- Email: [email protected]
Bedding aids
European Geriatric Medicine 1 (2010) 385–390
Technology applied to geriatric medicine
Bedding aids A. Clegg a,*, S. Smith b a Dunhill Medical Trust Research Fellow, Academic Unit of Elderly Care & Rehabilitation, Bradford Institute for Health Research, Temple Bank House, Bradford Teaching Hospitals NHS Foundation Trust, Duckworth Lane, Bradford, BD9 6RJ, United Kingdom b Academic Unit of Elderly Care & Rehabilitation, Bradford Institute for Health Research, Temple Bank House, Bradford Teaching Hospitals NHS Foundation Trust, Duckworth Lane, Bradford, BD9 6RJ, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 August 2010 Accepted 7 September 2010
Bed transfer is a basic mobility skill that is of critical importance to the maintenance of independence in older age. The ability of older people successfully to complete bed transfer can be compromised through the development of both general frailty and acute medical illness. Practical bedding aids can facilitate bed transfer. If the ability to complete bed transfer successfully is compromised, maintenance of skin integrity can be jeopardised, with consequent risk of pressure ulceration. There is a broad choice of pressure-relieving devices available to reduce the risk of pressure ulcer development, to aid symptomatic relief and to promote healing. A holistic assessment that incorporates considered clinical judgment should guide individual choice of pressure-relieving device. ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Keywords: Bedding aids Bed transfer Pressure ulcer Pressure relieving device Occupational therapy
1. Introduction Getting into and out of a bed (bed transfer) is a basic mobility skill [1] that is critical for the functional independence of older people at home. Indeed, the ability to complete bed transfer successfully is defined as one of the key activities of daily living (ADL) that help identify activity restriction and disability in old age [2]. Bed transfer is a complex task that requires adequate muscle strength in a number of important muscle groups. Loss of muscle strength in the important muscle groups that are responsible for achieving the complex task of bed transfer can compromise the ability of old people to participate in ADL, and can have a negative impact on safe, independent living at home. Loss of muscle strength can occur gradually or suddenly in old people. Gradual loss of muscle mass and strength (sarcopenia) is a central component of the frailty syndrome [3] and can develop either as a primary consequence of ageing or secondary to reduced physical activity, chronic disease or poor nutrition [4]. Sudden, catastrophic loss of muscle strength can occur as a result of stroke. Strategies that maintain the ability to complete the basic mobility skill of bed transfer can be of great importance when either gradual or sudden loss of muscle strength is experienced. Provision of physical assistance aids to frail old people has been demonstrated to be effective at slowing the rate of functional
* Corresponding author. Tel.: +44 01274 383440. E-mail address: [email protected] (A. Clegg).
decline in this vulnerable group [5]. Physical bedding aids designed to help maintain the ability to bed transfer are available and an occupational therapist (OT) assessment to help identify appropriate bedding aids can be of great value. Available bedding aids include bed ladders, leg lifters, bed levers, pillow lifters, slide sheets and hoists. 2. The occupational Therapist assessment OTs enable successful ADL participation, including safe completion of bed transfer. Successful ADL participation is achieved by an initial assessment to identify barriers that restrict ADL and by subsequent treatment to overcome these barriers, often through physical and environmental modification. The OT assessment of an old person will ideally take place in the home, but can be done in a hospital or an assessment centre. 2.1. Occupational therapist assessment of bed transfer The OT will observe the current method of bed transfer to identify and record restrictions and barriers. Management strategies that attempt to overcome these restrictions will also be recorded and an activity analysis will pinpoint which part of bed transfer is most difficult. The OT will consider how the physical barriers of muscle weakness and postural instability contribute to bed transfer restrictions, so that the most effective treatment solutions can be found. The contribution of extended resources such as family and carer availability and the physical environment of the elderly subject will also be considered.
1878-7649/$ – see front matter ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. doi:10.1016/j.eurger.2010.09.001
[(Fig._1)TD$IG]
386
[(Fig._3)TD$IG]
A. Clegg, S. Smith / European Geriatric Medicine 1 (2010) 385–390
Fig. 1. Bed ladder, hospital direct. http://www.patienthandling.com. The bed ladder is fixed to the foot of the bed and helps the patient to move from lying to sitting.
