WCET Journal. An Association of Nurses ISSN

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1 World Council of Enterostomal Therapists Journal WCET Journal An Association of Nurses ISSN Reprinted with permission of the World Council of Enterostomal Therapists and Cambridge Publishing Reprint: Outliers to the Braden Scale: Identifying high-risk ICU patients and the results of prophylactic dressing use C Tod Brindle This article is taken from Volume 30 Number 1 January/March 2010

2 Outliers to the Braden Scale: Identifying highrisk ICU patients and the results of prophylactic dressing use C Tod Brindle BSN RN ET CWOCN Clinical Nurse IV, Virginia Commonwealth University Medical Center, Wound Care Team 1201 E Marshall Street, Richmond, Virginia, USA Phone: Fax: [email protected] Abstract: This article describes the results of a 3-month pressure ulcer prevention initiative in the surgical trauma intensive care unit (STICU) of a trauma level one, Magnet facility in the USA. Our initiative included the creation of intervention bundles, a novel tool to identify the highest risk ICU patient and a unique prophylactic product application. In the 3-month performance improvement study surveying 93 patients, a total of 41 patients were identified for inclusion as high-risk using our developed tool and had a product applied prophylactically to protect the sacrum from pressure injury. None of the patients identified as high-risk developed pressure-related injury, while this product, which was hypothesised to address friction, shear and moisture, was in use. Introduction The Virginia Commonwealth University Health System is a 799-bed, trauma level one, Magnet facility in the USA. It is the nation s oldest existing civilian burn centre. We often find ourselves treating the highest acuity patients from the surrounding communities, counties in the Commonwealth and neighbouring states. With the responsibility to serve our patients who are the sickest of the sick, comes great risk through the financial impact of potential hospitalacquired pressure ulcers. By now, most facilities nationwide in the USA have identified areas of practice improvement to meet new Centers for Medicare and Medicaid Services (CMS) regulations 1. In the USA, CMS is the federal agency responsible for determining the reimbursement rates for hospitalised patients covered under their insurance plans. Unfortunately, the CMS regulations do not take into account that facilities who are structured to take on the sickest of the sick, may suffer unwarranted financial penalties for potential unavoidable pressure ulcers. Recently, experts have begun discussing the idea of risk adjustment; comparing risk to prevalence and incidence rates based on the acuity of the patient population 2. While this topic continues to be the source of heated debates 3, acute care facilities in the USA still lack the ability to defend the occurrence of hospital-acquired pressure ulcers despite exhausting all resources to prevent them through best practice interventions. For example, how does a facility and its staff prevent a pressure ulcer in a patient who: has a prolonged extrication from a motor vehicle crash is then sent via helicopter on a backboard for a prolonged period of time arrives in the trauma unit, is taken directly to the operating room for a 14-hour procedure in the supine position is haemodynamically unstable this entire time, with vasopressor support then arrives in the ICU and develops a suspected deep tissue injury (sdti) pressure ulcer developing 3 days after admission to the hospital. At what point in this example situation did the pressure ulcer occur? Given the haemodynamic instability and long transport time, did the pressure ulcer occur long before this patient arrived at our hospital? With only visual and palpation assessment technique available to us, is it a lack of an internal tissue tool that eludes our ability to detect the already comprised tissue damage of a sdti not yet apparent to us on the skin surface? In this example situation, the patient s skin may have shown no evidence of skin breakdown on admission to the trauma bay; however, within 3 days of admission to the hospital there is a pressure ulcer present. The ability of the hospital, medical and nursing staff to prevent this pressure ulcer was minimal, based on the above example. Should a hospital be ineligible for reimbursement for not documenting this pressure ulcer as present on admission, which was not detectable to the staff until at least 3 days later? Our hospital has been proactive in our prevention strategies for the last 4 years. Currently, our point incidence rate facility wide is 1.9% (excluding stage 1 pressure ulcers). While we are proud of our continuously declining numbers, our ICU population remains with unacceptable prevalence rates from 5 to 24%. The author decided to meet with the nursing leaders of one of its most highly acute units, the surgical trauma ICU, in an attempt to develop strategies to reduce pressure ulcers. A Focus on the Sickest of the Sick The ICU nurse in today s hospital has many responsibilities. As our nurses become more highly skilled, they incur greater workloads, which may take away from the everyday important basics of care: turning, cleaning and feeding. Unfortunately, increasing quality initiatives for pain control, fall risk and so on, lead to increased documentation requirements, further limiting the nurse s direct patient care time. Understanding the ever expanding checklist for our seasoned and new nurses alike, it is easy to appreciate how pressure ulcer prevention may not always receive the top priority. New regulations, however, spur the wound ostomy continence nurse (WOCN) to find a way to link skin care and pressure ulcer prevention to the ICU nurse s daily practice. WCET Journal Volume 30 Number 1 January/March

