Hospice patients comprised the majority of the study group the first 4 months; a combination of hospice and rehab participants evolved over the final two solicitation months. The forty-four (44) patients (24 men, 20 women) who participated in the mattress evaluation had an average age of 79 (range 47 to 98) years, average height of 66 (range 48 to 75) inches, and an average weight of 154 (range 85 to 270) lb. The mattress evaluation initially comprised 45 individuals; one person withdrew from the study on day 2 due to transition to alternate care. Of the 44 patients, 32 were from the hospice program and 12 from the rehabilitation facility. All 44 participants exhibited impaired mobility and/or activity: 16 were bedbound and 28 were chair-bed confined. All participants had at least one comorbidity, including cardiovascular disease, stroke, chronic obstructive pulmonary disease, dementia, chronic renal insufficiency, malignant carcinoma, arthritis, peripheral vascular disease, PU, amputation, severe contractures, incontinence, malnutrition, and/or impaired hydration that effected overall health status; 16 had one to two comorbidities, and 28 had more than three conditions. The average period for mattress observation was 53 (range 3–120) days. Most (33) patients were followed for more than 30 days; the remaining 11 individuals were discharged or died but provided relevant contributing data (see Table 1).
Thirty-three (33) patients (eight men, 25 women) who participated in the portable recliner support system evaluation were an average age of 82 (range 63–97) years, an average height of 65 (range 59–75) inches, and an average weight of 146 (range 90–245) lb. The participants for the chair support system included 32 hospice program patients and one rehabilitation program patient. All participants exhibited impaired mobility and/or activity: 32 were chair-bed confined, and one was ambulatory with assistance. All participants had one or more of the previously mentioned comorbidities that affected their overall health status; 19 had one to two comorbidities, and 13 had three or more conditions. The average period for gerichair support system observation was 39 (range 13–66) days, 27 were followed for more than 30 days, and the remaining six were discharged or died but provided relevant contributing data (see Table 1).
Four study participants utilized both devices during the trial; all others used either the mattress or the gerichair support surface. None of the participants (total 77) was independently ambulatory, 16 were totally bedbound, and the remaining patients were considered chair-bound status with either no ambulation ability or limited assisted ambulation.
Mattress results. Pretrial sleeping surfaces included 14 home or standard foam mattress (with or without overlay), 16 HSF mattresses similar to the study device, 12 air mattresses, and one recliner chair. The 44 participants predominantly ranked comfort, migration, immersion, and heel offloading on the trial product 2.5 or greater (good) (see Table 2). The poor (<1.8) ranking scores (3) for mattress comfort and (2) for immersion were associated with reports of excess back firmness and/or deep pelvic submersion in the severely contracted or obese individual. One participant was unsure of the pretrial device because he/she was too ill to recall prior experiences, and for another individual heel offloading was not applicable due to bilateral above-the-knee amputation. Otherwise, pretrial mattress rankings for comfort included 16 good, 20 fair, and seven poor. Comparatively for the trial mattress, 39 participants ranked comfort as good, two ranked it fair, and three ranked it poor. Migration control ranking of the pretrial mattress included 17 good, 17 fair, and nine poor, compared to the trial mattress that received rankings of 28 good, 13 fair, and three poor. For immersion into the mattress without bottoming-out on the pretrial mattress, 29 ranked it good, nine ranked it fair, and five ranked it poor, as compared to the trial mattress where 40 ranked it good, one ranked it fair, and two ranked it poor. Heel offloading through shared contact of the lower extremity and elimination of intense strike zones on the bony prominences of the heel/ankle region for the pretrial surface was ranked by 11 as good, 15 as fair, and 16 as poor, while the trial surface was ranked by 40 as good, one as fair, and one as poor.
