Bear of a Problem: Who should be sleeping in which bed?

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1 Bear of a Problem: Who should be sleeping in which bed? Dianne Mackey MSN, RN, CWOCN Wound/Skin Coordinator Kaiser Permanente San Diego California Evan Call MS, CSN (NRM) Adjunct Faculty Weber State University Ogden Utah Support Surface Proliferation = Confusion 2

Pressure Ulcer Prevention Program (PUPP) Perform regular skin and pressure ulcer risk assessments Manage moisture Provide nutritional support Educate patient and family Assess for and implement

2 Pressure Ulcer Prevention Program (PUPP) Perform regular skin and pressure ulcer risk assessments Manage moisture Provide nutritional support Educate patient and family Assess for and implement appropriate pressure redistribution support surface 3 Making Support Surface Choices How do clinicians compare and make decisions about the right support surface, for the right patient, at the right time? What are the decisions based upon? 4

products Can match the needs of an individual with correct food

3 Support Surface Testing and Labeling Nutritional Labeling 5 Provides essential information so consumers can compare food products Can match the needs of an individual with correct food products Promotes quality and safety of food products What is a Support Surface? 6

Standardized Terms and Definitions Categories: Grouping products by design and

extrinsic factors Components: Materials used in manufacturing; may consist of a

measure or describe the features of a support surface NPUAP (2007) 7 Categories

4 Standardized Terms and Definitions Categories: Grouping products by design and technology Features: Characteristics developed to address intrinsic and extrinsic factors Components: Materials used in manufacturing; may consist of a single component or may be used in combination Physical Concepts: Terms used to measure or describe the features of a support surface NPUAP (2007) 7 Categories of Support Surfaces Overlay Mattress Integrated Bed System Seat Cushion Overlay Seat Cushion 8

5 Categories of Support Surfaces 9 Overlay Designed to be placed directly on top of an existing surface. Mattress Designed to be placed directly on the existing bed frame. Integrated Bed System A bed frame and support surface that are combined into a single unit whereby the surface is unable to function separately. NPUAP(2007) Categories of Support Surfaces 10 Reactive Support Surface A powered or non-powered support surface with the capability to change its load distribution properties only in response to applied load (air/gel/foam overlay or high density foam mattress) Active Support Surface A powered support surface with the capability to change its load distribution properties with or without applied load (alternating pressure or rotational) NPUAP(2007)

6 Categories of Support Surfaces Non-Powered Any support surface not requiring or using external sources of energy for operation. Energy=D/C or A/C Powered Any support surface requiring or using external sources of energy to operate. Energy= D/C or A/C 11 NPUAP(2007) Features of Support Surfaces Zone A segment with a single pressure redistribution capability Multi-Zoned A surface in which different segments can have different pressure redistribution capabilities NPUAP (2007) 12

Features: Low Air Loss Provides a flow of air to assist in managing the heat and humidity (microclimate) of the skin NPUAP(2007) 13 Features: Alternating pressure

7 Features: Low Air Loss Provides a flow of air to assist in managing the heat and humidity (microclimate) of the skin NPUAP(2007) 13 Features: Alternating pressure Provides pressure redistribution via cyclic changes in loading and unloading as characterized by frequency, duration, amplitude, and rate of change parameters NPUAP(2007) 14

Features: Lateral Rotation A feature of a support surface that provides rotation about a

8 Features: Air Fluidized Provides pressure redistribution via a fluid-like medium created by forcing air through beads as characterized by immersion and envelopment NPUAP(2007) 15 Features: 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 NPUAP(2007) 16

9 Components of Support Surfaces 17 Air A low density fluid with minimal resistance to flow Water A moderate density fluid with moderate resistance to flow Gel A semisolid system consisting of a network of solid aggregates, colloidal dispersions or polymers which may exhibit elastic properties NPUAP (2007) Components of Support Surfaces Viscous Fluid A fluid with a relatively high resistance to flow Elastomer Any material that can be repeatedly stretched to at least twice its original length; upon release the stretch will return to approximately its original length 18 NPUAP(2007)

10 Support Surface Selection Determining the appropriate support surface is a process that changes as the individualʼs condition and health care setting changes. In addition, cost and product availability must also be considered 2010 WOCN 19 Support Surface Selection Criteria Identify at-risk patients (Braden score of <18) Assess bed and chair mobility Evaluate the patient for moisture associated skin issues Match performance features to address pressure ulcer(s) including the treatment of skin grafts and flaps 20

11 Support Surface Selection Criteria Evaluate patients ability to redistribute pressure when pressure ulcers are present on two or more turning surfaces Recognize the needs of the care provider Consider the care setting of the patient Think comfort! 21 Care Setting-Specific Formulary Standardize products Wide range of products to meet individual patient needs Reimbursement Renting versus purchasing Product safety and maintenance Ongoing education and in-services 22

for pressure ulcer development Limited evidence suggests that low air loss beds reduce the

12 Evidence for Prevention 53 RCTʼs thru Jan 2011 Use higher-specification foam mattresses rather than standard hospital foam mattresses for all individuals assessed as being at risk for pressure ulcer development Limited evidence suggests that low air loss beds reduce the incidence of pressure ulcers in intensive care 24 Cochrane Database of Systemic Reviews (2011)

13 Evidence for Prevention Pressure redistribution surfaces should be used in the operating room for individuals assessed to be at high risk for pressure ulcer development Two trials support the use of Australian standard medical sheepskin 25 (2011) Cochrane Database of Systemic Reviews Evidence for Treatment 6 RCTʼs Good evidence that air-fluidized and low air loss beds improve healing rates The relative merits of alternating air and constant low pressure surfaces is unclear Alternating pressure mattresses may be more cost effective than alternating pressure overlays Cochrane Database of Systemic Reviews (2008) 26

14 Clinical Practice Guidelines 27 Guideline Evidence There is insufficient evidence to support the choice of one specific pressure redistribution surface/device over another for the prevention and/or treatment of pressure ulcers. WOCN

15 Guideline Evidence: Prevention Utilize support surfaces (on beds and chairs) to redistribute pressure. Pressure redistribution devices should serve as adjuncts and not replacement for repositioning protocols. WOCN Guideline Evidence: Prevention No specific support surface or heel product has proven superior overall in decreasing pressure at the heel. WOCN

Guideline Evidence: Prevention Avoid synthetic sheepskin for pressure redistribution. It provides comfort but does NOT provide pressure distribution.

16 Guideline Evidence: Prevention Avoid synthetic sheepskin for pressure redistribution. It provides comfort but does NOT provide pressure distribution. WOCN Guideline Evidence: Treatment Consider using features that provide air flow over the surface of the skin to facilitate fluid evaporation if the skin is excessively moist. NPUAP/EPUAP 2009 For patients with large stage III or IV pressure ulcers or ulcers on multiple turning surfaces, a low-air-loss or airfluidized surface may be indicated. 32 WOCN 2010

17 Guideline Evidence More research and international standards for support surfaces are needed to provide more specific evidence-based guidance. NPUAP/EPUAP KEEP UP WITH THE LATEST EVIDENCE YOU ARE NOT ALONE 34

18 Physical Concepts: Evan Call MS, CSN (NRM) Pressure Redistribution Immersion Envelopment Shear Friction Micro-climate 35

SUPPORT SURFACES AND POSITIONING

SUPPORT SURFACES AND POSITIONING American Medical Technologies Irvine, CA 1 Disclaimer The information presented herein is provided for educational and informational purposes only and to promote the safeand-effective