Welcome to the 2006 Heartland Conference

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Welcome to the 2006 Heartland Conference
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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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Evidence Based Medicine

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

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Where Does Pressure Fit In Our Assessment
Hierarchy?

• Patient
• Position
• Pressure

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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 and Vet in bed
• Why five years of sacral pressure ulcers only in
  August?

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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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Client Postural Issues?

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

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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
  Cliffs 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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Be Prepared!!

• 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

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But First Two Key Items

• Wash your hands! For your sake and theirs, before
  and after the evaluation! Gloves??
• Make sure you use an isolation bag! Ours our a
  thin dry cleaning type bag

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So What Do We Actually Do With The Client?

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

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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 problem 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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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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Some Reminders

• Consistently place the mat in the same
  orientation so there is no confusion later.
• Position the mat square on the seat
• Confirm with your hands that the sensing mat is
  not hammocked
• Make sure the client is in a normal or neutral
  position you can replicate with other surfaces

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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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Pressure mapping systems help you redistribute
pressure they do not

• Relieve pressure
• Or
• Reduce pressure

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What About The Numbers???

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

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OK This Means What?

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

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Dont Forget Asymmetry!
Make sure the its the client not a misplaced
sensing mat?
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Thats More Like It!
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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 will or 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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Document the Most Commonly Used/Least Costly
Alternative

• Your years of experience or the typical funding
  parameters may lead you to a particular solution
• Scan, Store and describe what you did.
• This may take recording a number of scans as you
  try a number of variables. You can use 4 scan
  view to compare your solutions head to head.
• Be sure to describe what you did as you scan and
  store
• This will help answer the question
• Why the most likely or least costly solution did
• or did not work?

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A Standard Solution

• Foam cushion pressures still unacceptably high,
  and highly focused

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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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Power Chair After Adjustments
8 by 9 air insert in foam good pressure
distribution not as good though as the full air
cushion up only 4 hours
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Proposed Chair
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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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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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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Dont Forget Training and Biofeedback

• Training and testing for client and caregiver
  compliance
• No that solution your buddy has will not work for
  youSee!
• Dont over-inflate that air cushion!!
• What does a client have to do for weight shifts
  or tilts to actually benefit them
• Demonstrate appropriate positioning in Bed or Seat

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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 is unseen during the assessment?
• Some research and experience indicates that while
  the client maybe referred for a seating related
  pressure issue, 50 of the time the problem is in
  the bed not the seat. So, go pressure map the
  bed even with a seat mat if you need to.

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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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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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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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Evidence Based Practice Many Come To Rely On

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

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Other Pressure Mapping Related Tools

• Shear sensor
• Temperature Sensor
• Weight bearing assessment
• Range of motion training

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Conclusions

• Pressure mapping systems are dumb. It takes
  intelligent interpretation and application of the
  data to make good decisions that benefit the
  client
• They are powerful tools to help maximize care for
  your clients and to help ensure they receive it.
• They also have become standard of care for those
  needing rehabilitation seating.

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Remember Our Goal
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THANK YOU!