ROHO`s Beginnings Causes of Pressure Ulcers

5/25/2012
Australian agent for ROHO, Bodypoint, Heelift, Frog Legs, Spinergy, TiLite, Intimate Rider, V‐
Trak, Matrix and Xsensor products.
Malcolm Turnbull – Managing Director
Access to expert clinical advise from a pool of experienced seating clinicians
Deal directly with product development teams
www.seatingdynamics.com.au
ROHO’s Beginnings
1957, Robert H. Graebe witnesses an ischemic ulcer.
1971, ROHO® HIGH PROFILE® Cushion is introduced.
1973, ROHO incorporates.
ROHO distributes its products around the world.
Causes of Pressure Ulcers
Lack of blood flow caused by:
Tissue deformation
Decreased oxygen supply to tissues
Decreased drainage of waste products
DRY FLOATATION encourages blood flow
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DEFORMATION
of the vascular bed and lack of blood flow causes Pressure Ulcers
Cost of Pressure Ulcers
• In Australia, the cost of treating patients with Stage II or deeper pressure ulcers is estimated to cost between $61,230 and $100,000 per patient (Young 1997)
• Overall annual estimated costs in treating patients with pressure ulcers in Australia reportedly reached up to $350 million in 1997 (Woolridge 1997) • 95% of pressure sores are thought to be preventable (Hibbs 1988; Department of Health 1993)
What is Pressure?
PRESSURE = FORCE
AREA
Any force applied over a small area generates more pressure than the same force applied over a large area
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Dispelling Myths About Pressure
• Pressure is part of our daily lives
•Atmospheric pressure = 720mmHg
•Compression stockings
•The scuba diver analogy
• Distribution of pressure decreases peak pressure areas.
• A variety of factors influence blood flow.
Scuba diver at 10m deep = 1400 mm Hg
Assessment Process Is Critical.....
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Assessment Process Is Critical.....
–Pressure Ulcer Risk Factors
–Extrinsic Factors
–Excessive point pressure
–Intrinsic Factors
–Immobility
–Sensory loss
–Friction and shear forces
–Age
–Impact injury
–Disease
–Heat
–Body type
–Moisture
–Infection
–Posture
–Poor nutrition
–Smoking
–Incontinence
-Stress
Extrinsic Risk Factors for Pressure Ulcers
Components we can directly control and minimize the effects of:
•Pressure
•Shear
•Friction
•Moisture
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Deformation of Tissues
Pressure and Shear act together to deform soft tissues…
Shear Induced Ulcer
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ROHO Cells deform to minimise tissue
deformation caused by pressure, shear
and friction
Some Basic Principles
Immersion: Depth of penetration (sinking) into a support surface
Envelopment: The ability of a support surface to conform (or to fit or mould) around irregularities in the body
Immersion and Envelopment – Taken together these are a measure of the ability of a support surface to distribute load over the contact area of the body.
Immersion…
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Two Mechanisms
1. COMPRESSION Support surfaces that are designed using COMPRESSION will have reactive forces.
Two Mechanisms
2. DISPLACEMENT. Support surfaces that are designed using DISPLACEMENT will have hydrostatic forces. That is, material in the support surface will move to accommodate the shape.
Forces with Movement
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Forces with Movement
Envelopment
How intimate is the shape formed with the clients shape?
Tools we have to determine this?
Visual inspection
Palpation
Client feedback
Pressure mapping
Measuring Envelopment
The envelopment indenter designed to measure the ability of a product to envelop tissue
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And the results…
Air showed more even distribution of pressure
Not all cushions are made equal…..
Why Do We Prescribe Someone a Cushion?
• Clinical Reasoning
– Skin protection – redistribution of load
– Dynamic stability
– Positioning
– Comfort – sitting tolerance
– Heat and moisture dissipation
– Maintain optimal function
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ROHO DRY FLOATATION®
Designed to mimic water
Delivers Immersion and Envelopment
Resulting in Equalised Pressures
DRY FLOATATION® Capabilities
• Pressure Distribution
• Peak pressures are reduced
• Consistent pressure
• Air, like water, is a dynamic medium. Gel and foam are not as dynamic as air.
Foam Cushion
ROHO HIGH PROFILE® Cushion
DRY FLOATATION Capabilities
• Progressive positioning
• Dynamic and adjustable
• Stability
• Posture correction
• Changeable as the client’s needs change
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Stability and Posture……
The base system is the main
contributor to stability and posture –
customise as much as possible to
ensure proper fit.
