Introduction
Pressure relieving and redistributing devices are widely accepted methods of trying to prevent the development of pressure ulcers for people considered as being at risk (National Institute for Health and Care Excellence (NICE), 2019).
It is well recognised that all patients at risk of pressure ulcers should be regularly repositioned unless otherwise contraindicated (EPUAP 2019, NICE 2014). This should follow an individualised schedule based on risk assessment, clinical judgement, and what is tolerable for the patient. Repositioning can range from small shifts in position to full lateral tilt/turns, undertaken by either health and social care professionals, or by encouraging patients to reposition themselves. There has been much debate over what is the best position when laterally turning patients, with recommendations ranging from 90° to 30°.
The 30° tilt (Fig.1) is the preferred position by health care professionals to reposition a patient laterally (Wilson, 2008). This can be problematic to achieve because the pillows may not maintain their shape and may flatten under body weight forces, leading to a reduction of the angle of tilt and resulting in the body sustaining pressure and shear to areas not adequately relieved (Powers, 2016). A study by Woodhouse et al, (2019) also highlighted there was considerable variability in the repositioning techniques when using the 30° tilt, despite all participants having clinical experience in repositioning and had relevant training in pressure ulcer prevention.
A more recent study by Oomens (2016) found the optimal tilting angle for good pressure redistribution ranged from 20° to 30°. However, NICE does not specify a recommended or preferred position for optimal pressure redistribution for patients at risk of pressure ulcers.
Tilting platforms
In recent years there has been a growing demand for lateral tilting systems, which are placed underneath an existing dynamic mattress, to enhance the total function of the equipment provided to prevent
pressure ulceration occurring. Combining such equipment is most likely because of the increasing complexity of patients alongside a shortage of carers to provide regular manual repositioning.
Any positioning device used for pressure ulcer prevention should be biomechanically safe and effective in transferring the bodyweight forces without causing concentrated mechanical loads in tissues at or near the body-support contact sites. Lateral tilting positioners for pressure ulcer prevention or treatment should have structure and material components that allow immersion and envelopment along the body contours and thereby deliver the bodyweight forces as uniformly as possible over the contact sites (Kapp et al. 2019).
What is the difference between a lateral tilting/ rotation mattress and a lateral tilting device?
A lateral tilting mattress (OSKA Series5) gently tilts the patient from side to side every 10 minutes (with 5 minutes on each side). Two longitudinal air cylinders on one side inflate, while the two on the opposite side deflate, gently rotating the patient 20° to one side. After 5 minutes, the inflation pattern reverses, and the patient is rotated to the opposite side. This is ideal for palliative care settings or situations where manual turning is difficult.
A lateral rotation mattress (Heritage 11 and Optima Turn) system uses air to move the patient side-to-side in timed cycles to relieve pressure. The air pump raises one side of the mattress between 25° and up to 40° and holds. In a timed cycle, the mattress returns to the flat position and holds. The pump then raises the other side of the mattress. This movement helps redistribute pressure. However, this can place additional pressure on the opposite side. If a patient has skin breakdown on the hips, one must be careful to take that into consideration.
A lateral tilting device (Toto, KomfiTilt, Opera AutoTurn and Examove) is a device inserted between the mattress and a level bed base or bed frame on which the mattress rests. The lateral tilting device comprises at least two independent first and second inflatable cells, pneumatically independent and positioned at least partly symmetrically from one another in relation to a median axis of the tilting device. The lateral tilting device includes two inflatable compartments that are fitted on each side of the device. A method for the lateral tilting of the mattress includes inflating a said first or second cell and concomitant deflation of the other second or respectively first cell of the tilting device laid out under the mattress.
Multiple factors contributing to advanced pressure area care in tilting/turning devices
There are four key factors that contribute to effective pressure area care. When selecting equipment, consideration should be made whether each of these four factors are addressed.
1. Immersion and envelopment – by increasing the contact surface area and redistributing weight, the pressure is reduced.
2. Microclimate management – reducing the chance of heat build-up and sweating helps lower the risk of pressure damage.
3. Shear & friction reduction – reducing these two major contributing factors to pressure damage is important. Some systems like the OSKA Series5 have integrated anti-shear zones.
