Presenter Sharon Sutherland, PT got married to Scott Sutherland - - PDF document

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The Other Seat!

Where else is Skin Integrity preservation and postural management a critical consideration for the wheelchair-seated client? …. In the bathroom of course!

Sharon Sutherland (Pratt), PT Seating Solutions, LLC

sharronpra@msn.com http://www.seatingsolutionsllc.com

Presenter

— Sharon Sutherland, PT – got married to Scott Sutherland and

changed name from Sharon Pratt, PT J

— I am the Mum of 2 beautiful daughters: age 21 and 18…

Jennifer and Sarah

— Specialized in the field of Seating and Mobility for over 27 years

in Canada and the USA

— Experience includes clinical assessment through prescription;

funding policy, product design and development; clinical education and consultation worldwide

— Graduated from Trinity College, Dublin, Ireland. — Presently lives in Colorado, USA

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Disclosure

— I am the owner of Seating Solutions, LLC — The opinions expressed in this program are based

upon 27 years of working specifically in the field of Seating, Positioning and Mobility

— I do clinical consulting for Ottobock Mobility and Raz

Design.

— Pictures/graphics used throughout with permission

from Individual clients/patients and clinicians

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Abstract

A lot of time and resources are invested on skin integrity preservation and positioning strategies to help reduce the incidence of sitting acquired decubitus ulcers and postural deviations while sitting in manual and power wheelchairs. Regrettably, these clients are still at significantly high risk

• f the same seating challenges if they are using

improperly configured and poorly adjusted rehab shower commode chairs. This presentation will review the clinical and functional needs of rehab users in conjunction with the seating and positioning attributes of rehab shower commode chairs.

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Learning Objectives

• 1. Identify the Skin Integrity needs of Clients using

rehab shower, commode chairs

• 2. List the Postural and functional needs of clients

using rehab shower, commode chairs

• 3. List 2 critical product parameters that should be

considered when prescribing/selecting rehab shower, commode chairs

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Discussion points

— Important clinical considerations for the clients at

risk for skin integrity issues - when they are not in their wheelchair /seating mobility device - where are they and how is their skin being protected?

— How can best practice guidelines for skin integrity

preservation be implemented when using RCCs

— When faced with prescribing or selecting a RCC -

what are the top 3- 5 considerations?

— Interface pressure mapping- Can it be helpful in the

selection of Rehab commode chairs?

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Who Benefits from a Rehab Shower/ Commode chair? (RSCC)

Persons presenting with;

• Spinal Cord Injuries
• Traumatic Brain Injuries
• CP

, MS, ALS,

• Bariatric and/or Elderly profiles with functional limitations
• A mobility impairment
• Prolonged bowel / hygiene routines and at risk of pressure

sores

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WHAT CAN A RSCC DO FOR YOUR CLIENT?

• Provide safe transport for non-ambulatory or barely

ambulatory users

• Provides safe positioning and skin integrity

preservation for users who are at risk of decubitus ulcers from bowel and bathing programs lasting

• ne to three hours
• Eliminate unnecessary transfers – Very important
• 2nd most important mobility device! It is indeed the

“other seat”

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Thoughts from colleagues I have interviewed

• ver past several months

— Must have flexible/multiple access areas for client and/or

caregiver in commode seats/chairs

— If possible make postural supports removable or swing away

to make washing body parts easier

— Assess postural support needs if possible in the

shower...especially if the user is able to do part of the activity

• themselves. Support in the right place can make the

difference between being able to wash some body parts independently or not. Also you will see the impact the water has on muscle tone.

— “Must contain the splatter!” — Need to get over all toilet heights and yet manage lateral

stability… “Sometimes we get so high we tipple over laterally”

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Thoughts from colleagues I have interviewed over past several months

— Surface must be firm enough for transfer - soft enough for

skin protection

— Access right or left side of body -needs flexibility — Self access – client has to hook and reach - — Tilt often recommended for higher level quadriplegia C5 and

above or those with problems with blood pressure and /or tone

— For clients who function at level C6/7 will often recommend

self propel as opposed to tilt

— Remember best practices for weight shifting while on these

seats

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Thoughts from colleagues I have interviewed over past several months

— Bowel and bladder program best way to get reimbursement

– Miami as opposed to focusing on shower for example

— Can be on toilet for up to 3 hours- it can be fatal if client

gets impacted — Sitting - prepping and waiting ... Bowel program — Then shower program — Sitting tolerance over time (comfort)

— Client often will go home with attendant and then move on to

independent - need to factor that in when prescribing

— “I always order a pelvic positioning strap and a chest strap -

as a minimum ”

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Shorter rehab programs in the US..

