This Bed Is Just Right

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January/February 2005

By Michael Dionne

In 1987, I was introduced to my first patient whose body weight was in excess of 1,000 pounds. At that time there were very few equipment options available in beds and support surfaces for patients of significant size. Many facilities accomplished management through improvised fabrication. An example of this would be bolting adjoining in-house bed frames together. This often resulted in fractured bed frames, damaged motors, increased workers’ com-pensation claims for therapists and other medical staff, and patient injuries secondary to bed trauma.

Poor bed prescription can create problems in mobilization, prolonging the patient’s length of stay. However, a revolution in equipment began in the early 1990s, resulting in safer and more cost-effective work environments for both caregivers and those of signifi-cant size.

During bariatric rehab training sessions, I usually ask the caregivers to introduce themselves to the patient, get a good history and patient assessment, take a step back from the bed, and assess the environment including the very bed the patient is lying upon. Understanding the environment and acuity of the patient becomes a primary consideration in bed prescription.

The investment a facility makes may be very different depending more on the acuity of the patient and less on how dependent the patient is. For example, if a caregiver approaches a patient in the critical care environment, the bed may become the primary point of mobilization for that patient.

Mobilization of a very acutely involved dependent patient who is undergoing emergent diuretic activity for heart failure is not likely to be performed frequently with a lift. It simply is not reasonable for the busy intensive care unit (ICU) night shift nursing staff to locate a lift of sufficient capacity and attempt mechanical lift application of a sling to a target surface. If the critical care bed possesses the function of “full cardio chair positioning,” the likelihood that the patient will be mobilized to full sitting increases significantly. A bed that processes full cardio-chair function allows a single nurse to position the dependent patient into fully upright postures, simply by pressing a button or two. There is minimal risk of pulling vital lines, telemetry leads, and ventilation supportive accessories, allowing the task to be accomplished in a very cost-effective manner.

The alternative would be to employ a lift or side-glide device to the target surface, which for the population of size is time-consuming. It requires at least two caregivers, therefore it is used less frequently each day. Full cardio-chair positioning is available in several bariatric beds that allow foot egress. Keep in mind that for the dependent bariatric patient, walking may be contraindicated, noting that the caregiver would have no intention of walking such a patient. The foot egress bed provides the greatest upright for dependent patients, and at the same time reduces the consequences related to prolonged bed rest.

Indications for full cardio-chair positioning may include reducing prolonged flat bed rest and skin breakdown, while increasing benefit in antigravity postures specific to cardiac response, pulmonary response, psychological conquest, and peripheral vasomotor reflex and providing substitution patterns for those who have painful chest walls or post-operative abdominal or thoracic wounds. In the ICU the bed is often the initial point of progression.

Other features for all patients of size should include Trendelenburg switching in the hand control, for gravity - assisted boosting of the patient, because many patients are able to perform self-boosting — especially important for night shift staff. Patients who are postoperative abdominal or thoracic wall surgeries may be indicated for foot exit. This may prevent unnecessary wound dressing disruption and postoperative site irritation, and, most important, allow for upper extremity substitution patterns to compensate for painful mobility patterns. It is important to recognize that patients who are postoperative gastric bypass or chest wall surgeries may sleep in a reclining chair at home or compensate with several pillows placed at the head of the bed. This is a very natural compensatory technique for patients who seek temporary pain-avoiding patterns.

Side exit beds offer semi-cardio-chair positioning. This is accomplished by a combination of elevating the head of the bed, elevating the knee of the bed, and tilting the bed’s seat pan toward a head down position. While semi-cardio-chair positioning is also beneficial, the degree to which the patient is positioned against gravity is about 30% less when compared to full cardio-chair positioning.

Equipment that is highly versatile is vital. Bed prescription needs to allow the use of supine side-glide devices, sitting sliding boards, and sling loading lifts to accomplish safe mechanical conveyance to and from the various target surface postures. In such environments, patients have far less accessory lines, given the medical stability of such clients. Planning of transfer events from the bed includes coordination of supportive staff and equipment as needed. Staff needs to plan for the transfer of the patient out of the bed to allow transportation to other rooms in the facility. For these patients, dependency is no excuse for isolation. The side exit bed allows cost-effective management in conjunction with diverse transfer equipment options.

BARIATRIC INNOVATIONS
When a patient demonstrates dependence beyond the anticipated postoperative course, transition to a rehabilitation side exit bed surface is indicated. In the rehabilitation phase, the patient who is progressing from dependence will require constant monitoring of orthopedic alignment during therapeutic progression. This is most safely managed from the side exit bed by the licensed therapeutic staff.

