Danielle Collins, Prince of Wales Hospital - Interventions & seating options for pressure management
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Danielle Collins, Prince of Wales Hospital - Interventions & seating options for pressure management



Danielle Collins, Occupational Therapist, Seating Clinic, Prince of Wales Hospital delivered the presentation at 2013 Reducing Avoidable Pressure Injuries Conference. ...

Danielle Collins, Occupational Therapist, Seating Clinic, Prince of Wales Hospital delivered the presentation at 2013 Reducing Avoidable Pressure Injuries Conference.

The 2013 Reducing Avoidable Pressure Injuries Conference featured a comprehensive case study led program covering topics such as prevention of pressure injuries during the surgical patient journey and in people with Spinal Cord Injuries, meeting Standard 8, translating research into clinical practice and more.

For more information about the event, please visit: http://www.informa.com.au/pressureinjuries13



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Danielle Collins, Prince of Wales Hospital - Interventions & seating options for pressure management Danielle Collins, Prince of Wales Hospital - Interventions & seating options for pressure management Presentation Transcript

  • Prepared by Danielle Collins and Victoria Sim Occupational Therapists Prince of Wales Hospital Seating Clinic September 2013 More than just a chair: The role of a seating clinic in pressure injury prevention and management
  • Outline What is Seating Clinic? How & what do we assess? Interventions & seating options for pressure management Case Studies
  • What is Seating Clinic?
  • Our Clients People with ‘complex seating’ problems – have or are at risk of developing postural problems or pressure sores. People from any diagnostic group eg.MS, Spinal Injury, Stroke, Cerebral Palsy People from any geographical area – but we are a hospital based service
  • 4 Seating Clinic Process: Assessment and goals setting with client Fabrication / fitting of seating solutions, Trials Review, Modification, Ongoing review, application for funding. Client centred goals
  • Seating Anatomy 101 IT = Ischial tuberosity GT= Greater Trochanter Sacrum Coccyx ASIS = anterior superior iliac spine
  • The initial assessment –2 hrs History- whole of day approach Discussion of problems identified by client and referrer Discuss pressure injury history Postural assessment Pressure mapping if appropriate
  • 7 Postural Assessment Hands on assessment – In wheelchair – Lying on plinth – Sitting on edge of plinth – Reflex / spasm pattern – Pain – Functional seating needs
  • Pressure Ax- More than just a chair! Seating system- cushion and backrest Commode Other seating surfaces Posture and postural changes Transfers Sitting time- total Clothing choices Pressure relief techniques Spasm Moisture
  • Intervention Cushions- commercial and customised Backrests- commercial and customised Education on pressure relieving techniques Pressure mapping
  • Solutions- Commercial Cushion Off the shelf Modified
  • 11 Solutions- Commercial Backrests Off the shelf Modified
  • 12 Examples of customised mods
  • Case Study- Trish
  • T4 AIS A paraplegic since 2000 following a fall PMHx: diabetes, chronic back pain Lives rurally with daughter, carer and carer’s partner Previously independent with manual wheelchair mobility History of pressure injuries to left IT and GT Previous surgical intervention(2008)- debridement, VAC dressing and skin graft- 1year hospital admission Background
  • Presenting problems Sacrum- stage 2Left GT- stage 4
  • Problems identified History of poor skin integrity, scar tissue and tethered areas Multiple pressure injuries- no safe lying surface but prone Variable compliance with bedrest secondary to shoulder and neck pain and difficult due to hip contracture Conservative management vs surgical management Difficult home situation Risk of further skin breakdown if return to seating in manual wheelchair
  • Bedrest positioning
  • Skin post procedures- ready for seating!
  • Once healed- equipment explored No more manual wheelchair seating Power wheelchair trials- problems! Cushion trials and pressure mapping Education around pressure relieving techniques Seating options
  • Thinking beyond the chair…. Neuro psych involvement to ensure safe to make decisions Specialised wheelchair set up- PWC with tilt, seat to back angle on chair set to maintain skin integrity Sitting times monitored and capped at 2 hours at a time Not to sit everyday- continue with prone bedrest Pressure relieving regime- using tilt in PWC Safe transfer methods- sling, slide sheets, patslide Mattress upgrade Prone trolley options
