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  1. Support Surfaces Janice M. Beitz PhD, RN, CS, CNOR, CWOCN, CWS, MAPWCA, FAAN & Laurie McNichol MSN, RN, CNS, GNP, CWOCN, CWON-AP, FAAN Module #10

  2. Objectives Describe state-of-the-science related to patient repositioning and pressure ulcer prevention Analyze impact of clinical realities on ideal practices related to turning and unweighting patients Describe the state-of-the-science related to support surface selection Use an algorithm for evidence based support surface selection

  3. Not Rocket Science • Pressure ulcers due to the pressure and shear • Pressure related to immobility • Sounds very simple but…. • More than meets the eye!! N.B. Most Pressure Ulcers are Avoidable, Not All Pressure Ulcers are Avoidable. (Black et al, 2011)

  4. Pressure Ulcer • Pressure is a combination of magnitude (force or strength) and duration • Have to address both components for clinical effectiveness • Ask anybody in six inch spikes and they’ll agree

  5. Pressure Magnitude Interventions - Positioning devices - Pressure redistribution support surfaces (reactive) - Body posture changes

  6. Pressure Duration Interventions - Weight shifting - Active pressure redistribution support surfaces - Repositioning and turning to unweight pressure areas

  7. Patient Positioning and Turning State of the Science - Amazingly low level of evidence-based support of much of what we do - Much advice based on expert opinion - Keep pressure below critical closing pressure of 12- 32mm Hg (original work on healthy males); so reality is very different - Cochrane Review on repositioning (Moore and Cowman, 2012): No substantive support for effect of repositioning on pressure ulcer healing (was a focus on treatment)

  8. Science of Turning Frequency • In USA, turning frequency commonly suggested to be every two hours – not evidence based • Much Folklore About Origin (Hagisawa, et al, 2008; Krapfl and Gray 2008) • Recent research suggests that turning frequency must be individualized based on support surface in use and patient condition • Ironically older studies said this too (Sprigle & Sonenblum, 2011)

  9. Science of Turning Frequency • Some sources say two hour frequency is not enough • Wong (2011) studies effect of supine positioning on sacral trancutaneous O2: Two hour turns inadequate in elders • Some sources say two hour frequency is too much • Vanderwee et al, (2006). More frequent positioning on pressure reduction mattress did not reduce pressure ulcers (2 versus 4 hour repositioning) • In other words turning, repositioning unweighting must be in context! • Overall, repositioning every four hours on a quality pressure reducing surface may be as effective as every two hours (Krapfl et al, 2008; Vanderwee et al, 2007)

  10. Science of Turning Frequency • Joanna Briggs Institute • Reposition person as frequently as required (Campbell, 2013) (Level IV) • Cochrane Protocol Published in 2012 (Gillespie et al) • What is the most effective repositioning position for PUP? • What is the most effective repositioning schedule for PUP? • “The exact timing and mechanism for repositioning is unknown” (p. 3)

  11. More Recent Study(Still, Cross et al, 2012) • Two year study in SICU at Emory, before and after implementation of “Turn Team” – called a “Novel Strategy,” turned and repositioned all patients – all were on pressure redistribution surface (Journal of American College of Surgeons) • Did significantly lower pressure ulcer incidence

  12. Science of Positioning • Efficacy of patient positioning for pressure ulcer prevention (PUP) has been examined • Much heat and a little light • Full lateral positioning is discouraged; increased pressure over trochanter (Krapfl et al, 2008) • Usual suggestion is 30 degree side lying • Peterson et al (2010) used 15 healthy volunteers; repositioned by experienced ICU nurses: NOT reliable unloading of pressure points

  13. Science of Positioning • Generally recommended that head of bed not be at a 90 degree angle; sacral pressure increases (Krapfl et al, 2008) • Heel offloading is recommended (various devices or pillows) • Cochrane Protocol “Repositioning for pressure ulcer prevention in adults: (Gillespie et al, 2012): hopefully will shed more light

  14. Clinical Realities: Critical Care • Immobility and pressure ulceration – link of risk • Clinicians fear to move due to “Hemodynamic Instability” (not well defined in literature) • Real danger to ICU patients is the effect of not turning or not mobilizing patients (Brindle et al, 2013)

