Support Surfaces: Classifications and Decision Making
Skin and Wound Care. Produced by the Emory Nursing Wound Ostomy Continence Nursing Education Center.
Transcript
So now we're going to move ahead and we're going to finalize our discussion of support surfaces.
Speaker A:We're going to specifically focus on classification in relation to the mattress, in relation to the support medium, and how that relates to patient selection.
Speaker A:So we've already said that some of the key assessment factors, when you're selecting a surface for a patient, you have to look at the patient's weight.
Speaker A:Do you need a bariatric bed?
Speaker A:Bariatric surfaces do come with constant low pressure pressure redistribution surfaces and with alternating pressure surfaces.
Speaker A:So you can select a bariatric surface that provides the other features that you want.
Speaker A:You have to think about fall risk and whether or not you need a low bed.
Speaker A:You have to think, what did this patient score on mobility and activity subscale scores?
Speaker A:The vast majority of our patients score either 1 or 2 on mobility and activity.
Speaker A:So most of them do need either a pressure redistribution surface or an alternating pressure surface.
Speaker A:If they're diaphoretic, they need moisture control.
Speaker A:If they have existing breakdown, then you're typically going to use the highest level surface available to you.
Speaker A:So usually you would start with air instead of starting with foam.
Speaker A:Now, in the WOCN support surface algorithm decision making tool, they look at two things they look primarily at how did the patient score on the mobility subscale score?
Speaker A:How did the patient score on the moisture subscale score?
Speaker A:So you can access this online and a lot of agencies are using this to help staff nurses make appropriate decisions.
Speaker A:A lot of wound care nurses have taken this algorithm and then individualized it for their agency.
Speaker A:But basically it comes down to what we've just said.
Speaker A:If this patient scores low on the mobility subscale score and low on the moisture subscale score, then they need either a constant low pressure surface or an alternating pressure surface that does provide low air loss.
Speaker A:Because you're dealing both with the negative effects of immobility and the negative effects of moisture.
Speaker A:If they score 2 or less on the mobility subscale score, but 3 or higher on the moisture subscale score, then you've got to address immobility, but you do not have to worry about moisture.
Speaker A:So you can go with any pressure redistribution surface.
Speaker A:You can also use alternating pressure, but you don't need a surface with a low air loss feature.
Speaker A:In contrast, if you had a patient that was fairly mobile but very diaphoretic, you would be focused primarily on moisture management.
Speaker A:So you would select a surface that had low air loss to help control moisture.
Speaker A:In reality, most of our patients are going to fall into that first or second category.
Speaker A:Either they're going to score low on mobility and low on moisture, and they need either pressure redistribution or alternating pressure that also has a low air loss feature.
Speaker A:Or they're going to score low on mobility and they'll be high or normal on moisture, and you can just focus on pressure redistribution or alternating pressure.
Speaker A:Now let's talk about how surfaces are classified in terms of their relationship to the mattress or the bed.
Speaker A:There are overlays that are available that are designed to be placed on top of a standard mattress and to provide therapeutic effects.
Speaker A:So essentially, they're designed to convert a standard mattress into a pressure redistribution surface.
Speaker A:Some of them may also address moisture.
Speaker A:Now, one potential advantage, depending on your situation, is that these are usually single patient use.
Speaker A:So that means if you use an overlay in acute care, you could send it home with the patient.
Speaker A:It also means it's usually a good choice for a patient in the home care setting.
Speaker A:One consideration, if you're thinking about using overlays in an acute care setting or in an inpatient setting, you have to think about the height of the overlay.
Speaker A:Because if the overlay is, say, 4 inches thick, then it adds considerable height to the standard mattress, which increases the risk of entrapment and increases the risk of falls.
Speaker A:So a thick overlay can be a major patient safety issue.
Speaker A:And most inpatient facilities have moved away from 3 to 4 inch overlays.
Speaker A:And if they use overlays, they're using those that are low profile.
Speaker A:Now, talking about some of your low profile overlays, there are some air overlays that add very little height, but do add protection.
Speaker A:So they reduce the interface pressures, the pressure against the skin, by creating a conformable surface.
Speaker A:So they're designed to convert a standard mattress to a pressure redistribution mattress or to add additional protection if the patients already own a pressure redistribution mattress.
Speaker A:So look at the next to last bullet point.
Speaker A:There are some data available that indicate that you can add an over add an air overlay to an existing foam pressure redistribution surface and that it will give you added protection, that it will reduce the interface pressures.
Speaker A:So in our setting, we have pressure redistribution mattresses on all of our beds that are foam based.
Speaker A:We did a study and we used a pressure monitoring device.
