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

Pressure Management: Connecting the Dots