Choosing Appropriate
Support Surfaces
Betsy Willy MA, PT, CWS
Pathway Health Services
September 11, 2012
Lack of Standardized Testing
• Results in inability to compare products
• Standardized Testing Initiative by NPUAP
– Began with standardizing terms and definitions
– Established standards for testing materials
– Recruiting participants to develop research to
compare products using standardized measures
• Outcome – to provide the clinician with an
evidence based system to choose
appropriate support surface
Definition of Support Surface
(NPUAP)
• “A specialized device for pressure redistribution
designed for management of tissue loads, microclimate, and/or other therapeutic functions”
–
–
–
–
–
–
Any mattresses
Integrated bed system
Mattress replacement
Overlay
Seat cushion
Seat cushion overlay
Updated Terminology
• Static = non-powered
• Dynamic = powered
• Pressure reduction or relief = Pressure
Redistribution
Elements Critical To
Pressure Ulcer Prevention
•
•
•
•
•
Low Moisture retention
Reduced heat accumulation
Shear reduction
Friction reduction
Pressure redistribution
Properties to Consider
• Envelopment – the ability of the support
surface to conform, so to fit or mold around
irregularities in the body
• Immersion - The depth of penetration (sinking
into a support surface)
• Life Expectancy – the defined period of time
during which a product is able to effectively
fulfill its designated purpose
Components of Foam Support
Surfaces
• Viscoelastic Foam – (memory foam)
– a type of porous polymer material that conforms in
proportion to the applied weight
• Elastic Foam – (non-memory foam used for packing
boxes)
• Open cell foam – (sofa cushion)
– permeable structure with no barrier between cells allowing
gases or liquids to pass through the foam
• Closed Cell Foam
– Non permeable structure preventing gases or liquids from
passing through the foam
Other Components of Support
Surfaces
•
•
•
•
•
Air – in cells or bladder
Gel – in combination or alone
Water
Solid (solid seat insert)
Combination – foam/gel
Types of Support Surfaces
•
•
•
•
•
•
•
•
Foam Overlay (add height to mattress)
Water mattress
Alternating Air Pressure
Low Air Loss
Air Fluidized (glass beads with air)
Zone (pressure can be controlled by zone)
Multi zoned surface
Lateral Rotation (rotates about a longitudinal axis –
degree of turn, duration and frequency)
Low Tech Support Surfaces
Non Powered
High Tech – Powered Support
Surfaces
Desirable Characteristics
• Prevents loads surpassing Capillary Closing
of 32 mm/hg pressure
• Reduces moisture and heat accumulation
• Reduces shear and friction
• Is easy to use and maintain
• Is economical
• Allows for spontaneous movement on the
support surface
Cochrane Collaboration
Podcast
• Due to poor quality of
the studies to date
(2011), comparison of
the qualities between
various products
cannot be supported
by current research.
• Recommendations for
practice:
– High risk individuals
should be provided
replacement alternating
air mattress rather than
overlay
– Very high risk individuals
should be provided high
tech mattress such as
low or high air loss
Support Devices (WOCN)
Performance
Air
Characteristics fluidized
Low
air
loss
Alternating
air
Static
Flotation
Foam
Standard
Mattress
Increased
support area
Yes
Yes
Yes
Yes
Yes
No
Low Moisture
retention
Yes
Yes
No
No
No
No
Reduced heat
accumulation
Yes
Yes
No
No
No
No
Shear
Reduction
Yes
?
Yes
Yes
No
No
Pressure
reduction
Yes
Yes
Yes
Yes
Yes
No
Dynamic
Yes
Yes
Yes
No
No
No
Cost per day
High
High
Moderate
Low
Low
Low
NPUAP Recommendations
• “Support surfaces alone
can neither prevent nor
heal pressure ulcers.”
