Evaluating a pressure-redistribution mattress replacement system Heather Newton
Key words: Re-positioning ■ Pressure ■ Procurement
P
rocuring pressure-relieving equipment to meet patient and organisational needs can be challenging in today’s NHS, where improving or maintaining quality and affordability are key considerations. Moore (2013) suggests that the NHS has the potential to make substantial savings and improve quality through better procurement; however, in practice the decision-making process can at times be bureaucratic and time consuming. The Department of Health (DH) 2012 published best practice guidance on NHS procurement, which committed to ensuring that procurement was a central feature in driving quality and value in the NHS. It outlined a number of recommendations, including a need to standardise and reduce the variation of products used by the NHS, as well as the need to make more professional use of procurement partners (DH, 2012). Nichols (2014) acknowledges there is a large range of pressure-redistributing mattresses available and that health professionals have a responsibility to make the appropriate choice. Nichols also states that: ‘It is vital that every effort is made to identify those most at risk of developing pressure ulcers and implement interventions to reduce risk, of which pressure-redistributing equipment is a critical element’. (Nichols, 2014: 70)
Heather Newton, Consultant Nurse Tissue Viability, Royal Cornwall Hospitals NHS Trust. Truro, Cornwall Accepted for publication: October 2014
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Background The Royal Cornwall Hospitals NHS Trust (RCHT) has approximately 750 beds on three sites and serves a population of around 450 000, although this can increase during the summer months owing to a higher number of holidaymakers visiting the county. One of the challenges facing the hospital equipment library staff was the provision of pressure-redistributing equipment to the west of the county; to a smaller hospital with approximately 60 medical beds. An increasing number of acutely ill patients were being transferred to this hospital, and transporting the most appropriate pressure-redistributing equipment at the right time was proving to be difficult. The medical wards were heavily reliant on the use of dynamic mattresses and, at times, 40–50% of their patients were being nursed on a dynamic system. This became the main driver for this evaluation as it had become increasingly difficult to meet staff expectations and patient needs. Equipment requirements have historically been based on patient risk-assessment scores to ensure consistency of practice; however, this evaluation has highlighted the importance of skin assessment, patient repositioning and patient mobility in relation to the provision of an appropriate support surface to meet patient needs. In 2005 the Royal College of Nursing (RCN) recommended that consideration be given to the use of alternating or other high-tech pressure-relieving devices as a first-line preventive strategy for those at higher risk of pressure ulcers, when their clinical condition and history indicated a need for a higher level of technology, or when a low-tech device had failed (RCN, 2005). This was recommended despite there being very little evidence to suggest that these higher tech mattresses were any more effective than the lower tech foam alternatives. The recent National Institute of Health and Care Excellence (NICE) clinical guideline 179 (2014) suggests that a high-specification foam mattress for adults with a
© 2014 MA Healthcare Ltd
Abstract
Pressure ulcer prevention is high on the quality agenda and provision of pressure-relieving equipment to meet patients’ needs is an essential part of this process. This can be challenging in today’s NHS and this article explores the evaluation process that supported the procurement of the AtmosAir™ 4000 pressure-redistributing mattress replacement system. Outcomes suggest that, when combined with a robust repositioning and skin assessment regime, the AtmosAir 4000 performed well and dynamic mattress usage was reduced. Further evaluation over a longer period of time will be undertaken in future.
This article will explore a procurement process involving clinical, technical and financial appraisal to support decision making in relation to the purchase of the AtmosAir™ 4000 reactive pressure-redistribution mattress replacement system for an acute NHS trust in Cornwall. The mattress evaluation was undertaken over a 6-week period on one acute medical ward. Following removal of the mattress, there was a post-evaluation period of 2 weeks where the normal hospital high-specification foam mattresses were used. During this time, patient outcomes continued to be measured.
British Journal of Nursing, 2014 (Tissue Viability Supplement), Vol 23, No 20
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 24, 2015. For personal use only. No other uses without permission. . All rights reserved.
© ArjoHuntleigh
Figure 1. AtmosAir 4000 mattress replacement system
Figure 2. AtmosAir 4000 mattress replacement system: a cut-away section of the mattress showing the air cells and the foam
pressure ulcer may be an option and, if this is insufficient, the use of a dynamic support system should be considered. This appears to be moving away from the notion of using a dynamic mattress system as the first-line approach for patients with pressure ulcers or at very high risk, which is anecdotally common across many NHS trusts. Any decisions taken should, however, be based on an accurate risk assessment and clinical judgement. The National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and the Pan Pacific Pressure Injury Alliance (PPPIA) (NPUAP et al, 2014), however, suggest that patients at higher risk who cannot be repositioned frequently should be cared for on an active alternating support system. This strengthens the need to establish if a patient can reposition independently or how much assistance they need to reposition rather than placing all high-risk patients on a dynamic support system automatically on admission to hospital, just because of their risk score. This does not remove the need to use an active alternating mattress system where appropriate; however, it does raise the question of at what stage and for which patients they would best be used for. Dynamic pressure-redistributing mattresses have been an integral part of the pressure-relieving equipment portfolio for the RCHT alongside the use of static foam mattresses;
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AtmosAir 4000 The AtmosAir™ 4000 is a non-powered pressure redistribution mattress replacement system which uses Self Adjusting Technology™ (SAT).The mattress is a combination of pressure reducing foam, air cells and SAT valves. The non-powered longitudinal air cells and SAT valves automatically and instantly regulate the internal cushion pressures in reaction to body movement. As weight is applied to the mattress, air is displaced from the independent cells and exhausted via the tube set.This allows for a greater level of immersion and envelopment into the surface, further reducing tissue interface pressures as shown in Figure 1 and Figure 2. The AtmosAir 4000 mattress replacement system offers advanced features and benefits that provide clinically effective pressure redistribution and optimised patient comfort (ArjoHuntleigh, 2014), however, there is limited evidence that they can reduce the dynamic mattress requirements of an organisation. If they were shown to be effective at reducing pressure for high- to very high-risk patients in association with a robust repositioning plan, this would potentially mean a significant cost saving for an organisation, as well as maintaining the quality of care for patients. Dynamic systems could then be reserved for the vulnerable, highest risk patients who would benefit from active offloading of the tissues or who are unable to be manually repositioned. The clinical benefits of the mattress system were unclear, as the supporting evidence presented was largely from case studies that were based on single facility findings only (ArjoHuntleigh data on file, 2014). A clinical evaluation proposal was therefore discussed with ArjoHuntleigh that aimed to provide evidence to support its claims regarding product effectiveness in an acute clinical setting.
