Evaluation of the Dyna-Form Static Air HZ in a coronary care setting
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PRODUCT EVALUATION Evaluation of the Dyna-Form™ Static Air HZ in a coronary care setting KEY WORDS A year-long evaluation is underway in a cardiac unit in Wales to see whether a Cardiac intensive care switch to using Dyna-Form Static Air HZ for every patient (apart from when Dyna-Form Static Air HZ they are in Cardiac Intensive Care) would reduce the number of hospital-acquired Hospital-acquired pressure pressure ulcers (HAPUs) on the unit and also reduce the amount of money that was ulcers Prevention previously being spent on alternating pressure mattresses. Patients in this group have a particularly high risk of pressure ulcer development, and in the previous year 19 cases were documented. This article reports on the interim findings 5 months into the evaluation and discusses the problems of conducting an evaluation in a busy clinical environment. As yet, there have been no reported HAPUs in the 383 patients placed on the mattress to date. The attempt to reduce the number of pressure ulcers in this environment is part of the zero tolerance to pressure ulcers inspired by the 1000 lives campaign. T he prevention of pressure ulcers has The measure, described by Whitlock, has over been high on the clinical agenda in Wales the following years spread across many hospitals, since the inclusion of pressure ulcers including the Abertawe Bro Morgannwg as a quality measure as part of the 1000 Lives University, with the hope of eliminating avoidable Plus campaign (NHS Wales, 2010). Activity to pressure ulcers. Despite intensive interventions prevent pressure ulcers in Wales was escalated including the use of alternating pressure when they became part of a mandatory target mattresses (APAMs) and the implementation of which required a zero tolerance approach to SKIN bundles, the cardiac unit at Abertawe Bro pressure ulcer formation. Morgannwg University Health Board identified In 2011, Whitlock et al described the impact 19 hospital-acquired pressure ulcers (HAPUs) in of implementing a quality improvement the previous 12 months, all of which were in the programme based on Surface, Keep moving, cardiac area. Of the 19 pressure ulcers: Incontinence, Nutrition (or SKIN) bundles Ten were to the sacrum/buttocks: in acute care on the occurrence of pressure Of which one grade IV was related to ulcers. The study used the Institute for extended time in theatre, complications Health Improvement model of improvement and cardiac instability to undertake Plan Do Study Act cycles in Four were grade II order to transform staff attitudes to pressure Five that, when reviewed by the tissue ulcers from accepting them as an inevitability viability team, were identified as being JACQUI FLETCHER to active scrutiny and efforts to prevent moisture lesions Clinical Strategy Director, Welsh them. The use of the SKIN bundle alongside Nine were to the heel and these were a Wound Innovation Centre the very visible measure of the Safety Cross mixture of suspected deep tissue injury and (a ward-based measure of pressure ulcer grade II pressure ulcers. JULIE EVANS occurrence) resulted in a significant increase In addition to this there were five device-related Tissue Viability Nurse, Abertawe Bro Morgannwg in the days between the occurrence of pressure pressure ulcers. University Health Board ulcers. The cardiac unit is made up of an eight- 78 Wounds UK | Vol 11 | No 4 | 2015
PRODUCT EVALUATION bed intensive care unit, an eight-bed high Time on the operating table dependency unit (HDU) and a 25-bed ward. Frequency of repositioning The unit has an average length of stay of Immobility 7–10 days, with the most common reasons Older age for admission being elective coronary grafting Low albumin levels and coronary artery bypassing, which makes up Use of corticosteroids. 80% of admissions. Emergency care admissions In addition, several papers report a reluctance make up 10% of admissions and these patients go to reposition patients due to cardiac instability direct to the cardiac intensive care unit (CICU). (Brindle et al, 2013; Cooper, 2013). This Elective patients are admitted to the ward from intolerance to movement in cardiopulmonary theatre. They are then transferred to CICU post- status can cause delays or omissions in turning, operatively for 48–36 hours, moved down to cardiac repositioning and other interventions designed HDU for 24–48 hours, and then go back to the ward to improve a patient’s mobility, thereby increasing for 4–5 days before discharge. This is a complex the risk of pressure damage. pathway with five points of admission (ward, theatre, CICU, cardiac HDU, and then back to the ward) for EVALUATION OF THE DYNA-FORM the majority of patients, meaning that transfer of STATIC AIR HZ information — particularly regarding pressure ulcer An evaluation of the Dyna-Form Static Air HZ risk — is crucial. It also means that the patient may was proposed at the unit to