Speaker A:And so we put the pressure monitoring device on top of the mattress and had people of different weights lie on that mattress.
Speaker A:We recorded the pressure against the skin surface, and then we added the low profile air overlay and we redid the tissue interface pressure measurements.
Speaker A:And we did find A significant reduction in the interface pressures.
Speaker A:So now these are limited studies, but some agencies are beginning to use low profile air overlays as adjunct therapy to foam based pressure redistribution mattresses for very high risk patients or for patients who experience some degree of skin deterioration on the pressure redistribution mattress alone.
Speaker A:We need more data.
Speaker A:I just wanted you to be aware that we have a little bit of data and that you may see that as a recommendation in some agencies.
Speaker A:What about a mattress replacement?
Speaker A:Well, a mattress replacement, by definition, you take the existing mattress off the bed and you replace it with this therapeutic mattress that has additional features.
Speaker A:So it will combine the features of a standard mattress with high level pressure redistribution.
Speaker A:Some provide, not all.
Speaker A:So when you look at mattress replacements, there are standard mattress replacements, there are rental mattress replacements.
Speaker A:What you see here on this slide is a standard mattress replacement.
Speaker A:What does that mean?
Speaker A:It means this is designed for use as a standard hospital mattress.
Speaker A:It has been redesigned so that the core materials are designed to provide high level pressure redistribution, but also high level support.
Speaker A:The core is made out of materials that do not break down rapidly.
Speaker A:So they're designed for therapeutic effects over a three to five year period for multiple patients.
Speaker A:The mattress cover is designed to be conformable, but also designed so that it can be terminally cleaned between patients.
Speaker A:Now, some agencies are also using mattress covers over the mattress to provide additional protection in terms of infection control.
Speaker A:We need more data about that, but we are starting to see that happen.
Speaker A:So when you look at what's available in your agency, you will probably find that the standard hospital mattress in your agency combines these effects, provides pressure redistribution, provides a conformable surface, can be cleaned between patients, and is warrantied for between three and five years.
Speaker A:Really important to know what the warranty period is and where you fit within that period.
Speaker A:If you've got a warranty period of three years and you're on year two, it's time to look at what do we do next year.
Speaker A:Rental mattresses are available.
Speaker A:They're not widely used because you think about the difficulty in using a rental mattress.
Speaker A:You have to take the existing mattress off the bed, where are you going to put it in order to put the rental mattress on?
Speaker A:So for many agencies, this is just a very difficult option to implement.
Speaker A:What can you do with a rental mattress?
Speaker A:A lot.
Speaker A:Because when you think about a therapeutic surface, the therapeutic effects are in the mattress, typically not in the bed.
Speaker A:So most of your rental mattresses will be air support surfaces.
Speaker A:They're usually pump driven.
Speaker A:They will provide either alternating pressure or constant low pressure.
Speaker A:Most of them also provide moisture management.
Speaker A:The company will deliver them, they will set them up, but again, less commonly used just because of the difficulty in taking a mattress off the bed, getting another mattress on, what you do with the patient in the meantime, all of those things.
Speaker A:So instead you'll typically see rental beds use.
Speaker A:We don't use many rental mattresses, but we do use rental beds because you can bring a bed in, transfer a patient from the existing bed and mattress to the new rental bed and mattress, and then store the existing bed and mattress.
Speaker A:So rental beds replace the standard hospital bed.
Speaker A:They provide multiple therapeutic features.
Speaker A:So you might take a patient from a standard pressure redistribution mattress and put them on a rental bed that provides airflow because they're diaphoretic.
Speaker A:So most of your rental mattresses work either on, well, all of them work either on constant low pressure or alternating pressure.
Speaker A:Most provide airflow.
Speaker A:Many have in bed scales.
Speaker A:Many have pulmonary features such as percussion.
Speaker A:So it depends on what you need.
Speaker A:Rental beds are are the most expensive option, but they also give you the most therapeutic options.
Speaker A:Now let's look at support medium.
Speaker A:So foam is widely used.
Speaker A:You can get foam overlays.
Speaker A:Foam is typically the primary component in your hospital mattress, your standard hospital mattress that's used throughout your agency.
Speaker A:The problem with foam is there's tremendous variability in the quality and the level of therapeutic effects.
Speaker A:So you've all seen those Egg Crate foam mattresses that are very porous.
Speaker A:You can roll them up into very narrow cylinders and store lots of them, but they give you very little protection.
Speaker A:They're primarily for comfort.
Speaker A:In contrast, if you look at the mattresses that are in place throughout your agency, they're probably filled with high quality foam.
