2. Right Equipment…. Half the Story
Jacqui Fletcher Clinical Strategy Director
Welsh Wound Innovation Centre
@jacquifletcher3.....

3. 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’

4. 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 

5. 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

6. PRESSURE trial
Technical problems with mattresses 207 (on 131 overlays) and 370 (on 223 replacements)
Problems were
Nixon et al 2006

7. Nixon et al 2006 Problem Overlay Replacement Total
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
6 (3.5%)
10 (2.6%)
Unknown
5 (2.4%)
2 (1.2%)
7 (1.8%)
Nixon et al 2006

8. Inappropriate use of equipment — a source of skin damage and complaint

9. Patients vary considerably in size and body mass, yet we expect our equipment to cope with the majority of patients – is this reasonable?

10. 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?

11. Flat
Contoured
Mattress
195 cm
186 cm
Person
181 cm
210 cm

12. 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

14. When you do this
You may get this……
The heels travel along the mattress up to 15cm with the associated friction and shear forces

15. Doing this
can cause this

16. Changing shape?
Stress – force transferred per unit area of tissue (comes from both pressure and shear) Strain – measure of the amount of deformation

17. 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

18. Flat
Contoured
Mattress
195 cm
186 cm
Person
181 cm
210 cm
When you contour the foam over the frame it squeezes under the seat – and tries (but fails) to stretch under the knees

19. 2 piece frame
3 piece frame
4 piece frame

20. But the frame also needs a mattress!

21. Make the foam contour to the bed frame….
Stop the heels sliding
Stop the feet pressing on the bed end
Makes the mattress longer!

22. The effective use of add-on equipment — risk / benefit analysis, optimising pressure relief decision-making

23. Audit of appropriateness of equipment use
Not at risk
At Risk
High Risk
VHigh Risk
Not done
Arise 2 1
Foam
207
292
186 38 41
Dolphin
Duo2 10 21 33
Other
Primo 4 18 56 88
Repose 44
156
194 89

24. You could use add on equipment

25. 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

26. 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

27. Getting the best from your resources — releasing time to care

28. Jones & Tite 2013

29. 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.

30. 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!

31. 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

32. 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?

33. Heel assessment

34. Releasing time to care Getting it right Keeping it simple
Looking at the obvious – not creating a different problem by solving a problem!

35. 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 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,

36. jacqui.fletcher@wwic.wales
Thank You
@jacquifletcher3.....