SIMPLE INTERVENTIONS. EXTRAORDINARY OUTCOMES.

Transcription

1 SIMPLE INTERVENTIONS. EXTRAORDINARY OUTCOMES. Sage Products believes that evidence-based interventions lead to improved clinical outcomes. Our market-leading, innovative products solve real problems in the healthcare industry and are backed by proven clinical evidence. They make it easier for nurses to deliver essential patient care, helping to prevent healthcare-acquired infections and skin breakdown. Sage Products LLC 3909 Three Oaks Road Cary, Illinois USA Sage Products LLC 2016

2 Pressure Ulcer Prevention Comfort Shield Barrier Cream Cloths Prevalon Heel Protector Prevalon Turn & Position System Prevalon Seated Positioning System Simple Interventions. Extraordinary Outcomes.

3 Incontinence-Associated Dermatitis (IAD): a risk factor for pressure ulcers IAD is defined as an inflammation of the skin that occurs when urine or stool comes into contact with perineal or perigenital skin. 1 IAD is also a major risk factor for pressure ulcers. 2 IAD is often grouped with pressure ulcers, but they are not one and the same. A pressure ulcer is defined as any lesion caused by unrelieved pressure resulting in damage of underlying tissue. 3 Essentially, skin damage from a pressure ulcer occurs from the inside out, but IAD starts on the surface and works inward. Therefore, IAD should be distinguished from wounds caused by differing etiologies, such as full-thickness wounds (caused by pressure and shear) or linear lesions (caused by a skin tear). 1 IAD risk factors: 1 n Fecal incontinence n Frequency of incontinence n Poor skin condition n Pain n Poor skin oxygenation n Fever n Compromised mobility n Double (urinary and fecal) incontinence n Tissue tolerance impairments n Moisture n Alkaline ph REFERENCES: 1. Gray M, et al., J Wound Ostomy Continence Nurs Jan-Feb;34(1): Maklebust J, Magnan MA, Adv Wound Care. Nov 1994;7(6):25, 27-8, 31-4 passim. 3. Getting started kit: prevent pressure ulcers, how-to guide. Protecting 5 Million Lives From Harm Campaign, Institute for Healthcare Improvement Dec. 4. Gray M, Lerner-Selekof J, Junkin J, CE symposium in conjunction with 2006 WOCN Conference, Minneapolis, MN, 2006 June. 5. Junkin J, Moore-Lisi G, Lerner-Selekof J, What we don t know can hurt us: pilot prevalence survey of incontinence and related perineal skin injury in acute care. Poster presented at the Clinical Symposium on Advances in Skin and Wound Care (ASWC), Las Vegas, NV, 2005 Oct. 1 sage.uk@sageproducts.com

4 IAD prevalence Studies at long-term care facilities show IAD prevalence can range from 5.6% to 50%, while incidence rates range from 3.4% to 25%. 1 In acute care, one 976-patient study found 20.3% of patients were incontinent. 4,5 IAD prevalence for incontinent patients was 54% at three hospitals, affecting 11% of the general patient population. 4,5 Patients with fecal incontinence were 22 times more likely to have pressure ulcers than patients without fecal incontinence. 2 The odds of having a pressure ulcer were 37.5 times greater in patients who had both impaired mobility and fecal incontinence than in patients who had neither

5 Inadequate barrier application: a gateway to Incontinence- Associated Dermatitis (IAD) Multiple steps associated with traditional methods of incontinence care often mean barrier application is overlooked. Protecting the skin of incontinent patients is just as important as cleansing and moisturizing, 1 and failure to apply a proper barrier can lead to Incontinence-Associated Dermatitis (IAD), a known risk factor for pressure ulcers. 2 One study shows 54% of incontinent patients suffered from IAD, while 21% had two or more peri-skin injuries. 3,4 Barriers severely underutilized Compliance to a comprehensive protocol can help prevent skin injuries. 5,6 But tubed barriers can make compliance difficult. n A study of 76 protocols found barriers should cost 23.5 cents for each application, but facilities actually spend only 10 cents per day per incontinent patient. 7 REFERENCES: 1. Haugen V, Gastroenterology Nursing, 1997;20(3): Maklebust J, Magnan MA, Adv Wound Care. Nov 1994;7(6):25, 27-8, 31-4 passim. 3. Gray M, Lerner-Selekof J, Junkin J, CE symposium in conjunction with 2006 WOCN Conference, Minneapolis, MN, 2006 June. 4. Junkin J, Moore-Lisi G, Lerner- Selekof J, What we don t know can hurt us: pilot prevalence survey of incontinence and related perineal skin injury in acute care. Poster presented at the Clinical Symposium on Advances in Skin and Wound Care (ASWC), Las Vegas, NV, 2005 Oct. 5. Lyder CH, et al., Ost/Wound Mgmt Apr 2002;48(4): Clever K, et al., Ost/Wound Mgmt Dec 2002;48(12): Nix D, Ermer-Seltun, J Ost/Wound Mgmt Dec 2004;50(11): sage.uk@sageproducts.com

6 Comfort Shield Barrier Cream Cloths deliver proven IAD prevention and treatment Comfort Shield Barrier Cream Cloths provide easy, all-in-one incontinence care. Each premoistened, disposable cloth delivers one-step perineal cleansing, moisturizing and deodorizing all while treating and protecting skin with 3% dimethicone. The barrier is in the cloth, so you can be assured it is applied every time. Plus, our Peri Check Guide helps promote early identification of IAD through increased communication with staff. One-step: Clean + treat + protect Shield Barrier Cream Cloths are soft, skin-friendly and guarantee barrier application every time they re used. Keeping the skin protected means IAD and other skin problems can be prevented. PROVEN IAD TREATMENT SEE THE DIFFERENCE! 1 DAY 1 DAY 4 72-year-old patient with severely denuded, blistered skin and extreme pain from incontinence. After only 3 days using Shield Barrier Cream Cloths, patient s skin vastly improved; no discomfort. REFERENCES: 1. Sluser S, Consistency the key for treating severe perineal dermatitis due to incontinence. Poster presented at Clinical Symposium on Advances in Skin and Wound Care (ASWC), Las Vegas, NV, 2005 Oct