  15. Consensus Panel at Virginia Commonwealth University (VCU) • It is possible to turn and reposition almost all critically ill patients in the ICU without risk of potentially fatal changes in hemodynamic status • In some situations, some patients should not be turned including: • Develop life threatening arrhythmia • Are actively being fluid resuscitated for low blood pressure • Are actively hemorrhaging • Have changes in hemodynamic parameters that do not recover within 10 minutes of repositioning • Unstable fractures of pelvis and spinal injuries • In patient with a short-term (temporary) oral-pharyngeal airway (until stable endotracheal tube placed)

  16. Recommended Motto(Brindle et al, 2013) In general, all ICU patients should be turned until, “they give you a reason not to.” No one should assume the patient is too unstable; you must first allow the patient to fail (p. 259)

  17. Turning/Repositioning Strategies Go slow Get help Monitor response Individualize care based on trial turns Try small serial turns using 15 second technique and then in 30 degree position Consider continuous lateral rotation therapy Try to manually turn at least every 8 hours to see if “too hemodynamically unstable”

  18. Continuous Lateral Rotation Therapy In VCU ICU’s – use specific protocol Continuous Lateral Rotation Therapy (CLRT) off every two hours – patient manually repositioned to left or right for 30 minutes Then replaced supine and CLRT resumed

  19. Clinical Realities: Critical Care Patients left in stationary position too long develop “Gravitational Equilibrium” – may make it difficult to adapt to position changes Evidence in general supports negative effects of prolonged bed rest

  20. Summary of Turning and Repositioning Much published recommendations reflected historical and well-established practices Discussed science and best practices for turning, repositioning and unweighting Applied to daily realities of clinical care

  21. Support Surfaces The other part of the equation in patient care for pressure ulcer prevention

  22. Support Surfaces Using an evidence-and-consensus-based algorithm for decision making support

  23. Why Are We Talking About This? Current best evidence strongly supports efficacy of support surfaces for prevention of PU Evidence concerning use of support surfaces for treatment of PU is sparse but supportive

  24. Why Are We Talking About This? Because even if we have used a decision tree in the past, it was based on our own or some other person’s own ideas about what was best Because in this day and time of evidence based practice (EBP), we need something more Because it might just be harder than it looks

  25. An Algorithm Algorithm: Flow chart that provides a highly visual aid for managing multiple factors that go into decision making for support surface selection Criteria for Algorithm: Based on current best evidence whenever possible, based on consensus based best practices when evidence is lacking

  26. What Types of Support Surface Products? The algorithm was designed for specific categories of support surfaces (Overlays, Mattresses, Mattress Replacements, and Integrated Bed Systems) used for the prevention and treatment of pressure ulcers, excluding medical device related pressure ulcers.

  27. Development of Algorithm: Who Should Use It? Target Audience Included: Nurses Specialty and Advanced Practice Nurses Physical Therapists Occupational Therapists Physicians Physician Assistants

  28. Development of Algorithm: For Patients In Which Practice Settings? Algorithm was designed to be used with adult patients (including bariatric) in: Acute Care (Hospitals) Long Term Acute Care (LTAC) Long Term Care/Skilled Nursing Facilities (LTC/SNF/Rehab) Home Care (HHC)

  29. Development of Algorithm: Which Patients Were Excluded? Not to be used with patients <16 years old Not to be used in selected settings where LOS was <24 hours, e.g. Operating Rooms Interventional Services (Cath Lab, GI Lab, Interventional Radiology)

  30. Development of Algorithm: Are There Support Surface Product Exceptions? Selected surfaces were not incorporated into the algorithm Seating surfaces/cushions CLRT (Continuous Lateral Rotation Therapy) mattresses Proning beds Other specialty surfaces (used for patients with multiple fractures, unstable spines, etc.

