I serve as an expert in legal cases that often involve pressure ulcers. Recently I have been asked, while under oath: “Did the nurses follow the 30-30 rule”? My answer is usually something like: “I’m not sure what rule you are asking about.” And of course, the lawyer enlightens me with the rule that the head of the bed should not be over 30° degrees, and the patient should be positioned at a 30° lateral angle. My response? “Oh, yes, those are common practices, but I did not know it was a ‘rule’.” In legal work, rules cannot be broken unless the reason is stated. So, it is a major gain for the plaintiff if a rule was broken and harm (the pressure ulcer) followed.
In 1994, the first pressure ulcer prevention guideline was written. In that purple book, it stated: “Keep the head of the bed below 30 degrees, if consistent with the patient’s condition,” and “Position the patient at a 30 degree lateral position”.
Those great guidelines were followed closely. Support surfaces were designed to redistribute pressure at 30° of elevation. Foam preventive dressings were designed to reduce risk on the sacrum because the sacrum is where pressure ulcers occur when the head of the bed is at 30°. Wedges were created to hold patients at 30° lateral positions.
Today, the patients who are at risk for pressure ulcers have evolved and the old positioning guidelines do not universally work. The phrase “consistent with the patient’s condition” is still significant. Patients are frequently admitted with respiratory distress and with do not intubate orders. For those patients, 30° is not enough head of bed elevation to reduce dyspnoea. They are often placed at 60–80° elevation to aid breathing.
Pressure ulcers that occur from sitting high in bed (high-Fowler’s) occur on the lower buttocks and not the sacrum. Shearing is also a significant problem in patients sitting this high up. Patients who are obese and turned to 30° lateral are still on the sacrum. Obese patients who do not have the sacrum free from the bed develop linear pressure ulcers along both buttock cheeks, sometimes with a fold mark in the soft tissue.
We do not need a rule. Clinical judgement is needed to identify areas of risk from pressure and shear. The problem is that medical products were designed to support the 30-30 idea. Few support surfaces redistribute pressure and shear well when beyond 30°. Few preventive dressings are designed for the lower buttocks, although the heart-shaped dressings can be turned upside down to cover the buttocks.
Lawyers like rules. They are black and white, they were either followed or they were not. And if proof can be made that the pressure ulcer formed from not following the rule, the jury’s work is somewhat easier.
Change is needed. Products should be designed so that they can be modified to fit the patient’s condition. That means better support surfaces for head of bed positioning over 30° elevation that reduce pressure and shear, wedges that have marks on them to indicate the likely position of the pelvis, and dressings that come with instructions on how to pad the lower buttocks.