Fig. 3. Bed lever, Nottingham rehab supplies. The bed lever is used to aid in change of sleeping position and to enable bed transfer.
3. Bedding aids
5. Leg lifters
3.1. General information
Leg lifters (Fig. 2) can overcome the problem of weak hip flexors that can occur, for example, as a result of stroke or following hip replacement. The foot is placed in the loop and the weight of the leg is lifted onto the bed. The use of a leg lifter requires good sitting balance. Powered leg lifters are also available.
General information on bed height and mattress composition can be helpful to elderly people who experience difficulty with bed transfer. Transfer from bed to chair can be difficult if the bed is too low; conversely, transfer into bed can be problematic if the bed is too high. A number of simple aids to alter bed height is available. Mattress composition is also important; a mattress that is too soft or worn can be difficult both to shuffle up and from which to transfer. 4. Bed ladders
[(Fig._2)TD$IG]
Bed ladders (Fig. 1) are attached to the foot of the bed and enable the user to move more easily from a lying to sitting position.
6. Bed levers (also known as bed rails and bed sticks) Bed levers are usually securely fixed between the mattress and bed base (Fig. 3) but can be fixed underneath the bed (Fig. 4). They can be used to enable change of sleeping position at night. Bed levers are also used to recruit additional arm strength for the sit-tostand movement during bed transfer. 7. Pillow lifters Mechanical pillow lifters (Fig. 5) are used to aid lying to sitting
[(Fig._4)TD$IG]transfers in those who lack the upper body strength required to use
Fig. 2. Leg lifter, helping hand company. The foot is placed into the loop and the weight of the leg is lifted onto the bed.
Fig. 4. Bed lever (under bed).
[(Fig._5)TD$IG]
[(Fig._7)TD$IG]
A. Clegg, S. Smith / European Geriatric Medicine 1 (2010) 385–390
387
Fig. 5. Serena pillow lifter, Mountway Ltd. The mechanical pillow lifter is used to enable lying to sitting transfers in those without the strength to use a manual aid.
Fig. 7. Westholme H-System ceiling track hoist (Max 140kg). This hoist is fitted to a ceiling track.
a manual sitting aid (e.g. bed ladder). Pillow lifters are operated via a hand held control. They can be a cheaper alternative to purchase of a replacement profiling bed and are more easily transported. They offer the convenience of lifting the user without affecting the partner.
person and manual handling injuries to the carer. When in place under the supine person, the sheet is simply pulled in the direction of the desired movement.
8. Slide sheets
If a person is physically unable safely to undertake bed transfer, a hoist can be used by a carer to take the full weight of the subject. A suitably sized sling is securely fitted around the person in bed and the hoist operated (manually or electrically) to lift them into their chair. Hoists can be freestanding (Fig. 6) or ceiling mounted (Fig. 7).
Slide sheets are used by a carer to easily alter the position of the
[(Fig._6)TD$IG]person in bed. They reduce the risk of both friction burns to the
9. Hoists
10. Pressure ulcers & pressure relieving devices
Fig. 6. Sidhill portable bedhead hoist. A suitably sized sling is fitted around the person before the hoist is operated.
