Transcript PRACTICAL PRESSURE MAPPING

PRACTICAL
PRESSURE
MAPPING
Presented by:
Vista Medical
Andrew Frank
July 2006
Pressure Mapping –
What’s The Point?
Our Goal
To Prevent This!
Wound measurement using VEV MD
Some Sobering Numbers
 39% of SCI Veterans in Houston in the 3
Years studied were treated for a PU
 150 day average in Hospital
 $150,000 per Hospitalization.
– Garber, Rintala Journal of Rehabilitation
Research and Development, Sept/Oct. 2003
The Cost is Significant
 SCI general prevalence 25%-85%
 Mean cost in 1998 $37,288
 Total cost estimated up to $3.6 Billion
in 1999.
Incidence of Skin Breakdown in SCI
 Incidence of SCI continues to be 80%
male, 20% female
 Substantial physiological differences
between genders
 Increased incidence with increased age
Courtesy of LAURIE M. RAPPL, PT, CWS
SCI Skin Changes
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Collagen catabolism
Decreased amino acid concentration
Decrease in enzymes of biosynthesis
Decrease in proportion of Type I to Type II collagen
Decrease in density of adrenergic receptors
Poor collagen synthesis
Abnormal vascular reactions
Decreased blood flow
Decreased PO2 – 5X less than in innervated skin
Decreased fibronectin, glycoproteins for fibroblast activity
Increase in urinary excretion of GAG's, which are the ground
substance for collagen bundles
The skin below the injury is not the same as the skin above.
Courtesy of LAURIE M. RAPPL, PT, CWS
Wounds Are Not All The Same
Courtesy of LAURIE M. RAPPL, PT, CWS
Deep Pressure Ulcer Stage IV
Wound measurement using VEV MD
Shear Ulcer Stage III
Courtesy of D. Keast
Causes of Shear
No
No
Compression Tangential Forces Pinch
Shear
Shear
Shear
Summary of Causes
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Immobility
Incontinence
Pressure
Friction
Shear
Maceration a.k.a. Heat and Moisture
Evidence Based Practice
 We used to say outcomes
measures
 Why do we insist on an
x-ray for a broken wrist yet
we will provide AT with a
short paragraph or two
 Orthopedics get paid
because they use objective
tools like Biodex, Cybex,
etc.
Evidence Based Practice: It’s Here
 Veteran SCI patients guidelines are that
they be assessed with pressure mapping
annually.
 FL Medicaid reviewers frustrated.
 State of FL purchases 11 pressure
mapping for their SCI and Brain Injury
centers.
Tools To Gather Evidence
 Temperature
 Shear
 Pressure
Temperature Mapping
Shear Sensors
Pressure Mapping
Some Important Reminders About
Pressure Mapping
 Place the mat as close to the skin as
possible and with what they normally sit on.
 Consistently place the mat in the same
orientation so there is no confusion later.
 Position the mat square on the seat.
 Confirm with your hands that the sensing
mat is not hammocked.
 Make sure the client is in a “ normal” or
neutral position you can replicate with other
surfaces.
Be Prepared!! Are the Tools Ready?
 Don’t keep the IPM system in the
closet.
– No one wants to wait 30 minutes while you
set up.
 Have it up and running ready to use
 Install it on all the computers you use
 Know when was it last calibrated
Calibration Is Important
 Do you have the equipment to do it
 Does the calibration technique meet
researcher and expert users approval
 Do you have a protocol governing when,
who and where calibration is done?
 Does the system let you know if the
calibration was successful?
Example of a Calibration Kit
Are You Ready?
 Wash your hands! For your sake and
theirs, before and after the evaluation!
Gloves??
 Make sure you use an isolation bag! A
thin PE dry cleaning type bag or facility
garbage bag is fine.
How Long To Wait?
 Some advocate up to 45 minutes-not usually
practical-but you could use remote to test.
 Research indicates 6-8 minutes is a good
practical time (Stinson 2002).
 You need to be observant as it depends on
the solution you choose.
How Do We Make Sense Of
Pressure mapping?
 What can we really do?
 What do the numbers mean?
 How can we make good decisions?
We Can Only Redistribute:
We Can’t
 Relieve pressure
Or
 Reduce pressure
What About The Numbers???
 A particular number at a particular location does
not = success or safety.
 Key numbers to watch are
– Highest pressure-Where is the potential trouble?
 Focuses attention on key at risk areas
– Sensing Area- More is better! (Quantity of distribution)
 Are we expanding or contracting the area of the pressure
distribution on the surface?
– Coefficient of Variation - Lower the % the Better!
(Quality of distribution)
 How evenly is the pressure distributed over the surface?
How Do We Decide?
 Keep in mind that we are doing a case
study of one.
 No normative data is available yet to guide
our decisions for a particular patient type.
 The numbers are only bench marks to
refer to as we seek a better solution.
– Is a proposed position or product affording a
better pressure distribution, functional
capability and or comfort than another?