– Use as part of a total
program of prevention
and treatment
• Use standardized risk
assessment tool in
conjunction with
comprehensive
assessment to
determine risk level and
Tissue Tolerance Tool
• When PrU deteriorates
or fails to heal, consider
replacing support
surface with one that
provides more
aggressive pressure
redistribution, heat and
moisture reduction
• Reevaluate the whole
person for root cause
Overall Goal of Support
Surface
• Evenly distribute pressure over large
area
• Allows person to immerse (sink into
surface
• Decreases heat and moisture
Overall Recommendations
Overall Recommendations
• Do not use egg crate or foam
overlays
• An individualized turning
schedule should be
assessed with each surface
• Turning and repositioning is
required for all products
• Off load heels on any
surface
• Assess products periodically
for “bottoming out” and
document monitoring
• The less padding between
the skin and support surface,
the more effective the
surface can be
• Foam has a defined life
expectancy – when a
cushion retains the shape of
the buttocks, it needs to be
discarded
Shear Wounds
Contributing factors
Tear Drop shaped wounds caused by
separation of tissues when skin
remains stable on support surface and
boney structure slides resulting in
facial tissue tears
Wheelchair Surface
Skin Condition
Type of Pressure
Redistribution Surface
• At risk for breakdown
• Therapy referral to assess positioning and
W/C surface
• Foam wheelchair cushion at least 3-4 inch
high density or medical grade foam
• Or gel foam or all air cushion
• History of pressure ulcer(s) on the ischial
tuberosities, sacrum, and/or coccyx
• Therapy referral to assess positioning and
W/C surface
• Foam wheelchair cushion at least 3-4 inch
thick, high density or medical grade foam
• Gel W/C cushion
• Air W/C cushion
• Current pressure Ulcer(s) on the ischial
tuberosities, sacrum, and/or coccyx
• Therapy referral to assess positioning and
W/C surface
• Gel W/C cushion
• Air W/C cushion
• Sitting time limited and individualized
Off-loading Heels and Feet
• Side lying: Lateral
aspect of foot must be
off-loaded
– Pillow under lateral calf
of lower leg in side lying
– Pillow between knees
– Ensure feet are not
touching support surface
on any product
• Ambulatory
– Non-weight bearing on
ulcerated foot
• Supine – Pillow under
calf suspending heels
– Ensure feet are not
touching support surface
– Body pillow or pillows
under fitted sheet is
harder to displace
• Sitting – Use heel free
device
– Foam boots do not
redistribute pressure
Motorized Scooter
and Bedside Recliner
• 3-4 inch foam cushion places the center of
gravity of the individual too high for fall
prevention
• Use one inch gel cushion
• Limit time on device if this intervention is
not adequate to prevent non-blanching red
areas or to promote healing of pressure
ulcer
Maintenance and
Replacement
• Follow manufacturers
directions for pressure
settings
• Alarm lights on low air
loss mattresses
– Look first for air leaks with
stethoscope
– Check air hose connections
– Check pump function
• Monitor and document
that device is functioning
• Check all air devices for
adequate inflation
– Place flat hand under device
– Push up into air
– Should be able to displace
air to within 2 inches of body
part
– If you can touch the boney
prominence, increase air
pressure
Wheelchair cushions
• Open the cover and check components
of cushion
– Check for wear or deterioration of foam
and gel
– Ensure proper inflation if air cushion
– Research supports – the more
interconnecting air cells, the more
aggressive the pressure redistribution will
be through immersion
Air Cell Cushion and
Alternating Air Seat Cushion
Geri Chair vs Tilt in Space
• Severely contracted
individuals
– Require complex
positioning in bed – refer
to therapy for assistance
– Seating
• Tilt in space chairs
accommodate
contractures better than
Geri Chair
• If geri chairs are used,
add gel overlay and limit
time exposed to
pressure
• Constant movement
– Huntington’s Disease
• Wider bed
• Reduce friction
• Padded wall and floor
• Sliding into sacral sitting
– Prevent shear and
friction
• “Dump” seat or use
Gravity assisted Seating
by changing the wheel
position to lower the
back of the chair seat
Kyphotic Back
• Spinous processes at
high risk
– Choose wheelchair back
that will conform to the
individual’s back
• Keyhole – Keen
• Jay Personal back – Jay
• Deep Incrediback or
moldable incrediback by
Comfort Care
– Increase seat depth to
decrease pressure per
square inch
– Drop back of seat to
prevent sliding
Sacral Sitting
• If due to high extension
tone as in Parkinson’s
Disease
– To decrease tone and
stabilize pelvis try antithrust cushion with gel
under coccyx and ischial
tuberoscities with pelvic
belt to stabilize
– Belt is not a restraint if
person is dependent
– Lower seat back if
needed
Sacral Sliding
• Avoid use of wedge
cushion by dropping
back of seat
– Put back wheel in highest
axel position
– Front caster in lowest
axel position
– If this raises the knees to
high to allow feet flat for
self propelling, start with
a lower chair frame (hemi
or super hemi)
Resources
•
•
•
National Pressure Ulcer
Advisory Panel Support Surface
Standards Initiative; Terms and
Definitions Related to Support
Surfaces 01/29/2007
Pressure Ulcer Prevention and
Treatment; Quick Reference
Guide 2009 EPUAP and
NPUAP (www.npuap.org)
Wound Care; A Collaborative
Practice Manual for Health
Professionals, 3rd edition; Carrie
Sussman, Barbara BatesJensen; 2007 Lippincot,
Williams and Wilkins
•
•
•
Wound Resource Manual; Long
Term Care 4th edition, Pathway
Health Services
(www.pathwayhealth.com)
Cochran Collaboration PodCast
6/2011; Jill Hetherington;
Efficacy of use of pressure
relieving support surfaces in
prevention of pressure ulcers
Wound, Ostomy, and
Continence Nurses Society
(WOCN). Guideline for
prevention and management of
pressure ulcers.
Questions?
Kristi Wergin
Program Manager
Stratis Health
kwergin@stratishealth.org
www.stratishealth.org
Stratis Health is a nonprofit organization that leads
collaboration and innovation in health care quality and safety,
and serves as a trusted expert in facilitating improvement for
people and communities.
This material was prepared by Stratis Health, the Minnesota Medicare Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services
(CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 10SOW-MN-C7-12-116 083112