Pressure Ulcers Guidelines

Risk assessment and prevention of pressure ulcers:
a clinical practice guideline from the American College of Physicians

Authors: Amir Qaseem, Tanveer P Mir, Melissa Starkey, Thomas D Denberg

Publisher: Clinical Guidelines Committee of the American College of Physicians

Abstract: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations based on the comparative effectiveness of risk assessment scales and preventive interventions for pressure ulcers.

Methods: This guideline is based on published literature on this topic that was identified by using MEDLINE (1946 through February 2014), CINAHL (1998 through February 2014), the Cochrane Library, clinical trials registries, and reference lists. Searches were limited to English-language publications. The outcomes evaluated for this guideline include pressure ulcer incidence and severity, resource use, diagnostic accuracy, measures of risk, and harms. This guideline grades the quality of evidence and strength of recommendations by using ACP’s clinical practice guidelines grading system. The target audience for this guideline includes all clinicians, and the target patient population is patients at risk for pressure ulcers.

Full text: https://pubmed.ncbi.nlm.nih.gov/25732278/

Categorizing Incontinence

Incontinence: It takes a Team; Categorizing Incontinence

Publication: Provider Magazine

Author: Amy Mendoza

Publisher: American Health Care Association/National Center for Assisted Living

“Vetter Health Services, headquartered in Elkhorn, Neb., takes a restorative approach to bowel and bladder retraining. When new residents walk in the door, staff assess them for incontinence and take it a step further to determine the type of incontinence they have.

‘This can fall into one of four categories—stress, urge, transient, and functional,’ says Michelle Wallace, RN-BC, a certified registered rehabilitation nurse and clinical coordinator at Vetter. One of four clinical coordinators for Vetter, she has overseen operations regionally for the past six years and has a self-described passion for restorative care.”

Stress: Incontinence related to the weakening of the muscle structure. Sneezing, coughing, standing up, any kind of movement can cause a leakage.

Urge: Incontinence brought on by irritation of the urinary system. Stimulants come into play, and serious urgency is related to it. When a resident needs to go, they need to go immediately. 

Transient: Incontinence of a reversable type. The resident may have a urinary tract infection, or they are on a type of medication, something that is typically reversible. Once the particular issue is addressed, continence is restored.

Functional: Incontinence related to a functional limitation either with the resident’s ability to move or things in their environment that functionally inhibit them from being continent.

Mixed: Incontinence that could be a combination of any of the four types.”

Full text: https://www.providermagazine.com/Monthly-Issue/2019/November/Pages/Incontinence-It-takes-a-Team.aspx

“Incontinence: It takes a Team”; Provider Magazine, COPYRIGHT 2019.

NIV & COPD

Home Non-Invasive Ventilation Use Following Acute Hypercapnic Respiratory Failure in Chronic Obstructive Pulmonary Disease

Publication: Respiratory Medicine

Study Authors: Matos, P; Kampelmacher, MJ; Esquinas, AM

Publisher: Science Direct

In 2011, 166 COPD patients were studied to evaluate the effectiveness of Non-Invasive Positive Pressure Ventilation (NPPV). Half of the patients utilized the at-home therapy; the other half did not. Over the course of 6 months, these were the findings.

“Results: Patients in the NPPV post discharge group demonstrated superior event-free survival compared to the no-NPPV post discharge group (х2 = 23.8, p < 0.0001). The NPPV post discharge group had a statistically significant reduction in hospital readmissions (40% versus 75%, p < 0.0001) through 180 days from the index admission.

Conclusions: Patients who used NPPV following an admission for AECOPD with hypercapnic respiratory failure had lower readmission rates and improved event-free survival after 180 days from an index admission compared to patients who did not use NPPV post discharge.”

Full text: https://www.sciencedirect.com/science/article/pii/S0954611114001140

“Home non-invasive ventilation use following acute hypercapnic respiratory failure in COPD”; Respiratory Medicine, COPYRIGHT 2011.

NIV & ALS

Non-Invasive Ventilation (NIV) and Hypercapnia-Associated Symptoms in Amyotrophic Lateral Sclerosis (ALS)

Publication: Acta Neurologica Scandinavica

Study Authors: Dorst, J; Behrendt, G; Ludolph, AC.

Publisher: Wiley-Blackwell; Country of Publication: Denmark

Objectives: During the course of amyotrophic lateral sclerosis (ALS), progressive weakness of respiratory muscles leads to chronic hypercapnia which causes various symptoms like sleep disturbances, daytime fatigue, and depression. Non‐invasive ventilation (NIV) improves survival and quality of life, but little is known about its effect on these specific symptoms, in particular during the later course of disease. Our aim was to evaluate the short‐ and long‐term effects of NIV on hypercapnia‐associated symptoms in ALS.