Perhaps the greatest bed innovation in the last few years is the expandable support surface bed. For the first time, medical facilities have access to bariatric beds with load limits up to 1,000 pounds and an extraordinary degree of portability. The true rehab bed can expand to allow ease of patient rolling on a 48-inch surface for self-care activity and then approximate the side panels to allow transport between diagnostic centers and rehab departments. (The average hospital door is approximately 43 inches wide.) Portability is a significant issue in light of tragic scenarios experienced when evacuation may be required and a large number of patients have to be immediately moved. Such occurrences are not as rare as many would think, given the tornadoes and hurricanes that have plagued the South over the past couple of years. The greatest benefit of the expandable support surface includes ease of patient access. The caregiver may approximate the near side support surface to access the side-lying patient without crawling onto the bed surface, thereby reducing the risk of becoming an infection vector and diminishing potential back strain from prolonged overextended flexed postures. Too often, caregivers find themselves spinning the patient on a narrow standard 38-inch-wide bed, and/or doing prolonged bending over the edge of a wide bed in an attempt to reach the patient positioned in side lying away from the service side of the bed, resulting in the staff sustaining low back strain. Any night shift nurse can immediately identify with this scenario, since wound care or pericare would result in prolonged flexed postures for the caregiver.

Average internal hospital bed length is approximately 80 inches. Some manufacturers offer foot surface extensions to reach up to a length of 104 inches for the seven-foot-tall patient, though keep in mind that the average hospital elevator length is approximately 98 inches, thus limiting portability of the longer bed frame. Bed deck height is particularly important in the rehab setting where rehabilitation goals require the patient to return to a mobility pattern consistent with their potential restored function. Deck height is measured from the floor to the top of the bed’s metal deck surface. A deck height that matches or is lower than the intended wheelchair height is preferable. “High-low” function of 14 to 30 inches of the bed’s deck meets the majority of height requirements of patients. For shorter patients, even deck heights of 14 inches may require placement of a footstool under the patient’s feet during the debut sitting balance activity, to level the patient’s thigh and prevent the dependent patient from sliding downward. The consequence of a down-ward sloping thigh in the dependent patient with poor trunk control is sig-nificant. Footstools should be used only for standing postures.

MATTRESS TYPES
Supportive surfaces such as the low-air-loss air mattress support have become revolutionized in the past 5 years. In working with the population of size, the indications for air mattress support may include: pressure relief, moisture dissipation, mobility and boosting compromise, soft tissue deformity, pain, and compromised skin integrity.

Some viscoelastic foam mattresses provide nearly equal pressure relief, as do the low-air-loss mattress support surface. However, many patients of size have a tendency to sweat profusely. Some of the excessive sweating may have to do with a larger metabolic mismatch related to an insufficient skin surface area ability to dissipate internal heat. The foam mattress becomes an insulator. The benefit of the air mattress overlay is a greater ability to dissipate excessive moisture that may accumulate and cause skin breakdown. I would order an air mattress overlay, even if the patient is independent in pressure relief, provided that excessive sweat may contribute to macerated skin presentation and risk.

Pressure relief: While not unheard of, ulcers related to point pressure are far less common than ulcers related to dependent edema, friction, and excessive moisture accumulation. The air mattress overlay is perhaps the best tool to maintain point pressures below 30 mm Hg and within a safe range.
Boosting: I would order an air mattress overlay if I know that the frictional surface reduction is sufficient to allow the patient to perform boosting and mobility activity, without assistance when assistance is comparatively required on supportive foam surfaces.
Soft tissue deformity: I identify several soft tissue deformities that lead to problematic orthopedic alignment issues. When soft tissue contributes to postural pain syndromes, I would indicate an air mattress overlay to equa-lize supportive pressure and correct alignment where possible.
Pain: Patients who exhibit hypersensitivity from neuronal irritabil-ity in both central nervous system irritability, such as spinal cord injury, or peripheral nerve irritability, due to a host of issues such as shingles, may require reduced frictional support surfaces, while acutely symptomatic. The reduced friction minimizes severely painful support surface stress experienced during mobilization.
Compromised skin integrity: Patients who demonstrate compromise of skin integrity regardless of cause are most typically better off when placed upon a reduced frictional support surface in order to minimize shear force that may cause disruption of healing tissues.

In addition, many air mattress support surfaces now include rotation up to 40°, which assist in the mobilization of infiltrates within the lungs and may be used by the caregiver to augment ease of rolling the patient in preparation for pericare or wound care. When combined together, the bariatric bed and support systems become powerful tools to protect both the patients of size and those who work with them, increasing the safety of the work environment.

Michael Dionne has presented internationally regarding the topic of safety and may be contacted at www.bariatricrehab.com. Indications and contraindications are referenced from Dionne’s Bariatric Ergonomics.

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January/February 2005