1. Choosing Appropriate Support Surfaces
Betsy Willy MA, PT, CWS
Pathway Health Services
September 11, 2012

2. Lack of Standardized Testing
Results in inability to compare products
Standardized Testing Initiative by NPUAP
Began with standardizing terms and definitions
Established standards for testing materials
Recruiting participants to develop research to compare products using standardized measures
Outcome – to provide the clinician with an evidence based system to choose appropriate support surface

3. Definition of Support Surface (NPUAP)
“A specialized device for pressure redistribution designed for management of tissue loads, micro-climate, and/or other therapeutic functions”
Any mattresses
Integrated bed system
Mattress replacement
Overlay
Seat cushion
Seat cushion overlay

4. Updated Terminology Static = non-powered Dynamic = powered
Pressure reduction or relief = Pressure Redistribution

5. Elements Critical To Pressure Ulcer Prevention
Low Moisture retention
Reduced heat accumulation
Shear reduction
Friction reduction
Pressure redistribution

6. Properties to Consider
Envelopment – the ability of the support surface to conform, so to fit or mold around irregularities in the body
Immersion - The depth of penetration (sinking into a support surface)
Life Expectancy – the defined period of time during which a product is able to effectively fulfill its designated purpose

7. Components of Foam Support Surfaces
Viscoelastic Foam – (memory foam)
a type of porous polymer material that conforms in proportion to the applied weight
Elastic Foam – (non-memory foam used for packing boxes)
Open cell foam – (sofa cushion)
permeable structure with no barrier between cells allowing gases or liquids to pass through the foam
Closed Cell Foam
Non permeable structure preventing gases or liquids from passing through the foam

8. Other Components of Support Surfaces
Air – in cells or bladder
Gel – in combination or alone
Water
Solid (solid seat insert)
Combination – foam/gel

9. Types of Support Surfaces
Foam Overlay (add height to mattress)
Water mattress
Alternating Air Pressure
Low Air Loss
Air Fluidized (glass beads with air)
Zone (pressure can be controlled by zone)
Multi zoned surface
Lateral Rotation (rotates about a longitudinal axis – degree of turn, duration and frequency)

10. Low Tech Support Surfaces Non Powered

11. High Tech – Powered Support Surfaces

12. Desirable Characteristics
Prevents loads surpassing Capillary Closing of 32 mm/hg pressure
Reduces moisture and heat accumulation
Reduces shear and friction
Is easy to use and maintain
Is economical
Allows for spontaneous movement on the support surface

13. Cochrane Collaboration Podcast
Due to poor quality of the studies to date (2011), comparison of the qualities between various products cannot be supported by current research.
Recommendations for practice:
High risk individuals should be provided replacement alternating air mattress rather than overlay
Very high risk individuals should be provided high tech mattress such as low or high air loss

14. Support Devices (WOCN)
Performance Characteristics
Air fluidized
Low air loss
Alternating air
Static Flotation
Foam
Standard Mattress
Increased support area
Yes No
Low Moisture retention
Reduced heat accumulation
Shear Reduction ?
Pressure reduction
Dynamic
Cost per day
High
Moderate
Low

15. NPUAP Recommendations
“Support surfaces alone can neither prevent nor heal pressure ulcers.”
Use as part of a total program of prevention and treatment
Use standardized risk assessment tool in conjunction with comprehensive assessment to determine risk level and Tissue Tolerance Tool
When PrU deteriorates or fails to heal, consider replacing support surface with one that provides more aggressive pressure redistribution, heat and moisture reduction
Reevaluate the whole person for root cause

16. Overall Goal of Support Surface
Evenly distribute pressure over large area
Allows person to immerse (sink into surface
Decreases heat and moisture

17. Overall Recommendations

18. Overall Recommendations
Do not use egg crate or foam overlays
An individualized turning schedule should be assessed with each surface
Turning and repositioning is required for all products
Off load heels on any surface
Assess products periodically for “bottoming out” and document monitoring
The less padding between the skin and support surface, the more effective the surface can be
Foam has a defined life expectancy – when a cushion retains the shape of the buttocks, it needs to be discarded

19. Redistribution Surface
Bed Surface Guidance
Skin Condition
Type of Pressure
Redistribution Surface
At risk for breakdown
History of pressure ulcer(s)
Simple stage I or II ulcer with two turning surfaces still available
Non-powered foam pressure redistribution mattress (may be made of combined air chambers, gel and/or foam)
Multiple stage II’s over two turning surfaces
Unable to assume at least two positions
Stage III, IV, DTI or Unstageable ulcer on multiple turning surfaces
Pressure ulcers not responding on non powered surface
Powered Low air loss overlay or mattress
Pressure set to allow individual to immerse into the product without bottoming out
Multiple stage III, IV, DTI, or Unstageable ulcers
Large III, IV, DTI, or Unstageable ulcers on multiple turning surfaces
Flap, graft, or burns
Low air loss or air fluidized bed
Consider the individual’s pressure redistribution, shear and microclimate needs

