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Comparison of pressure redistribution surfaces based on peak pressure at bony prominences

John Welsh, OT

Background
Residential and acute care Prevention/treatment of pressure ulcers OTs role is to address the cause which includes the recommendation of therapeutic surfaces

Why?
$2 million per year for rentals Length of stay and cost associated with pressure ulcers continues to rise. 80% increase in pressure ulcer occurrence in acute care hospitals from 1993-2006 (Russo, 2008) Therapeutic surfaces are one of the most common interventions in prevention and treatment of pressure ulcers. Need independent evaluation using the same subjects in the same positions Manufacturers often display pressure maps for supine position only, if at all. For many patients this is not relevant. (Enriquez et al 2007) Pressure mapping of the same subject on the same bed frame in the same position showed discrepancies between surfaces of the same class.(Enriquez et al2007)

Hypothesis: Therapeutic surfaces will have lower peak pressures when compared to the standard mattress Are there differences between surfaces ability to redistribute pressure? Are some better than others?

Evidence

Literature Review
Improve QOL and healthcare efficiencies (Jenkins et al) Heel (26%) and Coccyx (20%) most common(Jenkins et al) We need more research comparing different support surfaces(McInnes et al) Foam overlays reduce incidence of ulcers compared to standard hospital mattress.(McInnes et al) Evidence for effectiveness of alternating pressure mattresses and high tech therapeutic surfaces is inconclusive (McInnes et al) Low tech dry flotation and air fluidized systems produce similar outcomes for prevention and treatment.(Economides et al) (Kato et al) Active alternating therapy vs reactive devices(Malbrain et al)

Evaluation of Surfaces
Therapeutic surfaces work on the principle of redistributing interface pressure thereby permitting circulation to skin around bony prominences Pressure mapping is a reliable measure of interface pressure(Stinson et al) Take readings between 6-10 minutes.(Stinson et al) Calgary Pressure Mapping Protocol is being developed to look at uniform pressure mapping standards and improve interrater reliability (Jillian Swaine, OT)

Relax for a second

Study Design
8 volunteers over the age of 65 8 different surfaces vs standard mattress 8 minutes before taking a reading Position with head of bed maximally raised

Use of the Active X Sensor for pressure mapping Peak pressure and Peak Pressure Index at the heels and sacrum were recorded

Methodology
Recruited 8 volunteers over the age of 65 Ladies Im asking you to lend your bottoms to science 2 days 8 surfaces vs standard hospital mattress Use of loose sheet and KCI Dri Flo pad to mimic hospital conditions Record peak pressures at coccyx and heels

Data Analysis:
Peak Pressure Index and Peak Pressure collected for each subject on each surface at the sacrum and heels T test and Wilcoxon rank test to compare for significance of surface vs standard mattress

Data Analysis
Mean Difference Between Standard and Therapeutic Mattresses for Peak Pressure Heel (N=7) (Pairwise t-tests) Control Standard Standard Standard Standard Standard Standard Standard Standard Mean 94.35 92.46 94.35 92.46 92.46 94.35 94.35 92.46 SD 44.69 41.11 44.69 41.11 41.11 44.69 44.69 41.11 Comparison KCI Therakair Versacare ROHO LAL ROHO OL Geomat OL Vicair Atmos Air Isoflex Mean 71.52 59.86 102.12 42.60 109.30 82.47 71.92 130.70 SD 25.04 18.33 21.03 13.03 42.66 18.21 13.45 32.88 t-test 1.43 2.27 -0.47 3.22 -0.67 0.78 1.36 -2.16 P value 0.21 0.06 0.66 0.02 0.53 0.47 0.23 0.08

Note. Results from nonparametric test (Wilcoxon Rank test) indicate significant differences between the standard mattress and Versacare (p=.03) and ROHO OL (p=.02). Both are showing lower means compared with the standard. P value between the standard mattress and Isoflex p = .09.

Data Analysis Heel Peak Pressure


Mean Difference Between Standard and Therapeutic Mattresses for Peak Pressure Sacrum (N=8) (Pairwise t-tests) P value Control Standard Standard Standard Standard Standard Standard Standard Standard Mean 73.93 73.80 75.75 73.80 73.80 75.75 75.75 73.80 SD 22.23 20.58 23.77 20.58 20.58 23.77 23.77 20.58 Comparison KCI Therakair Versacare ROHO LAL ROHO OL Geomat OL Vicair Atmos Air Isoflex Mean 84.87 78.89 69.30 90.19 80.68 85.00 75.83 100.78 SD 14.29 13.55 11.22 14.46 14.22 8.87 12.17 29.98 t-test -1.02 -0.59 0.50 -1.81 -0.71 -0.79 -0.01 -2.17 0.35 0.58 0.64 0.11 0.50 0.47 0.99 0.07

Note. Results from nonparametric test (Wilcoxon Rank test): p values between the standard mattress and ROHO OL = .09and between the standard mattress and Isoflex = .07.

