An exploration of the use of devices for the prevention of heel pressure ulcers in secondary care: A realist evaluation

Background
The heel is a particularly high-risk and problematic area for pressure ulcers (PU) to develop. The effectiveness of devices and the factors that lead to their use for the prevention of heel PUs is poorly understood.
Aims
1. To assess the effectiveness of devices used for the prevention of heel PUs.
2. Explore what factors influence the implementation, and how heel-specific devices are used (or not used) in secondary care.
Methods
To address aim 1: Systematic review of the evidence of effectiveness for devices in the prevention of heel PU.
Aim 2: Realist evaluation, including Phase 1 - theory elicitation through stakeholder interviews with Tissue Viability Nurse Specialists (TVNS) from across the UK and Phase 2 - testing theories using ethnography in three orthopaedic wards in the North of England.
Results
Systematic review: identified 29 trials with fifteen comparisons and eight meta-analyses conducted. Offloading devices were found to be effective in the prevention of ≥Category 1 and ≥Category 2 heel PUs when compared to standard care, but this is based on low to moderate quality evidence and intervention compliance was found to be an issue.
Realist evaluation Phase 1: Interviews with eight TVNS elicited thirteen candidate theories into three program theories, regarding the proactive and reactive use of offloading devices, along with patient factors that influenced their use.
Phase 2: Ethnography found that heel-specific devices are used in practice. Leadership, protocols, identification of high-risk patient groups, and access to devices influenced staff knowledge but did not necessarily increase device use.
Conclusion
Exploring the perceptions and realities of how offloading and heel-specific devices are used in practice can not only influence their use, but also inform how future device trials are designed and conducted to improve protocol compliance and reduce withdrawals and attritions.