Dr. Jeannine Maguire: Welcome everybody to this presentation brought to you today by HealHorizon, sponsored by O&M Halyard in partnership with PAWSIC. My name is Dr. Jeannine Maguire, and let me share with you a bit about PAWSIC before we jump into this exciting content today. PAWSIC is the Post Acute Wound & Skin Integrity Council. We are a 501(c)(6), we are a non-for-profit organization. We are all volunteers that represent an interprofessional team to serve as a resource and advocate for all those in post-acute care for skin health and wound issues. We provide webinars, education, guidelines, whitepapers, checklists, handouts, and others. Please check us out on our website and join PAWSIC today.

 
Without further ado, I'd like to take a moment now and introduce today's presenter, Michele Deppisch, who's also another physical therapist and a certified wound specialist and the president-elect for the National Pressure Injury Advisory Panel. Today's presentation is Optimizing Pressure Redistribution for Wound Prevention and Healing: Evidence-Based Approaches. Thank you so much, Michele. The floor is yours.
 

Michele Deppisch: Thank you, Jeanine, for that wonderful introduction. I wanted to let you know I have no conflicts of interest relevant to this topic, and I am not speaking on behalf of NPIAP. The opinions expressed in my presentation on my own. These are my objectives.

To arrive at these findings, trained abstractors reviewed more than 22,000 inpatient hospitalization records for each year using AHRQ's quality and safety review system called the QSRS. This program collected data that included 41 types of adverse events for each year for patients aged 18 to 64 and those 65 and older.
 

Eighty-five percent of the patients in this survey were 65 years and older, no surprise to any of us in health care. The AHRQ program sounds very similar to the Centers for Medicare and Medicaid's Electronic Clinical Quality Measures, now called eCQM program, which will begin withdrawing information directly from the EMR system on pressure injuries in fiscal year 2028, which actually starts in October of 2027. So we have between now and then in the acute care setting to learn how to accurately stage because time is of the essence. 
 

Looking at this data, one could extrapolate that health care providers have learned how to prevent pressure injuries, which is why the HAPI rates are so low compared to the treatment of existing pressure injuries. This would indicate that wound management requires more intensive education. 
 

Looking at this slide, which is from the 2025 new clinical practice guideline, is a new graphic. It's been in the clinical practice guidelines since I think 2014, maybe even 2009. It was in a different format, it looked very complex. What they've done this time is to manage it and put it into something a little bit simpler to understand, but I'm not going to take you through the entire deep dive into cells. So let me take you to the next slide, which will help you to understand the difference between the slow damage mechanics, which is traditional pressure ulcer formation that we learned, And then the fast damage, which is now pressure plus shear. 
 

So in this one, we have the first variable, it's the bed surface. Your patient arrives and is placed on the bed surface. The next one is the weight load, this is your patient. We add to that tissue. This weight load is wrapped in young tissue, which is strong and elastic, or it could be wrapped in older, thinner skin, which is not elastic. That actually leads us to our next variable and that is adding time. We have to make sure that our fourth variable is in there, and that's the amount of time that the patient spends on the surface. You have some control over the amount of time. So it is weight load, wrapped in what kind of skin, because that determines the tissue tolerance, to the amount of time you're going to leave a patient in that position. 
 

So here's what's happening inside this cell destruction that you don't see on the surface. Let's start at the starting point and go clockwise. We've got pressure, we're laying on the bed surface. And we begin to have some deformation of cells, so the cells don't like to be squished. Once they begin to be squished, what happens next is that they begin to rupture. As they rupture, they release their internal contents. That produces a chemical reaction into the system. And what happens next is, is that the body reacts by sending in the inflammatory macrophages and more fluid into the area, to fight what it believes is a new battle that it needs to solve.
 

That only makes the issue worse because we were compressed and we weren't getting circulation. That's why we were rupturing, and now the body's sending more circulation to us so we have even further compression. This is what we call the tip of the iceberg, when we see the superficial pressure ulcer, we don't see all the damage that happens below.
 

