Transcript Welcome to the 2006 Heartland Conference

Welcome to the
2006 Heartland Conference
Pressure Mapping –
What’s The Point?
Our Goal
To Prevent This!
Wound measurement using VEV MD
Evidence Based Medicine
• 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.
Where Does Pressure Fit In Our
Assessment Hierarchy?
• Patient
•
Position
•
Pressure
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 and Vet in bed
• Why five years of sacral pressure ulcers only in
August?
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
Client Postural Issues?
• Client Information Check list– Jeannie Minkel’s for example.
• Use camera as part of documentation
– Illustrate the challenges at the beginning
– Illustrate the solution recommended
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 “Cliffs
Notes” of what is relevant to
what you are doing.
– Learn about their lifestyle
and goals. Lifestyle can
trump good seating.
Be Prepared!!
• 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
But First Two Key Items
• Wash your hands! For your sake and
theirs, before and after the evaluation!
Gloves??
• Make sure you use an isolation bag!
Ours our a thin dry cleaning type bag
So What Do We Actually Do With
The Client?
•
•
•
•
•
•
Introduce pressure mapping
Capture how they are currently doing
Demonstrate the client’s challenges
Document least costly solutions
Provide as necessary an appropriate alternative
Communicate our findings effectively
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
•
•
•
•
45 year old SCI client – 25 year post injury C5 Quadriplegia
Long standing history of right side Stage I ulcer (has been worse)
Now problem 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.
Capture Them in Their
Existing Seating
• 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?
Some Reminders
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
Current Seating
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)
229.67
What is suspicious in this picture? Note the hexagon.
20.9
1
mmHg
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
Pressure mapping systems help you
redistribute pressure they do not:
• Relieve pressure
Or
• Reduce pressure
What About The Numbers???
• A particular number at a particular site 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?
OK This Means What?
• 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 than another?
Don’t Forget Asymmetry!
Make sure the it’s the client not a misplaced
sensing mat?
That’s More Like It!
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 will or 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.
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:
Why the most likely or least costly solution did
or did not work?
A Standard Solution
Foam cushion: pressures still unacceptably high, and highly focused
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”?
Power Chair: After Adjustments
8 by 9 air insert in foam: good pressure distribution not as good though as the
full air cushion: up only 4 hours
Proposed Chair:
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
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.
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.
Don’t Forget Training and
Biofeedback
• Training and testing for client and caregiver
compliance
– No that solution your buddy has will not work for
you…See!
– Don’t over-inflate that air cushion!!
– What does a client have to do for weight shifts or tilts to
actually benefit them
– Demonstrate appropriate positioning in Bed or Seat
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!
•
•
•
•
•
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 is unseen
during the assessment?
• Some research and experience indicates that while the client
maybe referred 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
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
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 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 also provides information that demonstrates why
you did what you did and when you did it, a.k.a.
Risk Management.
Conclusions:
• Pressure mapping systems are dumb. It takes intelligent
interpretation and application of the data to make good
decisions that benefit the client
• They are powerful tools to help maximize care for your clients
and to help ensure they receive it.
• They also have become standard of care for those needing
rehabilitation seating.
Remember Our Goal
THANK YOU!