Evaluation process The aim of the evaluation was to assess the performance of the AtmosAir 4000, to determine its suitability for preventing pressure ulcers in patients with up to a very high risk of developing pressure ulcers. In addition, the number of dynamic mattresses in use during the evaluation period was also measured to see if there was any reduction in requirements and what impact this may have had. Any patient that had pressure damage was excluded from the evaluation at this stage as there was little evidence to
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© ArjoHuntleigh
however, the evaluation has challenged this historical custom and questioned the need for this approach. The trust owns approximately 140 dynamic mattresses and it was becoming harder to justify the need to spend money on new mattresses when evidence demonstrating their effectiveness was inconclusive. The challenge for the organisation and in particular the tissue viability and equipment library teams was to explore an alternative solution to the management of high-risk patients in the west of the county that would be efficient and effective. It was at this stage that the AtmosAir 4000 reactive pressure redistribution mattress replacement system was identified as a possible solution. The mattress was chosen because it had been introduced into another South West regional hospital with good outcomes.
British Journal of Nursing, 2014 (Tissue Viability Supplement), Vol 23, No 20
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 24, 2015. For personal use only. No other uses without permission. . All rights reserved.
PRODUCT EVALUATION
© 2014 MA Healthcare Ltd
suggest the benefits of supporting healing of pressure ulcers or deterioration of damage. A request to undertake the product evaluation was tabled at the trust procurement group meeting. This included the rationale for the evaluation, the proposed method of evaluation and essential outcome measurement criteria. This included the mattress suitability for use with high- to very high-risk patients, the ability to maintain skin integrity and the ease of use by staff. Outcomes were measured in relation to clinical and technical performance and a financial appraisal took place. The procurement group supported the request. The clinical criteria for the evaluation are shown in Box 1. The evaluation took place over a 6-week period between February and April 2013. ArjoHuntleigh provided 25 mattresses, 23 of which were given to patients from the start of the evaluation. A total of 8 dynamic and 15 static foam mattresses were removed from the ward and 2 dynamic mattresses were left in situ for patients with existing pressure ulcers. On the day of the mattress delivery, all patients had their pressure ulcer risk and skin condition reassessed by nursing staff to ensure they were suitable for transfer to the AtmosAir 4000. Those patients with existing pressure ulceration (n=2) were not transferred onto the AtmosAir 4000, but continued to be nursed on their existing dynamic therapy surface. Staff training on the use of the mattress was provided by ArjoHuntleigh and support was offered throughout the evaluation process. Staff had already received training on risk assessment and skin assessment; however, the link practitioner continued to provide staff support. A record of each patient that was admitted and discharged throughout the evaluation period was made by the ward clerk, to ensure that the correct patient records were reviewed at the end of the evaluation. Outcomes were measured through a retrospective review of the patient records undertaken by the author. All of the outcomes relating to the criteria in Box 1 were recorded and analysed. The author chose to measure outcomes using the specified clinical data from the patient’s notes rather than asking the staff to complete an evaluation form, as it was felt that a higher number of patients’ data would be captured using this methodology. The author has found in the past that ward evaluation forms completed by busy ward staff often have a low return rate. However, this relied on the data being available within the patient record. Risk and skin assessments, together with mobility status, were reviewed along with patient’s demographic details and length of stay. Care delivered was analysed using the patient’s care plan and evaluation record. Nurses and therapists were also asked to provide feedback on the use of the mattress via an evaluation form. There were five responses in total; three from nurses and two from physiotherapists. The information was collated by the tissue viability link practitioner.
Results In total 62 patient records were reviewed. A total of 61 records were fully completed with all the required data, with one record incomplete. The results presented therefore will be out of 61 patients. Patients with existing pressure
British Journal of Nursing, 2014 (Tissue Viability Supplement), Vol 23, No 20
Box 1. Criteria for evaluation ■ Patient
age ulcer risk score using the Waterlow score ■ Length of hospital stay ■ Skin assessment on admission ■ Skin assessment throughout the hospital stay ■ Patient’s repositioning requirements ■ Care round frequency; assessed frequency of checking the patient comfort, toileting needs, position and nutritional requirements. ■ Patient mobility ■ Number of pressure ulcers that developed during the evaluation period ■ Pressure
Table 1. Results of AtmosAir evaluation Evaluation criteria
Outcomes
Patient age range
Age 22–100. Mean age 77
Waterlow risk assessment scores
Waterlow score range from 2–26 Mean 15
Length of patient stay
Between 1 and 32 days. Average stay 9 days
Number of patients admitted with intact skin
56/61 (92%) admitted with intact skin
Number of patients discharged with intact skin
54/61 (89%) discharged with intact skin
Number of patients who developed pressure ulcers
2/61 (3%) developed unavoidable pressure ulcers
Assessment of need for repositioning
100% of patients assessed
Number of patients who could reposition 50/61 (82%) could reposition themselves themselves in bed Number of patients requiring assistance to reposition
11/61 (18%) required assistance to reposition
Number of patients who were fully mobile
15/61 (24%) of patients were fully mobile
Number of patients requiring minimal assistance to mobilise
26/61 (43%) of patients needed minimal assistance
Number of patients who needed help to mobilise
20/61 (33%) of patients required help to mobilise
Care round frequency (also known as intentional rounding)
63% of patients required either hourly, 2-hourly or 4-hourly care rounding 32% required daily care rounding 5% of patients did not require care rounding
Number of dynamic mattresses used during the evaluation period
Two dynamic mattresses were used during the evaluation period for patients with pressure ulcers
ulcers were not placed on the trial mattresses and were therefore not reviewed. See Table 1 for results.
