Some Sobering Numbers 39% of SCI Veterans in Houston in the 3 Years studied were treated for a PU 150 day average in Hospital $150,000 per Hospitalization. –Garber, Rintala Journal of Rehabilitation Research and Development, Sept/Oct. 2003
The Cost is Significant SCI general prevalence 25%-85% Mean cost in 1998 $37,288 Total cost estimated up to $3.6 Billion in 1999.
Incidence of Skin Breakdown in SCI Incidence of SCI continues to be 80% male, 20% female Substantial physiological differences between genders Increased incidence with increased age Courtesy of LAURIE M. RAPPL, PT, CWS
SCI Skin Changes Collagen catabolism Decreased amino acid concentration Decrease in enzymes of biosynthesis Decrease in proportion of Type I to Type II collagen Decrease in density of adrenergic receptors Poor collagen synthesis Abnormal vascular reactions Decreased blood flow Decreased PO2 – 5X less than in innervated skin Decreased fibronectin, glycoproteins for fibroblast activity Increase in urinary excretion of GAG's, which are the ground substance for collagen bundles The skin below the injury is not the same as the skin above. Courtesy of LAURIE M. RAPPL, PT, CWS
Wounds Are Not All The Same Courtesy of LAURIE M. RAPPL, PT, CWS
Deep Pressure Ulcer Stage IV Wound measurement using VEV MD
Causes of Shear No Compression Tangential Forces Pinch No Compression Tangential Forces Pinch No Shear Shear Shear No Shear Shear Shear
Summary of Causes Immobility Incontinence Pressure Friction Shear Maceration a.k.a. Heat and Moisture
Evidence Based Practice We used to say outcomes measures Why do we insist on an x-ray for a broken wrist yet we will provide AT with a short paragraph or two Orthopedics get paid because they use objective tools like Biodex, Cybex, etc.
Evidence Based Practice: It’s Here Veteran SCI patients guidelines are that they be assessed with pressure mapping annually. FL Medicaid reviewers frustrated. State of FL purchases 11 pressure mapping for their SCI and Brain Injury centers.
Tools To Gather Evidence Temperature Shear Pressure
Some Important Reminders About Pressure Mapping Place the mat as close to the skin as possible and with what they normally sit on. Consistently place the mat in the same orientation so there is no confusion later. Position the mat square on the seat. Confirm with your hands that the sensing mat is not hammocked. Make sure the client is in a “ normal” or neutral position you can replicate with other surfaces.
Be Prepared!! Are the Tools Ready? Don’t keep the IPM system in the closet. –No one wants to wait 30 minutes while you set up. Have it up and running ready to use Install it on all the computers you use Know when was it last calibrated
Calibration Is Important Do you have the equipment to do it Does the calibration technique meet researcher and expert users approval Do you have a protocol governing when, who and where calibration is done? Does the system let you know if the calibration was successful?
Are You Ready? Wash your hands! For your sake and theirs, before and after the evaluation! Gloves?? Make sure you use an isolation bag! A thin PE dry cleaning type bag or facility garbage bag is fine.
How Long To Wait? Some advocate up to 45 minutes-not usually practical-but you could use remote to test. Research indicates 6-8 minutes is a good practical time (Stinson 2002). You need to be observant as it depends on the solution you choose.
How Do We Make Sense Of Pressure mapping? What can we really do? What do the numbers mean? How can we make good decisions?
We Can Only Redistribute: We Can’t Relieve pressure Or Or Reduce pressure
What About The Numbers??? A particular number at a particular location does not = success or safety. Key numbers to watch are –Highest pressure-Where is the potential trouble? Focuses attention on key at risk areas –Sensing Area- More is better! (Quantity of distribution) Are we expanding or contracting the area of the pressure distribution on the surface? –Coefficient of Variation - Lower the % the Better! (Quality of distribution) How evenly is the pressure distributed over the surface?