3 In our facility, the Braden Scale risk assessment tool (available at is used on all adult patients and the Braden Q for paediatric and neonatal patients. This tool is synonymous with accurately assessing risk of skin breakdown and has a high inter-relater reliability 4. In the author s opinion, this tool does identify increased risk for skin breakdown in the ICU patient; however, it may lose relevance among the nurses using it. For example, almost 100% of the patients admitted to the ICU have a Braden Scale less than 18, indicating they are at risk for breakdown. More often then not, in my observation, most of these patients fall between a score of 9 and 14. Does the staff registered nurse (RN) identify specific interventions that should be implemented on a patient who is a 10 versus a 13? Is this line of thinking necessary, or should all ICU patients be considered high-risk and treated equally? The ability to take this risk assessment one step further may help to identify those who need specialised intervention bundles of care. In addition, through the process of qualifying these patients as high-risk, with the use of an ICU-specific high-risk tool, the RN may benefit from the subconscious linking of their risk factors with pressure ulcer interventions. A meeting of STICU staff and the WOCN nurse sought to identify the variables which may lead to pressure ulcer formation in their patients. An attempt was made to explore the known variables related to pressure ulcer formation in the ICU and identify them as controllable versus uncontrollable (Table 1). The author examined which risk factors leading to pressure ulcer formation may be out of the realm of nursing prevention, for example use of vasopressive medications. Performance Improvement Study Creation After identifying controllable and uncontrollable risk factors in our ICU population, a tool was designed to qualify a patient for induction into the next phrase of our pressure ulcer prevention initiative, which was a trial of the prophylactic use of a product on the sacrum (Table 2). Risk factors were selected based upon known research identifying variables that may lead to pressure ulcers in the ICU patient Other selection criteria (Table 2) were chosen by the WOCN and RN staff based upon our experience of how events lead to increased pressure ulcer risk, due to their impact on care. An example of this would be a patient admitted following trauma who experienced cardiac arrest, or prolonged operating room (OR) procedure. Conditions or events were also used to identify patients secondary to the multiple variables associated with them. For example, sepsis was considered part of the automatic inclusion criteria due to the haemodynamic instability, perfusion/oxygenation challenges, immobility, pressor support, intubation, and other factors that are usually associated with this disease state. Additionally, the variables listed in Table 1 were also selected for the purpose of identifying the sickest of the sick in our trauma population. For example, an 8-hour OR time was selected as this represents extreme risk; research shows an incidence of 5.8% with OR times closer to 3 hours and a tripling of pressure ulcer risk after 4 hours 10, 11. Also, parameters for vasopressor medications were set to eliminate patients simply needing short-term pressor support following OR and focus on patients requiring long-term pressor use. Other variables indicate risk factors specific to our population. These included risk factors with limited research evidence, but suspected impact on perfusion and oxygenation, such as patients with a total artificial heart (Syncardia Systems Inc., Tuscon, AZ). If pressure ulcers could be reduced in the highest acuity trauma ICU patients, it was felt that these interventions may be applicable to our seven other ICU departments within our facility. Table 1. Risk factors. Controllable Immobility Friction Shear Moisture Nutrition* Activity Faecal incontinence Urinary incontinence Knowledge deficit: o Family education Uncontrollable Multiple OR procedures Mechanical ventilation Sedation/paralytics Traction/external fixators Spinal cord injury/paralysis Weeping anasarca Morbid obesity Shock/SIRS/MODS Cardiac arrest Vasopressors (multiple) Drive lines Nitric oxide ventilation Oscillating ventilation Malnutrition* Peripheral vascular disease Heart disease Diabetes mellitus Advanced age Liver failure Cigarette smoking *= Author is making the notation that while interventions to support proper nutrition may be implemented, the development of malnutrition may be uncontrollable give a patient's critical condition. 3

