Running Head: THE USE OF PREVENTATIVE DRESSINGS ON CRITICALLY ILL

PATIENTS

The Use of Preventative Dressings on Critically Ill Patients

By: Samantha Koens

Information Literacy to Support Academic Discourse

Julie Samms
THE USE OF PREVENTATIVE DRESSINGS ON CRITICALLY ILL PATIENTS 2

When first looking at pressure ulcers the most basic thinking is that they happen from

lying in one position for to long. In a normal healthy person the body repositions itself without us

even being aware in response to too much pressure for to long. In critically ill patients who are

sedated, have a decrease in sensation, perfusion problems, confusion, bedridden and other

common problems associated in the intensive care have an increased chance of developing

pressure sores. This topic is not only important for critical care nurses to consider but also nurses

in other practices because they may see patients who were previously discharged from critical

care that may still need pressure ulcer prevention strategies as they continue the healing process.

At St Josephs hospital in Bellingham Washington the skin protection program includes

the use of Mepilex dressings. In the Intensive Care unit, everyone who is admitted gets a

Mepilex dressing placed on their sacrum and other potential areas for skin breakdown. This is a

new practice just implemented in the last few years at this hospital. Before implementing the

dressings as a part of the skin breakdown prevention strategy a particular instance was seen

where preventative dressings could have been used was when a patient was critically ill and

requiring frequent repositioning. The patient was underweight which meant that they had boney

prominences that were at increased risk for breakdown. This patient did end up developing a

pressure ulcer on their sacrum, which in turn lead to an infection that was battled along with

trying to recover from pneumonia. With the use of a soft silicone dressing on admission along

with other pressure sore prevention techniques, we may have been able to prevent a pressure sore

on this patients sacrum.

While soft silicone dressings are a wonderful additive to a patients skin

prevention package we as nurses need to use our judgment as to which we are placing these

dressings on. While the research does suggest we place these dressings on every critically ill
THE USE OF PREVENTATIVE DRESSINGS ON CRITICALLY ILL PATIENTS 3

patient, from personal experience it has been found that placing a soft silicone dressing on a

patient that is incontinent can trap moisture under the dressing and cause irritation to the skin.

Special considerations need to be taken when creating a skin breakdown prevention program for

incontinent patients.

In classrooms nursing students are taught that the best way to prevent skin breakdown is

to reposition patients. Repositioning will always going to be one of the most important ways we

can prevent skin breakdown but there are other products that have been developed that if used in

conjunction with repositioning can provide even more benefit to our patients. Placement of

barrier dressings on critical care patients can prevent skin breakdown, which in turn decreases

instances of infection, and decreases healthcare costs. Evidence of prevention can be found in the

following articles.

Body

A systematic review on the use of prophylactic dressings to prevent pressure ulcers was

done in 2014 by Michael Clark and colleagues. Twenty-one articles were examined. Articles

suggested that using a dressing to prevent pressure ulcers were highly encouraged. When looking

in particular at the use of soft silicone dressings on the sacrum area the author found that there

was an improvement in prevention. The study states, a soft silicone foam dressing was applied

to the sacrum in trauma and critically ill patients, new pressure ulcers appeared in 3 of 161

whereas incidences were higher if no dressing was applied, 8 of 152 (Clark, 2014). The use of a

pressure dressing improves the outcomes of patients. By getting a pressure ulcer the patient is at

higher risk for infection and increase cost to the facility. The research found that the number one

pressure ulcer soft silicone dressing used in facilities is the Mepilex dressing.
THE USE OF PREVENTATIVE DRESSINGS ON CRITICALLY ILL PATIENTS 4

Joyce Black found in her research that after conducting a review of literature and finding

one prospective randomize control trial, three cohort studies, and two case series that a

recommendation is made for a five layer silicone bordered dressing such as Mepilex to prevent

skin breakdown (Black, 2014). The cost of preventing pressure ulcers on critical patients is

expensive but the cost the United States spends on pressure ulcers annually is estimated at 5-15

billion dollars annually (Black, 2014). The research examined patients that were high risk in the

ICU, ER, and OR and found that Mepilex five layer silicone border dressings applied to high risk

areas such as heels, elbows, and sacrum significantly lowers the chances of developing pressure

ulcers (Black, 2014). Joyce Black and colleagues recommend that Mepilex dressings be applied

to patients that are high risk, bed ridden, and immunocompromised. The article does mention that

the dressings have to be used in conjunction with other pressure reduction techniques such as

turning every two hours (Black, 2014). The study does not talk about the negatives in regards to

using the Mepilex dressing. They mildly suggest that these dressings may not work well with

incontinent patients but they do not go into much detail past that. Key considerations are given to

the fact that if these dressings are not applied correctly they will not do their job of protecting

skin (Black, 2014). According to the authors, choose a dressing that exceeds the area of tissue

that is at risk (Black, 2014). More research needs to be done on what types of patients we

should be placing the Mepilex dressings on but the research supports the use for prevention of

skin breakdown and cost reduction which is appealing to healthcare facilities that may not get

reimbursed for skin issues.

