DME

Making Professional Development Opportunities Work for You

Is it enough to just walk around an expo or attend a clinical presentation, conference or workshop? For me, ongoing development is not so much about meeting the hours required for registration. It is about filling my knowledge gaps and challenging my thinking. If you are just attending to tick off hours you may miss a valuable learning opportunity. Can you relate the new knowledge to a personal development goal? Writing a short reflection will provide evidence of development and assist you to consolidate what you have learned. One of the things I love about seating and mobility is that there are always new challenges and different ways to gain best outcomes. To make the most of any opportunities for ongoing education and development, it is important to be able to identify gaps in your knowledge or skills and seek out appropriate opportunities to meet these goals. Relating any skills or knowledge gained reflectively to enhance your practice will assist with achieving better outcomes for your clients.

Presenting case studies back to your team is another great way to facilitate open learning and development. For the more experienced clinicians, have you considered submitting at a conference? A case study of an interesting clinical case or a poster presentation is often a great way to start. This is an opportunity to give back to the profession as well as to increase your own skill set. If it’s a bit daunting maybe seek out a colleague to submit together.

Industry Shows

This week our New Zealand team have joined the annual Show Your Ability road show. The Disability Equipment Show travels to 5 cities and provides an opportunity for therapists, end-users and carers to see a range of Assistive Technology from different manufacturers all under one roof. In addition to seeing the newest technology on display, the expo offers an opportunity to see any updates to existing equipment. When I was working as a prescribing therapist I found this expo a chance to ensure I was up to date with what options were available. It’s a great opportunity to get hands on when comparing options. If you are a prescribing therapist, this knowledge can enhance your initial trial process. Attendance can also contribute to your ongoing professional development especially when linked to goals or used to reflectively guide practice. Permobil will be at all venues and we invite you to stop by to say hi and see our mobility and seating options.

Using Risk Assessments to Prescribe Cushions?

Can you use a risk assessment score to identify the best cushion for a user?

Risk Assessment Tools are commonly used to assist in the identification of an individual’s risk factors for developing a Pressure Injury (PI). The Waterlow, Braydon and Norton are 3 of the more well-known and commonly used tools. But can these outcome scores be used to prescribe seating?

Since moving to Australia, I have frequently been asked to match seating solutions to a Waterlow score. Waterlow is a commonly used pressure risk assessment. The Waterlow was designed by a Clinical Nurse Educator, Judy Waterlow in 1985. Its purpose was to assist in student education. The last update to the assessment tool was 2005.

In a clinical setting the Waterlow scorecard is used to identify risk. The higher the score the more risk factors for potentially sustaining a pressure injury have been identified. However, it is important to understand that these assessments only highlight risk factors and are not a definitive predictor of injury occurrence.

The collection of information is extremely subjective and has shown mixed inter-reliability in scoring. The information focuses on medical and health information, which is of course valid and recommended to be addressed in the health setting.

However, a risk assessment should only form one part of the clinical reasoning process when determining the best assistive technology solutions to assist someone in addressing and supporting their pressure management needs.This is reinforced on Judy Waterlow’s website, “It must be remembered that "Waterlow”, like all risk assessment scoring systems is a simplistic tool. Professional judgement must be used in determining the risk status of the patient/client.” (http://www.judy-waterlow.co.uk/waterlow_score.htm) The Braden Risk Assessment Tool could be seen as even more simplistic which again takes a subjective approach with a health/medical focus.

This is reinforced on Judy Waterlow’s website, “It must be remembered that "Waterlow”, like all risk assessment scoring systems is a simplistic tool. Professional judgement must be used in determining the risk status of the patient/client.” (http://www.judy-waterlow.co.uk/waterlow_score.htm) The Braden Risk Assessment Tool could be seen as even more simplistic which again takes a subjective approach with a health/medical focus.

