Development of An Enhanced Dynamic Surface Therapy Model for Pressure Ulcer Management

Abstract

Ulcer:

An ulcer (from Latin ulcus) is an open sore of the skin, eyes or lubricated membrane, by an initial scratch and generally maintained by an inflammation, an infection, and/or medical conditions which obstruct healing.

Pressure ulcer:

An ulcer due to local interference with blood circulation.

Persons are at risk who are

• Shrunken due to nutrition deficient,
• overweight,
• immobilized by adhesive friction, diabetic, or suffering from a circulatory disorder.
• at skin breakdown
• immune deficiency

There are no boundaries of Pressure ulcers as shown in Figure below and these ulcers may affect all irrespective of age no matter, home or hospital, giving anguish and eats industry’s resource.

Inopportunely, pressure ulcers are still common [1] with a substantial number occurring under medical supervision [2].  This has run to a rising tendency to categorize pressure ulcers as ‘medical errors’, as compared to simply say as a predictable progression of an existing condition [3].  Since unrelieved pressure is the key factor of pressure ulcers, the most appropriate intrusions must be those designed to alleviate risk by reducing exposure to the degree and duration of pressure. Intrusions, such as assisted repositioning routines, have been successfully endangered and effective for patients for decades when used in grouping with pressure-redistributing support surfaces.

Today’s challenge is to select appropriate support surface for Ulcer management to meet the potentials of following stockholders:

• Patient: (100 % increase in last decade): Efficiency, Ease, high-quality
• Caregiver: Effectiveness, Safety, Ease of use.
• Health care provider ($3M /year): Cost effective, Efficiency, Easy access.

Introduction.

Key factors of Ulcer Pathology

Pressure, Shear force, Friction                   Microcirculation / blood flow

Lymphatic system

Microclimate:

Temperature, moisture and the humidity at the tissue surface are also affecting factors of pressure ulcer development [19,20].  

Literature review:

Therapy Surfaces Design Principals

As per National Pressure Ulcer Advisory Panel (NPUAP) [4, 10]. Pressure-redistributing surfaces are categorized into one of two groups:

Reactive Surfaces: Constant low pressure and either powered or non-powered, single zone surface are simply designed to decrease pressure across the whole body by increasing the area of the body in contact with the surface.    

Dynamic support surface: A powered support surface with   the   ability to change   its load distribution properties, with or without applied load.

Review of the literature [11], [12], [13] shows that about 80 per cent of sores occur in the four anatomical positions,

• sacrum,
• ischium,
• trochanter and
• heel.

Pathology rules related to pressure   ulcer growth and exploration for the dynamics  between vulnerability and immobility is considered in this study.

Design of Enhanced Dynamic SurfaceTheraphy Model

Under this project, lot of  built-in features  in one Dynamic Surface  is expected to play a  very important role in the pressure distribution to manage and minimize the effect of  pressure ulcer or Ulcer management.

• Eleven to fifteen cells of special fabric have been used, connected with different series of hoses with pump for pressure redistribution. These cells inflate and deflate with required pulsation cycle and duration with low, medium and high pulsating options.

• Bio Sensors pad and matt  placed underneath the mattress to detect and prevents bottom out.

• Pressure redistribution  in all surface area  can be  monitored  and measured  through  an interface by sensors placed underneath the pad of surface for effective Ulcer management.
• Automatic Turning therapy reduces interference pressure with two air bladdlers on the both sides of surface which inflates and deflate with required timings.
• Air loss theraphy to control heat and humidity of skin touched with surface
• Smart Surface Technology infrared light emitters and receivers which continuously measure the patient’s depth of immersion to adjust the air pressure according the weight of patient.
• All these features will be controlled by specially designed pump attached with the mattress.

Methodology:

Performance measurement of Reactive surface vs Dynamic surface:

• Position of surface on bed: Flat
• Use of loose sheet / pad to mimic hospital conditions
• Using Bio Sensors, Peek pressure at heel and sacrum readings recorded from seven volunteers over the age of 65 on reactive surface and dynamic surface on same day.

Hypothesis testing for peak pressure at Sacrum:

Null: Peek Pressure at Sacrum are same on both surfaces

Alternate: Peek Pressure at Sacrum are NOT same on Surfaces

 Data Analysis:

t-test result and conclusion for peak pressure at Secrum on two surfaces.

There is a significant mean difference for Peak Pressure at Secrum between Reactive and Dynamic surfaces. Therefore, we accept the Alternate hypotheses. Peek Pressure at Sacrum are NOT same on reactive and Dynamic surface.    With the P<.05, Dynamic Surface is recommended to use for pressure ulcer management at Sacrum.

Hypothesis testing for peak pressure at Heel:

Null: Peek Pressure at Heel are same on reactive and Dynamic surfaces

Alternate: Peek Pressure at Heel are NOT same on reactive and Dynamic surfaces

t-test result and conclusion for peak pressure at Heel on two surfaces.

There is a significant mean difference for` Peak Pressure at Heel on Reactive and Dynamic surfaces. Therefore, we accept the Alternate hypotheses. Peek Pressure at Sacrum are NOT same on reactive and Dynamic surface.  With p<.0.05, Dynamic Surface is recommended to use for pressure ulcer management on Heel

Study shows that Dynamic pressure redistribution system which has a logical evolution of dynamic Therapy for injury avoidance and treatment is expected to meet the required standards due to its optimized design, specialized modelling characteristics.

