In June, Ana Endsjo, Stacey Mullis, and Kara Kopplin were guests on the podcast RN Huddle. This 2-part series was a continuation of RN Huddle’s partnership with the National Pressure Injury Advisory Panel (NPIAP) and focused on wheelchair wounds. In part 1, they discuss their seating and wound expertise and how to help prevent pressure injuries in patients. Ana, Stacey, and Kara talk through helpful tips and resources for healthcare professionals in multiple settings who work with wheelchair bound patients who are at risk or have current pressure injures. Click here to listen to the first part of the series and below is a transcript from that podcast.
Broadcasting from the UNMC College of Nursing. Get ready for RN Huddle, the podcast dedicated to bringing hot topics for and by nurses to the table.KEELER: Well, hello there and welcome to another episode of RN Huddle. This is your host, Heide Keeler, coming to you from Omaha, Nebraska. And thank you again for your patience as we connect to guests all over the country. Sometimes we encounter some system issues or connectivity issues, and we are trying our best to bring you the best audio quality that we can, so thank you for that.
Today’s episode again is another great one in that we are going to continue our partnership with the National Pressure Injury Advisory Panel or NPIAP and this podcast is part 1 of 2. We are going to be exploring what happens when wheelchairs and skin mix, and so what are these “wheelchair wounds” and what do we do with them? How do we prevent them? How do we treat them, etc.?
And so, to that we are having our host, Renee Paulin, my co-host, and we all know that Renee is all things wounds, and she is going to talk to three members of the Corporate Advisory Board for NPIAP. We’ve got Ana Endsjo, Kara Kopplin and Stacey Mullis to share their expertise on this topic. So, Renee, over to you.
PAULIN: Welcome to RN Huddle. This is your co-host, Renee Paulin, and I am excited to have three experts today from the Corporate Advisory Council with NPIAP. They work for Permobil, a premium manufacturer of complex rehabilitation technology namely manual wheelchairs, power wheelchairs and seating products for these specialty wheelchairs. They are experts in the seated posture for individuals. They serve who use wheeled mobility full time to perform their daily tasks. Being seated full time, this population is inherently at risk for pressure injuries and are going to share their insight and expertise with us today. I would like to introduce these experts; Ana Endsjo who is an occupational therapist and is lymphedema certified; Stacey Mullis who’s also an occupational therapist and certified in assistive technology; and Kara Kopplin who is a materials’ engineer and Engineering Chair of the U.S. ANSI RESNA Wheelchair and Related Seating Standards’ Community and U.S. expert to ISO Wheelchair Seating Standards Committee and U.S. ISO liaison to the ISO liaison for the European Wheelchair Standards Working Group. Boy, that’s a mouthful.
KOPPLIN: It is.
PAULIN: Wow, quite the team here, I’m so excited. We are lucky to have all three of you at once. Welcome to RN Huddle.
MULLIS: Thank you.
KOPPLIN: Thanks, we’re glad to be here.
PAULIN: Fantastic. So, first of all, let’s let our learners know a little bit about Permobil and how your team has participated with the NPIAP initiatives.
MULLIS: Yeah, thanks, Renee. This is Stacey speaking, by the way. Yeah, we are, as you mentioned, we’re a manufacturer of wheelchairs and seating products. And so, the people that we’re serving are seated full time and, like you mentioned, they’re inherently at risk for pressure injuries. While we understand that wound care is a specialty area of practice and we wanted, as a company, to learn more about how we can enter into that world and offer our seating expertise. And so, we’ve spent the past several years attending wound care shows as exhibitors and as speakers and we’ve been involved with, as you mentioned, the Corporate Advisory Council with the NPIAP, and what we’ve learned, in all of our experiences, is that there isn’t a lot being taught about the seated posture. And that often some of these wound care clinicians they are just not confident when it comes to dealing with a person who’s in a wheelchair who has a wound and what to do about that and what is best practice. And since it’s an area that hasn’t been talked about a lot, that’s where we’ve come in. We feel like we have that expertise that we can share, and we’ve been committed to developing resources for these wound care professionals. So, we’ve spent the past couple of years creating courses and resources and then doing things like this, talking with you today.
PAULIN: And many of our listeners are very familiar with the fact, like you said, those at risk or who have a pressure injury must have some sort of cushion in place for their chair. So, in addition to limiting maybe time in the chair one to two hours depending on what’s going on with the patient, there is this balance of needing them to get out of bed, but then also not compromising blood flow in the seated position. What are your thoughts on this? And what more can we do for our patient?
