Support surfaces for treating pressure ulcers

Support surfaces for treating pressure ulcers can be the difference between life and death. Why? The correct support surfaces, like an air mattress or a gel cushion, can maintain weight distribution and allow a wound to heal or prevent an injury from developing altogether. This week on the podcast, we welcome Ingrid Sidorov, RN to discuss the categories and types of support surfaces used to treat pressure ulcers.

Schenk: Hello out there. Welcome back to the podcast. My name is Rob. I’ll be your host for this episode. We are going to be talking about support surfaces for treating pressure injuries in nursing homes.

But before we get into it, I have an ask, and that is please like and subscribe wherever you get your podcast from if you are enjoying the content of these episodes. And while you’re at it, please check out our YouTube channel, the Nursing Home Abuse Podcast YouTube channel. Lots of videos over there, lots of information for you to learn about nursing home care. And with that, let’s get into the episode.

So today we are going to be talking about one particular type of intervention for pressure ulcers, and that is a support surface. What is a support surface? How do they work? What are the different types of support surfaces? But we don’t do that alone. We have an actual bona-fide expert on the show today – Ingrid Sidorov.

Ingrid has over 30 years experience dealing with these things. She’s been a nurse for over 30 years. Ingrid has practiced in critical care for 10 years and then went on to get her master’s degree in gerontological nursing to become a clinical nurse specialist. She is passionate about protecting the rights of older adults, especially in the long-term care setting, and about educating attorneys and healthcare providers about their care. Since then, she has practiced in home care, case management, research, education and various schools of nursing as well as in clinical settings and providing wound care consultation. Her position before becoming to OnPoint Legal Consulting full-time was as chief nursing officer at a pain site owned by the University of Penn School of Nursing. She has reviewed cases related to nursing home issues as well as writing pain and suffering reports for Mindy Cohen over at OnPoint since the year 2000. She has come on as full-time program director for long-term care at OnPoint four years ago and is delighted to be presenting today with us. So glad to have her on. She is a wealth of information. Ingrid, welcome to the show.

Sidorov: Thanks, Rob. Great to be here.

Schenk: Well I – before you came on the program, I read your background. You’re super highly qualified. In fact, I wanted to have you on after I was in the audience of one of your presentations regarding support surfaces and treating pressure ulcers that you did a few months back, and I was like, “Man, Ingrid has got a lot of info that I want to share with my audience,” so I appreciate you coming on and sharing that.

So anybody in the audience right now that wants to be educated or wants to learn more about pressure ulcers, we’ve had several episode about pressure ulcers, how they come about from a medical standpoint, how they’re prevented from an intervention standpoint in terms of assessments and care plans, so I’ll have those in the show notes and you can be able to go there first and listen if you want to. This episode, I would like to entirely dedicate to the prevention method of support surfaces and get exclusively into those weeds. So to the extent that somebody out there has more questions, I would direct you to those other episodes. 

And with that, Ingrid, now I want to try to kind of slide into this. With regard to pressure injuries, preventing pressure injuries through support surfaces, the first question that I have is what the heck is a support surface? When I say support surface as a term of art, what does it mean?

What is the purpose of support surfaces?

Sidorov: Well it’s sort of a fancy term that has evolved over time. Pressure ulcers used to be called decubitus ulcers. We call them pressure injuries. We call them pressure ulcers, pressure sores, bedsores. They’re all the same thing but the main thing is they’re all caused by pressure because pressure over a bony prominence is typically how a bedsore or a pressure ulcer happens. So a support surface is a fancy way of saying some sort of an application of a piece of equipment to provide pressure relief, particularly over bony prominences, like your coccyx or your sacrum or your hip. But remember, pressure ulcers can happen anywhere. They can happen on your nose from a nasal cannula for oxygen. It can happen on your heel, can happen any place where there’s pressure where there normally is not for a prolonged period of time.

Schenk: So by way of example then, a support surface can be anything from an air mattress on a bed or some type of cushion on wheelchair that someone sits on. Is that about right?

