Elizabeth I Helvig, MS, RN, CWOCN
This study grew out of a personal experience with a heel injury that developed during a brief surgical hospitalization, resulting in heel pain upon pressure that persisted for about eight months. I was curious about the chronic nature of pressure injury, leading me to wonder about the prevalence of heel injuries in at-risk geriatric medical patients.
The objective was to examine the usefulness of high-frequency ultrasound (HFU) to detect heel pressure injury in geriatric medical patients, to compare the prevalence rates of visualized pressure ulcers with the prevalence of hidden injury, and to determine if HFU could assist in predicting the development of heel pressure injury. I had three questions:
- What is the prevalence of clinically detectable heel pressure ulcers in an in-patient population of geriatric medicine patients, with a Braden score of 10-17, who have been hospitalized 28 days or less?
- What is the prevalence of heel injuries detectable by high-frequency ultrasound but without clinical signs of pressure injury in this same population?
- Can high-frequency ultrasound predict the development of clinically undetectable to clinically detectable pressure ulcers over a two to seven-day period?
Through monthly prevalence surveys conducted over 13 months, we assessed the heels of 520 patients who met the above criteria, finding 38 with heel pressure ulcers for a prevalence rate of 7.3 percent. One hundred of these 520 patients who consented and underwent a minimum of two heel ultrasounds at two-day intervals after the prevalence study made up the research sample. Scans were interpreted as normal, borderline, or abnormal. Ten (10.1 percent) of the 100 patients had normal ultrasound scans of both heels at baseline. The majority of scans were not normal. Eighteen (18.2 percent) patients had abnormal scans of both heels and 23 (23.2 percent) had an abnormal and borderline scan. Not enough visible pressure ulcers developed in the research population to answer the third question. A statistical correlation did not exist between abnormal scans and length of hospital stay or other associated factors, however the Braden friction/shear score showed a statistically significant relationship to injury in the right foot across time.
This study required huge support from the Departments of Nursing and Nursing Research at Rochester General Hospital. A Nursing Research Fellowship program led by Kathryn Gardner, PhD, RN provided a venue for exploring this clinical question. Thank you to the WOCN Center for Clinical Investigation for feedback to hone the research question and to the WOCN membership for the Members' Research Grant that helped pay for research assistants and data analysis.
The most enjoyable component of this research was working closely with dedicated research assistants Mary Beth Hanrahan, RN, CWON and Laurie VanDerMeid, RN, CCRN who arranged their lives around data collection for a year. Thank you to Cheryl Royce, RN, CWON for covering clinical consultation on research days. Karen Zulkowski, DNS, RN from Montana taught me to interpret ultrasound heel scans and helped me assign interpretation to over 1,000 sets of scans. I appreciate the hours of coaching, encouragement and data analysis that our hospital research nurse scientist, Lynn Nichols, PhD, RN, dedicated to this project.
One of the things I learned about the research process from doing this study was to keep notes on when and why changes were made which simplified the task of writing the manuscript. A second lesson was that having my research critiqued by two or three experienced nurse
researchers helped me to formulate my ideas and process better, and working with conscientious research assistants helped me share struggles and delights. I highly recommend participating in research so you too can be delighted at where the journey takes you!