Discussion The average age of the patients in this evaluation was 77 and therefore deemed at risk of developing pressure ulcers, especially when other factors were also considered such as mobility, nutritional status, and comorbidities. Patients’ age, if over 65, is recognised as a risk factor for pressure ulceration in the presence of other risk factors (Coleman et al, 2013). The majority of patients were at high risk of pressure ulcer development. This can have a direct link to the patient’s age,
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CRITERIA
AtmosAir 4000 evaluation n=61
Post AtmosAir 4000 n=26
Age range
22–100 (77)
46–95 (80)
Risk score
2–26 (15)
4–33 (18)
Length of stay
1–32 days
2–21 days
Skin intact on admission
90%
92%
Skin intact on discharge
94%
88%
CARE rounding completion
71%
46%
Repositioning required
17%
12%
Number of immobile patients
32%
31%
Number of Grade 2 pressure ulcers
3% (2)
12% (3)
where comorbidities, mobility, continence, dietary habits and skin integrity can all be altered as a person’s age increases. The length of patient stay was assessed to determine if a prolonged stay influenced the pressure ulcer outcome. This was not found to be the case as most patients did not have an extended hospital stay. Two patients out of 61 (3%) developed pressure ulcers during their stay. Root cause analysis of the patients who developed the grade 2 pressure damage found that, despite all the appropriate interventions that were put in place, the patient’s skin still broke down. This is defined as unavoidable pressure damage by the DH where, despite all appropriate interventions, the patient still develops pressure ulceration (DH, 2010). The majority of patients admitted, therefore, did not develop pressure damage despite being high risk. The value of regular skin assessments and the use of a SSKIN bundle approach (Wounds UK, 2013) was clearly demonstrated throughout this evaluation. Interventions such as repositioning were increased in some of the patients to ensure they did not develop any skin breakdown. Ongoing assessment of the skin is necessary in order to detect early signs of pressure damage, especially over bony prominences (NPUAP et al, 2014). The majority of these high-risk patients were able to mobilise and reposition themselves to relieve pressure, however, 18% could not do this for themselves, which again increased their pressure ulcer risk. Wilson (2011) suggests that all patients should be encouraged to reposition themselves, and if the patient remains in bed, their position should be changed regularly. International guidance recommends the use of active mattress systems when frequent movement is not possible (NPUAP et al, 2014). Care rounding, or intentional rounding as it is otherwise known, was introduced as part of a programme of quality improvement initiatives to reduce patient safety incidents such as falls and pressure ulcers (Woodward, 2009; Dix, 2012). It was therefore a valuable way of measuring the quality of care delivered and the impact of the interventions in relation to this evaluation. The frequency of the care rounds was variable as patients were all individually assessed as to their specific needs. It was reassuring to note that the frequency of rounding assessed by
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the nursing staff was delivered as per the assessment outcome. There were no additional dynamic mattresses used during the 6-week period.The two mattresses that were left in place on the ward at the start of the study were reused for patients admitted with pressure ulcers. This was an interesting outcome as there had been a high dependence on their use before the evaluation. It could be suggested that staff were very focused on the need to reposition their patients as they were taking part in an evaluation and this could have influenced the results. However, having a greater knowledge as a result of the enhanced training and support given with the introduction of the AtmosAir 4000 may also have increased their confidence in the product. This question was not asked of the staff when feedback was requested as it was an outcome that developed from the evaluation.
Post-AtmosAir 4000 evaluation Following removal of the AtmosAir 4000 mattresses from the ward, data continued to be collected for a further 2-week period to ascertain whether there was any difference in outcomes. Patients during this part of the study were placed onto the standard hospital high-specification foam mattress with dynamic mattresses available if required. During this time, 26 records were reviewed and the outcomes are described in Table 2. There was very little difference in the outcomes relating to patient age, risk profile and skin condition on admission. Patients in the post-AtmosAir 4000 evaluation had a shorter length of stay, but this had little impact on the outcomes. The main difference in the results was in relation to the completion of the care rounding documentation. More than half of the patient records did not support evidence of completion of the care rounding documentation, which may have been a reason for an increase in the number of pressure ulcers that developed, rather than the change in mattress system.
Staff feedback The AtmosAir 4000 was well received by clinical staff; however, they did find that the TheraTex™ cover was ‘slippery’ compared to the polyurethane covers that are used with most mattresses. The TheraTex material used for the mattress cover assists in the reduction of friction and shear forces; however, staff did not feel this was of particular benefit. The bed sheets did not stay in place especially at the head of the bed when the bed was in an upright position, which proved problematic.The physiotherapists also had concerns regarding the cover as they were finding that patients had an increased tendency to slide when sat on the edge of the bed, so were concerned that this might have the potential to increase fall rates. On discussion with a representative from ArjoHuntleigh it became apparent that a choice of cover was available and, following a small trial of two mattresses with Recovery 5™ multi-way stretch covers over a 2-week period, this met the ward staff ’s and therapists’ needs without increasing the risks for the patients. It is important to take into account the requirements of staff as well as patients, and it was beneficial to both that ArjoHuntleigh offered a choice of cover.