Rehab programs are now only 3-6 weeks in the US ... This means decisions are being forced before the client is ready.. Not accepting of the long term need Biggest challenges are

— 1. acceptance — 2. getting home environment ready — 3. affordability of the mods

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Home Environment

— Home environment detail is critical - just as for wheeled

mobility assessment

— Layout of bathroom - 20" wide door likely cannot self propel — Home mods necessary for most who self propel — Consider tub or lip on shower versus roll-in — Turning radius very important for home visit assessments — Detailed existing bathroom measurements must be taken — Consider whether client will be self propelling or have

attendant push

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Some Basics ….

Today we will be focusing more

• n the positioning and skin

integrity needs of the clients who use RSCCs as opposed to the home environments details

Lets review some critical facts about posture: skin and positioning

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The process of sitting in general

To sit we need to

— flex our hips — get our buttocks back as far as possible on the seat — weight bear through both of the ischial tuberosities

and/or undersurface of the great trochanters, posterior thighs and feet with the knees flexed.

— Ideally the trunk and head will be upright up and

balanced above the pelvis. ( spinal stacking concept)

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The process of sitting on a toilet seat: western style

We need to

— flex our hips — get our buttocks centered over the hole/aperture in the

toilet seat

— weight bear through undersurface of the greater

trochanters, posterior thighs and feet with the knees flexed

— Ideally the trunk and head will be upright and balanced

above the pelvis or leaning forward as necessary

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The process of elimination from a postural viewpoint

A Guide to Better Bowel Care: A Complete Program for Tissue Cleansing Through Bowel Management, chiropractic physician and nutritionist Dr Bernard Jensen identified the sitting toilet as a health threat to mankind:

— "It is my sincere belief that one of the bowel's

greatest enemies in civilized society is the ergonomic nightmare known as the toilet or john."

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The process of elimination from a postural viewpoint

— The ideal posture for Defecation is the full squat,

which provides the abdominal muscles with the proper support during the expulsion process, as contrasted with the familiar “sitting on a chair” posture that is so commonly assumed on a standard raised water closet or toilet seat. In the “sitting on a chair” posture the person trying to empty the bowel is essentially passive and unable to aid the body’s natural mechanism of evacuation.

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The Modern Toilet

— The “porcelain throne” was actually invented in the

UK as a way to “civilize” such a “barbaric” act as defecating.

— Previous to about the late 18th and early 19th

centuries, our ancestors didn’t have toilets and were pooping by the most natural way our bodies were meant to poop: by SQUATTING.

— In ancient civilizations, the only people sitting to poop

were royalty and the handicapped.

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The Modern Toilet

— Squatting was considered too lowly and an act of

the common folk. Sitting was a much more dignified posture as compared to the animalistic squatting position.

— The problem that arose is that the sitting posture

was more for the satisfaction of the ego rather than the function of the body. If one looks at the anatomy of the human colon, what you’ll find is that humans are the only species where our bowels have to move upward against gravity.

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So… Toileting, even with intact neuromuscular control, can be challenging to the body from the seated position

In addition to those facts… If we don’t know these clinical things about our clients…

How can we determine what minimal essential features are necessary for this client to function in any capacity from a seated position?

—

What level of skin protection is needed?

— Consider pressure distribution: shear management: microclimatic

management

—

How much positioning is needed?

— Postures needing accommodation or correction —

How much stability is needed for function?

— Consider lateral and forward reach

We gain all of this information through interview as well as

• ur hands on evaluation

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SKIN INTEGRITY

What do we need to think about?”

Excellent reference

— National Pressure Ulcer Advisory Panel, European

Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014

— The National Pressure Ulcer Advisory Panel - NPUAP »

Resources » Educational and Clinical Resources » Pressure Ulcer Prevention Points

— http://www.npuap.org/resources/educational-and-

clinical-resources/prevention-and-treatment-of-pressure- ulcers-clinical-practice-guideline/- New 2014

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U.S. Statistics

— Number affected by Pressure Sores in Hospitals: 2.5 million

patients per year.

— Cost: Pressure ulcers cost $9.1–$11.6 billion per year in the

• US. Cost of individual patient care ranges from $20,900 to

151,700 per pressure ulcer. Medicare estimated in 2007 that each pressure ulcer added $43,180 in costs to a hospital stay.