Loss of the basic mobility skill of bed transfer can be temporary (as a consequence of acute medical illness or fracture) or permanent. If the basic mobility skill of bed transfer is lost, the maintenance of skin integrity and prevention of pressure ulceration is of paramount importance. Pressure ulcers are areas of localised skin and tissue damage that usually occur over bony points of immobilised people and are caused by pressure, shear or friction forces [6]. Old people and people with impaired mobility are at increased risk of pressure ulcer development [7]. Different stages of pressure ulcer development are described and classified in the European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP) International Pressure Ulcer Classification System (Table 1). A complete pressure ulcer risk assessment that includes a nutritional assessment (e.g. Waterlow Score) is advocated in clinical guidelines [6,7] but there is uncertainty as to whether risk assessment reduces the incidence of pressure ulceration [8]. Pressure ulcers are common. New pressure ulcers have been estimated to occur with an incidence of 4% following hospital admission [9] and the annual incidence of new pressure ulcer formation in long term care has been estimated at 12.5% [10]. They
A. Clegg, S. Smith / European Geriatric Medicine 1 (2010) 385–390
388
Table 1 European pressure ulcer advisory panel (EPUAP) and national pressure ulcer advisory panel (NPUAP) pressure ulcer classification system [6]. Stage
Description
I (non-blanchable erythema)
Skin is intact with non-blanchable redness of a localised area, usually over a bony prominence. May indicate ‘‘at risk’’ subjects
II (partial thickness)
Partial thickness dermis loss presenting as a shallow open ulcer with a red pink wound bed without slough
III (full thickness skin loss)
Full thickness skin loss. Subcutaneous fat may be visible but bone, tendon & muscle are not exposed. Slough may be present
IV (full thickness tissue loss)
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present
[(Fig._8)TD$IG] can cause intractable pain and can have a negative impact on quality of life [11]. Pressure ulcers are also expensive to treat; the total cost of pressure ulceration in the UK has been estimated to represent 4% of the total NHS budget [10]. The direct cost attributable to a grade I pressure ulcer has been estimated at about £1K; the direct cost attributable to a grade 4 pressure ulcer has been estimated at about £10,500 [10]. In light of these important health and socioeconomic implications, the use of pressure-relieving devices in both the hospital and community to help prevent the development of pressure ulceration in old people who are immobile has been advocated in both national and international clinical guidelines [6,7]. 11. Pressure-relieving devices – technology Examples of pressure-relieving devices include pressurerelieving cushions, mattresses, overlays and beds. Pressurerelieving cushions are intended to be used on a normal seating surface, commonly a day chair or wheelchair. Pressure-relieving mattresses provide a complete support surface for the individual. Pressure-relieving overlays are lightweight devices that are intended to be used on top of an existing mattress and are more easily stored [12]. The aim of pressure-relieving devices is to reduce the magnitude and/or duration of pressure between an individual and the support service (the interface pressure) [13] and hence to reduce the risk of pressure ulcer development. Pressure-relieving devices are also used to help mitigate the symptoms of pressure ulcers and to promote pressure ulcer healing [12]. There are two main types of pressure-relieving devices; constant low-pressure (CLP) devices and alternating pressure (AP) devices. These two different types of pressure-relieving device rely on two different types of technology in order to achieve pressure relief. CLP devices aim to mould around the patient’s body, thus distributing the patient’s weight over a greater area, thereby reducing pressure on vulnerable areas. CLP devices differ in the material(s) used for construction and can be classified as ‘‘lowtech’’ or ‘‘high-tech’’. Examples of low-tech CLP devices include standard foam mattresses (Fig. 8), cushions (Fig. 9) gel-filled mattresses/overlays, air-filled mattresses/overlays and waterfilled mattresses/overlays. Low-tech CLP devices are commonly used in clinical practice. High-tech CLP devices include air fluidised beds (rarely used in clinical practice) and low air loss beds [13]. The operation of high-tech CLP devices requires a pumped air supply. AP devices are widely used in clinical practice. They reduce the duration of applied pressure by mechanical pressure variation. This is achieved by alternate inflation and deflation of air-filled cells, generating areas of alternate high and low pressure beneath the patient. While a variety of AP mattresses/overlays is available, it is recommended that an alarm should be incorporated in order to alert carers/nursing staff to any problem, such as a fault within the mattress or power failure [13]. Examples of an AP mattress (Fig. 10), AP overlay (Fig. 11) and AP seat cushion (Fig. 12) are provided.
Fig. 8. Pentaflex constant low pressure mattress, ArjoHuntleigh.
[(Fig._9)TD$IG]
12. Pressure-relieving devices – evidence base Although limited by a paucity of methodologically rigorous studies, a recent Cochrane review concluded that foam-based CLP mattresses, ‘‘higher-tech’’ CLP mattresses (e.g. air-fluidised mattresses) and AP mattresses all appear to more effective than standard hospital mattresses at preventing pressure ulcers [13]. There is no clear conclusive evidence to support the superiority of one single CLP or AP device. A 2006 UK Health Technology Assessment (HTA) Summary reported a cost-effectiveness analysis (CEA) that compared AP
Fig. 9. Pentaflex constant low pressure seat cushion, ArjoHuntleigh.
