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Pressure Injury Update: A Guide for Wheelchair Seating

Kara Kopplin is Director of Regulatory Science for Permobil Seating & Positioning Product Development. She’s also been the long-time Chair of the U.S. ANSI/RESNA Standards Committee for Wheelchair and Related Seating.

Asked for an update on pressure injuries from a standards perspective, Kopplin said, “For us, the big deal just before the pandemic was that the NPIAP/EPUAP/PPPIA [National Pressure Injury Advisory Panel/European Pressure Ulcer Advisory Panel/Pan Pacific Pressure Injury Alliance] pressure injury guidelines were published. That’s where everybody goes for state-of-the-art to understand ‘what we should do about pressure injuries.’”

From a seating and mobility manufacturer standpoint, Kopplin added, “All of us in the industry are working to comply with new European regulations that require evidence behind the claims for cushions, wheelchairs, and any medical device. So one nice thing is that we can take this clinical practice guideline (CPG), and it has literally thousands of articles from the literature that have already been analyzed and vetted by 300 experts. Since the scientific and clinical conclusions from these studies have been through that rigor, we can say, ‘This is state of the art: This is objective. As the world, this is where we currently are in our understanding of how to prevent and treat pressure injuries.”

Guidelines Specific to Seating

The pressure injury organizations study pressure management from a range of perspectives, considering etiology and interventions, Kopplin noted. In the new guidelines, “We see that seating is a part of that,” she said. “There’s mention of the ISO and RESNA standards for cushions, for pressure injury prevention, and there are guidelines for seating in the CPG, but for the most part, it’s about mattresses. And that was concerning for us, that the seating considerations weren’t as thorough.”

Additionally, many of the CPG seating guidelines focused rather narrowly on wheelchair cushions in isolation. The same can be said of the current ISO and RESNA test standards. “When seating is mentioned in the CPG, they don’t talk about the whole system,” Kopplin explained. “The cushion can’t do everything. You need to assess tilt and recline, ADLs, all the other aspects of seating and care, including 24 hours of care.”

Wheelchair Seating Pocket GuideIn an effort to build upon the CPG seating guidance, “Permobil collaborated with NPIAP and we wrote a guide,” Kopplin said. “Part of this ‘pocket guide’ pulls directly from the CPG: Here’s what the guidelines say about pressure injuries that are seating related. But the pocket guide goes one step further: ‘How should you screen at-risk people, according to the guideline, and what options do I have for seating to reduce that risk?’ The most important piece that wasn’t in the full CPG, which we added to this pocket guide, was ‘Who can help?’”

Educating Pressure Injury Prevention Allies

Many healthcare professionals who are familiar with pressure injuries are mostly knowledgeable about risks for patients who are in bed, Kopplin said.

“What we found is that a lot of doctors and nurses have their specialty, and they may even know all about pressure injuries, but they often just understand what’s needed when lying on a mattress,” she explained. “They may not know what to do as a next step. So we made a guide like a flow chart, saying you should get a nutrition consultant, get a wound care specialist. Consult with the therapy team and consider a seating evaluation.”

Kopplin said a major goal of the pocket guide is to inform healthcare professionals about additional resources they can call on. “For those of us who are involved in the seating end of things, we just really wanted to be able to draw out all of those points from the full CPG from the NPIAP and highlight them, and then take the conversation to the next level. A wound specialist may not know there are seating specialists who could help. There are a lot of silos in the care, so we’re trying to help bridge that.”

Kopplin added that RESNA and the NPIAP have started working more closely together. “U.S. standards for mattresses and wheelchair seating fall under ANSI/RESNA, but the mattress standards for pressure injury prevention are also part of NPIAP. The cushion standards are not; they fall directly under RESNA,” she explained. Recently, a liaison between RESNA and NPIAP has been reporting across the groups, and the two organizations began participating in each other’s conferences. Also, several testing and standards experts have become more active in both standards committees, to align protocols where possible.

A Complex Healthcare Problem

The new CPG is clear that it’s pressure or pressure in combination with shear that’s contributing to pressure injuries. “We have a whole standard we’re working on in ISO because there’s a lot of confusion around the word shear, which really includes external and internal shear forces, shear stresses, and shear strains,” Kopplin said. “Externally, you have shear forces, which are related to friction and the body sliding across the surface. We want to minimize those with the support surface, just like we want to reduce peak pressures with the support surface. But the reason is to not only prevent the external, friction-type wound. It’s also because internally, if you are pulling on the skin, the shear forces are causing internal tissue stress and strain, which is really that distortion and deformation that leads to cell and tissue death. That’s where deep tissue injury especially comes into play. Much faster than ischemia.”

Kopplin also supports more education on deep tissue injuries. “I think we also need better understanding of what shear is. All of us together, engineers and clinicians, need to clarify that understanding. And that’s what we’re trying to do with ISO as a start, to make a guide to explain clinically what do these terms mean, and what do I do about it? And having that understanding about what happens not just externally, but in the deep tissue.

“There’s no silver bullet, but we need to be aware of it, and we need to reduce it and manage it as best we can, along with the other patient risk factors for pressure injury.”

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This article originally appeared in the Mar/Apr 2021 issue of Mobility Management.

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