— Lawsuits: More than 17,000

lawsuits are related to pressure ulcers annually. It is the second most common claim after wrongful death and greater than falls or emotional distress.

— Pain: Pressure ulcers may be associated with severe pain. — Death: About 60,000 patients die as a direct result of a

pressure ulcer each year.

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Skin Breakdown Statistics

Prevalence values remain high

— 15.5% US healthcare facilities (Vangilder et al 2008)

— 28% sacral — 17.2% buttocks — 18% EU standard and academic hospitals (Vanderwee 2007) Spinal Cord Injury manual Wheelchair users

— 14-84% reported prevalence (Klotz et al 2002,

Rodriguez et al 1994, Thiyagarajan et al 1994)

— Most common site – ischial tuberosity

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Skin Breakdown Prevelance

Acute Care – 10-17% Home Care – 0-29% Long Term care – 2.3 – 28%

Hartford Institute for Geriatric Nursing, College of Nursing New York University 2007

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Pressure ¡Ulcer ¡-­‑ ¡Defini:on ¡

“Localized ¡injury ¡to ¡the ¡skin ¡and/or ¡underlying ¡:ssue ¡usually ¡over ¡a ¡bony ¡

prominence ¡as ¡a ¡result ¡of ¡pressure, ¡or ¡pressure ¡in ¡combina:on ¡with ¡

• shear. ¡A ¡number ¡of ¡contribu:ng ¡or ¡confounding ¡factors ¡are ¡also ¡

associated ¡with ¡pressure ¡ulcers; ¡the ¡significance ¡of ¡these ¡is ¡yet ¡to ¡be ¡ elucidated.” ¡

¡ ¡ ¡ ¡

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NPUAP ¡and ¡EPUAP ¡

EUPAP: ¡European ¡Pressure ¡Ulcer ¡Advisory ¡Panel ¡

¡ ¡ ¡ ¡ ¡NPUAP: ¡Na:onal ¡Pressure ¡Ulcer ¡Advisory ¡Panel ¡(USA) ¡

– 4 ¡yr ¡collabora/on ¡to ¡develop ¡interna/onal ¡clinical ¡guidelines ¡for ¡the ¡ preven/on ¡and ¡treatment ¡of ¡pressure ¡ulcers ¡ – Research ¡based ¡

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Pressure Ulcer Terminology

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Agreement reached

— Terminology change – category instead of stage

—

Non-hierarchical i.e. eliminates misconception of progression of Ià àIV

• r healing progressing IVà

àI

— 4 levels of tissue injury categories I – IV — Unclassified/unstageable and deep tissue injury will remain US

categories but are considered Category IV in EU

NPUAP ¡and ¡EPUAP ¡2009 ¡

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Extrinsic Risk Factors

— External physical forces

— Pressure/immobility — Friction — Shear — Moisture — Heat

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Intrinsic Factors

—

Poor nutrition

—

Incontinence

— Muscle atrophy — Aging skin — Orthopedic deformities — Excessive body heat — Decreased mental status — Smoking

—

Disease

— Diabetes, cancer, Aids,

Cardio-vascular

— Radiation, drug therapy

— Impaired circulation — Venous insufficiency — Arterial insufficiency

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Risk Assessment

—

Consider all bed-bound and chair-bound persons, or those whose ability to reposition is impaired, to be at risk for pressure ulcers.

—

Use a valid, reliable and age appropriate method of risk assessment that ensures systematic evaluation of individual risk factors.

—

Assess all at-risk patients/residents at the time of admission to health care facilities, at regular intervals thereafter and with a change in condition. A schedule is helpful and should be based on individual acuity and the patient care setting.

— Acute care: assess on admission, reassess at least every 24 hours or sooner if

the patient’s condition changes

— Long-term care: assess on admission, weekly for four weeks, then quarterly

and whenever the resident’s condition changes

— Home care: assess on admission and at every nurse visit. —

Identify all individual risk factors (decreased mental status, exposure to moisture, incontinence, device related pressure, friction, shear, immobility, inactivity, nutritional deficits) to guide specific preventive treatments. Modify care according to the individual factors.

—

Document risk assessment subscale scores and total scores and implement a risk-based prevention plan.

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Risk Assessment

— Select a valid & reliable tool — Braden Scale – Norton Scale & Waterlow Scale are examples — There is no one tool recommended for accuracy and repeatability — Use clinical judgement — Document and re-document often — Caution: Do not rely on a total risk assessment tool score alone as a

basis for risk based prevention. Risk assessment tool subscale scores and other risk factors should also be examined to guide risk- based planning.