Clinical appraisal The aim of the evaluation was to determine if the AtmosAir
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Table 2. AtmosAir: evaluation and post-evaluation compared
British Journal of Nursing, 2014 (Tissue Viability Supplement), Vol 23, No 20
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PRODUCT EVALUATION 4000 was suitable for use in the prevention of pressure ulcers in patients up to very high risk. This small evaluation identified that no patients, despite their increased clinical risk, developed avoidable pressure ulcers, however, two patients did develop grade-2 pressure damage which were subsequently deemed unavoidable. The AtmosAir 4000 did appear to be suitable for patients up to very high risk of pressure ulceration. The Theratex cover was replaced by the Recovery 5 multi-way stretch cover which then proved to be acceptable to the staff in practice. It is difficult to suggest that the AtmosAir 4000 alone had an impact on pressure ulcer reduction; however this small evaluation does identify that, when combined with regular skin assessment and a repositioning plan, pressure ulcers can be prevented in the high-risk patient group.
Technical appraisal Although the SAT within the AtmosAir 4000 mattress was a new concept for the ward staff, the mattress performed very well. The benefit of a non-powered system was that there was no noise, no cables and the mattress was easily transportable. The maintenance requirements were low compared to dynamic systems as there were no electro-mechanical parts.
Financial appraisal The AtmosAir 4000 is more expensive than the standard high-specification foam mattress in use in the trust; therefore the outcomes had to demonstrate a cost benefit in order to justify the extra expense. RCHT already has non-powered Repose™ overlay mattresses for out-of-hours use. They are only used for a maximum of 48 hours until a dynamic system can be obtained. A similar mattress to the AtmosAir 4000 was also evaluated by staff on the medical ward in the west of Cornwall; however, this was on a smaller scale with only two mattresses available for 2 weeks. The outcomes were very similar; therefore quotes were obtained for both products. There was no difference in the cost of the two mattresses. Based on this evaluation, a reduction in the requirements for dynamic mattresses was identified; this could, therefore, potentially lead to a cost savings This is only a forecast at this stage, and it was recommended that 50 mattresses were purchased to be able to consider a more robust financial appraisal over a longer time period.
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Conclusion This evaluation looking at patient-centred outcomes demonstrated that the mattress system was able to meet the needs of patients with high and very high pressure ulcer risks. In addition, there could be significant savings if they were used as the first-line management of patients with higher levels of risk, especially when the patients were able to be repositioned.These outcomes are supported by work undertaken in Maidstone and Tunbridge Wells NHS Trust where a whole systems approach was taken, including the use of the AtmosAir 4000 mattress, and there was a reduction in pressure ulcer incidence (Bedo, 2013). The Trust also employed other strategies at the same time, which may also have contributed to the results. It must be highlighted that clinical judgement and
British Journal of Nursing, 2014 (Tissue Viability Supplement), Vol 23, No 20
KEY POINTS n Using
a procurement model where clinical, financial and technical information was considered helped to structure the evaluation process
n The
AtmosAir 4000 mattress replacement system was a suitable mattress for patients with a high to very high pressure ulcer risk score when combined with a repositioning plan
n Outcomes
identified that a reduced number of dynamic mattress were used during the evaluation period
n The
use of clinical judgement, timely risk assessment and regular skin inspection should be the cornerstone of any pressure ulcer prevention strategy
appropriate and timely risk assessment, combined with regular skin inspection, should still be seen as the cornerstone of any pressure ulcer prevention programme. The selection of an appropriate support surface is an important and essential part of the care of patients at high to very high risk of pressure ulceration; however, as evidenced through this evaluation, continual reassessment of both the patient’s skin and their ability to reposition can have an impact on the choice of support surface being considered. In the light of these outcomes the RCHT has agreed to purchase the AtmosAir 4000 pressure redistribution mattress replacement system for the two wards in the west of Cornwall. The incidence of pressure ulcers will be monitored along with the use of dynamic systems over the next 6 months to determine if the findings are sustainable over a longer period of time. It is proposed that these outcomes will BJN then be reported in a further publication. Acknowledgements: The author would like to thank the RCHT equipment library staff, the tissue viability link practitioner and the ward nursing team as well as the ward clerk for their help with this evaluation. ArjoHuntleigh supplied the mattresses for the study, however the company was not involved in any other part of this evaluation Conflict of interest: this article was supported by ArjoHuntleigh ArjoHuntleigh (2014) Data on file (available on request) Bedo J (2013) Reducing hospital-acquired pressure damage: an NHS acute trust initiative. Br J Nurs 22(20): S24–8. doi: 10.12968/bjon.2013.22.Sup20.S24 Coleman S, Gorecki C, Nelson EA et al (2013) Patient risk factors for pressure ulcer development: systematic review. Int J Nurs Stud 50(7): 974–1003. doi: 10.1016/j. ijnurstu.2012.11.019 Department of Health (2012) NHS Procurement: Raising our game. DH, London Dix G, Phillips J, Braide M (2012) Engaging staff with intentional rounding. Nurs Times 108(3): 14–6 Moore A (2013) Buying power–an HSJ procurement supplement. Health Service Journal (online) http://tinyurl.com/n3or5au (accessed 20 October 2014) Department of Health (2010) Defining avoidable and unavoidable pressure ulcers. http://tinyurl.com/cprcnn6 (accessed 20 October 2014) National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance (2014) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. 2nd edn. Cambridge Media, Perth National Institute for Health and Care Excellence (2014) Pressure ulcers: prevention and management of pressure ulcers. Clinical Guideline 179. http://tinyurl.com/ lvuf7zx (accessed 20 October 2014) Nichols E (2014) Pressure redistributing mattresses: when, where are they appropriate. Wound Essentials. 9(1): 70–8 Royal College of Nursing (2005) The use of Pressure-Relieving Devices (Beds, Mattresses and Overlays) for the prevention of pressure ulcers in primary and secondary care. RCN, London Wilson M (2011) How to…Ten top tips: preventing pressure ulcers. Wounds International 2(3) Woodward J (2009) Effects of rounding on patient satisfaction and patient safety on a medical-surgical unit. Clin Nurs Spec 23(4):200–6 Wounds UK (2013) Pressure ulcer prevention in the acute setting: Using Aderma in practice. Wounds UK 9(4. Suppl): 1-20
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Key words: Re-positioning ■ Pressure ■ Procurement
P
