Pressure-redistributing Support Surfaces Research Articles

Pressure Distribution Comparison among Standard Seating Surfaces and Strap Seating System

AIMS: Pressure injuries (PIs) are common issues that can be minimized through the use of pressure-redistributing support surfaces. Cushions that provide immersion and contour are considered the most effective for pressure relief; however, others are readily available on the market. The aim of this study is to determine how a wheelchair equipped with Comfort Tension Seating®(CTS) compares to standard sling seating, foam, and a high-end pressure redistributing contoured cushion. 
 
 MATERIALS & METHODS: Pressure redistribution qualities as measured through peak pressure index (PPI) using pressure mapping technology were gathered on four different seating surfaces -standard sling seat, CTS, and two cushion types flat cross-section foam, contoured-cushion, and CTS. Twenty non-disabled participants trialed each cushion for five minutes each. The methods of this study are described and outcomes analyzed by comparing the PPI and comfort of the four cushions.
 
 RESULTS: A Wilcoxon signed-rank test, and related samples Friedman’s two-way analysis of variance by ranks (ANOVA) was calculated. The results show that there is a significant difference between each of the cushions in comfort and pressure redistribution. There was a statistically significant difference in mean PPI between the three groups in which the CTS performed better than the sling and flat cross-section foam, but not quite as good as the high-end contoured cushion (p <.001). 
 
 CONCLUSION: While not as optimal as the contoured M2 foam cushion, the CTS seating surface appears to provide superior pressure-redistributing performance compared to sling and flat cross-section foam. This suggests that the CTS could be used as a support surface for many applications, except for individuals with high-level PI risk, without using tilt and recline features.

Pressure Redistribution Crib Mattress

Selective use of pressure-redistributing support surfaces is considered an essential component of a pressure injury prevention bundle. Critically ill children who are too big for an isolette but too little for a bed are usually placed in critical care cribs that have unique features such as moveable side rails and a built-in scale for weighing the patient, but they do not have a mattress designed to redistribute pressure. The primary aim of this quality improvement project was to evaluate a pressure redistribution mattress designed for use in critical care cribs. We retrospectively reviewed 22 charts of critically ill pediatric patients who participated in a product trial completed over a 12-week period in a stand-alone children's hospital in the Western United States. We reviewed demographic data, skin assessments, Braden Q Scale score, and support surface use. Our review revealed no pressure injury occurrences over the 12-week data collection period. Findings from this quality improvement project suggest that the pressure-redistributing mattress, when used as part of an intervention bundle, prevents pressure injuries in critically ill pediatric patients.

Interface pressure mapping pilot study to select surfaces that effectively redistribute pediatric occipital pressure

AimThe aim of this pilot study was to better inform clinical decisions to prevent pediatric occipital pressure ulcers with quantitative data to choose an appropriate reactive support surface. MaterialsA commercially available capacitive pressure mapping system (XSENSOR, X3 Medical Seat System, Calgary, Canada) was used to evaluate a standard pediatric mattress and four commercially available pressure-redistributing support surfaces. MethodsThe pressure mapping system was validated for use in the pediatric population through studies on sensitivity, accuracy, creep, and repeatability. Then, a pilot pressure mapping study on healthy children under 6 years old (n = 22) was performed to determine interface pressure and pressure distribution between the occipital region of the skull and each surface: standard mattress, gel, foam, air and fluidized. ResultsThe sensor was adequate to measure pressure generated by pediatric occipital loading, with 0.5–9% error in accuracy in the 25–95 mmHg range. The air surface had the lowest mean interface pressure (p < .005) and lowest peak pressure index (PPI), defined as the peak pressure averaged over four sensels, (p < .005). Mean interface pressure for mattress, foam, fluidized, gel, and air materials were 24.8 ± 4.42, 24.1 ± 1.89, 19.4 ± 3.25, 17.9 ± 3.10, and 14.2 ± 1.41 mmHg, respectively. The air surface also had the most homogenous pressure distribution, with the highest mean to PPI ratio (p < .005) and relatively high contact area compared to the other surfaces (p < .005). ConclusionThe air surface was the most effective pressure-redistributing material for pediatric occipital pressure as it had the lowest interface pressure and a homogeneous pressure distribution. This implies effective envelopment of the bony prominence of the occiput and increasing contact area to decrease peak pressure points.

