“Health & Wealth for Wales” “Health & Wealth For Wales”

“Health & Wealth for Wales” “Health & Wealth For Wales” Right Equipment…. Half the Story Jacqui Fletcher Clinical Strategy Director Welsh Wound Innovation

“Health & Wealth for Wales” “Health & Wealth For Wales” Equipment drives me crazy It solves so many problems It creates so many problems We abuse it on a regular basis – then blame it when it ‘doesn’t work’

“Health & Wealth for Wales” “Health & Wealth For Wales” Outline of the session Inappropriate use of equipment — a source of skin damage and complaint The effective use of add-on equipment — risk/benefit analysis, optimising pressure relief decision-making Getting the best from your resources — releasing time to care

“Health & Wealth for Wales” “Health & Wealth For Wales” Poor use of equipment An HTA report by University of York Multi centre RCT PRESSURE trial 1971 patients, compared alternating overlay to alternating mattress replacement

“Health & Wealth for Wales” “Health & Wealth For Wales” PRESSURE trial Technical problems with mattresses 207 (on 131 overlays) and 370 (on 223 replacements) Problems were Nixon et al 2006

“Health & Wealth for Wales” “Health & Wealth For Wales” ProblemOverlayReplacementTotal Plug / electricity not turned on 40 (19.3%) 33 (19.2%) 73 (19.3%) Transport / static mode 4 (1.9%) 25 (14.5%) 29 (7.7%) CPR 24 (11.6%) 4 (2.3%) 28 (7.4%) Connectors / tubing / mattress position 8 (3.9%) 11 (6.4%) 19 (5.0%) Settings 53 (25.6%) 12 (7.0%) 65 (17.2%) Alarming 20 (9.7%) 31 (18%) 51 (13.5%) Deflated / low pressure 49 (23.7%) 45 (6.2%) 94 (24.8%) Pump failure 0 (0%) 3 (1.7%) 3 (0.8%) Broken part 4 (1.9%) 6 (3.5%) 10 (2.6%) Unknown 5 (2.4%) 2 (1.2%) 7 (1.8%) Nixon et al 2006

“Health & Wealth for Wales” “Health & Wealth For Wales” Inappropriate use of equipment — a source of skin damage and complaint

“Health & Wealth for Wales” “Health & Wealth For Wales” Patients vary considerably in size and body mass, yet we expect our equipment to cope with the majority of patients – is this reasonable?

“Health & Wealth for Wales” “Health & Wealth For Wales” Do you know if….. Your mattresses are the same size as your beds? Staff were taught (and do) the correct sequence to articulate bed frames? Your high specification foams contour fully to the bed frames? How your frames contour?

“Health & Wealth for Wales” “Health & Wealth For Wales” FlatContoured Mattress195 cm186 cm Person181 cm210 cm

“Health & Wealth for Wales” “Health & Wealth For Wales” Articulation If the bed articulates in such a way the mattress moves away from the frame, staff tend to pad inappropriately If the bed articulates in such a way the foam is pushed down tight against the frame you can get the heels pressed against the frame / equipment

“Health & Wealth for Wales” “Health & Wealth For Wales”

“Health & Wealth for Wales” “Health & Wealth For Wales” When you do this You may get this…… The heels travel along the mattress up to 15cm with the associated friction and shear forces

“Health & Wealth for Wales” “Health & Wealth For Wales” Doing this can cause this

“Health & Wealth for Wales” “Health & Wealth For Wales” Changing shape? Stress – force transferred per unit area of tissue (comes from both pressure and shear) Strain – measure of the amount of deformation

“Health & Wealth for Wales” “Health & Wealth For Wales” Strain and Stress Excessive internal stresses and strains will hinder transport processes. Effect of internal stress and strain will vary depending on – Morphology (size/shape) of the tissue layers Stiffness and strength of the tissues Aging, lifestyle, chronic injury, disease will cause changes in morphology/strength soft tissues Heterogeneous response – external loading will produce different tissue responses at different body locations

“Health & Wealth for Wales” “Health & Wealth For Wales” FlatContoured Mattress195 cm186 cm Person181 cm210 cm When you contour the foam over the frame it squeezes under the seat – and tries (but fails) to stretch under the knees

“Health & Wealth for Wales” “Health & Wealth For Wales” 2 piece frame 3 piece frame 4 piece frame

“Health & Wealth for Wales” “Health & Wealth For Wales” But the frame also needs a mattress!