MULLIS: When it comes to looking at the cushion this is one of the misconceptions that, I think the three of us on this call today for sure have heard, is that when there is someone with a wound, they’re seated in a wheelchair that the first thing to do is to look at the cushion. And certainly, it’s important to look at the cushion, to look at what they’re seated on, but the greatest misconception or the thing that maybe doesn’t happen as often as it should, is looking at the entire seating system. So, when we talk about support surfaces we think of mattresses, we think of cushions, but if you think about the seated posture, the support surface isn’t just the cushion, there’s also pressure being distributed through the legs, the feet, the back. So, it’s important when we’re looking at the seated posture and we’re wanting to get somebody out of bed safely to look at the wheelchair system and how the pressure is being distributed throughout the body instead of just at the seat surface.
ENDSJO: I’d like to add to that actually. This is Ana speaking now, and I think Stacey made some really great points that while someone is in the seated posture that there’s many areas of the body coming into contact with the wheelchair system and we have to start understanding that it’s beyond the cushion, right? And I always make this joke, but I always say we can’t walk out into the community and just wear a pair of pants, we have to put on a top. And it’s the same thing. When we’re looking at someone, we can’t just worry about what’s going on in the pelvis area and, I think that in the past, when people started using wheelchairs years and years and years ago, they didn’t even have cushions in the wheelchair system. So, it was a cushion that was, kind of, developed first and was perfected first, and so it is normal that our brains, kind of, go to that area. But just like I said, we have to put a shirt on too and we also have to think about what’s going on throughout the trunk, throughout the head, throughout the arms, throughout the legs, and really start considering every piece of that puzzle when we’re thinking about wheelchairs. And, I think, that brings us to another really good point is that this is a specialty area of practice, and this is important for us to understand as a nurse or a physician that, you know, that responsibility of choosing that equipment really should fall on the shoulders of a specialist in this area and should really be a specialized therapist that can come in there and take a look at it. So, don’t feel like as the doctor, as the nurse, my goodness I have to learn all about cushions, and I have to learn all about all the support surfaces like the back support and any type of secondary postural support. You know, utilize the team and really look for a great therapist that can come in there and help you with that because beyond just the equipment inside of the chair it also has a lot to do with what is the base? What kind of wheelchair am I putting them in? What is the configuration of the wheelchair? So that I can allow someone that maybe does have a wound but is a professor at a university and they can’t just be in their chair for 1 to 2 hours. Let’s create a system that allows them to be in that chair for 4 to 5 hours, which is what they need, and decrease the risk of pressure injury from occurring or even helping the pressure injury that exists to heal. (9:01)
PAULIN: Yeah, very good point and let’s explore the role of the therapist that you’re saying. Who is appropriate? And, you know, some facilities are limited on who they have on staff. So, what would you recommend?
ENDSJO: I’ll start with that question. I think that the best recommendation that I can give to anyone, because you’re right, there’s a lot of facilities, there are a lot of hospitals, there are a lot of seating clinics that maybe don’t have a specialized therapist in seating and positioning. And so, I think the NPIAP has done a fantastic job in their 2019 Clinical Practice Guideline of really laying out what should we be doing as an organization at that organizational level? And they did a really good job of just saying educate, making sure that you bring your facility, whatever type of facility it is, whatever type of organization that you’re working for, to top-notch. You’ve got to make sure that you bring in some type of system and make some type of process within your organization to make sure you’re doing the right thing from screens all the way to the referral process. And if you do not have the staff that has that educational level or that knowledge base and they actually say this in one of their recommendations, then put in a process to get them there, provide the education that they need. So, I always say education, education, education. There are plenty of courses out there. There are plenty of specialized therapists. Really start looking at where the holes are within your organization and filling those gaps.
So, I think, taking a good first step would be looking at the recommendations from the guidelines and really thinking about what can we do to fill in those gaps and get that staff educated? And I think that, like I said, this is just a great first step.
PAULIN: So, with the resources or education if there was a facility or a learner here that’s listening and wondering, Okay, where do I start? Is there maybe some type of education or webinar or some course? Where would you direct them to? The NPIAP site, I would assume?
ENDSJO: Well, we, actually at Permobil, we have a couple of different series that we have developed specifically to teach therapists on seating and wheeled mobility and currently actually Ana is working on three courses that are directed towards nurses relating to seating and wheeled mobility. And so Permobil would be a great place for any listener to go to, permobil.com, to request more information on our education options or they can reach out to us directly as well.
PAULIN: And would this education include the maintenance of some of these cushions? Because that, I know, always is another task to keep up with in different facilities, especially if they are air-filled.
