- Thirty enrolled patients had existing pressure damage to their heels and this improved over 14 days using the low-friction bootees
- Low-friction bootees should be considered as part of routine pressure ulcer prevention practice in all settings
A small, non-controlled evaluation of low-friction bootees for the management of heel PU (hPU) was undertaken over a two week period in three different settings: a community intermediate care hospital, a residential care home and an acute stroke unit.
Initially, 30 patients were identified as being at high risk of developing a hPU. This was assessed clinically. Patients were also included if their heels had existing signs of pressure damage, blistering, non-blanching and blanching erythema, and category 2 ulceration.
Fifteen patients fully completed the evaluation over the period of 14 days. The mean age of participants was 86 years. The low-friction bootee was worn constantly whilst seated in bed and in chairs, and was only removed for hygiene care and heel checks.
During the evaluation, none of the patients were individually mobile. Due to a risk of falling, products were not worn to walk in and so patients who had to mobilize for rehabilitation in the community hospital removed the bootees for this activity.
All participants had pressure mapping and ultrasound of pedal pulses prior to and after evaluation by the tissue viability specialist nurse. Pressure mapping showed reduced peak heel pressures when the bootees were applied and, in the final review, reduced pain, increased comfort and ease of use, and reduced visual signs of heel damage. These results indicate that a standardized care pathway approach to heel protection, using low-friction heel bootees, is effective across all care settings for the prevention and reduction of heel pressure damage.
Despite the variety of products available, including boots, wedges, gel supports and mattresses, heel pressure ulcers are reported to be the most prevalent of hospital acquired PUs (VanGilder et al, 2008). Recently, Guest et al (2017) calculated that the NHS spends between £1400 and £8500 over 12 months on the treatment of a PU, depending on the severity.
Personal costs to the patient include discomfort, pain, decreased quality of life and limitations in mobility (Gorecki et al, 2010). Strategies that focus on preventing PUs benefit both the patient and the NHS and should take into account cost, effectiveness, comfort, choice and ease of application (Wilson, 2002). The heel is particularly vulnerable and this is due to the weight of the foot and leg, a thin layer of skin, the shape of the calcaneus and often a poor blood supply in higher risk patients (Langelmo, 2015).
Biomechanical research has demonstrated that tissue deformation can lead to cell death faster than hypoxia (Gefen & Weihs, 2016). The stretching and squashing caused by friction and shearing can cause this damage and static friction puts stresses under the skin surface even if using other devices (Gefen, 2017).
Due to a high incidence of reporting in heel PU, the Tissue Viability Lead nurse (AS) performed an evaluation of low friction fabric bootees (LFB: APA Parafricta, Bedford, UK), in the North Lincolnshire and Goole NHS Trust. The evaluation took place across three different settings: a residential home, intermediate care, and an acute stroke ward. This demonstrated the cycle of care and that the risk is present irrespective of the setting.
Enrolled patients were provided with LFB and these were used when the patients were sitting in a chair and in bed. Due to the risk of falls, they were not used when mobilizing.
The inclusion criteria were: patients aged >65 years, assessed at red risk level on the local Trust risk assessment tool (RA) which has a traffic light system of risk level. All patients in the red risk level, who had existing pressure damage to the heels in category 1-2, were selected. All were assessed as high risk using Doppler ultrasound and RA.
All patients had pressure mapping performed on their heels prior to intervention and once LFB were in place, both on the floor surfaces and on the bed. The XSENSOR ForeSiteTM pressure map (XSENSOR Technology Corporation, Calgary, Alberta, Canada), was used. The patients were evaluated over 14 days. Low friction bootees were removed for hygiene care and heel checks.
Fifteen patients completed the evaluation and are shown in Table 1. Fifteen patients were excluded due to: discharge from setting prior to completion; death; and enrolment criteria not met. One patient withdrew when their mobility was increased during rehabilitation. Wearing LFB when walking is not recommended as this increases the risk of falls.
