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7th EPUAP Open Meeting, Tampere,
Finland
Pressure Ulcer Prevention and Management, Poster Abstracts, September
2003
CLINICAL BENCH-MARKING – MAKING A DIFFERENCE THROUGH TEAM
WORK
Jackie Stephen-Haynes RGN DN DipH BSc(Hons) Masters in Clinical Nursing
Lecturer and Practitioner in Tissue Viability for Worcestershire Primary
Care Trusts and University College Worcester. Stourport Health centre,
Worcester St, Stourport on Severn, Worcestershire. DY13 8EH Tel: 07775–792775
Jackies_h@btopenworld.com
Introduction
The aim of this presentation is to highlight the constructive effect clinical
benchmarking can have in making a difference to pressure ulcer prevention
and management. Clinical benchmarking was defined as a process through
which best practice is identified and continuous improvement pursued through
comparison and sharing.
Method
A project was undertaken in the three Worcestershire Primary Care Trusts
with representation from each of the six community hospitals and each
of the nine areas within the county. Clinical benchmarking begins to challenge
and legitimises the fundamentals of nursing practice. It does this by
questioning our application of evidence-based healthcare ‘what we
know’ and ‘what we do’.
To facilitate the implementation of benchmarking with a determination
to improve clinical practice I have worked with the Institute of reflective
practice utilising their co-learning in practice as a framework to develop
the team. We have undertaken a detailed understanding of the culture of
the workplace and factors that assist or hinder them in taking practice
forward, identified their own position in terms of taking practice forward
in Tissue Viability, identified how it was possible to gain help from
colleagues within the team.
Results
The team developed a mission statement; ground rules and audit tools based
upon the clinical benchmarks. All team members have undertaken an audit
of the 9 clinical benchmark factors within each community hospital and
in each area of the community.
The audits have clearly identified the areas for practice that can be
improved and staff have acknowledged that some changes make more effective
use of resources and that not all changes require extra funding.
Each team has developed a Clinical-benchmarking folder of evidence, which
includes National and local policy and guidelines, Clinical benchmarking
audit tools, results, implications for practice, practical implementation,
education and research, and patient information leaflet.
Summary
Together the team is utilising clinical benchmarking to take practice
forward. A plan has been developed from both a strategic and practical
implementation perspectives. The audit have demonstrated that we have
made a difference in pressure ulcer prevention and management and key
areas for future improvement have been identified.
DEVELOPMENT OF AN EASY DECISION TREE FOR THE SELECTION
OF A COMFORTABLE SUPPORT SURFACE WITHIN THE SCOPE OF THE GERMAN HEALTH
SYSTEM FOR THE HOME CARE PATIENTS
P Diesing, D Hochmann and U Boenick.
Technical University of Berlin, Department if Biomechanical Engineering,
Berlin, Germany
Paticipants of the BVMed – Workgroup – U Gabler (ADL), A Bugs
(Air-systems), H-J Flohr (Gerromed), E Goller (Hill-Rom), B Billen (ROHO),
D Piossek (BV Med), P Diesing (TU Berlin)
Introduction
German law defines the rules supplying support surfaces to non-hospital
patients with a high risk for pressure ulcer in the SGB V (Sozialgesetzbuch
V). This law stipulates that for the reimbursement of the costs for
a support surface, the product must be included in the German list of
technical aids (Hilfsmittelverzeichnis), which was developed by the health
insurances. The classification for this list is fixed by the organisation
of the health insurances. The essential question, which support surface
is the right one for which patient is not answered by this documentation.
Because of a revision to this list, the companies selling those products
have designed, under the leadership of the BVMed and the TU Berlin, a
decision tree, a new classification and a glossary, which should help
the health insurances to select the right support surface for the patient.
Methods
The main idea behind the classification is that the decision for a support
surface should be based on the risk of developing a pressure ulcer or
on the risk that a pressure ulcer will not heal. It should not generally
be based on the grade of an existing ulcer. This should help avoiding
high costs with pressure ulcers by having an adapted prevention. The formal
decision tree is based on the decision tree used in the USA for the last
year. For the support surfaces, it is differentiated between:
- Mattresses vs. overlay
- Powered vs. non-powered devices
- Special features within the different groups.
The decision tree and the decision rules are worked out
in meetings with the companies AirSystems, ADL, Gerro-Med, Hill-Rom and
ROHO. The responsible person from the BVMed and scientists from the TU
Berlin also participated in this workgroup.
Results
As a result of this process, a decision tree was established with something
similar to an instruction for use, a classification of support surfaces
based on technical features of the products, and a glossary which defines
and explains the products.
This information is bundled in a brochure, which should be printed by
the BVMed and should also be available on the Internet.
The rules used for the decision tree could not be fixed by evidence-based
medicine, but rather by the consensus of the clinical experience of the
participants.