The prevalence, prevention and multilevel variance of pressure ulcers in Norwegian hospitals: A cross-sectional study

BackgroundPressure ulcers are preventable adverse events. Organizational differences may influence the quality of prevention across wards and hospitals. ObjectiveTo investigate the prevalence of pressure ulcers, patient-related risk factors, the use of preventive measures and how much of the pressure ulcer variance is at patient, ward and hospital level. DesignA cross-sectional study. SettingSix of the 11 invited hospitals in South-Eastern Norway agreed to participate. ParticipantsInpatients ≥18years at 88 somatic hospital wards (N=1209). Patients in paediatric and maternity wards and day surgery patients were excluded. MethodsThe methodology for pressure ulcer prevalence studies developed by the European Pressure Ulcer Advisory Panel was used, including demographic data, the Braden scale, skin assessment, the location and severity of pressure ulcers and preventive measures. Multilevel analysis was used to investigate variance across hierarchical levels. ResultsThe prevalence was 18.2% for pressure ulcer category I–IV, 7.2% when category I was excluded. Among patients at risk of pressure ulcers, 44.3% had pressure redistributing support surfaces in bed and only 22.3% received planned repositioning in bed. Multilevel analysis showed that although the dominant part of the variance in the occurrence of pressure ulcers was at patient level there was also a significant amount of variance at ward level. There was, however, no significant variance at hospital level. ConclusionsPressure ulcer prevalence in this Norwegian sample is similar to comparable European studies. At-risk patients were less likely to receive preventive measures than patients in earlier studies. There was significant variance in the occurrence of pressure ulcers at ward level but not at hospital level, indicating that although interventions for improvement are basically patient related, improvement of procedures and organization at ward level may also be important.

Preventing needlestick injuries

Healthcare practitioners face diverse challenges presented by an ageing population, reducing funds, public demand for better health care, and a zero tolerance to avoidable healthcare-acquired injuries, such as pressure ulcers. To support the reduction in avoidable pressure ulcers European Pressure Ulcer Advisory Panel and National Institute for Health and Clinical Excellence guidelines recommend patient repositioning, the provision of either an active or reactive pressure-redistributing support surface and, for some, complete and permanent off-loading of the tissue. Guy's and St. Thomas's NHS Foundation Trust recognised that an evidence-based prevention strategy was required to reduce the incidence of pressure ulcers in line with the Harm Free Care initiative. As part of the prevention strategy, eTRACE was implemented, an online clinical ordering system that uses the patient's clinical risk assessment in conjunction with the Trust's clinical protocols to recommend appropriate equipment selection. Additionally the system supports the organisational and national reporting/management requirements. This article will review the clinical and economic evidence to support the introduction of eTRACE and how this system has contributed to the Trust's agenda in reducing avoidable pressure ulcers.

Reducing avoidable pressure ulcers: an online clinical ordering system

Healthcare practitioners face diverse challenges presented by an ageing population, reducing funds, public demand for better health care, and a zero tolerance to avoidable healthcare-acquired injuries, such as pressure ulcers. To support the reduction in avoidable pressure ulcers European Pressure Ulcer Advisory Panel and National Institute for Health and Clinical Excellence guidelines recommend patient repositioning, the provision of either an active or reactive pressure-redistributing support surface and, for some, complete and permanent off-loading of the tissue. Guys and St Thomas's NHS Foundation Trust recognised that an evidence-based prevention strategy was required to reduce the incidence of pressure ulcers in line with the Harm Free Care initiative. As part of the prevention strategy, eTRACE was implemented, an online clinical ordering system that uses the patients' clinical risk assessment in conjunction with the Trust's clinical protocols to recommend appropriate equipment selection. Additionally the system supports the organisational and national reporting/management requirements. This article will review the clinical and economic evidence to support the introduction of eTRACE and how this system has contributed to the Trust's agenda in reducing avoidable pressure ulcers.