rocuring pressure-relieving equipment to meet patient and organisational needs can be challenging in today’s NHS, where improving or maintaining quality and affordability are key considerations. Moore (2013) suggests that the NHS has the potential to make substantial savings and improve quality through better procurement; however, in practice the decision-making process can at times be bureaucratic and time consuming. The Department of Health (DH) 2012 published best practice guidance on NHS procurement, which committed to ensuring that procurement was a central feature in driving quality and value in the NHS. It outlined a number of recommendations, including a need to standardise and reduce the variation of products used by the NHS, as well as the need to make more professional use of procurement partners (DH, 2012). Nichols (2014) acknowledges there is a large range of pressure-redistributing mattresses available and that health professionals have a responsibility to make the appropriate choice. Nichols also states that: ‘It is vital that every effort is made to identify those most at risk of developing pressure ulcers and implement interventions to reduce risk, of which pressure-redistributing equipment is a critical element’. (Nichols, 2014: 70)
Heather Newton, Consultant Nurse Tissue Viability, Royal Cornwall Hospitals NHS Trust. Truro, Cornwall Accepted for publication: October 2014
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Background The Royal Cornwall Hospitals NHS Trust (RCHT) has approximately 750 beds on three sites and serves a population of around 450 000, although this can increase during the summer months owing to a higher number of holidaymakers visiting the county. One of the challenges facing the hospital equipment library staff was the provision of pressure-redistributing equipment to the west of the county; to a smaller hospital with approximately 60 medical beds. An increasing number of acutely ill patients were being transferred to this hospital, and transporting the most appropriate pressure-redistributing equipment at the right time was proving to be difficult. The medical wards were heavily reliant on the use of dynamic mattresses and, at times, 40–50% of their patients were being nursed on a dynamic system. This became the main driver for this evaluation as it had become increasingly difficult to meet staff expectations and patient needs. Equipment requirements have historically been based on patient risk-assessment scores to ensure consistency of practice; however, this evaluation has highlighted the importance of skin assessment, patient repositioning and patient mobility in relation to the provision of an appropriate support surface to meet patient needs. In 2005 the Royal College of Nursing (RCN) recommended that consideration be given to the use of alternating or other high-tech pressure-relieving devices as a first-line preventive strategy for those at higher risk of pressure ulcers, when their clinical condition and history indicated a need for a higher level of technology, or when a low-tech device had failed (RCN, 2005). This was recommended despite there being very little evidence to suggest that these higher tech mattresses were any more effective than the lower tech foam alternatives. The recent National Institute of Health and Care Excellence (NICE) clinical guideline 179 (2014) suggests that a high-specification foam mattress for adults with a
© 2014 MA Healthcare Ltd
Abstract
Pressure ulcer prevention is high on the quality agenda and provision of pressure-relieving equipment to meet patients’ needs is an essential part of this process. This can be challenging in today’s NHS and this article explores the evaluation process that supported the procurement of the AtmosAir™ 4000 pressure-redistributing mattress replacement system. Outcomes suggest that, when combined with a robust repositioning and skin assessment regime, the AtmosAir 4000 performed well and dynamic mattress usage was reduced. Further evaluation over a longer period of time will be undertaken in future.
This article will explore a procurement process involving clinical, technical and financial appraisal to support decision making in relation to the purchase of the AtmosAir™ 4000 reactive pressure-redistribution mattress replacement system for an acute NHS trust in Cornwall. The mattress evaluation was undertaken over a 6-week period on one acute medical ward. Following removal of the mattress, there was a post-evaluation period of 2 weeks where the normal hospital high-specification foam mattresses were used. During this time, patient outcomes continued to be measured.
British Journal of Nursing, 2014 (Tissue Viability Supplement), Vol 23, No 20
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 24, 2015. For personal use only. No other uses without permission. . All rights reserved.
© ArjoHuntleigh
Figure 1. AtmosAir 4000 mattress replacement system
Figure 2. AtmosAir 4000 mattress replacement system: a cut-away section of the mattress showing the air cells and the foam
pressure ulcer may be an option and, if this is insufficient, the use of a dynamic support system should be considered. This appears to be moving away from the notion of using a dynamic mattress system as the first-line approach for patients with pressure ulcers or at very high risk, which is anecdotally common across many NHS trusts. Any decisions taken should, however, be based on an accurate risk assessment and clinical judgement. The National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and the Pan Pacific Pressure Injury Alliance (PPPIA) (NPUAP et al, 2014), however, suggest that patients at higher risk who cannot be repositioned frequently should be cared for on an active alternating support system. This strengthens the need to establish if a patient can reposition independently or how much assistance they need to reposition rather than placing all high-risk patients on a dynamic support system automatically on admission to hospital, just because of their risk score. This does not remove the need to use an active alternating mattress system where appropriate; however, it does raise the question of at what stage and for which patients they would best be used for. Dynamic pressure-redistributing mattresses have been an integral part of the pressure-relieving equipment portfolio for the RCHT alongside the use of static foam mattresses;
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AtmosAir 4000 The AtmosAir™ 4000 is a non-powered pressure redistribution mattress replacement system which uses Self Adjusting Technology™ (SAT).The mattress is a combination of pressure reducing foam, air cells and SAT valves. The non-powered longitudinal air cells and SAT valves automatically and instantly regulate the internal cushion pressures in reaction to body movement. As weight is applied to the mattress, air is displaced from the independent cells and exhausted via the tube set.This allows for a greater level of immersion and envelopment into the surface, further reducing tissue interface pressures as shown in Figure 1 and Figure 2. The AtmosAir 4000 mattress replacement system offers advanced features and benefits that provide clinically effective pressure redistribution and optimised patient comfort (ArjoHuntleigh, 2014), however, there is limited evidence that they can reduce the dynamic mattress requirements of an organisation. If they were shown to be effective at reducing pressure for high- to very high-risk patients in association with a robust repositioning plan, this would potentially mean a significant cost saving for an organisation, as well as maintaining the quality of care for patients. Dynamic systems could then be reserved for the vulnerable, highest risk patients who would benefit from active offloading of the tissues or who are unable to be manually repositioned. The clinical benefits of the mattress system were unclear, as the supporting evidence presented was largely from case studies that were based on single facility findings only (ArjoHuntleigh data on file, 2014). A clinical evaluation proposal was therefore discussed with ArjoHuntleigh that aimed to provide evidence to support its claims regarding product effectiveness in an acute clinical setting.