determine whether experience five different pressure-redistributing placing the patient on a surface designed for people surfaces during his or her stay. at a higher risk of pressure damage immediately on The hospital was using more than its contracted admission would reduce the number of pressure number of APAMs and was looking to both ulcers occurring and also reduce the amount improve patient outcomes and reduce costs. of additional equipment (specifically APAMs The staff working in the cardiac unit were and heel boots) being used. The Dyna-Form keen to reduce the incidence of pressure ulcers Static HZ was previously evaluated in a group and acknowledged the specific challenges of of general medical patients (Fletcher, 2014) to the patient group that they cared for. Patients determine equivalence with existing equipment. in the coronary care setting present with an This 26-patient evaluation identified that no increased risk of pressure damage. Paul et al new damage occurred during the evaluation (2014) identified that 6% of patients developed and concluded by recommending that further pressure damage within a high-volume cardiac evaluation be carried out in patients who had a care environment. Brindle and Wegelin (2012) greater risk of pressure damage. performed a prospective study on the use of a Dyna-Form Static Air HZ is a mattress prophylactic dressing in cardiac surgery patients replacement system that combines the benefits of and identified that in the control group eight effective air displacement technology with the best pressure ulcers developed in four patients (from of modern foams for a new standard of innovative a sample of 35), again suggesting a high rate of pressure ulcer prevention and management. A occurrence in this patient group. Feuchtinger et new and unique ‘air only’ intelligent heel zone al (2005) performed a literature review to identify and specially designed U-Core effectively off- specific risk factors in cardiac patients, identifying load pressure on the particularly vulnerable heel the following factors: area. The U-Core is the outer foam frame of the Tissue tolerance for oxygen due to mattress, which has carefully placed slits that allow temperature manipulation the mattress to conform better to an articulating Vasoactive drugs bed frame. Dyna-Form Static Air HZ is specifically Hypotensive periods designed for patients considered to be at ‘very Reduced haemoglobin and haematocrit high risk’ of pressure ulcer development (Direct levels. Healthcare Services, 2015). Other significant factors were: The evaluation is being performed over a Wounds UK | Vol 11 | No 4 | 2015 79
PRODUCT EVALUATION [Type here] [Type here] PLEASE LEAVE THIS FORM IN PATIENT KARDEX. PLEASE LEAVE THIS FORM IN PATIENT KARDEX. WHEN COMPLETED LEAVE IN RED/YELLOW WHEN COMPLETED LEAVE IN RED/YELLOW FILE ON NURSES’ STATION FILE ON NURSES’ STATION Section 1: Please complete on admission to the unit Section 3 Date of admission: End of evaluation of mattress Patient data: *Date *Age: *Gender: M F *Height (f/m): *Weight (kg): Patient ID: How many days was the mattress in use? Reason for completion of evaluation – please tick Diagnosis: Patient Patient Patient requires Patient died Other please discharged transferred higher state specification Start of Evaluation of mattress mattress Waterlow Pressure Ulcer Risk Score Status Pressure Ulcer No pressure ulcers developed New pressure ulcer developed Existing pressure ulcer: Existing pressure ulcer improved Existing pressure ulcer deteriorated Are there already any existing pressure ulcers: YES NO If new pressure ulcer developed, please add grade and localisation: If yes, please add grade and location and healing response Grade (EPUAP) D / NC / I Grade I Healing yes/no /static / Grade (EPUAP) don’t know Grade I Grade II Grade II Grade III Grade III Grade IV Grade IV D= Deteriorated NC= No Change I = Improved Section 2 in Cardiac ITU *Please check your response (1 = No/ Poor 5 =Yes / Excellent) : Don’t 1 2 3 4 5 know Date and Time Patient put on air mattress_____________________ (if applicable) How easy was mattress to use? Date and Time patient returned to HZ _________________________ In your opinion were patient turning times reduced during treatment? (if applicable) Figure 1. Sections 1–3 of the form used by staff to evaluate the use of the Dyna-Form Static Air HZ. 2 12-month period with all mattresses on the the Welsh Wound Innovation Centre. During coronary care ward being replaced with the Static the first month of the evaluation it became 3 Air HZ, with an interim analysis at 5 months. After evident that there was confusion among staff approval via local governance procedures, local about who should start the documentation and champions were identified to support the evaluation it was difficult to track when the patient was and training was given to all staff across all shifts, transferred on to and off the APAM in CICU. The including night duty. form was therefore amended and a new section The same evaluation form was used as had added specifically for CICU staff to complete been used in the previous study (see Figure 1) (see section 2 of Figure 1). Further support and to ensure consistency of data capture (Fletcher, training were then put into place. 