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Client Evaluation -Observe

— Skin inspection — Weight bearing surfaces — areas of redness — open sores

— Skin folds — Areas between iliac crest and rib cage as seen in

severe scoliotic sitting postures

— Note the following every time

— Skin temperature

— Edema

— Change in tissue consistency in relation to

surrounding tissue.

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Client Evaluation -Observe

— Method of transfer between all surfaces

— Pay attention to the sling type if being used

— Method of weight shifting… Is it effective and being

done consistently regardless of sitting surface?

— When the client is not in their chair – where are they?

— Bathroom commode: for how long — Bath seat: for how long — Bed sleep surface-position: for how long — Couch : for how long — Armchair: for how long — Car seat ; for how long — Recreational activity : for how long

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My Skin Risk Analysis - Relative to Seating

For me: these are the top 3 questions I must know the answers to….

— Is there presence of non blanchable erythema or open wounds on the

seated surfaces?

— If yes = High Risk — Is there a history of non blanchable erythema or open wounds on the

seated surfaces?

— If yes = High risk — Can the client do an independent effective weight shift consistently? — If no, for any reason = High risk

These clients likely need full pressure management through the cushion, back support +/- weight shifting technology everywhere they sit for extended periods of time….

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At The End Of The Assessment

— I should know If the client is

— High Risk — Moderate risk , or — Low risk for skin breakdown

— And why …. Remember to document the “WHY”

— With this information I know where to go on the

ladder of solutions for all areas of care.

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Mechanical Loading and Support Surfaces: Best practice guidelines

— Reposition bed-bound persons at least every two hours and chair-bound

persons with overall goals of care.

— Consider postural alignment, distribution of weight, balance, stability, and

pressure redistribution when positioning persons in any seating devices

— Teach chair-bound persons, who are able, to shift weight every 15 minutes

— 15 minutes every hour when using weight shifting technology (guideline).

— Use a written repositioning schedule. — Place at-risk persons on pressure-redistributing mattress and seated

surfaces.

— Avoid using donut-type devices and sheepskin for pressure redistribution. — Use pressure-redistributing devices in the operating room for individuals

assessed to be at high risk for pressure ulcer development.

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Mechanical Loading and Support Surfaces: Best practice guidelines

— Use lifting devices (e.g., trapeze or bed linen) to move persons rather than

drag them during transfers and position changes.

— Use pillows or foam wedges to keep bony prominences, such as knees and

ankles, from direct contact with each other. Pad skin subjected to device related pressure and inspect regularly.

— Use devices that eliminate pressure on the heels. For short-term use with

cooperative patients, place pillows under the calf to raise the heels off the

• bed. Place heel suspension boots for long-term use.

— Avoid positioning directly on the trochanter when using the side-lying

position; use the 30° lateral inclined position.

— Maintain the head of the bed at or below 30° or at the lowest degree of

elevation consistent with the patient’s/resident’s medical condition.

— Institute a rehabilitation program to maintain or improve mobility/activity

status.

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Skin Integrity Protection from what everywhere the client sits?

Microclimatic Moisture, Heat, Humidity

Shear

Pressure

Friction

Immobility ¡

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Summary of some very important considerations

— Remember to check the Clients skin yourself — Think about everywhere the client may be sitting/lying/

standing

— Implement and document a best practice for determining

duration and frequency of whatever weight shifting technique is to be used — This is very important

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Critical anatomical consideration

When considering seat supports in the bathroom –the clients very narrow ischial base

• f support is a critical

consideration. In the commode seat: the aperture width/size is an important consideration not

• nly for skin protection but also

for stability. Generally the ischials are “ in the hole” which means the load is being taken on the undersurface of the greater trochanters

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What this information translates into while using bathroom equipment

— Remember the pelvic size doesn’t grow once we become

adults…. “ Bummer…. Its not that we have big bones like Momma said!!!! “

— Anthropometrics don’t lie!!!!!!

— Male distance between Ischials – 4-4.5” — Female distance between ischials – 5-6.5” — General width between undersurface supporting area on

trochanters is approximately 9-11”

— So regardless of overall body width… Pelvis must be supported…

We can’t have ‘ falling in” … or potential for high pressure areas

— The “Hole” size/shape is critical ….. Otherwise known as the”

aperture”….