7 Proven clinical outcomes PROFESSIONAL GUIDELINES 2009 EUROPEAN PRESSURE ULCER ADVISORY PANEL AND NATIONAL PRESSURE ULCER ADVISORY PANEL 1 Prevention and Treatment of Pressure Ulcers Skin Care 12. Protect the skin from exposure to excessive moisture with a barrier product in order to reduce the risk of pressure damage.... n Randomized controlled trial proves effectiveness A 4-month study of 464 nursing home residents evaluated use of Shield Barrier Cream Cloths versus water and ph neutral soap. Residents using Shield saw a reduction in the prevalence of IAD from 22% to 8%, while residents using soap and water saw IAD prevalence increase from 23% to 27%. The study also found a decrease in IAD severity in residents using Shield, while no improvement was seen with soap and water GLOBAL IAD EXPERT PANEL 2 Prevention and Management of IAD After cleansing, skin should be protected to prevent IAD. The performance of an individual product is determined by the total formulation and not just the skin protecting ingredient(s). Continence care wipes (i.e. 3-in-1 products) may have the advantage of simplifying care by combining products to reduce the number of steps involved, saving clinician/ caregiver time and potentially encouraging adherence to the regimen. A UK study found a 54% reduction in IAD after implementing the Shield Barrier Cream Cloths. 5 A skin cleanser with a ph range similar to normal skin is preferred over traditional soaps WOCN GUIDELINE FOR PREVENTION AND MANAGEMENT OF PRESSURE ULCERS MANAGING INCONTINENCE 3 Combined products can be used to save time and make providing perineal care easier for the care giver. Combined products include moisturizing cleansers, moisturizer skin protectant creams, and disposable washcloths that incorporate cleansers, moisturizers, and skin protectants into a single product. (Beeckman, et al., 2009) REFERENCES: 1. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel; Beeckman, D et al., Evidence-based Practice in Wound Care: Toward Addressing Our Knowledge Gaps. The Journal of Rehabilitation Research and Development JRRD 48.3 (2011): Vii. Incontinence-Associated Dermatitis: Moving Prevention Forward. Wounds International. Web. 21 Jan Wound Ostomy and Continence Nurses Society. Guideline for Prevention and Management of Pressure Ulcers; June Beeckman D, et al., A 3-in-1 perineal care washcloth impregnated with dimethicone 3% versus water and ph neutral soap to prevent and treat incontinence-associated dermatitis. Journal of Wound, Ostomy and Continence Nursing, Nov/Dec 2011; 38(6). 5. Pukiova I. Clean, Moisturise and Protect! A Standardization Approach to Preventing Incontinence-Associated Dermatitis. Poster presented at EWMA 2015; London, UK; May, Heinemann K. Effectiveness of a clinically proven 3-in-1 perineal care washcloth in the prevention of IAD on a geriatric unit. Poster presented at EPUAP 2015; Ghent, Belgium; September. 7. Hall K, Clark R, Henderson K, Implementing nurse-driven interventions to improve incontinence-associated dermatitis and hospital-acquired pressure ulcers. Poster presented at Clinical Symposium on Advances in Skin & Wound Care, Sept n In a study on a high-risk patient population, patients receiving an intervention that included Shield Barrier Cream Cloths following each incontinence episode had an IAD rate of zero versus patients using multiple products who had an IAD rate of 25%. Patients using Shield had a rate of zero hospital-acquired pressure ulcers versus a rate of 83% for those using multiple products. 7 Patients who developed IAD and HAPU 30% 25% 20% 15% 10% 5% 0% A German study found a 57% reduction in IAD after implementing the Shield Barrier Cream Cloths. 6 DEVELOPMENT OF IAD AND HAPU 6/24 5/24 Control Group 83% of patients who developed IAD went on to develop HAPU 0/25 0/25 Developed IAD Developed HAPU Intervention Group 5 sage.uk@sageproducts.com

8 Comfort Shield Barrier Cream Cloths with Dimethicone OURS THEIRS Comfort Comfort Shield Barrier Cream Cloths are strong and absorbent. They gently cleanse while delivering a proven layer of barrier protection. Clinically proven to help prevent IAD and HAPU when used as part of a standardized incontinence cleanup intervention/protocol. The all-in-one skin cleansing, moisturizing, deodorizing, treatment and barrier protection with ever use that helps maximize compliance to incontinence care protocols. n Proven barrier protection. 3% dimethicone formula was proven equivalent to traditional tube barrier creams by Northwestern University s Department of Dermatology. 1 n Hypoallergenic, gentle and non-irritating. n Breathable, transparent dimethicone barrier makes skin assessment easy. n Allows the use of other products such as anti-fungals without removing dimethicone barrier. n Helps eliminate mess of standard zinc oxide and petroleum-based barriers; makes each cleanup easier. n Helps treat and prevent perineal dermatitis; helps seal out wetness. n Convenient tubs contain 24 cloths for extended use. Not all skin barrier cloths are equal A study designed to test the effectiveness of incontinence barriers found that Comfort Shield significantly outperformed all other products. Comfort Shield allowed 3-5 times less artificial urine to pass through than the leading competitors. 2 Comfort Shield thick emulsion Vs. Others Barrier effectiveness and product performance characteristics should be considered when choosing skin protectant products designed for barrier effect. REFERENCES: 1. West D, Northwestern Univ Dept of Dermatology, Chicago, IL, Feb West D, Comparison of Skin Barrier Effectiveness for Products Containing Dimethicone. Poster presented at: Symposium on Advanced Wound Care, Fall 2014, Oct ; Las Vegas, NV