Sidorov: That’s right, because when you think about it, people in nursing homes or hospitals spend a good deal of time still, often in a bed or in a wheelchair. And the less mobile somebody is, the more likely it is that their skin can break down. So there’s special kinds of mattresses that you can put – there’s three levels of them that you can put over a bed mattress, and then there’s also something called a Roho cushion typically that’s used on a wheelchair or a chair when people are out of bed to protect their backside from breaking down, which is a real typical place.

Schenk: And so if I understand correctly, the purpose of a support surface, what we’re calling a support surface, is to in some small way or maybe in a major way redistribute weight and kind of redistribute the pressure on that particular part of the body. Did I get that about right?

Sidorov: That’s right, so redistributing the way that somebody’s body is laying on the mattress so that it’s more fluid and not prolonged in one spot. But just because you have a pressure mattress or an overlay or level one, two or three, Roho, doesn’t mean the person doesn’t need to be turned. And what I like to say is that a care plan, which is sort of the guiding principle for taking care of people, needs to include, if somebody has something like breakdown in their sacrum or their coccyx, they need to not only say turning every two hours but turning right to left, right to left and limiting time out of bed so the pressure is not on that backside.

Schenk: That makes sense. And that’s why I wanted to make sure to caveat this at the beginning of the episode that there are dozens if not hundreds of interventions that one could use to prevent pressure injuries regardless of their cause, whether it’s from medical instrument or pressure or from laying there, that the support surface should be one intervention in many that is in a care plan. So I hear you on that. It’s super important for somebody listening to this, a support surface or air mattress, Roho, whatever the case may be is not the end all be all. It’s almost a team effort. You need – it’s an All-Star on that team – it’s not the only team member in the prevention of pressure injuries.

So that actually is a good segue, Ingrid, in terms of what are the factors that a nursing home staff, a RN, in that assessment, in the implementation of a care plan, what are the factors that go into selecting a support surface for a particular resident?

What factors go into selecting the proper mattress?

Sidorov: Well typically most people who go into nursing homes are at risk for breakdown whether it’s because they have something like diabetes or whether they’re not keeping well-nourished or they have some other disease process like arthritis that’s keeping them from moving. So everybody in the nursing home should be at high alert for just about everybody in there to be at risk for breakdown.

Typically what you see with somebody who is less mobile like somebody that’s just come out of surgery, who had a hip replaced and they’re going to a skilled nursing facility to be rehabbed, that person’s at risk of a heel breaking down because they’re just not mobile enough.

So certainly if you are at risk, the least thing they should probably do is have a level one surface, which is sort of like a gel overlay, something static. It used to be egg crates kind of mattresses that at least provide some pressure redistribution.

If somebody starts to break down and things are getting worse, then you need to go to the level two type of mattress, which means that something is going on electronically. It’s plugged in and there are some cells moving around, there’s some air moving around to kind of keep things in motion even more the next level up, and that’s what I would want to see on my loved one if they were starting to break down, even with something as simple as a stage one that means that the skin is starting to turn red showing that pressure’s happening. Move up the level of mattress and get them on a level two mattress, something that’s plugged in.

If somebody’s really, really badly high risk, wounds are worsening even though they’ve got a level two mattress and you’re keeping them as mobile as you can, keeping them hydrated, keeping them nourished with protein, keeping them clean and dry, then you go to a level three bed, which is typically called a Clinitron bed. That’s really a type of mattress where – I should use proper terminology here – it’s the highest pressure redistribution and it’s like a fluid-like medium forcing air through beads. So the person is really floating. And even then when they’re on that kind of bed, they still need to be repositioned every hour or two.

Schenk: So if I understand correctly then, it seems as though there are three categories of support surfaces and each one of them has more and more level of redistribution properties to them. Am I hearing that correctly?

What are the 3 types of pressure redistribution surfaces?

Sidorov: That’s correct, yes.

Schenk: Then can you tell me – and it seems the worse off somebody is – I don’t want to say that – the more high risk someone is for developing a pressure injury, the more likely it is they need a higher level of one, two, three. Who is determining or – I don’t want to say that – who determines what groups these are? Is it like a national pressure ulcer advisory panel thing? Or do you know?