Don’t Forget Asymmetry!
Make sure that it’s the client not a misplaced sensing mat?
That’s More Like It!
Where Does Pressure Fit In
Our Assessment Hierarchy?
 Patient
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Position
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Pressure
So Here We Go! In Brief…
1.
2.
3.
4.
5.
Introduce pressure mapping
Capture how they are currently doing
Demonstrate the client’s challenges
Document usual/least costly solutions
Provide as necessary an appropriate
alternative
6. Communicate our findings effectively
PM Clinical Wizard
Multi-System Analysis
Braden Scale
for Predicting Pressure Sore Risk
– Validated Long term care Geriatric tool
– Useful to expand areas of investigation
– Nutrition, incontinence and out of chair
activities
Focusing On The Wrong P
Can Cost You!
– Client and O’Malley’s
 Beautiful seating solution in clinic but a wood
stool at the bar defeats the benefits
– Caregiver impact on Vet with repetitive
injury
 Why five years of sacral pressure ulcers only in
August?
Learn About the Patient
 Gather any background
information you deem
pertinent and record in
the client information
tab.
– General, equipment
related for future
reference.
– Don’t rewrite the patient
file but do include the
“Cliff Notes” of what is
relevant to what you are
doing.
– Learn about their lifestyle
and goals. Lifestyle can
trump good seating.
Client Positioning Issues?
 Client Information Check list– Jeannie Minkel’s for example.
 Use camera as part of documentation
– Illustrate the challenges at the beginning
– Illustrate the recommended solution and
the good results
Picture the Posture
1) Introduce Pressure Mapping
 Explain the process
– To remove any
apprehensions
– Involve client and/or
caregivers in the process
– Allow them to interact
with the technology
 They won’t be able to
while you do the
assessment or they will
confuse your work
 Make sure you use your
hands to limit
hammocking
Client’s Background
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45 year old SCI client – 25 year post injury C5 Quadriplegia
Long standing history of right side Stage I ulcer (has been worse)
Now problems with left side Stage I ulcer and NOT problems on right side.
Cannot stay up longer than 4 hours
Current Complaint
 Unable to be up for longer than 4 hours due
to redness in both Ischial Tuberosities, with
left being the worst.
 Secondary is concern over the tail bone
pressure which occurs with current position
and/or recline
 Goal of assessment/intervention: able to be
up 6 hours min, but preferably 8 hours each
day.
2) Capture Them in Their
Existing Seating
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Now that they have sat for a while in their existing mobility device
scan, store and describe
– Keep your comments related to the specific scan stored.
– General information should be in client information tab
– Confirm what you see with your hands! Don’t trust all you see on
the screen confirm it!
– Make notes with the thought in mind that you need to understand
them 3-6 months down the road.
– Make sure you turn the client away from the screen so they can no
longer interact with the pressure mapping system.
This will help answer the question:
Why do we need to make changes or spend money?
Current Seating
What is suspicious in this picture? Note the hexagon.
Use Your Hands!!
2
2
3
2
200
4
2
10 24 46 69 104 91 116 73 41 17
2
15 38 53 62 70 62 95 64 59 33 17
180.1
8
16 27 49 76 62 63 46 82 78 72 28 18
4
19 30 56 117 42 31
5
28 59 70 38 34
3
42 31 81 135 34 13
9
20 49 78 49 36 15
160.2
2
140.3
120.4
44 49 69 104 37 16 12 17 89 84 59 46 41
2
32 36 51 82 60 51 31 62 65 54 48 39 50
5
23 37 45 49 56 45 14 39 49 35 47 35 36
4
18 33 44 35 41 45
9
100.5
80.6
37 33 34 29 25 27
60.7
18 22 28 27 32 24 15 20 20 35 20 28 22
2
11 14 34 31 30 23 11 17 27 37 28 17 29
40.8
18
8
20 24 24 26
8
8
26 37 25 20 16
5
6
19 19 25 17
3
5
23 36 24 24
9
Coefficient of variation (%)
73.66
2
9
12 16 27
2
19 27 35 19
8
Average (mmHg)
34.23
Maximum (mmHg)
134.90
9
Sensing area (in²)
What really is at the 135 mmHg location??
229.67
20.9
1
mmHg
3) Demonstrate What Their
Challenge Is
 If possible have the client sit upright on a firmer
surface like a mat table or a foam cushion. This
should be part of the larger mat evaluation.
– Scan, store and describe where the boney prominences
are. Confirming with hands and noting coordinates on
screen.
This will help answer the questions:
What is the client’s boney architecture like?
Is it all there? How rotated is the pelvis,etc.?
Why won’t a simple solution be sufficient?
On A Firm Flat Surface
Don’t put the client at risk doing this. A mat table or
firmer foam cushion might be good choices.
4) Document the Most Commonly
Used/Least Costly Alternative
 Your years of experience or the typical funding
parameters may lead you to a particular solution
 Scan, Store and describe what you did.
