Befuddled About Support Surfaces? Become an Expert

Befuddled About Support Surfaces? Become an Expert
Welcome to WS45 Befuddled About Support Surfaces? Become an Expert Presenter: Karen Lerner

Objectives 1. Describe how and why support surfaces address extrinsic factors 2. List at least 3 potential opportunities for support surface application 3. Examine practice standards and codes of ethics for health care professionals and ATPs (RESNA and NRRTS) and how these relate to pressure ulcers and support surfaces 4. Match a specific product’s features to benefit a specific patient population

Speaker Disclosure Regional VP, Pressure Prevention
Karen A. Lerner, RN, MSN, ATP, CWS Regional VP, Pressure Prevention Drive DeVilbiss Healthcare

Skin Largest organ in the body 15% of total body weight 21 square feet
9 lbs. 11 miles of blood vessels 300 million skin cells Renews itself every 28 days ½ dust in your home is dead skin No extra holes

Pressure Injury

Pressure Injury Bedsore Decubitus Decubitus Ulcer Pressure Sore
Pressure Damage Pressure Lesion Pressure Ulcer Pressure Injury Stage 1, 2, 3 and 4 (not Stage I, II, III or IV)

Individual Death- 60,000 Americans affected: 2.5 million Painful
Quality of life

Healthcare Facilities
$15 billion Hospital stays – 3- 5x longer Increased work load Litigation Reportable Patients with Pis as primary or secondary dx are dced to LTC 3x more than other dx More dressing changes, more medications, more documentation Neglect, malpractice, elder abuse, bad publicity Reportable to state and federal agencies- published and accessible ot public

Health Care Facilities

Medical errors – 3rd leading cause of death in US
Society Medical errors – 3rd leading cause of death in US

Society

Who gets pressure injuries?
Spinal Cord Injuries - 25% - 85% Elderly with Femoral Fractures - 66% Quadriplegics - 60% Skilled Nursing Facilities - 23% 66% of pressure ulcers develop in pelvic region

Top Intrinsic Risk Factors Immobile and partially immobile Incontinent Insensate Heavily medicated Nutritional impairment Weight loss Elderly Excess moisture or dryness Medical conditions affecting blood flow Smoking Limited alertness Muscle spasms Sound like typical your clients?

Spinal cord injury Traumatic brain injury Cerebral palsy Muscular dystrophy Spina bifida Osteogenesis imperfecta Arthrogryposis Amyotrophic lateral sclerosis Multiple sclerosis Paralysis or paresis

Who gets pressure ulcers?
Alzheimer’s & Non-Alzheimer’s Dementia Parkinson’s Debility Cancers Chronic Kidney/ESRD CVA/Stroke Congestive Heart Failure (CHF) & other heart diseases Failure to Thrive Liver failure Pneumonia & non-infectious respiratory

History 2001 2007 2010 2014 2015? NPUAP established Support Surface Standards Initiative (S3I) as a task force Terms and Definitions developed and validated S3I is sanctioned by American National Standards Institute (ANSI) through RESNA to develop technical standards for support surfaces First 4 standards are approved by ANSI International Organization of Standards (ISO) creates committee to develop international standards for support surfaces mattress, integrated bed system, mattress replacement, overlay, or seat cushion or seat cushion overlay Remember from part 1, support surfaces, whether for bed or wheelchair are all designed to help reduce extrinsic risk factors and prevent ischemia or lack of blood flow and hypoxia (lack of oxygen) to the skin so it does not die or necroses. NPUAP charged a committee to review terms, definitions and testing of bed support surfaces First thing they realized is they had to define what a support surface is and NPUAP committee decided that support surface includes seat cushions. So we really need to say BED support surfaces and WHEELCHAIR support surfaces © 2015 National Pressure Ulcer Activity Panel 17