And you can see then, going the rest of the way at about 9:00 before we get back to the buttocks, is that we have more loss and more damage, and we wind up having more ischemia to the whole process. This can be determined by the amount of time that you allow the patient to stay in one position. And now, what can you do to change the rate of damage?
 

And so the rate of damage can be affected by two types of shear. This is a ballistic gel and the upper-left image is just across of the dermis, and we see the different vascular system and some little organelles that are in there. And now we have shear stress, which is primarily in layman's terms, a compression type of stress.Straight down onto the bed surface, you can see that there's some distortion there. Now, we add to that what we call shear strain. And shear strain is pressure first, and then it shifts or moves on a parallel surface to the bed. 
 

Where do we commonly see this? This is when the patient, the head of the bed is raised 30 degrees, the legs of the patient are completely extended outward. As the head goes up, you notice that there is a slide downward toward the foot of the bed, and what has happened is, is that the weight-bearing skin has stuck to the surface. The skeleton and the upper weight load have pulled against all of that tissue. So again, down pressure we get waste products, we get a slow cell death. This occurs in hours. 
 

Then if we have shear, what happens next is we have deformation of cells, we disrupt the cytoskeleton, it breaks down, and it breaks down in minutes. Remember, shear is your worst enemy when it comes to developing pressure injuries. 
 

So in this clinical question, considerations that are in the new 2025 guideline. It's set up really different than what you've expected from previous clinical practice guidelines and it asks you clinical questions. So what are general considerations when selecting a support surface for an individual at risk with pressure injuries? And it now gives you evidence to look at that that they believe is important, that you should take into consideration when you're looking at a support surface. 
 

And I think you'll also see that the research or the evidence is different than what it has been in the past. Often, we saw case studies from different industries that might've had prophylactic dressings, or they might've had a certain mattress, things like that. Grade, G-R-A-D-E, looks at methodology in a far more in-depth view. So it has to be a very significant, unbiased research study before they're going to give you evidence on it. So the supporting evidence that you'll see is graded different. Most of the industry case series are talked about as good practice. It doesn't diminish them. It's a different method of looking at grade, so don't throw the baby out with the bath water there. Make sure that you're looking at it and understanding what you're looking at. 
 

This is a great table for consideration. And before I start, you can see all the different features. Why am I talking about the bed? You got plenty of other things to do. You want to look at the skin, you want to look at pressure injuries. Everybody brings a patient in, they go into the open room. And whatever bed's in there is the bed they get, excluding the fact that they would be bariatric and you'd have to order a specialty bed. We need to look at our bed surfaces, that's where the patient is.
 

We can't be looking for pressure injury prevention and our bed's working against us. So I'm here to raise the flag that we have to pay attention to what bed we're putting our patients on. How are you supposed to know this? You are not. The person who makes up your bed algorithm or what you're going to rent when, needs to go back and revisit the bed surfaces or resources you have in your facility and then redo that bed algorithm so that you know certain beds have more immersion, certain beds have more envelopment, certain beds have better management of microclimate, certain beds have better management of shear. Then that goes on your bed algorithm, but here, we're giving you some of the basic features that you look at for a bed.
 

And the Support Surface Standards Initiative out of S3I looks at these, and we provide clinical relevance documents for the public. It's usually published through Advances, so we'd be able to tell you: Why is this important? Why is pressure redistribution foam an important feature? Why is microclimate management an important feature? And here you can see what different features, if this is the bed in the left column, it tells you what are the features and then what we call the characteristics and clinical considerations. 
 

So a full body support surface is what we call them. We do not call them beds and mattresses, we call them full body support surfaces. And the full body support surface, it can be an overlay, it can be design, it can be an integrated bed system, but it is what you need. The first thing you need to look at is its ability for pressure redistribution. All these beds, very expensive, are designed first for pressure redistribution, and we're going to talk about what pressure redistribution is. 

They can be made of gel. All beds don't have to be air, they can be made of air cells or air bladders. They can be made of medical-grade beads, those air-fluidized beds, and they can also be made of a combination of these components. So I want to talk to you about how does a bed provide pressure redistribution? That's your first principle of pressure injury prevention is pressure redistribution. 
 