9 Maximize compliance Help meet IHI recommendations to keep supplies at the bedside of at-risk incontinent patients 1 Implementing Shield Barrier Cream Cloths and providing bedside access enhanced staff compliance to an incontinence care protocol and resulted in a nearzero rate of HAPUs. The rate was maintained over time and resulted in significant cost savings. 2 n Point-of-use access. 24-packs, 8-pack, and 3-pack all compatible with Shield Barrier Station. Help meet IHI recommendations to keep supplies at the bedside of at-risk incontinent patients 1 REDUCE IAD, IMPROVE COMPLIANCE Adding Shield Barrier Station reduced one facility s IAD incidence to 0% and boosted compliance to 97%!* *Schmitz T, Location, location, location: incontinence care supplies at the bedside. Nursing Management, Dec 2010, CE available. REFERENCES: 1. Getting started kit: prevent pressure ulcers, how-to guide. Protecting 5 Million Lives from Harm Campaign, Institute for Healthcare Improvement, 2006 Dec. 2. Krapfl L, Improved access to incontinence care products leads to a reduction in facility acquired pressure ulcers. Poster presented at 42nd Annual WOCN Conference, June 12-16, sage.uk@sageproducts.com

10 Peri Check Guide Promote early identification of a major pressure ulcer risk factor Comfort Shield Barrier Cream Cloths feature Peri Check Guide peel-and-stick labels to facilitate daily skin inspection. They empower staff to observe and report skin issues to the patient s nurse, and promote rapid response through early identification of skin breakdown and Incontinence-Associated Dermatitis (IAD), a known risk factor for pressure ulcers. In one study, Peri Check helped reduce pressure ulcers to zero in a facility. 2 The same study found that Peri Check improved non-licensed staff s knowledge about pressure ulcer development and resulted in enhanced communication between non-licensed staff and RNs EUROPEAN PRESSURE ULCER ADVISORY PANEL AND NATIONAL PRESSURE ULCER ADVISORY PANEL 3 Prevention and Treatment of Pressure Ulcers Skin Assessment 3. Inspect skin regularly for signs of redness in individuals identified as being at risk of pressure ulceration. 7. Document all skin assessments, noting details of any pain possibly related to pressure damage.... JOINT COMMISSION 2009 National Patient Safety Goals 4 Improve Staff Communication Create steps for staff to follow when sending patients to the next caregiver. The steps should help staff tell about the patient s care. Make sure there is time to ask and answer questions. * Excerpts from the Joint Commission 2009 Hosp Nat Pt Safety Goals.... IHI 5 MILLION LIVES CAMPAIGN 5 2. Reassess Risk for All Patients Daily Adapt documentation tools to prompt daily risk assessment, documentation of findings, and initiation of prevention strategies as needed. * 3. Inspect Skin Daily Educate all levels of staff to inspect the skin any time they are assisting the patient Upon recognition of any change in skin integrity, notify staff so that appropriate interventions can be put in place. *Processes that can be put in place to ensure daily inspection of the skin. REFERENCES: 1. Federal Register, Vol. 72 No. 162, 2007 Aug; Carr D, Benoit R, The role of interventional patient hygiene in improving clinical and economic outcomes. Advances in Skin and Wound Care, Feb (2): European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel; Hospital/Critical Access Hospital National Patient Safety Goals. Joint Commission, Getting started kit: prevent pressure ulcers, how-to guide. Protecting 5 Million Lives from Harm Campaign, Institute for Healthcare Improvement, 2006 Dec

11 IAD Assessment Tool For monitoring and evaluating patient skin injury Create awareness of patient skin condition and facilitate clinical intervention. Damage from moisture and pressure ulcers are among the most common skin injuries. However, a large percentage of these injuries can be avoided. Your Sage Representative will provide a a brief, yet thorough Incontinence- Associated Dermatitis (IAD) Assessment in your facility to help you: n Identify skin issues at the two most common sites for pressure ulcers: the heels and the sacrum. n Track your facility s prevalence rate of IAD, a risk factor for pressure ulcers. n Improve awareness of your facility s compliance to protocol. n Target effective interventions, which may improve patient outcomes. n Illustrate the benefits of using Sage s skin-protecting interventions both clinically and financially. LET US HELP YOU VALIDATE YOUR SUCCESS! Protect YOUR patients skin before skin injury develops into a pressure ulcer. n Incontinence is a significant risk factor for skin breakdown 1, such as pressure ulcers and incontinence-associated dermatitis (IAD). Applying a barrier after each episode with Comfort Shield Barrier Cream Cloths can help prevent these conditions. Clinically significant published outcomes. n One facility saw a 53% decrease in IAD over a 10-month period after implementing an IAD Prevention Strategy including the use of Comfort Shield Barrier Cream Cleansing Cloths at the bedside. 2 n Ask your Sage Representative to provide you with additional clinical outcomes. REFERENCES: 1. Maklebust J, Magnan MA, Adv Wound Care. Nov 1994;7(6):25,27-8,31-4 passim. 2. MacPherson SAWC sage.uk@sageproducts.com

