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Pressure Management:
Connecting the Dots from
Admittance to Release
Rick Fontaine
V.P. Business Development
Tempur-Pedic North America Inc., Medical Division
Pressure Management: Connecting the Dots
Why the focus on Pressure Management?• Many patient care issues are associated with
pressure.
– PATIENT COMFORT
• A Clinically Significant Factor– Pain, Sleep, Medication, Service demand (Call lights)
– Pressure is the defining cause of Pressure Ulcers.
• Costly– <LOS, <Supplies, <Treatment
• Quality Indicator– CMS, JCAHO, Legal Community
• Impact Reimbursement– CMS
Pressure Management: Connecting the Dots
Pressure Ulcer Frequency • Incidence in acute care
– 0.4% to 38.0%1
• Average LOS– 10.6 days2
• 4.6 days general population3 (230%)
• Overall prevalence– 72,664 discharges2
• 24.445 per 1000 discharges with LOS >5 days4
• Total Charges– $30,7942
• $20,455 Mean Charges3 (155%)
1 Lyder CH. Pressure ulcer prevention and management. JAMA. 2003;289:223-2262 CCS principle diagnosis category 199, Chronic ulcer of Skin3 Statistics for all US community hospital stays 2&3 HCUP/AHRQ data. Most recent published year, 2004
4 AHRQ Pressure Ulcer Data 2003
Pressure Management: Connecting the Dots
Source of admission
• Nursing Home– 5.24%
• Other hospital– 5.87%
• Emergency Department– 40.35%
HCUP/AHRQ data. Most recent published year, 2004
Pressure Management: Connecting the Dots
Facts are…
• Admission can take lots of time.– 12, 14, 18 hours or longer
• can pass between the time a patient presents to the ED and when they are admitted to a Med/Surg bed.
• Waiting, diagnosis, procedure, OR, and transport time all add up.
• ICU bed availability can result in overnight stays (sometimes multiple)
Pressure Management: Connecting the Dots
CMS Findings
• …the view that pressure ulcer prevention was a nursing issue…is a major barrier…1
• …medical staff were…resistive…that they play a major role in pressure ulcer prevention…1
• …interventions…dependent on…staffing…are most difficult to sustain…1.
• ..hospitals found…the most sustainable interventions… were institutionalized.1
• Focusing…programs on the nursing staff is limited…pressure ulcer prevention requires a multidisciplinary effort. 1
1 Lyder CH, et al., Preventing Pressure Ulcers in Connecticut Hospitals… Joint Commission Journal on Quality and Safety 2004: 30(4), 205-214
Pressure Management: Connecting the Dots
Researcher’s assessment• “In the study we found that most
(nursing focused) prevention strategies did not prevent pressure ulcers.”
• “One thing we hypothesized was that most people are admitted to (the hospital) through the ER, thus prevention must begin at point of entry NOT (the) medical or surgical unit.”1
1 Courtney H. Lyder, N.D.
Interpersonal correspondence, April 2007
Pressure Management: Connecting the Dots
Conclusions?
• If… – there are ample reasons to avoid pressure
related complications, and..
– nursing interventions alone are not shown to be effective in this effort, and…
– evidence suggests institutionalized, automatic approaches deliver the best outcomes;
• Then…– the solution is most likely found in a global
approach to pressure management.
Pressure Management: Connecting the Dots
Support Surfaces
• Any structure or device,
– intimately in contact with the patient, – onto which part or all of their weight is
borne.
• Mattresses• Pads• Cushions• Prosthetic devices
• Not all support surfaces have therapeutic value.
Pressure Management: Connecting the Dots
Contemporary Support Surface Thinking
• National Pressure Ulcer Advisory Panel
– Support Surface Standards Initiative (S3I)• Eliminates artificial thresholds
• Establishes the technically accurate concept of:
Pressure Redistribution
Pressure Reduction
Pressure Relief
Pressure Management: Connecting the Dots
Pressure Redistribution
• Transferring load bearing from areas prone to pressure damage to areas less likely to break down.