Speaker A:Also known as viscoelastic foam or high specification foam.
Speaker A:This is foam that's designed to provide support and conformability.
Speaker A:These foams are also available commercially.
Speaker A:So when you look at your Tempur Pedic mattresses and comparable mattresses, they use viscoelastic or high specification foam, High level support, high level conformability, very effective reactive surfaces.
Speaker A:But do foams provide moisture management?
Speaker A:No.
Speaker A:So if your patient needs moisture management, a foam surface is not going to be what you want.
Speaker A:What about gels?
Speaker A:We don't use a lot of gels.
Speaker A:There are some gel overlays available, but they're very heavy.
Speaker A:There are some rental mattresses that are gel based, even heavier.
Speaker A:So most of the time, if you have a gel based product, it's a wheelchair cushion.
Speaker A:Now the good thing about gel is that it's a very thick fluid.
Speaker A:So it can be very effective if you have a heavy patience, a wheelchair cushion.
Speaker A:But it's very sensitive to heat and cold.
Speaker A:So if it's been exposed to cold, it's going to be pretty rigid and you're going to have to massage it or it's going to have to warm up before it provides even pressure distribution does not provide moisture management.
Speaker A:So gel is one of those niche products.
Speaker A:A lot of us use positioning pillows that are gel based, but you will see very few overlays, very few mattresses that are gel based just because of the weight issue.
Speaker A:Many of our products are air based.
Speaker A:So you can get air overlays, you can get air mattresses, you can get air beds.
Speaker A:What's the advantage of air?
Speaker A:It's lightweight, it's a gas, obviously, so it's extremely conformable.
Speaker A:So it provides very high level pressure redistribution.
Speaker A:Air is also the base for your alternating pressure systems.
Speaker A:So you've got air systems that are pressure redistribution air systems that are alternating pressure.
Speaker A:You can get air mattresses with a pump, you can get them without a pump.
Speaker A:Now, if you have an air mattress or an air overlay that is connected to a pump, the advantage is the pump maintains constant inflation and you don't really have to worry about it unless you have a power outage and the whole system goes down.
Speaker A:If you have an air overlay that has no pump, then you have to manually inflate it and you have to just monitor to be sure that it is correctly inflated.
Speaker A:But the advantage is you're not electricity dependent.
Speaker A:So, yes, you can get it pump driven or you can get an overlay that's manually inflated.
Speaker A:Either one works.
Speaker A:If you're looking for moisture management, you're looking for a system that's pump driven and that has perforations in the COVID And that system will be marketed as low air loss.
Speaker A:So that's the terminology you're looking for.
Speaker A:So here we're back to low air loss provides microclimate control.
Speaker A:We've already talked about this.
Speaker A:Many of the air support surfaces with a low air loss feature have many other therapeutic features as well.
Speaker A:So most of them provide zoned air support, meaning that the level of inflation in the trunk is different than the level of inflation in the lower extremity area or the head area.
Speaker A:So that zoned air support is designed to provide the highest level pressure redistribution and to match the level of support with patient weight in that area.
Speaker A:And essentially, all of your low air loss mattresses provide moisture control, microclimate control, because they have those micro perforations in the surface.
Speaker A:There is a device out there.
Speaker A:Actually, there's a number of devices in this category known as dolphin technology.
Speaker A:It's like, well, what is that?
Speaker A:Well, they call it dolphin technology because they pattern these surfaces based on technology that was developed to transport dolphins.
Speaker A:Dolphins are very heavy, so they developed a very high level system for dolphin transport.
Speaker A:And what they used was fluid immersion technology.
Speaker A:There's constant computerized adjustment of the mattress underlying the dolphin, or in our case, the patient, so that there's constant sensing of interface pressures across the contact area and constant adjustments to maintain very low interface pressures so that you get very high level pressure redistribution.
Speaker A:So it's a very effective very high level pressure redistribution, constant low pressure system.
Speaker A:And they come in standard and in bariatric air fluidized.
Speaker A:We mentioned this already.
Speaker A:These are your sand beds, bead beds, a tank filled with siliconized glass beads.
Speaker A:You can get the tank or you can get a hybrid version.
Speaker A:So if you look at the hybrid version on top, then the upper trunk area is basically low air loss technology.
Speaker A:So it's an air support surface with airflow.
Speaker A:And then from the waste out, it is that sand bed technology.
Speaker A:It's the siliconized beads that are maintained in constant flux by airflow.
Speaker A:What are the advantages of the either the air fluidized or the hybrid surface?
Speaker A:This is considered to be the highest level protection you can get because the patient's literally floating on air.