  • Prone Options Prone wheelchair Prone shower trolley
  • Interface Pressure Mapping
  • Interface Pressure Mapping What is Interface Pressure Mapping? How do we use it? What are the limitations of IPM? What are the Clinical Applications of IPM? (Lipka, 1997) – Case study from POWH Seating Service
  • What is Interface Pressure Mapping? Pressure mapping is used to show the distribution of pressure across a surface. It measures the INTERFACE pressure distributed by a subject across a support surface (e.g. cushion, mattress, backrest) It is helpful in assessing a single person on various surfaces using the same device and scale.
  • How do we use it? We look at the distribution of pressure across the surface aiming for even dispersion throughout the image When high peak pressures are identified (“red” areas) the clinician uses their clinical judgement to determine appropriate intervention Useful as an education tool for pressure relieving and re- assurance
  • Now to see what we are talking about!
  • Limitations of Pressure Mapping Provides a “snap shot” in time Does not measure shear or contour forces Pressure mat and cover can provide a “false” read due to hammocking effect or bunching Confusion between Interface Pressure and Capillary closing pressure Results not transferable between clients Requires clinical judgement to interpret results Clients can become reliant on it
  • Clinical Applications
  • Objective representation of Peak Pressure
  • Differential comparison of Support Surfaces Frame 1: RGK Foam cushion Frame 2: Roho Frame 3: Jay 2 Deep Contour Frame 4: Jay 2 with different well Size
  • Effectiveness of Weight Shifting Interventions
  • Effectiveness of Weight Shifting Interventions (Cont)
  • Effectiveness of Weight Shifting Interventions (Cont)
  • Fabricating Custom Seating
  • Measure Postural Abnormality & Correction Initial Cushion Set-up (open valve) Cushion adjusted using Quadtro Valve
  • Documentation and funding E.g to Justify 45 degrees tilt in space (over standard 27 degrees) No Tilt 45 ˚ Tilt27˚ Tilt
  • Case Study- Trent
  • Background 33year old T4 AIS A paraplegic Injury sustained when he was 18 Lives with 2 brothers, mother lives nearby and assists with wound dressings Utilises a manual wheelchair for all mobility needs Plays wheelchair basketball
  • Problem list upon Referral • Stage 3 pressure area – right GT. Developed approximately 3 months ago. • Normally sits on foam in manual wheelchair. Seating position has changed since sitting on low profile roho • Pressure area believed to be caused by toilet seat – sits on padded toilet seat • Works as Office Manager–recommended 3/52 weeks bedrest to heal pressure area
  • Between Referral & Seating Clinic Intervention Spent 3 weeks on bed rest then returned to work 12 hours /day Taking rest breaks every 2 hours at work Trial of electrical stim to heal wound Purchased alternative toiletting equipment Hired Trinova alternating air cushion on wheelchair (funded trough CRS)
  • Assessment Transfers: Self transfers without sliding board. Good lift & clearance from wheels Clothing: Wearing 4 way stretch lower body garments Toileting & shower equipment – reluctant to change Mattress: Sleeping prone or on left side Had been seen via MDT who had reviewed nutrition risk factors Workstation set-up
  • Seating Clinic Intervention – Pressure Mapping Frame 1: Trinova (All inflated) Frame 2: Trinova cycle 1 Frame 3: Trinova Cycle 2 Frame 4: Roho HP
  • More than just a Chair – Car seat Frame 1: Action Pilot (foot clear of brakes) Frame 2: Action Pilot (normal position) Frame 3: Roho LP (foot clear of brakes) Frame 4: Roho LP normal position)
  • More than just a chair – Seating Clinic Holistic approach to assessment and management Multidisciplinary approach critical to good outcomes Skilled intervention with equipment selection, prescription and set-up can assist with management of avoidable pressure injuries
  • References Bar, C. (1998). Pressure: Why measure it and how. A presentation at the 14th International Seating Symposium. Vancouver, BC. Lipka, D. (1997). An overview of pressure mapping systems. Technology SIS Quarterly. American Occupational Therapy Association. (7) 4. Schlemer, MR & Bunning, ME (1999) www.wheelchairnet.org/wcn_wcu/SlideLectures/MS/3PressureMapping.pdf Rappl, L. Poster Presentation at RESNA 2005
  • Seating Clinic Prince of Wales Hospital Email“: rehabeng@sesiahs.health.nsw.gov.au Ph: (02) 9382 5286