12 Copyright 2008 Joan Junkin. All rights reserved. Please send request for permissions to 1. Bliss DZ, Zehrer C, Savik K, et al. Incontinence-associated skin damage in nursing home residents: a secondary analysis of a prospective, multicenter study. Ostomy Wound Manage. 2006;52: Institute for Healthcare Improvement. Prevent Pressure Ulcers: How-To Guide. May Available at: accessed 10/21/ Gray M, Bliss DB, Ermer-Seltun J, et al. Incontinence-associated dermatitis: a consensus. J Wound Ostomy Continence Nurs. 2007;34: IAD-IT INCONTINENCE-ASSOCIATED DERMATITIS INTERVENTION TOOL (IAD-IT) 1. Cleanse incontinence ASAP and apply barrier. 2. Document condition of skin at least once every shift in nurse s notes or per organization s policy for documenting skin breakdown. HIGH-RISK EARLY IAD MODERATE IAD SEVERE IAD FUNGAL APPEARING RASH Skin Care for Incontinent Persons The #1 priority is to address the cause of incontinence. Use this tool until incontinence is resolved. DEFINITION Skin is not erythematous or warmer than nearby skin but may show scars or color changes from previous IAD episodes and/or healed pressure ulcer(s). Person not able to adequately care for self or communicate need and is incontinent of liquid stool at least 3 times in 24 hours. 1 Skin exposed to stool and/or urine is dry, intact, and not blistered, but is pink or red with diffuse (not sharply defined), often irregular borders. In darker skin tones, it might be more difficult to visualize color changes (white or yellow color) and palpation may be more useful. Palpation may reveal a warmer temperature compared to skin not exposed. People with adequate sensation and the ability to communicate may complain of burning, stinging, or other pain. Affected skin is bright or angry red in darker skin tones, it may appear white, yellow, or very dark red/purple. Skin usually appears shiny and moist with weeping or pinpoint areas of bleeding. Raised areas or small blisters may be noted. Small areas of skin loss (dime size) if any. This is painful whether or not the person can communicate the pain. Affected skin is red with areas of denudement (partial-thickness skin loss) and oozing/bleeding. In dark-skinned persons, the skin tones may be white, yellow, or very dark red/purple. Skin layers may be stripped off as the oozing protein is sticky and adheres to any dry surface. This may occur in addition to any level of IAD skin injury. Usually spots are noted near edges of red areas (white or yellow areas in dark skinned patients) that may appear as pimples or just flat red (white or yellow) spots. Person may report itching which may be intense. 3. Notify primary care provider when skin injury occurs and collaborate on the plan of care. 4. Consider use of external catheter or fecal collector. 5. Consider short term use of urinary catheter only in cases of IAD complicated by secondary infection. INTERVENTION 1. Use a disposable barrier cloth containing cleanser, moisturizer and protectant If barrier cloths not available, use acidic cleanser (6.5 or lower), not soap (soap is too alkaline); cleanse gently (soak for a minute or two no scrubbing); and apply a protectant (ie: dimethicone, liquid skin barrier or petrolatum). 3. If briefs or underpads are used, allow skin to be exposed to air. Use containment briefs only for sitting in chair or ambulating not while in bed. 4. Manage the cause of incontinence: a) Determine why the patient is incontinent. Check for urinary tract infection, b) Consider timed toileting or a bladder or bowel program, c) Refer to incontinence specialist if no success. 3 Include treatments from box above plus: 5. Consider applying a zinc oxide-based product for weepy or bleeding areas 3 times a day and whenever stooling occurs. 6. Apply the ointment to a non-adherent dressing (such as anorectal dressing for cleft, Telfa for flat areas, or ABD pad for larger areas) and gently place on injured skin to avoid rubbing. Do not use tape or other adhesive dressings. 7. If using zinc oxide paste, do not scrub the paste completely off with the next cleaning. Gently soak stool off top then apply new paste covered dressing to area. 8. If denuded areas remain to be healed after inflammation is reduced, consider BTC ointment (balsam of peru, trypsin, castor oil) but remember balsam of peru is pro-inflammatory. 9. Consult WOCN if available. Include treatments from box above plus: 10. Position the person semiprone for 30 minutes twice a day to expose affected skin to air. 11. Consider treatments that reduce moisture: low air loss mattress/overlay, more frequent turning, astringents such as Domeboro soaks. 12. Consider the air flow type underpads (without plastic backing). Ask primary care provider to order an anti-fungal powder or ointment. Avoid creams in the case of IAD because they add moisture to a moisture damaged area (main ingredient is water). In order to avoid resistant fungus, use zinc oxide and exposure to air as the first intervention for fungal-appearing rashes. If this is not successful after a few days, or if the person is severely immunocompromised, then proceed with the following: 1. If using powder, lightly dust powder to affected areas. Seal with ointment or liquid skin barrier to prevent caking. 2. Continue the treatments based on the level of IAD. 3. Assess for thrush (oral fungal infection) and ask for treatment if present. 4. For women with fungal rash, ask health care provider to evaluate for vaginal fungal infection and ask for treatment if needed. 5. Assess skin folds, including under breasts, under pannus, and in groin. 6. If no improvement, culture area for possible bacterial infection