Evaluation process The aim of the evaluation was to assess the performance of the AtmosAir 4000, to determine its suitability for preventing pressure ulcers in patients with up to a very high risk of developing pressure ulcers. In addition, the number of dynamic mattresses in use during the evaluation period was also measured to see if there was any reduction in requirements and what impact this may have had. Any patient that had pressure damage was excluded from the evaluation at this stage as there was little evidence to
© 2014 MA Healthcare Ltd
© ArjoHuntleigh
however, the evaluation has challenged this historical custom and questioned the need for this approach. The trust owns approximately 140 dynamic mattresses and it was becoming harder to justify the need to spend money on new mattresses when evidence demonstrating their effectiveness was inconclusive. The challenge for the organisation and in particular the tissue viability and equipment library teams was to explore an alternative solution to the management of high-risk patients in the west of the county that would be efficient and effective. It was at this stage that the AtmosAir 4000 reactive pressure redistribution mattress replacement system was identified as a possible solution. The mattress was chosen because it had been introduced into another South West regional hospital with good outcomes.
British Journal of Nursing, 2014 (Tissue Viability Supplement), Vol 23, No 20
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 24, 2015. For personal use only. No other uses without permission. . All rights reserved.
PRODUCT EVALUATION
© 2014 MA Healthcare Ltd
suggest the benefits of supporting healing of pressure ulcers or deterioration of damage. A request to undertake the product evaluation was tabled at the trust procurement group meeting. This included the rationale for the evaluation, the proposed method of evaluation and essential outcome measurement criteria. This included the mattress suitability for use with high- to very high-risk patients, the ability to maintain skin integrity and the ease of use by staff. Outcomes were measured in relation to clinical and technical performance and a financial appraisal took place. The procurement group supported the request. The clinical criteria for the evaluation are shown in Box 1. The evaluation took place over a 6-week period between February and April 2013. ArjoHuntleigh provided 25 mattresses, 23 of which were given to patients from the start of the evaluation. A total of 8 dynamic and 15 static foam mattresses were removed from the ward and 2 dynamic mattresses were left in situ for patients with existing pressure ulcers. On the day of the mattress delivery, all patients had their pressure ulcer risk and skin condition reassessed by nursing staff to ensure they were suitable for transfer to the AtmosAir 4000. Those patients with existing pressure ulceration (n=2) were not transferred onto the AtmosAir 4000, but continued to be nursed on their existing dynamic therapy surface. Staff training on the use of the mattress was provided by ArjoHuntleigh and support was offered throughout the evaluation process. Staff had already received training on risk assessment and skin assessment; however, the link practitioner continued to provide staff support. A record of each patient that was admitted and discharged throughout the evaluation period was made by the ward clerk, to ensure that the correct patient records were reviewed at the end of the evaluation. Outcomes were measured through a retrospective review of the patient records undertaken by the author. All of the outcomes relating to the criteria in Box 1 were recorded and analysed. The author chose to measure outcomes using the specified clinical data from the patient’s notes rather than asking the staff to complete an evaluation form, as it was felt that a higher number of patients’ data would be captured using this methodology. The author has found in the past that ward evaluation forms completed by busy ward staff often have a low return rate. However, this relied on the data being available within the patient record. Risk and skin assessments, together with mobility status, were reviewed along with patient’s demographic details and length of stay. Care delivered was analysed using the patient’s care plan and evaluation record. Nurses and therapists were also asked to provide feedback on the use of the mattress via an evaluation form. There were five responses in total; three from nurses and two from physiotherapists. The information was collated by the tissue viability link practitioner.
Results In total 62 patient records were reviewed. A total of 61 records were fully completed with all the required data, with one record incomplete. The results presented therefore will be out of 61 patients. Patients with existing pressure
British Journal of Nursing, 2014 (Tissue Viability Supplement), Vol 23, No 20
Box 1. Criteria for evaluation ■ Patient
age ulcer risk score using the Waterlow score ■ Length of hospital stay ■ Skin assessment on admission ■ Skin assessment throughout the hospital stay ■ Patient’s repositioning requirements ■ Care round frequency; assessed frequency of checking the patient comfort, toileting needs, position and nutritional requirements. ■ Patient mobility ■ Number of pressure ulcers that developed during the evaluation period ■ Pressure
Table 1. Results of AtmosAir evaluation Evaluation criteria
Outcomes
Patient age range
Age 22–100. Mean age 77
Waterlow risk assessment scores
Waterlow score range from 2–26 Mean 15
Length of patient stay
Between 1 and 32 days. Average stay 9 days
Number of patients admitted with intact skin
56/61 (92%) admitted with intact skin
Number of patients discharged with intact skin
54/61 (89%) discharged with intact skin
Number of patients who developed pressure ulcers
2/61 (3%) developed unavoidable pressure ulcers
Assessment of need for repositioning
100% of patients assessed
Number of patients who could reposition 50/61 (82%) could reposition themselves themselves in bed Number of patients requiring assistance to reposition
11/61 (18%) required assistance to reposition
Number of patients who were fully mobile
15/61 (24%) of patients were fully mobile
Number of patients requiring minimal assistance to mobilise
26/61 (43%) of patients needed minimal assistance
Number of patients who needed help to mobilise
20/61 (33%) of patients required help to mobilise
Care round frequency (also known as intentional rounding)
63% of patients required either hourly, 2-hourly or 4-hourly care rounding 32% required daily care rounding 5% of patients did not require care rounding
Number of dynamic mattresses used during the evaluation period
Two dynamic mattresses were used during the evaluation period for patients with pressure ulcers
ulcers were not placed on the trial mattresses and were therefore not reviewed. See Table 1 for results.
