Choosing a therapeutic support surface can be a challenging endeavor for clients, caregivers, and HME providers. Usually, caregivers and rehabilitation professionals are most concerned about the pressure management potential of the support surface and its ease of use. Clients are usually concerned with comfort and the impact on their functional abilities. Sometimes these goals are mutually exclusive. HME providers often end up in the middle, trying to meet the needs of everyone. Ensuring that the “right” support surface is provided will enable HME providers to build better relationships with the health care team. With more HME providers as part of the team, client satisfaction will go up and follow-up calls for customer complaints will go down.

Selling to Facilities
The US Agency for Health Care Policy and Research and the Registered Nurses Association of Ontario have developed guidelines to assist clinicians in choosing an appropriate support surface. Both organizations recommended a high specification foam mattress instead of a standard hospital mattress for clients who are at a moderate-to-high risk of developing pressure ulcers. For HME providers, this means there is an opportunity to sell support surfaces directly to facilities. Clients who use these specialty mattresses in the facility may be more likely to purchase them for home use upon discharge.

Another recommendation^1,2 is to use a static support surface if the client can assume a variety of postures, without bearing weight over the pressure sore, and without fully compressing the surface. A dynamic surface (one maintained by an air pump) is recommended when the client fully compresses the static surface, or can not assume a variety of postures without bearing weight on the pressure ulcer, or if the wound does not show evidence of healing. Despite these guidelines, there is no compelling independent evidence that one type of support surface is better at relieving pressure than all others under all circumstances.³ This fact may assist HME providers to negotiate with clinicians for a different category of device that better meets the client’s other needs.

Linda Norton, OT

The Best Support Surface
Although interface pressure is an important consideration when choosing a therapeutic support surface, other factors include client considerations, caregiver considerations, product parameters, and environmental issues. Comfort is usually the primary consideration for clients considering the purchase of a therapeutic support surface. If the client is not comfortable, they will not be satisfied with the surface regardless of its other beneficial properties—leading to complaints to HME providers or abandonment of the equipment. Other factors to consider include the impact on the client’s functional abilities, the client’s weight, and body type.

Caregivers are usually concerned with the impact of the surface on the ease of client care as well as the ease of operation. Devices with simple controls are usually learned more easily and are more likely to be used correctly, especially where there are multiple caregivers. Product parameters include issues such as cost to the client, ongoing cost of maintenance and repair of the surface, as well as durability. Ideally, it is better to sell a surface that is durable and reliable rather than having to complete emergency service calls.

The final issue is whether the client has the space for the intended system. Some systems may require a hospital bed, rather than the client’s regular bed. Accommodating another bed within the client’s home may not be feasible.

All of these factors need to be considered and balanced to ensure a successful recommendation of a support surface. HME providers may be able to assist clinicians with this process by becoming a reliable source of information and thus a valued team member. For example, the HME provider may be able to suggest a different product that would better address the client’s expressed concerns, or be easier for the caregiver to use and maintain.

Types of Support Surfaces
Therapeutic support surfaces can be divided into several categories. Static support surfaces include foam overlays, foam replacement mattresses, or static flotation overlays (gel, air). Dynamic systems (maintained with a pump) include alternating air, low air loss, air fluidized, and those with a turning/rotation component. Moving to a dynamic system should be done with caution because they are usually more expensive and have a greater impact on the client’s independence with bed mobility and transfers. Examining the advantages and disadvantages of these surfaces will help HME providers suggest the best category.

Foam overlays (four-inch egg crate/convoluted foam) may initially provide adequate pressure distribution. However, they can wear out quickly and require frequent replacement. Often, the client finds the surface too warm. Foam overlays tend to degrade quickly when exposed to moisture. Usually, they do not negatively impact the client’s ability to move in bed, or impede their transfers. This overlay is best suited for continent clients who require a short-term solution (to use while accessing funding).

Foam replacement mattresses tend to fit standard hospital beds but may be able to be ordered in custom sizes for an increased cost. This option may necessitate the client purchasing a hospital bed for home, bringing out the issue of finding space within the home. Transfers and bed mobility are not usually negatively affected by this type of surface, and little, if any, maintenance is required. This type of mattress may not provide adequate pressure distribution. Some of these mattresses may be able to be adapted with air cells, or other material that can increase the pressure distribution properties. This type of mattress may be best recommended for facilities, where they can switch between foam and other inserts depending on the needs of the clients—or for clients who do not have the resources to maintain other types of surfaces.

Static overlays/mattresses may consist of viscoelastic foam, gel, air, or combinations of media. Many of these surfaces require little maintenance (except for some air overlays) and may provide better pressure distribution than foam overlays or foam replacement mattresses. Surfaces that envelop the client, or where the client significantly sinks into them, tend to decrease independence in bed mobility and transfers because it is more difficult for the client to move. Surfaces that significantly increase the surface-to-floor height may also have a negative impact on transfers. This type of surface is best suited for the client who needs more pressure distribution than foam overlays or foam replacement mattresses provide, but does not want to move to a dynamic system.

Alternating air mattresses, low air loss mattresses, and mattresses with rotational or turning components usually have large air bolsters, and an air pump that moves air into/through the surface. These types of mattresses have significant impacts on the client and caregivers because they may reduce independent bed mobility, and make transfers more difficult. Clients and their significant others may find the noise of the pump disturbing. Some clients may also wake up when the mattress moves or experience increased spasticity. These support surfaces usually have a control panel on the pump, which may be complex depending on the number of features of the surface. This complexity may make it difficult for caregivers to set and use appropriately.

These dynamic surfaces are suited to clients where concern over pressure ulcers takes precedence. For palliative care, clients may find that a mattress with a turning/rotational component is more comfortable for repositioning than being turned by caregivers.

Recommending the Mattress
Clinicians, clients, and HME providers should work together to determine the best category of support surface. A balanced approach that considers client preference, caregiver issues, cost, affordability, comfort, and pressure management will ensure appropriate recommendations.

Education and Hands-on Care
Therapeutic support surfaces do not replace good, hands-on care. Clients will still require repositioning and intervention from caregivers. Education is an important part of ensuring the therapeutic support surface meets the client’s needs and is used appropriately. This education should include surface setup, cleaning, maintenance, trouble-shooting of common problems, transfers, and when to call for service. Hands-on demon-strations in conjunction with simple hand-out material will ensure that the equipment is used consistently between different caregivers. To ultimately find success in this product category, HME providers must develop relationships with clinicians, listen and address client and caregiver concerns, and recommend a surface that meets all of these needs.

Linda Norton, OT, is rehabilitation education coordinator for Shoppers Home Health Care, an HME provider in Ontario, Canada. Norton has presented workshops across North America on seating and mobility and pressure ulcer management. She can be reached via e-mail: lnorton@shoppershomehealthcare.ca.  

References available online at www.hhcdealer.com.