[(Fig._10)TD$IG]
A. Clegg, S. Smith / European Geriatric Medicine 1 (2010) 385–390
389
reduced length of hospital stay and consequent reduced associated hospitalisation costs [14]. 13. Choosing a pressure relieving device
[(Fig._1)TD$IG]
Fig. 10. Autologic alternating pressure mattress, ArjoHuntleigh.
There is a broad choice of available pressure-relieving devices. A UK purchasing review identified more than 300 pressure-relieving products from 42 suppliers, with a choice of 133 CLP mattresses alone [12]. A decision on the most suitable pressure-relieving device should be made on the basis of an individual patient assessment that includes assessment of ulcer severity, ulcer location and individual risk [7]. As there is currently no clear evidence to support the superiority of one individual pressure-relieving device, it is advised that cheaper models should be considered. A low tech CLP mattress or overlay should be considered for those at risk of pressure ulcer development or those with a grade 1 pressure ulcer. A high tech CLP device or an AP device should be considered for those who present with a grade 1–4 pressure ulcer [12]. 14. Conclusion
Fig. 11. Autologic alternating pressure mattress overlay (designed to fit on top of an existing mattress), ArjoHuntleigh.
replacement mattresses and AP overlays. The CEA indicated that AP replacement mattresses are likely to be more cost-effective than AP overlays, with a mean cost saving of about £75 per patient. This cost saving was principally as a result of a delay in time to ulceration of 10.4 days (95% Confidence Interval 24.40–3.09 days),
[(Fig._12)TD$IG]
The basic mobility skill of bed transfer is critically important for the maintenance of independence in old age. The ability of older people successfully to complete bed transfer can be compromised through the development of both general frailty and acute medical illness. A number of practical treatment solutions exist to help enable successful bed transfer. These solutions are widely available and can be readily identified by skilled healthcare professionals working in multidisciplinary teams to facilitate the comprehensive assessment of frail elders. If the ability to complete bed transfer successfully is compromised, skin integrity can be jeopardised and risk of pressure ulcer development increases. There is a broad range of pressure-relieving devices available which reduce the risk of pressure ulcer development, aid symptomatic relief and facilitate healing. A holistic assessment that incorporates considered clinical judgment should guide individual choice of pressure-relieving device. Conflicts of interest statement The authors have no conflict of interest. Acknowledgements We would like to thank Professor Graham Mulley and Dr Sarah Stowe, Department of Elderly Medicine, St James University Hospital, Leeds for their helpful comments during the preparation of this article. Figs. 8–12 used to illustrate the article were kindly supplied by ArjoHuntleigh. References
Fig. 12. Day Care alternating pressure seat cushion, ArjoHuntleigh.
[1] Isaacs B. Clinical and laboratory studies of falls in old people. Prospects for prevention. Clin Geriatr Med 1985;1(3):513–24. [2] Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J 1965;14:61–5. [3] Fried L, Walston J. Frailty and Failure to Thrive. In: Hazzard W, et al., editors. Principles of Geriatric Medicine and Gerontology. 5th ed. McGrawHill; 2003. [4] Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al. Sarcopenia: European consensus on definition and diagnosis: report of the European Working Group on Sarcopenia in Older People. Age Ageing 2010;39(4):412–23. [5] Mann WC, Ottenbacher KJ, Fraas L, Tomita M, Granger CV. Effectiveness of assistive technology and environmental interventions in maintaining independence and reducing home care costs for the frail elderly. A randomized controlled trial. Arch Fam Med 1999;8(3):210–7.
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[6] European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009 [7] Pressure ulcer management. National Institute for Health and Clinical Excellence Clinical Guideline. June 2005 [8] Moore ZEH, Cowman S. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews 2008;3 [Art. No.: CD006471]. doi:10.1002/14651858.CD006471.pub2. [9] Clark M, Watts S. The incidence of pressure sores within a National Health Service Trust hospital during 1991. J Adv Nurs 1994;20(1):33–6. [10] Bennett G, Dealey C, Posnett J. The cost of pressure ulcers in the UK. Age Ageing 2004;33(3):230–5.
