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The first in a series of articles and research papers proposing an alternative trajectory. Identifying the manual and mechanical handling link to force-related tissue damage in both patients and carers during present inbed care practices. Click here to view the paper.

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The missing synergy when moving patients being cared for ‘inbed’ – Part 2

Introduction

The philesynergetic approach to caring for patients ‘inbed’ uses gravity, the correct synergetic layers and the patient’s own body mass to provide safe patient’s rest, movement and stability on their resting surface.

(N.B. click image above for video about philesynergetic approach – The Safety Dance)

Using this approach, any external forces that may be generated can be managed in a controlled manner; to regulate their rate and effect as a means to avoid resting surface-patient skin interface “force focal spots”.

In so doing, enables the patient’s internal homeostatic and tensegrity mechanisms to prevent any tissue / cell recovery thresholds, from being exceeded and prevents tissue damage whilst maintaining the patient’s tissue integrity.

However, to achieve this philesynergetic approach, there are eight key areas of change in practice that need to be understood and adopted.

1. Correct synergetic layers
2. Understanding the forces that are at work when a patient is moved
3. Preventing / reducing / controlling resistant forces
4. Working WITH – rather than against – gravity
5. Using and complementing the body’s natural, internal prevention mechanisms for maintaining tissue integrity.
6. Identifying the physical risks to carers when manually moving and restabilising patients ‘inbed’
7. Taking a combined ergonomic and biomechanical approach to remove the risks to both carers and patients associated with inbed care and movement.
8. Scaling up adoption of the philesynergetic approach across both health and social care

These are discussed in more detail below.

1: Correct synergetic layers

As previously described in part one of this blog, we introduced the fact that the correct synergy is needed to protect skin and tissue integrity when a patient is confined to bed. To achieve this, both the patient’s clothing and bedsheets need to act as additional outer layers to the patient’s skin tissue with no movement between them or the patient’s skin and therefore requires a high friction interface synergy.

We also identified that the underside of the bedsheet and the upper surface of the bed mattress cover needs to be able to move freely over and against each other with absolute minimum resistance. In other words, to allow initial movement (stiction) and with low resistance when moving (friction) as they are sliding interfaces and as such, should be of a very low friction interface synergy.

2: Understanding the forces that are at work when a patient is moved

However, even with this correct layer synergy, there is still a high risk of tissue damage. This is because many of the present accepted and recommended products, methods and practices continue to expose the skin and tissue to unnecessary stresses and forces. This is mainly due to the present practice of working against gravity during the caring acts of supporting, moving and stabilising the patient. The resulting surface/patient interface forces can impact the skin and transcend to disseminate throughout the body’s tissue.

The present practices of physically and/or mechanically moving a person’s body mass* or body part on a resting surface**, can subject it to unnecessary additional forces. In so doing, this has a direct effect on the body’s mass which and can result in both the loading and distorting the related skin and tissues. This is particularly true if the presenting resting surfaces – skin and tissue interface surfaces – are resisted/prevented from moving (sliding).

Unnecessary forces can originate from the deformation/distortion of the presenting resting surface shape that results in a “bow wave effect“ resistance force to the direction of movement. This altered resting surface shape being the result of the combination of both the presenting body part shape and the weight of the relevant body mass (e.g. ‘butt print’ immersion, or concaves caused by a patient’s heel, hip, scapular and/or coccyx etc.). This “bow wave effect” can also be created when moving patients on specialist bed mattresses that are in a dynamic mode.

Those areas of patient’s skin and tissue that are immersed in these deformed/altered resting surface concaves are particularly vulnerable to the differing forces that are generated through patient movement.

These forces are then both transmitted to and transferred through the patient’s skin interface surface areas, where they then disseminate throughout the body mass tissues and can progress into the deep tissues, which results in the skin and tissue integrity being compromised.

The present practices of moving patients on resting surfaces predominantly involves one of the following methods:
• Encouraging and providing for independent self-movement
• Carer(s) manually assist the patient to move themselves
• Carer(s) manually handle/moving them
• Moving them mechanically+

In order for patients to be moved by any of the methods above, they need to overcome the presenting gravitational forces. In so doing, this can create and generate patient skin/resting surface interface “force focal spots” which can then transcend through the patient’s skin and tissues during the body mass movement. It is also extremely difficult for carers to manual handle the patient’s movement in a uniformed, controlled manner that is slow enough to avoid creating these ‘force focal spots”.