“Health & Wealth for Wales” “Health & Wealth For Wales” Make the foam contour to the bed frame…. Stop the heels sliding Stop the feet pressing on the bed end Makes the mattress longer!

“Health & Wealth for Wales” “Health & Wealth For Wales” The effective use of add-on equipment — risk / benefit analysis, optimising pressure relief decision-making

“Health & Wealth for Wales” “Health & Wealth For Wales” Audit of appropriateness of equipment use Not at riskAt Risk High Risk VHigh Risk Not done Arise2 11 Foam Dolphin 11 Duo Other2 21 Primo Repose

“Health & Wealth for Wales” “Health & Wealth For Wales” You could use add on equipment

“Health & Wealth for Wales” “Health & Wealth For Wales” Meeting the challenges One patient had pillows in place but the patients heels were on top of the pillows and not overhanging and the other patient had nothing. At this stage the observer intervened to reposition the pillows for the first patient to ensure heels were overhanging the end of the pillows and asked carers to use pillows for the other….. Pillows remained in place for two of the patients effectively but for one patient the pillow had squashed since the last observation and heels were resting on the bed slightly. (at 30 minutes post Bundle intervention) Turley 2014

“Health & Wealth for Wales” “Health & Wealth For Wales” Poor use of equipment Overlays on bed frames Replacements on top of mattresses Mattresses up side down Patient sat in chair with no cushion Patient on incontinence pads Blankets or pillows under heels

“Health & Wealth for Wales” “Health & Wealth For Wales” Getting the best from your resources — releasing time to care

“Health & Wealth for Wales” “Health & Wealth For Wales” Jones & Tite 2013

“Health & Wealth for Wales” “Health & Wealth For Wales” Introduction of hybrid mattresses In the first 3 months the Trust has made financial savings equating to more than 25K with no increase in pressure ulcers. The reduction of costs is associated with moving equipment, decontamination and rental charges. By effectively reducing the requirement for dynamic air mattresses we have also released nursing time back to care.

“Health & Wealth for Wales” “Health & Wealth For Wales” Getting it right Think about what makes the patient at risk Generally this is –Immobility –Insensate –Lack of blood supply / oxygenation Target the area at risk A higher specification mattress isn’t always the answer!

“Health & Wealth for Wales” “Health & Wealth For Wales” If it is the heels that at are at risk because of poor blood supply Does the patient need a high specification mattress? Do a specific heel assessment

“Health & Wealth for Wales” “Health & Wealth For Wales” Can you actually see the skin? By the time you prevent the clot And stop the patient slipping in the anti embolic stocking And add in a pressure reduction device How often is this all removed and what impact does it have on mobility?

“Health & Wealth for Wales” “Health & Wealth For Wales” Heel assessment

“Health & Wealth for Wales” “Health & Wealth For Wales” Releasing time to care Getting it right Keeping it simple Looking at the obvious – not creating a different problem by solving a problem!

“Health & Wealth for Wales” “Health & Wealth For Wales” References Jones L, Tite M (2013) Do you really know how soon your patient is on an alternating mattress in a hospital setting? A study examining opportunities in safety, effectiveness and improved patient experience. Poster presented at Wounds UK Conference, Harrogate Nixon JNixon J, Nelson EA, Cranny G, Iglesias CP, Hawkins K, Cullum NA, Phillips A, Spilsbury K, Torgerson DJ, Mason S; PRESSURE Trial Group Pressure relieving support surfaces: a randomised evaluation. Health Technol Assess Jul;10(22):iii-iv, ix-x, Nelson EACranny GIglesias CPHawkins KCullum NAPhillips A Spilsbury KTorgerson DJMason SPRESSURE Trial Group Health Technol Assess.

“Health & Wealth for Wales” “Health & Wealth For Wales” Thank