In his practice, Dr. Wendelken most often finds pressure ulcers on the heel, typically the retrocalcaneal surface and the lateral heel. He also encounters numerous pressure ulcers on the ankle over the malleolus as well as pressure ulcers along the lateral aspect of the foot (base of the fifth metatarsal at the styloid process). In his clinic, Dr. Suzuki has seen quite a few “ankle” pressure ulcers over the lateral malleolus or even the medial malleolus as some of his patients sleep on their sides. This may turn the ulcer into a chronic ulceration at the tip of the malleolus, according to Dr. Suzuki. Additionally, Dr. Wendelken finds pressure ulcers in areas such as the medial first and lateral fifth metatarsal heads. Other less common areas where pressure ulcers form are the proximal fibula head and the anterior ankle, according to Dr. Wendelken. He notes the anterior ankle ulcer is commonly caused by a dressing that one did not properly apply and is usually too tight. Multiple guidelines recommend the use of a heel protection device that completely offloads the heel to help prevent the development of heel pressure injuries. 1,2 Prevalon ® Heel Protectors are the number one brand of heel protection. 3 They offer continuous heel offloading to protect your patients’ heels. START A TRIAL Choose the optimal heel protector Dr. Wendelken notes that in each case, the medical record must document the severity of the condition sufficiently to demonstrate the medical necessity for a pressure reducing support surface. Several stakeholders supplied new evidence, however none was suitable for inclusion in the surveillance review for various reasons (unpublished research, unsuitable evidence type, not in scope, outside search dates).

A cross-referral to the NICE guideline on peripheral arterial disease: diagnosis and management will be made from recommendation 1.4.26. Dr. Sage evaluates the wound for signs of infection and evaluates the foot for signs of ischemia. If infection is present, he says debridement and/or antibiotics may be necessary, but he does not debride stable, non-infected blisters or eschars. When a new patient presents with what appears to be a pressure ulcer on the lower extremity, Dr. Wendelken proceeds with a vascular assessment that includes an ankle/brachial index, a neuropathy assessment that utilizes the Semmes Weinstein test, and an assessment of mobility and range of motion. Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles, and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo. This is a randomised controlled study (RCT) to investigate the effectiveness of Prevalon Boots when used to prevent heel pressure injury among orthopaedic hospital patients. Orthopaedic in-patients with either no visible heel pressure damage or category I heel damage will be identified by their health care provider and willing patients, meeting the inclusion and exclusion criteria, will be consented.I despise those heel cradle cushions,” says Dr. Suzuki. “They are widely used pillow boots that are attached directly to the heel itself. They add bulk to the heel and do nothing to prevent or offload heel pressure ulcers.” Q: Do you recommend or prescribe a bed or mattress for their pressure issues? A: Under the Limited License, Licensee has the rights to use and display the Training Video internally to its employees. Licensee agrees that the Limited License excludes the following rights to: A stakeholder queried the use of the term 'confined' in the guideline introduction because it implies an inability to move rather than reduced mobility, or choosing not to mobilise. This term is used in the first paragraph of the introduction to describe people in whom pressure ulcers typically occur. However the second paragraph goes on to note that all patients are potentially at risk of developing a pressure ulcer, but they are more likely to occur in people who are seriously ill, have a neurological condition, impaired mobility, impaired nutrition, or poor posture or a deformity. Therefore the risk factors in the introduction are wider than patients confined to bed or a chair and cover many different at-risk groups.

the patient has limited mobility (i.e., the patient cannot independently make changes in body position significant enough to alleviate pressure and at least one of the conditions A-D below); or NICE guideline CG179 recommendations 1.4.3 and 1.5.3 refer to the International NPUAP‑EPUAP [2009] Pressure Ulcer Classification System. This has had 2 revisions since 2009, therefore the reference to a specific year will be deleted. In one study, implementation of a heel pressure ulcer prevention protocol that included Prevalon Heel Protector resulted in a 28% decrease in facility- acquired heel pressure ulcers over a one-year period. Continued use of the Prevalon Heel Protector over four years, coupled with in-depth education, continuous monitoring of compliance, and continual reporting of outcomes to ensure accountability, resulted in a cumulative 72% decrease in heel pressure ulcers. 4 A study published in JWOCN found the use of Prevalon and a heel pressure injury prevention protocol led to a 95% decrease in heel pressure injuries. 2

Choose the optimal heel protector

A cross-referral to the NICE guideline on diabetic foot problems: prevention and management will be made from recommendations 1.4.26 and 1.5.24. Individuals in bed who are completely immobile should have a care plan that includes the use of devices that totally relieve pressure on the heels, most commonly by raising the heels off the bed.” 2 Depending on the stage of the ulcer, Dr. Wendelken prescribes a number of offloading boots for pressure redistribution. He has lately had “great results” with the Waffle Heel Elevator Custom (EHOB). In his practice, Dr. Sage most often sees pressure ulcers on hospital patient consults, usually in seriously ill patients who have been on prolonged bed rest. He notes that he does not see nursing home patients or make house calls. Q: What kind of offloading boot or brace do you prescribe to your pressure ulcer patients? A: A stakeholder drew attention to one of their products which prevents pressure ulcers in the operating theatre. The product is a high-specification foam mattress and is therefore covered by the recommendations for high-specification foam mattresses in the guideline. We found no evidence in the current surveillance review specifically concerning this product.

Dr. Wendelken notes a group 1 mattress overlay may be indicated and is covered by the Centers for Medicare and Medicaid Services (CMS) if the mattress meets the following conditions: Calf Cradles completely elevate the heels and distribute pressure over the lower leg without creating undue pressure on the Achilles tendon Stakeholders requested a definition of a high-specification foam mattress be added to the guideline. It was noted that the guideline examined evidence on a variety of different high-specification mattress types, and the guideline committee were therefore unable to be highly specific about the nature of mattresses and so used the term 'high-specification foam mattress' (which is also used by the NPUAP/EPUAP/PPPIA guideline).Dr. Suzuki routinely recommends beds and mattresses. As he notes, the general recommendation on beds is that patients with minor pressure ulcers (stage 1 or 2) should have a memory foam mattress or mattress topper (overlay) a minimum of 3 inches high, which patients can buy without prescriptions in most bedding stores and in larger markets at stores like Costco or Target. Dr. Suzuki says patients with more substantial pressure ulcers (stage 3 or 4) will most likely need a powered air bed (i.e. low air loss, air fluidized, etc.), saying that will require prescriptions, detailed medical records for submission, and help from a local medical supply durable medical equipment company. A cross-referral to the NICE guideline on sepsis: recognition, diagnosis and early management will be made from recommendation 1.4.18. A cross-referral to the NICE guideline on antimicrobial stewardship: systems and processes for effective antimicrobial medicine use will be made from recommendations 1.4.21, 1.4.22, 1.5.18 and 1.5.19. Kazu Suzuki, DPM, CWS, views treating pressure ulcers like treating any other wounds. He starts with a thorough history, figures out when and how the pressure ulcers started, and what kind of pressure formed the ulcers. Similarly, Martin Wendelken, DPM, emphasizes the importance of having a clear understanding of the patient’s activities of daily living and ability to perform those functions, and includes a Braden Scale assessment on the patient. the patient has any stage pressure ulcer on the trunk or pelvis, and at least one of the conditions A-D below.