Wound Assessment

Healthcare practitioners face diverse challenges presented by an ageing population, reducing funds, public demand for better health care, and a zero tolerance to avoidable healthcare-acquired injuries, such as pressure ulcers. To support the reduction in avoidable pressure ulcers European Pressure Ulcer Advisory Panel and National Institute for Health and Clinical Excellence guidelines recommend patient repositioning, the provision of either an active or reactive pressure-redistributing support surface and, for some, complete and permanent off-loading of the tissue. Guy's and St. Thomas's NHS Foundation Trust recognised that an evidence-based prevention strategy was required to reduce the incidence of pressure ulcers in line with the Harm Free Care initiative. As part of the prevention strategy, eTRACE was implemented, an online clinical ordering system that uses the patient's clinical risk assessment in conjunction with the Trust's clinical protocols to recommend appropriate equipment selection. Additionally the system supports the organisational and national reporting/management requirements. This article will review the clinical and economic evidence to support the introduction of eTRACE and how this system has contributed to the Trust's agenda in reducing avoidable pressure ulcers.

An RCT to determine the effect of a heel elevation device in pressure ulcer prevention post-hip fracture

A randomised controlled trial set out to determine whether there are differences between complete offloading and standard care in terms of the number of new pressure ulcers (PUs) developing on the heels of older patients with fractured hips and the number or severity of new PUs on other areas of their bodies. Patients aged over 65 years in a fracture trauma unit with fractured hips were randomly allocated to receive heel elevation (DM Systems, Evanston, Illinois) plus pressure-redistributing support surface or standard care (pressure-redistributing support surface alone). Exclusion criteria included existing heel damage. Patients were assessed on pre- and postoperative days for the occurrence of new pressure damage. Patients completed a satisfaction questionnaire at discharge. 119 patients were recruited into the control group and 120 into the intervention group. Independent t-tests and chi-squared analysis showed both groups were comparable at baseline. Thirty-one subjects (26%) in the control group developed PUs compared with eight in the intervention group (7%, p<0.001). No subjects in the intervention group developed a PU on their ankles, feet or heels, whereas 29 subjects in the control group did (p<0.001). Kaplan-Meier survival curves indicated that subjects in the control group were more likely than those in the intervention group to suffer pressure damage at all time points (p=0.001). A sensitivity analysis showed that when subjects lost to follow-up were assigned the worse outcome (PU positive) those in the intervention group were still less likely to develop PUs than the control group (p=0.001). The offloading device was rated as comfortable overall by 59% of subjects. The findings suggest that offloading reduces the incidence of heel ulcers.

Pressure-redistributing support surface use and pressure ulcer incidence in elderly hip fracture patients.

To evaluate the association between pressure-redistributing support surface (PRSS) use and incident pressure ulcers in older adults with hip fracture. Secondary analysis of data from prospective cohort with assessments performed as soon as possible after hospital admission and on alternating days for 21 days. Nine hospitals in the Baltimore Hip Studies network and 105 postacute facilities to which participants were discharged. Six hundred fifty-eight people aged 65 and older who underwent surgery for hip fracture. Full-body examination for pressure ulcers; bedbound status; and PRSS use, recorded as none, powered (alternating pressure mattresses, low-air-loss mattresses, and alternating pressure overlays), or nonpowered (high-density foam, static air, or gel-filled mattresses or pressure-redistributing overlays except for alternating pressure overlays). Incident pressure ulcers (IPUs), Stage 2 or higher, were observed at 4.2% (195/4,638) of visits after no PRSS use, 4.5% (28/623) of visits after powered PRSS use, and 3.6% (54/1,496) of visits after nonpowered PRSS use. The rate of IPU per person-day of follow-up did not differ significantly between participants using powered PRSSs and those not using PRSSs. The rate also did not differ significantly between participants using nonpowered PRSSs and those not using PRSSs, except in the subset of bedbound participants (incidence rate ratio=0.3, 95% confidence interval=0.1-0.7). PRSS use was not associated with a lower IPU rate. Clinical guidelines may need revision for the limited effect of PRSS use, and it may be appropriate to target PRSS use to bedbound patients at risk of pressure ulcers.

