PRACTICAL PRESSURE MAPPING

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PRACTICAL PRESSURE MAPPING
Presented by Andrew Frank Vista Medical
July 2006
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Pressure Mapping Whats The Point?
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Our Goal
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To Prevent This!
Wound measurement using VEV MD
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Some Sobering Numbers

• 39 of SCI Veterans in Houston in the 3 Years
  studied were treated for a PU
• 150 day average in Hospital
• 150,000 per Hospitalization.
• Garber, Rintala Journal of Rehabilitation
  Research and Development, Sept/Oct. 2003

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The Cost is Significant

• SCI general prevalence 25-85
• Mean cost in 1998 37,288
• Total cost estimated up to 3.6 Billion
  in 1999.

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Incidence of Skin Breakdown in SCI

• Incidence of SCI continues to be 80 male, 20
  female
• Substantial physiological differences between
  genders
• Increased incidence with increased age

Courtesy of LAURIE M. RAPPL, PT, CWS
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SCI Skin Changes

• Collagen catabolism
• Decreased amino acid concentration
• Decrease in enzymes of biosynthesis
• Decrease in proportion of Type I to Type II
  collagen
• Decrease in density of adrenergic receptors
• Poor collagen synthesis
• Abnormal vascular reactions
• Decreased blood flow
• Decreased PO2 5X less than in innervated skin
• Decreased fibronectin, glycoproteins for
  fibroblast activity
• Increase in urinary excretion of GAG's, which are
  the ground substance for collagen bundles
• The skin below the injury is not the same as the
  skin above.

Courtesy of LAURIE M. RAPPL, PT, CWS
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Wounds Are Not All The Same
Courtesy of LAURIE M. RAPPL, PT, CWS
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Deep Pressure Ulcer Stage IV
Wound measurement using VEV MD
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Shear Ulcer Stage III
Courtesy of D. Keast
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Causes of Shear

• No Compression Tangential Forces
  Pinch
• No Shear Shear
  Shear

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Summary of Causes

• Immobility
• Incontinence
• Pressure
• Friction
• Shear
• Maceration a.k.a. Heat and Moisture

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Evidence Based Practice

• We used to say outcomes measures
• Why do we insist on an x-ray for a broken
  wrist yet we will provide AT with a short
  paragraph or two
• Orthopedics get paid because they use objective
  tools like Biodex, Cybex, etc.

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Evidence Based Practice Its Here

• Veteran SCI patients guidelines are that they be
  assessed with pressure mapping annually.
• FL Medicaid reviewers frustrated.
• State of FL purchases 11 pressure mapping for
  their SCI and Brain Injury centers.

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Tools To Gather Evidence

• Temperature
• Shear
• Pressure

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Temperature Mapping
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Shear Sensors
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Pressure Mapping
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Some Important Reminders About Pressure Mapping

• Place the mat as close to the skin as possible
  and with what they normally sit on.
• Consistently place the mat in the same
  orientation so there is no confusion later.
• Position the mat square on the seat.
• Confirm with your hands that the sensing mat is
  not hammocked.
• Make sure the client is in a normal or neutral
  position you can replicate with other surfaces.

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Be Prepared!! Are the Tools Ready?

• Dont keep the IPM system in the closet.
• No one wants to wait 30 minutes while you set up.
• Have it up and running ready to use
• Install it on all the computers you use
• Know when was it last calibrated

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Calibration Is Important

• Do you have the equipment to do it
• Does the calibration technique meet researcher
  and expert users approval
• Do you have a protocol governing when, who and
  where calibration is done?
• Does the system let you know if the calibration
  was successful?

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Example of a Calibration Kit
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Are You Ready?

• Wash your hands! For your sake and theirs, before
  and after the evaluation! Gloves??
• Make sure you use an isolation bag! A thin PE
  dry cleaning type bag or facility garbage bag is
  fine.

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How Long To Wait?

• Some advocate up to 45 minutes-not usually
  practical-but you could use remote to test.
• Research indicates 6-8 minutes is a good
  practical time (Stinson 2002).
• You need to be observant as it depends on the
  solution you choose.

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How Do We Make Sense Of Pressure mapping?

• What can we really do?
• What do the numbers mean?
• How can we make good decisions?

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We Can Only Redistribute We Cant

• Relieve pressure
• Or
• Reduce pressure

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What About The Numbers???

• A particular number at a particular location does
  not success or safety.
• Key numbers to watch are
• Highest pressure-Where is the potential trouble?
• Focuses attention on key at risk areas
• Sensing Area- More is better! (Quantity of
  distribution)
• Are we expanding or contracting the area of the
  pressure distribution on the surface?
• Coefficient of Variation - Lower the the
  Better! (Quality of distribution)
• How evenly is the pressure distributed over the
  surface?

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How Do We Decide?

• Keep in mind that we are doing a case study of
  one.
• No normative data is available yet to guide our
  decisions for a particular patient type.
• The numbers are only bench marks to refer to as
  we seek a better solution.
• Is a proposed position or product affording a
  better pressure distribution, functional
  capability and or comfort than another?

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Dont Forget Asymmetry!
Make sure that its the client not a misplaced
sensing mat?
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Thats More Like It!
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Where Does Pressure Fit In Our Assessment
Hierarchy?