Summary
The presented classification is intended to lead in the direction of an
evidence-based decision tree for support surfaces. However, with the currently
existing studies it is not possible to define rules that allow an accurate
evidence-based choice of a support surface.
For the health insurance companies this decision tree allows to choose
a product based on a clinical consensus. In the future the rules should
be checked by several randomised trials.
Contact: diesing@bmt1.kf.tu-berlin.de
A NEW MODULAR TEST SYSTEM FOR THE MECHANICAL AND
MICROCLIMATIC EVALUATION OF SUPPORT SURFACES
P Diesing, D Hochmann and U Boenick.
Technical University of Berlin, Department if Biomechanical Engineering,
Berlin, Germany.
Introduction
The evaluation of the mechanical and microclimatic properties of support
surfaces is important for various groups. The manufacturer wants to optimise
his products for the best pressure relief and good microclimatic properties.
The nurse in the hospital wants to know if a system works correctly with,
for example, obese or heavily perspiring patients. The health insurances
want to pay only for products that have a clinical effect. Due to the
lack of clinical studies for all products in this field, these groups
requested standardised laboratory tests to predict the clinical effect
of a system. In answer to this request, a project was initiated at the
TU Berlin (funded by the Otto-Bock-Stiftung) to perform clinical tests,
construct test equipment and try to correlate the results to a new test
standard for support surfaces.
Methods
The main idea was to develop a test machine that is able to perform all
necessary tests to characterize support surfaces. Due to its modular design,
the machine can test both cushions and mattresses. The machine consists
of a frame with a controlled driving unit and interchangeable modules
for the different parameters. The modules should be designed for the mechanical
and thermal stresses with pressure, shear, temperature and humidity. Those
parameters should be controlled within physiologic and pathologic ranges.
The modules are designed to be as simple as possible and should simulate
the conditions of a human body in a standardized and reproducible way.
The limit values have been acquired in clinical tests of geriatric patients.
The effect of these experiments is detected by the same sensor that was
used beforehand for the acquisition of the clinical data
Results
The test machine built worked as intended. An important feature is that
the output of the machine could be adapted in a wide range to the requirements
of the evaluation. Even though the conditions at the patient cannot be
emulated in a completely physiological way, the resulting ranking was
the same as in volunteer trials. The tests characterize the support surfaces
in terms of their microclimate and mechanical properties. On the other
hand, the first results showed that the standard deviation of these properties
in this test procedure is much smaller than that of volunteer tests. This
makes it much easier to create a reproducible standard for those tests.
Summary
The developed test machine increases the reproducibility of the evaluation
results for support surfaces. The device can be easily adapted to different
test procedures for different parameters. The use of the same sensors
as in the clinical tests for microclimate and pressure mapping eliminates
errors in the measurement technique. Based on the results of the clinical
trial with geriatric patients, which should be finished at the end of
the year, a classification for the different parameters should be adapted.
This classification should improve the prediction of which support surfaces
can improve the outcome of the patients.
Contact: diesing@bmt1.kf.tu-berlin.de
A CLINICAL EVALUATION OF THE KCI PROFICARE MATTRESS
REPLACEMENT SYSTEM
Fiona Collins
Tissue Viability Consultancy Services Ltd, Eastbourne, England
Introduction
It is widely accepted that providing an appropriate pressure reliving
mattress is essential for those people who are very high risk or who have
established pressure ulcer damage. The KCI Proficare Mattress Replacement
System can provide both dynamic alternating and static pressure management
and is intended to help prevent and manage pressure ulcers while optimizing
comfort. It consists of 17 individual air cells which can be removed during
treatment to optimize pressure relief, surrounded by a breathable waterproof
two-way stretch cover.
Method
The aim of the clinical evaluation was to examine the effect of the KCI
Proficare Mattress Replacement System on the healing of pressure ulcer
damage. Five nursing home residents with established pressure damage consented
to evaluate the Mattress over an eight week period. The wound(s) of each
resident which were predominantly Grade 3 and 4 (EPUAP, 2001) were photographed
prior to the evaluation commencing. The resident’s existing mattress
was replaced with a KCI Proficare Mattress Replacement System. The wounds
were photographed on day two and thereafter weekly, for eight weeks. Medical
and demographic information was obtained.
Results
The pressure ulcers in all of the residents demonstrated healing during
the evaluation period, with one resident’s ulcer completely closing.
One of the residents whose wound was making good progress died suddenly
during week seven of the evaluation. All of the residents reported the
mattress to be comfortable and staff comments concurred with this opinion.
None of the mattresses suffered mechanical failure during the evaluation
period.
Summary
This small evaluation would suggest that the KCI Proficare Mattress Replacement
System can be effective at assisting in the healing of severe pressure
damage in high-risk subjects. Furthermore, all of the residents who used
the Mattress informally reported the mattress to be comfortable. Staff
comments were also extremely positive.
These results are encouraging, although it is unwise to draw any firm
conclusions from such a small population. A larger study may be indicated
in order to provide comparative evidence.