Material and Methods: We prospectively analyzed sleep disturbance, daytime fatigue, and depression using standardized scales (Pittsburgh sleep quality index [PSQI], Stanford sleepiness scale [SSS], Beck depression inventory [BDI], and Clinical hypoventilation score [CHS]) in 58 patients with NIV. Follow‐up was done every 3 months up to a maximum of 24 months.

Hypercapnia‐Associated Symptoms: Baseline values of PSQI, SSS, BDI, CHS, and ALSFRS‐R are shown in Figure 2. The majority of patients (70.3%) showed pathological results in the PSQI. The BDI revealed mild depression in n = 9 patients (15.6%), a moderate depression in n = 6 patients (10.3%), and a severe depression in n = 2 patients (3.4%). Median BDI was higher in patients with bulbar onset (11.5; 95% CI: 9.0‐18.0) than in patients with spinal onset (7.0; 95% CI: 4.0‐8.5; P = 0.011), indicating a higher incidence of depression in bulbar patients. For SSS and CHS, there are no pathological threshold values. The CHS, which comprises all known hypercapnia‐associated symptoms, was significantly higher in patients with pCO >45 mm Hg (24.0; 95% CI: 16.0‐32.0) than in patients with pCO ≤45 mm Hg (11.0; 95% CI: 9.0‐18.0).

Graph: Baseline values of scores for hypercapnia‐associated symptoms and ALSFRS‐R Colored lines mark pathological thresholds (PSQI) and thresholds for mild, moderate, and severe depression (BDI). ALSFRS‐R, amyotrophic lateral sclerosis functional rating scale; BDI, beck depression inventory; CHS, clinical hypoventilation score; PSQI, Pittsburgh sleep quality index; SSS: stanford sleepiness scale

Results: We found significant improvements of all outcome parameters except BDI within the first three months after NIV initiation. The median PSQI improved from 6.5 (95% CI: 5.0‐8.5) to 6.0 (95% CI: 4.5‐7.0; P = 0.042), the SSS from 3.0 (95% CI: 2.0‐4.0) to 2.0 (95% CI: 2.0‐3.0; P = 0.004), and the CHS from 22.0 (95% CI: 19.5‐25.0) to 18.0 points (95% CI: 12.0‐23.5; P = 0.013). Patients with bulbar and spinal onset were not significantly different, and positive effects were long‐lasting.

Conclusions: Our data show that NIV improves hypercapnia‐associated symptoms within the first 3 months after initiation in spinal as well as bulbar patients, and that beneficial effects are long‐lasting.

In summary, our data indicate that, NIV improves blood gases, quality of sleep, and daytime fatigue, confirming previous studies, beneficial effects are long‐lasting and may be preserved by adjusting ventilation times and parameters, the effects are present in patients with bulbar involvement as well, and other hypercapnia related symptoms such as morning headache, vegetative symptoms, and cognitive decline might improve as well, although further studies are needed for confirmation.”

Full text: https://onlinelibrary.wiley.com/doi/abs/10.1111/ane.13043

“Non-invasive ventilation and hypercapnia-associated symptoms in amyotrophic lateral sclerosis.” Acta neurologica Scandinavica, COPYRIGHT FEBRUARY 2019.

The Necessity of Seat Elevation for Power Wheelchairs

RESNA Position on the Application of Seat Elevation Devices for Power Wheelchair Users

Authors: Schiappa, MS ATP; Piriano, PT ATP/SMS; Bernhardt, PT MPT ATP; Shea, MA OTR ATP; Maurer, PT MPT ATP; Rosen, PT MPT MSMS ATP/SMS; Lange, OTR/L ABDA ATP/SMS; Schmeler, PhD OTR/L ATP; Dicanno, MD

Publisher: Rehabilitation Engineering and Assistive Technology Society of North America

What is a seat elevation device for a wheelchair? 

“A power seat elevation device is a seat function component of a wheelchair that raises and lowers users while remaining in a seated position through the use of an electromechanical lift system to provide varying amounts of vertical seat to floor height. It does not change the seated angles or the seat’s angle relative to the ground. A seat elevation device may elevate vertically from a standard seat height or may lower the user closer to the floor.”

Why is seat elevation so important to its user?

“Wheelchair mobility is often only considered from the perspective of people moving from one point to another on a two-dimensional plane. Vertical movement is necessary for people to function and participate in a three- dimensional world. A common intervention that provides vertical mobility within a wheelchair is a seat elevation device.”