[11] Hopkins A, Dealey C, Bale S, Defloor T, Worboys F. Patient stories of living with a pressure ulcer. J Adv Nurs 2006;56(4):345–53. [12] Buyers guide. Pressure-redistribution mattresses and overlays. NHS Purchasing and Supply Agency. Centre for Evidence Based Purchasing. CEP08042. November 2008. Available from ttp://www.pasa.nhs.uk/pasa/Doc.aspx%3FPath=%255BMN%255D%255BSP%255D/NHSprocurement/CEP/CEP08042.pdf [13] McInnes E, Cullum NA, Bell-Syer SEM, Dumville JC, Jammali-Blasi A. Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews 2008;4 [Art. No.: CD001735]. doi:10.1002/14651858.CD001735.pub3. [14] Nixon J, Nelson EA, Cranny G, Iglesias CP, Hawkins K, Cullum NA, et al. Pressure relieving support surfaces: a randomised evaluation. Health Technol Assess 2006;10(22):1–163 [iii–iv, ix–x].
Technology applied to geriatric medicine
Bedding aids A. Clegg a,*, S. Smith b a Dunhill Medical Trust Research Fellow, Academic Unit of Elderly Care & Rehabilitation, Bradford Institute for Health Research, Temple Bank House, Bradford Teaching Hospitals NHS Foundation Trust, Duckworth Lane, Bradford, BD9 6RJ, United Kingdom b Academic Unit of Elderly Care & Rehabilitation, Bradford Institute for Health Research, Temple Bank House, Bradford Teaching Hospitals NHS Foundation Trust, Duckworth Lane, Bradford, BD9 6RJ, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 August 2010 Accepted 7 September 2010
Bed transfer is a basic mobility skill that is of critical importance to the maintenance of independence in older age. The ability of older people successfully to complete bed transfer can be compromised through the development of both general frailty and acute medical illness. Practical bedding aids can facilitate bed transfer. If the ability to complete bed transfer successfully is compromised, maintenance of skin integrity can be jeopardised, with consequent risk of pressure ulceration. There is a broad choice of pressure-relieving devices available to reduce the risk of pressure ulcer development, to aid symptomatic relief and to promote healing. A holistic assessment that incorporates considered clinical judgment should guide individual choice of pressure-relieving device. ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Keywords: Bedding aids Bed transfer Pressure ulcer Pressure relieving device Occupational therapy
1. Introduction Getting into and out of a bed (bed transfer) is a basic mobility skill [1] that is critical for the functional independence of older people at home. Indeed, the ability to complete bed transfer successfully is defined as one of the key activities of daily living (ADL) that help identify activity restriction and disability in old age [2]. Bed transfer is a complex task that requires adequate muscle strength in a number of important muscle groups. Loss of muscle strength in the important muscle groups that are responsible for achieving the complex task of bed transfer can compromise the ability of old people to participate in ADL, and can have a negative impact on safe, independent living at home. Loss of muscle strength can occur gradually or suddenly in old people. Gradual loss of muscle mass and strength (sarcopenia) is a central component of the frailty syndrome [3] and can develop either as a primary consequence of ageing or secondary to reduced physical activity, chronic disease or poor nutrition [4]. Sudden, catastrophic loss of muscle strength can occur as a result of stroke. Strategies that maintain the ability to complete the basic mobility skill of bed transfer can be of great importance when either gradual or sudden loss of muscle strength is experienced. Provision of physical assistance aids to frail old people has been demonstrated to be effective at slowing the rate of functional
* Corresponding author. Tel.: +44 01274 383440. E-mail address: [email protected] (A. Clegg).