MULLIS: Yeah. The courses that I was just referring to are more principle based. So, it’s more the principles to understand, but we certainly do have information on how to care for a cushion or maintain a cushion. And when it comes to that piece of the puzzle, Renée, I would, again I think Ana mentioned the team, and we in healthcare we’re used to working as a team with the physicians, the nurses, the therapists and, in this case, when it comes to seating and wheeled mobility, there’s another team member that’s important to understand and that’s the supplier. So, there are different types of equipment suppliers out there and some provide more basic-level equipment and other suppliers provide more specialized-type equipment. Those types of suppliers typically employ an assistive technology professional. And when we’re talking about seating and wheeled mobility it’s really good to work with a supplier who has an assistive technology professional or ATP for short because they are specialists on the equipment side. So, they bring that piece to the seating team so we’ve got our physicians, nurses, therapists, but another team member that’s really critical is the ATP because they can, then, bring that expertise of the product. They can train the end-users. They can train the caregivers on proper maintenance and use of the product. So, I think, Ana alluded to it, that’s kind of the nice part of working as a team is that we can each bring our expertise and it’s not all on one person to know everything.KOPPLIN: I would like to add to that. This is Kara. Permobil has also worked with NPIAP to develop a pocket guide to bring attention to all of these questions about cushions and seating systems and what the Clinical Practice Guideline has to say about that. We hold out those details from the 2019 guideline and put them in this guide and that’s part of it. And then it also describes the different management techniques for the seated person that are included in the guideline like to immerse and envelop the body and/or offload it. But then taking it a step further and answering some of those questions that you asked, Renée, like who do you call? What is the decision-making process? Where should you turn if you don’t have that expertise in your facility? So, this is available for free on the NPIAP website and Permobil can also send a hard copy, if that’s preferred over an electronic one. So, we’re really pleased about that collaboration and think that’s a great starting point for anyone with questions about seating and pressure injury prevention.
PAULIN: Yes, definitely on the NPIAP’s site, yeah, you can download it, print it off, it’s fabulous. Really, like you guys have mentioned, looking at the whole picture of the patient in the seating position, not just throwing a cushion in place and knowing where the feet are located. And so, when you’re talking about back support you mentioned that sometimes there’s a concern of putting a pillow behind their back, but maybe that would cause too much pressure on the sacrum or the coccyx area. Are there tips on that strategy as well? Because I know it is an interprofessional team effort, it seems like, coming together when working with patients in the seated position.ENDSJO: So, when it comes to figuring out what equipment, what’s the best fit for someone, I think the most important thing to understand is that we’re all different, right? And I’m going to make a joke, but we have a friend and a colleague that used to say all the time, you know, there’s a butt for every cushion and a cushion for every butt and it’s the same for the back support and the same for the head support, we’re all just so different. And it is impossible, and you definitely should, kind of, raise an eyebrow if someone tries this with you but you know it’s impossible to say that this specific cushion or this specific back support is perfect for everyone, because it’s just not true, right? And some people have bonier prominences. Some people have a little bit more tissue. So, you just have to look at that specific person. So, we always say that when you’re looking at the equipment you have to think the keyword is adjustability. How can that equipment be adjusted and changed and changed again to accommodate or correct whatever that person’s issues are? So yes, by just, kind of, putting a pillow behind someone it’s not going to do the trick, right? You really have to look at what is this person’s posture? What is the curvature of their spine? Of their pelvis? What do their bony prominences look like? How much residual tissue do they have? And really fit the equipment to that person.
And so, there’s a lot of equipment out there that through whatever it is is constructed with. We have some back supports, for example, that use a cable system. We have others that use aluminum moldable stays. You know, bone products, air products that can be adjusted and readjusted to put pressure in an area that didn’t have pressure placed before to, kind of, fill in the gaps and then also relieve pressure where something’s really digging into the back support or really digging into the cushion. And that’s what’s key to understand is that you need to look for products that have that adjustability so that you can reconfigure something to everyone’s specialized shape and need because everyone is so drastically different.
PAULIN: Great. What other recommendations can you three provide to a facility that may have many in-house acquired pressure injuries or has done poorly, you know, maybe their quality indicators, they’re concerned about a state survey didn’t look so good when it comes to pressure injuries and wound management? What would you suggest?
ENDSJO: I think that’s going back to the point that I made before is that this, and Stacey mentioned it at the very beginning, when it comes to seating and positioning this is a specialty area of practice. And many people think that therapists go into school, and we are taught this and, you know, this is something that is ingrained in our heads, how to position someone correctly, and it’s just not the case. And it’s the same for nursing, the nursing world as well. You know, they go to school, and they don’t come out a WOCN, they don’t come out with that specialty area, that’s something that they have to look for, that they have to study and get the certification and become specialists in and this is the exact same thing with seating for therapy.
So, it is important to understand that again, at that organizational level, look at your gaps. What don’t we have on staff? Do we not have a seating specialist that really feels confident in this area? And if we don’t, let’s make them that. You know, anyone can go through and get the specialty education, start to feel more confident and that is important to choose someone to become that person. And, I think, a lot of times, especially in general settings and like the nursing home setting, like the hospital setting, you have a lot of therapists that are asked to, kind of, be a specialist in a lot of different areas. They’re dealing with stroke patients, so they have to be a neurological therapist and then they’re dealing with someone who has had some kind of injury, now they have to be an orthopedic therapist. Then they have someone who has a seating need and now they have to switch gears again and be a specialty-seating therapist, and it’s just a lot to take on, right?