4 For a period of 3 months between August and November 2008, a total of 93 patients were admitted into the STICU. All patients were on a low air loss surface during this time frame: SPORT Low Air Loss, Synergy Air Elite or Total Care Bariatric Low Air Loss, manufactured by Hill-Rom, Batesville, Indiana. During this time, all patients were assessed using the Braden Scale and then with the high-risk identifier tool designed by the writer. In this time frame, 41 patients were selected as high-risk, based on our newly created tool. All patients in the STICU were provided with a standard intervention bundle created by the WOCN nurse and STICU RN group (Table 3). This meant that all patients, whether selected as high-risk or not, would receive the same preventative interventions for care. The exception, however, came with the 41 high-risk individuals. For the 41 high-risk individuals, the author hypothesised that out of all the controllable risk factors, the three most common in literature and this population in particular were friction, shear and moisture Often, in our clinical experience, we see the effects of insensible fluid loss, perspiration, obese skin folds, turning and repositioning tactics and continuous head of bed greater than 30 to be major offenders of friction, shear and moisture. This ICU population found most of its pressure ulcers to be located either on the sacrum, or started within the gluteal fold along the coccyx. The author determined that if a dressing could be applied prophylactically to the sacrum and gluteal fold, there may be a positive reduction of these risk factors to prevent skin injury. Because of this, an absorbent, soft silicone self-adherent foam dressing product, (Mepilex Border Sacrum, Molnlycke Healthcare, Norcross, GA) was applied to intact skin of all patients identified by the tool as high-risk. This dressing was chosen due to our previous use of its sister dressing, the Mepilex Border (Molnlycke Healthcare, Norcross, GA). These dressings are not marketed as a prophylactic dressing, but instead as a topical foam dressing for use as a primary or secondary dressing choice. In the case of the product trial, the author decided that the atraumatic adhesion technology and its shape, which allows coverage of the sacrum and separation of the gluteal folds, might reduce friction, shear between the gluteal skin folds as well as during patient repositioning and absorb moisture on intact skin as well as resist skin damage from minor faecal incontinence. Since the dressing could be removed without traumatising the skin, routine skin assessments could still be done without causing further skin injury. Of note, the author contacted the manufacturer to request these dressings for trial. The manufacturer did not initiate or have any input into the development or monitoring of this product trial. Additionally, although the company graciously provided free product samples throughout the duration of the trial, all performance improvement study measures and methods were independently dictated by this WOCN nurse. All product education for application and use provided by the RN staff was also given by the WOCN nurse. For 3 months, all patients in the surgical trauma ICU were monitored for skin breakdown. Any patient found to be highrisk by our hospital-developed qualifying tool, was followed using a tracking form created by the author. Additionally, any patient who was not found to be high-risk by the qualifying tool, but developed a sacral pressure ulcer, was also tracked. Results During 3 months of evaluation, no high-risk patients (0/41) as identified by our tool developed a hospital-acquired pressure ulcer while the sacrum dressing was in use. In total, 6 (6/93) patients developed sacral pressure ulcers. Three of these six patients (3/52) were deemed not high-risk by the author s tool and did not have the dressing applied. The remaining three pressure ulcers developed in patients, who previously had the dressing applied, used the product for days then this was subsequently discontinued with intact skin. However, after the dressing was discontinued (either due to discharge to the floor or end of product trial) three patients (3/41) then developed pressure ulcers after the sacral dressing was no longer in use. In fact, these three patients were at considerably lower risk after the product was discontinued and still a pressure ulcer formed, than they were while the dressing was in use and the skin remained intact. Of the 41 patients selected for prophylactic use of the sacral dressing, many of them had extensive risk factors, prolonged ICU stays (longest use equaled 92 days) and profound haemodynamic instability. Table 5 shows a summary of case studies to illustrate this point. The fact that three patients deemed low risk developed pressure ulcers shows that they still had risk factors that may have lead to pressure ulcer formation. Such risks as spinal cord injury were present, but the overall condition of those patients was not considered to be representative