HEEL PROTECTION FOR THE PREVENTION AND CARE OF PRESSURE ULCERS

HEEL PROTECTION FOR THE PREVENTION AND CARE OF PRESSURE ULCERS Every heel needs protection.

WHY HEEL PROTECTION MATTERS. The heels are the most common site for facility-acquired pressure ulcers in long-term care facilities and the second most common site for pressure ulcers overall. 4 They are commonly associated with severe pain, risk of infection and lengthy hospital stays. The Centers for Medicare and Medicaid Services (CMS) will not reimburse hospitals for stage III or IV pressure ulcers that are not present on admission. THE NUMBERS DON T LIE. Pressure ulcers affect millions of people each year and can cause severe pain, infection and lengthy hospital stays. The heels are the second most common site for pressure ulcers overall but they are preventable. 4 $ 9-11 BILLION 2.5 MILLION 60,000 $ 43,180 Cost to treat pressure ulcers annually in the U.S. 2 Number of people in the U.S. affected by pressure ulcers each year 2 Number of patients who die as a direct result of pressure ulcers each year 2 Average cost of a hospital stay for pressure ulcer stages III & IV 1 30.3 % The percentage of all pressure ulcers that develop on the heel 3 Medline is your single source for heel protection devices. According to clinical experts, the most effective pressure ulcer prevention for the heels is pressure relief known as offloading. 4 Offloading is achieved with heel protection devices that relieve pressure by elevating the heel. Medline offers a broad array of heel protection devices to fit your needs and budget. These devices are a vital component of a pressure ulcer prevention program at your facility. 2 MEDLINE

BUILT-IN ANTIMICROBIAL PROTECTION Medline s Heelmedix, Heel Raiser Ultra, and Heel Raiser Pro are the only heel devices to carry the Ultra-Fresh name, which means you can be assured our devices are treated with antimicrobial agents to inhibit the growth of unwanted microbes within the heel device* that will provide the following key benefits:» Help inhibit the growth of bacteria and fungi responsible for creating unpleasant smells and staining.» Control unwanted microbes on the fabric to help keep devices fresh, hygienic, and odor free. How Ultra-Fresh keeps heel devices fresh and protected 8 Stay cleaner and more durable with Ultra-Fresh* 2 bacteria, mould & mildew builds up * surfaces are more durable & more hygienic 1 moisture occurs 3 discolouration & decay Ultra-Fresh Treated Surface Unprotected Surface In an untreated device (see the image above at right), perspiration can encourage the growth of bacteria. This growth can lead to unpleasant odors and product discoloration. Devices treated with Ultra-Fresh remain fresh by actively inhibiting the growth of bacteria and fungi. By protecting heel protectors from unwanted microbes, Ultra-Fresh antimicrobial helps to keep the devices clean, fresh, and odor free. *Ultra-Fresh is an EPA-registered antimicrobial. This product does not protect users or others from disease-causing bacteria. Always clean according to Instructions for use. Ultrafresh is a registered trademark of Thomson Research Associates. 1-800-MEDLINE (633-5463) medline.com 3

HEELMEDIX All-in-one pressure relief and skin protection. Medline s Heelmedix, designed with the help of clinicians, offers supreme offloading and foot drop protection as a vital part of your pressure ulcer prevention program. Gray straps pull down on sides to help protect against foot drop Patented side hole design minimizes chance of DVT tubing touching patient s skin Equipped with a 3-hole option on each side of the boot for DVT tubing 4 MEDLINE

Benefits Screen printing of toes and heel eliminates confusion to ensure the boot is applied properly» Offloads the heel and helps redistribute pressure.» Fabric surface treated with Ultra-Fresh antimicrobial treatment which helps to inhibit odor-causing bacteria.*» Screen printing of toes and heel eliminates confusion to ensure the boot is applied properly.» Open heel design allows for airflow and easy monitoring.» Gray straps pull down on sides to help protect against foot drop.» Patented side hole design minimizes chance of DVT tubing touching patients skin.» Inner lining helps reduce friction and shearhalf the friction of the competitor.**» Includes mesh laundry bag to simplify washing and sorting. An optional wedge can be used to help prevent medial and lateral rotation. * Ultra-fresh EPA registered antimicrobial does not protect users or others from disease-causing bacteria. Always clean according to instructions for use. **Data on file. 1-800-MEDLINE (633-5463) medline.com 5