References
EPUAP (2001) Pressure ulcer classification.
EPUAP Business Office. Wound Healing Unit.
Department of Dermatology. Churchill Hospital. Oxford.
www.epuap.org/gltreatment.html
PORTABLE NMR SPECTROSCOPY OF THE SOFT TISSUES:
A NORMATIVE STUDY
Duncan Bain, John Henton, Graham Nicholson and Martin Ferguson-Pell
Centre for Disability Research and Innovation, University College London
Introduction
Technologies are now emerging to assist in the early identification of
superficial pressure ulcers 1. There is still a need for diagnosis of
pressure ulcers hat originate deeper in the tissues. Nuclear magnetic
resonance (NMR) provides the potential for non-invasive examination of
the tissues beneath the skin. Parameters relevant to pressure ulcers,
such as ischaemia, oedema, and inflammatory responses, have previously
been examined for other purposes using NMR. Alikacem et al2 examined inflammatory
responses to encapsulated foreign bodies using NMR, and found that certain
NMR parameters correlated strongly with blood activation studies and histology.
Klein3 evaluated the viability of skin flaps using magnetic resonance
spectroscopy. Richard et al4 examined age-related modifications of MRI
parameters in the skin in vivo, relating the changes to structural deterioration.
Physico-chemical and morphologic parameters of skin layers and subcutaneous
tissue in the lymphedematous limb have been studied in vivo using magnetic
resonance imaging5. Problems with this approach hitherto have been as
follows: MRI is an expensive procedure, both in terms of capital and consumables.
This limits not only its use for bulk data-gathering, but also its ultimate
application as a routine screening tool for pressure ulcers.
NMR spectroscopy, conversely, is much less expensive, but has historically
only been suitable for in vitro samples, owing to the small size of available
chambers. Recently, a mobile NMR device similar to a geological bore-hole
probe has been developed for applications in materials science6. Using
a small, hand-held probe incorporating permanent magnets, inhomogeneous
polarising and radio-frequency magnetic fields are applied to arbitrarily
large samples from one side.7 To examine the usefulness of this technology
for early identification of sub-dermal pressure ulcers, and for the characterisation
of abnormal properties of soft tissues, a normative study was conducted
to establish the range of values of NMR parameters that occur in normal
tissues in different subjects, and in different parts of the body.
Methods
A hand-held permanent magnet surface coil was used to measure NMR parameters
in the skin and underlying tissues of twenty healthy subjects. Measurements
were made on the sacrum, buttocks, scapula, forearm, trochanter, and heels.
T2 was measured at the surface, and at 5mm depth.
Results
Inter-subject variations in normal subjects are of lower order than intra-subject
inter-body-site variations. The NMR map of the body may, therefore, be
considered relatively generalisable for the normal population. T2 at 5mm
depth was sensitive to body-fat, and correlated with body mass index.
Earlier work indicates that NMR parameters in incipient pressure sores
fall outside the range measured in normal subjects.
Summary
The applicants now propose to conduct an extensive study of the NMR parameters
associated with pressure ulcers, compared with those of normal tissue.
This process will generate a normative database, document the natural
history of the pressure ulcer from an entirely unseen perspective, and
identify possible strategies for prediction, early identification, and
improved intervention decisions.
References
1. Bain D, Ferguson-Pell M, Mcleod A: Skin evaluation apparatus. World
patent WO0060349
2. Alikacem N, Strman PW, Marois Y, Jakubiec B, Roy R, and Guidoin R.
Non-invasive follow-up of tissue encapsulation of foreign materials. A
magnetic resonance imaging and spectroscopy breakthrough. ASAIO J
1995 Jul-Sep; 41(3): M617–24.
3. Klein HW, Gourley IM. Use of magnetic resonance spectroscopy in the
evaluation of skin flaps. Ann Plast Surg Jun; 20(6):547-551
4. Richard S, Querleux B, Bittoun J, Jolivet O, Idy-Peretti I, and de
Lacharriere O, Characterisation of the skin in vivo by high resolution
magnetic resonance imaging: water behaviour and age-related effects.
5. Idy-Peretti I, Bittoun J, Alliot FA, Richard SB, Querleux BG, and Cluzan
RV. Lymphedematous skin and subcutis: in vivo high resolution magnetic
imaging evaluation. J Invest Dermatol 1998 May; 110(5): 782–787.
6. Blumich B, Blumler P, Eidmann G, Guthausen A, Haken R, Schmitz U, Saito
K, and Zimmer G. The NMR-mouse: construction, excitation, and applications.
Magn Reson Imaging. 1998 Jun–Jul; 16(5–6): 479–84
7. Zimmer G, Guthausen A, and Blumich B. Characterization of cross-link
density in technical elastomers by the NMR-MOUSE. Solid State Nucl
Magn Reson. 1998 Sep; 12(2–3): 183–90.
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