13 PREVALENCE AND COST The heel and ankle bone are the second and fifth most common sites for pressure ulcer development. 1 One study found 43% of hospital-acquired pressure ulcers (HAPUs) developed on the heel. 2 But, HAPUs are largely preventable. 3 HUMAN COST 4,5,6 n Pain n Length of stay n Infection risk n Amputation PREVALON HEEL PROTECTOR Uniquely designed to prevent heel pressure ulcers while keeping the foot and leg in a neutral position. Professional guidelines and recommendations HEEL ULCER PREVENTION NPUAP/EPUAP Prevention Guidelines 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 without putting pressure on the Achilles tendon. 8 Wound Ostomy and Continence Nurses Society Guidelines Maintaining alignment [with a pillow] may be difficult if the patient moves. In addition, pillows do not prevent plantar flexion contracture or lateral leg and foot rotation. 9 FINANCIAL COST: PU Stage Treatment Cost 7 I 1,000 II 6,000 III 10,000 IV 14,000 A published study recommended patients be treated with a heel-suspending device after a minimum of 6 hours of immobility and within 24 hours of immobility to prevent plantar-flexion contractures. 8 REFERENCES: 1. Amlung SR, Miller WL, Bosley LM, Adv Skin Wound Care. Nov/Dec 2001;14(6): Walsh J, DeOcampo M, Waggoner D, Keeping heels intact: evaluation of a protocol for prevention of facility-acquired heel pressure ulcers. Poster presented at the Symposium on Advanced Wound Care, San Antonio, TX, Apr Beckrich K, Aronovitch SA, Nursing Economic. Sep/Oct 1999;17(5): Fowler E, Scott-Williams S, McGuire J. Practice recommendations for preventing heel pressure ulcers. Ostomy Wound Management 2008;54(10): Russo, AC, at al., Hospitalizations Related to Pressure Ulcers Among Adults 18 years and Older, 2006, Heath Care Cost and Utilization Project, Agency for Health Care Research and Quality Statistical Brief #64, Dec Mannari, at al Successful Treatment of Recalcitrant Diabetic Heel Ulcers with Topical Becaplermin (rh PDGF-BB) Gel, Wounds. 2002;14(3). 7. NHS Department of Health Pressure Ulcer productivity calculator. First published 10 June Available at Accessed January 12, Cuddigan JE, Ayello EA, Black J. Saving heels in critically ill patients. WCET Journal. 2008;28(2): Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for prevention and management of pressure ulcers. Mount Laurel (NJ): June p. (WOCN clinical practice guideline; no. 2). 11 sage.uk@sageproducts.com

14 The experts suggest the optimal heel protector should: 3 Elevate the heel off underlying support surface. 1 3 Prevent foot-drop and rotation of the leg. 1 3 Maintain grip on the foot while in place as patients may be moving the leg. 1 3 Decrease friction and/or shear. 1 3 Heel is visible when the device is in place. 3 3 No pressure on the Achilles tendon. 3 3 Ability to accomodate sequential compression devices, negative pressure wound therapy, tubing, traction and other essential devices. 3 3 Has straps that do not damage skin and are loosely applied to avoid pressure on dorsum and lateral edge of foot and the lower leg. 3 3 Remains in place without causing pressure to other foot surfaces. 2 3 A device with an anti-rotation wedge maintaining neutral position of the lower extremity to prevent hip external rotation and subsequent lateral knee and/or malleoli pressure ulcers and/or peroneal nerve compression. 3 Presented at EWMA 2015 London, UK May, 2015 REFERENCES: 1. Lyder C. Never Events: Can The Congressional Mandate Be Met? Poster Presented at the Institute of Health Care Improvement (IHI), Orlando, FL December 6-8, Rajpaul K., The use of heel protectors in the prevention, treatment and management of pressure ulcers. Poster presented at EWMA 2015; London, UK; May 13-15, Loehne H. Limited Mobility and the Foot: Plantar Flexion Contractures, Heel and Malleoli Pressure Ulcers, Peroneal NerveDamage How Can We Prevent Them? What Happens If We Don t? Poster presented at the 26th Annual Symposium on Advanced Wound Care (SAWC); May 1-5,

15 The foundation of an effective heel protector: its ability to grip the limb Prevalon s unique dermasuede interior gently grips the foot Prevalon Heel Protector was specifically designed to address the problem of patient movement and its negative effect on heel offloading. Prevalon s unique dermasuede fabric interior gently grips the limb so it remains fully offloaded, even when the patient is moving. Our specialized fabric and coating creates maximum grip control with the texture of fine velvet. This soft fabric contours to and cradles the leg, calf, ankle and foot to help prevent them from rotating within the boot or sliding out of the boot maintaining effective heel offloading. PUBLISHED STUDIES Several published studies show that a heel protector must stay in place on the foot and maintain offloading for effective prevention of heel pressure ulcers. n A recent poster presented at the Symposium on Advanced Wound Care concluded as patients shift, the ability of a heel protecting boot to grip the limb and retain optimal off-loading positioning is vital to the function of the device. Furthermore, the study found evaluation of the heel protector s grip is necessary for determining effectiveness in reducing risk of heel pressure ulcers. 1 n One article found that a heel protector was more effective in reducing heel PrU incidence if it did not dislodge during patient movement. 2 n According to another article, clinical considerations in selecting an optimal heel protector should include the device s ability to remain in place while the patient is moving the leg. 3 Dermasuede fabric holds the limb securely in place while preserving patient comfort. It s also a breathable material, so the limb remains cool while inside the heel protector. PREVALON HEEL PROTECTORS ENHANCED ABILITY TO GRIP THE LIMB 3 Prevalon s dermasuede fabric contours to and gently cradles the leg, calf, ankle and foot to maintain effective heel offloading. Testing shows significantly more force is required to dislodge the Prevalon Heel Protector from the limb than with other heel protectors. 3 REFERENCES: 1. Bill B, Pedersen J, Call E, Human cadaver testing to determine the reliability of heel boot positioning or grip of eight commercially available pressure relieving heel protector boots. Poster presented at SAWC, April 2012, Atlanta, GA. 2. Salcido R, Lee A, Ahn C, Heel pressure ulcers: purple heel and deep tissue injury. Advances in Skin & Wound Care, Aug 2011;24(8): Lyder C, Getting serious about preventing heel pressure ulcers in hospitals. WCET Journal, Oct/Dec 2011;31(4) sage.uk@sageproducts.com