Sidorov: Yes, that is a national pressure advisory panel. The standards of care, it’s not rocket science. Nurses working in nursing homes and physicians and nurse practitioners all know that the main deal with the pressure ulcer prevention and worsening or deterioration is getting the pressure off, so like I said, turning and repositioning, limiting time out of bed and the use of one of these mattresses is really important. There are sometimes in nursing homes, there’s a wound care nurse that’s involved in making the decisions. Sometimes it’s the physician that decides there needs to be an order for it because it needs to be paid for by insurance. But certainly it’s in nursing’s domain to keep track of somebody’s skin and to keep track of risk factors, because everybody has a risk assessment done on a regular basis in a nursing home, and then to make sure, monitor if skin is breaking down or getting worse that the care plan is updated to include more interventions.

Schenk: That makes sense. And so can you kind of walk us through a little more, a little bit more in depth on the three levels? Like what’s the difference between the group one or the group two or the group three? Like what are some examples of them and what makes them different from one another?

What are some examples of Group 1 support surfaces?

Sidorov: Well like I said, the group one is just either an inflated mattress, think of like an inflatable mattress that people sleep on the floor that gets inflated, it’s not plugged into anything, or an egg crate mattress used to be used. They decided that they didn’t really do as much good as they thought that they did, or there’s an actual overlay that’s sort of like an overlay that people put on their own beds to make them softer. But again, not plugged in, level one, the bare minimum of what probably should be on every bed of the nursing home.

What are some examples of Group 2 support surfaces?

Now if somebody’s in an intensive care unit, by the way, where often things can happen, they are automatically put onto beds that are level two, that are moving and not static and provide comfort and skin redistribution.

Schenk: Right. And it’s interesting that you say this because in terms of even if you’re on a group three or group two level, I might not be saying that right, but level two or level three support surface, it is still important to have turning and repositioning scheduled. It’s still important to have other interventions to make sure the skin is clean, like continent care is provided, this type of thing because it’s not the end all be all. It’s one component. Even if you have the best group three support surface in the world, you’re still going to need to have all these other interventions.

Sidorov: Yeah, the main things are besides getting the pressure off again is nutrition, and a lot of times people in nursing homes, one of the things that happen when we get older is we don’t have an appetite because we don’t feel well or there’s diminishing number of taste buds so food doesn’t taste as good as it used to, or you need help eating and the person that’s helping you eat like an aide is rushed and not trying to make sure you’re getting everything you need. Sometimes the family should get involved and say, “How’s his appetite? Let’s think about bringing things in that he or she likes like peanut butter or things that are high in protein.”

I always say getting the family involved in these circumstances is so important because typically everybody from the get go when they go into a nursing home or a skilled nursing facility are at risk for skin breakdown, and it does take a team, including the family. Sometimes people don’t want to cooperate, so that’s when you need to get the family involved and say, “Hey Dad, you don’t do that, you know your skin can break down and you can end up with a bedsore and in the end you can get an infection. And we don’t want to see that happen.” So think of a whole team, the interdisciplinary team from the therapist to the nutritionist to the nurses to the aides to the family to the physician all involved in preventing and keeping wounds from getting worse.

Schenk: Family involvement is definitely a theme that has reoccurred in this podcast, everything from what you just said, “If Dad is being noncompliant,” if dad is wanting to smoke, you’ve got to say, “Dad, you’ve got to listen to what they’re saying. You’ve got to turn and reposition when they want to. You’ve got to quit that smoking because smoking is not going to let that pressure wound heal as good.” Family involvement is super critical.

And speaking of family involvement, Ingrid, what are some questions, what are some observations a family member can make if their loved one has a pressure injury already or, as you mentioned, is at a high risk for pressure injury? Like for example, do they walk in and go, “Hey,” to the director of nursing or to whoever, go, “Hey, give me a group three support surface?” What are some things they can ask about or request in your opinion?

How can families help their loved ones avoid pressure wounds?