The value of systematic evaluation in determining the effectiveness and practical utility of a pressure-redistributing support surface

Introduction Up to 20% of hospital patients will have pressure ulcers; more than half will be nosocomial and are associated with high treatment cost, increased morbidity, complaints and litigation. Consequently, patient safety programmes may include the provision of pressure-redistributing mattress replacements (PRM). However, despite the different functionality of PRMs, there is often little information to support clinical prescription; with some mattresses potentially unsuitable for a busy acute care environment: this is particularly true for mattresses which require manual adjustment each time the patient changes position. Methods A systematic prospective investigation of a new PRM was conducted over a 5-month period; following a convenience sample of high-risk hospital patients. The device automatically detects the angle of back rest, optimises cell inflation and reduces the risk of user error and sub-optimal support. Outcomes reported: ulcer prevention, healing, usability. Results A convenience sample of 60 patients were included; 39 (65%) had existing wounds. A single patient developed erythema to the sacrum (1.6%) while the majority of existing wounds (69%), including full thickness injury, improved or healed. The utility of the device was well received by staff and patients. Conclusion Although ideal, effectiveness studies (such as RCTs) are difficult to control in wound care and seldom reflect the natural challenges encountered in a busy hospital. By contrast the data arising from this pragmatic evaluation showed the mattress to be compatible with the care setting and also suitable for the vulnerability of the population and so provided the necessary information to inform subsequent clinical practice.

Use of Pressure-Redistributing Support Surfaces Among Elderly Hip Fracture Patients Across the Continuum of Care: Adherence to Pressure Ulcer Prevention Guidelines

Use of Pressure-Redistributing Support Surfaces Among Elderly Hip Fracture Patients Across the Continuum of Care: Adherence to Pressure Ulcer Prevention Guidelines

Use of Pressure-Redistributing Support Surfaces Among Elderly Hip Fracture Patients Across the Continuum of Care: Adherence to Pressure Ulcer Prevention Guidelines

To estimate the frequency of use of pressure-redistributing support surfaces (PRSS) among hip fracture patients and to determine whether higher pressure ulcer risk is associated with greater PRSS use. Patients (n = 658) aged >or=65 years who had surgery for hip fracture were examined by research nurses at baseline and on alternating days for 21 days. Information on PRSS use and pressure ulcer risk factors was recorded at each assessment visit. Other information was obtained by interview and chart review. A PRSS was observed at 36.4% of the 5,940 study visits. The odds of PRSS use were lower in the rehabilitation setting (adjusted odds ratio [OR] 0.4, 95% confidence interval [CI] 0.3-0.6), in the nursing home (adjusted OR 0.2, 95% CI 0.1-0.3), and during readmission to the acute setting (adjusted OR 0.6, 95% CI 0.4-0.9) than in the initial acute setting. There was wide variation in frequency of PRSS use by admission hospital, even after adjusting for pressure ulcer risk factors. The relationships between PRSS use and pressure ulcer risk factors were not strong. In this study of hip fracture patients, adherence to guidelines for PRSS use was low and was based more on facility-related factors than on patient risk. There is an urgent need for health care providers to improve strategies for the prevention of pressure ulcers in high-risk patients.

Wound-Product Selection and Innovations

TOPIC: Preventing Facility-Acquired Pressure Ulcers in a Diverse Acute Care Population Using A Pressure Redistributing Surface PURPOSE: To reduce the number of facility-acquired pressure ulcers in a diverse acute care population by using pressure-redistributing surfaces. METHOD: The recent regulatory change in the Inpatient Prospective Payment System (IPPS) provides an incentive for acute care hospitals to take pressure ulcer prevention seriously. As a Magnet credentialed hospital, Mercy Medical Center has consistently tracked facility-acquired pressure ulcer data and has benchmarked with the National Databank of Nursing Quality Indicators (NDNQI). While our pressure ulcer data has always compared quite favorably, the recent payment ramifications of IPPS provided us with an opportunity for improvement. Our current pressure redistributing support surfaces did not meet the mobility and safety needs of our diverse patient population. A multidisciplinary committee was formed to make recommendations for future purchase of beds and support surfaces. This was a two-year endeavor. The factors that were considered included: pressure redistribution as supported by clinical trials, infection control, ease of cleaning and maintenance, staff and patient safety, and ease of patient bed mobility. The Wound Ostomy and Continence Nurses played an integral role in the process and decision making. Members of the committee visited prospective bed and mattress companies. A product fair was done to seek staff input and concerns. The committee also looked at buying contracts for best pricing. Financial constraints must be recognized in all capital purchases. CONCLUSION: We were able to achieve near zero incidence of facility-acquired pressure ulcers while meeting the mobility and safety needs of a diverse patient population in a cost-effective manner.