2014). The CICU did not switch from APAMs due to the patients being at high risk during their RESULTS short stay in the unit. Visits to the ward to support This represents an interim analysis carried out staff with the documentation and address any at 5 months to identify lessons learned and the ongoing queries were made every week by the outcomes that have been observed so far. tissue viability nurse and supporting team from Forms have been returned for 41 patients, but 80 Wounds UK | Vol 11 | No 4 | 2015
PRODUCT EVALUATION seven had insufficient data to report. Data are Table 1. Demographic details therefore presented regarding the remaining 34 Minimum Maximum Mean All patients. Of those whose data were used, there All (M:F) All (M:F) (M:F) were 11 women and 23 men with an average age Age 50 (54:50) 84 (81:84) 69.1 of 69. The patients’ pressure ulcer risk scores Risk Score 5(5:7) 30 (30:25) 13.9 (Waterlow) ranged from 5 to 30 and one patient had a grade II pressure ulcer on admission. clinical staff, with decisions made at key points Two patients developed pressure ulcers during of a patient’s care pathway. This initiative aims this period. After a root cause analysis, however, to simplify one area of activity and reduce staff these were attributed to an extended period in actions by implementing an all-in-one equipment theatre with complications and an extended time solution at the first point of care. in the CICU, again due to complications. No The initial stage of the evaluation suggests that patient developed a pressure ulcer due to the use so far the initiative has been successful. Due to of the Dyna-Form Static Air HZ. the low monthly pressure ulcer occurrence due to previous initiatives, however, it is important DISCUSSION to continue the evaluation for the full 12 months Data capture has been challenging in the initial to ensure that this change is a true change and phase of the evaluation, but it has been possible to not a product of chance. The reduction in the monitor the occurrence of pressure ulcers in other occurrence of pressure ulcers so far suggests ways, such as via Datix reporting and Safety Cross, that it is possible to improve the quality of care, and therefore we are confident that in comparison simplify nursing processes and achieve financial with the previous 12 months, the number of savings by switching to the Dyna-Form Static Air pressure ulcers that have occurred is considerably HZ mattress. Wuk lower and those that have occurred cannot be attributed to time spent on the new mattress. REFERENCES Brindle CT, Malhotra R, O’Rourke S et al (2013) Turning Use of the new mattress has simplified and repositioning the critically ill patient with hemodynamic nursing procedures and reduced the use of APAMs instability: a literature review and consensus recommendations. J on the ward. Completing evaluation forms has Wound Ostomy Cont Nurs 40(3): 254 –67 been challenging for the ward staff within their Brindle CT, Wegelin JA (2012) Prophylactic dressing application to reduce pressure ulcer formation in cardiac surgery patients. J normal busy clinical environment, despite the Wound Ostomy Cont Nurs 39(2): 133–42 appointment of product champions. Cooper KL (2013) Evidence-based prevention of pressure ulcers in the This study is a clear example of where real- intensive care unit. Crit Care Nurs 33(6): 57–66 world evaluation activity varies from the research Direct Healthcare Services (2015) Product Information Page. Available at: http://directhealthcareservices.co.uk/products/ activity, when actions would be much more dyna-form-static-air-hz-2-2 (accessed 16.10.2015) controlled. The mattresses are being evaluated Feuchtinger J, Halfens RJ, Dassen T (2005) Pressure ulcer risk factors in the setting they would be used in and within a in cardiac surgery: a review of the literature. Heart Lung 34 (6): 375 normal environment. This real-world approach –85 to the building of evidence does not replace the Fletcher J (2014) Development and preliminary evaluation of a static air mattress with a heel flotation zone. Wounds UK 10 (3): 80–7 randomised controlled trial but does provide an NHS Wales (2010) 1000 Lives Plus. Pressure Ulcer Safety Cross. alternative and equally valuable form of evidence Available at: http://www.1000livesplus.wales.nhs.uk/pressure- with strong relevance to daily practice. ulcers (accessed 16.10.2015) Paul R, McCutcheon SP, Denend LT, Zenios SA (2014) Sustaining pressure ulcer best practices in a high – volume cardiac care CONCLUSION environment. Am J Nursing 114 (8): 34 –44 The prevention of pressure ulcer occurrence is a Whitlock J, Rowlands S, Ellis G, Evans A (2011) Using the SKIN Bundle multifaceted intervention requiring considerable to prevent pressure ulcers. Nursing Times 107: 35, 20-23 assessment skill and preventive activity from Declaration of interest The product evaluation and preparation of the manuscript was supported by Direct Healthcare Services Ltd Wounds UK | Vol 11 | No 4 | 2015 81