Sidorov: Well I think the first thing is just being educated and knowing that your loved one is probably at risk for their skin breaking down. I think that if you go in and you always find Mom or Dad in the same position lying on their back, that’s not a good sign and then you get either the supervisor or the director of nursing to say, “Hey, I’m expecting to see my mom or dad is turned every two hours. How are you making sure that’s happening? How’s their appetite? What’s going on with that?” They have document typically the amount of consumption of meals that’s happening. They’re only eating 25 to 50 percent, they’re probably not getting enough. Ask for a nutritionist to come see them and see about supplements that are high in protein and calories because you need both.

I think that if you go in and you notice your mom and dad is incontinent, whether it’s urine or bowels, they’re really, really at higher risk and that you want to make sure that they’re being kept clean and dry. I think that those really – that they’re keeping hydrated. If they need help to drink – again, thirst receptors also go down, so a lot of times older people aren’t thirsty. They don’t know to pick up that thing of water and drink.

So I think you need to go in concerned and just keeping an eye on things and keeping an open dialogue with the nursing aides who are typically the ones on the front lines and the nurses and let them know that you’re interested and that you’re there and you’re part of the team to help that not happen, to help skin breakdown not happen, and if it does, to get right on top of it because 90 percent of pressure wounds are preventable and even when somebody is on hospice, there still needs to be interventions done to keep skin from breaking down because it’s an organ like all other organs that may start to break down. But the nurses are still responsible for keeping that skin as protected as it can be.

Schenk: I think that to your point with family involvement, it’s critical that a family member, at least one family member is involved in the assessment in care planning process where these decisions are made, whether or not the resident will receive a level one, level two or level three. I think, again to your point, the family member should say, “What support surface are you providing to my loved one who is at high risk for pressure injury and why is that decision being made? If it’s a level one, why is it a level one versus a level two, level three?” Get answers to those questions. Make them think about these. And I think that increases the likelihood of they’re not going to fall off the cracks. But speaking of that, what…

Sidorov: I do have one more thing to add besides that because you’re talking about family involvement.

Schenk: Sure.

What is a family care meeting?

Sidorov: There has to be regular care plan meetings where the family and the resident are always invited. I review a lot of charts and a lot of times I see the resident is not present and the family member is not present. You do not have to be in the facility, you can do it by phone, but I highly recommend as often as you can being part of that care plan meeting, which should be happening on a regular basis, including when something changes. For example, if somebody falls or they get a bedsore, then there should be an immediate care plan meeting happening for everybody, the nutritionist, the therapist, the nurses, the aides, the physician and the family member and the resident to start talking about it and being educated about it and taking steps immediately to take care of things.

Schenk: That’s right. So just for the audience out there, in the state of Georgia, there are times in which there is going to be a comprehensive assessment followed by a comprehensive care plan. In Georgia, the minimum amount of time is every year, that should happen that there is a comprehensive head-to-toe assessment including a skin integrity assessment and then a care plan that is made from that. The other time that there is a comprehensive assessment and a comprehensive care plan is going to be if there’s some type of significant change in condition. Developing a pressure injury is going to be a significant change in condition, so those are two times at minimum that you’re going to want to be involved.

The ones that are quarterly, I don’t even know what the correct word for it is but it’s kind of like a mini assessment. It’s not comprehensive in the sense of the annual one, but it’s enough that you want to be involved in it. And again, if there are changes to that person, to the resident’s condition, it’ll be handled at that time in the care plan. So those are multiple times a year in which you should be involved in the care planning process.

Sidorov: Or you can also, as a family member, you can say, “I want a care plan meeting. I want to have a meeting with the team to discuss what’s going on with my mother and father.” It doesn’t have to be set up by them. You can request it and get that meeting to happen whenever you want it.

Schenk: Whenever you want it. And I was going to say that in your anecdotal experience, Ingrid, are all nursing homes or most nursing homes equipped with level three support services? Like is this something that like, well if Medicare doesn’t pay for it or whatever, we’re not getting it? Can you kind of go into a little bit about the availability of these support services?

What are some examples of Group 3 support surfaces?