Support Surface Definition
Wounds, UK,

Categories* Powered or Non-Powered Mattress Replacement or Overlay
Reactive or Active Integrative Bed System NPUAP recommends all bed support surfaces are categorized this way * Proposed by NPUAP in 2007 as part of the Support Surfaces Standards Initiative (S3I)

Categories

Categories Pressure relief Pressure reduction Static Dynamic
Eliminated terms Pressure relief Pressure reduction Static Dynamic Clinicians, researchers and engineers that made up the NPUAP’s support surface initiative recommended we eliminate commonly used language when discussing bed support surfaces. It was suggested that static and dynamic are never used to describe support surfaces. The HPUAP initiative believes these are marketing terms and should no longer be used. Two of the biggest terms suggested for elimination were pressure relief and pressure reduction. On earth we really can’t eliminate pressure due to gravity. The best we can do is redistribute it. Remember… (go to next slide)

Pressure Redistribution
Person cannot be weightless and so cannot be completely free of pressure. Can reduce pressure over bony prominences via: Immersion & envelopment by increasing area of contact with support surface (Pressure = Force/Area) OR Contact can be temporarily removed and shifted to other areas Pressure is the primary contributing factor to Pressure Ulcers. Remember r they are not called Mystery Ulcers. Goal of any support surface is to minimize pressure by increasing the area and thereby redistributing it.

Support Surfaces What medical equipment do you typically order? Beds?
Bath equipment? Wheelchairs? Transfer devices? Communication devices? Gait trainers? Lift chairs? And virtually anything else in order to totally satisfy our clients’ needs? Bed Support surfaces?

RESNA Standards of Practice for ATPs #6. Individuals shall use available resources to meet the consumers’ identified needs including referral to other professional, practitioners or sources which may provide the needed product or service

RESNA Standards of Practice for ATPs #10. Individuals shall inform the consumer about all device options and funding mechanisms available regardless of finances, in the development of recommendations for assistive technology strategies

RESNA Standards of Practice for ATPs #11. Individuals shall consider future and emerging needs when developing intervention strategies and fully inform the consumer of those needs

RESNA Code of Ethics Hold paramount the welfare of persons served professionally Inform and educate the public on rehabilitation/assistive technology and its applications

Patient Self-Determination
Purpose: Inform patients of their rights regarding decisions toward their own medical care, and ensure that these rights are communicated by the health care provider. Goals: To prevent cruel over treatment of elderly/disabled To save money and pain Health care providers must impart full, accurate and unbiased information so patients can make informed decisions about their health care

Patient Self-Determination
"The patient's right of self-decision can be effectively exercised only if the patient possesses enough information to enable an intelligent choice....The physician has an ethical obligation to help the patient make choices from among the therapeutic alternatives consistent with good medical practice." —American Medical Association, position statement on informed consent

What caused this?

Pressure Compression hosiery is good for you
Hyperbaric therapy helps heal pressure ulcers 760 mmHg = atmospheric pressure 32 mmHg= capillary closing pressure? Controversial

Reswick and Rogers Curve
Pressure Reswick and Rogers Curve High pressure over short time = pressure ulcer Low pressure over long time = pressure ulcers

Pressure Pressure = Force/Area Maximize the Area = Lower pressure
Pressure = 100/10, then pressure is 10 Pressure = 100/100, then pressure is 1 Peak pressures or pressures over small areas, like bony prominences, are the cause of pressure ulcers

Pressure Redistribution

What caused this?

Extrinsic Risk Factors

Support Surfaces Digital Pulsation Analog Immersion Group 1
Pressure Relief Cell on Cell Zoned Lateral Rotation Microclimate Low Air Loss Reactive Envelopment Panel Lock Out Alternating Pressure True Low Air Loss Friction Coefficient Dynamic Group 2 Pressure Redistribution Blower Bottoming Out Pressure Injury Stages Pressure Mapping Static Auto Firm Moisture Vapor Transmission Rate

Group 1 US Medicare term or category for Prevention or Pressure Reduction Support Surface Low to moderate risk for pressure ulcer development Minimal redistribution of pressure Some shear decrease & microclimate control Inexpensive (compared to Group 2s) Read slide Many different kinds and types and definitions NPUAP: “Do not use small cell alternating pressure air mattresses or overlay.” “Use higher specification foam mattresses rather than standard hospital foam mattresses for al individuals assesses as big at risk for pressure ulcer development.”