How Do We Decide? Keep in mind that we are doing a case study of one. No normative data is available yet to guide our decisions for a particular patient type. The numbers are only bench marks to refer to as we seek a better solution. –Is a proposed position or product affording a better pressure distribution, functional capability and or comfort than another?
Don’t Forget Asymmetry! Make sure that it’s the client not a misplaced sensing mat?
Where Does Pressure Fit In Our Assessment Hierarchy? Patient Position Pressure
So Here We Go! In Brief… 1.Introduce pressure mapping 2.Capture how they are currently doing 3.Demonstrate the client’s challenges 4.Document usual/least costly solutions 5.Provide as necessary an appropriate alternative 6.Communicate our findings effectively
Multi-System Analysis Braden Scale for Predicting Pressure Sore Risk –Validated Long term care Geriatric tool –Useful to expand areas of investigation –Nutrition, incontinence and out of chair activities
–Client and O’Malley’s Beautiful seating solution in clinic but a wood stool at the bar defeats the benefits –Caregiver impact on Vet with repetitive injury Why five years of sacral pressure ulcers only in August? Focusing On The Wrong P Can Cost You!
Learn About the Patient Gather any background information you deem pertinent and record in the client information tab. –General, equipment related for future reference. –Don’t rewrite the patient file but do include the “Cliff Notes” of what is relevant to what you are doing. –Learn about their lifestyle and goals. Lifestyle can trump good seating.
Client Positioning Issues? Client Information Check list- –Jeannie Minkel’s for example. Use camera as part of documentation –Illustrate the challenges at the beginning –Illustrate the recommended solution and the good results
1) Introduce Pressure Mapping Explain the process –To remove any apprehensions –Involve client and/or caregivers in the process –Allow them to interact with the technology They won’t be able to while you do the assessment or they will confuse your work Make sure you use your hands to limit hammocking
Client’s Background 45 year old SCI client – 25 year post injury C5 Quadriplegia Long standing history of right side Stage I ulcer (has been worse) Now problems with left side Stage I ulcer and NOT problems on right side. Cannot stay up longer than 4 hours
Current Complaint Unable to be up for longer than 4 hours due to redness in both Ischial Tuberosities, with left being the worst. Secondary is concern over the tail bone pressure which occurs with current position and/or recline Goal of assessment/intervention: able to be up 6 hours min, but preferably 8 hours each day.
2) Capture Them in Their Existing Seating Now that they have sat for a while in their existing mobility device scan, store and describe –Keep your comments related to the specific scan stored. –General information should be in client information tab –Confirm what you see with your hands! Don’t trust all you see on the screen confirm it! –Make notes with the thought in mind that you need to understand them 3-6 months down the road. –Make sure you turn the client away from the screen so they can no longer interact with the pressure mapping system. This will help answer the question: Why do we need to make changes or spend money?
Current Seating What is suspicious in this picture? Note the hexagon.
Use Your Hands!! What really is at the 135 mmHg location??
3) Demonstrate What Their Challenge Is If possible have the client sit upright on a firmer surface like a mat table or a foam cushion. This should be part of the larger mat evaluation. –Scan, store and describe where the boney prominences are. Confirming with hands and noting coordinates on screen. This will help answer the questions: What is the client’s boney architecture like? Is it all there? How rotated is the pelvis,etc.? Why won’t a simple solution be sufficient?
On A Firm Flat Surface Don’t put the client at risk doing this. A mat table or firmer foam cushion might be good choices.
4) Document the Most Commonly Used/Least Costly Alternative Your years of experience or the typical funding parameters may lead you to a particular solution Scan, Store and describe what you did. This may take recording a number of scans as you try a number of variables. You can use 4 scan view to compare your solutions head to head. Be sure to describe what you did as you scan and store This will help answer the question: How well did the usual or least costly solution performed for the client?
A “Usual” Solution Foam cushion: pressures still unacceptably high, and highly focused
5) Provide an Alternative Solution if Necessary If you’re not satisfied with the “normal” solution try another and validate or challenge. Again this may take recording a number of scans as you try a number of variables. Be sure to describe what you did as you scan and store This will help answer the question: Why are we recommending a solution different than the least costly or “usual”?