Table 1. Existing support surfaces and heel pressure damage at enrolment
||Type of mattress
||Current heel prevention
|Residential care home (N=7)
||Static foam: 2
Powered hybrid: 1
Air alternating dynamic: 4
Offloading—1 patient had offloading boot to left heel
|Bed-bound & immobile: 4
Bed or chair: 3
|Blanching erythema: 1
Non-blanching erythema: 6
DTI: 1, offloading boot in place
|Community hospital (N=4)
||Static foam: 3
Powered hybrid: 1
|Offloading using pillow elevated on foot stool when sat in chair: 2
||Bed or chair: 4
Assisted walking: 3 (rehabilitation programme)
|Non-blanching erythema: 2
Category 2: 1
DTI with blister: 1
|Stroke ward at acute hospital (N=4)
||Powered hybrid: 1
Air alternating dynamic: 3
Repose wedge: 1
|All bed bound, unable to self-reposition
||Non-blanching erythema: 3
DTI with blistering: 1, using Repose wedge
After the application of LFB, pressure mapping showed reduced peak heel pressure (Table 2). When combined with an offload wedge, pressure was further reduced. One patient in residential care had a peak heel pressure on the bed of 104 mm Hg. After introducing LFB, this was reduced to 65 mm Hg. When a wedge was used as well, pressure reduced to 20 mm Hg.
Table 2. Pressure mapping of patients’ heels in bed and seated: representative patients
|Care setting and patient location
||Average/peak heel pressures:standard care
||Average/peak heel pressures: LFB
|Residential care home
Patient in bed, high-risk foam mattress
|Ave. 45 mm Hg
Peak 124 mm Hg, right heel
|Ave 27 mm Hg
Peak 79 mm Hg*
|Residential care home
Patient in bed, static foam mattress
|Ave. 28 mm Hg
Peak 104 mm Hg, right heel
|Ave. 23 mm Hg
Peak 65 mm Hg
|Community intermediate care hospital
Patient sitting in standard high seat chair in bedroom, heels on floor
|Ave. 63 mm Hg
Peak 195 mm Hg
|T=0: Ave. 44 mm Hg
Peak 112 mm Hg
T=10 mins post-application: Ave. 39 mm Hg
Peak 83 mm Hg
|Residential care home
Patient sitting in lounge chair with heels resting on floor
|Ave. 21 mm Hg
Peak 51 mm Hg, left heel
|Ave. 15 mm Hg
Peak 36 mm Hg
|Acute hospital stroke ward
Patient lying on powered hybrid mattress
|Ave. 42 mm Hg
Peak 214 mm Hg
|Ave. 34 mm Hg
Peak 99 mm Hg
|Acute hospital stroke ward
Patient lying on air-alternating dynamic mattress
|Ave. 24 mm Hg
Peak 78 mm Hg, right heel
|T=0: Ave. 29 mm Hg
Peak 49 mm Hg
T=10 mins post-application: Ave. 21 mm Hg
Peak 35 mm Hg
A patient on the stroke ward had a peak heel pressure of 214 mm Hg on a hybrid mattress. This was reduced to 99 mm Hg when LFB was applied. Another patient on the stroke ward had a peak heel pressure of 78 mm Hg on a dynamic mattress system. This was reduced to 35 mm Hg using LFB. In the community hospital, a patient had a heel pressure of 195 mm Hg when sitting in a chair with feet resting on the floor. With LFB, this was reduced to 83 mm Hg.
All signs of pressure damage resolved within seven days (Table 3, Figure 1). During the 14 day period, no further damage occurred. Patient ease of application and comfort scored highly and all patients were adherent.
Table 3. Evaluation of heels at day 14 for 15 patients in low-friction bootees, all 3 settings
|Performance rating of LFB 1=poor, 4=excellent
||Appearance of skin at end of treatment
||Patient, carer, health professional view on LFB
|14 patients rated as 'excellent' (score=4)
1 patient rated as 'good' (score=3)
|All non-blanching & blanching erythema fully resolved to normal intact skin after 3–4 days
1 DTI* resolved after 7 days
2 blistered DTIs reduced in size, reabsorbed dry and intact
|All responses were for bootees to be continued as a treatment due to ease of use, comfort factor and positive results. Patient adherence was not an issue
Figure 1. Clinical and pressure mapping outcomes for one representative patient
15 patients completed the evaluation (Table 1). 15 patients were excluded because of deaths; discharges from the settings prior to completion; enrolment criteria not met. 1 patient withdrew when their rehabilitation programme increased their mobility. Walking wearing LFB is not recommended; doing so may present a falls risk. Pressure mapping (Table 2) showed reduced peak heel pressure after application of the LFB. Pressure reduced further in combination with an offloading wedge. One patient in residential care had peak heel pressure on the bed of 104mm Hg, reduced to 65 mm Hg after introducing LFB. Pressure reduced further to 20mm Hg when a wedge was also used. A patient on the stroke ward had peak heel pressures of 214 mm Hg on a hybrid mattress, reduced to 99mm Hg with LFB applied. On the same ward a patient on a dynamic mattress system had peak heel pressure of 78mm Hg which reduced to 35mm Hg. In the community hospital a patient sitting in a chair with feet resting on the floor had heel pressure of 195 mm Hg, reduced to 83 mm Hg with LFB. All signs of pressure damage resolved within 7 days (Table 3, Figure 1). No further damage occurred in the 14 day period. Patient comfort and ease of application scored highly. All patients were adherent.