Group 2 US Medicare term or category for Treatment or Pressure Relief Support Surfaces Therapeutic OR high end prevention Better (than Group 1s) for pressure redistribution and managing shear Low Air Loss designed for microclimate control Read slide Many different kinds and types and definitions Evidence NPUAP: “Replace the existing mattress with support surface that provides better pressure redistribution, shear reduction and microclimate control….” “Beds with low air loss features resulted in better healing outcomes for stage Iliad IV pressure ulcers than a foam mattress.”

Group 3 Medicare term or category for Air Fluidized beds
Most often used in LTC, Rehab, Acute care or other institutions Evidence that group 2s are just as effective for managing pressure ulcers In US, HPCPS E0194 is difficult to get covered in home Unlike Group 1 and 2 support surfaces, there is one definition for a group 3 support surface and that definition is: Bed with body support provided by thousands of tiny soda-lime glass or silicone beads suspended by pressurized, temperature-controlled air. The patient rests on a polyester filter sheet that covers the beads. Among coverage criteria is monthly documentation must state patient would have to be admitted into hospital for treatment without this E0194 Blue chip makes the Airus Group3s are not part of CB round 1 or 2 Not to be confused with E0193, a rarely used group 2 ss HPCPS that integrates a bed frame with a powered group p2 ss; Medicare describes is a powered air floatation bed

Air Fluidized A feature of a support surface that provides pressure redistribution via a fluid-like medium created by forcing air through beads as characterized by immersion and envelopment GROUP 3 – A group 3 support surface is covered if the patient has a stage III or stage IV pressure ulcer, is bedridden or chair-bound, would be institutionalized without the use of the group 3 support surface, the patient is under the close supervision of the patient’s treating physician, at least one (1) month of conservative treatment has been administered (including the use of a group 2 support surface), a caregiver is available and willing to assist with Provider needs health records stating patient care and all other alternative equipment has been considered and ruled out. Very difficult to get coverage in the home.

Zoned and Multi-zoned Zone - A segment with a single pressure redistribution capability Multi-zoned - A surface in which different segments can have different pressure redistribution capabilities Important to determine whether or not patients’ bodies fits the appropriate zones

Zoned and Multi-Zoned Single Bladder Latitudinal Longitudinal
Multi-cell Important to determine whether or not patients’ bodies fits the appropriate zones

Panel Lock Out Protects the pressure and comfort settings from ill-advised or inadvertent tampering Available with digital pumps (not analog) Read slide

Lateral Rotation A feature of a support surface that provides rotation about a longitudinal axis as characterized by degree of patient turn, duration, and frequency Drive offers lateral rotation with on demand low air loss for facilitating pulmonary drainage and pressure offloading. Drive understands lateral rotation has been proven to decrease the incidence of pneumonia, respiratory complications, and atelectasis and eliminate pulmonary congestion of the lungs.

Lateral Rotation Healthy, mobile turn several times an hour while sleeping Complications of immobility include: Pressure ulcers Urinary tract infections Pulmonary/respiratory complications Death A mobile, healthy person turns and repositions several times every hour while sleeping. Immobilized people or those with limited mobility are at risk for pressure ulcers, urinary tract infections, and pulmonary/respiratory complications such as pneumonia and actelectasis (lung collapse). If an immobile or partially immobile person is not manually turned and repositioned while in bed, negative sequelea, even death can occur.