decline in this vulnerable group [5]. Physical bedding aids designed to help maintain the ability to bed transfer are available and an occupational therapist (OT) assessment to help identify appropriate bedding aids can be of great value. Available bedding aids include bed ladders, leg lifters, bed levers, pillow lifters, slide sheets and hoists. 2. The occupational Therapist assessment OTs enable successful ADL participation, including safe completion of bed transfer. Successful ADL participation is achieved by an initial assessment to identify barriers that restrict ADL and by subsequent treatment to overcome these barriers, often through physical and environmental modification. The OT assessment of an old person will ideally take place in the home, but can be done in a hospital or an assessment centre. 2.1. Occupational therapist assessment of bed transfer The OT will observe the current method of bed transfer to identify and record restrictions and barriers. Management strategies that attempt to overcome these restrictions will also be recorded and an activity analysis will pinpoint which part of bed transfer is most difficult. The OT will consider how the physical barriers of muscle weakness and postural instability contribute to bed transfer restrictions, so that the most effective treatment solutions can be found. The contribution of extended resources such as family and carer availability and the physical environment of the elderly subject will also be considered.
1878-7649/$ – see front matter ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. doi:10.1016/j.eurger.2010.09.001
[(Fig._1)TD$IG]
386
[(Fig._3)TD$IG]
A. Clegg, S. Smith / European Geriatric Medicine 1 (2010) 385–390
Fig. 1. Bed ladder, hospital direct. http://www.patienthandling.com. The bed ladder is fixed to the foot of the bed and helps the patient to move from lying to sitting.
Fig. 3. Bed lever, Nottingham rehab supplies. The bed lever is used to aid in change of sleeping position and to enable bed transfer.
3. Bedding aids
5. Leg lifters
3.1. General information
Leg lifters (Fig. 2) can overcome the problem of weak hip flexors that can occur, for example, as a result of stroke or following hip replacement. The foot is placed in the loop and the weight of the leg is lifted onto the bed. The use of a leg lifter requires good sitting balance. Powered leg lifters are also available.
General information on bed height and mattress composition can be helpful to elderly people who experience difficulty with bed transfer. Transfer from bed to chair can be difficult if the bed is too low; conversely, transfer into bed can be problematic if the bed is too high. A number of simple aids to alter bed height is available. Mattress composition is also important; a mattress that is too soft or worn can be difficult both to shuffle up and from which to transfer. 4. Bed ladders
[(Fig._2)TD$IG]
Bed ladders (Fig. 1) are attached to the foot of the bed and enable the user to move more easily from a lying to sitting position.
6. Bed levers (also known as bed rails and bed sticks) Bed levers are usually securely fixed between the mattress and bed base (Fig. 3) but can be fixed underneath the bed (Fig. 4). They can be used to enable change of sleeping position at night. Bed levers are also used to recruit additional arm strength for the sit-tostand movement during bed transfer. 7. Pillow lifters Mechanical pillow lifters (Fig. 5) are used to aid lying to sitting
[(Fig._4)TD$IG]transfers in those who lack the upper body strength required to use
Fig. 2. Leg lifter, helping hand company. The foot is placed into the loop and the weight of the leg is lifted onto the bed.
Fig. 4. Bed lever (under bed).
[(Fig._5)TD$IG]
[(Fig._7)TD$IG]
A. Clegg, S. Smith / European Geriatric Medicine 1 (2010) 385–390
387
Fig. 5. Serena pillow lifter, Mountway Ltd. The mechanical pillow lifter is used to enable lying to sitting transfers in those without the strength to use a manual aid.
Fig. 7. Westholme H-System ceiling track hoist (Max 140kg). This hoist is fitted to a ceiling track.
a manual sitting aid (e.g. bed ladder). Pillow lifters are operated via a hand held control. They can be a cheaper alternative to purchase of a replacement profiling bed and are more easily transported. They offer the convenience of lifting the user without affecting the partner.
person and manual handling injuries to the carer. When in place under the supine person, the sheet is simply pulled in the direction of the desired movement.
8. Slide sheets
If a person is physically unable safely to undertake bed transfer, a hoist can be used by a carer to take the full weight of the subject. A suitably sized sling is securely fitted around the person in bed and the hoist operated (manually or electrically) to lift them into their chair. Hoists can be freestanding (Fig. 6) or ceiling mounted (Fig. 7).