Sidorov: You don’t see level threes very often. They’re more likely to be in facilities like long-term ventilator facilities, because that’s real serious stuff. Typically a level two should be enough if somebody’s being repositioned, unless their skin is really breaking down all over the place, you’re not going to see a Clinitron. It has to be well-documented for your insurance to pay for it, but insurance will pay for it, but of course it’s more expensive. And it would be like renting equipment. It’s not sitting in the supply room in the basement of a nursing home. It gets rented from an equipment company, which would deliver it and pick it up once it’s done being used.

Level twos should be within facility storage room and should be available. One of them is called an air mattress and another one is called the alternating pressure mattress – or low-air loss, I mean, is the first one, which supplies air flow to keep the skin dry and to relieve pressure. And then the alternating pressure mattress uses like two sets of air cells to expand and contract continuously. And either is fine to use, frankly, but they should be within the nursing home’s easy reach to get on the bed.

Sometimes what you may see is if somebody orders the mattress and then it takes two or three or four or seven days to get on the bed, that’s something else to be aware of. If that is being requested, that should be put on the bed as soon as possible, certainly within 24 hours, because again, skin can break down just inside a few hours.

Schenk: Would a layman be able to tell the difference between these mattresses? Like if a regular person off the street walked into a resident’s room, is it like weird-looking? Can you perceive the change in position that it’s redistributing?

How can you tell the differences between the mattresses?

Sidorov: Typically they’re a few inches deep and what you would notice is there’s a noise that goes with it and it’s also plugged in. It would be underneath the sheet so it’s not readily visible, but you would see a plug coming from the extension cord or a plug coming from the bottom of the bed and you would see some kind of mechanism at the bottom of the bed that controls the amount of pressure happening. If it’s just an overlay like what I talked about before, when you go in, just feel the bed and you’ll know the difference between just a mattress with a sheet over it versus some kind of a gel overlay. It just feels different. But you wouldn’t hear anything. You would feel the bed to know that it’s there.

Schenk: And I think that’s an important point for the audience out there is to understand that because I know that in my cases, oftentimes the family member will say, “I never saw a support surface. I never saw an air mattress or anything like that,” but the records say, “Yeah, it was there the whole time,” and maybe there’s pictures that show it too because the family member doesn’t know what to look for. They’re thinking like, I don’t know, that they’re floating in space or something, but I think sometimes you can perceive that there’s nothing there but there actually is something.

Sidorov: Family, when you know that they’re at risk, like I said, get involved in the beginning, and if skin starts to break down, say, “What are you doing? What are we doing about pressure? What are we doing about feeding him? What are we doing about keeping him hydrated and keeping him or her clean and dry?” It’s not rocket science.

Schenk: Ingrid, thank you so much. This has been a lot of useful information for our audience. I mean you obviously know in your 30-plus years of experience that pressure injuries are a major problem, so every which way that I can educate my audience about how to prevent them, how to heal them timely is extremely important. So we appreciate you coming on the show.

Sometimes there are attorneys who do listen to this and sometimes these attorneys are plaintiff’s attorneys. And if you’re a plaintiff’s attorney and you represent people that have been injured in nursing homes and you want to learn more about this topic, you want to talk to Ingrid, who is a legal nurse consultant about how she can help you, Ingrid, what’s the best way that attorney can get ahold of you?

Sidorov: The best way to reach me is by emailing me and that’s ingrid@onpointlnc.com, so ingrid@onpointlnc.com. And I sit in front of my computer all day, Monday through Friday, and I’m pretty quick to get back to people, so I’d be happy to discuss cases, merit screens, help you determine whether it’s a case or not, help you determine the experts you need, etc.

Schenk: And I can vouch for Ingrid. Ingrid has screened, I don’t know, at least 50 cases of ours. So Ingrid, thank you so much for being on the show and we’ll look forward to working with you here in the future.

Sidorov: Indeed. Thank you. Thanks for the opportunity.

Schenk: Really great to have an awesome expert like Ingrid on the show. I know that really getting down in the nitty gritty of support surfaces and air mattresses and stuff was needed because we always talk about interventions as a whole, but really wanted to shine a light on support surfaces today.

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