Evaluating Replacement Mattresses

BY I L E N E F L E I S C H E R A N D D I A N E B R Y A N T -^"^ Abstract: A multidisciplinary team evaluated four replacement mattresses. The mattress that was found to be most effective in preventing pressure ulcers was then compared to the static air mattress. The study's results and outcomes areptvsented.* [Nuts Manage 1997:28(8):38,4O-4i] AMONG HOSPITALized patients in ;icute care settings, Vo to 14% wUl dei ^ velop a pressure ulcer; the estimated cost to treat these wounds is between and S8(>,(K)0 per patient.' In some states, third-party reimbursement for hospital-acquired pressure ulcers has stopped. Pressure, immobility and malnutrition all contribute to the development of a pressure ulcer. A multidisciplinary team (nursing, central transport service, purchasing, biomedical engineering and management engineering) formed to determine which products would help to alleviate one risk factorpressure,
Collecting baseline information
EXHIBIT II

PRESSURE ULCER PREV/! LENCE SURVEYS

standard hospital mattress A. 7/90 B. 4/91 16% 17% (63/405) (13/76) 14% 14% (55/405) (11/76) Comfortex Apollo mattress C 2/92 D. 5/92 E. 7/92 77% 8% 7% (5/60) (29/377) (4/59) 5% 5% 7% (3/60) (19/377) (4/59)

% of patients with pressure ulcers % of patients with hospitalacquired pressure ulcers

Before c\;iliiating an\' pressure-reducing mattresses, two enterostomal therapy (ET) nurses and one rehabilitation nurse responsible for the project collected data. (See Exhibit I.) Results are shown in Exhibit II, column A.
EXHIBIT 1

DATA SURVEY
To obtain baseline information regarding pressure ulcers to examine skin integrity to identify ulcers, 5tages 1 through IV Time frame 1990-1992 Location: 720-bed teaching hospital Population: All gynecology, medical and surgical patients Sample: 405 patients 8 9 % of possible population Purpose:

Of the total number of patients with pressure ulcers, 49% were in the surgical division, 49% were in the medical division and 2% were in the gynecological division. Location of patients revealed that 79% were on a general floor and 21% were in an intensive care unit (ICIT). Following the data collection, nursing, purchasing and biomedical engineering reviewed the literature and various products.- The committee selected four replacement mattresses whose companies claimed the)" reduced pressure to compare to the standaRl hospital mattress. See Exhibit HI for stud}' criteria. If their claims were true, pressure ulcers would decrease as the standard hospital mattresses were replaced with one of the selected prtxJucts. Prior to tliis study, a static air mattress overlay was the only device used to decrease pressure other than specialty beds. Because it was difficult to track the sui^cal ICU patients due to the large volume of patient movement from unit to unit, a general surgical unit was entered into the trial. Although each unit was to trial 20 patients on all four mattress types. Standard Textile entered the trial late and was tried onl>' on the general surgical floor The trial began in October 1990.

The Replacement Mattress Assessment identified patients at risk for skin breakdown using tlie Braden Scale.^ (See Exhibit IV) The registered nurses caring for patients on a trial mattress completed the assessment form daily To increase reliability, an ET nurse began collecting data on each patient on a trial miittress.
Determining a trend

After re\ie\ving this new data, we noted a trend: the Comfortex mattress
EXHIBIT III

MAHRESS REPLACEMENT STUDY

Purpose: To compare four replacement mattresses Location: 720-bed teaching hospital Population: One general medical unit One general orthopedic unit One general surgical unit One medical intensive care unit Therarest by Kinetic Concepts Genesis by Comfortex Apollo by Comfortex Maxifloat by Baxter All-ln-One by Standard Textile The Replacement Mattress Assessment

Products*:

Tool:

'All products have been improved or modified since 1992. These updates would have to be individually analyzed to detennine any significant impact on the clinical effectiveness of the products.

ILENE FLEISCHER, MS, RN, CETN,/s a Clinical Nurse Specialist and an Enterostomal Therapy Nurse at Brigham and Women's Hospital, ond DIANE BRYANT, MSN, RN, CETN, (s an Enterostomal Therapy Nurse, Nursing Department, at Baston Medical Center in Boston, Massachusetts. The authors wish to thank the multidisciplinary team involved in die mattress trial. Vhis study was done from I990to 1992. All of the products are sbll available on the market, although their brand name or manufacturer may have changed. Al! the products have been improved and modified since 1992. Moreover, some companies have sold certain product lines; others have merged and some have changed the name of their products.