4. Alternating pressure – changing the areas of pressure every 5-10 minutes enables reperfusion of the blood vessels. Micro-shifts mimic the regular movements of a healthy body.
Other key considerations
A. Shear forces – tilting a mattress up at 30° (which should not be confused with the 30° tilt (Fig.1)) can cause shearing on the patient’s skin.
B. Risk of falls & entrapment – tilting devices lift a patient to such a degree they often specify the need for siderails to lower the risk of the patient rolling out of bed. However, introducing siderails to this situation could cause risk of entrapment.
C. Patient comfort – tilting platforms and all-air rotation devices can provide a substantial tilt which some patients may find too aggressive and increase anxiety of being tipped out of bed.
D. Multiple pumps – If an alternating mattress is used along with a tilting platform, this will result in there being two powered pumps. Whereas a mattress with an integral tilting function avoids the extra noise, electricity usage, trailing wires, risk of breakdown and servicing requirements of an extra pump.
Lateral Tilting mattresses
Series5 – Lateral Tilt mode is an alternative to alternating pressure, in which two cylinders inflate on one side while the opposite pair deflate. This cyclical action creates a series of subtle micro-turns across the centre, longitudinal access resulting in the patient being held in a lateral tilt (approximately 20°) for a period of 5 minutes on either side. These micro-shifts mimic the regular movements of a healthy body. There is a 2-minute period of change while the tilt moves to the other side.
Physically tilting a mattress up at 30° (not to be confused with the 30° tilt (Fig.1)) can cause shearing on the patient’s skin. The anti-shear zones built into the outer fabric cover of the Series5 provide protection against the effects of macro shear and pivot-induced (rotational) shear caused by the heel, sacrum, and scapula from “digging into” the surface during the Series5 30° tilt.
If an alternating mattress is used along with a tilting platform, this will result in there being two powered pumps. With its integral tilting function, the active air system of the OSKA Series5 provides the caregiver with the choice of three distinct modes of powered operation:
Float (“powered flotation”) (Figure. 3) Provides good pressure redistribution through immersion and envelopment, and continually re-calibrates the air system, in response to any changes in position on the mattress, to remain at that selected pressure level. This is a static mode and because it does not perform micro-shifts to change pressure, manual repositioning at a 30° angle or more should be used to totally relieve the pressure at bony prominences. Though micro-shifts change pressure points, manual repositioning is still required.
Alternating Pressure mode (Figure 4) An active therapy added to pressure redistribution (float) that alternates inflating and deflating every other cylinder to mimic the often-subconscious shifts that individuals perform when asleep or when sensing discomfort from being in one position too long. Alternating pressure is also used when patients must be placed on an existing pressure injury. Though micro-shifts change pressure points, manual repositioning is still required.
Lateral Tilt mode is an alternative to alternating pressure, in which two cylinders inflate on one side while the opposite pair deflates. This cyclical action creates a series of subtle micro- turns across the centre, longitudinal access (Figure. 5) resulting in the patient being held in a lateral tilt (approximately 20°) for a period of 5 minutes on either side. There is a 2-minute period of change while the tilt moves to the other side.
Lateral tilting is a much more comfortable way of alternating the pressure than lying on traditional style alternating air cells. Delivering built-in, gentle lateral tilting therapy all-in-one system, patient comfort is therefore optimised. The gentle side to side tilt provides a substantial tilt which patients can tolerate without increasing anxiety of being tipped out of bed.
Patented inner bolster gives a “cradling effect” for user safety. The reinforced outer edge of the mattress supports patients sitting on the mattress edge during ingress and egress from the bed. Firm sides give edge-of-bed stability directing patients back towards the mattress centre, reducing the potential for contact with bedframe side rails. The firm side walls and a special Safety-Edge design help reduce risk of falls and entrapment.
Heritage 11 Digital Turn
The Heritage II Digital Turn Dynamic Mattress Replacement system has 2 key features.
1. It provides a 1 in 2 alternating system, where the deflated cell fully re-inflates before the next cell deflates. Eliminating
the movement some patients experience with the traditional alternating cells.