And so why do we call it pressure redistribution instead of pressure relief? And it's because when we have pressure relief, we talk about that, as it implies, complete elevation off of the surface. And if we have complete elevation off of the surface, that is relief, as if you took the heel and lifted it up off the bed. So pressure redistribution means that the patient has immersed into the bed and the bed has come up and wrapped around it. In the commercial world, let's think of us on a soft Tempur-Pedic mattress. You go to lay down and you can just feel it come up around you. All right. So when you laid down, that was immersion. When you felt the bed come up and around you, then that was envelopment. 
 

And what happens is, when I lay down, let's say my pressure points, and we'll use the heel and the sacrum as an example. The bony prominences on my sacrum and the bony prominence of my heel are focused. All the pressure is focused right on a pinpoint, as you see in the egg on the left, that's poor envelopment, it's concentrated. It's like standing on a trampoline. This is my bed at home or commercial surface, it gets some envelopment. And then the other, the last is a complete envelopment, more like an air fluidized or if you were floating in a swimming pool, then the water's coming up and around you. 
 

So what's this pressure redistribution? As I said, it is the number one item that you need to have. And benefits are definitely reduced pressure and then we've got to have pressure gradients need to be reduced because that's shear.
 

We looked at shear, we have to make sure we reduce shear. And then we had to make sure we have to reduce any potential for tissue deformation. So look at that bed, when the patient comes in, you can see what you're getting. Are you getting an active football player who just fell on the field? Or are you getting grandma, who has thin, wrinkled skin?
 

And now take a glance at the bed that's open to you in that open room, is that really the bed that we need to have in there? You need to make sure that you can move that bed, they're all on wheels. Get the bed in there that you need to have. 
 

A little comedy here, and so is more immersion and envelopment the best? No, it's not the best. And so you've got to make sure that you have just enough but not too much, or if you have too much, you get a term called bottoming out. When S3I, the Support Surface Standards Initiative, the clinicians, we did a survey. And we asked clinicians if high levels of immersion and envelopment were always ideal in preventing pressure injuries? Thank goodness, about 58% of them got it right and said, "No, that's not true." The reasons they gave for it being not true were bottoming out can occur. Too much an immersion and envelopment can limit the patient from getting out of the bed if they were trying if were on early mobility. And then also increased immersion and envelopment has been shown to increase the microclimate of patients' skin, as reported at the last WOCN Conference by Dr. David Brienza. 
 

So support surface categories, there's two overarching types of pressure redistribution. And so you may see this in your bed algorithm that first it'll say a reactive support surface. I just want you to know what that is. The reactive support surface can be powered or nonpowered. You've laid on those beds where if you lay on one side, you'll see it elevate the mattress, that elevated opposite you at the other end of the bed. It does work, it has immersion, it has envelopment, and it's there to reduce the pressure contact layers you see in the image on the left.
 

Active support surfaces are usually powered, and they also have immersion capabilities, but you may also see that they are alternating pressure or offload. Sometimes you'll see them as alternating pressure and they have offload. So they have different cycles where the bed baffles or bladders, you'll see some will go up and some will go down, some will go up and some will go down.
 

So one of the benefits for this, and our benefits are that this is going to offload pressure from different parts of the body at different times, reduced peak pressure over body prominences, pressure gradients are reduced. The surface has a greater hold on the patient, which leads to less shear. So the potential for tissue deformation is reduced, because we're up and down and we spread out the weight load. And then also this alternating pressure can increase skin perfusion when tissues are offloaded. 
 

We've had people tend to automatically order a traditional continuous low air loss bed thinking it's going to do all these things for them. It may not be the bed for your patient, so you may need alternating pressure. You may just need a reactive surface and you don't need to go to the big gun, so to speak. 
 