16 THREE HEEL PROTECTORS THAT EFFECTIVELY GRIP THE LIMB PREVALON HEEL PROTECTOR I n Offloads the heel. PREVALON HEEL PROTECTOR II n Offloads the heel. n Reduces plantar flexion contracture risk. PREVALON HEEL PROTECTOR III n Offloads the heel. n Reduces plantar flexion contracture risk. n Helps prevent lateral rotation, reducing risk of peroneal nerve damage

17 PREVALON HEEL PROTECTOR FEATURES I DERMASUEDE FABRIC INTERIOR Gently grips limb so it remains fully offloaded even when patient is moving. LOW-FRICTION OUTER SHELL Slides easily over bed sheets. Helps maintain patients freedom of movement. CLOSURE STRAPS Secures Heel Protector I. VISIBLY FLOATS HEEL FOR EASY MONITORING SCD COMPATIBLE 15 sage.uk@sageproducts.com

18 PREVALON HEEL PROTECTOR FEATURES II DERMASUEDE FABRIC INTERIOR Gently grips limb so it remains fully offloaded even when patient is moving. RIP-STOP NYLON Slides easily over bed sheets. Helps maintain patients freedom of movement. CONTRACTURE STRAP Helps prevent plantar flexion contracture. EXPANDABLE STRAPS Stretches to accommodate lower limb edema. No sharp edges or irritating surfaces. VISIBLY FLOATS HEEL FOR EASY MONITORING SCD COMPATIBLE

19 PREVALON HEEL PROTECTOR FEATURES III DERMASUEDE FABRIC INTERIOR Gently grips limb so it remains fully offloaded even when patient is moving. VISIBLY FLOATS HEEL FOR EASY MONITORING EXPANDABLE STRAPS Stretches to accommodate lower limb edema. No sharp edges or irritating surfaces. SIZING CHART: Calf Circumference (in.) Prevalon Heel Protector Petite Prevalon Heel Protector Calf Circumference (cm.) SCD COMPATIBLE 17 sage.uk@sageproducts.com

20 CLINICALLY VALIDATED Supported by more peer-reviewed studies than all other brands combined. 1 RIP-STOP NYLON Slides easily over bed sheets. Helps maintain patients freedom of movement. CONTRACTURE STRAP Helps prevent plantar flexion contracture. INTEGRATED ANTI-ROTATION WEDGE Helps prevent lateral foot and leg rotation, reducing the risk of peroneal nerve damage. REFERENCES: 1. Data on file

21 PROVEN RESULTS: PREVENTION AND TREATMENT FROM THE #1 BRAND OF HEELP ROTECTION 1 Prevalon brings you more proven clinical studies and financial outcomes than any other brand. Heel ulcer reduction n A study published in JWOCN found the use of Prevalon and a heel ulcer prevention protocol led to a 95% decrease in heel pressure ulcers. 2 n Another study published in JWOCN demonstrated a 100% prevention of both heel pressure ulcers and plantar flexion contracture over a seven month period when using the heel protector device. 3 n A UK study found the early utilisation of heel protectors has shown a reduction in the number of acquired heel pressure ulcers over the twelve month period and has resulted in an overall return on investment of 55, n Another UK study found a sustained 67% reduction in stage III and IV pressure ulcers to the heels. This sustained reduction was observed despite increases in patient acuity within the Trust according to a robust skin assessment conducted on all patients on admission and throughout9 their hospital stay. These findings suggest the use of a heel protector aid in the reduction of heel pressure ulcer incidence. Use of the heel protectors rose from 448 devices in 2009 to 3,008 in 2014, resulting in a total return on investment of 272, PYRAMID OF EVIDENCE 6 COHORT STUDIES CASE CONTROL STUDIES CASE SERIES CASE REPORTS IDEAS, EDITORIALS, OPINIONS SYSTEMATIC REVIEWS AND META-ANALYSES RANDOMIZED CONTROLLED DOUBLE BLIND STUDIES 4 Peer-Reviewed Publications 29 Posters Presented 1 Patient Case Study ANIMAL RESEARCH IN VITRO ( TEST TUBE ) RESEARCH 2 Independent Laboratory Tests REFERENCES: 1. GHX Trend Report (Dollars),4th Quarter, 2011 Hospital; Annualized markets based on last 4 quarters data. 2. Lyman V, Successful Heel Pressure Ulcer Prevention Program in a Long-Term Care Setting. J Wound Ostomy Continence Nurs Nov-Dec;36(6): Meyers T, Preventing Heel Pressure Ulcers and Plantar Flexion Contractures in High Risk Sedated Patients. J Wound Ostomy Continence Nurs Jul-Aug;37(4): Rajpaul K., The use of heel protectors in the prevention, treatment and management of pressure ulcers. Poster presented at EWMA 2015; London, UK; May 13-15, Acton C. Heel pressure ulcers; How do we prevent them and evaluate practice? An example within an acute care hospital. Poster presented at EPUAP 2015; Ghent, Belgium; September 16-18, Adapted from Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence-based medicine what it is and what it isn t. BMJ. 1996;312(7023): sage.uk@sageproducts.com