• Patient
• Position
• Pressure

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So Here We Go! In Brief

• Introduce pressure mapping
• Capture how they are currently doing
• Demonstrate the clients challenges
• Document usual/least costly solutions
• Provide as necessary an appropriate alternative
• Communicate our findings effectively

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PM Clinical Wizard
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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

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Focusing On The Wrong P Can Cost You!

• Client and OMalleys
• Beautiful seating solution in clinic but a wood
  stool at the bar defeats the benefits
• Caregiver impact on Vet with repetitive injury
• Why five years of sacral pressure ulcers only in
  August?

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Learn About the Patient

• Gather any background information you deem
  pertinent and record in the client information
  tab.
• General, equipment related for future reference.
• Dont rewrite the patient file but do include the
  Cliff Notes of what is relevant to what you are
  doing.
• Learn about their lifestyle and goals. Lifestyle
  can trump good seating.

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Client Positioning Issues?

• Client Information Check list-
• Jeannie Minkels for example.
• Use camera as part of documentation
• Illustrate the challenges at the beginning
• Illustrate the recommended solution and the good
  results

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Picture the Posture
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1) Introduce Pressure Mapping

• Explain the process
• To remove any apprehensions
• Involve client and/or caregivers in the process
• Allow them to interact with the technology
• They wont be able to while you do the assessment
  or they will confuse your work
• Make sure you use your hands to limit hammocking

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Clients 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 problems with left side Stage I ulcer and NOT
  problems on right side.
• Cannot stay up longer than 4 hours

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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.

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2) 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! Dont 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?

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Current Seating
What is suspicious in this picture? Note the
hexagon.
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Use Your Hands!!
What really is at the 135 mmHg location??
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3) Demonstrate What Their Challenge Is

• If possible have the client sit upright on a
  firmer surface like a mat table or a foam
  cushion. This should be part of the larger mat
  evaluation.
• Scan, store and describe where the boney
  prominences are. Confirming with hands and
  noting coordinates on screen.
• This will help answer the questions
• What is the clients boney architecture like?
• Is it all there? How rotated is the
  pelvis,etc.?
• Why wont a simple solution be sufficient?

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On A Firm Flat Surface
Dont put the client at risk doing this. A mat
table or firmer foam cushion might be good
choices.
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4) Document the Most Commonly Used/Least Costly
Alternative

• Your years of experience or the typical funding
  parameters may lead you to a particular solution
• Scan, Store and describe what you did.
• This may take recording a number of scans as you
  try a number of variables. You can use 4 scan
  view to compare your solutions head to head.
• Be sure to describe what you did as you scan and
  store
• This will help answer the question
• How well did the usual or least costly solution
  performed for the client?

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A Usual Solution

• Foam cushion pressures still unacceptably high,
  and highly focused

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5) Provide an Alternative Solution if Necessary

• If youre 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?

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An Alternate Solution
8 by 9 air insert in foam good pressure
distribution not as good though as the full air
cushion up only 4 hours
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Proposed Solution
On properly adjusted air cushion. F9 is right
IT Good pressure distribution Up 6 hours am 4
hours evening - meeting goal
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Before therapist correction
Change In Posture?
After therapist supported left PSIS area
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6) Develop a Simple FourStep 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.

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Compare and Choose
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Print Your Choices
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Print Your Choices
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Dont 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.

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Use Pressure Mapping As Visual Feed Back

• Client and caregiver buy in and compliance
• No that solution your buddy has will not work for
  youSee for yourself. Better client and
  caregiver buy in.
• Dont over-inflate that air cushion!! Use it
  wisely.
• How far do they have to go for adequate weight
  shift using tilt or other means.
• Demonstrate appropriate positioning in bed or
  seat so the caregiver doesnt defeat your work.

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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.

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What Do You Do When It All Looks Bad?

• Sometimes you have to leave well enough alone
• Clients 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.
  

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Maybe its 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

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What Do You Do When It All Looks Good?

• Sometimes everything you do in the seat looks
  good.
• If it does, back up and take a good look at where
  the wound is or what their history is. What is
  not obvious and unseen during the assessment?
• Some research and experience indicates that the
  referral is for a seating related pressure issue,
  50 of the time the problem is in the bed not the
  seat. So, go pressure map the bed even with a
  seat mat if you need to.

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Why Do We Share WhatWe 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

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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.

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Clinical Benefits

• Objective evidence of need
• Focuses Resources-80/20 rule
• Better solutions mean fewer visits
• Client information is organized over time in an
  easy to use and share format.

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Evidence Based Practice Many Have Come To Rely On

• HMOs are requiring pressure mapping for use as a
  benchmark to become a contracted vendor with
  them.
• Those with the most success using pressure
  mapping take time to educate their Case Managers
  and other payers.
• It provides information that demonstrates why you
  did what you did and when you did it, a.k.a. Risk
  Management.

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Where Can Pressure Mapping Be Useful?

• Seating and positioning assessment including
  seat, back and wheelchair configuration
• Support Surfaces/Bed selection and monitoring
• Dont be afraid to take a seat mat into the bed
  setting
• Orthotics and Prosthetics design and fitting
• Hand grip assessment and ergonomic design
• Wound clinics, especially when teamed with VEV
• Pressure garment-wraps or one piece

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Conclusions

• Pressure mapping systems require intelligent
  interpretation and application of the data to
  make good decisions.
• They are powerful tools to help maximize care for
  your clients and to help ensure they receive the
  AT solutions they need.
• They have also become standard of care for those
  needing rehabilitation seating.

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Remember Our Goal
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THANK YOU!