Joyce Black comments on the use of support surfaces for the prevention and/or treatment of pressure ulcers, saying, it is one of the most cost-effective options available, however, it remains one of the least used[1].

With many healthcare treatments concordance is a cost factor and a patient's refusal becomes crucial to whether the treatment is used or not. For example, when a nutritional supplement is prescribed but not consumed, it can become especially costly because it has often already been opened at the bedside. This means that it cannot be returned, yet the patient has not benefitted. However, patients rarely 'refuse' support surfaces and in fact many are hardly aware that they have been placed on them. Furthermore, most support surfaces have a life span of around five years and while costly to procure can be in use for a long time.  

The problem seems to more one of implementation and indeed, the mode of action of any given support surface seems to be a bit of a mystery to many clinicians.  As Dr Clark discusses in this article, the NPUAP's Support Surface Standards Initiative (S3I) attempts to define the attributes of support surfaces in order to link them to the causes of pressure ulcers[2]. For example, immersion and envelopment are attributes designed to reduce exposure to pressure. These terms are seldom used and yet they are the reason that support surfaces reduce pressure ulcer formation.
In the US, the phrase 'low air loss' is probably the most poorly understood of all support surface terms. It is often thought to refer to an integrated bed system, which contains alternating pressure, a drying feature and at times a lateral rotation system. When the definition of low air loss is examined, however, this in fact only provides a steady low grade flow of air, which leaks from the surface of the bed. The purpose of low air loss is actually to dry the skin. However, lots of manufacturers have made beds and used the term 'air' in the title, which has led to the impression that they all contain the components mentioned above, when many do not.  Of course, this has led to clinicians expecting any surface referred to as an 'air bed' to perform to the same standards as the most advanced products.
When advanced integrated beds are used for high-risk patients, the beds' functions can be easily misunderstood, with clinicians believing that they can take care of the skin and that no turning is needed.  This misconception abounds and it is not unusual to hear clinicians speak of the bed 'turning the patient'.  While the bed may be moving side-to-side, patients are not in reality 'turning', in that their body never leaves the bed. Pressures on the skin may change, but are not entirely relieved.  

When these lateral rotation beds or 'turn assist' beds, are used, clinicians delivering care at the bedside must be cautioned to actually turn the patient and inspect the skin (noting especially if the skin can tolerate the rotation of the bed). Significant shear injuries have occurred when the patients have been rotated laterally, especially if the skin is already damaged (eg, in deep tissue injuries).

One of the original goals of S3I was to develop a consistent set of term and standardised tests so that when a bed is manufactured it can only be labelled as having certain attributes if it meets preestablished standards.  This process has been slow, but I believe that when it is fully implemented a clinician should be able to prescribe a support surface knowing exactly what kind of pressure redistribution, shear force reduction and microclimate management it will provide. Furthermore, with the addition of smart technology, support surfaces will be able to sense the current status of pressure, shear and microclimate and adjust to the original prescription.

Every patient has a bed. They are the most ubiquitous devices in clinical practice, yet their use remains under-appreciated.  Patients who spend 24 hours a day in the same bed are often unable to tell us that the bed is uncomfortable. Therefore, it is vital that all clinicians understand how support surfaces work, which patients require advanced therapy and when support surfaces are not operating at their full potential.

References

1. Lyder CH, Preston J, Grady J et al. Quality of care for hospitalized Medicare patients at risk for pressure ulcers. Arch Intern Med 2004; 161(12): 1549-54.
2. NPUAP. Support Surface Initiative Terms and Definitions of Support Surface. Available at: http://www.npuap.org/NPUAP_S3I_TD.pdf (accessed 1 July, 2011).

Author
Joyce Black, PhD, RN, CPSN, CWCN, FAAN, is Associate Professor of Nursing, University  of Nebraska Medical Center, Omaha, Nebraska US

See the article: Understanding support surfaces by clicking here.