Using an innovative lateral tilt mattress for pressure ulcer management in a spinal injury patient

Introduction

The daily cost of pressure ulcers (PU) in the UK is significant at approximately £3.8 million.¹ These generally preventable wounds present obvious physical complications and challenges for patients and often affect their emotional wellbeing. Caring for patients with pressure ulcers also has a significant impact for healthcare providers in terms of financial cost and the requirement for additional nursing time.  

Whilst pressure ulcers can affect almost every patient cohort, Spinal Cord Injury (SCI) patients can be particularly vulnerable. Spinal Cord Injury is a debilitating, sometimes life-threatening injury that can have long-term impacts on patients’ physical, psycho-social and emotional health and wellbeing.²  

In the UK approximately 2,500 patients per year present with an SCI with pressure ulcers being the most common secondary complication following injury.³  

The increased pressure ulcer prevalence rates in SCI patients have been attributed to spending prolonged periods in the seated position, with wheelchair users reportedly sitting for up to eighteen hours per day in their chairs.⁴ 

For many SCI patients the combination of prolonged sitting, lack of sensation and limited mobility/ability to reposition themselves, elevates the pressure ulcer risk level still further (see Figure 1). The result is that SCI patients can develop some of the most severe pressure related tissue injuries, with the sacrum and buttocks being the most common location for PU development in this patient cohort.⁴

Figure 1. Common factors affecting the pressure ulcer risk level of Spinal injury patients.

The most effective method to prevent pressure ulcers is regular repositioning, however concordance with this is often poor especially when pain and discomfort are contributing factors.⁵ 

To support pressure ulcer prevention and management protocols it is important for healthcare professionals and specialist teams to have access to effective pressure area care support surfaces. These will reduce the risk of further pressure damage and provide the best care, comfort and quality of life for patients.

Aim

The aim of this case study is to report how a comprehensive care plan, including use of an innovative lateral tilt support surface, can assist pressure ulcer healing and improve quality of life for a spinal injury patient with significant pressure damage and complex pain management requirements.

Patient History

A 60-year-old female patient with a history of spinal injury and cauda equina syndrome lived alone and was cared for by a lay carer.  To maintain her independence she chose to remain in her wheelchair for long periods of time. Due to the pain caused by her spinal injury, she preferred to sit upright at 90 degrees for comfort, rarely changing position and remaining in her wheelchair all day.  At night she used a dynamic mattress, however, due to the pain she remained sat at 90 degrees even when in bed.  

The patient had an indwelling urinary catheter that regularly bypassed due to positional changes and her nutritional intake was poor, eating snacks equating to one meal per day. 

In September 2021, a Category 4 pressure ulcer measuring 5.5 x 6.5 x 5.0cm (=179cm³) developed on her right buttock. Following an initial assessment by the district nurses, she was admitted to hospital with sepsis.  

Following surgical debridement of the wound, she was discharged eight weeks later onto a hybrid mattress.  The community TVN team assessed the wound on discharge and found no change in wound volume.  The patient’s indwelling urinary catheter remained insitu but despite the bypassing, the patient’s skin remained free of moisture associated skin damage.  Nutritional intake was still poor and so referral to the Dietitian was made and nutritional supplements prescribed.

The patient stated the hybrid mattress was very uncomfortable, reporting disturbed sleep and complained of pain even when sitting at 90-degrees on the mattress. This greatly impacted her quality of life.  The patient reported the sensation of ‘being sat in a hole’ which impacted on her independence and also had negative impact on her catheter.

Intervention

Following several evaluations of various lateral tilting systems and mattresses which the patient found uncomfortable, the TVN recommended the OSKA Series5 lateral tilt mattress (see Figure 2) to assist with repositioning, pressure redistribution, patient comfort and to aid PU healing.  With the exception of changing to the new support surface no other elements of the patient’s care package, wound care, or patient situation changed.

Unlike traditional alternating pressure air mattresses the Series5 mattress relies on a unique configuration of air cells within the mattress to deliver a gentle lateral tilt for patients (see Figure 3).  These small movements result in micro-shifting the patient alternately between their left and right sides to redistribute pressure at the patient / support surface interface every ten minutes.

Results

After replacing the hybrid system with the OSKA Series5 mattress, the patient did not report any further issues with pain or discomfort and the nursing team reported improvements to the patient’s sleep quality and overall quality of life. 

In addition, the Tissue Viability team also noted a significant 46% reduction in wound volume to 97.5cm³ (7.5 x 6.5 x 2.0cm) which indicates the wound is making solid progress regarding its wound healing trajectory.  

This significant improvement has been noted even though the patient remained nutritionally compromised and was unable to frequently reposition herself.

Discussion

When choosing a support surface for complex patients it has historically been a balancing act between comfort and performance. In broad terms foam mattresses would offer better comfort with limited pressure redistribution while alternating pressure air mattresses could deliver excellent pressure redistribution, often at the expense of patient comfort.

This particular SCI patient presented multiple challenges to the community healthcare team which complicated the provision of effective pressure area care in this specific case. 

Not only was the patient at the highest risk of pressure ulceration, and presented with an existing Category 4 pressure ulcer, but they also had the additional complication of significant pain that greatly impacted the patient comfort and quality of life. In this particular instance, the patient pain levels limited the options for delivering optimal pressure area care to the patient by traditional means of foam, hybrid or full air mattresses.

Although support surfaces are only one part of an effective pressure ulcer prevention and management care plan, they must ideally be able to manage the pressure area care needs of complex patients (including those with SCI) without causing or exacerbating problems for the patient in other areas. The delivery of safe, effective pressure area care will often focus on the clinical goals of preventing further pressure damage and promoting pressure ulcer healing where wounds already exist.  Almost without exception, these clinical goals should not be viewed in isolation and the provision of any new PAC support surface should encompass a holistic patient assessment which includes any impact, or potential impact (positive or negative) on patients’ pain levels, quality of life and comfort. 

Innovative, alternative support surfaces are now available that can offer the highest levels of clinical performance and patient comfort. These give clinicians a viable alternative to more traditional foam, hybrid or alternating therapy support surfaces when managing complex cases.   

For this specific complex SCI patient, the micro-shifts in patient position offered by the OSKA Series5 have delivered effective pressure area care to prevent further pressure ulceration and support full-thickness pressure ulcer healing. In addition, the mattress has also helped reduce patient pain and enhanced their quality-of-life.

Lateral tilt therapy represents a highly effective alternative to more traditional ‘alternating pressure’ or more typical hybrid support surfaces.

Conclusion

With an increased prevalence rate of pressure ulcers in SCI patients, having access to new and innovative technologies within the community can help ensure the multi-faceted needs of these complex patients can be met.  

The use of specialised support surfaces can enable clinicians to provide safe and effective pressure area care whilst also enhancing patient comfort and quality of life.