Among the results for the three categories of pretrial versus trial product, mattresses in Category A included 15 nonpowered pretrial units that were compared to the trial unit. Pretrial standard device category comfort rankings were five good, six fair, and four poor; trial mattress comfort in this category was ranked as 13 good and two poor. Migration control on the pretrial product was ranked as eight good, five fair, and two poor; trial mattress was ranked as nine good, five fair, and one poor. Immersion on the pretrial products was ranked as nine good, four fair, and two poor; trial mattress immersion was ranked as 14 good and one poor. Heel offloading on the pretrial product was ranked as three good, six fair, and five poor; trial mattresses were ranked as 13 good and one poor. One participant with bilateral lower extremity amputation marked heel offloading as not applicable.
Mattress Category B included 16 nonpowered pretrial products compared to the trial mattress. Comfort on the pretrial HSF category was ranked five good, nine fair, and two poor; on the trial mattress 15 ranked comfort as good and one as fair. Migration control ranking on the pretrial product included seven good, seven fair, and one poor versus 11 good, three fair, and two poor on the trial mattress. Immersion rankings on the pretrial product included 11 good, three fair, and one poor versus 15 good and one fair on the trial product. Heel offloading rankings on the pretrial product included six good, four fair, and six poor versus 15 good and one fair on the trial mattress.
Mattress Category C consisted of 12 powered products compared to the trial product. Comfort rankings on the pretrial air products included six good, five fair, and one poor versus 10 good, one fair, and one poor on the trial mattress. Migration control ranking on the pretrial product included two good, five fair, and five poor versus seven good, four fair, and one poor on the trial product. Immersion ranking on the pretrial product included nine good, two fair, and one poor compared to 11 good and one poor on the trial product. Heel offloading ranking on the pretrial product included two good, five fair, and five poor compared to 12 good on the trial product.
For the 43 participants who ranked their pretrial equipment, overall pretrial and trial rankings were compared to determine statistical significance in comfort, migration, immersion, and heel offloading. The negative sum rank for comfort (372.50) was higher than the positive rank (62.50), which indicates the postscore is higher than the pre-score. The Wilcoxon signed rank revealed significantly greater mattress comfort during the trial (z = -3.35, P <0.001). As shown in Table 3, similar statistically significant improvements occurred during the PRSS trial period for migration, immersion, and heel offloading.
Wilcoxon signed rank tests were conducted between pre- and posttrial scores on ratings for comfort, migration, immersion, and heel offloading in each of the pretrial categories as a direct comparison to various product types. When analyzed by categories, sleep surface comparisons show statistically significant and higher posttrial scores for the trial mattress in the following areas: heel offloading for standard surfaces, comfort and heel offloading for alternative high-specification mattresses, and migration and heel offloading for air mattresses (see Table 4).
Pain. Twenty-seven of the mattress trial participants reported pain associated with their pretrial mattress at the onset of the evaluation; 19 of these individuals reported improvement in their pain status they associated with the trial mattress introduction, eight reported their pain was unchanged, and one reported increased pain after the trial mattress replaced a sleep recliner.
Falls. No falls were associated with transfer or repositioning on the trial mattress. The two participants who had experienced repeated falls from their pretrial mattress ceased having fall issues with the introduction of the trial mattress. Feedback on mattress safety and fall prevention included comments that the mattress does not shift on the bed frame during transfer and the firm wide edge provides stability with sitting and grasping assistance during egress. One bariatric patient reported the mattress center was too soft, making egress difficult.
PU. Among the 44 mattress participants, 26 — 23 hospice program participants and three rehab participants — had preexisting PUs. A total of 35 preexisting PUs were followed during the trial; 17 healed, 10 improved, seven remained unchanged, and one coccyxgeal ulcer deteriorated from a Stage II to Stage III in an obese individual who required continual upright positioning in the final weeks of life. Of the 35 preexisting PUs, five were Stage I, 14 Stage II, 13 Stage III, and three were unstageable, eschar-covered ulcers. The number of PUs in each stage that healed or improved included four Stage I, eight Stage II, 12 Stage III, and all three unstageable (see Figure 1). New-onset Stage II PUs occurred in two participants; one hip ulcer developed on day 60 in a severely malnourished individual with a preexisting, unchanged coccyx ulcer, and one intermittent recurring sacrococcygeal ulcer developed on day 48 in a person who was severely contracted who remained in a continual upright sitting position due to gastric reflux. The latter individual had healed preexisting heel and hip ulcers during her observation period.
