Offering Support for Client Needs
Several years ago I consulted on a malpractice case involving a plaintiff who suffered a pressure ulcer after a particularly long hospitalization, rehabilitation and home care convalesces for an acute illness. As I thoroughly reviewed the chart, his care seemed to be quite comprehensive, using adequate screening for risk and using appropriate protocols for care. Sophisticated topical wound care treatments and recumbent support surfaces were being used along the continuum of care. The full-thickness ulcer was located on the patient's coccyx. What key piece of equipment was missing and could have helped heal this ulcer, if not prevent it from occurring? A pressure reducing cushion, of course.
Approximately 25 percent of pressure ulcers occur on the sacral/coccygeal region and about half of these are due to the seated posture. A full 85 percent of seated dependent develop pressure ulcers, and 66 percent of pressure ulcers occur on the pelvis. The ischial tuberosities account for another 24 percent of pressure ulcers. Since pressure equals weight over surface, people who sit are at greater risk for developing a pressure ulcer due to the sitting posture and use of less surface area to distribute the body's weight and the angular nature of the seated bony structures. The Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline Number 3; Pressure Ulcers in Adults: Prediction and Prevention requires the use of pressure-reducing devices and requires us not to use donut-type devices. Let's take a closer look at specific cushion types and their pros and cons.
Cushion Types
When looking at your choice of wheelchair cushions, there are four mediums that typically make up products--foam, gel, fluid, air and combinations thereof. Foam products tend to be lower cost, but do not provide the amount of pressure relief and positioning of other mediums. Foam products have memory--they always want to return to their original shape and hence the client typically has to conform to the product. Foam products tend to be low maintenance but need frequent replacement due to eventual product compression and the inability to repair foam. Gel products, not to be confused with viscous fluid products, are very heavy, do not conform well to the client and are not repairable. It also is difficult to customize gel without significantly increasing the weight of the product. However, the cost and durability of gel often make it an attractive choice to clients. Fluid products, while still a heavier product choice, are often made with a lightweight foam base with fluid pockets in critical pressure areas. Fluid has the ability to conform to the client and provide a degree of positioning. Air products vary in configuration and ability to provide stability and pressure relief. A multi-cell or compartment design will contribute to increased pressure distribution and stability. While air products have some maintenance due to initial adjustments, those same adjustment characteristics allow the product to change as a client's needs change, thus allowing air products to conform to the client without deforming tissue. It also is easy to customize air cushions.
Cushion Criteria
While cushions range dramatically in configuration, people selecting a product must consider what the cushion should do. These criteria can be broken down in to three critical areas, providing:
1. Stability
Proximal stability at the pelvis will allow for improved distal function and help to maintain good alignment. The more custom the fit, the more stability. Remember, though, that the product must provide "dynamic stability" to facilitate normal movement and functional activity from a stable, yet constantly active, posture. Since stability needs may change throughout the day, consider products that can change quickly and easily, as the clients' needs change. We want to allow for functional movement without restraining. Pelvic stability and alignment also will contribute to minimization of secondary complications and maximization of functional potential.
2. Protection
The wheelchair cushion plays an important role in prevention of secondary complications such as pressure ulcer formation, respiratory compromise and formation of skeletal abnormalities. This dictates that the cushion medium should do the following: conform to the client (decrease tissue deformation); be able to change as the clients' needs change; and be simple to maintain with a long life expectancy. In a typical scenario examining pressure relief products, air, fluid, gel and foam meet these requirements. Stability and protection must be examined together, as they go hand in hand with function.
3. Comfort
The client should be able to maintain the chosen seated position for an extended period of time. This will decrease the amount of time a client spends in bed, thus increasing function and social interaction. However, even the best wheelchair cushion does not eliminate the need for weight shifts or performance of frequent pressure relief techniques.