So here, you can see in this image, the patient was in a nice dual foam. You see two layers of foam, so it's a nice dual-foam mattress. A lot of times that's the standard mattress in the hospital. And the head of the bed was raised. You can see that there was some resistance by the purple arrows aiming toward her buttocks. But the large green arrow is showing you what has happened. The weight-bearing skin has stuck to the surface. Her skeleton and her upper non-weight-bearing body load weight have slid down toward the foot of the bed. What's this going to give you? This is going to give you now shear. And what could have prevented it? As I said earlier, what could have prevented it was if we had bent the knees before we raised the head of the bed, so that we hold the pelvis in place. 
 

This is it. This is how you're going to capture the pelvis. Don't have to raise it high, 15 to 25 degrees, just enough to keep the pelvis in place and then elevate the head of the bed. We need to remember to do that. So often, maybe a patient gets done with their bath. What happens is, they're a little damp. Even though the bath blanket was down, they're still a little damp, and the head of the bed comes up.
 

Without thinking, the patient says, "I'd like to have my head raised." So we raise the head, forget to raise the knees first, and then what happens next is, is we get shear. 
 

There's also the possibility that in many of these automatic beds, where there is knees come up with the head, you've got to make sure that the patient's pelvis is in what we call the seat section. So it's got to be in the middle between those two gatches, that's the seat section of a support surface. 
 

In this slide, I wanted you to see what actually was happening and get a good look at the skeleton here. You can see in the left image, we'll go to the top first, the pieces. First, we have skin surface laying down flat on the bed. And there's the skeleton and we're going to watch the L5 vertebrae. And when the head of the bed comes up and the pelvis is continued, the legs are still out straight. What we see is, is that L5 graded down over that tissue, and moved about three-fourths of an inch. It doesn't sound like much, but imagine that happening over and over and over again all day long. It's eventually going to shear that tissue that's down over the sacral area. 
 

Now, to see it in action, you can see what it looks like when that bony structure just rides over those internal tissues. Think of the fine lymphatic system and the fine vascular system that's being sheared. Once it's sheared, then we begin to have our ischemia into the area, and it's going to wind up being the tip of the iceberg. These are the pressure injuries that have undermining. 
 

How do you help with your support surface? What can you do, in addition to positioning? You can look at the cover makeup. What is it? A stretch fabric, a four-way stretch? Is it vapor permeable? So your cover fabric will make a difference in holding the patient in place and reducing shear, just even turning side to side.
 

Also, making sure that the articulation of the frame and the head of the bed elevation, those things also help to reduce shear. Although this presentation is not on the multilayer silicone foam dressings, which we call prophylactic dressings, those are also an answer to your reducing shear, and moving and positioning systems, turning and repositioning, those are also another means to reduce shear.
 

So in this, we want to look at different positions that people slide into in the wheelchair. You see them especially in our long-term care facilities. And as you look at it from a skeleton's point of view, you can see how the ischial tuberosities are just grating into that chair. So now thinking back, what's the cushion?
 

Now, this is where we need to make sure that someone who does not have good sitting posture or good trunk control, has a good seating cushion or they're going to break down. And then they're going to be in bed, and you're going to have to make sure that you're turning them off of that pressure injury and onto what they need to do for pressure injury healing. Do we have to move them and find another bed? 
 

So let's start at the beginning, make sure if they're in a specialty bed, they need to have a specialty cushion. In long-term care, OT and PT often work with seating positions. And then maybe, for example, the patient with the pelvic obliquity, maybe they need postural sides or a specialty back to their wheelchair, not just the seat cushion.
 

Maybe they need, if they're just using a house wheelchair, those are the ones we really need to go back and look at and make sure that there's a cushion into them. And they are appropriate, they are in good condition, and that the leg rests are at a 90/90 angle, so that we're not getting too much pressure into the heels. Or they're able to slide because they're not at the right angle for that.
 

What's the recipe? Prolonged sitting, abnormal posture. Skin ages add to it. Decreased sensation, they're not going to tell you that they feel pressure on those peak, bony areas. And then decreased mobility. Once you put them in the chair, they're stuck in that position, and so what are we going to get? Increased pressure resulting in a pressure injury.
 