An Alternate Solution 8 by 9 air insert in foam: good pressure distribution not as good though as the full air cushion: up only 4 hours
Proposed Solution On properly adjusted air cushion. F9 is right IT: Good pressure distribution Up 6 hours am + 4 hours evening - meeting goal
Before therapist correction Aftertherapist supported left PSIS area Change In Posture?
6) Develop a Simple Four Step Report Use comparison view to choose and tag the frames that tell the story Print off the report with client information, in color or in grey scale for faxing. Or copy and paste it into a new or existing Word document you use.
Don’t Forget Remote! Use Remote to monitor the performance of the proposed solution in real world use or over an extended period of time. –Remote can evaluate real time activities, e.g. bouncing down stairs. –Monitor with Remote to see if the client does weight shifts or tilts over time. Or, if they tilt, did the go far enough to get the hoped for benefit.
Use Pressure Mapping As Visual Feed Back Client and caregiver buy in and compliance –No that solution your buddy has will not work for you…See for yourself. Better client and caregiver buy in. –Don’t over-inflate that air cushion!! Use it wisely. –How far do they have to go for adequate weight shift using tilt or other means. –Demonstrate appropriate positioning in bed or seat so the caregiver doesn’t defeat your work.
Some Common Mistakes You stop using your hands and let technology make decisions for you. You try every choice available. You may have a mountain of cushions to try but go with your experience first. Time is precious and trying everything can be confusing.
Sometimes you have to leave “well enough alone” –Client’s trocanter is over 200 mmHg and has been for some time without incident only alternative is high pressure on proven risk area of right I.T. Monitor it. Use the tool to teach movement-help the client find alternate pressure redistributing positions in their seating. –T3 and 2 wounds-use pressure mapping as a biofeedback tool to help a nervous T3 discover how much(little) they have to move to achieve significant pressure reduction for at risk areas. What Do You Do When It All Looks Bad?
Maybe it’s the Tool! Wrinkles in mat Poor placement of mat Hammocking of mat Out of date calibration Damaged mat Get your hands in there and find out
What Do You Do When It All Looks Good? Sometimes everything you do in the seat looks good. If it does, back up and take a good look at where the wound is or what their history is. What is not obvious and unseen during the assessment? Some research and experience indicates that the referral is for a seating related pressure issue, 50% of the time the problem is in the bed not the seat. So, go pressure map the bed even with a seat mat if you need to.
Why Do We Share What We Just Did? To help ensure it benefits the client –That they get what they need And to get your good work acknowledged and paid for
Pressure Mapping Reports Enhance Decision Making in the Care Team With objective information better decisions are made, e.g.. –Due to Sacral wound a physician orders bed rest, but to you it looks a little high to be seating induced. –So you go check the bed with an IPM, and you clearly identify the cause! –Now you have objective data to discuss with the physician. Allowing more seating time and securing a better bed for the client.
Clinical Benefits Objective evidence of need Focuses Resources-80/20 rule Better solutions mean fewer visits Client information is organized over time in an easy to use and share format.
Evidence Based Practice Many Have Come To Rely On HMOs are requiring pressure mapping for use as a benchmark to become a contracted vendor with them. Those with the most success using pressure mapping take time to educate their Case Managers and other payers. It provides information that demonstrates why you did what you did and when you did it, a.k.a. Risk Management.
Where Can Pressure Mapping Be Useful? Seating and positioning assessment: including seat, back and wheelchair configuration Support Surfaces/Bed selection and monitoring –Don’t be afraid to take a seat mat into the bed setting Orthotics and Prosthetics design and fitting Hand grip assessment and ergonomic design Wound clinics, especially when teamed with VEV Pressure garment-wraps or one piece
Conclusions: Pressure mapping systems require intelligent interpretation and application of the data to make good decisions. They are powerful tools to help maximize care for your clients and to help ensure they receive the AT solutions they need. They have also become standard of care for those needing rehabilitation seating.