Alternating Pressure A feature of support surfaces that provides pressure distribution via cyclic changes in loading and unloading as characterized by frequency, duration, amplitude, and rate of change parameters This is the gold standard in Europe. No real evidence and in US everything in health care is supposed to be evidence based. Gold standard in USA is LAL. APMs are firmer than LAL. Nearly all Drive models are combination LAL and APM Alternately inflates and deflates air cells to redistribute pressure

Alternating Pressure We don’t really know why it works or how to set the alternation We do know it works Various cycle times allow patients to get used to alternating More frequent probably better This is the gold standard in Europe. No real evidence and in US everything in health care is supposed to be evidence based. Gold standard in USA is LAL. APMs are firmer than LAL. Nearly all Drive models are combination LAL and APM

Pulsation How does Pulsation differ from alternating and when should pulsation be used? Pulsation differs from alternating: Duration of peak inflation is shorter Cycling time is more frequent. Pulsation is theorized to increase lymphatic drainage (may decrease extremity swelling) by having a “massaging” benefit It can also enhance patient comfort and relieve pain Gentle stimulating action aids in increased capillary blood flow to skin

Pulsation Example: reduces air flow every seconds to 50% comfort setting Many manufacturers include pulsation Accomplished in a variety of ways No clinical evidence Gentle stimulating action aids in increased capillary blood flow to skin

Low Air Loss A feature of a support surface that provides a flow of air to assist in managing the heat and humidity (microclimate) of the skin Where low air loss takes place and the moisture vapor permeable transfer rate of the cover are paramount to measuring clinical effectiveness and efficacy of low air loss and may be more important than the LPM of the pump or blower. The use of a plastic or rubber or other air blocking product on LAL, virtually eliminates the LAL’s ability to control the microclimate. Pressure redistribution, and shear and friction reduction capabilities remain

It is not all about liters per minute
Low Air Loss It is not all about liters per minute Where does the low air loss take place? What is the vapor transmission rate? Diapers, rubber lined pads, Chux? Where low air loss takes place and the moisture vapor permeable transfer rate of the cover are paramount to measuring clinical effectiveness and efficacy of low air loss and may be more important than the LPM of the pump or blower. The use of a plastic or rubber or other air blocking product on LAL, virtually eliminates the LAL’s ability to control the microclimate. Pressure redistribution, and shear and friction reduction capabilities remain

True Low Air Loss No consensus; no definition
Generally accepted that Blower must move at least 100 lpm for support surface to be True Low Air Loss

Low Air Loss

Moisture Vapor Permeable (MVP)
Measure of the passage of water vapor through a substance MVP (Moisture Vapor Permeable) = MVTR (Moisture Vapor Transmission Rate) = MVT (Moisture Vapor Transmission) . The effect of temperature has not been definitively investigated. Higher MVP rate > better control of the microclimate But High MVP= Less water resistance > maceration may occur Cleaning a cover with MVP may be more difficult High MVP rate may not protect underlying support surfaces

Is it all about the cover? MVP rates are reduced when foam mattresses are covered with non-stretch and two-way stretch covers. Patient movement can increase MVP rates Plastic or rubber lined incontinence pads or diapers virtually prevent MVP As moisture vapor transmission rate (MVTR) increases, water resistance decreases Many other variables affect MVP rates: Nylon, Urethane, Polyurethane, Polystyrene Coated Polyurethane, Neoprene, Poly Vinyl PVC + Rubber, Latex Where low air loss takes place and the moisture vapor permeable transfer rate of the cover are paramount to measuring clinical effectiveness and efficacy of low air loss and may be more important than the LPM of the pump or blower. The use of a plastic or rubber or other air blocking product on LAL, virtually eliminates the LAL’s ability to control the microclimate. Pressure redistribution, and shear and friction reduction capabilities remain

