ABSTRACT
Improving Quality of Care through Patient-Centered Seating Patient satisfaction, fall prevention and maintenance of skin integrity are concerns that span the continuum of care. As patients become less mobile due to decline in health status seating becomes a major intervention in their daily lives. Falls, pain and pressure ulcer incidence can be associated with ineffective seating. Economical constraints limit the seating product choices available in hospitals, outpatient facilities, long-term care facilities, and home care settings. Quality of care is impacted by the quality of seating. Ergonomic principles should serve as a guide to effective seating in medical settings and care regimens. This study demonstrates the value of high-specification foam products that have been structured for postural support as well as skeletal off-loading. High-specification foam products are structured with various foam configurations and grades of firmness that are intentionally placed to address skeletal weighting zones and static forces. The following study results report on the implementation of a high-specification foam support system designed to fit a standard gerichair.

PURPOSE
Establish the effect of a high-specification foam geri chair support surface on the safety, comfort and skin integrity of individuals confined to a standard geri chair seating system.

METHODS
A search of current evidence-based literature on support surfaces clinical efficacy was conducted through PubMed and revealed insufficient evidence for the determination of best practice off-loading devices for pressure ulcer prevention and treatment on chairs, yet supported the need for pressure redistribution equipment for debilitated individuals.

A proposal for the study of a new high-specification foam support surface for a standard gerichair was submitted and approved by the Ethics Committee of a large non-profit Hospice Agency.

Subjects for the study were selected from this Hospice Agency over a four month period, then over the next four months from a VA Rehabilitation Center. All subjects and/or their caregiver were informed regarding their rights of participation. The volunteer group for the gerichair support system totaled 33 individuals, 94% were from a hospice program and 6% from a rehabilitation facility.

Subjects were solicited to participate for a minimum thirty day evaluation unless a request for termination was voiced or a change in their condition resulted in discharge or death. Individuals were selected for participation in the study by their individual nurse managers if the patient or caregiver expressed dissatisfaction with existing gerichair support surface or the individual was observed to have discomfort, falls, skin changes or positioning issues allegedly associated with existing support surfaces. Patients residing in a facility setting were seen daily by a nurse manager and patients residing at home were seen weekly by a nurse manager to ensure continuing product satisfaction. Study investigators obtained data reports from nurse managers, study subjects and caregivers every 7 to 21 days. Two co-investigators were instructed in the use of a common data collection form that included patient and caregiver perceptions regarding general comfort, migration, transfer safety, surface pelvic immersion, product ability to conform to body contours, effect on positional pain, and ability to off-load heels. Wound healing reports were obtained on existing wounds and on any new skin changes at each visit as were fall history before and during the study. Subject age, sex, length of observation, pre-existing conditions, height and weight were collected also.

Both the Hospice and the Rehabilitation agencies had pressure ulcer prevention and treatment protocols that included individualized repositioning schedules, support surfaces, skin hygiene, incontinence barriers, routine skin inspections and weekly wound measures. End of life hospice programs endorse palliative care goals which do not include nutritional programs, rehab or aggressive wound care thus the majority of study subjects were on supportive care only. The subjects from rehabilitation were on nutritional programs, disease management and physical therapy programs to optimize their health status.

The study included a new pre-market high-specification foam device designed with various foam structures & firmness ratings to correlate with skeletal weighting for optimal alignment, pressure redistribution & contact area. Product trials included one seating system custom sized to fit a standard gerichair inclusive of back, seat, arms and footrest.

RESULTS
The subjects who participated in the gerichair support system evaluation ranged in age from 63 to 97 years with an average age of 82. The group was comprised of 8 males and 25 females with an average height of 65” (height range 59-75”) and an average weight of 146lb (weight range 90-245lb). All 33 participants exhibited impaired mobility and/or activity, 32 subjects were chair-bed confined, 1 was ambulatory with assistance. All participants had co-morbidities that effected their overall health status, 19 subjects had one to three co- morbidities while 13 subjects had more than three conditions such as cardiovascular disease, stroke, chronic obstructive pulmonary disease, dementia, malignant carcinoma, arthritis, peripheral vascular disease, pressure ulcer, severe contractures, incontinence, malnutrition and impaired hydration. The average period for gerichair support system observation was 39 days (observation range 13-66 days), 27 subjects were followed for more than 30 days, the remaining 6 individuals were discharged or expired but provided relevant contributing data.

Of the 33 participants 100% rated the general comfort as improved compared to their previous surface; 17 of the participants expressed pain related to sitting at the onset of the evaluation and 100% of these individuals or their caregivers reported resolution or improvement in their pain status which they associated with the support surface introduction. Additional feedback relative to comfort was expressed as positive behavioral changes evident on multiple individuals who had previously attempted to get out of the chair or continually called out to be returned to bed became quiet and content with implementation of the gerichair support system.

Previous support surfaces that were replaced by the evaluation surface included; 50% gel/foam seat cushion, 12% generic foam seat cushion, 18% gerichair with no additional support, and 20% miscellaneous seating systems.

Support surface safety was rated 100% as no falls, leaning over or migration were associated with the device. Users and caregivers reported improved posture and alignment in 100% of the subjects.

Immersion and off-loading observations included ability of the support surface to conform to body contours without excessive submersion, lower extremity support as evidenced by heel suspension when reclined, and maintenance of skin integrity as evidenced by no new pressure ulcers and stable or improved status of existing pressure ulcers. Of the 33 participants 100% were observed to have good immersion of the back, pelvic and lower extremity areas. Of the 33 participants 39% had pre-existing pressure ulcers with a total of 20 wounds; 17 ulcers healed and the remaining 3 improved. Pre-existing wounds include; 2 stage I, 6 stage II, 10 stage III, and 2 unstageable ulcers. The 3 wounds that improved but not fully healed were all lower extremity PU; 2 unstageable and 1 stage III. No new onset pressure ulcers occurred

CONCLUSIONS
Quality of life was improved on all subjects when sitting directly related to improvements in the gerichair surface. Postural alignment not only provided comfort and safety but was interpreted by significant others as improved appearance in regards to self dignity.

Behavioral issues such as calling out, refusal to remain in chair and restlessness were resolved by the implementation of the high-specification foam support.

Wound healing progress was noted in stage I, II and III pressure ulcers through care plan revisions of the gerichair support surface alone. Implementation of ergonomically designed high-specification foam support surfaces can improve safety, comfort and tissue integrity over standard gel/foam supports.

Small sample size, historical reporting and convenience sampling are limitations of this study. Random control studies may be useful in establishing clinical guidelines for product classification, levels of efficacy and design requirements of all support surfaces. Ongoing design and study of alternate seating systems using high-specification foam support devices continues by this writer in an effort to improve the quality of care for our chair confined highly vulnerable populations.