— If sitting on a tub transfer bench that has not factored this in –

lateral stability and pressure management is compromised

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Postural/Functional needs

• f our clients

— Consider the support and space needed during transfer — What's needed to lean side to side and stabilize while

“taking care of business” independently

— What’s needed when an assistant is involved for the

toileting detail

— I think of postural support in terms of

— Inferior and posterior support as our primary support

surfaces

— Gravity assist as necessary for postural support and/or

weight shifting

— Lateral and /or anterior support as the assistants to the

primary support surfaces – consider for what activity and what duration: the purpose…

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Example of Postural support options & considerations beyond the seat and back

• Swing away Laterals – how adjustable are they for optimal

support?

• Arm troughs for more upper extremity support
• consider any interference between the two
• Can the client hook on one side and lean safely to other for

access to body as well as for any necessary lateral lean weight shifts?

• Is the material easily ripped and therefore prone to water

logging?

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Example of Postural support options & considerations beyond the seat and back

— Consider a tray as upper extremity support – lean

forward option

— Chest and pelvic positioning straps — Elevating legrests ( consider any space limitations) — Head rests — Lateral thigh support/s ( remember the impact these

may have on body access)

— Foot positioning Right – Left – Center – Angled — Anterior slope or rearward slope in seat..

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Tilt in Space RSCC

— Consider — Ease of use and durability of

tilt mechanism

— Range of rearward tilt

possible

— Range of Anterior tilt possible — Weight load capacity — Sitting width versus overall

width

— Self propelled or attendant

pushed?

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A clinical challenge that seems to be consistent in a lot of geographic areas

— Clinicians feel like they are forced by funding

circumstances to “settle” for equipment that may not be meeting the full needs of the client especially in the area of skin integrity and optimal positioning.

— They have worked diligently to secure an optimal

wheeled mobility device with appropriate seating for skin protection and positioning but are fearful that so much time spent in the bathroom on less than optimal equipment can result in life threatening consequences

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Can Interface Pressure Mapping be helpful as an adjunct to the assessment findings?

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What we learned from Interface pressure mapping

— Size- location and shape matters… when it comes to the

relationship between the buttocks, (the bony structures/ tissue) and the aperture

— Seat Material matters when it comes to load distribution

initially as well as over time

— Back support matters when we are looking at positioning as

well as load distribution The clinicians involved were blown away with the differences between these 3 pieces of equipment. They believe they will from then on pay more attention to what they are prescribing for clients who are at risk for skin integrity issues and who will be using RCCs for any length of time.

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Given this information… Seat style is important….

—

Consider opening location

—

Material: durability; load distribution; infection control

—

Aperture dimensions- measure them

—

Overall dimension and shape of sitting surface

—

Interface with frame; does it facilitate desired access?

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Back Supports

—

What are the options available?

—

Can I adjust angle and height to get the desired posterior loading necessary for my client?

—

Is seat depth or where the clients buttocks are positioned impacted by the back support?

—

Just as in the wheeled mobility world – no seat works alone without optimal posterior loading

—

Is it easy to clean and does it comply with infection control?

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In Summary: Think about this clinical information

— Anthropometrics – bony dimensions — Postural presentation

— Anterior pelvic tilt - lordosis — Posterior pelvis tilt- kyphosis — Pelvic obliquity and rotation- scoliosis-windsweeping

— Skin integrity presentation

— High risk — Moderate risk — Low risk

— Length of time in position for bowel bladder management

regimes as well as for shower regimes

— Need for Independent function and/or Assistant control/help

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Translation of the clinical information

— Anthropometrics – bony dimensions

— Aperture:

— Dimensions — Location

— Access point location

— Postural presentation

— Anterior pelvic tilt - lordosis — Posterior pelvis tilt- kyphosis — Pelvic obliquity and rotation- scoliosis-wind sweeping

— Aperture and support surface shape — Seat adjustability/customization — Back support adjustability — Feet support adjustability

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Translation of the clinical information

Skin integrity presentation — High risk — Moderate risk — Low risk

— Support surface material/contact area

— Pressure distribution/shape and material — Ease of transfers/shear reduction/yet enough friction for wet bodies

— Length of time in position

— Weight shift ability.. Independent or dependent (tilt for example) — Arm supports/location/weight load tolerances — Foot loading ability — Back support ability for optimally loading/set up — Lateral and or anterior assisting supports

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We’ve come a long way with toilet seat design!!!

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Thank you for attending this presentation!

Questions ?

Sharon Sutherland, PT Sharronpra@msn.com www.seatingsolutionsllc.com

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