Similarly, the “force focal spots” can also happen when carers are grasping the material that’s being used to move the patient, as increased tension is created from the point of grip down, along the material to the point where it passes under the patient’s body mass. This can be seen with visible tension lines. For example, under the buttocks and/or the back of the shoulders in the sitting and/or laying repositioning.

There are also a number of further contributing factors that create ”force focal spots” when patients are being physically moved during ‘inbed’ care.
The fact that any manual handling contact (hands on) with the patient, can cause unnecessary trauma to the skin’s surface generating resulting forces that can transcend into the patients skin and tissues. Such examples would include:
• When turning patients in bed and during carrying out personal care (carer/patient interface).
• Also, when inserting and removing items between the patient –resting surface interface, such as changing sheets or incontinence slides and during insertion/removing hoist slings and this can very often involve the practice of the pressing down on the bed mattress surface to create space to facilitate insertion /removal.

Therefore, these identified practices in the care, movement and any restabilising of the patient’s position ‘inbed’, are in fact creating unnecessary forces that are predominantly originating from outside the patient’s body mass and are working against the ever present gravitational forces. Resulting in the patient’s skin and tissue integrity being compromised.

3: Preventing / reducing / controlling resistant forces

To control resistant forces, and prevent the “bow wave effect” occurring in the bed mattress surface during any movement, the mattress should be of a type that can both immerse the body shape when required and step up (to static mode) to a more level/firmer surface when a patient is moving and/or being re-stabilised.

We therefore strongly recommend hybrid mattresses types that are made up of individual cells containing foam, which are encased in air. This type of mattress allows it to be inflated (step up)
to produce a firmer, flatter surface when repositioning or restabilising the patient, so as to prevent the formation of resistant forces from the “concave“ or “bow wave effect” deformation during patient movement. Once the patient movement or stability has been achieved, this type of hybrid step up/down mattress can then be returned to the (step down) desired dynamic state, allowing the required amount of body mass immersion.

4: Working WITH – rather than against – gravity

Currently, bed frame support surfaces have many options. Many work in only the flat or profiling horizontal plane. Here are some of them:

A typical example of the altered direction in gravitational pull forces, is when someone is put into a sitting position in bed by raising the bed back rest.
• During this repositioning procedure, the patients resting body mass is re-orientated and therefore their centre of gravity is shifted.
• The change in the angle of the acting gravitational pull forces therefore results in the patient migrating down the bed whilst loading their resting surface interfacing skin and tissues.
• However, when the correct synergies are in place, the effective use of the knee brake facility and the counterbalancing forces (tilting in space) can prevent migration down the bed and the patient’s stability can be maintained without loading the skin and tissues.

Similarly, by tilting the patient onto their side (as when turning them) across the bed – perpendicularly as opposed to horizontally up the bed -then their body mass is subject to the same type of altered gravitational pull forces
• This can result in tissue distortion, shear and irreversible tissue damage and cell death within minutes.
• Again, with the correct interfaces and stabilising, counterbalancing forces, then tissue integrity can be maintained.

To summarise: moving and stabilising patients – either manually or mechanically – against gravity causes tissue loading. To address this, there is a requirement to work WITH gravity on the correct interfaces and support surfaces so that any potential tissue loading is avoided.

5: Using and complementing the body’s natural, internal prevention mechanisms for maintaining tissue integrity

Working with gravity whilst using the correct interfaces and support surfaces, prevents the risk of exceeding the patient threshold of resistance at which varying tissues and cells may become damaged.

In other words, allowing the bodies internal safety protection mechanisms, homeostasis and tensegrity to control the rate and effect of any externally generated ”force focal spot” and internal forces. These forces are then either contained locally and/or dissipated at a safer reduced intensity over a wider tissue area, maintaining tissue integrity.

This is particularly important for both those patients who have lost their innate ability to rejuvenate tissue and/or have a reduced threshold of resistance (pathophysiology).

This echoes the words of Einstein, “A clever person solves the problem A wise person avoids it”. In other words, protecting tissue integrity by using the body’s natural protection mechanism is always preferable to treating the damage caused through the present ‘inbed’ care and positioning practices.

6: Identifying the physical risks to carers when manually moving and restabilising patients ‘

Moving patients physically is a risk to carers. They are responsible for ensuring both their own and the patient’s health and safety. Despite training and assessment, there is a natural human tendency for behavioural drift.