When you look at this, this is a pressure mapping. And everyone loves to look at pressure mapping because it gives us an idea of how we did with seating that patient. And so when you look at the different structures here, you can see starting at the left top, there's your standard cushion. Next, we went to a foam cushion. You can almost see the layers of the foam. Then we went to a cushion that looks to be somewhat like a waffle. Down on the bottom row, we have an air-foam cushion and then we have an air-adjustable cushion. So what we want is blue. The more blue we have, the better off we are, and that gives us an idea of the best pressure relief. However, it's not the end-all. Just because you put them on a good cushion, you have to remember that they have to have pressure relief or offloading. 
 

So here are some examples from some nursing education of different ways that we can sit in a chair and offload the buttocks and the ischial tuberosities in the sacral area. You need to in practice, as stated in the clinical practice guideline.
 

In a sitting position, you're supposed to every 15 minutes, do an offloading or pressure relieving for 20 to 30 seconds for adequate reperfusion. Again, skin tolerance will tell you what you need, and I believe that now many places are no longer using what we see right here is the geri chair.
 

Before you put any kind of device, so I want to offload the heel, but before I do that, what do I need to look at? I need to look at the skin. So I need to look at temperature. I need to see what's going on, because you know that those patients have complained, "Oh, I don't want to wear my heel boots because they're so hot." And the heel boot company is telling you, "Oh, ours aren't hot." Well, the patient's telling you that it is hot. So what's my temperature of that lower extremity of my foot and leg? What's my color? Because that's going to be the indicator when I come back to check and see if there's any pressure occurring in spots of the heel boot. And then am I getting any moisture?
 

I need to know is my skin already wet or very dry to begin with? If I pinch it, does it return to its normal state easily or is it very slow? So that's telling me my reperfusion could be lacking. My integrity, do I already have open areas? Am I already looking at that heel because it's pink? Then I know that I have areas to check. So if that heel is pink and that's why I'm putting the device on, I need to make a good note of how pink is it? How large is it? Is it going to change any? Because then is what we have to make sure that we're tracking. 
 

So as I put my heel device on, I'm going to put it on someone. Not going to put it on everybody because maybe everybody doesn't need it. But I'm going to put it on someone who has poor sensation. Diabetes, definitely, that's the number one thing that is in the clinical practice guideline. People with diabetes have the most problems with the most skin and pressure injury concerns. Impaired circulation, well, that comes with diabetes. Peripheral vascular disease comes with diabetes.
 

Poor nutrition, just because someone's obese does not mean that they have good nutrition. They could have very poor nutrition. So we have to feed from the inside in order to make sure that our pressure injuries heal or are prevented. It's part of a concept that Joyce Black has used in many of her lectures. 
 

And I'm actually going to speak with her on this same thing, is the three-legged stool, it requires pressure relief. Find the pressure, make sure the next leg is, diagnose it correctly, what is it? And then we're going to treat it correctly. Dress it with the appropriate dressings, but the third leg is nutrition. If you don't feed it, it's not going to heal no matter what you do for it. So don't let the snacks that the patient's supposed to have, those cans of Boost, don't build a pyramid on the nightstand. Make sure the patient drinks those or takes in the snacks that they're supposed to have. 
 

When you come back after you've applied it, make sure that it fits correctly. Make sure it's not cutting in. It's not too tight for the girth of their leg. There's no indentation from the device anywhere on the leg and the posterior ankle is supported. Skin check, when you to reposition the patient, you should take the boot off, check the area, put the boot back on again. Don't just roll them over into a new position and not check the skin. 
 

In the upper-left corner, the visual of the ankle, it's that posterior. If you can see, I don't know if you can see my cursor, but that the vascular system is outlined here, and you can see how shallow it is along the back of the Achilles. So if you elevate the heel with a pillow and you go perpendicular, so I've just laid it across the foot of the bed.
 

What's going to happen is, is that pillow, as it compresses, will actually compress into the posterior ankle, and begin to reduce or impair circulation down into the foot. What you're supposed to do with a pillow is elevate the heel so that your hand clears the heel and the mattress surface, and it goes the length of the leg, not across the back of the ankle.
 