Stability and Posture……
Hierarchy of priority.....
All seating will have compromises.
As a wheelchair user my priority is skin protection, function, comfort then posture. When I look at most able bodied people it seems that comfort is a priority (is your posture perfect now?).
Stability……
Maximum lateral stability will involve support at the ITs and GTs.
To support the GTs requires immersion (at least 50mm) and envelopment.
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Stability……
ROHO:
When set up correctly:
1. Hydrostatically supports ITs and GTs.
2. IsoFlo Valve locks air to maintain positioning and stability.
3. Quadtro Select and Contour Select. 4. Hybrid Elite.
5. Maintains skin integrity.
Important ROHO Facts:
• No weight limit on neoprene products
• ROHO products are 100% neoprene and contain no latex
• Easy to clean and disinfect
• Adjustment process creates a custom fit
• Meets strictest flame retardant standards
• UV safe
• Repairable – entire cells can be replaced
As Felix always says “Sit IN IT not ON IT!”
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ROHO Range Study – Brienza and co…
Two Groups – Aged Care:
1st Group of 120 given a segmented foam cushion
2nd Group of 112 given a Skin Protection Cushion
SPC made up of ROHO QS HP, Jay 2 Deep Contour, Invacare Infinity Cushion
Clients given choice of what cushion. Brienza, D. K., Sheryl; Karg, Patricia; Allegretti, Ana; Olson, Marian; Schmeler, Mark; Zanca, Jeanne; Geyer, Mary Jo; Kusturiss, Marybeth; Holm, Margo (2010). "A Randomized Clinical Trial on Preventing Pressure Ulcers with Wheelchair Seat Cushions." Journal of the American Geriatrics Society. Results…
The Skin Protection Cushions work!
6.7% people in the segmented foam group developed PU
0.9% of people in the SPC developed a PU
Brienza, D. K., Sheryl; Karg, Patricia; Allegretti, Ana; Olson, Marian; Schmeler, Mark; Zanca, Jeanne; Geyer, Mary Jo; Kusturiss, Marybeth; Holm, Margo (2010). "A Randomized Clinical Trial on Preventing Pressure Ulcers with Wheelchair Seat Cushions." Journal of the American Geriatrics Society. 13
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Results…
Information obtained from the study….
“The most notable results were in the sample of participants exhibiting kyphosis, in which no ROHO users developed sacral pressure ulcers, as opposed to 14%‐20% of the other foam and skin protection cushion users.”
“As displacement increased, the shear stress and interface pressures measured on the Jay 2 Deep cushion also increased, while the ROHO Quadtro Select High Profile cushion values remained fairly constant.”
Brienza, D. K., Sheryl; Karg, Patricia; Allegretti, Ana; Olson, Marian; Schmeler, Mark; Zanca, Jeanne; Geyer, Mary Jo; Kusturiss, Marybeth; Holm, Margo (2010). "A Randomized Clinical Trial on Preventing Pressure Ulcers with Wheelchair Seat Cushions." Journal of the American Geriatrics Society. Chronic Wounds – Foam with ROHO…
14 Clients monitored over a 24 month period
Spinal Cord Injured, 10 cervical level– 10 of 13 using ROHO High Profile Cushion
One client on bedrest for 5 years due to PU!
Charisse Turnbull and David Huynh
Gluteal Challenge ‐ download at Resources page at www.seatingdynamics.com.au
Chronic Wounds – Foam with ROHO…
Over 80% reported the base precented further skin breakdown.
Over 90% reported they had reduced bedrest time due to PU.
Over 80% reported longer sitting times.
90% reported improved posture and positioning
Charisse Turnbull and David Huynh
Gluteal Challenge - download at Resources page at www.seatingdynamics.com.au
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The ROHO Mattress Overlay
1 section= 180 interconnected 75mm high cells
4 sections= complete mattress 87cm x 188cm
18.5kg total, 3.6kg per section
Flame‐resistant neoprene rubber
NO WEIGHT LIMIT, CPR READY
Hand‐made: patch or repair damaged cells
2 yr. warranty
The Sofflex Mattress Overlay
1 section= 20 interconnected 90mm high cells
3 sections= complete system 92cm x 69cm each
6 lbs total, 2 lbs per section
Flame‐resistant polyurethane
300lb/ 136kg wt. limit
Machine‐made: patch or replace only damaged section
12‐month warranty
The Prodigy Mattress Overlay
1 section= 20 interconnected 90mm high cells
3 sections= complete system 92cm x 69cm each
6 lbs total, 2 lbs per section
Flame‐resistant polyvinyl
300lb/ 136kg wt. limit
Machine‐made: patch or replace only damaged section
12
‐month warranty
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Choosing a Mattress
Some things to Consider:
1.