When carers move or re-stabilise patients:

1. To move them, they must work against gravitational forces that are keeping the patient stable on the support surface.
2. It requires physical effort from the carers.
3. To do this, they create a high risk of biomechanically compromising their posture.
4. Thereby increasing the risk of musculoskeletal injuries to their backs (micro tears to tissues).

7: Taking a combined ergonomic and biomechanical approach to remove the risks to both carers and patients associated with inbed care and positioning

We believe that anticipatory design of ‘inbed’ products and processes is essential to remove the risk to patients and their carers so that the practice of repositioning and stabilising a patient can be safer by:

1. Preventing back injuries to the carers
2. Using the patient’s own innate homeostatic and tensegrity protection system to maintain the integrity of their skin and tissues.

This philesynergetic care approach (also known as the Safety Dance [link to new video]) means that

1. A patient can be rested, repositioned and stabilised by using gravity without the need for manual handling
2. This both significantly reduces any biomechanical compromise and avoids any resultant musculoskeletal injury to the carer.
3. This approach reduces “force focal points” and tissue distortion force transcending thought the skin.
4. Allows patients to be supported, repositioned and stabilised in a controlled rate and uniformed manner
5. Allows repositioning and stabilising to be at a sufficiently slow rate and allow the skin’s homeostatic and tensegrity processes to safely dissipate potentially tissue-damaging forces.
6. Uses a bedframe of a type that has multi-tilt; a hybrid mattress that is made up of individual cells containing foam which are encased in air; and a correct synergetic layered inbed care management system. For example,

o Hybrid mattresses such as the Dyna-Form Mercury Advance-powered hybrid
o Perpendicular plane tilt, Toto Patient Turner
o Multi-plane tilt bedframes such as the Centrobed Arctic Turning Bed
o Synergetic layers are intrinsic to the Biotechsis inbed care management products and designed to be intuitive.

8: Scaling up adoption of the philesynergetic approach across both health and social care

Getting this philesynergetic care approach to be widely adopted requires:

• Raised profile. More health and social care professionals need to be aware that the approach exists and that it is the best practice when moving patients confined to bed.
• Governing standards, need to be updated to recognise improvements in technology and best practice. For example, ISO/TR 12296:2012(en) Ergonomics — Manual handling of people in the healthcare sector
• “Buy in”. Health and social care organisations need be committed to implementing it as the standard. This will need a change in thinking and practice regarding safer patient care and carers’ safety.
Designing out unsafe practice and designing in safer care.

Will you join the safety dance?

Footnotes: * by body part/mass we mean limbs, leg, arm, shoulder, hips or a combination thereof * * by resting surface, we mean a bed, chair, trolley or theatre table etc. + Moving the patient physically and/or by mechanical means to overcome gravitational forces

Please click on coloured text above for related links. Alternatively, please use the links below:

http://www.phil-e-slide-uk.com/news.php?s=the-missing-synergy-when-moving-patients-being-cared-for-inbed-part-1
https://player.vimeo.com/video/191134199
http://www.phil-e-slide-uk.com/news.php?s=the-forgotten-interface-when-caring-for-patients-confined-to-bed
http://www.phil-e-slide-uk.com/news.php?s=no-matter-how-well-intentioned-care-is-how-tissue-integrity-is-protected-tells-all
http://www.arjohuntleigh.co.uk/knowledge/pressure-ulcers/clinical-and-economic-evidence
http://www.phil-e-slide-uk.com/news.php?s=the-einstein-effect-on-inbed-care
http://www.phil-e-slide-uk.com/news.php?s=unconscious-and-behavioural-drift
https://www.fastcodesign.com/3045039/the-next-big-thing-in-design-fewer-choices
http://www.phil-e-slide-uk.com/biotechsis.php
http://www.phil-e-slide-uk.com/news.php?s=the-challenge-of-innovative-product-adoption-in-health-social-care
http://www.phil-e-slide-uk.com/news.php?s=improving-safe-patient-care-the-knowledge-gap
http://www.phil-e-slide-uk.com/news.php?s=the-impact-of-emerging-technology-on-inbed-care
http://www.phil-e-slide-uk.com/news.php?s=is-the-ideal-inbed-care-environment-fantasy-or-a-possibility
http://www.phil-e-slide-uk.com/news.php?s=changing-the-way-we-think-about-safe-patient-care

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