38

Nursing Management / Vol. 28 No. 8

EXHIBITIV

REPLACEMENT MATTRESS ASSESSMENT

Medical record no. Date Age Name of replacement mattres Significant medical condition Unit

Plea5e place the appropriate code by the affected area and put the date at the top of the column. If skin site is not listed, place in the last row. Code: 1) Skin intact 3) Superficial wound 5) Yellow or black tissue on wound 2) Reddened area 4) Deep wound 6) Draining wound Dates Skin 5ite affected Trochanter Sacrum Heels Ischii Buttocks Shoulder5 Elbows Record type of treatment used on ulcer(s). If change occurs, record new treatment along with date. Did patient find product comfortable? Yes No If no, explain: Unable to obtain Too hot LJ Too cold Too hard G Too soft G Other J explain: Any problems with replacement mattress? Linen didn't fit well G Difficult to do CPR Q Difficult to transfer patient in and out of bed G Complaints from housekeeping about cleaning G Other: Nurse's overall opinion of the effectiveness of the mattress for this patient Place a check in the appropriate box. Dates Better Worse No effect Braden Scale Dates g 1. Completely limited o^ 2. Very limited =S 5, Slightly limited "^ ^ 4, No impairment ^ 1, Constantly moist 3 2. Very moist g 5. Occasionally moist E 4. Rarely moist 1, Bedfast .? 2, Chairfast 'Q 3. Walks occasionally < 4. Walks frequently ^ 1. Completely immobile = 2. Very limited 3. Slightly limited * 4, No limitations E 1, Very poor s 2. Probably adequate g 3, Adequate ^ 4, Excellent c ^ 1. Problem ^ c 2, Potential problem It '^ 3, No apparent problem Totals
Staff response Reason off the bed

was most effective regarding maintenance or improvement of patients' skin integrity, particularly those at risk. (See Exhibit V^ Exhibit VI reveals small differences in the scores, thereby indicating similar potential for skin ba-akdown of ilic patients involved in the trial. Thus, the committee decided to ask some companies to withdraw from the trial. Standard Textile entered the trial late and because there was less data on this mattress, it.s product was included in the next trial. At that time, the Cxjmfortex mattress was changed from the Genesis to the Apollo, which met the safety requirements of the Boston Fire Department. During ihis period, a prevalence survey of the pressure ulcers on these units was conducted. The results of the data are seen in Exhibit II, column B. Of particular note was the 14% prevalence of hospital-acquired pressure ulcers in both surveys. To compare the effectiveness of the Comfortex and Standard Textile mattresses t(j the static air mattress overlay, a graduate nurse collected data for a period of 4 weeks. The trial was conducted frtjm June 18 tlirougli Jul)' 16. 1991, If a static air mattress was ordered for a patient, he/siie would first be assessed using the Braden Risk Assessment Scale. If a patient's score was lef>s than 17, he/she wotUd be placed randomly on one of the three mattresses. Ratients were followed daily, Monday through Friday, 7:0() a.m. to y.iH) p.m. In the former trial, it was found that incontinence was the only fector that directly affected a patient's skin integrity. The Braden Scale score helped determine if a patient's risk for skin breakdown had increased, decreased or stayed the same. After 4 days, patients were usually taken out of the trial; the previous trial showed that if a change occurred, a patient's skin condition worsened b> day 2 or 3. ('omtbn level was assessed the day a patient came off a product.
Choosing a replacement mattress

It was found that all three companies

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Nursing Management / Vol 28 No. 8

EXHIBIT V

SKIN CONDITION OF PATIENTS WITH BRADEN SCALE SCORE <17 WHILE ON THE TRIAL MATTRESSES
Patients at risk for skin breakdown Bener Worse Same Total
NA; Data not available

Kinetic Concepts

Comfortex

Baxter 3

Standard Textile

3 2 5 10

0 0 II 11

4 13 20

NA NA NA NA

EXHIBIT VI

SUMMARY OF BRADEN SCALE SCORES AND PATIENT DAYS ON PRESSURE-REDUCTION MATTRESSES

Baxter Number of patients at risk Braden score <17 on admission Number of patients not at riskBraden score >17 on admission Patients at riskrange of Braden Scale scores Patients at riskmean of Braden Scale scores Number of days patients at risk were on each mattress 18 11
Kinetic Concepts Comfortex (Genesis) Standard Textile 5 1