Speaker A:Many plastic surgeons consider this the surface of choice, post flap.
Speaker A:So they want their patient on this bead bed or sand bed post flap, because it maintains very low interface pressures, eliminates shear and friction, maintains moisture control.
Speaker A:But dehydration can be a significant issue, especially if your patient's older and vulnerable.
Speaker A:If you have open wounds, you have to be really careful with the type of dressing you use because the dressing can dehydrate and cause problems with wound healing.
Speaker A:These beds can be very disorienting because you're literally in the bed and you hear the airflow and all you're seeing is the ceiling.
Speaker A:So that can be an issue.
Speaker A:And it's almost impossible to get the patient out of the bed.
Speaker A:So if you're trying to do any kind of therapy with the patient, the standard air fluidized bed would not be a good choice.
Speaker A:Also, it's very difficult to do head of bed elevation on the standard surface.
Speaker A:If you're using the hybrid version, it's much easier.
Speaker A:You can elevate the head of the bed.
Speaker A:It is easier, though still difficult to get the patient out of the bed.
Speaker A:So you just have to know, do I need this surface or could I manage this patient on an air surface with low air loss feature?
Speaker A:Could I manage this patient on an alternating pressure surface with low air loss feature?
Speaker A:Is there something specific that I need from this air fluidized bed?
Speaker A:So typically use is restricted to patients post flap or if you have a patient with stage three, four pressure injuries and they have not healed, they have not progressed on another air support surface.
Speaker A:There's limited data that placement on this air fluidized surface may promote healing.
Speaker A:So very limited data, but definitely worth a try if you have done everything else.
Speaker A:Chair cushions.
Speaker A:We've already talked about any high risk patient who gets up in the chair needs a chair cushion.
Speaker A:We never use donut devices.
Speaker A:If you're looking at short term use, you can use foam, you can use air, you can use gel.
Speaker A:If you're looking at long term use, like your wheelchair bound patients, typically you're going to use a different type of device.
Speaker A:It's going to be a different type of air support surface.
Speaker A:So like a vinyl air cushion or a gel cushion.
Speaker A:Usually you want physical therapy input or a seating clinic to evaluate the patient so they make sure that the cushion fits the wheelchair and works with other considerations like it promotes trunk stability and multiple other factors that have to be considered when you're selecting a wheelchair for someone who's wheelchair bent.
Speaker A:So we've just said foam, gel and air are options within chair cushions.
Speaker A:One good thing about foam, it does provide seating stability, so it helps hold the patient in position.
Speaker A:Not a good choice if your patient's incontinent and some patients find that it interferes with transfers, they literally have to be able to lift themselves up and out of the chair.
Speaker A:It doesn't do well with sliding boards because the foam creates too much friction.
Speaker A:What about gels?
Speaker A:Well, gels are good choices for heavier patients.
Speaker A:Fine for a patient who has incontinent episodes.
Speaker A:Because it can be cleaned.
Speaker A:Doesn't interfere with transfers because gel cushions have a slit cover.
Speaker A:So transfers are pretty easy.
Speaker A:It can become cold or hot.
Speaker A:Sometimes you have to massage the gel if it's gotten cold.
Speaker A:And air, of course, is frequently the medium of choice.
Speaker A:Because it's lightweight, it's extremely conformable, it's covered with a waterproof surface that can be easily cleaned.
Speaker A:Doesn't interfere with transfers.
Speaker A:The one thing you have to think of with air cushions is that they can be punctured.
Speaker A:So you have to think, well, what kind of activities is this patient involved in?
Speaker A:Again, for short term use, that's where most of you are, you're probably going to use foam or air at the bedside.
Speaker A:You'll pick air if the patient's incontinent.
Speaker A:For patients who are wheelchair bound, you really want to get physical therapy or a seating clinic involved in making the best decision for that patient.
Speaker A:So, finally, what's your role as the wound nurse?
Speaker A:What's your role in managing support surfaces?
Speaker A:So first of all, you do want to assist with product and vendor selection.
Speaker A:So you want to look at the surfaces that are on every bed.
Speaker A:Do you have high quality standardized pressure redistribution surfaces?
Speaker A:What's the warranty period?
Speaker A:And are you replacing your mattresses at appropriate intervals?
Speaker A:Secondly, you want to see what's available to you and your staff in terms of rental surfaces.
Speaker A:So do you have low air loss surfaces available on a rental basis?
Speaker A:Do you have alternating pressure surfaces available on a rental basis?
Speaker A:If you need that, what do you have in the way of chair cushions?
Speaker A:Do you have access to continuous lateral rotation therapy for your patients with adult respiratory distress syndrome?
