Introduction
The author has written this paper with two intentions. the first is to introduce the reader to the STAGE IV MATTRESS OVERLAY; the second is to provide the clinical outcome of a patient with a Stage IV pressure ulcer to both buttocks. It is not the author's intention to endorse any product, rather, information will be presented in a case study format.

It is estimated by the National Pressure Ulcer Advisory Panel that over 1 million Americans have pressure ulcers (1989). Studies have shown the prevalence of pressure ulcers to be between 3 and 10 percent in the acute care setting and as high as 45 percent in chronic care facilities (Steinberg,1989). Pressure ulcers are associated with a four fold increase in mortality risk among geriatric patients and nursing home residents (Allman, 1989). The cost of pressure ulcers has been estimated to be between $15,000 and $86,000 per patient with a median cost of $27,000 (Melcher et al.,1989).

These figures are astounding and health care costs will continue to escalate as we approach the twenty first century. Caregivers must be knowledgeable, cost effective and efficient regarding moneys spent for health care. the use of specialty beds is one important economic issue facing all health care personnel in acute care settings, extended care facilities and home care settings. Since their introduction in the 1970's, specialty mattresses and beds have become a widely accepted and utilized method of providing pressure relief. Most hospitals rent theses elaborate devices at a daily rate and although rental rates can vary, the extensive service and support needed for maintaining the beds makes them a considerable expense.

The cost and prevalence of pressure ulcers forces health care providers to utilize cost-effective solutions without compromising the quality of care or efficacy of the specialty bed. Due to recent technological advances, a new generation of therapeutic pressure relief has emerged - the low air loss mattress overlay. The following is an example of one such device, with a description of its advances and benefits.

THE STAGE IV MATTRESS OVERLAY
The STAGE IV MATTRESS OVERLAY, designed by SenTech Medical Systems, Inc., fits over the existing mattress on hospital beds, turning them into the equivalent of the high cost specialty low airloss alternating beds currently being used in most hospitals today. the STAGE IV MATTRESS OVERLAY has a unique self monitoring function that allows the pump to maintain the preset pressure within the air sacs, automatically compensating for position changes. The quilted fitted coverlet, as well as the STAGE IV MATTRESS OVERLAY's low airloss benefits, helps to maintain a dry and cool environment under the patient's body. All these features combined, allows the STAGE IV MATTRESS OVERLAY to effectively address four of the major causes of skin breakdown.

The following is a case study presentation of an actual patient placed on the STAGE IV MATTRESS OVERLAY on the day of admission to a rehabilitation facility. To maintain confidentiality the author has agreed at her request to change her initials and to not disclose the facility. To maintain confidentiality the author has agreed at her request to change her initials and to not disclose the facility where she was a patient.

Mrs. J, is an 83 year old woman, with a past medical history significant for squamous cell carcinoma of the anus which was resected 11 years ago and subsequently treated with radiation therapy. She was presented to an acute care facility in April, 1994 after she had developed some pain in her buttocks region. She was found to have a large abscess overlying her sacrum and on 4/9/94 underwent a primary diverting colostomy with extensive excision of the sacral abscess. Her course was complicated by septicemia and multiple adjacent soft tissue infections. Other past medical history includes; 1. Insulin Dependent Diabetes Mellitus. 2. Hypertension. 3. History of urinary incontinence. Prior to the present illness she was completely independent, community mobile and driving.

On 4/29/94 she underwent an attempt at local repair with bilateral gluteal rotation flaps. the wounds were dressed with normal saline wet to dry dressing changes every 4 hours and the patient was ordered to remain in the prone position until healing had occurred. Postoperative necroses of the flaps developed and she underwent debridement and marsupialization of the wound. After continued significant breakdown in the sacral region, on 7/8/94 she had a split thickness skin graft with a harvest site from the posterolateral thigh on the left.

After an extended three and one half month stay in acute care it was felt that the wounds were stable and ;plans were begun for discharge. Mrs. J was admitted to a rehabilitation facility in the Boston area on 7/22/94 for continued management of this complicated sacral wound and for rehabilitative therapies. On admission to rehabilitation, the patient was evaluated and placed on a STAGE IV MATTRESS OVERLAY. Prior to this the patient had been lying prone since her admission to acute care. In order to participate in rehabilitative therapies it was determined that she could now be supine since low air loss therapy had been instituted. A foley catheter was placed to prevent urine from leaking into the wound.

On examination, the buttock wound measured 41 cm long from left hip to right hip. The edges measured 9 cm wide and the middle of the wound measured 13 cm wide. the wound bed was pink and clean with scattered pinpoint areas of necrotic tissue (Figures 1--warning: graphic content). A graft site to the left posterior thigh was evident with scabbing and minimal bleeding and no evidence of infection. There was only a scant amount of purulent drainage and a culture was obtained. The patient was allowed to lay supine and went prone only for dressing changes. Normal saline wet to dry dressings were ordered with packing to the buttocks wound and the graft site was left open to air.

Three days later the culture grew back MRSA (Methicillin Resistant Staphylococcus Aureus) and she received a 10 day course of Vancomycin. Within three weeks there was remarkable improvement to the wound. There continued to be minimal drainage, however it was now serous in nature. the graft site had completely healed and the buttock wound had demonstrated significant granulation. On 9/28/94 the patient's wounds were re-photographed (Figures 2--warning: graphic content). Wound measurements at this time were as follows; there was one area to the lower aspect of the right buttock which measured 7 cm long and 2 cm wide. Finally the third area still remaining open to the lower aspect of the left buttock measured 7 cm long, 1 cm wide at the edges, and 4 cm wide in the middle. The rest of the wound had granulated.

The nursing care that was provided to Mrs. J. while a patient in rehabilitation was an integral factor in the healing of her decubitus ulcer. In this situation, meticulous nursing care combined with the low airloss and pressure relieving properties of the STAGE IV MATTRESS OVERLAY, provided an ideal situation for rapid and successful wound healing. the staff and Mrs. J. were all very pleased with the performance of the STAGE IV MATTRESS OVERLAY. Mrs. J stated that it was very comfortable and that she never felt as if she was floating on air. She was able to shift her weight readily on the mattress and participate in therapy while lying supine. The staff reported that the mattress was easy to maintain and that it was easy to transfer Mrs. J. while she was on it. Mrs. J. remained on the SenTech STAGE IV MATTRESS OVERLAY throughout her stay in rehabilitation and was discharged to a nursing home on 10/4/94.

References

Allman, R.M., Pressure Ulcers Among the Elderly.
The New England Journal of Medicine, 320: 850-853, March 30, 1989.

Melcher, R.E., Long, R.L., Gelbart, A.O. Pressure Sores in the Elderly: A Systematic Approach to Management. Postgrad Med. 83:229, 1988

Steinberg, J. Prevalence of Decubitus Ulcers: Issues of Concern.
Decubitus, 2:50, 1989.

The National Pressure Ulcer Advisory panel: Pressure Ulcers Prevalence, Cost, and Risk Assessment. Consensus Development Conference Statement.
Decubitus, 2:24, 1989.