2. It has the option of right and left or bilateral turn to assist in a manual or provide automatic turning at variable times between 10 – 30 minutes.
Optima Turn
Optima Turn is a dynamic mattress replacement system which has two longitudinal air cells, one on each side of the mattress, which inflate to achieve 30° repositioning. Auto-turning supports continuous 30° turning whilst firm air cell side bolsters combined with the bed rails prevent the patient from slipping off the mattress and feeling trapped, uncomfortable, or hurt by the railings during turning. Optima Turn supports upper body turning only.
Lateral tilt device
It could be argued that the manual repositioning of a patient into the 30° tilt position (Fig.1) discussed earlier is very different from equipment which lifts the side of a mattress up by 30°. The degree of this shift in the mattress positioning requires clinicians to consider the holistic assessment of their patients and balance decision making between perceived improvement in pressure relief with potential risks such as falls.
Toto
This device automatically turns patients by tilting them from the left to the right side, using inflatable air cells within the platform, which sits underneath the existing mattress on the bed. The system fits most nursing bed frames and can be positioned under any existing mattress (except pocket sprung). The accompanying control unit is placed at the end of the bed and has all the necessary information and settings to fully control and adapt the time intervals and positions, according to the patient’s requirements.
Ekamove
The Ekamove is an automated, sensor-controlled patient positioning system which is designed to turn patients up to 30°, without the intervention of a healthcare professional. The Ekamove air chamber is placed under a section of a mattress and inflated to laterally lift the person lying on it. Operated via a control unit, you can select a separate positioning time for each step of the process and therefore give better protection to the affected areas of the patient’s body.
Opera AutoTurn system
The Opera® AutoTurn is a lateral turning system that sits under any mattress. The AutoTurn redistributes pressure through its inflating and deflating air cells at a constant flow. The automatic frequent turning supports care givers in the regular turning of high-risk individuals utilising the 0-30° lateral turning positioning system for prevention and treatment of pressure ulcers. The system automatically turns the user gently and quietly, without the intervention of a carer.
Advantages of combining immersion, envelopment and micro-shifts
In conclusion, no product will ever replace good nursing, which includes an individualised schedule based on risk assessment, clinical judgement and what is tolerable for the patient. This individualised plan of care may also outline a turning regime which, depending on the needs of the individual, may include the 30° tilt position. In support of this, an all-in-one therapy system which provides effective and proven pressure redistribution (OSKA UK, 2018), tissue immersion and envelopment alongside a regular, built in, gentle lateral tilting movement, has to be the next innovation in support surface technology that clinicians have been asking for and patients will welcome and find easy to adjust to.
Lateral tilting mattress and devices
References
Kapp S, Gerdtz M, Gefen A, Prematunga R, Santamaria N. (2019). An observational study of the maintenance of the 30° side-lying lateral tilt position among aged care residents at risk of developing pressure injuries when using the standard care pillow and a purpose-designed positioning device. Int Wound J. 16(5):1080-1086. doi: 10.1111/iwj.13142.
National Institute for Health and Care Excellence (NICE). 2019. Pressure ulcers: prevention and management. Clinical Guideline. www.nice.org.uk/guidance/cg179
Oomens, CWJ., Broek, M., Hemmes, B., Bader, DL., 2016. How does lateral tilting affect the internal strains in the sacral region of bed ridden patients?-a contribution to pressure ulcer prevention. Clinical Biomechanics. 35. pp7-13.
OSKA UK., 2022. Rethinking the optimum pressure relieving mattress for patients requiring the best care White Paper. OSKA UK. Havant. www.oska.uk.com
Powers, J., 2016. Two methods for turning and positioning and the effect on pressure ulcer development: a comparison cohort study. Journal of Wound Ostomy and Continence Nursing. 43 (1). pp 46-50.
Woodhouse, M., 2014. The physiological response of soft tissue to periodic repositioning as a strategy for pressure ulcer prevention. Clinical Biomechanics, pp. 166-174.
Woodhouse, M., Worsley, PR., Voegeli, D., Schoonhoven, L., Bader, D., 2019. How consistent and effective are current repositioning strategies for pressure ulcer prevention? Applied Nursing Research. 48. Pp 58-62.
