F314 and pressure relief: the new federal guidelines have much to say about support surfaces and repositioning.

When CMS released F314 in November 2004, facilities spent most of their time educating staff on these new guidelines for assessing and documenting pressure ulcers. However, a key component of the new regulations that has been overlooked in some facilities is the use of support surfaces and the process for pressure redistribution.

The new interpretive guidelines ask facilities to determine the appropriate support surfaces or devices to be used by matching the devices' potential therapeutic benefit with the resident's specific situation. Regulators will also monitor the effectiveness of pressure redistribution devices based on their potential to address the individual resident's risk, the resident's response to the product, and the characteristics and condition of the product.

Facilities should be selecting and using support surfaces as indicated by the resident's pressure ulcer risk status. In many instances, facilities are using pressure ulcer risk assessments that address several different levels of risk. Specific support surface/pressure redistribution device(s) need to be identified for each level of risk. The facility also needs to incorporate this new information in the facility's policies and procedures, with input from the facility medical director.

Thus, for example, if a resident has been identified as a pressure ulcer risk and the facility is using an overlay product, but the overlay is not properly inflated per the manufacturing recommendations or the resident does not fall within the weight requirements for the product, the facility could be cited for not properly addressing the proper support surface if the resident develops a pressure ulcer.

Staff should monitor pressure redistribution devices/support surfaces for "bottoming out." Bottoming out refers to inadequate support from a mattress overlay or seat cushion as determined by a hand check. To perform a hand check, the caregiver places an outstretched hand (palm up) under the overlay or cushion below the pressure ulcer or the part of the body at risk for a pressure ulcer. If the caregiver feels less than an inch of support material, the patient has bottomed out and the support surface is inadequate. The resident should be able to assume a variety of positions without bearing weight on the pressure ulcer and without bottoming out. Examples of pressure redistribution devices involved in this assessment are four-inch convoluted foam pads, gel mattresses, air-fluidized mattresses, and low-air-loss mattresses.

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Static pressure redistribution devices such as solid foam, convoluted foam, and gel mattresses may be indicated if the resident is at risk for pressure ulcer development or delayed healing. Dynamic support surfaces such as alternating-air mattresses and mechanical seats that change shape and redistribute pressure may be indicated, again, when a resident is at risk for pressure ulcer development or delayed healing. This latter type of support is used when the resident is unable to assume a variety of positions without weight bearing on a pressure ulcer, bottoms out on a static support surface, or has an ulcer that does not show evidence of healing.

Low-air-loss or air-fluidized beds might be indicated if a resident has developed large stage III or IV pressure ulcers. The drying effect of a low-air-loss or air-fluidized support surface may help prevent additional ulcers when excess moisture on intact skin is identified as a risk factor in these cases.

Sheepskin, heel protectors, and elbow protectors are important for providing comfort and reducing friction, but they are not effective at redistributing pressure. Similarly, specialized pressure-reduction cushions or surface supports may be used to extend the time a resident can sit in a chair; however, use of a cushion or support does not eliminate the need for repositioning.

Repositioning plans need to be assessed for each resident based on the resident's skin risk evaluation. Repositioning is, of course, critical for a resident who is immobile or dependent on staff for repositioning. For residents at risk of friction or shearing during repositioning, the repositioning plan may require the use of lifting devices. For residents who can change positions independently, an assessment should be performed to determine the need for supportive devices to facilitate these position changes.

The repositioning plan and pressure redistribution devices/support surfaces should be addressed in the comprehensive care plans. The care plans need to be consistent with the individual resident's needs and goals. The resident's family members and significant others may need to be educated on why repositioning is important and given instruction on how to reposition. Pain should also be assessed to ensure that residents are not refusing to reposition themselves because of pain they may be experiencing.

Facilities should also have a system in place for communicating the care plans to all appropriate caregivers, the resident representative(s), and the resident. Under the F314 interpretive guidance, in order for the resident to make an informed choice about care and treatment or to refuse treatment, the facility must discuss with the resident and/or the resident representative(s) the resident's condition, treatment options, expected outcomes, and consequences of refusing treatment.

Consumers today want to know all the facts. Does the facility provide education on the pressure ulcer disease process--e.g., the risk factors for developing a pressure ulcer, the clinical symptoms of the various stages of pressure ulcers, medications that may affect wound healing, noncompliance or comorbidities that may affect wound healing, and education on the complications that may develop because of pressure ulcers? Does the faciilty address the resident's concerns and offer relevant alternatives if the resident has refused specific treatments? Is this information addressed in the plan of care and reviewed upon any significant changes or upon the request of the resident, resident representative(s), or the facility?

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Manufacturer's recommendations also play a key role under the F314 interpretive guidance. It is important that facilities adhere to manufacturer's recommendations for proper use of pressure redistribution devices/support surfaces and maintain this information for future staff training and use. The manufacturer's recommendations may also be referred to during the survey process and for routine audits during the CQI process. The Pressure Ulcer Committee should continually be reviewing the each product's appropriateness for various levels of risk the facility has identified on its risk assessments and change product types accordingly.

Finally, as a general rule, as pressure redistribution devices/support surfaces continue to advance and change, facilities should be advancing, as well, by implementing the new products appropriately to residents' specific needs.

Karen Merk, RN, BS, CRNAC, is a Clinical Consultant at Briggs Corporation. To send your comments to the author and editors, please send e-mail to [e-mail].

BY KAREN MERK, RN, BS, CRNAC