Heelmedix continued... Available in Three Sizes to Accomodate All Patients To fit Heelmedix properly, measure the circumference of the patients calf at its largest point. Color-coded tags (shown below) help to quickly identify size. HEELMEDIX HEEL PROTECTOR PROTECTEUR DE TALON PROTECTOR DE TALÓN Ultra-Fresh is an antimicrobial treatment to protect the product MDT823330P PETITE PETITE PEQUEÑA HEELMEDIX HEEL PROTECTOR PROTECTEUR DE TALON PROTECTOR DE TALÓN Ultra-Fresh is an antimicrobial treatment to protect the product MDT823330SW STANDARD STANDARD ESTÁNDAR HEELMEDIX HEEL PROTECTOR PROTECTEUR DE TALON PROTECTOR DE TALÓN Ultra-Fresh is an antimicrobial treatment to protect the product MDT823330XL X-LARGE GRANDE TAILLE X X-GRANDE 5-11 inches calf circumference (12.7-27.9 cm) 11-19 inches calf circumference (27.9-48.2 cm) 19-25 inches calf circumference (48.2-63.5 cm) Item No. Description Pkg MDT823330P Heelmedix Heel Protector, Petite 1/ea MDT823330SW Heelmedix Heel Protector, Standard w/ Wedge 1/ea MDT823330 Heelmedix Heel Protector, Standard 1/ea MDT823330CS Heelmedix Heel Protector, Standard 4/cs MDT823330XL Heelmedix Heel Protector, X-Large w/ Wedge 1/ea MDT823330W Heelmedix Stabilizer Wedge 2/ea MDT823331W Heelmedix Stabilizer Wedge 1/ea Study 1: Antibacterial Protection Assessment Heel protectors can harbor bacteria from the humid environment created by perspiration and an abundance of nutrients. Proliferation of these microbes can cause unwanted odors. Heelmedix with built-in Ultra-Fresh protection demonstrated excellent antibacterial activity compared to an untreated boot. Results and Conclusion*» Heelmedix treated with Ultra-Fresh demonstrated excellent antibacterial activity against the MRSA test organism by inhibiting bacterial growth underneath the sample.» The untreated boot sample failed to show antibacterial activity, allowing MRSA to proliferate. Heelmedix treated with Ultra-Fresh will remain clean, fresh and odor-free.» AATCC Test Method 147 Methicillin-resistant Staphylococcus aureus (MRSA)* Ultra-Fresh treated boot AATCC Test Method 147 Methicillin Resistant Staphylococcus aureus (MRSA)* Sample Description Test Results Visual Observation Conclusion Heelmedix treated with Ultra-Fresh No bacterial growth under specimen Pass Untreated pressure relieving boot Heavy bacterial growth under specimen Fail Untreated boot * Methicillin resistant Staphylococcus aureus (MRSA) is a standard test organism and its use is not meant to indicate any benefits from the Ultra-Fresh treatment other than odor and stain protection and prevention of product degradation. Ultra-Fresh does not protect users or others against disease causing bacteria. 6 MEDLINE

