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.”

In 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.”

Download the Wheelchair Seating Pocket Guide for free:
https://tinyurl.com/seatingguide.