1.Using t-test: there was a significant mean difference for Peak Pressure Heal between the standard mattress (M=92.46; SD=41.11) and ROHO OL mattress (M=59.86; SD=18.33), t(6)= 2.27, p < .05. 2.Using Wilcoxon test: Peak Pressure Heel for Versacare mattress (Mdn=57.7 ) differed significantly from the standard mattress (Mdn=89.7). OR: Peak Pressure Heel for Versacare mattress (Mdn=57.7) were significantly lower than the Peak Pressure Heel for the standard mattress (Mdn=89.7). 3.No signficant change in Peak Pressure at the sacrum vs standard mattress 4.You can report the effect sizes, using Cohen benchmarks, for significant differences (Wilcoxon test). The effect size for versacare mattress is -.59 and for ROHOL OL .63. Both have medium effect sizes (which is great). Note. We report means for t-test and medians for Wilcoxon test. Variables with border line significance (e.g, PPS for Isoflex p= .07) could become significant with a larger sample size.

Results and Interpretation

Differences between surfaces may to be diminished with the head of the bed up and in some cases this position may create higher peak pressures than on a standard surface Therapeutic surfaces may address other causes of skin breakdown such as shear(10x pressure) or friction which could not be measured eg. ROHO cells vs foam or low friction covering The use of healthy subjects may have mitigated the effect of the surfaces due to the presence of ahem adipose tissue and muscle compared to frail or emaciated individuals and cannot Sample size not large enough to produce significant results Even on the most effective surface the median peak pressures at the coccyx generated were more than double the pressure relief standard of 32 mmHg capillary pressure in healthy individuals

Importance of mobilization, bed positioning, turning and education Mattresses may create a false sense of security Supports NPUA recommendation that heels should be managed separately Larger study with patients/residents at high risk should be done but $, time and ethical considerations

Questions?

REFERENCES Enriquez, Elizabeth Limouze RN, BSN, MPH, CWOCN; Holland, Diane L. P.T., CWS, DAPWCA, CPed PRESSURE MAPPINGIT'S THE PEAK THAT COUNTS, AND ALL SPECIALTY MATTRESSES ARE NOT EQUAL: 1356 Journal of Wound, Ostomy and Continence Nursing Issue: Volume 34(3S) Supplement, May/June 2007, p S54 Economides NG; Skoutakis VA; Carter CA; Smith VH Evaluation of the effectiveness of two support surfaces following myocutaneous flap surgery.(includes abstract);; Advances in Wound Care, 1995 Jan-Feb; 8 (1): 49-53 (journal article - research, tables/charts) ISSN: 1076-2191 PMID: 7795873 CINAHL AN: 1995011076. Jenkins ML, O'Neal E. Pressure ulcer prevalence and incidence in acute care. Adv Skin Wound Care. 2010 Dec;23(12):556-9. Kato H., Inoue T., Torii S. EMBASE A new postoperative management scheme for preventing sacral pressure sores in patients with spinal cord injuries. Annals of Plastic Surgery. 40 (1) (pp 39-43), 1998. Date of Publication: 1998. Malbrain M; Hendriks B; Wijnands P; Denie D; Jans A; Vanpellicom J; De Keulenaer B; Journal of A pilot randomised controlled trial comparing reactive air and active alternating pressure mattresses in the prevention and treatment of pressure ulcers among medical ICU patients.(includes abstract); Tissue Viability, 2010 Feb; 19 McInnes E, Cullum NA, Bell-Syer SEM, Dumville JC, Jammali-Blasi A. Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD001735. DOI: 10.1002/14651858.CD001735.pub3 Stinson M, Porter A, Eakin P. Measuring interface pressure: A laboratory-based investigation into the effects of repositioning and sitting. Am J Occup Ther 2002;56:185-190. Ebsco AtoZ [Context Link] Stinson MD, Porter-Armstrong AP, Eakin PA. Pressure mapping systems: reliability of pressure map interpretation. Clin Rehabil. 2003 Aug;17(5):504-11. Sprigle S, Dunlop W, Press L. Reliability of bench tests of interface pressure. Assistive Technology 2003; 15:49-57

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