13 12

20
16

8-17 15.13 4.2

6-17 12.6 3,7

6-17 12.81
4.2

10-17 15.14
5.2

original 14% before the mattresses arrived. In May 1992, a hospital-wide prevalence stirvey was done on all the units with the new mattress. (See Exiiibit IJ, column D). The results of the third survey, completed by the two ET nurses, are shown in Exhibit II, coltimn E. This study was done from 1990 to 1992. All of the products are still available on the market, although they all have been modified and improved since 1992and in some cases their brand name was changed to reflect the differences. Moreover, some manufacturers have sold their pnxluct lines and others have been bought out or merged. Thus, the hospital s ET nurses plan to continue coordinating hospitalwide prevalence surveys twice a year as an ongoing qualit)' improvement project. No mattre.ss alone will eliminate pressure ulcers; expert nursing care is essential. "^ References
1. Bryant, R.A., .\cute and Chronic Wounds; Nursing Management, (St. Louis; Mosby Year Book, Inc., 1992); Maklcbust, J, and M. Sicggrecn, Pressure (leers: (iuidelitiesfiir Ptvventiori and i\ursing Management. (West Dundee. IL: S.N Publications. 1991); and Krasncr. D., Chronic Wound Care: A Clinical .Source Book for Healthcare Professionais. (King of Prussia. PA: Health Management Publications, 1990). 2. Dougbt>-. D., P Faircbild and S. Stogis, "Your Patient; Which Therapy?', Journai of Enterostomal Therapy, 1990, 17;15'^-159; Jester, J. and V Weaver, "A Repon of Clinical Investigation of Various Support Surfaces Used for the Prevention, Early Inter\Tntion and .Management of Pressure Ulcers," Ostomy and Wound Management. 1990, 26;39-44; Johnson, Q., C. Daley and V Franciscus. "A Clinical ,Stud>' of Hospital Replacement Mattresses," Journal of EnterostomtU Nursing, 1991. ia:15,VIS7; A, Kedas, R. Frank and J. Mcgougb, "Universal Pressure Sore Precauiion," yoKma/ of Enterostomtd Nursing, l<)90. 17:237-240; and Hover A.E. and T. Krouskop, "Pressure Relief Characteristics of a New Foam Overlay; A Preliminary Performance Evaluation."/ourna/ of Enterostomal Nursing. 1992, 19;44-i7. 3. Bergstrom. N., PJ, Detnuth and B.J, Braden. "A Clinical Trial of the Braden Scale for Predicting Pre.ssure Sore Risk," Nursing Clinics of North America. 1987, 22:417428, 4. Mendenhall, W, and T, Sincich, Statistics for Engineers and Computer Sciences. 2nd ed. (San Francisco; Dellcn Publishing Co., 1988), pp.320-329. 41

had products that were clinically acceptable and therapeutically equivalent. Exhibit vn is an estimate based on the data collected. A 95% confidence interval was calculated for each mattress. The actual percentage lies within this range. If the confidence intervals overlap, no statistically significant difference exists between the products."* According to statistical analyses, all three products were clinically effective, thus, economic considerations and nursing preference became the deciding factors. If we converted to a replacement mattress and eliminated the static air mattress and 2-inch egg crates, a savings over a 5-year period of more than $700,000 was estimated. Included in the analysis were estimated costs: overlay ($73,554 per year); eggcrates ($56,(X)0 per year); de-

livering the overiay to the floor (12.5 minutes) and the estimated nursing labor (10 minutes to place the mattress and 2 minutes for hand checks each shift). Storage was not calculated, nor was the expected increase in cost due to inflation. The committee decided to purchase the Comfortex Apolloreplacementmattress because of the company's quality assurance program and guaranteed staff development programs. In addition, we preferred the handles on the mattress and the coverings rate of moisture vapor transmission. To evaluate the effectiveness of the mattress, three pressure ulcer prevalence surveys have been done. In February 1992, the two ET nurses surveyed the same units represented in the studies. The results were dramatic. (See Exhibit EXHIBIT VII II, column C). STATUS OF WOUNDS ON DIFFERENT MATTRESSES Three out of the Better/ Lower Upper Sample 60 patients had a Same limits limits size Comfortex Apollo 72% 49% 95% 15 hos pital-acqu i red Gaymar Sof Care 90% 77% 100% 20 pressure ulcer; a Standard Tejctile 88% 73% 100% 18 5% prevalence rate All-ln-One compared to the

August 1997/Nursing Management