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 79PRODUCT 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 | 2015PRODUCT 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 81A 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 DataPOSITIVE 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.You can also read