So, it really is identifying the need within your organization to find one person to take that and to own it and give them the opportunity for that education because you’re never going to do great on state surveys, you’re never going to start to solve the issue until you start to learn who’s at high risk for pressure injuries, understanding that it’s more than just a cushion, understanding that it’s the entire seating system and then giving them and empowering them with tools through the education to start doing that well.
So, for those facilities that are getting a lot of penalties and they’re doing poorly on state surveys, I would say you’re going to have to go back to the organizational level and look at filling in that gap again.
MULLIS: And, you know, I just want to step in, this is Stacey, just on a practical level so…I think Ana is spot on in terms of recognizing a need and then equipping therapists to meet that need. But in the meantime, like what do you do when you don’t have somebody trained yet or you work in a wound care clinic without a therapist and you don’t even know if there’s a local seating clinic, like what practically should a clinician do? And I go back to, and this is from my own experience, when I first started out when I didn’t know anything about seating, I called a supplier who had an ATP on staff, and I relied on their expertise. That’s a good approach if you’re stuck and you don’t have somebody that is equipped yet. Then reach out to an experienced supplier. So, somebody that has an ATP on staff and tell them, just say, Hey, I have this client and they have a wound. I’m not sure if I need to change their equipment or not and they’ll come in and they’ll problem solve through it with you. But utilize their expertise while you’re learning yourself or while your team, your organization, is training somebody.
ENDSJO: Absolutely. And I’m going to just make one more point which I think is so critical and I think, again, the NPIAP did a great job of this in the Clinical Practice Guideline is, kind of, switching gears from being reactive after pressure injury has occurred and being more proactive to start identifying people at risk. So, you know, you’re starting to see a lot of in-house acquired wounds within your organization, I think we’d probably have to start back from scratch and say, Okay. Did we miss something here? Did we miss, you know, looking at the population that we serve? Do we need to do a better job of recognizing who’s at risk to begin with? And they did a fantastic job of laying out risk factors. And, I think, my favorite quote in there is that they say that the number one contributing and compounding factor for pressure injury development, the risk factor is immobility. And when you think about seating and positioning, that pretty much is everyone, right? I mean, you wouldn’t be a wheelchair user if you didn’t have some type of mobility limitation. So, they really are laying it out there for us that when you’re dealing with a population that is a wheelchair user and then look at everything else that’s compounding that, they’re dealing with comorbidities, diabetes, circulation issues, you know, and then if you start to get into the geriatric population on top of that, they’re having the natural age-related changes of the skin integrity. So, we need to start looking at, is the population that we’re serving within our systems and say, Okay, we need to start getting better at screening from the very get-go, performing more quarterly screens, more annual screens as soon as someone comes into our care and recognizing these risk factors that the NPIAP has laid out for us and realizing that pretty much everyone that’s a wheelchair user is going to have some type of risk factor that would then warrant the need for a skin protection product. So, we, kind of, have to switch gears and stop just looking at cost and trying to just put anything under them, we need to start putting quality products, products that are built with skin protection properties to be more preventative and proactive to minimize the risk of the pressure injury from occurring, and in the past what we’ve done is we, kind of, waited until it happened and then started to treat it.
PAULIN: It would be a lot more expensive, too.
ENDSJO: Yes, absolutely.
PAULIN: A lot more so…
PAULIN: Well, thank you. This is fantastic and a lot to take in when it comes to thinking about our protocols and definitely some great tips on how to approach posture and seating guidelines. We hope our listeners today will take a peek at the Clinical Practice Guidelines on the NPIAP site and we will also link it on our RN Huddle to the pocket guide. Thank you Ana, Stacey and Kara for your time today.
ENDSJO: Thank you.
KOPPLIN: Thank you for having us.
MULLIS: Thank you.
KEELER: We look forward to another talk with all of you for part 2 of the Permobil/NPIAP podcast. Follow us as we continue to discuss appropriate seating interventions for our patients and then the funding aspects for these various devices and support surfaces. Thank you for listening to RN Huddle. See you next time.
KEELER: Well Renée, Ana, Kara and Stacey thank you so much for this discussion about wheelchair wounds and really giving us a good handle on what resources are available. It’s really important to understand how these devices can affect skin and so we really appreciate your sharing your expertise today.
So that’s all we have for today’s episode of RN Huddle. I really hope that you’ll join us for part 2 of this discussion when we really get into some of the nitty-gritty of prevention and treatment. So, please, join us next time for another episode of RN Huddle.
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