 This may take recording a number of scans as you
try a number of variables. You can use 4 scan view
to compare your solutions head to head.
 Be sure to describe what you did as you scan and
store
This will help answer the question:
How well did the usual or least costly solution
performed for the client?
A “Usual” Solution
Foam cushion: pressures still unacceptably high, and highly focused
5) Provide an Alternative Solution
if Necessary
 If you’re not satisfied with the “normal”
solution try another and validate or challenge.
 Again this may take recording a number of
scans as you try a number of variables.
 Be sure to describe what you did as you scan
and store
This will help answer the question:
Why are we recommending a solution
different than the least costly or “usual”?
An Alternate Solution
8 by 9 air insert in foam: good pressure distribution not as good though as the
full air cushion: up only 4 hours
Proposed Solution
On properly adjusted air cushion. F9 is right IT: Good pressure distribution
Up 6 hours am + 4 hours evening - meeting goal
Change In Posture?
Before
therapist
correction
After
therapist
supported left
PSIS area
6) Develop a Simple Four
Step Report
 Use comparison view to choose and tag the
frames that tell the story
 Print off the report with client information, in color
or in grey scale for faxing.
 Or copy and paste it into a new or existing Word
document you use.
Compare and Choose
Print Your Choices
Print Your Choices
Don’t Forget Remote!
 Use Remote to monitor the performance of the
proposed solution in real world use or over an
extended period of time.
– Remote can evaluate real time activities, e.g.
bouncing down stairs.
– Monitor with Remote to see if the client does weight
shifts or tilts over time. Or, if they tilt, did the go far
enough to get the hoped for benefit.
Use Pressure Mapping As Visual
Feed Back
 Client and caregiver buy in and compliance
– No that solution your buddy has will not work for
you…See for yourself. Better client and caregiver buy
in.
– Don’t over-inflate that air cushion!! Use it wisely.
– How far do they have to go for adequate weight shift
using tilt or other means.
– Demonstrate appropriate positioning in bed or seat so
the caregiver doesn’t defeat your work.
Some Common Mistakes
You stop using your hands and let
technology make decisions for you.
You try every choice available. You
may have a mountain of cushions to
try but go with your experience first.
Time is precious and trying everything
can be confusing.
What Do You Do When It
All Looks Bad?
 Sometimes you have to leave “well enough
alone”
– Client’s trocanter is over 200 mmHg and has been for some time
without incident only alternative is high pressure on proven risk
area of right I.T. Monitor it.
 Use the tool to teach movement-help the client
find alternate pressure redistributing positions in
their seating.
– T3 and 2 wounds-use pressure mapping as a biofeedback tool to
help a nervous T3 discover how much(little) they have to move to
achieve significant pressure reduction for at risk areas.
Maybe it’s the Tool!
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Wrinkles in mat
Poor placement of mat
Hammocking of mat
Out of date calibration
Damaged mat
Get your hands in there and find out
What Do You Do When
It All Looks Good?
 Sometimes everything you do in the seat looks good.
 If it does, back up and take a good look at where the
wound is or what their history is. What is not obvious
and unseen during the assessment?
 Some research and experience indicates that the referral
is for a seating related pressure issue, 50% of the time
the problem is in the bed not the seat. So, go pressure
map the bed even with a seat mat if you need to.
Why Do We Share What
We Just Did?
 To help ensure it benefits the client
– That they get what they need
 And to get your good work
acknowledged and paid for
Pressure Mapping Reports
Enhance Decision Making in the
Care Team
 With objective information better
decisions are made, e.g..
– Due to Sacral wound a physician orders
bed rest, but to you it looks a little high
to be seating induced.
– So you go check the bed with an IPM,
and you clearly identify the cause!
– Now you have objective data to discuss
with the physician. Allowing more
seating time and securing a better bed
for the client.
Evidence Based Practice
Many Have Come To Rely On
 HMOs are requiring pressure mapping for use as
a benchmark to become a contracted vendor with
them.
 Those with the most success using pressure
mapping take time to educate their Case
Managers and other payers.
 It provides information that demonstrates why you
did what you did and when you did it, a.k.a. Risk
Management.
Where Can Pressure Mapping
Be Useful?
 Seating and positioning assessment: including
seat, back and wheelchair configuration
 Support Surfaces/Bed selection and monitoring
– Don’t be afraid to take a seat mat into the bed setting
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Orthotics and Prosthetics design and fitting
Hand grip assessment and ergonomic design
Wound clinics, especially when teamed with VEV
Pressure garment-wraps or one piece
Conclusions:
 Pressure mapping systems require intelligent
interpretation and application of the data to make
good decisions.
 They are powerful tools to help maximize care for
your clients and to help ensure they receive the AT
solutions they need.
 They have also become standard of care for those
needing rehabilitation seating.
Remember Our Goal
THANK YOU!