Right Equipment…. Half the Story Jacqui Fletcher Clinical Strategy Director Welsh Wound Innovation Centre @jacquifletcher3.....

Equipment drives me crazy It solves so many problems It creates so many problems We abuse it on a regular basis – then blame it when it ‘doesn’t work’

Outline of the session Inappropriate use of equipment — a source of skin damage and complaint   The effective use of add-on equipment — risk/benefit analysis, optimising pressure relief decision-making    Getting the best from your resources — releasing time to care 

Poor use of equipment An HTA report by University of York Multi centre RCT PRESSURE trial 1971 patients, compared alternating overlay to alternating mattress replacement

PRESSURE trial Technical problems with mattresses 207 (on 131 overlays) and 370 (on 223 replacements) Problems were Nixon et al 2006

Nixon et al 2006 Problem Overlay Replacement Total Plug / electricity not turned on 40 (19.3%) 33 (19.2%) 73 (19.3%) Transport / static mode 4 (1.9%) 25 (14.5%) 29 (7.7%) CPR 24 (11.6%) 4 (2.3%) 28 (7.4%) Connectors / tubing / mattress position 8 (3.9%) 11 (6.4%) 19 (5.0%) Settings 53 (25.6%) 12 (7.0%) 65 (17.2%) Alarming 20 (9.7%) 31 (18%) 51 (13.5%) Deflated / low pressure 49 (23.7%) 45 (6.2%) 94 (24.8%) Pump failure 0 (0%) 3 (1.7%) 3 (0.8%) Broken part 6 (3.5%) 10 (2.6%) Unknown 5 (2.4%) 2 (1.2%) 7 (1.8%) Nixon et al 2006

Inappropriate use of equipment — a source of skin damage and complaint

Patients vary considerably in size and body mass, yet we expect our equipment to cope with the majority of patients – is this reasonable?

Do you know if….. Your mattresses are the same size as your beds? Staff were taught (and do) the correct sequence to articulate bed frames? Your high specification foams contour fully to the bed frames? How your frames contour?

Flat Contoured Mattress 195 cm 186 cm Person 181 cm 210 cm

Articulation If the bed articulates in such a way the mattress moves away from the frame, staff tend to pad inappropriately If the bed articulates in such a way the foam is pushed down tight against the frame you can get the heels pressed against the frame / equipment

When you do this You may get this…… The heels travel along the mattress up to 15cm with the associated friction and shear forces

Doing this can cause this

Changing shape? Stress – force transferred per unit area of tissue (comes from both pressure and shear) Strain – measure of the amount of deformation

Strain and Stress Excessive internal stresses and strains will hinder transport processes. Effect of internal stress and strain will vary depending on – Morphology (size/shape) of the tissue layers Stiffness and strength of the tissues Aging, lifestyle, chronic injury, disease will cause changes in morphology/strength soft tissues Heterogeneous response – external loading will produce different tissue responses at different body locations

Flat Contoured Mattress 195 cm 186 cm Person 181 cm 210 cm When you contour the foam over the frame it squeezes under the seat – and tries (but fails) to stretch under the knees

2 piece frame 3 piece frame 4 piece frame

But the frame also needs a mattress!

Make the foam contour to the bed frame…. Stop the heels sliding Stop the feet pressing on the bed end Makes the mattress longer!

The effective use of add-on equipment — risk / benefit analysis, optimising pressure relief decision-making

Audit of appropriateness of equipment use Not at risk At Risk High Risk VHigh Risk Not done Arise 2   1 Foam 207 292 186 38 41 Dolphin Duo2 10 21 33 Other Primo 4 18 56 88 Repose 44 156 194 89

You could use add on equipment

Meeting the challenges One patient had pillows in place but the patients heels were on top of the pillows and not overhanging and the other patient had nothing. At this stage the observer intervened to reposition the pillows for the first patient to ensure heels were overhanging the end of the pillows and asked carers to use pillows for the other….. Pillows remained in place for two of the patients effectively but for one patient the pillow had squashed since the last observation and heels were resting on the bed slightly. (at 30 minutes post Bundle intervention) Turley 2014

Poor use of equipment Overlays on bed frames Replacements on top of mattresses Mattresses up side down Patient sat in chair with no cushion Patient on incontinence pads Blankets or pillows under heels

Getting the best from your resources — releasing time to care

Jones & Tite 2013

Introduction of hybrid mattresses In the first 3 months the Trust has made financial savings equating to more than 25K with no increase in pressure ulcers. The reduction of costs is associated with moving equipment, decontamination and rental charges. By effectively reducing the requirement for dynamic air mattresses we have also released nursing time back to care.

Getting it right Think about what makes the patient at risk Generally this is Immobility Insensate Lack of blood supply / oxygenation Target the area at risk A higher specification mattress isn’t always the answer!

If it is the heels that at are at risk because of poor blood supply Does the patient need a high specification mattress? Do a specific heel assessment

Can you actually see the skin? By the time you prevent the clot And stop the patient slipping in the anti embolic stocking And add in a pressure reduction device How often is this all removed and what impact does it have on mobility?

Heel assessment

Releasing time to care Getting it right Keeping it simple Looking at the obvious – not creating a different problem by solving a problem!

References Jones L, Tite M (2013) Do you really know how soon your patient is on an alternating mattress in a hospital setting? A study examining opportunities in safety, effectiveness and improved patient experience. Poster presented at Wounds UK Conference, Harrogate Nixon J, Nelson EA, Cranny G, Iglesias CP, Hawkins K, Cullum NA, Phillips A, Spilsbury K, Torgerson DJ, Mason S; PRESSURE Trial Group Pressure relieving support surfaces: a randomised evaluation. Health Technol Assess. 2006 Jul;10(22):iii-iv, ix-x, 1-163.

jacqui.fletcher@wwic.wales Thank You jacqui.fletcher@wwic.wales @jacquifletcher3.....