Preventing Pressure Injuries in the Acute
Burn Population: The Role of Low Air Loss
A review of recent burn care text outlines the
risk of complications for patients in the acute
phase as well as rehabilitation. While risks include
seemingly more critical issues such as permanent
disfigurement, disability, and serial surgeries for
skin grafts and contractures, a pressure injury (PI)
is a serious complication that many burn patients
may develop. Braden Scale for Predicting
Pressure Sore Risk tells us that burn patients are
often at high risk of PI development due to poor
nutrition, immobility, and excessive moisture.1
Recently, the use of a high-volume low air loss (LAL)
therapeutic mattress has been found to reduce
the incidence of PI in the acute burn population.2
Burn Incidence in the United States
In 2016, the American Burn Association (ABA)
reported that 486,000 burn injuries received medical
There were 3,275 deaths from residential
fires, 310 from vehicle crash fires, and 220 from
Burn injuries accounted for 40,000
hospitalizations, and of these, 30,000 were treated
at hospital burn centers. More than 60 percent of
the estimated US acute care hospitalizations related
to burn injury were admitted to 128 burn centers.3
In 2014, Hop et al. performed a systematic review of
literature that had been published internationally
from 1950 to 20124
and reported that burn care
is typically expensive: the mean total healthcare
cost per burn patient in high-income countries was
In addition to these costs, the average
hospital-acquired pressure injury (HAPI) can cost
a facility as much as $70,000.5
This amount may
be higher in the burn population due to multiple
comorbidities, such as immobility and protein loss.
Caring for the Acute Burn Patient
While it has been reported in the past that risk
factors and incidence of PI in the acute care burn
population are not well known,6
there is some
data to suggest that burn patients are particularly
at risk of developing PIs based on admission
Braden Scale scores.7
A support surface is a critical
tool in care of the acute care burn patient. Air
fluidized therapy (AFT) has been used in the
past but may be hot and noisy, and can cause
unnecessary dryness for the patient—thus, nurse
and patient satisfaction with AFT has been low.
What is Low Air Loss?
LAL support surfaces provide airflow to
assist in managing the heat and humidity
(microclimate) of the skin5 , as well as remove
excess moisture when a burn patient’s wounds
excrete fluid. Excess moisture and increased temperature are risk factors for PI formation.
Knight et al.2 conducted a pilot study examining
incidence of PIs in 18 patients admitted to an acute
burn unit whose therapy included use of a highvolume LAL therapeutic mattress. Patients presented
with a wide range of severity of burns from first to
third degree, as well as different types. Using a highvolume LAL mattress resulted in an incidence rate
of 5.5 percent—much lower than the 38 percent
typically experienced in an intensive care unit.5
These study results are promising for planning
future care of the acute care burn population.
||Air Fluidized Therapy
||High-Volume Low Air Loss
|How it Works
- Mattress filled with fluid and beads
- Heated air pushes through beads to
control mattress firmness
- Immersion mode promotes proper
- Airflow vents directly through top
cover to manage patient microclimate
- Dificult to move patient out of bed
- Weighs 1,630 lbs.
- Mattress can be placed on multiple
bed frames, helping patient and staff
- Weighs 55 lbs.
- Patients often complain of heat and noise
- May dehydrate the patient and their skin
- Bed capacity (weight and height) is
- Bed is cool and quiet, and vented air
manages patient microclimate
- Bed accommodates a wide variety of
Interview with an expert: William C. Lineaweaver, M.D., FACS
Dr. Lineaweaver is medical director of the Joseph
M. Still Burn and Reconstructive Center in Jackson, Miss. He is a
board-certified plastic surgeon, fellowship trained in hand and microsurgery, and has extensive experience
caring for acute burn patients.
Tell us about the unique
challenges of treating
acute burn patients.
There are two major problems we face generally. The first is the initial assessment,
resuscitation, and the treatment planning of any given burn patient—every burn
patient is different. The second is how to organize the burn center itself in order to
help clinics, floors, intensive care units, and operating rooms deal with burn patients
as quickly, efficiently, safely, and productively as possible.
Had you tried highvolume LAL before?
How did it go?
The principal bed prior to our current Sizewise Immerse™ was the Hill-Rom Clinitron®
Rite Hite® it has the bags for the lower half of the body, and then cushions for the
upper half. It provided flexibility in terms of sitting up, eating, etc. We had pretty
satisfactory experience with it in terms of prevention of pressure injuries and
maintenance of reconstructed tissue such as skin grafts and flaps. It was very hard
to get patients in and out of it, conversion to any kind of emergency platform was
difficult, and it was incredibly hard to move.
What was your final
grade on Immerse?
Based on the experience we've had with the Immerse bed—experience that
continues now long past the pilot study, I'd give Immerse an “A” for patient support/
clinical and an “A” for operational ease of use. From the nurse perspective, you might
even get an “A+” on operational ease of use. Immerse seems very intuitive to use,
very easy to control, and easy to move around and take back and forth from surgery.
I also think it is very straightforward to convert Immerse to a critical platform for
Tell us about your
Immerse pilot study.
We selected patients who needed substantial bed support and began to watch
them very closely to see how well [Immerse] supported them, and how well it
adapted to nursing and other operational aspects. The study included 18 patients
over 18 months. The study outcomes were excellent. There was only one patient that
developed a pressure injury, arguably while hospitalized on the bed, but that patient
may well have had the initial portions of that injury before he/she arrived. Either way,
one out of 18 is very good. That's 5.5 percent. And in these high-risk patients, there
could be a much higher rate of expected pressure injuries.
What are your
I would recommend Immerse for any patient who has a potential for developing
a pressure injury. That recommendation can be extended into a remarkable list,
including some patients that we often don't think about. For example, an elderly
patient with a hip fracture who is waiting be operated on and the waiting time
extends 18 to 24 hours after the fracture. That patient is at risk for a PI while waiting
to go to surgery. Each specialty and each practice may have its own subset of
patients that can be considered high risk and of the population for whom this bed is
Looking forward, if you
are going to continue to
publish, what would your
data points be?
Great question. I think, at some point going forward, we’ll break out our burn
patients and our non-burn patients. We also have a new colleague here who will be
doing more micro-surgery—operations such as a free flap to the scalp after a skull
resection. We are going to want to have that patient sitting up, in effect, so that we
can position his head so there is no pressure on the flap. This case is just one example
of the types of procedures we can start utilizing the bed for.
I would also just stress that with so many of our product utilizations, an absolutely
invaluable element is our relationship with the representative supporting the
product. Our Sizewise representative has been able to explain the bed to us, inservice the nurses,
follow up its use, and answer all questions. This is exactly the kind
of relationship we need to have for a new product.
Development of a PI can greatly increase the already
significant cost of treatment of the burn patient.
Preventing PIs will reduce overall costs and improve
outcomes for this population. A high-volume LAL
mattress may improve patient and nurse satisfaction
compared to traditional care used in this population.
About the Author
Erica Thibault, RN, MS, CNS, CWON
Erica is the Clinical Manager at Sizewise, as well as a registered
nurse, a certified wound, ostomy and continence nurse
(WOCN), and a clinical nurse specialist (CNS).