Where low air loss takes place and the moisture vapor permeable transfer rate of the cover are paramount to measuring clinical effectiveness and efficacy of low air loss and may be more important than the LPM of the pump or blower. The use of a plastic or rubber or other air blocking product on LAL, virtually eliminates the LAL’s ability to control the microclimate. Pressure redistribution, and shear and friction reduction capabilities remain

Cell on Cell or Cell in Cell
Static, firm air pressure is maintained in bottom half or inside mattress air bladder or cell via division in air bladder or cell Prevents “bottoming out” Stays inflated during power outages or patient transit Read slide This is just the description

Prevents long periods of therapy interruption
Return to Alternating Prevents long periods of therapy interruption Available with digital pumps (not analog) Read Slide Return to therapy permits therapy to begin if is left in care mode for > 2 hours Safety and care giver benefit feature

Autofirm or Max Inflate
Rapid hyper-inflation of the air cells or baffles Available with digital pumps (not analog) Easier to turn & position patients May require less force than traditional draw sheets & pillows May also decrease nursing time required for turning & repositioning patients May reduce risk of injury to caregivers' backs, shoulders & wrists & may improve patient & caregiver compliance to turning/ repositioning protocol When a support surface is set in auto firm the pressure redistribution, or ability to help get blood flow to the skin, is hampered; look for auto- reset within minutes Can also help patients transfer- firm surface Makes air cells perform like rollers, making it easier to turn & position patients, & may require less force than traditional draw sheets & pillows May also decrease nursing time required for turning & repositioning patients May reduce risk of injury to caregivers' backs, shoulders & wrists & may improve patient & caregiver compliance to turning/ repositioning protocol When a support surface is set in auto firm the pressure redistribution, or ability to help get blood flow to the skin, is hampered; look for auto- reset within 30 minutes

Static vs. Autofirm? Static stops alternation
Mattress should not be as firm in static mode as it is with autofirm Static should suspend alternation with patient somewhat immersed and enveloped into (not onto) mattress Autofirm has zero immersion or envelopment Available with analog and digital pumps

Seat Inflate or Fowler Prevents “bottoming out” when the head of bed is elevated 30 degrees or higher Extra air is pumped or blown into the air cells under the patient’s hips Can be manual, or automatic Available with digital pumps/blowers Read slide

Self-Adjusting Technology
Adjusts without outside or additional power Open or closed. Open: proper support to every patient regardless of weight with interconnected valves, plumbed to the outside air, that adjust without power. Closed has preset air chambers Easier egress/ingress Looks “homey” patient care and all other alternative equipment has been considered and ruled out. GROUP 3 – A group 3 support surface is covered if the patient has a stage III or stage IV pressure ulcer, is bedridden or chair-bound, would be institutionalized without the use of the group 3 support surface, the patient is under the close supervision of the patient’s treating physician, at least one (1) month of conservative treatment has been administered (including the use of a group 2 support surface), a caregiver is available and willing to assist with

Bottoming Out and Hand Checks
Foam and cushion check: Out stretched hand, palm up, between the undersurface of the overlay or mattress or cushion, can readily palpate patient’s boney prominences Checked with client in supine position with head flat or no more than 30 degrees elevated and in side lying position Sliding one hand vertically between the air cells and directly under the patient Should be about a hand’s width or 4 fingers of air or clearance under the patient. If there is bottoming out, means the pressure setting is inadequate (or too low) When one places an outstretched hand, palm up between the undersurface of the overlay or mattress and can feel the patient’s boney prominences. This bottoming out criterion should be tested with the patient in the supine position with the head flat and slightly elevated (no more than 30 degrees), and in the side lying position. If there is bottoming out that means the pressure setting is inadequate (or too low) Bottoming out can be checked by sliding one hand vertically between the air cells and directly under the patient. There should be about a hand’s width, or 4 fingers of air or clearance under the patient. If you can feel the patient’s body resting on your hand adjust the pressure setting towards firm Wait 10 minutes and repeat hand check. Initially set the comfort setting knob on the control unit to the softest selection Adjust towards firm as needed for patient comfort User judgment must be applied to properly adjust the pressure to the setting that best suits the patient If there is an incident of bottoming-out, simply adjust the pressure range a little higher.