  31. An Evidence-and Consensus-Based Support Surface Algorithm: Publication McNichol, L, Watts, C., Mackey, D., Beitz, J., Gray, M. Identifying the Right Patient for the Right Surface at the Right Time: Generation and Content Validation of an Algorithm for Support Surface Selection. J Wound Ostomy and Continence Nurs. 2015:42(1)19-37 Terminology related to support surfaces (Table 3) and glossary (Box 4) are included in the manuscript

  32. An Evidence-and Consensus-Based Support Surface Algorithm: Web-Based Access Web based version launched March 31, 2015 Google Chrome or Mozilla Firefox Internet Explorer 11 if Chrome or Firefox not available Fully compatible with smartphone/tablet browsers (both Apple and Android) Practice with Case Studies

  33. You’ve Got This! Give answers to the two scenarios based on algorithmic guidance

  34. Case Scenario: Acute Care Ruth Ingalls, 82 years old, is admitted to an orthopedic unit in a large urban hospital with a fractured left hip due to a fall in her home. Her skin is intact. Her Braden Scale total score at admission is 13. Her Braden mobility subscale score = 2 and her moisture subscale score = 2. Past Medical History: Congestive heart failure, hypertension, and urinary incontinence. She is 5’2” and weighs 145 lbs. Admission lab values: WBC’s 12.2, Hgb 10, Hct 24, electrolytes WNL. Albumin is 3.0. What support surface would you recommend?

  35. Case Scenario: Home Care Ben Miller is a 75 year old gentleman who sustained a left Cerebral Vascular Accident (CVA) with significant right sided paresis. His 3-day hospital course was uneventful and he was transferred to a skilled nursing facility (SNF) for 3 weeks of rehabilitation. While in the SNF, he developed bilateral heel pressure injuries, which are now covered with eschar. On admission to home health, the nurse’s notes reveal the above noted pressure injuries along with incontinence associated dermatitis in the perineal area. Braden Scale Score on admission is 12 with a moisture subscale score of 2 and a mobility subscale score of 2. Patient required moderate to maximum assistance with transfers and ambulation. His 80 year old wife is the primary caregiver. Past medical history includes hypertension, Type II diabetes, obesity, benign prostatic hypertrophy and urinary incontinence. Admission lab values: WBC’s 14.4, Hgb 11, Hct 23, electrolytes WNL. Prealbumin is 12. What support surface would you recommend?

  36. Key Nursing Concepts Assessment Caring Communication Education Evidence-based Practice Prevention Healing Pain Safety Treatment

  37. Key Nursing Diagnoses Alteration in Comfort r/t Impaired Skin Integrity Impaired Tissue Integrity Potential for Injury

  38. Key Nursing Practice Issues Tissue pressure that can cause ulcers is a combination of magnitude (force or strength) and duration Both should be addressed: Support Surface AND Repositioning

  39. Websites for Further Information on Types of Wounds - Association for the Advancement of Wound Care - Canadian Association for Wound Care - National Pressure Ulcer Advisory Panel - World Union of Wound Healing Societies - Wound Ostomy Continence Nurses Society

  40. References Black, J.M., Edsberg, L.E., Baharestani, M.M., Langemo, D., Goldberg, M., McNichol, L., Cuddigan, J., and National Pressure Ulcer Advisory Panel (2011). Pressure ulcers: Avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound Management, 57(2), 24-37. Brace, J. (2010). Deep tissue injury pressure ulcers among elderly patients. Dissertation: University of Virginia. UMI AA13435914. Brindle, C.T., Malhotra, R., O’Rourke, S., Currie, L., Chadwik, D., Falls, P., Adams, C., Swenson, J., Tuason, D., Watson, S., & Creehan, S. (2013). Turning and repositioning the critically ill patient with hemodynamic instability. A literature review and consensus recommendations. Journal of WOCN, 40(3), 254-267. Campbell, J. (2013). Pressure area care (older adult). Recommended practice. 7 pages.7/18/2013. Joanna Briggs Institute. Fong, E. (2015). Pressure ulcers: Prevention and Management. Joanna Briggs Institute. 5 pages. 12/5/2015. Gillespie, B.M., Chaboyer, W.P., McInnes, E., Kent, B., & Whitty, J.A. (2012). Repositioning for pressure ulcer prevention in adults (Protocol). The Cochrane Collaboration Database of Systematic Reviews, Issue 7, Article number CD009958. DOI: 10.1002/14651858.CD009958.