Repositioning Guidelines Often Not Followed

Repositioning Guidelines Often Not Followed

Controversies and opinions: Why evaluate limb compression interventions as if they were pressure-redistributing support surfaces?

Controversies and opinions: Why evaluate limb compression interventions as if they were pressure-redistributing support surfaces?

Evidence-based practice and support surfaces: are we throwing the baby out with the bath water?

This study aimed to explore aspects of the effectiveness of three pressure-redistributing support surfaces in routine clinical practice. A non-randomised prospective cohort study was used, with skin outcomes reported for 219 subjects at risk of pressure ulcer development. Few instances of new pressure damage were observed; these related to specific clinical issues, such as incontinence and inadequate use of cushions when sitting. Of the 77 subjects (33.3%) with pressure ulcers on recruitment into the study, most (n=70) either improved or remained unchanged following allocation of the support surface. Cohort studies do not indicate the efficacy of an intervention but may give an indication of effectiveness--that is, the clinical outcomes that may be observed in routine clinical practice.

Changing pressure-redistributing mattress stocks: costs and outcomes

There remains considerable confusion regarding the selection of appropriate pressure-redistributing support surfaces, although it is accepted that use of low-pressure foam mattresses is likely to reduce the incidence of pressure ulcers compared with standard hospital mattresses. In this study, a 650- hospital replaced its mattress stock with low-pressure foam mattresses with over pounds sterling 100 000 cost savings in the first year after implementation. Incidence and prevalence data were recorded but given the challenges of interpreting apparent trends in the data (due to the lack of robust data collection methodologies and no case-mix adjustment) these data were not included.

Pressure sore treatment: Evidence of effectiveness.

The treatment of established pressure sores in the UK has markedly changed since David et al1 reviewed this area of nursing practice in 1983. For example, the use of novel wound-management products and pressure-redistributing support surfaces has been quickly established throughout the NHS.

Pressure sore treatment.

The following three papers were presented at a recent master class held in association with Smith and Nephew. The first presents a guide to the appraisal of published data focusing on risk assessment tools and grading systems. The second highlights the need for randomised controlled clinical trials to provide high-quality evidence for the use of pressure-redistributing support surfaces, while the third paper discusses the need for the development and implementation of pressure sore guidelines that have been based on high-quality evidence.

A Randomised Stratified Survey of the Current use of an Alternating Pressure Air Mattress Within the National Health Service

Summary Little is known about the range and variability of pressure area care within the UK. While pressure-redistributing (PR) mattress use has become widespread during the past ten years, there is little information on how such devices are used. This paper describes a randomised stratified survey of the current use of one PR support surface. 412 mattresses were included in the survey, of which 329 were in use at the time of the visit of the data collector to the provider unit. 74.2% of mattresses in use were found in hospitals. Of the 329 mattresses, 80.2% were being used to prevent the development of sores. The majority of subjects had been assessed using the Waterlow Scale, with 73.6% judged to be at high or very high risk of developing sores. Seventeen (5.2%) subjects developed sores post allocation of the mattress. At the time of mattress allocation, 98 subjects had 130 established sores, of these sores 57 (43.8%) were reported to be full-thickness (severe). The majority of sores (76.5%) were reported to be improving following allocation of the PR mattress. Five key implications for nursing practice were identified through the data collected during this survey - a new indication for use of the APAM, the confusion over relative effectiveness of PR surfaces, the loss of PR mattresses to the NHS, the manual repositioning of mobile patients and the shortage of PR cushions within the NHS.