Here are just some boots that you see, heel boots that are common. What you want to see also is, is that they're supposed to prevent, you want to prevent any breakdown, and you want to make sure that they work. They've got to work according to what's happening within what you desire. I'm trying to figure out what I wanted to tell you. It's doing what you wanted it to do. So make sure that that's the heel boot that you have that's working correctly. You don't want to have too much rolling out of the foot, and you don't want to have too much roll in. You want to put it into a comfortable position, which is a slight amount of external rotation. If neutral is 12:00, it's probably going to rest normally at what would be the toes pointing to 10:00. 
 

Microclimate we're starting, so microclimate has to do with our water and temperature. So skin cannot tolerate too much water. It becomes weak and separates, and it becomes more susceptible to friction.
 

Damp skin sticks to the surface and becomes more susceptible then to sticking when you're trying to turn someone, and we begin to actually cause shear at that point in time. Then we have increased temperature. If I increase the temperature, I'm going to stimulate the body to produce more fluid into the area, and that's not what we're looking for. We're not looking for more fluid in the area. 
 

So too much water is not good. Too less water can make the skin dry and crack, and then too much temperature can make the skin produce perspiration. Sources that we often see, you see perspiration, you see urine, you see stool, you see wound exudate. If you've got a leaky drain or a leaky ostomy, what we call transepidermal water loss.
 

And then what does it lead to? It's going to lead to enough moisture that you need to be looking at a bed that had what we call microclimate management assistance. 
 

When I talk about microclimate, what am I talking about? I'm talking about the temperature and the humidity at the skin surface that's weight-bearing on the bed. I'm not talking about microclimate on the belly. I'm talking about microclimate, if the patient's supine, on the buttocks, on the back, on the thighs, down around the lower leg. And so as I lay in the bed, then my temperature can elevate. And as I elevate my temperature, I begin to perspire so I'll produce humidity.
 

And so the bed that we're looking for that will help to withdraw this humidity and keep the skin from becoming overhydrated, is a bed that has microclimate management built into it. I'm going to state it now and I'll state it a lot coming up, does not mean it's a low-air-loss bed. A low-air-loss bed is designed for pressure redistribution.
And just by coincidence the way it's designed, it does have some airflow that comes out the zippers, out the seams, or it may intentionally have airflow. Those are the beds that have the built-in microclimate management. 
 

So this is how it works. I've got the motor, my motor's putting air in here. There's intentional air. The red arrows show you the cover, and then my patient up here is not moving a whole lot, so we've got a lot of perspiration and microclimate going on. So the bed is helping by letting it drip through the cover. It goes through the sheet, the sheet's on top of the cover. The cover then is going to absorb moisture from the sheet and then take it away.
 

And as it flows around the bed, it evaporates or they may have an exit for air to come out and air to come in, depends on how it's designed. But I want you to see how this works. Here's the sheet, water comes down and it flows out and around. You've got to make sure that you have a bed that can do that. 
 

So if we've got offloading and you still have to turn your patient, just because they're on a low-air-loss bed, that doesn't go away. You still have to do that. It's important that you understand the bed's only going to help you, if you provide it or let it help you. And make sure that you've got, if this is where your bed algorithm will come in, it can tell you on a spectrum, this is how beds are tested or support surfaces are tested. 
 

So if they're testing a bed for microclimate management assistance, it will produce a number. The number doesn't mean that bed is good or bad, it just means the amount of assistance it can provide you. So first, it provides you pressure redistribution, and we look at that number. But if we're looking at microclimate and let's say the values come out to be 1 to 10. Maybe a bed that has a 1 or a 2 would be the kind of bed that we would put in outpatient surgery, people aren't going to be there long.
 

Early mobility program, people are coming in with their orthopedic condition and then they're leaving quickly, I don't need to give them a lot of microclimate support. 
 