of the high acuity patients that were the focus of the performance improvement study. In the future, the author s high-risk selection tool would need modification after rigorous testing of its reliability. The RN staff found the dressing to be easy to apply, it remained in place, was atraumatic to the patient s skin, it was resistant to minor faecal incontinence (major faecal incontinence managed by faecal management systems) and absorptive. In fact, the WOCN nurse experienced a surprising finding when turning a septic patient who had profound weeping anasarca with 1-3 litres of insensible fluid loss. During a turn to assess the patient s skin, the sacral dressing was found to be swollen with fluid. Upon removing the dressing, however, the skin presented as dry and intact! This phenomenon was noted on two patients. However, this discovery further supported our hypothesis that our universal application of the sacral dressing decreased maceration injury resulting from perspiration or insensible fluid loss and collection around the sacrum. Finally, positive outcomes were found through the use of the qualifying tool for high-risk ICU patients. It is the author s belief that as the RNs were forced to critically think about all the aspects of their care that could increase risk for pressure ulcer formation; they began to link their tasks and assessments with pressure ulcer prevention. For example, RN staff now thought of sacral pressure ulcers anytime they hung a bag of Levophed, or the length of time without pressure redistribution or in one position such as a patient with diabetes returning from a 10-hour procedure. To the WOCN nurse, this line of thinking is commonplace; however, for the multitasking ICU nurse, pressure ulcer risk factors do not always take priority. This ICU risk assessment tool allowed them to ingrain the idea of prevention into their entire plan of care. Discussion Identification of high-risk, critically ill patients and interventions to prevent pressure ulcers remains a clinical challenge. This clinical inquiry was a result of the author simply looking for a way to further aid prevention in this isolated high-risk population within our facility (see Table 4). In retrospect, various factors, including the astounding reduction of sacral pressure ulcers, suggest that more information and study is needed. Obstacles to performing a well-controlled research study, in the future, include the plethora of varying comorbidities found in these WCET Journal Volume 30 Number 1 January/March

5 Table 2. Intervention bundle. Adult ICU Mepilex Sacrum Criteria TABLE 2 PATIENT SELECTION CRITERIA: Automatically apply if patient: 1. Has a surgical procedure >8hours (may be cumulative surgeries = 8hrs). 2. Cardiac arrest this admission 3. Vasopressors >48hours 4. In SHOCK, SIRS, MODS Apply if patient has five or more of the following: Weeping edema / anasarca Traction Morbid obesity Age >65 y.o. Diabetis Mellitus Bed Rest Liver Failure Malnutrition (prealbumin <20, Albumin <2.5 or NPO greater than 3 days) Sedation / Paralytics >48hours Mechanical ventilation >48 hours Quadraplegia or spinal cord injury Nitric oxide ventilation Restraints Drive lines (LVAD, RVAD, Balloon pump) Past history of pressure ulcers SACRUM Dressing APPLICATION: Daily Expectations: 1. Apply as illustrated above 2. Date dressing 3. Peel back daily, assess skin and reseal existing dressing 4. Document findings 5. Remove & discard every 3 days 6. Reapply as long as patient meets criteria **If patient is incontinent: dressing does not have to be changed. If only top of dressing is soiled simply wipe off. ** If dressing does not stay intact >24hr due to incontinence, discontinue & use barrier cream or alternative management. Photo taken from Molnlycke Health Care US, LLC. website 5

6 Table 3. High-risk qualifying tool. VCUHS STICU Pressure Ulcer Prevention TABLE 3 INTERVENTIONS FOR DAILY PRACTICE: Author: C. Tod Brindle, BSN, RN, ET, CWOCN, CLIN IV; Virginia Commonwealth University Health System, Richmond, VA STICU staff: Turn: At least every 2 hr and PRN (ask reporting RN for time of last turn) If on continuous lateral rotation therapy: Rotation 18 hrs per day; Manual turn every 2 hrs: stop rotation, reposition R or L x 30 minutes, place supine, resume rotation Weight shift: If full 30-degree turn not possible due to traction or hemodynamic instability: If patient up in chair, shift weight every 30 minutes to 1 hr Pressure/shear/friction bundle: Float heels using vertical pillows from knee to ankle Use Heel Offload Device (H.O.L.D) if patient agitated (see protocol); Lift sheet/turn sheet to reposition in bed; If bariatric specialty bed needed: consult Wound Care Team; Chair-bound patients: order 4-inch foam wheelchair pad Skin bundle: Skin checks every shift and PRN with each turn; Limit number of linens, NO plastic chux or diapers Barrier cream, moisturizer, every 12 hours and PRN incontinence, to all patients not receiving sacral dressing; Educate patient/family/caregivers on pressure ulcer risk, interventions, and encourage participation in care (provide Pressure Ulcer Education trifold to family) Nutrition bundle: Registered dietician to determine palb, Alb and other lab frequencies; Encourage water/hydration; Assist patient with meals if taking PO Device check: Ensure no devices under patient: IV lines, tubing, etc Evaluate need for ET tube repositioning Document: Braden score, interventions provided, new interventions used, status changes, or new risk factors determined. Notes: WCET Journal Volume 30 Number 1 January/March