20. Shear Wounds
Tear Drop shaped wounds caused by separation of tissues when skin remains stable on support surface and boney structure slides resulting in facial tissue tears

21. Type of Pressure Redistribution Surface
Wheelchair Surface
Skin Condition
Type of Pressure Redistribution Surface
At risk for breakdown
Therapy referral to assess positioning and W/C surface
Foam wheelchair cushion at least 3-4 inch high density or medical grade foam
Or gel foam or all air cushion
History of pressure ulcer(s) on the ischial tuberosities, sacrum, and/or coccyx
Therapy referral to assess positioning and W/C surface
Foam wheelchair cushion at least 3-4 inch thick, high density or medical grade foam
Gel W/C cushion
Air W/C cushion
Current pressure Ulcer(s) on the ischial tuberosities, sacrum, and/or coccyx
Sitting time limited and individualized

22. Off-loading Heels and Feet
Side lying: Lateral aspect of foot must be off-loaded
Pillow under lateral calf of lower leg in side lying
Pillow between knees
Ensure feet are not touching support surface on any product
Ambulatory
Non-weight bearing on ulcerated foot
Supine – Pillow under calf suspending heels
Ensure feet are not touching support surface
Body pillow or pillows under fitted sheet is harder to displace
Sitting – Use heel free device
Foam boots do not redistribute pressure

23. Motorized Scooter and Bedside Recliner
3-4 inch foam cushion places the center of gravity of the individual too high for fall prevention
Use one inch gel cushion
Limit time on device if this intervention is not adequate to prevent non-blanching red areas or to promote healing of pressure ulcer

24. Maintenance and Replacement
Follow manufacturers directions for pressure settings
Alarm lights on low air loss mattresses
Look first for air leaks with stethoscope
Check air hose connections
Check pump function
Monitor and document that device is functioning
Check all air devices for adequate inflation
Place flat hand under device
Push up into air
Should be able to displace air to within 2 inches of body part
If you can touch the boney prominence, increase air pressure

25. Wheelchair cushions Open the cover and check components of cushion
Check for wear or deterioration of foam and gel
Ensure proper inflation if air cushion
Research supports – the more interconnecting air cells, the more aggressive the pressure redistribution will be through immersion

26. Air Cell Cushion and Alternating Air Seat Cushion

27. Geri Chair vs Tilt in Space
Severely contracted individuals
Require complex positioning in bed – refer to therapy for assistance
Seating
Tilt in space chairs accommodate contractures better than Geri Chair
If geri chairs are used, add gel overlay and limit time exposed to pressure
Constant movement
Huntington’s Disease
Wider bed
Reduce friction
Padded wall and floor
Sliding into sacral sitting
Prevent shear and friction
“Dump” seat or use Gravity assisted Seating by changing the wheel position to lower the back of the chair seat

28. Kyphotic Back Spinous processes at high risk
Choose wheelchair back that will conform to the individual’s back
Keyhole – Keen
Jay Personal back – Jay
Deep Incrediback or moldable incrediback by Comfort Care
Increase seat depth to decrease pressure per square inch
Drop back of seat to prevent sliding

29. Sacral Sitting If due to high extension tone as in Parkinson’s Disease
To decrease tone and stabilize pelvis try anti-thrust cushion with gel under coccyx and ischial tuberoscities with pelvic belt to stabilize
Belt is not a restraint if person is dependent
Lower seat back if needed

30. Sacral Sliding Avoid use of wedge cushion by dropping back of seat
Put back wheel in highest axel position
Front caster in lowest axel position
If this raises the knees to high to allow feet flat for self propelling, start with a lower chair frame (hemi or super hemi)

31. Resources
National Pressure Ulcer Advisory Panel Support Surface Standards Initiative; Terms and Definitions Related to Support Surfaces 01/29/2007
Pressure Ulcer Prevention and Treatment; Quick Reference Guide 2009 EPUAP and NPUAP (
Wound Care; A Collaborative Practice Manual for Health Professionals, 3rd edition; Carrie Sussman, Barbara Bates-Jensen; 2007 Lippincot, Williams and Wilkins
Wound Resource Manual; Long Term Care 4th edition, Pathway Health Services (
Cochran Collaboration PodCast 6/2011; Jill Hetherington; Efficacy of use of pressure relieving support surfaces in prevention of pressure ulcers
Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for prevention and management of pressure ulcers.

32. Questions?
Kristi Wergin Program Manager Stratis Health

33. Stratis Health is a nonprofit organization that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities. 
This material was prepared by Stratis Health, the Minnesota Medicare Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 10SOW-MN-C