Testing shows Heelmedix offers exceptional heel offloading. Study 2: Heel OffLoading Using a pressure-sensing mat, 19 patients in a long-term care facility were tested for heel pressure on a mattress, in a Heelmedix device, and in the competitor s device. Heelmedix completely offloaded the vulnerable heel area. Here are the pressure mapping conclusions: Red dotted line indicates heel contact area 115.23 Mattress had the highest heel pressure. contact area 41.71 Competitor s average pressure on contact area. contact area 29.82 Heelmedix completely offloaded the vulnerable heel area. g/cm 2 0.4 5 9.6 14.1 18.7 23.3 27.9 32.5 37 41.6 46.2 50.8 55.4 59.9 64.5 69.1 73.7 78.3 82.8 87.4 92 Study 3: Plantar Flexion Prolonged plantar flexion (a toe-down motion of the foot at the ankle) can contribute to foot drop. Foot drop is a condition of uncontrolled plantar flexion that can develop in non-ambulatory patients. Results and Conclusions*» Heelmedix demonstrated a 24.5% greater resistance to plantar flexion and twice the supportive strength of the competitor.» The strapping design on Heelmedix was able to prevent a foot drop beyond 40 degrees under all force conditions, while heel offloading on the competitor s boot was not able to stop this severe foot drop angle. Study 4: Strap Durability Straps on a heel protector are important for ensuring that the boot stays properly fitted for each individual patient. If straps have the capability of stretching out there is a potential that the boot will not remain secure on the patient. Results and Conclusions*» Heelmedix straps were relatively unchanged following repetitive strap pulls compared with the competitor s straps, which increased 89.53% in length.» When tested under tension to failure, Heelmedix straps were three times stronger than the competitor s. MAXIMUM PRESSURE EXERTED PER ANGLE The strapping design on Heelmedix was able to prevent a foot drop beyond 40 degrees under all force conditions. TENSILE STRENGTH AT BREAK Heelmedix straps required over three times more force to break than the competitor s straps. 200 300 150 250 200 100 150 50 100 0 Heelmedix Boot Prevalon Boot 10 o 20 o 30 o 40 o DEGREE CHANGE 50 0 Heelmedix Boot Prevalon Boot *Data on file 1-800-MEDLINE (633-5463) medline.com 7

HEELMEDIX SE Pressure relief and skin protection all in one. By completely offloading the heel, Medline s Heelmedix SE delivers effective pressure relief to help prevent skin breakdown. Inner material helps to reduce friction and shear Relieve pressure and protect vulnerable heels. Allows for DVT tubing with one opening on each side of the boot. 8 MEDLINE

Benefits» Helps prevent pressure ulcers by completely offloading the heel and delivering effective pressure relief.» Promotes air circulation and easy monitoring by openly floating the heel.» Allows for DVT tubing with one opening on each side of the boot.» Helps reduce friction and shear with suede-like inner lining. Item No. Description Pkg MDT82500CS Heelmedix SE, Heel Protector 4/cs Clinical Study Shows Effective Results* - Using a pressure-sensing mat, 19 patients in a long-term care facility were tested for heel pressure on a mattress, a pillow and in a Heelmedix SE. Heelmedix SE completely offloaded the vulnerable heel area. Here are clinically proven pressure mapping results: Red dotted line indicates heel contact area 115.23 Mattress had the highest heel pressure. contact area 64.40 Pillow reduced heel pressure compared to mattress. contact area 29.82 Heelmedix SE completely offloaded the heel. g/cm 2 0.4 5 9.6 14.1 18.7 23.3 27.9 32.5 37 41.6 46.2 50.8 55.4 59.9 64.5 69.1 73.7 78.3 82.8 87.4 92 Allows for DVT tubing *Data on file. 1-800-MEDLINE (633-5463) medline.com 9

HEEL RAISER ULTRA 3 sizes to get the best fit. Anatomical strapping pattern for optimal fit Opening on each side for DVT tubing devices (hidden behind wedge) Optional wedge adds stability 10 MEDLINE 1-800-MEDLINE (633-5463) medline.com 10

Benefits» Completely offloads the heel» Anatomical strapping pattern offers best fit for the patient» Available in 3 sizes to accommodate all patients» Optional stabilizing wedge» Compatible with DVT devices» Includes mesh laundry bag to simplify washing and sorting Item No. Description Pkg MDT82705CS Heel Raiser Ultra Heel Protector 4 ea/cs MDT82705WCS Heel Raiser Ultra w/wedge 4 ea/cs MDT82705P Heel Raiser Ultra Petite 4 ea/cs MDT82705XL Heel Raiser Ultra X-Large 4 ea/cs MDT82705WG Stabilizing Wedge 1 pr Clinical Study Shows Effective Results * - Using a pressure-sensing mat, 10 subjects were tested for heel pressure on a mattress and in a Heel Raiser Ultra. The Heel Raiser Ultra completely offloaded the heel area. Here are the pressure-mapping conclusions: Red dotted line indicates heel contact area 138.8 mmhg on a Mattress. Max peak pressure on contact area for the subject above was 0 mmhg. mmhg 0.4 5 9.6 14.1 18.7 23.3 27.9 32.5 37 41.6 46.2 50.8 55.4 59.9 64.5 69.1 73.7 78.3 82.8 87.4 92 *Data on file. 1-800-MEDLINE (633-5463) medline.com 11

