴⁰ who reported the development of only 3 stage 1 pressure injuries with the use of a silicone foam preventive dressing in the sacral region of 80 at-risk patients.

In this study, alterations in the skin, such as blanchable erythema, desquamation, pruritus, skin damage, and discomfort during dressing removal were observed due to the strong adhesion of both dressings to the skin. The results were similar in both groups, but the frequency of complaints of discomfort and presence of pain during dressing removal was significantly greater in the hydrocolloid group than that in the foam group.

Limitations

The major limitations of the study were the small sample size and lack of control group receiving standard preventive care alone. This is an initial investigation that may advance the understanding of prevention of pressure injuries in at-risk patients. Further studies with a larger number of patients are necessary to compare different age groups, clinical situations, and vulnerable skin areas.

Conclusion

Standard preventive measures combined with the use of either hydrocellular foam or hydrocolloid plate dressings contributed to the prevention of pressure injuries in at-risk patients. Although none of the patients in both groups developed a pressure injury, alterations in the skin, such as blanchable erythema, desquamation, pruritus, and skin damage caused by the strong adhesion between the prophylactic dressing and the skin were observed in the sacral and trochanteric regions in both groups, with no significant differences between groups. However, hydrocolloid plate was associated with significantly more discomfort and pain during dressing removal.

Acknowledgments

Authors: Fabiana da Silva Augusto, MS, RN¹; Leila Blanes, PhD, RN²; Paula Zhao Xiao Ping, RN³; Celina Mayumi Morita Saito, MS, RN⁴; and Lydia Masako Ferreira, PhD, MD⁵

Affiliations: ¹Graduate Student, Graduate Program in Translational Surgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil; ²Adviser and Vice-coordinator, Graduate Program in Science, Technology and Management Applied to Tissue Regeneration; and Deputy Director of Nursing, São Paulo Hospital, UNIFESP; ³Intensive Care Unit, São Paulo Hospital, UNIFESP, São Paulo, Brazil; ⁴Nurse Manager, São Paulo Hospital, UNIFESP; and ⁵Full Professor, Division of Plastic Surgery, Department of Surgery, UNIFESP

Correspondence: Fabiana da Silva Augusto, MS, RN, Division of Plastic Surgery, UNIFESP, Rua Botucatu 740, 2o. andar, CEP 04023-062 São Paulo, SP, Brazil; fabianasaugusto@gmail.com

Disclosure: Financial support for this study was provided by Smith & Nephew, Inc (Hull, United Kingdom). The sponsors had no involvement in the study design; in the collection, analysis, and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication. All authors disclose that no competing financial interests exist.

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