Full text: https://www.resna.org/Portals/0/Documents/Position%20Papers/RESNA_App%20of%20Seat%20Elevation%20Devices%202019.pdf

Summary: “Power seat elevation devices allow an individual who uses a power wheelchair to independently change their seat to floor height. Increasing seat height can increase functional reach (vertical and horizontal reaching ability) as well as decrease the amount of overhead reaching that is required. Overhead reach can lead to injury and pain of the shoulder, neck and upper extremities. Changing the seat height in relation to other surfaces can increase transfer safety and efficiency as well as reduce injuries and fall risk. Seat elevation devices can also improve line of sight with others and with the environment. Without a more direct line of sight, individuals in wheelchair tend to assume cervical extension which can lead to fatigue, pain and even elicitation of a symmetrical tonic neck reflex (STNR). Power seat elevation devices are an important power wheelchair seat function which can improve overall function; safety; efficiency; and reduce fatigue; injury; and pain to minimize the risk for adverse medical outcomes and resulting healthcare costs.”

“RESNA Position on the Application of Seat Elevation Devices for Power Wheelchair Users” Approved by RESNA Board of Directors in 2019.

Bronchiectasis in Primary Care

“Non-cystic fibrosis (CF) (bronchiectasis) is a common chronic lung condition, which occurs due to damage to the airways leading to persistent cough, sputum production and recurrent chest infections (Hill et al, 2018). This article focuses on the adult patient and describes the pathophysiology, aetiology, investigation, and management of bronchiectasis in the primary care setting. The aim is to raise awareness of this disease, which is increasing in prevalence and to empower community nurses with information to support patients through the bronchiectasis disease trajectory.”

Courtesy of Shirley Pickstock; JCN 2020, Vol 34, No 1

Tilt, Recline & Elevating Legrests for Wheelchairs

RESNA Position on the Application of Tilt, Recline, and Elevating Legrests for Wheelchairs Literature Update

Authors: Dicianno, MD; Lieberman, MSOTR/L, ATP; Schmeler, PhD, OTR/L, ATP; Souza, PhD, PT; Cooper, MPT, ATP; Lange, OTR, ABDA, ATP/SMS; Liu, PT, PhD; Jan, PT, PhD

Publisher: Rehabilitation Engineering and Assistive Technology Society of North America

Tilt, recline, and elevating legrests are features that can be operated manually or as power options that can be added to wheelchairs. The beneficial effects of these seat functions have been reported as a clinical consensus statement in prior work (Dicianno et al., 2009). The purpose of this manuscript is to update this RESNA Position on the application of tilt, recline, and elevating legrests with more current and additional scientific literature. It is RESNA’s position that these features are often medically necessary, as they enable certain individuals to:

  • Realign posture and enhance function
  • Enhance visual orientation, speech, alertness, and arousal
  • Improve physiological processes such as orthostatic hypotension, respiration, and bowel and bladder function
  • Improve transfer biomechanics
  • Regulate spasticity
  • Accommodate and prevent contractures and orthopedic deformities
  • Manage edema
  • Redistribute and relieve pressure
  • Increase seating tolerance and comfort
  • Independently change position to allow dynamic movement

Special precautions must be exercised when utilizing these features in order to avoid the risk of injury, such as shear wounds. A licensed medical professional (i.e. physical or occupational therapist) must be involved with the assessment, prescription, trials and training in the use of the equipment and a specialty certified professional is recommended.

Tilt systems allow clients to change their seat angle orientation in relation to the ground while maintaining a constant seat to back angle and seat to legrest angle. Traditional tilt operates in the sagittal plane. Most tilt systems tilt posteriorly in this plane, but some systems offer anterior tilt. Other tilt systems such as rotational and lateral tilt operate in coronal or oblique planes. 

Recline allows clients to change seat to back angle and maintain constant seat angle with respect to the ground. 

Elevating legrests allow clients to change the leg and/or footrest angle relative to the seat in order to flex or extend the knee. Some legrests articulate, that is, lengthen while extending the knee.

Full text: https://www.resna.org/Portals/0/Documents/Position%20Papers/RESNA%20PP%20on%20Tilt%20Recline_2017.pdf

Summary: It is RESNA’s position that tilt, recline, and elevating legrests are medically beneficial for wheelchair users by: improving functional reach and access to enable participation in ADLs; managing posture and fatigue; improving mobility and lower limb function in those with some preservation of lower limb strength; improving range of motion and reducing the risk of contractures; promoting vital organ capacity including pulmonary, bowel and bladder function; promoting bone health; improving circulation; reducing abnormal muscle tone and spasticity; reducing the occurrence of pressure ulcers and skeletal deformities; and providing numerous psychosocial and quality of life benefits. The findings in this paper are supported by select peer-reviewed literature and current clinical practice. 

“RESNA Position on the Application of Tilt, Recline, and Elevating Legrests for Wheelchairs Literature Update” Approved by RESNA Board of Directors on February 23, 2015.