Slide sheets are used by a carer to easily alter the position of the
[(Fig._6)TD$IG]person in bed. They reduce the risk of both friction burns to the
9. Hoists
10. Pressure ulcers & pressure relieving devices
Fig. 6. Sidhill portable bedhead hoist. A suitably sized sling is fitted around the person before the hoist is operated.
Loss of the basic mobility skill of bed transfer can be temporary (as a consequence of acute medical illness or fracture) or permanent. If the basic mobility skill of bed transfer is lost, the maintenance of skin integrity and prevention of pressure ulceration is of paramount importance. Pressure ulcers are areas of localised skin and tissue damage that usually occur over bony points of immobilised people and are caused by pressure, shear or friction forces [6]. Old people and people with impaired mobility are at increased risk of pressure ulcer development [7]. Different stages of pressure ulcer development are described and classified in the European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP) International Pressure Ulcer Classification System (Table 1). A complete pressure ulcer risk assessment that includes a nutritional assessment (e.g. Waterlow Score) is advocated in clinical guidelines [6,7] but there is uncertainty as to whether risk assessment reduces the incidence of pressure ulceration [8]. Pressure ulcers are common. New pressure ulcers have been estimated to occur with an incidence of 4% following hospital admission [9] and the annual incidence of new pressure ulcer formation in long term care has been estimated at 12.5% [10]. They
A. Clegg, S. Smith / European Geriatric Medicine 1 (2010) 385–390
388
Table 1 European pressure ulcer advisory panel (EPUAP) and national pressure ulcer advisory panel (NPUAP) pressure ulcer classification system [6]. Stage
Description
I (non-blanchable erythema)
Skin is intact with non-blanchable redness of a localised area, usually over a bony prominence. May indicate ‘‘at risk’’ subjects
II (partial thickness)
Partial thickness dermis loss presenting as a shallow open ulcer with a red pink wound bed without slough
III (full thickness skin loss)
Full thickness skin loss. Subcutaneous fat may be visible but bone, tendon & muscle are not exposed. Slough may be present
IV (full thickness tissue loss)
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present
[(Fig._8)TD$IG] can cause intractable pain and can have a negative impact on quality of life [11]. Pressure ulcers are also expensive to treat; the total cost of pressure ulceration in the UK has been estimated to represent 4% of the total NHS budget [10]. The direct cost attributable to a grade I pressure ulcer has been estimated at about £1K; the direct cost attributable to a grade 4 pressure ulcer has been estimated at about £10,500 [10]. In light of these important health and socioeconomic implications, the use of pressure-relieving devices in both the hospital and community to help prevent the development of pressure ulceration in old people who are immobile has been advocated in both national and international clinical guidelines [6,7]. 11. Pressure-relieving devices – technology Examples of pressure-relieving devices include pressurerelieving cushions, mattresses, overlays and beds. Pressurerelieving cushions are intended to be used on a normal seating surface, commonly a day chair or wheelchair. Pressure-relieving mattresses provide a complete support surface for the individual. Pressure-relieving overlays are lightweight devices that are intended to be used on top of an existing mattress and are more easily stored [12]. The aim of pressure-relieving devices is to reduce the magnitude and/or duration of pressure between an individual and the support service (the interface pressure) [13] and hence to reduce the risk of pressure ulcer development. Pressure-relieving devices are also used to help mitigate the symptoms of pressure ulcers and to promote pressure ulcer healing [12]. There are two main types of pressure-relieving devices; constant low-pressure (CLP) devices and alternating pressure (AP) devices. These two different types of pressure-relieving device rely on two different types of technology in order to achieve pressure relief. CLP devices aim to mould around the patient’s body, thus distributing the patient’s weight over a greater area, thereby reducing pressure on vulnerable areas. CLP devices differ in the material(s) used for construction and can be classified as ‘‘lowtech’’ or ‘‘high-tech’’. Examples of low-tech CLP devices include standard foam mattresses (Fig. 8), cushions (Fig. 9) gel-filled mattresses/overlays, air-filled mattresses/overlays and waterfilled mattresses/overlays. Low-tech CLP devices are commonly used in clinical practice. High-tech CLP devices include air fluidised beds (rarely used in clinical practice) and low air loss beds [13]. The operation of high-tech CLP devices requires a pumped air supply. AP devices are widely used in clinical practice. They reduce the duration of applied pressure by mechanical pressure variation. This is achieved by alternate inflation and deflation of air-filled cells, generating areas of alternate high and low pressure beneath the patient. While a variety of AP mattresses/overlays is available, it is recommended that an alarm should be incorporated in order to alert carers/nursing staff to any problem, such as a fault within the mattress or power failure [13]. Examples of an AP mattress (Fig. 10), AP overlay (Fig. 11) and AP seat cushion (Fig. 12) are provided.