7 Table 4. Study at a glance. Study length August-November 2008 Patients studied 93 patients evaluated. 41 patients met high-risk inclusion criteria: Sacral silicone foam dressing applied to all 41 patients. Number of pressure ulcers developing on patients using sacral dressing 0. Total number of pressure ulcers in 3 months: six (four DTI, two unstageable) three patients either not included in study due to low risk, or missed during evaluation three patients had intact skin during use of dressing for consecutive days. Developed pressure ulcer after discontinuation of product due to end of study or discharge from ICU. Longest consecutive use of product by patient in study 92 days (NO pressure ulcer development). AVERAGES Patient age: 46.7 years. Number of days of dressing use per patient: 16. Number of surgeries: 3.9 (range 0-25 total per patient). critically ill patients, which all may lead to pressure ulcer formation. One of the questions from our trial is, did the underlying comorbidities (chronic) of the three patients developing pressure ulcers, whom were deemed low-risk, have more impact on pressure ulcer formation than the more acutely ill patients, who were breakdown-free? The findings of a 2007 study by Suriadi et al. suggest factors related to pressure ulcer formation are not readily accounted for on standard risk assessment tools, such as cigarette smoking, body temperature and interface pressures 16. The results of the aforementioned process for pressure ulcer reduction leave many opportunities for future growth and improvement. Areas of further investigation and discussion centre largely on the need for: the identification of high-risk ICU patients, further research regarding risk factors in the critically ill, well-controlled, double blinded research studies to verify these results and more extensive product tests. The complexity of identifying the needs of critically ill patients on the individual level may support the need for standard, bundled interventions for all ICU clients. While this may be the easier solution, nursing is constantly encouraged and mandated to direct care towards the individual needs of their patients. Because of this, there could be a benefit to the development of a high-risk identifying tool used to more directly impact care and prevention strategies. The author s tool used in this PI study serves as a first draft that may now be further investigated and tested for wider use. Moreover, did the creation of this tool alone serve to reduce the pressure ulcer incidence in this study through a Hawthorne effect or by focusing the nurse s attention to risk? Indeed, there was a strong conscious understanding of how each facet of the patient s condition could make them more susceptible to skin breakdown. The question then becomes, could a high-risk ICU tool supplement the Braden Scale to further reduce pressure ulcer formation? Finally, more in-depth study is needed to ascertain whether the proper use and application of a prophylactic dressing prevents sacral pressure ulcer formation. As the author, I want to make sure that it is clear that I am not advocating that nurses start relying on a dressing application rather than their own bedside care. No product could ever replace bedside nursing care. Furthermore, more inquiry into the mechanism by which the sacral dressing may reduce certain risk factors that may lead to pressure ulcer formation, namely: friction, shear and moisture needs to occur. The presentation of dry intact skin underneath this dressing, in the face of extremely ill, septic and high-risk ICU patients after multiple OR procedures was very impressive. As of now, this dressing has been added to the preventative intervention bundle of our 28-bed surgical trauma ICU population and is being applied prophylactically to patients deemed at risk. To further test these results, a larger, randomised study is needed and is currently in process. Additionally, another WOCN nurse on our team is developing a protocol for preoperative application to test its benefits in this patient population. While its true mechanisms of prevention are unknown, the benefit of the sacral dressing appeared to be realised within this study population. In the face of devastating physical and emotional insults to our patients and the impact of financial regulations to American acute care facilities, the future appears to be filled with fervour for proactive, defensive prevention. The query is simple: in the face of impending government regulations such as from CMS and providing the best outcomes for our patients, what else can be done to prevent pressure ulcers? Especially, when it seems we have exhausted all possibilities. After identifying our sickest patients and providing them with evidence-based