– Shifting loading forces away from: • the occiput, scapulae, sacrum, coccyx,
greater trochanters of the femur, heels, and malleolus
– And redistributing them into the adjoining tissues
• The goal is to eliminate areas of “peakiness”.
Pressure Management: Connecting the Dots
How Support Surfaces Work
• Immersion
– Increasing patient contact area by sinking more deeply into the support surface.
• Lower interface pressure due to increased denominator.
• Envelopment
– Equalizing loading forces by efficiently molding to body contours.
• Flattens the “peak to average” ratio (“Peakiness”).
Pressure Management: Connecting the Dots
Compression Resistive Materials
• Widely used in basic mattresses and pads.
– Typically foam, innerspring, and “hammocking” types of support surfaces.
– Generally most effective in redistributing pressure secondary to immersion.
– Tend to be “peaky” • resistance increases as the material more
deeply compresses.
Pressure Management: Connecting the Dots
Fluid/Fluidized Materials
• Frequently used in preventative / therapeutic support surfaces.
– Includes gases, liquids, and select visco-elastic materials (gel, foam, etc.).
• Primary efficacy based on envelopment.– Immersion important but secondary.
• Tend towards lower shear.
• Efficacy impacted by use.
Pressure Management: Connecting the Dots
Standard Foam 2” OR Pad
654629
374
312943
68207744
3022222927273293531572
61942314248394550544639226
223313023192324185
245
81216
3145
1334
3215
14
2
1022
2
5121116131684
414243742336433413836377
2221622305737484652705244342624
2064530293333363533384543402817
23
13191495
620222211
5
147
21212
2034282
15323711
5248
24294
13
57
219792
21697
3
94
Minimum (mmHg)
Maximum (mmHg)
Average (mmHg)
Variance (mmHg²)
Standard deviation (mmHg)
Coefficient of variation (%)
Horizontal center (in)
Vertical center (in)
Sensing area (in²)
Regional distribution (%)
0.00
92.53
23.17
335.34
18.31
79.04
11.27
43.20
330.20
100.00 1
10.9
20.8
30.7
40.6
50.5
60.4
70.3
80.2
90.1
100
mmHgMax / Avg. = Ratio of 3.99
Pressure Management: Connecting the Dots
Pressure Management 2” OR Pad
131527213222
16
28
43916242017131014172831271046
782867373033323339322238621995
81029414844354049432686
2
32
615252414313201911
343014
6109
398
42729
77
36
551
811
9192733323622321314
3
4162443415255595547594936227
31622345544505055435549382719
62335233530162342495242268
1774
1317134
422
5172014
172214
420199
4172519
10111
11147
97
2111
41
2
62196
2521
212366
26463
Minimum (mmHg)
Maximum (mmHg)
Average (mmHg)
Variance (mmHg²)
Standard deviation (mmHg)
Coefficient of variation (%)
Horizontal center (in)
Vertical center (in)
Sensing area (in²)
Regional distribution (%)
0.00
67.28
20.02
258.71
16.08
80.35
12.47
44.81
392.73
100.00 1
10.9
20.8
30.7
40.6
50.5
60.4
70.3
80.2
90.1
100
mmHgMax / Avg. = Ratio of 3.36
Pressure Management: Connecting the Dots
Connecting …………………....…………..the dots…………….• At least 50% of hospitalized patients
are at risk and/or acutely uncomfortable
• Risk experienced is costly– Pressure-related tissue damage– Discomfort results in service demands and
potential injury (falls, wandering, etc.)
• It is only possible to manage the risk by providing interventions at all areas of patient contact.
Pressure Management: Connecting the Dots
Support Surface Applications
• Medical/Surgical Beds• Intensive care beds• Stretchers / Transport carts• OR table mattresses• Imaging device mattresses• Wheelchairs• Recliners
Anywhere a patient at risk might remain for longer than 30 minutes between position change.
Pressure Management: Connecting the Dots
Considerations when selecting a support surface.
– Clinical efficacy– Comfort– Safety– Transfer “ability” – Procedural imperatives– Nursing / Patient care
requirements– Mobility– Cost-effectiveness – Longevity