Pressure ulcer prevention.

The purpose of this collective review is to outline the predisposing factors in the development of pressure ulcers and to identify a pressure ulcer prevention program. The most frequent sites for pressure ulcers are areas of skin overlying bony prominences. There are four critical factors contributing to the development of pressure ulcers: pressure, shearing forces, friction, and moisture. Pressure is now viewed as the single most important etiologic factor in pressure ulcer formation. Prolonged immobilization, sensory deficit, circulatory disturbances, and poor nutrition have been identified as important risk factors in the development of pressure ulcer formation. Among the clinical assessment scales available, only two, the Braden Scale and Norton Scale, have been tested extensively for reliability and/or validity. The most commonly used risk assessment tools for pressure ulcer formation are computerized pressure monitoring and measurement of laser Doppler skin blood flow. Pressure ulcers can predispose the patient to a variety of complications that include bacteremia, osteomyelitis, squamous cell carcinoma, and sinus tracts. The three components of pressure ulcer prevention that must be considered in any patient include management of incontinence, nutritional support, and pressure relief. The pressure relief program must be individualized for non-weight-bearing individuals as well as those that can bear weight. For those that can not bear weight and passively stand, the RENAISSANCE Mattress Replacement System is recommended for the immobile patient who lies supine on the bed, the stretcher, or operating room table. This alternating pressure system is unique because it has three separate cells that are not interconnected. It is specifically designed so that deflation of each individual cell will reach a ZERO PRESSURE during each alternating pressure cycle. The superiority of this system has been documented by comprehensive clinical studies in which this system has been compared to the standard hospital bed as well as to two other commercially available pressure relief mattresses. The most recent advance in pressure ulcer prevention is the development of the ALTERN8* seating system. This seating system provides regular periods of pressure relief and stimulation of blood flow to skin areas while users are seated. By offering the combination of pressure relief therapy and an increase in blood flow, the ALTERN8* reportedly creates an optimum pressure ulcer healing environment. Foam is the most commonly used material for pressure reduction and pressure ulcer prevention and treatment for the mobile individual. For those immobilized individuals who can achieve a passive standing position, a powered wheelchair that allows the individual to achieve a passive standing position is recommended. The beneficial effects of passive standing have been documented by comprehensive scientific studies. These benefits include reduction of seating pressure, decreased bone demineralization, increased blander pressure, enhanced orthostatic circulatory regulation, reduction in muscular tone, decrease in upper extremity muscle stress, and enhanced functional status in general. In the absence of these dynamic alternating pressure seating systems and mattresses, there are enormous medicolegal implications to the healthcare facility. Because there is not sufficient staff to provide pressure relief to rotate the patient every 2 hours in a hospital setting, with the exception of the intensive care unit, the immobile patient is prone to develop pressure ulcers. The cost of caring for these preventable pressure ulcers may now be as high as 60,000 dollars per patient. The occupational physical strain sustained by nursing personnel in rotating their patients has led to occupational back pain in nurses, a major source of morbidity in the healthcare environment.

Technological advances in powered wheelchairs.

During the last 40 years, there have been revolutionary advances in power wheelchairs. These unique wheelchair systems, designed for the physically immobile patient, have become extremely diversified, allowing the user to achieve different positions, including tilt, recline, and, more recently, passive standing. Because of this wide diversity of powered wheelchair products, there is a growing realization of the need for certification of wheeled mobility suppliers. Legislation in Tennessee (Consumer Protection Act for Wheeled Mobility) passed in 2003 will ensure that wheeled mobility suppliers must have Assistive Technology Supplier certification and maintain their continuing education credits when fitting individuals in wheelchairs for long-term use. Fifteen other legislative efforts are currently underway in general assemblies throughout the US. Manufacturers, dealers, hospitals, and legislators are working toward the ultimate goal of passing federal legislation delineating the certification process of wheeled mobility suppliers. The most recent advance in the design of powered wheelchairs is the development of passive standing positions. The beneficial effects of passive standing have been documented by comprehensive scientific studies. These benefits include reduction of seating pressure, decreased bone demineralization, increased bladder pressure, enhanced orthostatic circulatory regulation, reduction in muscular tone, decrease in upper extremity muscle stress, and enhanced functional status in general. In February 2003, Permobil, Inc., introduced the powered Permobil Chairman 2K Stander wheelchair, which can tilt, recline, and stand. Other companies are now manufacturing powered wheelchairs that can achieve a passive standing position. These wheelchairs include the Chief SR Powerchair, VERTRAN, and LifeStand Compact. Another new addition to the wheelchair industry is the iBOT, which can elevate the user to reach cupboards and climb stairs but has no passive standing capabilities. In addition, the physically immobile patient must be seated on an ERGODYNAMIC Seating System 2000, which is inflated by the alternating pressure compressor 8080. This seating system has a deep center seam between the two ischial-support chambers, which provides a recess for the coccyx. The pre-ischial crossbar compartment inflates during each cycle to prevent the pelvis from slipping forward. It is essential that the physician of the immobile patient order two ERGODYNAMIC Seating Systems 2000 because the patient must have an additional seating system in the case one leaks. Moreover, two compressors are necessary because each compressor must be serviced after 2500 hours of use. For the protection of the consumer, these pressure relief systems must be supplied and serviced by a Certified Rehabilitation Technology Supplier such as Wheelchair Works Inc. Despite the indisputable scientific evidence of the medical benefits of passive standing for the immobile user, few individuals have access to these revolutionary wheelchairs. Consequently, it is mandatory that the medical community, headed by specialists in physical and occupational therapy as well as rehabilitation medicine, CRTS, and manufacturers collaborate in a national education campaign to convince Medicare/Medicaid and all commercial insurance companies to approve immediately these assisted technologies. This program is essential so that the physically immobilized patient can achieve the undisputed physical benefits of passive standing.