Bottoming Out and Hand Checks
Use of hand checks was removed from the International Pressure Ulcers Guidelines in 2014 Softer settings generally result in more pressure redistribution A too soft setting can depress patient’s body in the center & possibly bottom the patient out Goal: Achieve a level body position (heavier pelvis will always be more immersed) with the lowest comfort setting When one places an outstretched hand, palm up between the undersurface of the overlay or mattress and can feel the patient’s boney prominences. This bottoming out criterion should be tested with the patient in the supine position with the head flat and slightly elevated (no more than 30 degrees), and in the side lying position. If there is bottoming out that means the pressure setting is inadequate (or too low) Bottoming out can be checked by sliding one hand vertically between the air cells and directly under the patient. There should be about a hand’s width, or 4 fingers of air or clearance under the patient. If you can feel the patient’s body resting on your hand adjust the pressure setting towards firm Wait 10 minutes and repeat hand check. Initially set the comfort setting knob on the control unit to the softest selection Adjust towards firm as needed for patient comfort User judgment must be applied to properly adjust the pressure to the setting that best suits the patient If there is an incident of bottoming-out, simply adjust the pressure range a little higher.

Pumps and Blowers Pumps are less powerful than blowers
Both are compressors that supply air at increased pressure Air output is measured in liters per minute (lpm) Read the slide. No one needs to be an expert but should know basics of what we sell.

Pumps and Blowers Analog pump Digital pump/Blower
Controlled by the user Adjustments have to be done by hand at the pump Digital pump/Blower Microprocessor controlled Pressure sensors react to patient movement Automatically adjust air flow to keep pressures distributed properly & effectively. Analog pumps are less expensive to manufacturer; are not necessarily weaker than digital pumps but have fewer features and no feedback

Pumps and Blowers Blower
Capable of transferring or wicking more moisture vapor away from the patient than a pump Helping to maintain the microclimate or proper skin temperature and humidity Allow greater immersion and envelopment Better offloading and greater pressure redistribution May reduce pain and enhance comfort Blowers are Better (than pumps) May be zero power outage protection with Blowers Blowers are better is what I want you to remember. When you sell our blower based low air systems for thousands of dollars I want you to know why. Later we will discuss the benefits of these features.

Immersion and Envelopment
Immersion: Depth of penetration (sinking) into a support surface. Envelopment: The ability of a support surface to conform, so to fit or mold around, irregularities of the body Immersion and envelopment are how one’s weight is distributed across the surface of the bed so as to have equal weight distribution and pressure redistribution Difficult to transfer or move Read the slide Although this prevents the patient from having pressure areas, it may make independent movement difficult. Therefore, it is important to keep in mind the mobility goals for your patient when selecting a support surface. Shear forces are minimized by having a loose fitting but tightly woven covering material Best practice: research says, highest level of immersion, up to 2/3 of body may be immersed, Immersion allows redistribution of pressure near bony prominences and increases potential for body weight to be shifted to areas around other bony prominences. Examples of irregularities that affect envelopment are cares in clothing, bedding or seat covers. Poor=only enveloping support surfaces may cause locally high peak pressure the could increase the risk to tissue break down

Immersion and Envelopment
Read the slide Although this prevents the patient from having pressure areas, it may make independent movement difficult. Therefore, it is important to keep in mind the mobility goals for your patient when selecting a support surface. Shear forces are minimized by having a loose fitting but tightly woven covering material Best practice: research says, highest level of immersion, up to 2/3 of body may be immersed, Immersion allows redistribution of pressure near bony prominences and increases potential for body weight to be shifted to areas around other bony prominences. Examples of irregularities that affect envelopment are cares in clothing, bedding or seat covers. Poor=only enveloping support surfaces may cause locally high peak pressure the could increase the risk to tissue break down

Hammocking Hammock Effect - The tight cover prevents immersion and envelopment of the patient, resulting in suspension above the support surface and no pressure redistribution Fitted sheets are generally discouraged to avoid “hammocking” across the deflating, during alteration, cells & to allow for full immersion and envelopment with low air loss mattresses. The “tucking in” of a fitted sheet may apply residual pressure to the skin during the off-loading cycle in alteration.