How about the person in ICU who's not going anywhere? I have to turn and reposition them, they're immobile right now. They're on a ventilator. They're receiving medication that is causing them to maybe third space. That patient needs the bed that had a ranking number closer to 10. So that's why we need to know what the difference is between these bed surfaces, so you know you put your patient on the right bed and the bed is working with you, not against you. So this is the history of low– Let me see if I can get the right. There we go. It started in the '70s. Initially, here's our inflatable appliance that Scales developed. And then in 1990, Stroh came up with a low air loss mattress that had air flowing through it and out the seams, to here we are in the '90s, we have dozens of products. There's no standard currently to base performance, like which one of the beds is best? There just isn't. It is what does your patient need? And here's where you are on the spectrum. So no one bed is the best, despite whatever the marketing people may tell you. What does your patient or your unit, or the patient population for which you're buying beds, what do they need? What's their standard or their most average clinical appearance? That's what you're looking for and that's how you're going to look at beds. 
 

To clarify, S3I on the website wanted to deprecate or put away the term low air loss, but it is a construction design of a bed, so we couldn't do that. So our education is, when you say low air loss, think pressure redistribution surface and not microclimate.
 

We were getting people to order low air loss beds, buy low air loss beds to manage microclimate, and then they were complaining that they were still getting pressure injuries. Of course, you are. That wasn't what the bed was originally designed for. Pressure redistribution, microclimate management assistance, and not all air beds are what we call the low air loss, what you think of the low air loss design support surface. 
 

We can have active airflow that can provide microclimate management, air-fluidized particles and alternating pressure beds. All of those do provide the same, can provide microclimate management. 
 

You have your microclimate management bed, and if you look at this, we've got here's my surface, my cover. I have a sheet, I have two long incontinence pads with a fiber back. I have another sheet, and then I have a quilted reusable incontinence pad, and then I have a smaller incontinence pad. All these layers, this bed's doing nothing. What we've done is we've prevented immersion, we've prevented envelopment. And then we've also, if the bed was providing microclimate assistance, there's no microclimate getting through here, because anything dripping is stopped right here at the quilted incontinence pad, which was the intention for capturing whatever was going on. I'll take a quick guess that this patient had C. diff and diarrhea constantly, and so people were trying to protect the cover was the answer we got when asked why the bed was made like this.
 

Let's not protect the cover; the cover can be cleaned. Let's protect the patient. We call this the baklava bed. Now what happens when you use all these layers? And so in this first study over here on the left, it may be a little too small for you to see, but my total heat withdrawal is the darker blue, and my ability to evaporate moisture is the lighter or lower blue.
 

So with a fitted sheet, I'm at 82% of heat withdrawal, so I'm going to not overheat the patient. Therefore, I'm not going to cause the patient to produce a lot of moisture, in addition to what's there. Then we lower our capabilities. This is a fitted sheet and one breathable incontinence pad. This is a fitted sheet and a slider sheet. We drop down here, we're now at 61%, and this is a fitted sheet and a maximum strength disposable pad. This is a fitted sheet and a quilted reusable chux. This is a bed with 6 layers, as we were looking at it, so now you can see we're not withdrawing any heat practically out of here. And we've only got 2% of evaporative capacity.
 

So here's what a standard foam surface is. So my standard foam surface is nearly what I did to my expensive bed. I brought it down into this area. I could have put them on a different bed and saved some money if that was what I was going to do. Layers matter, you need to remember that. Layers matter. 
 

Here's a pressure mapping on a low air loss surface with a fitted sheet. This is a low air loss surface with a fitted sheet and a breathable, disposable pad. This is the low air loss bed with 6 layers of linen over here to over here. And then you wonder why that patient got a pressure injury. You took away immersion, envelopment, and you took away the ability for microclimate management assistance.
 

Turning and repositioning. It's as you turn and reposition the patient, it's important that you work for the 30-degree angle on the pelvis. There's research to indicate that at 30 degrees, that's the best angle for the pelvis to relieve areas of pressure. Patient with a larger BMI may have to go to 40 or 45 degrees in order to get that same pressure relief. But your normal patient in the normal BMI range, 30 degrees is the way to turn them because it reduces the bony prominences into the bed frame. 
 