So, with all this in mind, clinicians should take a systematic look at what product best fits their clients' needs. Evaluation should include clinical trial for at least one "normal" or typical 24-hour period, skin checks before and after seated periods to assess for potential pressure problems, performance of functional tasks while seated including activities of daily living, wheelchair propulsion and balance activities that may mimic daily encounters (reaching tasks, throwing, etc.). Furthermore, clinicians should use computerized pressure mapping technology when available to objectively substantiate their clinical findings and provide documentation for funding sources. Pressure mapping not only aids in equipment selection and justification of equipment, but it also is an invaluable education tool. The flexible pad connected to a computer can enhance understanding of skin issues, and through its dynamic display the clinician can assess the effectiveness of pressure relief techniques.
We must remember and understand where the client will function (school, home, work and community) and who the primary caregiver will be. Approach each selection critically and try to anticipate long-term changes such as weight fluctuations, activity level and the progressive nature of a disease or disability. Consider the clients' age and whether or not he or she is a permanent or temporary wheelchair user. Also, educate the client and yourself regarding the cushion choices and funding sources that are available. Realize that even the best wheelchair cushions do not eliminate the need for maintenance, frequent pressure relief, or eventual product replacement. Give the client the opportunity for feedback and recognize that functional tasks, specifically transfers, may require slight modifications on different surfaces.
Cost and Reimbursement
Of course, once we choose a product that suits our clients' needs we also must consider funding options and price. Cushions range in price from approximately $30 for a piece of one-inch foam to $1,000 for powered cushion choices. Average pricing for high-end positioning and pressure relieving cushions is $300 to $500. There is, however, usually sufficient funding for such products. Medicare B will pay for a wheelchair cushion upon discharge to the home if the client is at risk for skin breakdown and has a wheelchair. Wheelchair cushions are assigned Medicare codes, the most common being EO192 and EO176. The client is responsible for 20 percent of the Medicare allowable. Private insurance companies and state public funding agencies will evaluate reimbursement options on a case-by-case basis. In all three situations, a good letter of medical necessity listing the clients' impairments and the functional benefits of the seating support surface should be completed by the treating clinician. Assistive technology suppliers are well versed in these funding codes and can be helpful in billing appropriately. What other details do we need to hone in on with relation to cushions?
The Finer Points
We must:
- Know the clients' goals, involve the rehabilitation team and educate our clients and ourselves about cushion choices and the importance of their use.
- Utilize available technology, such as pressure mapping, to make informed product choices, evaluate product effectiveness and to back up subjective findings.
- Take advantage of the clinical expertise offered by wheelchair cushion manufacturers and seek out educational opportunities and continuing education programs that they may offer.
This evaluation process, in conjunction with assistive technology assessment, will ensure that clients receive the appropriate seating surface at the onset.
Take a look at your seated dependent clients who may not be living independently in the community. How long do they sit in a normal day? If they are unable to stand or perform a complete weight shift, they are at risk and in need of a pressure-reducing cushion. The part- or full-time wheelchair user is only one at-risk candidate to address. We also must consider the long-term and nursing home resident, many of whom sit the majority of the day. Additionally, the acute care patients who begin rehabbing and getting up from their therapeutic bed or overlay, are also at risk. I often review protocols for facilities that state if the patient gets up from a therapeutic support surface, he or she should be placed on a pillow. Pillows are for comfort only. They do not constitute a pressure-relieving device.
The BIG Picture
Be mindful that a cushion's function and usefulness is limited. No cushion, no matter how protective, has been found to consistently maintain interface pressures below capillary closing pressures (less than 32 mm Hg). The importance of weight shifts, whether they are performed as a push-up from the seated position, a side-to-side movement or a bend at the waist, are paramount in relieving pressure from occluded areas, especially the ischial tuberosities and the sacrum in a seated position. Another caveat to mention is that no cushion is maintenance free, regardless of what the product literature or sales representatives may attest. A hand check should be performed at regular intervals to assess that there is some form of medium (air, foam, gel or viscous fluid) between the patient and the base or bottom of the cushion. Is an adjustment needed if the client is using an air or fluid product? Does the product need to be replaced if he or she is using a foam product? Considering a patient's holistic needs, including the addition of a pressure-reducing cushion, will give that patient, and you, a comprehensive advantage to fighting the pressure ulcer dilemma while offering the client the additional benefits of stability and comfort.
This article originally appeared in the March 2002 issue of HME Business.