Key features

• Surface is intended to support patients up to 300 kg to provide the unsurpassed pressure redistribution prevent tissue damage.
• Surface is designed 8” inflated cell height with an anti-sink upper body section which supports patients in profiled positions to reduce the risk of bottoming out.
• Automated sensor pad is used underneath the entire surface with the combination of an automatic blower to readjust cell pressures.
• Single handed Cardio Pulmonary Resuscitation (CPR) is a quick release function placed on the surface which permits rapid air deflation for emergencies, short-term physiotherapy and patient transfers.
• Few heel cells allowing the caregiver to remove heel pressure from this high-risk area, and supplying no pressure for the most vulnerable patients such as existing wounds.
• Low air loss therapy minimizes tissue deformation and pressure-induced discomfort.
• Heat and humidity management of skin.
• Pulsation therapy to improve blood flow
• Turning therapy reduces interference pressure
• Smart Surface Technology employs infrared light emitters and receivers that continuously measure the patient’s depth of immersion to create a customized pressure profile for each patient
• Eight-inch air suspension depth for enhanced patient immersion

References:

1. Lockyer-Stevens NA. Developing information base for purchasing decisions: a review of pressure-relieving beds for at-risk patients. Professional Nurse 1994; 9: 534-42.

2. Gebhardt KS, Bliss MR, Winwright PL, Thomas J. Pressure-relieving supports in an ICU. J Wound Care 1996; 5(3): 116-21.

3. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996; 312(7023): 71-2.

4. Cullum N, Deeks J, Sheldon TA, Song F, Fletcher AW. Beds, mattresses and cushions for pressure sore prevention and treatment. Cochrane Database Syst Rev 2000; (2): CD001735.

5. Thomas DR. Issues and dilemmas in the prevention and treatment of pressure ulcers: a review. J Gerontol A Biol Sci Med Sci 2001; 56(6): M328-40.

6. Cullum N, Nelson EA, Flemming K, Sheldon T. Systematic reviews of wound care management: (5) beds; (6) compression; (7) laser therapy, therapeutic ultrasound, electrotherapy and electromagnetic therapy. Health Technol Assess 2001; 5(9): 1-221.

7. Hampton S. Evaluation of the new Cairwave Therapy System in one hospital trust. Br J Nurs 1997; 6(3): 167-70.

8. Hibbs P. Tissue viability. Action against pressure sores. Nurs Times 1988; 84(13): 68-73.

9. Livesley B. Pressure sores. Airwaves take the pressure. Nurs Times 1986; 82(32): 67-71.

10. Bliss MR. Aetiology of pressure sores. Reviews in Clinical Gerontology 1993; 3: 379-97.

11. Brienza DM, Karg PE, Brubaker CE. Seat cushion design for elderly wheelchair users based on minimization of soft tissue deformation using stiffness and pressure measurements. IEEE Trans Rehabil Eng 1996; 4(4): 320-7.

12. Dinsdale SM. Decubitus ulcers: role of pressure and friction in causation. Arch Phys Med Rehabil 1974; 55(4): 147-52.

13. Reichel SM. Shearing force as a factor in decubitus ulcers in paralegics. J Am Med Assoc 1958; 166: 762-3.

14. Sacks AH. Theoretical prediction of a time-at-pressure curve for avoiding pressure sores. J Rehabil Res Dev 1989; 26(3): 27-34.

15. Bennett L, Lee BY. Vertical shear existence in animal pressure threshold experiments. Decubitus 1988; 1(1): 18-24.

16. Neumark OW. Deformation, not pressure, is the prime cause of pressure sores. Care Science and Practice 1981; 1: 41-6.

17. Hussain T. Experimental study of some pressure effects on tissue, with reference to bed-sore problem. J Pathology Bacteriology 1953; 66: 347-58.

18. Reswick JB, Rogers JE. Experience at Rancho Los Amigos hospital with devices and techniques to prevent pressure sores. In: Kenedi RM, Cowden JM, Scales JT, editors. Bedsore Biomechanics. Baltimore: University Park Press, 1976; 301-10.

19. Allen V, Ryan DW, Lomax N, Murray A. Accuracy of interface pressure measurement systems. J Biomed Eng 1993; 15(4): 344-8.

20. Dabnichki P, Taktak D. Pressure variation under the ischial tuberosity during a push cycle. Med Eng Phys 1998; 20(4): 242-56.

21. Krouskop TA, Garber SL. Interface pressure confusion. Decubitus 1989; 2(3)

22. Bader DL, Hawken MB. Pressure distribution under the ischium of normal subjects. J Biomed Eng 1986; 8(4): 353-7.

23. Enriquez, Elizabeth Limouze RN, BSN, MPH, CWOCN; Holland, Diane L. P.T., CWS, DAPWCA, CPed

24.  PRESSURE MAPPING—IT’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

25. 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

26. Jenkins ML, O’Neal E. Pressure ulcer prevalence and incidence in acute care. Adv Skin Wound Care. 2010 Dec;23(12):556-9.