  41. References Gillespie, B.M., Chaboyer, W.P., McInnes, E., Kent, B., Whitty, J.A., Thalib, J. (2014). Repositioning for presure ulcer prevention in adults (Review). The Cochrane Collaboration Database of Systematic Reviews, Issue 4, Article number CD009958. DOI: 10.1002/14651858.CD009958. pub2. Joanna Briggs Institute (2013). Pressure area care. Recommended practice. 1/7/2013. Joanna Briggs Institute (2011). Pressure area care: Turning an older person in bed. Recommended practice. 10/24/2011. Joanna Briggs Institute (2008). Best Practice: Pressure ulcers – Prevention of pressure-related damage. 12(2), 4 pages. ISSN: 1329-1874. Joanna Briggs Institute (2008). Best practice: Pressure ulcers-Management of pressure related tissue damage. 12(3), 4 pages. ISSN: 1329-1874. Kaitani, T., Tokunaga, K., Matsui, N., & Sanada, H. (2010). Risk factors related to the development of pressure ulcers in the critical care setting. Journal of Clinical Nursing, 19, 414-421.

  42. References Krapfl, L.A., & Gray, M. (2008). Does regular repositioning prevent pressure ulcers? Journal of WOCN, 35(6), 571-577. Ligita, T., Jaya Jekara, R. (2008). Skin care strategies to prevent pressure ulcer forpatients in acute care settings: A systematic review (protocol). Joanna Briggs Institute. McInnes, E., Jammali-Blasi, A., Bell-Syer, SEM, Dumville, JC, Middleton, V., Cullum, N. (2015). Support surfaces for pressure ulcer prevention (Review). Cochrane Database of Systematic Reviews, 9. Art. No. CD001735.DOI: 10.1002/14651858.CD001735. pub5. McNichol, L, Watts, C., Mackey, D., Beitz, J., Gray, M. Identifying the Right Patient for the Right Surface at the Right Time: Generation and Content Validation of an Algorithm for Support Surface Selection. J Wound Ostomy and Continence Nurs. 2015:42(1)19-37 Moore, Z.E.H. & Cowman, S. (2012). Repositioning for treating pressure ulcers (review). Cochrane Database of Systematic Reviews, 9, CD006898.DOI: 10.1002/14651858. Moore, Z., Cowman, S., & Conroy, R.M. (2011). A randomized controlled clinical trial of repositioning, using the 30° tilt, for the prevention of pressure ulcers. Journal of Clinical Nursing, 20, 2633-2644.

  43. References Moore, Z.E.H. & Webster, J. (2013). Dressings and topical agents for preventing pressure ulcers. Cochrane Database of Systematic Reviews, 8, Article number CD009362. DOI: 10.1002/14651858.CD009362.pub2 Mordifi, S.Z., Kent, B., Phillips, N., & Tho, P.C. (2011). Use of mobility subscale for risk assessment of pressure ulcer incidence and preventive interventions: A systematic review. JBI Library of Systematic Reviews, 9(56), 2417-2481. O’Connell, A., Lockwood, C., & Thomas, P. (2008). Pressure ulcers – prevention of pressure related tissue damage. JBI Best Practice Technical Report, 4(2), 1-33. ISSN 1833-7732. O’Connell, A., Lockwood, C., & Thomas, P. (2008). Pressure ulcers-management of pressure related tissue management. JBI Best Practice Technical Report, 4(3), 34-42, ISSN 1833-7732. Peterson, M.J., Schwab, W., Van Postrum, J.H., Gravenstein, N., & Caruso, L.J. (2010). Effects of turning on skin-bed interface pressures in healthy adults. Journal of Advanced Nursing, 66(7), 1556-1564.

  44. References Reddy, M., Gill, S.S., Rochon, P.A. (2006). Preventing pressure ulcers: A systematic review. JAMA, 296(8), 974-983. Slade, S. (2013). Pressure area care: Prevention. Joanna Briggs Institute, 5/3/2013, 5 pages. Still, M.D., Cross, L.C., Dunlap, M., Rencher, R., Larkins, E.R., Carpenter, D.L., Buchman, T.G., & Coopersmith, C.M. (2013). The turn team: A novel strategy for reducing pressure ulcers in the surgical intensive care unit. Journal of American College of Surgeons, 216, 373-379. Vanderwee, K., Grydonck, M.H.F., DeBacquer, D., & DeFloor, T. (2007). Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions. Journal of Advanced Nursing, 57(1), 59-68. Wong, V. (2011). Skin blood flow response to 2-hour repositioning in long-term care residents: A pilot study. Journal of WOCN, 38(5), 529-537.