Discussion The average age of the patients in this evaluation was 77 and therefore deemed at risk of developing pressure ulcers, especially when other factors were also considered such as mobility, nutritional status, and comorbidities. Patients’ age, if over 65, is recognised as a risk factor for pressure ulceration in the presence of other risk factors (Coleman et al, 2013). The majority of patients were at high risk of pressure ulcer development. This can have a direct link to the patient’s age,
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CRITERIA
AtmosAir 4000 evaluation n=61
Post AtmosAir 4000 n=26
Age range
22–100 (77)
46–95 (80)
Risk score
2–26 (15)
4–33 (18)
Length of stay
1–32 days
2–21 days
Skin intact on admission
90%
92%
Skin intact on discharge
94%
88%
CARE rounding completion
71%
46%
Repositioning required
17%
12%
Number of immobile patients
32%
31%
Number of Grade 2 pressure ulcers
3% (2)
12% (3)
where comorbidities, mobility, continence, dietary habits and skin integrity can all be altered as a person’s age increases. The length of patient stay was assessed to determine if a prolonged stay influenced the pressure ulcer outcome. This was not found to be the case as most patients did not have an extended hospital stay. Two patients out of 61 (3%) developed pressure ulcers during their stay. Root cause analysis of the patients who developed the grade 2 pressure damage found that, despite all the appropriate interventions that were put in place, the patient’s skin still broke down. This is defined as unavoidable pressure damage by the DH where, despite all appropriate interventions, the patient still develops pressure ulceration (DH, 2010). The majority of patients admitted, therefore, did not develop pressure damage despite being high risk. The value of regular skin assessments and the use of a SSKIN bundle approach (Wounds UK, 2013) was clearly demonstrated throughout this evaluation. Interventions such as repositioning were increased in some of the patients to ensure they did not develop any skin breakdown. Ongoing assessment of the skin is necessary in order to detect early signs of pressure damage, especially over bony prominences (NPUAP et al, 2014). The majority of these high-risk patients were able to mobilise and reposition themselves to relieve pressure, however, 18% could not do this for themselves, which again increased their pressure ulcer risk. Wilson (2011) suggests that all patients should be encouraged to reposition themselves, and if the patient remains in bed, their position should be changed regularly. International guidance recommends the use of active mattress systems when frequent movement is not possible (NPUAP et al, 2014). Care rounding, or intentional rounding as it is otherwise known, was introduced as part of a programme of quality improvement initiatives to reduce patient safety incidents such as falls and pressure ulcers (Woodward, 2009; Dix, 2012). It was therefore a valuable way of measuring the quality of care delivered and the impact of the interventions in relation to this evaluation. The frequency of the care rounds was variable as patients were all individually assessed as to their specific needs. It was reassuring to note that the frequency of rounding assessed by
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the nursing staff was delivered as per the assessment outcome. There were no additional dynamic mattresses used during the 6-week period.The two mattresses that were left in place on the ward at the start of the study were reused for patients admitted with pressure ulcers. This was an interesting outcome as there had been a high dependence on their use before the evaluation. It could be suggested that staff were very focused on the need to reposition their patients as they were taking part in an evaluation and this could have influenced the results. However, having a greater knowledge as a result of the enhanced training and support given with the introduction of the AtmosAir 4000 may also have increased their confidence in the product. This question was not asked of the staff when feedback was requested as it was an outcome that developed from the evaluation.
Post-AtmosAir 4000 evaluation Following removal of the AtmosAir 4000 mattresses from the ward, data continued to be collected for a further 2-week period to ascertain whether there was any difference in outcomes. Patients during this part of the study were placed onto the standard hospital high-specification foam mattress with dynamic mattresses available if required. During this time, 26 records were reviewed and the outcomes are described in Table 2. There was very little difference in the outcomes relating to patient age, risk profile and skin condition on admission. Patients in the post-AtmosAir 4000 evaluation had a shorter length of stay, but this had little impact on the outcomes. The main difference in the results was in relation to the completion of the care rounding documentation. More than half of the patient records did not support evidence of completion of the care rounding documentation, which may have been a reason for an increase in the number of pressure ulcers that developed, rather than the change in mattress system.
Staff feedback The AtmosAir 4000 was well received by clinical staff; however, they did find that the TheraTex™ cover was ‘slippery’ compared to the polyurethane covers that are used with most mattresses. The TheraTex material used for the mattress cover assists in the reduction of friction and shear forces; however, staff did not feel this was of particular benefit. The bed sheets did not stay in place especially at the head of the bed when the bed was in an upright position, which proved problematic.The physiotherapists also had concerns regarding the cover as they were finding that patients had an increased tendency to slide when sat on the edge of the bed, so were concerned that this might have the potential to increase fall rates. On discussion with a representative from ArjoHuntleigh it became apparent that a choice of cover was available and, following a small trial of two mattresses with Recovery 5™ multi-way stretch covers over a 2-week period, this met the ward staff ’s and therapists’ needs without increasing the risks for the patients. It is important to take into account the requirements of staff as well as patients, and it was beneficial to both that ArjoHuntleigh offered a choice of cover.