Speaker A:For patients who need those surfaces as a first step in an early mobility program, you want to consent.
Speaker A:When you're selecting surfaces, you want to think about how much support you get from the vendor when it comes especially to your rental services.
Speaker A:So many times you'll have several different companies and they have comparable product lines.
Speaker A:So you want to think, well, how much support do I get from this vendor?
Speaker A:So this is, I'm using these rental surfaces.
Speaker A:What's the timeframe for delivery?
Speaker A:So if I order this surface at 1:00 on Tuesday, when are we going to get it?
Speaker A:What kind of support is there?
Speaker A:If we have any problems in terms of troubleshooting, how much support do they provide in staff education in terms of appropriate use of their support surface line?
Speaker A:So you think about not only the specific products, but also how much backup is there behind that product line.
Speaker A:Most of you will end up developing a decision making tool and algorithm that helps your staff select the appropriate surface for an individual patient.
Speaker A:Some of you will end up in a gatekeeper role.
Speaker A:Now, this is not typically anyone's favorite position, but in some agencies they make the wound care team the approval authority for use of rental surfaces.
Speaker A:So if I wanted a rental bed, I would have to call you the wound care nurse.
Speaker A:You would have to come look at the patient and say, yes, a rental surface is needed for this patient.
Speaker A:This is the one I would recommend.
Speaker A:Now, to keep things simple for you and for the staff, you go right back to do everything you can with your standardized surfaces.
Speaker A:So make sure, you have good quality standardized surfaces.
Speaker A:That's going to reduce the number of patients who will need rental surfaces.
Speaker A:Think about do you need different surfaces in your intensive care units?
Speaker A:And for most agencies, the answer is yes.
Speaker A:So if you go to a standard medical surgical unit in most agencies, you're going to find a good quality foam based pressure redistribution system with a conformable cover.
Speaker A:If you go to the intensive care units in general, you will find air support surfaces that are typically pump driven, that have additional features depending on the type of patients managed in that particular unit.
Speaker A:So you might find an air support surface, pump driven in bed scales, percussion feature.
Speaker A:You might find continuous lateral rotation feature.
Speaker A:The more you can build into the standard surfaces, the more you can anticipate common needs with your standard surfaces, the fewer rental surfaces you will need.
Speaker A:What about bariatrics do you want to purchase bariatric surfaces or do you want to use them on a rental basis?
Speaker A:So these are things you have to think about.
Speaker A:In the gatekeeper role.
Speaker A:You want to minimize the number of decisions that come your way.
Speaker A:You do not want to spend your day as the bed police, but you might need to spend some time in that role to assure appropriate utilization of support surfaces and cost effective utilization of support support surfaces.
Speaker A:So here's that slide you've been looking for, the summary slide.
Speaker A:So, three ways to classify support surfaces by therapeutic effects.
Speaker A:By far the most important.
Speaker A:So when you think about therapeutic effects, you think, how does this surface manage the adverse effects of immobility?
Speaker A:Is it a pressure redistribution surface or is it an alternating pressure surface?
Speaker A:And does it matter to me in this case which one I use?
Speaker A:Does it also provide moisture management?
Speaker A:Is there a low air loss feature?
Speaker A:Is it air fluidized?
Speaker A:Is that important?
Speaker A:In this situation, you think about relationship to the mattress or the bed.
Speaker A:So for most patients you will be using a mattress replacement.
Speaker A:You will have replaced the old mattresses with new upgraded hospital mattresses that incorporate pressure redistribution features with a conformable surface and the ability to provide terminal cleaning.
Speaker A:You may or may not elect to use antimicrobial mattress covers for additional protection.
Speaker A:You think about the support medium.
Speaker A:So is foam fine for this patient or do you need to upgrade to air?
Speaker A:When it comes to decision making guidelines, you want to provide your staff with an algorithm, but they're always going to be thinking about, can I use a standard surface, do I need a bariatric surface, do I need a low bed, can I use standard pressure redistribution with foam, or do I need an air surface?
Speaker A:Do I need moisture management?
Speaker A:And are there other features that this patient needs?
Speaker A:You want to support your staff by providing them very clear tools for decision making.
Speaker A:And ideally, you want to minimize the amount of time you spend in the gatekeeper role.
Speaker A:We know that support surfaces can be very confusing.
Speaker A:We will spend some time during bridge week talking about support surfaces.
Speaker A:But if you have specific questions about this content, feel free to contact one of the faculty members and we'll try to walk you through it.
Speaker A:Okay, we are through with this and our next class.
Speaker A:We will start to focus on wound healing.
Speaker A:Thank you.