A 351 PATIENT EVALUATION OF THE DYNA-FORM STATIC AIR HZ MATTRESS IN A CARDIOTHORACIC UNIT Fletcher J , Evans J and Cooper H 1 2 2 1 Jacqui Fletcher Limited Abertawe Bro Morgannwg University Health Board 2 Contact: jacqui.fletcher@live.com Introduction Results ITU Patients Despite intensive pressure ulcer prevention strategies being in place, patients on the Cardiothoracic Ward were Over a 1 year period 351 patients completed the evaluation (125 female, 206 males, 20 not recorded) – see Table 1 143 patients were cared for in ITU for a part of their stay, overall they spent on average longer on the HZ mattress still developing a small but consistent number of pressure ulcers. Over the previous 12 months, 24 pressure ulcers for demographic details. No patient developed a pressure ulcer whilst on the HZ mattress. (11.8 days) than patients who did not require an ICU stay (8.6 days) despite their increased risk (average Waterlow occurred of which 9 were heel pressure ulcers (10 sacral and 5 device related). It was therefore decided to evaluate 18.3 compared to non ITU patients average 8.9) and increased length of stay. None of these patients developed a There were 8 patients who developed 9 hospital acquired pressure ulcers however following a full root cause a new mattress, the Dyna-Form Static Air HZ mattress. In addition, there was a high use of alternating pressure pressure ulcer whilst on the HZ – see Table 2. analysis procedure it was identified that all of the patients had been cared for on the APAM systems and had mattresses (APAMs) resulting in a high spend. extended periods in theatre. 2 were deemed to be equipment related. The Cardiothoracic Unit cares for 2 main groups of patients those having cardiac surgery e.g. coronary artery Spend on APAMs was significantly reduced with only 1 patient outside of CITU requiring an APAM (compared to bypass surgery; heart valve surgery; aortic surgery and those having thoracic surgery e.g. lobectomy, to remove All Patients Mean (Range) 11 in the 4 months prior to the evaluation). one or more lobes of a lung; pneumonectomy, to remove a lung; chest-wall deformities (pectus surgery). Both groups of patients are generally admitted via the Cyril Edwards Ward (CE) but follow different pathways; Age 71.2 (30 – 89) patients undergoing cardiac surgery are warmed in theatre and then go to the cardiac intensive care unit (CITU) before returning to the ward, patients undergoing thoracic surgery are cooled in theatre and then go Cardiac High Dependency Unit (CHDU) prior to return to the ward. 351 PATIENTS Weight 83.24 (46.5 – 170) Waterlow post ITU 18.3 (12 – 25) Method Mattresses across the admission ward (CE) and CHDU were all replaced with the Dyna-Form Static Air HZ mattress; CITU retained their APAM mattresses. Patient data was collected on admission, on return from CITU and NO PATIENT DEVELOPED A PU WHILST ON THE STATIC AIR HZ Number of days on HZ 11.8 (1 – 34) immediately prior to discharge. This included their risk status and presence / absence of pressure ulcers. For the first 4 months forms were completed by ward / unit staff however there was a very poor compliance rate. After analysis of the first 4 months data a dedicated member of staff (HC) was allocated to follow the forms and SPEND ON APAMS SIGNIFICANTLY REDUCED Table 2. ITU Patients Demographic Data ensure they were fully completed. Discussion All Patients Mean (Range) Female Mean (Range) Males Mean (Range) Use of the Dyna-Form Static Air HZ alongside education on the appropriate use of the equipment has been beneficial for the patients and staff of the Cardiothoracic Unit. Despite the reduction in use of APAMs, the overall Age 67.9 (21 – 98) 67.5 ( 21 – 89) 68 (26 – 93) number of pressure ulcers has reduced across the area suggesting that a good quality standard mattress with a specific heel zone plays a role in prevention of their occurrence. Height 164.8 cm (111 – 184) 156.5 (131 – 170) 170.4 (111 – 184) Collecting the data over the time period proved challenging but the allocation of a specific member of staff to follow up the forms made a significant improvement in the data quantity and quality. Weight 81.7 kg (42 – 170) 72.9 (42 – 126.1) 86.9 (48.3 – 170) Conclusion Waterlow on Admission 8.9 (1 – 20) 8.8 (4 – 20) 8.9 (1 – 20) Patients have been safely nursed on the new hybrid mattresses for as long as 34 days. Over this evaluation, patients were on the hybrid for 3007 days with no pressure damage occurring. Use of the hybrid mattresses Days on HZ 8.6 (1 – 34) 8. 9 (1 -34) 8.4 (1 – 34) has resulted in reduction in the number of patients developing pressure damage and cost savings (based on: not developing PU, not using additional APAMs and there was no additional heel protection used). Days in ITU 1.9 (1 – 7) The hybrid mattress has proven to be effective in this group of patients. Table 1. Demographic Data