Clinical appraisal The aim of the evaluation was to determine if the AtmosAir
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Table 2. AtmosAir: evaluation and post-evaluation compared
British Journal of Nursing, 2014 (Tissue Viability Supplement), Vol 23, No 20
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PRODUCT EVALUATION 4000 was suitable for use in the prevention of pressure ulcers in patients up to very high risk. This small evaluation identified that no patients, despite their increased clinical risk, developed avoidable pressure ulcers, however, two patients did develop grade-2 pressure damage which were subsequently deemed unavoidable. The AtmosAir 4000 did appear to be suitable for patients up to very high risk of pressure ulceration. The Theratex cover was replaced by the Recovery 5 multi-way stretch cover which then proved to be acceptable to the staff in practice. It is difficult to suggest that the AtmosAir 4000 alone had an impact on pressure ulcer reduction; however this small evaluation does identify that, when combined with regular skin assessment and a repositioning plan, pressure ulcers can be prevented in the high-risk patient group.
Technical appraisal Although the SAT within the AtmosAir 4000 mattress was a new concept for the ward staff, the mattress performed very well. The benefit of a non-powered system was that there was no noise, no cables and the mattress was easily transportable. The maintenance requirements were low compared to dynamic systems as there were no electro-mechanical parts.
Financial appraisal The AtmosAir 4000 is more expensive than the standard high-specification foam mattress in use in the trust; therefore the outcomes had to demonstrate a cost benefit in order to justify the extra expense. RCHT already has non-powered Repose™ overlay mattresses for out-of-hours use. They are only used for a maximum of 48 hours until a dynamic system can be obtained. A similar mattress to the AtmosAir 4000 was also evaluated by staff on the medical ward in the west of Cornwall; however, this was on a smaller scale with only two mattresses available for 2 weeks. The outcomes were very similar; therefore quotes were obtained for both products. There was no difference in the cost of the two mattresses. Based on this evaluation, a reduction in the requirements for dynamic mattresses was identified; this could, therefore, potentially lead to a cost savings This is only a forecast at this stage, and it was recommended that 50 mattresses were purchased to be able to consider a more robust financial appraisal over a longer time period.
© 2014 MA Healthcare Ltd
Conclusion This evaluation looking at patient-centred outcomes demonstrated that the mattress system was able to meet the needs of patients with high and very high pressure ulcer risks. In addition, there could be significant savings if they were used as the first-line management of patients with higher levels of risk, especially when the patients were able to be repositioned.These outcomes are supported by work undertaken in Maidstone and Tunbridge Wells NHS Trust where a whole systems approach was taken, including the use of the AtmosAir 4000 mattress, and there was a reduction in pressure ulcer incidence (Bedo, 2013). The Trust also employed other strategies at the same time, which may also have contributed to the results. It must be highlighted that clinical judgement and
British Journal of Nursing, 2014 (Tissue Viability Supplement), Vol 23, No 20
KEY POINTS n Using
a procurement model where clinical, financial and technical information was considered helped to structure the evaluation process
n The
AtmosAir 4000 mattress replacement system was a suitable mattress for patients with a high to very high pressure ulcer risk score when combined with a repositioning plan
n Outcomes
identified that a reduced number of dynamic mattress were used during the evaluation period
n The
use of clinical judgement, timely risk assessment and regular skin inspection should be the cornerstone of any pressure ulcer prevention strategy
appropriate and timely risk assessment, combined with regular skin inspection, should still be seen as the cornerstone of any pressure ulcer prevention programme. The selection of an appropriate support surface is an important and essential part of the care of patients at high to very high risk of pressure ulceration; however, as evidenced through this evaluation, continual reassessment of both the patient’s skin and their ability to reposition can have an impact on the choice of support surface being considered. In the light of these outcomes the RCHT has agreed to purchase the AtmosAir 4000 pressure redistribution mattress replacement system for the two wards in the west of Cornwall. The incidence of pressure ulcers will be monitored along with the use of dynamic systems over the next 6 months to determine if the findings are sustainable over a longer period of time. It is proposed that these outcomes will BJN then be reported in a further publication. Acknowledgements: The author would like to thank the RCHT equipment library staff, the tissue viability link practitioner and the ward nursing team as well as the ward clerk for their help with this evaluation. ArjoHuntleigh supplied the mattresses for the study, however the company was not involved in any other part of this evaluation Conflict of interest: this article was supported by ArjoHuntleigh ArjoHuntleigh (2014) Data on file (available on request) Bedo J (2013) Reducing hospital-acquired pressure damage: an NHS acute trust initiative. Br J Nurs 22(20): S24–8. doi: 10.12968/bjon.2013.22.Sup20.S24 Coleman S, Gorecki C, Nelson EA et al (2013) Patient risk factors for pressure ulcer development: systematic review. Int J Nurs Stud 50(7): 974–1003. doi: 10.1016/j. ijnurstu.2012.11.019 Department of Health (2012) NHS Procurement: Raising our game. DH, London Dix G, Phillips J, Braide M (2012) Engaging staff with intentional rounding. Nurs Times 108(3): 14–6 Moore A (2013) Buying power–an HSJ procurement supplement. Health Service Journal (online) http://tinyurl.com/n3or5au (accessed 20 October 2014) Department of Health (2010) Defining avoidable and unavoidable pressure ulcers. http://tinyurl.com/cprcnn6 (accessed 20 October 2014) National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance (2014) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. 2nd edn. Cambridge Media, Perth National Institute for Health and Care Excellence (2014) Pressure ulcers: prevention and management of pressure ulcers. Clinical Guideline 179. http://tinyurl.com/ lvuf7zx (accessed 20 October 2014) Nichols E (2014) Pressure redistributing mattresses: when, where are they appropriate. Wound Essentials. 9(1): 70–8 Royal College of Nursing (2005) The use of Pressure-Relieving Devices (Beds, Mattresses and Overlays) for the prevention of pressure ulcers in primary and secondary care. RCN, London Wilson M (2011) How to…Ten top tips: preventing pressure ulcers. Wounds International 2(3) Woodward J (2009) Effects of rounding on patient satisfaction and patient safety on a medical-surgical unit. Clin Nurs Spec 23(4):200–6 Wounds UK (2013) Pressure ulcer prevention in the acute setting: Using Aderma in practice. Wounds UK 9(4. Suppl): 1-20
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