interventions, could the addition of a prophylactic dressing provide the last needed deterrence to skin breakdown? Clearly, there remain many questions to answer. Because of this, the author has used this initial performance improvement study as a catalyst for more rigorous evaluation. A randomised research study is now being developed to recreate this initial pilot and test the impact of prophylactic dressing application in a multi-site cardiothoracic ICU population. References: 1. Armstrong D, Ayello E, Capitulo K et al. New Opportunities to Improve Pressure Ulcer Prevention and Treatment: Implications of the CMS In-patient Hospital Care Present on Admission (POA) Indicators/Hospital-Acquired Conditions (HAC) Policy. A consensus paper of the International Expert Wound Care Advisory Panel. Adv Skin Wound Care 2008; 21(10): Lynn J. Adjusting for Risk and Pressure Ulcer Formation. Lecture from the 11th National Pressure Ulcer Advisory Panel Biennial Conference, 27 February 2009, Washington, DC. 3. Conners B. The Present on Admission Rule in Acute Care. Lecture from the 11th National Pressure Ulcer Advisory Panel Biennial Conference, 27 February 2009, Washington, DC. 4. Braden BJ & Bergstrom N. Clinical utility of the Braden Scale for Predicting Pressure Sore Risk. Decubitus 1989; 2(3): Elliott R, McKinley S & Fox V. Quality Improvement Program to Reduce the Prevalence of Pressure Ulcers in an Intensive Care Unit. Am J Critical Care 2008; 17:

8 6. Reilly E, Karakousis G, Schrag S & Stawicki SP. Pressure ulcers in the intensive care unit: The forgotten enemy. OPUS 12 Scientist 2007; 1(2): Shahin E, Dassen T & Halfens R. Incidence, prevention and treatment of pressure ulcers in intensive care patients: A longitudinal study. Int J Nurs Stud 2009; 46: Shahin E, Dassen T & Halfens R. Pressure ulcer prevalence and incidence in intensive care patients: a literature review. Nurs Crit Care 2008; 13(2): Nijs N, Toppets A, Defloor T, Bernaerts K, Milisen K & van den Berghe G. Incidence and risk factors for pressure ulcers in the intensive care unit. J Clin Nurs 2008; 18: Price M, Whitney J & King C. Development of a Risk Assessment Tool for Intraoperative Pressure Ulcers. JWOCN 2005; 32(1): Walton-Geer P. Prevention of Pressure Ulcers in the Surgical Patient. AORN 2009; 89(3): Doughty D. Prevention and Early Detection of Pressure Ulcers in Hospitalized Patients. J Wound Ostomy Continence Nurs 2008; 35(1): Worley C. Skin Failure: The permissible Pressure Ulcer? Dermatol Nurs 2007; 19(4): Gray M, Bohacek L, Weir D & Zdanuk J. Moisture vs Pressure: Making Sense Out of Perineal Wounds. J Wound Ostomy Continence Nurs 2007; 34(2): Mayrovitz H & Sims N. Biophysical Effects of Water and Synthetic Urine on Skin. Adv Skin Wound Care 2001; 14(6): Suriadi, Sanada H et al. Risk factors in the development of pressure ulcers in an intensive care unit in Pontianak Indonesia. Int Wound J 2007; 4(3): Table 5. Case study snapshot.* Case studies Number of days in STICU Outcome 23-year-old female admitted from outside hospital following emergency C-section. Complications: HELLP syndrome, (haemolysis, elevated liver enzymes, low platelets), sepsis, fungal necrotising abdominal fasciitis with severe systemic complications. 25 surgeries. Anasarca, prolonged vasopressor support, ventilation, multiorgan dysfunction syndrome, malnutrition. 26-year-old male fell greater than 50 feet off high rise, landing on his back. Complications: tension haemopneumothorax with pneumomediastinum and diaphragmatic haematoma, pelvic and spine burst fractures, devascularisation of left kidney, severe liver and spleen lacerations, ex lap with open abdomen, cardiac arrest x2. Patient unable to be turned for 9 days due to severe haemodynamic instability requiring four pressors, oscillating ventilator. 119 Dressing used for 92 consecutive days (changing every 3 days). 63 Patient not turned x9 days with arterial blood pressure of 70/30s despite maximum us of vasopressors. Then turned only once daily for additional week. No sacral pressure ulcer. No sacral pressure ulcer. 60-year-old male motor cycle crash victim with severe injuries to CNS and lungs. Complications: Cardiac arrest, quadriplegia, six surgeries, anasarca, ventilator dependency. 57-year-old male, life-flighted (transported by helicopter) after motor cycle crash. Complications: cardiac arrest with nine episodes of defibrillation, maximum vasopressors, head injury, multiple surgeries, ventilation. 38 No sacral pressure ulcer upon discharge from ICU to floor. Patient developed unstageable pressure ulcer 1 week later after dressing discontinued, despite ongoing low air loss mattress and interventions. 20 No sacral pressure ulcer during use of dressing for 20 days. Then product trial ended: patient continued on same low air loss surface, in same unit, with same interventions, only barrier cream instead of sacral dressing. Developed sdti 1 week after discontinuation of sacral dressing. * These patients were selected as they are both: representative of patients in our trauma level one ICU and had very high acuity scenarios depicting the effectiveness of the dressing. WCET Journal Volume 30 Number 1 January/March