A similar study that supported the use of silicone dressings was a randomized control trial

that focused on 440 trauma and critically ill patients (Santamaria, 2015). The results stated that,

there were significantly fewer patients with pressure ulcers in the intervention group compared
THE USE OF PREVENTATIVE DRESSINGS ON CRITICALLY ILL PATIENTS 5

to the control group (Santamaria, 2015). The author states that there is a ten percent difference

in the incidence between the two groups (Sanatamaria, 2015). It is further emphasized that the

earlier the dressings are applied the better the outcomes were for patients (Santamaria, 2015). By

using the five-layer silicone dressings we can further prevent patients from getting pressure

ulcers. By using an inclusion criteria like the this research study for patients that should receive

Mepilex dressing we can eliminate patients who do not need them and place the on patients that

could benefit from a dressing. Patients that are at high risk for infection, that are already

compromised could benefit the most from receiving Mepilex.

A similar study that supported the use of pressure ulcer dressings was found in the

American journal of critical care. The authors did a study on three intensive care units on over

two hundred patients at risk for skin breakdown. Inclusion criteria into the study was the patient

had to have sepsis, be on a vasopressor, shock, MODS, Cardiac Arrest, or be going into a surgery

that would force them to be in the same position for several hours (Byrne 2016). According to

the research, the number of unit- acquired sacral pressure ulcers decreased by 3.4 to 7.6 per

1000 patient days depending on the unit (Byrne, 2016). The authors emphasize that the use of

an inclusion criteria to make sure that patients that are high risk are getting the pressure ulcer

dressings prevents them from being used on patients that do not need them (Byrne, 2016). Other

inclusion criteria include bed rest, expected stay >5 days, hemodynamic instability, diabetes,

mechanical ventilation, sedation, Braden score >12, history of vascular disease, malnutrition, and

hemodialysis (Byrne, 2016). This article supports the use of pressure dressings and the authors

state that, findings suggest that the dressing could decrease cost for institutions and improve

patient care, contributing to the body of knowledge about interventions to minimize the risk of

pressure ulcers (Byrne, 2016). Mepilex is shown to not only prevent pressure ulcers in high-risk
THE USE OF PREVENTATIVE DRESSINGS ON CRITICALLY ILL PATIENTS 6

patients but can also decrease healthcare costs to facilities. The important thing to remember

about these dressings is that they are a piece of the prevention strategy. They also need to be used

on certain patients. Education needs to done on the proper use of these dressings. The authors

talk about an instance where the dressing actually caused skin breakdown (Byrne, 2016). Jaime

and colleagues state that, a deep tissue injury was located on the patients left buttock that

resulted from pressure caused by the patient lying on a partially dislodged sacral dressing

(Byrne, 2016). This finding was particularly important because healthcare personnel need to be

checking the dressings constantly in order to maintain patency.

Peggy Kalowes, Valeria Messina, and Melani Li looked at soft silicone foam dressings in

critically ill patients. The findings were similar to other studies that this article has found. The

authors conducted a randomized controlled trial of 366 patients that were receiving pressure

ulcer prevention (Kalowes 2016). One hundred eighty four participants were selected to receive a

soft silicone dressing applied to their sacrum and the other one hundred eighty four were chosen

to participate in usual care (Kalowes, 2016). According to the study, the incidence rate of

hospital acquired pressure ulcers was significantly less in patients treated with the foam

dressings than in the control group (Kalowes, 2016). This study is more evidence that the use of

the soft silicone dressing otherwise called Mepilex can be used as a preventive measure for

critically ill patients.

A meta-analysis done by Simon Barrett looks specifically at the use of Mepilex and silver

alginate used together to help improve outcomes in high risk patients (Barrett, 2009). Mepilex ag

showed no growth of bacteria for up to forty eight hours after application (Barrett, 2009). This

raises the question about how often barrier dressings should be changed due to bacteria growth.

Barrett states that, the combined attributes of each component of this dressing allow both the
THE USE OF PREVENTATIVE DRESSINGS ON CRITICALLY ILL PATIENTS 7

control of pain and infection to be achieved simultaneously (Barrett, 2009). Simons study

further reiterates the point that even though these dressings are prophylactic in preventing skin

breakdown they need to be changed ever so often (Barrett, 2009). On further examination the

author of this article could not find an exact date of when to change the MEpilex dressings.

