Ten Tips for Selection

What can a support surface do to prevent and treat pressure ulcers?

Prevention and treatment of soft tissue breakdown remains a top priority among clinicians and providers in home health. A big piece of that mystery includes appropriate choice of preventative and therapeutic support surfaces. Four key extrinsic risk factors that contribute to pressure ulcer development are:

  • Pressure
  • Shear
  • Friction
  • Moisture

These factors are also the only things that can be physically influenced by a support surface. Pressure can deform the skin and underlying tissue occluding blood flow and causing ischemia, all of which are precursors to pressure ulcers.

What are the most important scientific criteria when selecting a support surface?

A support surface can be for the recumbent or seated individual. These products attempt to distribute pressure and conform to the engaging body, thus maximizing contact area and minimizing peak pressures. So, what environment does the skin want?

Effective support surfaces exhibit five basic standards in their technology. These principles offer relief from the effects of pressure, shear, friction and moisture. They are:

  • Low surface tension or the ability for the body to sink in without tissue deformation
  • Low friction and low shear, the product should be made of a material that produces little friction or shear against the skin
  • Freedom of motion, which basically means that the surface should move with the end-user, tracking with their movements
  • Constant restoring force, fancy physics terminology that means that the surface does not exhibit a spring recoil effect. In other words, the surface should not push back against the user's tissue no matter how much she or he immerses
  • Moisture and heat dissipation, maintaining normal skin temperature and moisture levels may be important in certain individuals; excessive moisture is one of the four extrinsic risk factors for the development of pressure ulcers.

What is the difference between various support surfaces?

Support surfaces can be arranged into two categories: Preventative (or the outdated term "pressure reducing") and Therapeutic (formerly known as "pressure relieving"). There is no such thing as "pressure relief." Pressure must go somewhere. Unless our body composition changes and we physically lose weight, the forces we exert remain constant. We can only manipulate or distribute these forces.

Preventative support surfaces are lower cost products used for the prevention of pressure ulcers and the treatment of lower stage pressure ulcers. Often they are used for acute or short-term needs. They typically reduce interface pressure, but not necessarily below the level required to close capillaries. The prevention configurations include: Overlays comprised of air, both non-powered and powered, foam, gel and water and Mattress replacements which are generally comprised of high density foam.

Therapeutic support surfaces are products used to treat higher stage or multiple pressure ulcers. They are a better choice for chronic or longer term use because of their durable construction. These products typically reduce interface pressure below capillary closing pressure. Therapeutic configurations include:Overlays, Mattress replacements, Full-bed systems and Bariatric systems. These products are represented by one or more of the following technologies: non-powered advanced, low air loss, powered air, air fluidized and hybrid systems.

How can a support surface be acquired?

Support surfaces can be rented or purchased. It is important to consider the end-user, her or his needs, their ability to pay any necessary co-pays, electrical costs, rental or maintenance agreements, etc. Some important questions to address if the product is to be purchased are: What is the warranty? What is the company's reputation and availability? Does the manufacturer and the distributor of the product have easy access to their products? Do they have a Web site? How about an (800) telephone number, a trial program, clinical documentation and educational resources? How long can the product be rented before an option to purchase is available? Who will set the product up? How is it cleaned? Is it easy to use?

Length of need and end-user resources are two important criteria to address when deciding whether to rent or purchase.

What are the little known problems with support surfaces in home care?

End user acceptance or compliance (a clinical term I try not to use!) is probably one of the most important, but least contemplated criteria for choosing a support surface. The individual must be comfortable lying or sitting on the system and her or his family must be comfortable using the system. Life and care is complicated enough. Consumers demand home care products that are user friendly.

Another overlooked problem is power consumption, power failures, and blackouts (example: California). When a powered product is provided, an additional expense relating to electrical consumption is incurred by the patient, sometimes as high as $40. or more a month for a typical home care system. What happens in a power failure? An important aspect of the client's wound care can be interrupted.

Probably the most frequently seen, but little known problem with support surfaces in home care is lack of continuity of care. The client may be protected by a quality support surface overlay or mattress only to start rehabilitation and begin getting out of bed to sit on an easy chair, wheelchair or recliner; but 66 percent of pressure ulcers occur on the pelvis. A support surface or therapeutic cushion is just as important as the recumbent support surface. If fact, 70 percent of an individual's weight is distributed over a much smaller surface area which dramatically increases risk for pressure ulcers.

When is low air loss necessary?

Often times the term low air loss is used incorrectly to describe a therapeutic support surface. Therapeutic support surfaces should be chosen based on the client's needs. If the client has issues with skin moisture, diaphoresis and heat accumulation, moisture dissipation, in the form of low air loss, can be beneficial.

What specifics should be addressed before choosing a various support surface in home care?

Questions include:

  • Is additional space needed?
  • Is the system portable and compact?
  • Is there a weight limit on the system?
  • Is patient movement considered?
  • Is the system easily maintained?
  • Is the system reimbursable?
  • Is the system zoned to address different body segments?
  • Can the system be customized to meet the needs of individual's body shape?
  • Are special linens needed?

How can a support surface be independently evaluated?

Performance can certainly be evaluated by trial. I am from the "show-me state" (Missouri), I like to try a product for myself to see if it does what the company claims. I need to talk with others who have used the product. What do they think? These are a couple subjective ways to quickly assess the capabilities of the product.

Performance of support surfaces can be evaluated with interface pressure mapping. This allows the provider to assess the interface pressure measurement in millimeters of mercury. It demonstrates areas of peak pressure and potential tissue breakdown but is not a sure-fire indicator of tissue necrosis. It can, however, show us how well a product compares with another and how well it distributes pressure.

Where can a provider go to find more information about support surfaces and chronic wound care?

Much information can be obtained from support surface manufacturers and a multitude of Web sites. Unfortunately, much of this information is biased and must be evaluated carefully. The Wound Ostomy and Continence Nurses Society offers a comprehensive Web site at www.wocn.org that may offer some unbiased standards as well as the American Academy of Wound Management at www.aawm.org and the National Pressure Ulcer Advisory Panel at www.npuap.org. A thorough literature search produces quite a bit of recent clinical and scientific studies as do recent text books such as Chronic Wound Care: A Clinical Source Book for Healthcare Professional, Third Edition, HMP Communications (800) 237-7285, which just rolled off the press a couple of months ago.

What other things are important when caring for client with pressure ulcers?

Support surfaces are only a small part of the total care plan. Other important aspects of care include the client's overall health and any concurrent diseases, what does the client do every day? What is her or his routine? Are there aspects of their ADLs that could be causing chronic problems with pressure, shear, friction and moisture? How is her or his nutritional status, what medications is she or he taking, is there a history of pressure ulcers? Does the client have any dependent edema? Is the wound bed wet or dry? Is there any dead tissue within the wound? What type of topical treatment is required?

Therapy must be considered on a holistic plane. It is imperative that we assess the whole client, not just the "hole" in the client!

This article originally appeared in the September 2001 issue of HME Business.

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