22 A history of innovation Sage Products has constantly improved and refined our line of Prevalon Heel Protector. From a simple engineered pillow, to the innovative and effective heel protector it is today, Prevalon has helped prevent and treat against heel pressure ulcers and plantar flexion contracture as well as increase protocol compliance Sage adds additional access ports to the Standard Size Prevalon to accommodate more Intermittent Compression Devices Sage diversifies the product line with Prevalon Heel Protector I to accommodate a variety of patient needs Sage launches Prevalon Petite for smaller patients Decision Tree presented at 2008 SAWC Conference, clarifying when to use a heel 2007 protector. Jill Walsh publishes Evaluation of a Protocol for Prevention of Facility- Acquired Heel Pressure Ulcers in JWOCN NPUAP/EPUAP releases updated Pressure Ulcer Prevention & Treatment Clinical Practice Guideline Tina Meyers poster Successful Prevention of Heel Ulcers and Foot Drop in the High Risk Ventilation Patient Population presented at World Union of Wound Healing Societies in Toronto. Shows zero pressure ulcers and a $1.9 million revenue preservation Sage launches Prevalon with Integrated Foot and Leg Stabilizer Wedge. Prevalon takes over as the market leader in heel protection Sage s field-based research finds pillows and other products don t float the heel properly and don t effectively protect against heel pressure ulcers Sage launches the first generation Prevalon Pressure-Relieving Heel Protector Sage launches second generation Prevalon featuring ripstop nylon outer surface, tag to help visualize proper fit, bag with printed instructions, integrated stretch panels and the Foot and Leg Stabilizer Wedge to help prevent lateral rotation. REFERENCES: 1. GHX Market Intelligence Trend Report (Dollars), 3rd Quarter, 2009 Hospital.Market; Annual market represents last 4 quarters of data

23 PREVALON TM TURN & POSITION SYSTEM Helps prevent sacral pressure ulcers and promotes safe patient handling. Prevent sacral pressure ulcers and healthcare worker injury Turning and repositioning patients according to your facility s turning schedule is crucial in preventing sacral pressure ulcers. Current methods including draw sheets and pillows have multiple challenges that present risks to patients and staff. The Prevalon Turn & Position System 2.0 is is an evolution in turning and positioning safety. Unlike lift slings and plastic slide sheets, the Prevalon Turn & Position System 2.0 stays under the patient at all times. It s always ready to assist with turning, repositioning, and boosting the patient. This makes it possible for nurses and staff to achieve compliance to a q2 turning protocol while providing the best care and minimizing additional stress on the patient. Now with enhanced microturn, the system makes it easy to comply with turning schedules while protecting staff from injury. All that is necessary to position the patient at the appropriate angle is a quick microturn, which requires 90% less exertion than traditional methods using draw sheets. 1 The newly designed Glide Sheet and Anchor Wedge System work together, creating a high-quality turn. Once placed under the patient, the wedges help to initiate patient turning. Exertion (lbf sec) THE PREVALON TURN & POSITION SYSTEM 2.0 REQUIRES 90% LESS EXERTION TO POSITION PATIENTS VS. DRAW SHEETS DRAW SHEETS SPH Exertion Test 9.2x more 32.6 SAGE TAP % LESS EXERTION Products tested 21 sage.uk@sageproducts.com

24 PREVALON TURN AND POSITION SYSTEM Patient Benefits n Helps prevent sacral pressure ulcers by offloading the sacrum. n Maintains 30-degree side lying position. n Helps prevent shear and friction forces on the patient s skin. n Manages moisture due to incontinence and other conditions. n Creates an optimal microclimate for the skin. Staff Benefits n Nurse-friendly system helps staff more easily follow best practice prevention guidelines. n Requires fewer nurses and less time to turn. n Reduces exertion needed to turn and boost patients. Decreases strain on staff s hands, wrists, shoulders, and backs. n Proven compatibility with low air loss surfaces, meaning it can remain under the patient at all times, making it easier and more convenient for nurses to comply with a q2 turning protocol. n Minimizes the frequency of boosting and other repetitive positioning tasks. PROVEN RESULTS: PREVENTION AND COST SAVINGS 84% Sacral Pressure Ulcer Reduction 2 90% Less Exertion 1 60% Less Time 3 35% Less Staff 3 Reduction in Staff Injury and HAPUs 4 58% reduction in employee injury = $247,500 savings A study demonstrated that a safe patient handling initiative including the Prevalon Heel Protector and Prevalon TM Turn 28% reduction in HAPUs = $184,720 savings & Position System can help ensure appropriate patient repositioning for HAPU prevention, prevent caregiver injuries, and save costs associated with HAPU and healthcare worker injury. REFERENCES: 1. Testing conducted by Sage Products LLC, data on file. 2. Powers J. A Comparative Study on Two Methods for Turning and Positioning and the Effect on Pressure Ulcer Development. Poster presented at the 27th Annual Symposium on Advances in Skin and Wound Care, Oct Hall K, Clark R, Save the butts: preventing sacral pressure ulcers by utilizing an assistive device to turn and reposition critically ill patients. Poster presented at 25th Annual Symposium on Advanced Wound Care Spring/Wound Healing Society meeting, Apr Way, H, Safe Patient Handling Initiative Results in Reduction in Injuries and Improved Patient Outcomes for Pressure Ulcer Prevention. Poster presented at 2014 Safe Patient Handling East Conference, March 27,

25 Prevalon TM Turn & Position System 2.0 FEATURES The Low-Friction Glide Sheet works with the Anchor Wedge System to provide true friction and shear protection. The top of the Glide Sheet has Dermasuede material, which grips the M 2 Microclimate Body Pad and keeps it in place. MINIMIZE FRICTION AND SHEAR PROTECT STAFF The boost straps promote proper body mechanics and reduce the reliance on grip strength. LESS EXERTION A quick, gentle microturn positions the patient at the appropriate angle. REFERENCES: 1. Pedersen J, Bill B, Call E, In vitro Measurement of the Impact of Transfer and Positioning Devices on Microclimate when Left in Place Following Use. Poster presented at SAWC sage.uk@sageproducts.com

26 The Body Wedge System reduces pressure by offloading the patient s sacrum. The system significantly reduces the exertion needed to achieve proper side lying positioning. REDUCE PRESSURE The Anchor Wedge helps the patient maintain a natural position when the head of the bed is raised. It also reduces the need for boosting and minimizes shear and friction. The only device proven compatible with all low air loss mattresses 1 The M 2 Microclimate Body Pad protects the patient s skin by effectively absorbing and locking in moisture while allowing air to flow through. MANAGE MOISTURE