Heel Slope Foot end of the mattress slopes down
Increases load on the calves Decreases load on the heels On average, heel pressures are reduced by about 27% with heel slopes compared to flat designs The USA’s National Pressure Ulcer Advisory Panel (NPUAP) has issued this directive: “Ensure that the heels are free of the surface of the bed. Heel-protection devices should elevate the heel completely (offload them) in such a way as to distribute the weight of the leg along the calf.“

Support Surface Standards Initiative (S3I)
Evidence? Support Surface Standards Initiative (S3I) Read the slide Guidance is often quoted. Current evidence remains inconclusive NPUAP: Among their concerns are the following: Conclusion based on admittedly low-quality studies Absence of certain studies that limits making a definitive inference, such as conducting a study on the same mattress with and without air escaping through the cover in order to isolate the effect of the LAL feature; there is no such study in the literature Imprecise description of clinical situations

Pressure Mapping Pressure mapping had a low to inverse
Read the slide Guidance is often quoted. Current evidence remains inconclusive NPUAP: Among their concerns are the following: Conclusion based on admittedly low-quality studies Absence of certain studies that limits making a definitive inference, such as conducting a study on the same mattress with and without air escaping through the cover in order to isolate the effect of the LAL feature; there is no such study in the literature Imprecise description of clinical situations Pressure mapping had a low to inverse correlation to pressure ulcer prevalence

Evidence? NPUAP: Among their concerns are the following:
Read the slide Guidance is often quoted. Current evidence remains inconclusive NPUAP: Among their concerns are the following: Conclusion based on admittedly low-quality studies Absence of certain studies that limits making a definitive inference, such as conducting a study on the same mattress with and without air escaping through the cover in order to isolate the effect of the LAL feature; there is no such study in the literature Imprecise description of clinical situations

Evidence There is no standardize testing or requirements for support surfaces “Appropriate support surfaces or devices should be chosen by matching a device’s potential therapeutic benefit with the resident’s specific situation: for example, multiple ulcers, limited turning surfaces and ability to maintain position” Read the slide Guidance is often quoted. Current evidence remains inconclusive NPUAP: Among their concerns are the following: Conclusion based on admittedly low-quality studies Absence of certain studies that limits making a definitive inference, such as conducting a study on the same mattress with and without air escaping through the cover in order to isolate the effect of the LAL feature; there is no such study in the literature Imprecise description of clinical situations

Evidence Wound, Ostomy, Continence Nurses Society (WOCN)
Insufficient evidence to support the choice of one specific pressure redistribution surface/device over another At-risk patients should not be placed on an ordinary, standard hospital mattress. Consider other than interface pressure e.g., skin surface tension, shear force, temperature, humidity, the magnitude & duration of interface pressure, pressure & blood flow distribution & adult versus pediatric patients Read slide WOCN is the Wound Ostomy Continence society. When one refers to a wound care nurse they are usually CWOCNS, Certified Wound Ostomy Continence Nurses No one agrees and there is no evidence.

Federal Tag 314 (F-Tag 314) Evidence
“Appropriate support surfaces or devices should be chosen by matching a device’s potential therapeutic benefit with the resident’s specific situation: for example, multiple ulcers, limited turning surfaces and ability to maintain position.” Federal Tag 314 came around in It pertains to LTC document on preventing and treating pressure ulcers

All concerned groups agree that more investigation is needed
Evidence Despite being inconclusive and requiring more studies, there is evidence in the literature that indicates the effectiveness of certain therapy support surfaces in specific patient conditions All concerned groups agree that more investigation is needed When folks ask for proof and pressure mapping studies remind them of the evidence.

