In search of support

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In search of support
In search of support
No matter what name they're given — pressure ulcer, bedsore, decubiti — few conditions encountered by long-term care professionals are more common, costly or do more to erode resident quality-of-life.

In addition to their devastating effects on residents, long-term care facilities with high rates of pressure ulcers must also deal with high costs of treating the condition, and the risk of potential litigation by patients and their families if the ulcer is deemed as avoidable had proper care been given.

“Pressure ulcers are very painful, and in fact, some patients can even die from them because they can become infected and the patient may have to undergo amputation,” points out Joyce Black, PhD, RN, CWCN, FAAN, co-chair of the National Pressure Ulcer Advisory Panel's Education Committee.

Therefore, the best treatment for pressure ulcers lies in prevention, Black says. There are a multitude of different support surfaces to help long-term care professionals thwart bedsore development before it begins — and to quickly treat the ulcers if they do develop, she adds.

As most veteran caregivers know, gone are the days of long-term care residents sleeping on traditional innerspring mattresses or egg crate foam pads. Instead, facilities are more likely to buy, or rent, therapeutic support surfaces that prevent and treat pressure ulcers by molding to the body to maximize contact, redistribute weight and reduce pressure. Some patients at high-risk for developing bedsores — or those that already have them — may even find themselves placed in “integrated bed systems” that virtually eliminate friction, help maintain normal skin temperature and keep moisture at bay.

With so many options to choose from, however, it can be difficult for new long-term care providers to determine how likely it is that a resident will develop a wound, and, therefore, what each resident may need. But spending even a few minutes when a resident is admitted to assess his or her mobility and prior history of pressure ulcer development can go a long way in providing a blueprint for individualized pressure relief.

“There are all kinds of fancy assessments nurses will use to determine relative risk, but really it all boils down to: Can the resident move?” Black says. “It's not hard to prevent pressure ulcers if you come up with a plan to make it work.”

Choosing right

Residents who are admitted to a long-term care facility with a relatively low risk of developing a pressure ulcer — typically those who do not spend lengthy periods in bed, and who still have the strength to turn themselves — are often placed on a mattress or mattress overlay categorized by the Centers for Medicare & Medicaid Services as a Group 1 support surface.

These surfaces, which facilities may rent or purchase, are made of high-density foam, air or gel and are designed to conform to the contours of the body so that pressure is distributed over a larger surface area rather than concentrated over a resident's bony prominences, including the tailbone, elbows, heels, hips, ankles, shoulders, back and scalp.

One of the most basic support surfaces for low-risk patients is a high-density foam mattress, which can be placed directly on the existing bed frame. Residents essentially sink into the mattress and pressure is redistributed equally throughout their body.

It's important to invest in good quality foam, however, says Steve Warren, vice president of Skil-Care Corporation.
“Mostly, you want it to be resilient over time, but also, patients placed on lower-density foam mattresses have a higher likelihood of rolling off the bed if they're lying at the outside edge of the mattress and it depresses too much,” Warren notes.

Or alternatively, at times residents can sink too low into a foam mattress, making it more difficult to get out of bed, Black adds.

Gel overlay pads, designed to be placed on top of a resident's existing mattress, also help distribute pressure evenly and reduce friction and shear by moving every time a resident moves, Warren explains. The pads consist of several gel bladders inside a high-density foam core. They tend to keep the skin cooler than foam alone.

Alternating pressure pads also fit on top of a regular mattress, and assist in preventing pressure ulcers by alternately inflating and deflating the pad's air-filled cells to constantly change pressure points. One downside of overlays, however, is that they increase the height of the mattress, sometimes making it taller than the side rail, so there's an increased risk of falling, Black points out.

Pressure ulcer activity has to be diligently monitored by staff, experts agree. But once a resident has developed a pressure ulcer it's important for her or him to be moved to one of the CMS-categorized Group 2 support surfaces.

These include powered or non-powered alternating pressure mattresses and powered air flotation beds — often referred to as low-air loss mattresses. These can be placed directly over a hospital bed frame and provide pressure relief to help wounds heal faster and keep the skin dry.

The idea behind low-air loss is that the mattress “floats” the patient on air-filled cells while circulating air across the skin to reduce moisture without drying out therapeutic dressings and keep the resident more comfortable. Black says the mattresses do this very well, provided the resident can move himself a fair amount to let the air out.

Caregivers also should monitor patients on low-air loss mattress for dehydration, particularly those who have other medical risk factors beyond a pressure ulcer, says Bardia Anvar, MD, a surgeon with Skilled Wound Care.

Some manufacturers also offer “convertible” air/foam surfaces, allowing facilities to be more flexible and effective in the care they deliver. One Joerns healthcare model, for example, features air and foam technology that, when in its non-powered state, enables the surface to automatically adjust to each user's weight and body profile without the need for caregiver intervention or the use of a pump. With the addition of an optional powered control unit, the mattress can combine its non-powered immersion with alternative pressure therapy.

This drives the true value of convertible surfaces; facilities can leverage one surface for both pressure ulcer prevention and treatment, says Doug Ferguson, the director of marketing for patient care at Joerns.

Finally, for patients with multiple advanced stage pressure ulcers or muscle flaps who have not had treatment success with Group 2 mattresses, a facility may want to consider placement on a Group 3 support surface. In these “integrated bed systems,” known as air-fluidized beds, the resident is immersed in silicone-coated beads that simulate the movement of fluid by having air circulated through them. These beds can help prevent further damage by maintaining near normal blood flow and optimizing tissue oxygenation.

From bed to chair
Too often, the tendency when discussing support surfaces in long-term care is to focus only on a resident's mattress or mattress overlay, says Charlie Trapani, president of Tycon Medical. But pressure ulcers also can develop during a short stint sitting in a chair.

“A facility might have a resident in the right bed for 90% of the time and then they take them out and put them in a wheelchair or seat that's not properly padded and all of a sudden they develop a pressure ulcer from that two-hour sit,” Trapani says.

The best approach, he says, is for facilities to purchase a variety of foam seat cushions and lumbar support for wheelchair use, and make sure staff are using them every time they place a resident — particularly one at high-risk for pressure ulcer development — in a chair or wheelchair.

Repositioning obligation

While choosing the right support surfaces can be an important tool in preventing and treating pressure ulcers, it's also crucial to change the position of residents who are immobilized when in bed or up in a chair, Black says. She recommends turning residents every two hours, or even more often, if necessary.

“The two factors you have to account for in pressure ulcer prevention are the intensity, or the magnitude, of the pressure and the duration of the pressure,” Black says. “The beds can deal with the magnitude component, but no support surface will change the duration. The only way you can change duration is to move the patient.”