Worldwide Pressure Injury Prevention Day (next held on 21 November 2024) is a poignant reminder of the importance of preventing pressure injuries to promote overall wellbeing & quality of life.
Pressure injuries remain a common problem in the Australian healthcare system. Prevalence amongst inpatients in Australian and New Zealand acute-care hospital has been reported at 12.9%, with a hospital-acquired pressure injury prevalance of 7.9%.1 This number significantly increases with age, and can be as high as 70% in elderly patients with orthopaedic problems.2
Experiencing a pressure injury can significantly impact a patient’s cognitive and psychological wellbeing. Even simple tasks such as reading, writing, eating, and drinking may become challenging, and motivation often decreases, potentially slowing the recovery process.
Pressure injuries not only bring pain and discomfort but also diminish quality of life for patients, while posing a substantial financial burden on healthcare and social care systems.
Based on a 12.9% prevelance rate, the total cost of pressure injuries in Australian public hospitals is around $9.11 billion.3 This includes:
- The opportunity cost of excess length of stay – $3.60 billion
- Treatment costs – $3.59 billion
- Productivity loss associated with pressure injuries – $493 million
The impact of pressure injuries on patients’ health and wellbeing is often underestimated. Understanding the severity of these injuries is essential to improving patient outcomes and quality of life.
Among elderly patients, pressure ulcers are associated with a fivefold increase in mortality, with in-hospital mortality rates ranging from 25% to 33%.2
A key factor in prevention that is often overlooked is the role of proper seating in maintaining skin health and preventing discomfort. In this article, we’ll delve into why seating plays a critical role in pressure care and how choosing the right seating solutions can make a significant difference for those at risk.
How are pressure injuries formed?
Pressure injuries can develop quickly, with studies showing that in the lying position, injuries under bony areas can occur within just one to six hours of sustained pressure.4
In a seated position, the risk can be even higher with poor posture or an unsuitable chair. The below information, alongside other resources from Seating Matters, will assist you in the correct provision of clinical, therapeutic seating to manage posture and pressure care. Seating Matters chairs are meticulously designed by our clinical team to address these needs, helping to protect patients and support their comfort and health.
Body Weight Distribution
In a typical upright sitting position, our body weight is distributed as follows:
75% through the buttocks and thighs
19% through the feet
4% through the back
2% through the arms
The Ischial Tuberosities (ITs) bear a significant portion of this weight, with 75% of body weight supported by just 8% of the body’s surface area. This makes proper seating essential to manage pressure effectively and support healthy posture in a seated position.
Pressure & Abnormal Posture
Posture and pressure injuries are inextricably linked. When a person sits in an abnormal posture, their weight may not be taken equally across the ITs. For instance, in individuals with a pelvic obliquity, a larger portion of their weight is directed through the lower IT, resulting in higher pressure on that side. This uneven pressure increases the risk of developing a pressure injury.
Deviated vs. Normal Posture
Identifying and understanding an individual’s posture is a crucial step towards improving their seating position and overall wellbeing. This process involves evaluating the causes and effects of deviated postures, and determining how to correct or improve these.
The Four Principles of Effective, Clinical Seating™
When carrying out a seating assessment, there are several key points which must be addressed to help manage pressure or reduce the risk of pressure injury development. When considering pressure management in seating, it is common to think only about the cushion on the chair. It is the most predominant element and often the first and only step used to address pressure management in seating.
To achieve effective pressure management in seating, The Four Principles of Effective, Clinical Seating™ should be considered.
These are:
- Load the body
- Provide postural support
- Allow effective repositioning
- Use a proper cushion
Loading the Body
When you increase an individual’s surface area contact with their chair, you reduce the pressure exerted through any point. It is imperative that the chair is measured and adjusted to the size and shape of the patient and adjusted to load their body properly. By maximising the amount of contact the patient can have with the chair through the feet, legs, femurs, arms and back, you are ensuring that pressure is being evenly distributed, thus reducing the amount of pressure through any given part of the body.
For example, when loaded properly, the feet take 19% of the body’s weight in seating. If there is no footplate on your chair, or the feet are incorrectly loaded, this 19% of weight will be going through the buttocks and thighs instead, therefore increasing weight, pressure and risk in this area.
Providing Postural Support
Renowned occupational therapist, Martina Tierney often emphasises that “pressure and posture are inextricably linked” and research supports that improved posture directly enhances pressure management.
For example, an individual with scoliosis who leans to the left in their chair will bear more weight on one side of the pelvis, increasing the risk of skin breakdown on that side due to uneven pressure. Proper support on the left side will help to stabilise the patient in a midline posture and equalise the distribution of pressure through the body, rather than it being focused on a smaller area. To this end, the correct use of lateral and head supports will ensure improved posture, balanced loading, and reduced risk of pressure injury.
Effective Repositioning
The International Guidelines recommend that all individuals with or at risk of pressure injuries be repositioned on an individualised schedule, unless contraindicated.5
Repositioning can involve adjusting the seated position, lifting the body off the weight-bearing area, or standing. However, these maneuvers can be energy-intensive, time-consuming, and sometimes result in patients not receiving sufficient or consistent weight shifts.
Studies indicate that a 45° tilt “maximises the potential for significant blood flow increases and pressure reduction” by fully offloading the pelvis and re-oxygenating the tissue. With caregiver or user-operated 45° tilt in a chair, repositioning becomes simpler and supports regular, effective weight shifts. If a 45° tilt is unsuitable, a 30° tilt can still offer beneficial repositioning and support for pressure management.
The Cushion
There are various cushions on the market that provide different levels of support, postural alignment, and pressure management, making it essential to choose one that meets each individual’s specific needs.
Seating Matters chairs come standard with a visco-memory foam cushion, designed with two foam layers: a top layer that allows for immersion and support of bony areas like the pelvis, and a bottom layer that provides a stable base. While this cushion is effective for many patients, some may require an additional cushion prescribed by a wound care clinician. In such cases, having a chair with a removable cushion and a solid base board to secure the new cushion is crucial.
Cushion coverings should be made from multi-directional stretch fabrics to prevent hammocking. These fabrics should be breathable to prevent excessive moisture on the skin.
References
1. Rodgers, Sim & Clifton (2021). Systematic review of pressure injury prevalence in Australian and New Zealand hospitals. Collegian.
https://www.sciencedirect.com/science/article/abs/pii/S1322769620301177
2. Grey, J.E., Harding, K.G., Enoch, S. (2006). Pressure ulcers. BMJ 2006;332:472.
3. Ngheim, S., Campbell, J., Walker, R., Byrnes, J., Chaboyer, W (2022). Pressure injuries in Australian public hospitals: A cost of illness study
https://www.sciencedirect.com/science/article/pii/S0020748922000207
4. Gefen, A. (Oct 2008). How much time does it take to get a pressure ulcer? Integrated evidence from human, animal, and in vitro studies. Ostomy Wound Management, 54(10), 26-35.
5. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance (2019). Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide. Emily Haesler (Ed.). https://guidelinesales.com/pag…