HEEL RAISER PRO Provides heel protection and effective pressure relief. The Heel Raiser Pro s breathable fabric helps control heat and moisture levels for optimum comfort and protection. Adjustable straps offer a better fit Durable exterior glides over sheets reducing friction and shear Top folds down for smaller feet or more airflow to the toes Completely offloads the heel, redistributing pressure along the calf Benefits» Completely offloads the heel, redistributing pressure along the calf.» Treated with Ultra-Fresh antimicrobial treatment which helps to inhibit odor-causing bacteria.*» Breathable fabric helps control heat and moisture levels.» Top folds down for smaller feet, and increases airflow to toes.» Anatomical strapping pattern offers best fit for the patient.» One size fits most.» Easily wipes clean.» Machine washable, mesh laundry bag included. Item No. Description Pkg MDT82650CS Heel Raiser Pro, Heel Protector 4/cs *Ultra-fresh EPA registered antimicrobial does not protect users or others from disease-causing bacteria. Always clean according to instructions for use. 12 MEDLINE

Studies show Heel Raiser Pro demonstrates exceptional heel offloading. Study 1: Heel Raiser Pro offers greater heel offloading Using a pressure-sensing mat, 19 subjects in a long-term care facility were tested for heel pressure on a mattress, a pillow and in a Heel Raiser Pro. Here are the pressure mapping conclusions: Red dotted line indicates heel Average pressure on contact area 115.23 Mattress had the highest heel pressure. Average pressure on contact area 64.40 Pillow reduced heel pressure compared to only a mattress. Average pressure on contact area 43.83 Heel Raiser Pro completely offloaded the vulnerable heel area. g/cm 2 0.4 5 9.6 14.1 18.7 23.3 27.9 32.5 37 41.6 46.2 50.8 55.4 59.9 64.5 69.1 73.7 78.3 82.8 87.4 92 Study 2: Heel Raiser Pro offloading shown to be more effective over a longer period of time The study compared the duration of effective offloading of the Heel Raiser Pro and the competitor s inflatable pressure-relief boot in a controlled laboratory setting. Results and Conclusions 9» The Heel Raiser Pro was shown to have the greater average starting height, the better (smallest value) average height loss per day; and the longest estimated duration of effective offloading compared to the competitor s inflatable boot.» The rate of height loss for the Heel Raiser Pro was much less than that of the competitor, which allows for the Heel Raiser Pro to be used for a much longer period of time before offloading would be lost.» Air can be added to the competitor s product, if needed. However, the Heel Raiser Pro can provide offloading without re-inflating the device. The rate of height loss for the Heel Raiser Pro was much less than that of the competitor 25 Average Height Measurements 20 15 Heel Raiser Pro manufactured by Medline 10 Competitor 5 0 0 1 2 3 4 5 6 7 8 9 10 TIME (Days) 1-800-MEDLINE (633-5463) medline.com 13

HEEL RAISER Effectively offloads heels. The Heel Raiser s super soft and comfortable lining reduces friction and shear to help protect against skin breakdown. Soft and comfortable material to help prevent friction and shear Anatomical strapping pattern reduces migration and foot drop Open heel design promotes air circulation and allows for easy monitoring 14 MEDLINE