But when administered by trained health care providers, a Cochrane search found “The Braden scale is the recommended validated and reliable tool for assessing pressure injury risk in critically ill adults.”https://www.cochrane.org/CD006471/WOUNDS_risk-assessment-tools-used-preventing-pressure-ulcers. Cochrane’s overview of risk assessments key message is;  ‘We cannot be certain whether the use of a risk assessment tool makes any difference to the number of new pressure ulcers that develop among people who are at risk. The certainty of evidence ranged from low to very low”, as such I strongly question the appropriateness of selecting a cushion based on a risk assessment score.

This is not to say risk assessments don’t play an important role in the prevention and management of pressure injuries. It’s not to say they can’t provide valuable information and direction to addressing the needs of one’s skin and underlying tissue because they can and do. However, they provide us limited information on the assistive technology needs.

 Jennifer Brit, a Canadian OT, developed the Pressure Management Assessment Tool (PMAT)http://www.hsc.mb.ca/files/SSS-PressureMgmt.pdf  I like its comprehensive approach and how it identifies areas where further education or skill training can be implemented as part of a holistic approach. If you are prescribing equipment for people at risk of pressure injury this is another tool you need to consider.

The pressure redistribution surface that’s chosen needs to be the result of the clinical reasoning process. All seating surfaces provide varying levels of immersion and envelopment. A variety of factors need to be considered when selecting the best option for that individual including, but not limited to:

1. Postural symmetry: Is the user supported in their most functional position. Is the pelvis neutral with even loading through both Ischial tuberosities (Sitting Bones). How will you address this in the seating?
2. Pressure History: has the user had a pressure injury before? What was the cause? Is this area at risk of reoccurrence? How will you redirect pressure away from any vulnerable areas? Are you using seating with strong evidence-based research guiding its design and use?
3. Ability to independently reposition and how: Do you need to consider the contours, the fabric, the surface materials or other accessories that could impede? Or is the functional impairment impacting this capacity and you need to consider multi-positional power functions?
4. MAT – Did a MAT assessment identify any restrictions to range that will impact on seated posture? How can these be addressed to provide best positioning
5. Functional independence: Will contours or lateral supports support functional capacity or decrease it? What other ways can support be provided?
6. Cognition / career support: How will equipment and skin be monitored and maintained? The cushions that provide the highest pressure redistribution or setting up a customised cushion require clinical support. Will the end user be able to manage or have the supports in place to assist if required.
7. History and experience: What did the user previously use? What did they like and dislike about it?
8. Comfort and seating tolerance: Has the user recently been on bed rest or recently sustained an injury or illness? Do they need something more complex position-wise or is it purely for occasional use? Will the user tolerate the positioning or will it need to be graded? How can the seating position be graded?

Are you trying to load the GTs and let the ITs immerse into a different density foam or fluid or are you trying to maximise overall immersion or loading? Are you trying to decrease direct pressure or sheer forces? Can the cushion do it all …or do you need to consider secondary supports?

There is much to consider when prescribing seating for full time mobility users. When a user has been diagnosed with a Grade 4 or unstageable injury, usual medical recommendation is to stay off it. It is crucial that a multi-disciplinary approach is taken when looking at pressure management.

Although we need specialised seating to support individuals with pressure injuries, specialised seating alone can’t resolve pressure injuries. It is important to incorporate medical treatment and advice into the management plan. In some cases, multiple seating might be required on different seats or for interim use while an at-risk user is building seating tolerance.

Pressure injuries can result in life threatening situations, long term hospitalisation and have a significant impact on independence and quality of life. Risk assessment tools address the health and wellbeing of tissue but do not correspond to development of injury especially in relation to postural positioning and support.

If you’re new to mobility and seating prescription or want a refresher or upskill we have a range of workshops that we run throughout Australia and New Zealand. https://permobil.com.au/permobil-academy/on-site-courses/ We can facilitate these with your local dealer or you can contact us about running clinical sessions for your team.

For further information contact us education.au@permobil.com

Tracee-lee Maginnity