Fig. 8. Pentaflex constant low pressure mattress, ArjoHuntleigh.
[(Fig._9)TD$IG]
12. Pressure-relieving devices – evidence base Although limited by a paucity of methodologically rigorous studies, a recent Cochrane review concluded that foam-based CLP mattresses, ‘‘higher-tech’’ CLP mattresses (e.g. air-fluidised mattresses) and AP mattresses all appear to more effective than standard hospital mattresses at preventing pressure ulcers [13]. There is no clear conclusive evidence to support the superiority of one single CLP or AP device. A 2006 UK Health Technology Assessment (HTA) Summary reported a cost-effectiveness analysis (CEA) that compared AP
Fig. 9. Pentaflex constant low pressure seat cushion, ArjoHuntleigh.
[(Fig._10)TD$IG]
A. Clegg, S. Smith / European Geriatric Medicine 1 (2010) 385–390
389
reduced length of hospital stay and consequent reduced associated hospitalisation costs [14]. 13. Choosing a pressure relieving device
[(Fig._1)TD$IG]
Fig. 10. Autologic alternating pressure mattress, ArjoHuntleigh.
There is a broad choice of available pressure-relieving devices. A UK purchasing review identified more than 300 pressure-relieving products from 42 suppliers, with a choice of 133 CLP mattresses alone [12]. A decision on the most suitable pressure-relieving device should be made on the basis of an individual patient assessment that includes assessment of ulcer severity, ulcer location and individual risk [7]. As there is currently no clear evidence to support the superiority of one individual pressure-relieving device, it is advised that cheaper models should be considered. A low tech CLP mattress or overlay should be considered for those at risk of pressure ulcer development or those with a grade 1 pressure ulcer. A high tech CLP device or an AP device should be considered for those who present with a grade 1–4 pressure ulcer [12]. 14. Conclusion
Fig. 11. Autologic alternating pressure mattress overlay (designed to fit on top of an existing mattress), ArjoHuntleigh.
replacement mattresses and AP overlays. The CEA indicated that AP replacement mattresses are likely to be more cost-effective than AP overlays, with a mean cost saving of about £75 per patient. This cost saving was principally as a result of a delay in time to ulceration of 10.4 days (95% Confidence Interval 24.40–3.09 days),
[(Fig._12)TD$IG]
The basic mobility skill of bed transfer is critically important for the maintenance of independence in old age. The ability of older people successfully to complete bed transfer can be compromised through the development of both general frailty and acute medical illness. A number of practical treatment solutions exist to help enable successful bed transfer. These solutions are widely available and can be readily identified by skilled healthcare professionals working in multidisciplinary teams to facilitate the comprehensive assessment of frail elders. If the ability to complete bed transfer successfully is compromised, skin integrity can be jeopardised and risk of pressure ulcer development increases. There is a broad range of pressure-relieving devices available which reduce the risk of pressure ulcer development, aid symptomatic relief and facilitate healing. A holistic assessment that incorporates considered clinical judgment should guide individual choice of pressure-relieving device. Conflicts of interest statement The authors have no conflict of interest. Acknowledgements We would like to thank Professor Graham Mulley and Dr Sarah Stowe, Department of Elderly Medicine, St James University Hospital, Leeds for their helpful comments during the preparation of this article. Figs. 8–12 used to illustrate the article were kindly supplied by ArjoHuntleigh. References
Fig. 12. Day Care alternating pressure seat cushion, ArjoHuntleigh.
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