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3.
4.
5.
6.
7.
8.
Storage and portability
Repair and maintenance costs
Infection control
Pressure Distribution Capabilities
Ability to move in bed
Electricity Costs
Function in and out of the surface
Positioning while in bed – sitting?
Launceston Hospital
Assessment process – multi disciplinary with client input
3 years ago adopted ROHO Mattress as high risk support surface
Yet to be published by CNC Wounds reports a significant decrease in Sacral PUs
Significant saving in maintenance/rental/electricity costs
Cover Options
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ROHO Product Line: Cushions
Accessory and Special Cushions
ROHO can make cushions to your specifications
Standard accessory cushions MINI‐MAX® and PACK‐IT® Cushions
Commode and Toilet Seat Cushions
Lumbar and Sacral Cushions
ADAPTOR® Cushion
A Special Mention For...
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Clinical Evidence
239 population – over 65 – fractured hip – no PU at beginning
119 in control group, nursed on Alternating Pressure Mattress
120 nursed on APM with Heelift
29 in control group developed a PU at heel or ankle
0 issued a Heelift developed heel or ankle PU
“An RCT to determine the effect of a heel elevation device in pressure ulcer prevention post‐hip fracture.” Journal of Wound Care, July 2011. J. Donnelly,1 PhD, BSc(Hons) Health Studies, MCGI, RGN, ONC; J. Winder,2 PhD, CSci, MIPEM, Health & Rehabilitation Sciences Research Institute; W.G. Kernohan,2 PhD, BSc, CPhys, MInstP, School of Nursing and Institute for Nursing Research; M. Stevenson,3 Senior Lecturer in Medical Statistics. Basic Staging Guidelines
NPUAP Definitions
Stage I
Observable pressure related alteration of
intact skin which may include changes in:
skin temperature (warmth or coolness)
tissue consistency (firm or boggy feel)
sensation (pain, itching).
The ulcer appears as a defined area of
persistent redness in lightly pigmented
skin and may appear with persistent red,
blue, or purple hues in darker skin tones.
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Stage II
Partial thickness skin loss
involving epidermis, dermis, or
both. The ulcer is superficial and
presents clinically as an
abrasion, blister or shallow
crater.
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Stage III
Full thickness skin loss involving damage to, or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
Stage IV
Full thickness skin loss with
extensive destruction, tissue
necrosis, or damage to muscle,
bone, or supporting structure
(example: tendon or joint capsule).
Undermining and sinus tracts also
may be associated with stage IV
pressure ulcers.
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Unstageable Wounds
Wound Bed not visible
No “Back Staging”
Suspected Deep Tissue Injury
Purple or maroon localized area of discolored intact skin or blood‐filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. 21
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Suspected Deep Tissue Injury
Suspected Deep Tissue Injury
Suspected Deep Tissue Injury
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Is this a pressure ulcer?
Incontinence‐related dermatitis is frequently confused with a pressure ulcer
Differential diagnosis
Staging guidelines are only for pressure ulcers
Phases of wound healing
Acute wounds‐ progress through 3 overlapping phases
Inflammatory, defensive or reaction phase
Proliferation of fibroblastic connective tissue phase
Granulation tissue maturation to remodeling phase
TIME AFTER INJURY
4 TO 6 DAYS
4 TO 21 DAYS
21 DAYS TO 2 YEARS
Phases of wound healing
1. Chronic wounds‐ healing usually extends beyond 21 days
2. Longer time due to pressure, infection, poor nutrition, poor circulation and disease
3. Requires increased emphasis on pressure management, nutritional support and infection control
4. Chronic wounds usually stall between the inflammatory and proliferative phases
TIME AFTER INJURY
4 TO 6 DAYS
4 TO 21 DAYS
21 DAYS TO 2 YEARS
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A Seating Resource
An on‐line training course in seating, specifically aimed at spinal cord injured but applicable to all seating:
http://www.aci.health.nsw.gov.au/networks/spinal‐seating
Or Google “Spinal Seating”
SDL Website
Product information, images, brochures, case studies, clinical studies, videos
www.seatingdynamics.com.au
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