The double layer of the low friction fabric in the bootee provides a micromovement which alleviates the microcirculation of pressure in the heels. If a person is lying in bed, static frictional forces occur if the patient is moved because the heels travel with gravity. This distorts the skin, cells and internal heel structure. This can be minimized using low friction fabric. (Gefen, 2017)
The heel tissue needs to be protected but a balance is required between alleviating tissue deformations in a sustainable manner and allowing the rest of the body to move freely. Patients do not always accept offloading heel boots or gel pads.
Standard care should always be applied with correct support surfaces and heel offloading if at risk of pressure damage. As shown in this evaluation, the addition of low friction fabric further reduces stresses to the heel. The microenvironment is crucial and the bootee is lightweight and breathable for patient comfort, resulting in a high compliance rate.
The use of low friction fabrics in routine practice for patients at high risk of heel ulceration adds benefit to standard care strategies. The patient journey through care settings requires a multidisciplinary approach in order to minimize the risk and the implementation of easy to use but effective measures that can continue regardless of where the care is delivered.
- Gefen A. Why is the heel particularly vulnerable to pressure ulcers? Br J Nurs. 2017;26(Suppl 20):S62–S74;
- Gefen A, Weihs D. Cytoskeleton and plasma-membrane damage resulting from exposure to sustained deformations: a review of the mechanobiology of chronic wounds. Med Eng Phys. 2016;38(9):828–833;
- Gorecki C et al. Development of a conceptual framework of health-related quality of life in pressure ulcers: a patient-focused approach. Int J Nurs Stud. 2010;47(12):1525–1534;
- Guest JF et al. Health economic burden that different wound types impose on the UK’s National Health Service. Int Wound J. 2017;14(2):322–330;
- Langelmo D. Heel pressure ulcers: 2014 International Pressure Ulcer Prevention & Treatment Guidelines. February 2015. http://tinyurl.com/y7q542b8 (accessed 22 May 2018);
- VanGilder C et al. Results of nine international pressure ulcer prevalence surveys: 1989 to 2005. Ostomy Wound Manage. 2008;54(2):40–54;
- Wilson A. Prevention of heel pressure ulcers in an orthopaedic unit. Nurs Times. 2002;98(25):53–54
Produced from materials originally authored by Alison Schofield, Tissue Viability Service Lead and Trust Quality Pressure Ulcer Prevention Lead, North Lincolnshire and Goole NHS Foundation Trust.
APA Parafricta Ltd’s range of Parafricta®-branded medical garments and bedding have been clinically proven to offer protection to fragile skin from the damaging effects of friction, which can lead to painful skin breakdown and ulceration (medically known as “pressure” or decubitus ulcers and commonly known as “bedsores”). The products can also ease movement in bed for patients with impaired mobility.
Parafricta® medical products are expertly designed to be easy to use and apply to the areas most at risk of skin damage and ulceration. They are washable and reusable. Bootees are used to protect the vulnerable heel area and undergarments to protect the lower back and buttocks. Parafricta® bedding offers greater ease of movement and comfort to patients whilst in bed, including for patient suffering other fragile skin conditions (e.g. premature babies and burns patients).
Parafricta® medical products incorporate proprietary ultra-low friction fabrics to protect patient skin. Friction can cause skin to stick to surfaces on sheets and mattresses which leads to jolting or wrenching and damages the skin’s structure and integrity. Parafricta® ultra-low friction fabrics move much more freely and smoothly over skin and the underlying surface. The technology employed in Parafricta® products is covered by granted and pending patents (for example European Patent EP1 641420 B1).
Published research has demonstrated that use of Parafricta® garments can reduce the cost of treating skin damage by £63,000 per 100 at risk patients. Elimination of “pressure” ulcers is a key objective of the NHS’s Harm-Free Care agenda and the new Clinical Commissioning Groups in England are incentivising successful reduction in the prevalence of skin damage with extra payments to providers of acute and community care.
Parafricta technology has other potential applications in the non-medical arena such as sportswear and consumer products. Please contact Parafricta if you have a non-medical enquiry.
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