Evidence They’re not called Mystery Ulcers Pressure Redistribution is the mainstay for the prevention of pressure ulcers in at risk individuals. NPUAP Recommended AGAINST including pressure redistribution mattresses as part of the Competitive Bidding process

Evidence

Match the Product to the Patient
NPUAP/EUAP position WOCN society position Other pressure ulcer governing bodies NPUAP: Provide a support surface that is properly matched to the individual’s needs for pressure redistribution, shear reduction, and microclimate control When Providers and their customers ask us to give them a decision tree for support surfaces, like many other manufactures, we can, but we prefer to teach Match the patient to the product

Clinical Decision Making
Ask 8 Questions

8 Questions How does the patient transfer? Is the patient continent?
Does the patient have a hospital bed or are they willing to get hospital bed? Height and weight? Prior experience on support surfaces? Does patient lie supine all day without repositioning? With head of bed or foot of bed elevated over 30 degrees for > 2 hours each day? Is the patient/caregiver or facility worried about power outage or electric bills? Is falling or climbing out of bed a concern?

Funding?

Case Study A Francis is a 61-year-old female with multiple sclerosis, leaving her bedridden and unable to move her legs. Despite being on a gel overlay, she has developed a stage 3 pressure ulcer at her sacrum perhaps because she refuses to be turned due to the severe pain she experiences each time her right leg is moved. This has made it very difficult for caregivers to provide wound care and keep Francis clean. Furthermore, pain medication has not been effective for Francis’ very intense but transient pain. What bed support surface(s) would help keep Francis happy and healthy at home?

Do you agree with what was ordered? Why or why not?
Case Study B Mr. Diamond is a 90-year-old man who has been admitted to the hospital with pneumonia. He fell at home three months ago and was also hospitalized at that time for a fractured ankle and a stage 2 pressure injury on his right greater trochanter. After 7 days in the hospital Mr. Diamond is discharged to home with a hospital bed and wheelchair and home health care. The admitting HHA nurse finds Mr. Diamond to be very thin; he weighs 10 pounds less than when he was hospitalized after his fall. His diaper is saturated with urine, and his perineal skin is raw. He does not move himself in the bed and his equally elderly wife says she is having difficulty caring for him. Mrs. Diamond says that her husband does not eat well, often does not take all his medications and does not like to get out of bed. The nurse recognizes that Mr. Diamond is at high risk for developing a full thickness pressure injury and orders a donut cushion and fake sheep skin heel booties. Do you agree with what was ordered? Why or why not?

Case Study Mr. Brad Tamblyn is an 88 year old male with primary diagnoses of CHF, CVA, left hemiplegia, and bilateral lower leg lymphedema. 210 lbs., 5’ 5” tall. Medical HX: Recurrent stage 2 sacral pressure injuries; recently diagnosed with Alzheimer’s. For the past 10 years Mr. Tamblyn has used a power wheelchair for mobility and independence but can no longer safely drive his power wheelchair; he’s reluctantly getting used to a mwc; recently left home for an assisted living residence. Wellness Director asked you to help “get Brad what he needs.”

Case Study Mr. Wes Wadden, 55 years old, 5'10" 175 pounds, is a well-nourished, non-smoker, diagnosed with Amyotrophic Lateral Sclerosis five years ago. He can no longer walk more than a few steps with a walker and has been confined to bed or wheelchair for the past two months. He cherishes any remaining independence he has and refuses to sleep in a hospital bed, preferring to sleep in his queen sized bed with his wife. Mr. Wadden can still stand for an assisted stand and pivot transfer. He does not want to use a patient lift. His medical history is significant for re-occurring stage 1 pressure ulcers on his sacrum and coccyx, and chronic pain.

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