Benefits» Completely offloads the heel.» Top folds down to accomodate small feet and increase airflow to toes.» Soft, comfortable material prevents friction and shear.» Open heel design promotes air circulation and allows for easy monitoring.» Includes mesh laundry bag to simplify washing and sorting.» One size fits most. Item No. Description Pkg MDT823296 Heel Raiser, Heel Protector 4/cs Tests show Heel Raiser provides greater heel offloading. Study 1: Heel Raiser offers greater heel offloading* Using a pressure-sensing mat, 19 patients in a long term care facility were tested for heel pressure on a mattress, a pillow and in a Heel Raiser. The Heel Raiser completely offloaded the vulnerable heel area. Here are the pressure mapping conclusions: Red dotted line indicates heel contact area 115.23 Mattress had the highest heel pressure. contact area 64.40 Pillow reduced heel pressure compared to mattress. contact area 43.83 Heel Raiser completely offloaded the heel area.. g/cm 2 0.4 5 9.6 14.1 18.7 23.3 27.9 32.5 37 41.6 46.2 50.8 55.4 59.9 64.5 69.1 73.7 78.3 82.8 87.4 92 Study 2: Heel Raiser shown to remain less humid for longer time High humidity trapped in the material of the boot could cause the skin cells to become stressed and more susceptible to breakdown. The study measured and compared the microclimate inside the Heel Raiser and a competitor s inflatable heel protector by applying heat and water vapor at a constant rate to the surfaces of the two pressure relieving boots. Results and Conclusions*» The Heel Raiser performed better in managing humidity compared to the competitor s heel protector. On average, the competitor retained 23% more humidity than the Heel Raiser. The design and materials of the Heel Raiser allowed the boot to remain significantly less humid.» The Heel Raiser took significantly longer to achieve its maximum humidity, allowing it to stay more comfortable for the patient for a longer amount of time. 90.00 80.00 70.00 60.00 50.00 40.00 30.00 20.00 ON AVERAGE THE HEEL RAISER RETAINED 23% LESS HUMIDITY THAN THE COMPETITOR S INFLATABLE BOOT. Average % Retained Humidity Inside Boot 10.00 0.00 *Data on file Competitor Heel Raiser 1-800-MEDLINE (633-5463) medline.com 15

SKINTEGRITY Total Skin Health Solution Medline is your complete skin management solution. Heel protection devices are just one component of Medline s Skintegrity comprehensive skin management program. Skintegrity emphasizes standardization of care across the continuum through customized education, clinically-proven*, evidence-based products and ongoing outcomes management. Skintegrity is part of the Medline clinical solutions program. Our solutions include: Education: Our courses cover the basics of care and teach teamwork, leadership and how to implement change. Products: Our clinically-proven products* provide breadth and depth across the continuum of care. Outcomes: Our useful tools ensure that learnings get applied to practice and help track results. *Contact Medline Industries, Inc. for data related to the Skintegrity line of products To learn more, contact your Medline representative, visit us at medline.com, or call 1-800-MEDLINE. Medline Industries, Inc. One Medline Place, Mundelein, IL 60060 FOLLOW US BLOG Medline United States 1-800-MEDLINE (633-5463) medline.com info@medline.com Medline Canada 1-800-396-6996 medline.ca canada@medline.com Medline México 01-800-831-0898 medlinemexico.com mexico@medline.com REFERENCES 1. Federal Register: Department of Health and Human Services Centers for Medicare & Medicaid Services Part II, p. 48473 Tuesday, August 19, 2008. 2. http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/putool1.html 3. Amlung SR, Miller WL, Bosley LM, The 1999 National Pressure Ulcer Prevalence Survey: A Benchmarking Approach, Adv Skin & Wound Care. Nov/Dec 2001;14(6):297-301 4. Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for preventing heel pressure ulcers. Ostomy Wound Management. 2008;54(10):42:48. 5. Langemo D, Thompson P, Hunter S, Hanson D, Anderson J. Heel pressure ulcers: stand guard. Advances in Skin & Wound Care. 2008;21(6):282-292. 8. http://www.ultra-fresh.com/how-antimicrobials-work/fresh/ 9. Evan Call MS, CSM (NRM) 1 Daniel L. Young, PT, DPT 2 1 Weber State University, Ogden Utah; 2 Associate Professor, Department of Physical Therapy, University of Nevada, Las Vegas; 3 Vice President, Clinical and Technical Strategy, Skin and Wound Care Division, Medline Industries Inc. Some products may not be available for sale in Mexico or Canada. We reserve the right to correct any errors that may occur within this brochure. 2016 Medline Industries, Inc. Medline, Heelmedix, and Heal Raiser and Skintegrity are registered trademarks of Medline, Industries, Inc. Ultrafresh is a registered Trademark of Thomson Research Associates. Prevalon is a registered trademark of Sage Products, Inc. MKT 1672034 / LIT809 / 5M / SG / 30