POSITIVE OUTCOMES FOR PATIENTS, STAFF AND HEALTH BOARD WHEN BEDS ARE PRE-EQUIPPED WITH A DYNAMIC SURFACE – DYNA-FORM STATIC AIR HZ ® Heather Hodgson, Lead Nurse Tissue Viability Acute and Partnerships, Greater Glasgow and Clyde. e-mail: heather.hodgson@ggc.scot.nhs.uk Introduction Results Organisations rent pressure relieving surfaces that play an integral part in preventing pressure damage. Over the past decade pressure relieving surfaces have become The mattresses have been in place for 12 weeks. sophisticated, less complicated and individual costs reduced. The success of these surfaces cannot be argued; however it could be argued that it would be more beneficial Senior charge nurses, staff nurses, health care to patients, staff and the organisation if beds were pre-equipped with a pressure relieving surface. assistants and patients were interviewed to The opening of a new hospital provided an opportunity to explore this option. The rationale being: determine whether this approach was proving • Instant provision of pressure relieving surface to vulnerable patients. beneficial in terms of patient and staff benefit. • Within the pre-existing rental contractual arrangements it could take up to four hours to receive a mattress and another 30 minutes to transfer the patient, 100% of staff interviewed commented positively however having a high-specification mattress provides instant therapy. and do not want to revert back to the rental system. Efficient and effective use of resources The benefits derived included: It takes two nurses, 30 minutes each to inflate and transfer a patient onto a therapeutic mattress. This equates to one hour of nursing time as a minimum, this time will increase if the patient is unable to assist or if there is additional equipment e.g. intravenous line, urinary catheter etc. Using a bed pre-equipped with a pressure relieving surface should also 100 hours of nursing time over 12 months* TIME SAVING have positive outcomes in terms of moving and handling: a rental mattress weights around 20kg which requires to be lifted on and off a bed, and patients require to be transferred on and off mattresses. It was decided that 118 receiving beds would be pre-equipped with Dyna-Form Static Air HZ – A New Generation of Static Support Surface, developed in conjunction Less skin marking INSTANT PRESSURE RELIEF with the Welsh Wound Innovation Centre. The mattress was selected for the following reasons: • Dyna-Form Static Air HZ is specifically designed for patients considered to be at ‘Very High Risk’ of pressure ulcer development. RENTAL COSTS • Dyna-Form Static Air HZ is a mattress replacement system that combines the benefits of effective air displacement technology with the best of modern foams for a new standard £5k over 12 months* DRASTICALLY REDUCED of innovative pressure ulcer prevention and management. A new and unique ‘air only’ Intelligent Heel Zone and specially designed U-Core effectively offload pressure on the particularly vulnerable heel area. With patient compliance REDUCED MOVING AND HANDLING enhanced through the high levels of comfort offered and requiring no powered pump the system is ideal in community and palliative care settings whilst the clinical benefits and OF PATIENTS AND EQUIPMENT ease of use make it equally suitable in the acute ward environment. Incorporating air and foam and air only cells in the unique low pressure heel zone, a patented valve system allows Reactive Airflow System (RAS™) technology to adjust to the patient’s body weight and movement. INCREASED PATIENT COMFORT Dyna-Form Static Air HZ pressure maps 20% better than a high specification foam mattress and has a higher maximum weight capacity of up to 40 stone / 254kg. All component AND COMPLIANCE parts are interchangeable and replaceable, maximizing product life, reducing dynamic mattress usage and offering a very cost effective solution to pressure care management. * Over 118 beds only The vapour permeable, multi way stretch fabric cover incorporates high frequency welded seams and deep flap zip protection conforming to the strictest infection control policies. Discussion & Conclusion The trailing of equipping all beds with a pressure relieving mattress has proved beneficial in a very short space of time and the benefits in terms of cost effectiveness will increase as time increases. With time pressure on nurses becoming more evident, this simple approach appears to have huge positive impacts in terms of efficient and effective use of resources and patient safety. Already staff have verbalized that they would not wish to return to the previous rental system and suggested that it would be a ‘nightmare’ if this were to happen. In a very short period of time, the utilization of a high specification mattress on all in-patient beds has proved beneficial for patients, staff and the organisation.
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