27 Prevalon TM Turn & Position System XL/XXL FEATURES MINIMIZE FRICTION AND SHEAR The matress cover secures to most extra-wide hospital beds and can be used in place of a fitted/flat hospital sheet to help reduce friction. REDUCE PRESSURE The larger size Glide Sheet and M 2 Microclimate Body Pad accommodate bariatric patients. REFERENCES: 1. Pedersen J, Bill B, Call E, In vitro Measurement of the Impact of Transfer and Positioning Devices on Microclimate when Left in Place Following Use. Poster presented at SAWC sage.uk@sageproducts.com

28 REDUCE PRESSURE The larger size wedges redistribute pressure for bariatric patients. Includes velcro strips that attach to Low- Friction Glide Sheet, locking Body Wedges in place under the patient. The only device proven compatible with all low air loss mattresses

29 PREVALON TM SEATED POSITIONING SYSTEM Designed to improve compliance to the seated position and promote patient and clinician safety. Bedside chair challenges The health benefits of sitting in a bedside chair are well documented. However, there are several challenges that make it difficult to achieve this goal. Positioning patients in the bedside chair can put clinicians and patients at risk for injury. Boosting and repositioning can put clinicians at risk for musculoskeletal disorders (MSDs) which include back pain, sciatica and rotator cuff injuries. 1 Once patients are in the chair, they may become uncomfortable and lack the confidence to stay seated. Benefits of Mobility 2-4 n Improved muscle strength n Reduced oxidative stress n Reduced inflammation n Positive mood changes n Less fatigue Safe & Secure Sitting Slouching can lead to discomfort and falls. The Prevalon TM Seated Positioning System helps patients maintain a secure, seated posture. This provides stability and helps minimize the risks associated with slouched sitting. REFERENCES: 1. Occupational Safety and Health Administration (OSHA), Guidelines for nursing homes: ergonomics for the prevention of musculoskeletal disorders, Gomez-Cabrera MC, Domenech E, Viña J.Moderate exercise is an antioxidant: upregulation of antioxidant genes by training. Free Radic Biol Med. 2008:44: Winkelman C, Higgins PA, Chen YJK, et al. Cytokines in chronically critically ill patients after activity and rest. Biol Res Nurs. 2007;8: Herridge MS, Batt J, Hopkins RO. The pathophysiology of long-term outcomes following critical illness. Crit Care Clin. 2008;24: sage.uk@sageproducts.com

30 Safely glide patients to the upright position The Prevalon TM Seated Positioning System makes it easier for clinicians to safely glide patients to an optimal upright-seated position without lifting. It is uniquely engineered to keep the seated patient in place, minimizing the need for repetitive boosting and repositioning. It is also comfortable for patients, which may improve their confidence and compliance to chair sitting. Help Improve Safety n FORCE Patient is glided into position, not lifted n REPETITION Secures patient to minimize repetitive boosting and repositioning n POSTURE Promotes proper ergonomics and body mechanics while making it easy for nurses to reposition patient Promote Comfort and Confidence A recently published study found that nurses were more likely to use the Seated Positioning System over traditional efforts of pulling patients upright in chairs. The use of the Seated Positioning System: 1 n Enhanced nurses confidence in not hurting themselves n Promoted greater compliance in following their facility s repositioning and mobilizing patient protocols n Provided a bundled approach that focused on preventing patient falls and pressure ulcers and reduced employee injuries GLIDE PATIENTS WITHOUT LIFTING Staff benefits n Reduces Boosting Innovative one-way glide resists forward movement, ensuring patients remain in the optimal position. n Promotes Proper Ergonomics Multi-grip handles improve healthcare worker posture and body mechanics. Patient benefits n Redistributes Pressure Multi-chamber air cushion provides comfort and security while allowing patient to shift in chair. n Manages Moisture Microclimate Management Pad is effectively absorbant to protect patients skin while allowing air to flow through. REFERENCES: 1. Kowal C, Enhancing Compliance to the Seated Position of a Hospital Mobility Bundle: A Mixed Method Case Study, Am J SPHM, 2014;4(1):

31 Validate and celebrate your success Changing practice in healthcare involves significant effort and above all else data. Evaluation is critical, but as a busy clinician or supply chain professional, you may not have resources to gather, analyze and report on your own. We can help. CustomerOne is your expert resource for customized measurement and data analysis. Our exclusive team of professionals will generate comprehensive reports tailored to your specific requirements. Reports include: n Executive Outcome Summary A true success story it highlights a clinical intervention with a Sage product, including pre- and post-intervention data, clinical outcomes and return on investment. n Return on Investment Report Measures the financial impact of positive clinical outcomes and the financial value in partnering with Sage. n Cost Analysis Compares current process cost to a proposed Sage intervention while taking into account the cost of a hospital-acquired infection/wound. Includes a break even point or projected return on investment. n Clinical Outcome Report Measures correlations of compliance to specific clinical protocols and the clinical outcomes achieved. n Protocol Compliance Report Measures compliance to a specific clinical protocol. CustomerOne professionals will support all of these areas and more. You ll receive meaningful, actionable results that can be shared with core decision-makers across your facility all to drive change. Let us help validate your success! To learn more about CustomerOne call sage.uk@sageproducts.com

32 Your Partners in Prevention Help reduce SSIs by addressing multidrug resistant organisms on your patient s skin prior to surgery with 2% Chlorhexidine Gluconate Cloth Comfort Bath Cleansing Washcloths eliminate the contamination risk from bath basins Provide comprehensive oral care with Q Care Oral Cleansing and Suctioning Systems Help reduce the risk of staff injury with the Prevalon Liftaem Mobile Patient Transfer System