People are always asking, "What bed can I use if I don't have to turn my patient?" Well, there isn't a bed that you don't have to turn your patient. Everybody on every bed needs to be turned, and why? Because we need to get the sacrum off.
 

People are saying, "Oh, they turned." And if I go in and look at them, so their shoulders are up, but their sacrum is still in contact. So on a total body rotation bed, these beds do change and shift some pressure. So the upper one is a total rotation where the patient is placed in it and then held firm and the frame rotates. These bottom ones are bed surfaces that the mattress chambers come up and come down. They are pulmonary, they were designed for pulmonary function improvement. So you need to remember this is a pulmonary bed. If the sacrum and the shoulder blades are not coming off, you didn't really turn that patient.
 

Here one of the studies looked at 50% of the pressure injuries in a six-month period on that continuous rotation bed. They had increased pressure injuries. And then pressure injuries decreased when manual repositioning was implemented on the same rotational bed. You should be able to put your hand through, so as I turn my patient and supporting the trunk, the upper trunk, the rib cage. And then I'm supporting the upper thighs and down to the knees, and so I should be able to put my hand through and feel that sacrum is open and exposed so we know it's offloaded. The turning position so often is right, supine, left. Try the, since we know the supine area is at high risk, change your rotation to right, left, supine or left, right, supine. Don't keep going to the middle every time, because that's the area where you know you're going to get the pressure injury most commonly. 
 

Bariatric patients, this does matter, you have to take this into consideration. Don't try and squeeze them onto a bed because you don't have one in there. If you've got to do something for a minimum time, then you've got to make sure that you're going to be able to get that bariatric bed.
 

And get that bariatric bed quickly, because we know that pressure from side rails, because you're going to have to restrain that patient, can be then working on their skin. And it will be like the tip of the iceberg, we won't really see it until it actually blossoms out. But it'll be where the side rails contain the patient and the bed was just too small for them.
 

So on guidance, these are things that you need to pay attention to. What happens, what do you need to do? So as you rent this specialty bed, you need to think to yourself, or if you're going to buy it, "Where am I going to use it? What kind of surface do I need? What's the population for that particular type of surface?"
 

Make sure that you think to yourself, "Do I need the surface for falls, fall risk patients, or for patients with contractures? Does the frame and the side rails meet your safety requirements? Do they need an active surface or a reactive surface?" Maybe they just need foam, so what are you putting in your units? One bed throughout the hospital is not going to work.
 

If they're immobile, remember, they may need high levels of immersion and envelopment. If they're in an early mobility, they may need a foam or a foam and gel combination where it's easy to get in and out of. Do your research with your vendor of interest. Find out the results of their standard methodology testing for immersion, envelopment, microclimate, and shear. They know that they can get this information on, the testing methodology is out on a research website. They just have to come to NPIAP, and they can see where they have to go to get the research. 
 

Review your current facility algorithm, make updates, and remember, no one bed is perfect for everybody. 
 

So my key takeaways for you, pressure injuries begin with the weight load over a time period resting on a surface. You control the time and the type of surface. 
 

Turning and repositioning are critical, not going away. Do you need a turn team because we don't have enough nurses? How are we going to manage this? It's just got to be done because that's your first line of defense. 
 

Full body support surface and chair cushion for pressure redistribution are one technique to prevent pressure injuries.
 

The heel must always be clear of the surface and the posterior vascular supply must be protected. 
 

Bed linen, less is best. The sheet must fit the bed correctly. Don't let it hammock. A flat sheet can actually then become assistance with transfers, and pulling the patient back up into bed.
 

What's not on here but another takeaway is, is once you position the patient, make sure that you take two hands, push them together. Press it down into the mattress underneath the patient, and go from head to toe and release any skin that may have gotten pulled when you were turning and repositioning. Pressing it down, pressing the mattress surface down, lets the body recoil and then you can let the mattress come back up again. So it's a gentle press down. 
 

And I believe– Thank you for joining me. Thank you for your time.

Michele Deppisch, PT, CWS, FACCWS​, is the president elect of the National Pressure Injury Advisory Panel and vice chair of Support Surface Standards Initiative – S3I​.