Portable recliner (seating) PRSS outcomes. Most (31) of the 33 participants ranked the trial seating general comfort, migration control, immersion, and heel offloading as good; scores exceeded 2.5. All 33 participants ranked the trial seating PRSS as good in comfort, migration control, and immersion; 31 ranked heel offloading good and two ranked it fair.
Twenty-eight participants were able to recall pretrial equipment for ranking purposes. Pretrial seating replaced by the trial recliner PRSS seating included 11 gel/foam hybrid seat cushions, eight generic foam seat cushions or recliners with no additional support, and nine miscellaneous seating systems. For overall pretrial device comfort, none ranked it good, nine ranked it fair, and 19 ranked it poor. Migration control on the pretrial device was rated good by four, fair by three, and poor by 21. Immersion rankings were noted as good by six, fair by 13, and poor by nine. Heel offloading was ranked as good by two, fair by two, poor by 18, and not applicable by six individuals who had a pretrial device that did not include heel suspension (see Table 2).
Seating Category A comfort ranking included six good and five fair; all 11 participants ranked the trial PRSS as good. Pretrial product migration control was ranked poor by all 11 respondents; all 11 ranked the trial product as good. Immersion on the pretrial cushion ranking included four good, four fair, and three poor; all 11 ranked trial PRSS immersion as good. Heel offloading on the pretrial product was rated as poor by all 11 participants; 10 rated the trial PRSS good and one rated it fair.
Seating Category B ranking for comfort when no cushion or a standard foam was used was rated poor by seven and fair by one of eight participants; all eight ranked the trial PRSS comfort as good. Migration control ranking on the pretrial seating included five poor, one fair, and one good; all eight rated the trial product as good. Immersion ranking pretrial was rated as three poor, four fair, and one good; all rated the trial PRSS as good. Pretrial heel offloading included six poor, one fair, and one good, versus seven good and one fair on the trial PRSS.
Seating Category C for all four categories on miscellaneous seating systems using the trial PRSS was ranked as good by all nine participants in this group.
For the 28 participants who ranked their pretrial equipment, Wilcoxon signed rank tests were conducted between pre- and postscores on ratings for comfort, migration, immersion, and heel offloading for participants who used a portable recliner with or without support. The results indicate statistically significant differences between pre- and postscores for all ratings. The higher negative sum-ranks indicate a higher postscore (see Table 5).
Wilcoxon signed rank tests were conducted between pre- and post-scores on ratings for comfort, migration, immersion, and heel offloading for seating devices in categories A, B, and C. The results indicate statistically significant differences between pre- and postscores for all ratings (see Table 6).
Pain. Seventeen participants said they had pain related to sitting at the onset of the evaluation; all of these individuals reported their pain resolved or improved during the trial period, which they associated with the support surface introduction. Additional undocumented feedback relative to comfort was observed as positive behavioral changes evident in multiple individuals based on perceptions of previous attempts to get out of the chair or continual calling out to be returned to bed; these patients had become quiet and content with implementation of the recliner PRSS.
Safety. Seating surface safety on the trial recliner PRSS was a major concern in all care settings; no falls, leaning over, or migration were reported with the trial device. Users and caregivers reported cessation of sliding down, improved posture, and alignment in all of the study participants. Although no falls had occurred on the prestudy seating products, multiple complaints of fall risk were expressed by caregivers associated with patients sliding down in the chair before the new device was implemented.
PU. Of the 33 study participants, 13 hospice patients had 20 PU; no PU were present on enrollment in the rehabilitation center. No new PU occurred during the seating trial. Preexisting PU included two Stage I, six Stage II, 10 Stage III, and two unstageable, eschar-covered ulcers. Of the total 20 wounds, 17 ulcers healed and three improved; the improved wounds all occurred on a lower extremity (two unstageable and one Stage III) (see Figure 2).