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					                  MATTRESS AUDIT POLICY




                                      Amendments
 Date        Page(s)                   Comments                          Approved by




         Compiled by:        Elaine Inglis, Senior Nurse Equipment Resources
         Ratified by:        Nursing & Midwifery Committee
                  Date:                    21st January 2004
         Review date:        January 2006
         Comments to:                      Elaine Inglis




  Volume 6                First Ratified                       Issue 1      Page 1 of 5
Medical Devices           January 2004
                  ASHFORD & ST PETER’S HOSPITALS NHS TRUST

POLICY & PROCEDURE FOR THE MONITORING OF DYNAMIC PRESSURE
RELIEVING & STATIC FOAM PRESSURE REDUCING MATTRESSES

See also:         Management of Medical Devices Policy
                  Cleaning & Disinfection Policy
                  Policy and Procedure for the Disposal of redundant, surplus or obsolete
                  Equipment
                  Confidentiality Policy

         Introduction
         The Trust has a range of systems available to prevent and treat pressure ulcers.
         To ensure the Trust makes the best use of the resources available a weekly
         audit of dynamic pressure relieving systems, supplied by Huntleigh Healthcare
         and an annual audit of static foam pressure reducing mattresses, supplied by
         Medical Support Systems (MSS) is in place.

     2. Definitions
        2.1    Dynamic Pressure Relieving System (DPRS)
               The DPRS provides an alternating surface allowing tissues to
               experience periods of no, or very little, pressure thus facilitating
               capillary refill to prevent pressure induced-damage to the tissues.
        2.2    Static Foam Pressure Reducing Mattress (SFPRM)
               The SFPRM closely follows the contours of parts of the body where
               there is direct contact with the supporting surface and thereby
               redistributes pressure over a large surface area.

     3. Aims & Objectives of:
        a.    Dynamic Pressure Relieving System audit
              • To monitor the contract with Huntleigh Healthcare
              • To gather information on use of the dynamic systems within the
                 Trust
              • To ensure appropriate allocation of dynamic system
              • To ensure correct use and application the dynamic system
              • To ensure the dynamic system is in working order
              • To provide workbased education and troubleshooting to the wards

         a.       Static Foam Pressure Reducing Mattress audit
                  • To monitor the contract with Medical Support Systems
                  • To ensure the mattress is ‘fit for purpose’ and clinically effective
                      for the patient
                  • To ensure the condition of the cover and mattress insert is
                      undamaged

4.       Frequency of Audits
         7.1      Dynamic Pressure Relieving Systems
               Weekly at St Peter’s Hospital site
               Due to usage a minimum of monthly at Ashford Hospital site
  Volume 6                     First Ratified                  Issue 1       Page 2 of 5
Medical Devices                January 2004
         4.2      Static Foam Pressure Reducing Mattress
                  Annually in October across the Trust

5.       Data collected for Dynamic Pressure Relieving Systems Audit:
               • Patient name
               • Patient location
               • Waterlow Score
               • Pressure Ulcer Status
               • Dynamic system in use
               • Appropriateness of dynamic system in use
               • Serial number of mattress and pump
               • Status of dynamic system i.e. Fixed bed, rented or owned
               • Condition of dynamic system – mattress and pump

6.       Data collected for Static Foam Pressure Reducing Mattress
         Audit:
                • Serial / batch number
                • Mattress size and depth
                • Condition of mattress i.e. outside coverings, foam inserts

7.       Procedure for implementation for Dynamic Pressure Relieving System
         Audit
         7.1   When first arriving on ward introduce team to the Nurse in charge

         7.2      The Equipment Library Representative and/or Wound Management
                  Practice Development Facilitator with a member of ward staff, check
                  bedside notes for Waterlow Risk Assessment Score and assess
                  appropriateness of the mattress in use.

         7.3      Huntleigh representative records the data. In order to maintain patient
                  confidentiality at no time may the representative from Huntleigh view
                  the patient’s notes.

         7.1      If the team question a Waterlow Risk Assessment Score or
                  appropriateness of the Dynamic Pressure Relieving System a request to
                  the ward based member of staff is made for a reassessment of the
                  Waterlow Risk Assessment Score and use of the dynamic pressure
                  relieving system.

       7.5        If there is any disagreement the final decision on the patient’s clinical
                  need for a dynamic mattress system rests with the Wound Management
                  Practice Development Facilitator.

         7.6      If the mattress is not required it is to be removed by the ward staff and
                  cleaned according to the Trust’s Cleaning and Disinfection Policy,
                  deflated and returned to the Equipment Library via porters in an
                  appropriate bag.
  Volume 6                     First Ratified                   Issue 1        Page 3 of 5
Medical Devices                January 2004
         7.7.     In the event of an alternative mattress being required the patient will
                  remain on the current dynamic system until an alternative can be
                  provided by the Equipment Library.

8. Responsibilities
      8.1   Nurse Adviser Huntleigh Healthcare
            To record information
            To provide information on Dynamic Pressure Relieving Systems
            To provide education and training
            To check working order of dynamic systems
            To monitor the number of rented systems on site
            To ensure correct and appropriate use of Dynamic Pressure Relieving
            Systems

         8.2      Equipment Library Representative
                  To ensure confidentiality, privacy and dignity of patients
                  To liaise between the patients, relatives, ward staff, Wound
                  Management Practice Development Facilitator and Huntleigh Nurse
                  Adviser
                  To provide education and training
                  To ensure correct and appropriate use of dynamic systems
                  To check working order of Dynamic Pressure Relieving Systems

         8.3      Ward Staff
                  To liaise between the patients, relatives, Equipment Library
                  Representative, Wound Management Practice Development Facilitator
                  and Huntleigh Nurse Adviser
                  To ensure confidentiality, privacy and dignity of patients
                  To provide assistance to the Huntleigh Nurse Adviser when the
                  Equipment Library Representative and Wound Management Practice
                  Development Facilitator are not available.
                  To provide clinical information where necessary
                  To access Waterlow Risk Assessment Score when required
                  To remove, clean and return Dynamic Pressure Relieving Systems to
                  the Equipment Library.

         8.4      Wound Management Practice Development Facilitator
                  To provide advice on calculating the Waterlow Risk Assessment
                  Score in the clinical area.
                  To provide training with regards to the Waterlow Risk Assessment
                  Score and Hibbs Pressure Ulcer Grading System.
                  To provide clinical advice and training in regard to individualised
                  patient care for those patients with a pressure ulcer.
                  To follow up patients with a pressure ulcer to determine outcome.
                  To be final arbiter, where there is disagreement, in determining the
                  correct Dynamic Pressure Relieving System for each patient based on
                  Waterlow Risk Assessment Score, clinical judgement, clinical need and
                  patient preference.

  Volume 6                     First Ratified                   Issue 1        Page 4 of 5
Medical Devices                January 2004
                  To advise on the appropriate Static Foam Pressure Reducing Mattress
                  or Dynamic Pressure Relieving System for discharge.




  Volume 6                    First Ratified               Issue 1      Page 5 of 5
Medical Devices               January 2004

				
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