Further research will have to be done on when to change to best prevent the growth of bacteria.

Conclusion

On further examination of the previous articles, it was found that Mepilex dressings are

best practice in order to prevent skin breakdown when used in conjunction with other skin

breakdown methods. The use of Mepilex along with repositioning, specialty beds, and other

products greatly improves chances of not getting a pressure ulcers.

In the future, using Mepilex dressings as routine prevention in the skin care program is

something that could be implemented in a variety of healthcare settings. Using criteria when a

patient is admitted to find patients that are high risk and then placing preventative products on

and implementing repositioning on a regular basis may help reduce the number of pressure

ulcers. In turn nursing needs to look at patients and realize that some people do not need a

preventative dressing. Patients that are mobile, have normal sensation, and good perfusion would

not benefit from these dressings.

Because there is such a limited amount of articles out there that address the negatives

about the soft silicone dressings otherwise known as Mepilex the question that comes to mind is,

what are some of the problems with the Mepilex dressings? Further research needs to be done to

find out whether these dressings are compatible with everyone who is in critical care or if they

can pose some risk factors for certain patients. Research also needs to be done on how often

these dressings should be changed. Like anything else, having a preventative dressing on the skin
THE USE OF PREVENTATIVE DRESSINGS ON CRITICALLY ILL PATIENTS 8

for to long is a harbor for bacteria. No specific guidelines were found on how often to change the

dressings. When asking nurses in the Intensive Care unit when they think the dressings need to

be changed there was no definitive answer. Some nurses stated that the dressings should be

changed when they are visibly soiled, others would say every few days. In experience it was

found that some patients had a dressing that had been dated back one-week prior. How often do

we need to change these dressings?

The intensive care unit at St Josephs hospital has just in the past few years started

incorporating Mepilex dressings into their pressure ulcer prevention program. Looking into the

future it would be beneficial to patients to see a pressure ulcer prevention program with criteria

that would make patients eligble to get a prophylactic dressing placed if they need it. As

healthcare advances we find that we are constantly trying to find evidence based ways to

improve our practice. When looking at the prophylactic soft silicone dressings we need to

question when would we not use these dressings? The Research supports the use of the dressings

for pressure ulcer prevention but in personal experience they have been found to not benefit

incontinent patients. More research needs to be done to find when these dressing would not be

used for pressure ulcer prevention.

 THE USE OF PREVENTATIVE DRESSINGS ON CRITICALLY ILL PATIENTS 9

Citations

Black, Joyce, Michael Clark, Carol Dealey, Christopher T. Brindl, Paulo Alves, Nick Santamaria, and
Evan Call. Dressings as an Adjunct to Pressure Ulcer Prevention: Consensus Panel
Recommendations. International Wound Journal 12, no. 4 (August 2015): 48488.
doi:10.1111/iwj.12197.

Byrne, Jaime, Patricia Nichols, Marzena Sroczynski, Laurie Stelmaski, Molly Stetzer, Cynthia Line,
and Kristen Carlin. Prophylactic Sacral Dressing for Pressure Ulcer Prevention in High-Risk
Patients. American Journal Of Critical Care: An Official Publication, American Association Of
Critical-Care Nurses 25, no. 3 (May 2016): 22834. doi:10.4037/ajcc2016979.

Clark, Michael, Joyce Black, Paulo Alves, Ct Brindle, Evan Call, Carol Dealey, and Nick Santamaria.
Systematic Review of the Use of Prophylactic Dressings in the Prevention of Pressure Ulcers.
International Wound Journal 11, no. 5 (October 2014): 46071. doi:10.1111/iwj.12212.

Kalowes, Peggy. Five-Layered Soft Silicone Foam Dressing to Prevent Pressure Ulcers in the
Intensive Care Unit. American Journal of Critical Care 25, no. 6 (November 2016): E10819.
doi:10.4037/ajcc2016875.

Santamaria, Nick, Marie Gerdtz, Sarah Sage, Jane McCann, Amy Freeman, Theresa Vassiliou,
Stephanie De Vincentis, et al. A Randomised Controlled Trial of the Effectiveness of Soft
Silicone Multi-Layered Foam Dressings in the Prevention of Sacral and Heel Pressure Ulcers in
Trauma and Critically Ill Patients: The Border Trial. International Wound Journal 12, no. 3
(June 2015): 3028. doi:10.1111/iwj.12101.