1. Pressure Management: Connecting the Dots from Admittance to Release Rick Fontaine V.P. Business Development Tempur-Pedic North America Inc., Medical Division

2. Pressure Management: Connecting the Dots Why the focus on Pressure Management? Many patient care issues are associated with pressure. –PATIENT COMFORT A Clinically Significant Factor –Pain, Sleep, Medication, Service demand (Call lights) –Pressure is the defining cause of Pressure Ulcers. Costly –<LOS, <Supplies, <Treatment Quality Indicator –CMS, JCAHO, Legal Community Impact Reimbursement –CMS

3. Pressure Management: Connecting the Dots Pressure Ulcer Frequency Incidence in acute care –0.4% to 38.0% 1 Average LOS –10.6 days 2 4.6 days general population 3 (230%) Overall prevalence –72,664 discharges 2 24.445 per 1000 discharges with LOS >5 days 4 Total Charges –$30,794 2 $20,455 Mean Charges 3 (155%) 1 Lyder CH. Pressure ulcer prevention and management. JAMA. 2003;289:223-226 2 CCS principle diagnosis category 199, Chronic ulcer of Skin 3 Statistics for all US community hospital stays 2&3 HCUP/AHRQ data. Most recent published year, 2004 4 AHRQ Pressure Ulcer Data 2003

4. Pressure Management: Connecting the Dots Source of admission Nursing Home –5.24% Other hospital –5.87% Emergency Department –40.35% HCUP/AHRQ data. Most recent published year, 2004

5. Pressure Management: Connecting the Dots Facts are… Admission can take lots of time. –12, 14, 18 hours or longer can pass between the time a patient presents to the ED and when they are admitted to a Med/Surg bed. Waiting, diagnosis, procedure, OR, and transport time all add up. ICU bed availability can result in overnight stays (sometimes multiple)

6. Pressure Management: Connecting the Dots CMS Findings …the view that pressure ulcer prevention was a nursing issue…is a major barrier… 1 …medical staff were…resistive…that they play a major role in pressure ulcer prevention… 1 …interventions…dependent on…staffing…are most difficult to sustain… 1...hospitals found…the most sustainable interventions… were institutionalized. 1 Focusing…programs on the nursing staff is limited…pressure ulcer prevention requires a multidisciplinary effort. 1 1 Lyder CH, et al., Preventing Pressure Ulcers in Connecticut Hospitals… Joint Commission Journal on Quality and Safety 2004: 30(4), 205-214

7. Pressure Management: Connecting the Dots Researchers assessment In the study we found that most (nursing focused) prevention strategies did not prevent pressure ulcers. One thing we hypothesized was that most people are admitted to (the hospital) through the ER, thus prevention must begin at point of entry NOT (the) medical or surgical unit. 1 1 Courtney H. Lyder, N.D. Interpersonal correspondence, April 2007

8. Pressure Management: Connecting the Dots Conclusions? If… –there are ample reasons to avoid pressure related complications, and.. –nursing interventions alone are not shown to be effective in this effort, and… –evidence suggests institutionalized, automatic approaches deliver the best outcomes; Then… –the solution is most likely found in a global approach to pressure management.

9. Pressure Management: Connecting the Dots Support Surfaces Any structure or device, –intimately in contact with the patient, –onto which part or all of their weight is borne. Mattresses Pads Cushions Prosthetic devices Not all support surfaces have therapeutic value.

10. Pressure Management: Connecting the Dots Contemporary Support Surface Thinking National Pressure Ulcer Advisory Panel –Support Surface Standards Initiative (S3I) Eliminates artificial thresholds Establishes the technically accurate concept of: Pressure Redistribution Pressure Reduction Pressure Relief

11. Pressure Management: Connecting the Dots Pressure Redistribution Transferring load bearing from areas prone to pressure damage to areas less likely to break down. –Shifting loading forces away from: the occiput, scapulae, sacrum, coccyx, greater trochanters of the femur, heels, and malleolus –And redistributing them into the adjoining tissues The goal is to eliminate areas of peakiness.

12. Pressure Management: Connecting the Dots How Support Surfaces Work Immersion –Increasing patient contact area by sinking more deeply into the support surface. Lower interface pressure due to increased denominator. Envelopment –Equalizing loading forces by efficiently molding to body contours. Flattens the peak to average ratio (Peakiness).

13. Pressure Management: Connecting the Dots Compression Resistive Materials Widely used in basic mattresses and pads. –Typically foam, innerspring, and hammocking types of support surfaces. –Generally most effective in redistributing pressure secondary to immersion. –Tend to be peaky resistance increases as the material more deeply compresses.

14. Pressure Management: Connecting the Dots Fluid/Fluidized Materials Frequently used in preventative / therapeutic support surfaces. –Includes gases, liquids, and select visco- elastic materials (gel, foam, etc.). Primary efficacy based on envelopment. –Immersion important but secondary. Tend towards lower shear. Efficacy impacted by use.

15. Pressure Management: Connecting the Dots Standard Foam 2 OR Pad Max / Avg. = Ratio of 3.99

16. Pressure Management: Connecting the Dots Pressure Management 2 OR Pad Max / Avg. = Ratio of 3.36

17. Pressure Management: Connecting the Dots Connecting ………………….... …………..the dots……………. At least 50% of hospitalized patients are at risk and/or acutely uncomfortable Risk experienced is costly –Pressure-related tissue damage –Discomfort results in service demands and potential injury (falls, wandering, etc.) It is only possible to manage the risk by providing interventions at all areas of patient contact.

18. Pressure Management: Connecting the Dots Support Surface Applications Medical/Surgical Beds Intensive care beds Stretchers / Transport carts OR table mattresses Imaging device mattresses Wheelchairs Recliners Anywhere a patient at risk might remain for longer than 30 minutes between position change.

19. Pressure Management: Connecting the Dots Considerations when selecting a support surface. –Clinical efficacy –Comfort –Safety –Transfer ability –Procedural imperatives –Nursing / Patient care requirements –Mobility –Cost-effectiveness –Longevity

20. Pressure Management: Connecting the Dots