Völker MiS Activ. The active Micro-Stimulation-System for bedsore prophylaxis, mobilisation, pain reduction and the promotion of perception.

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1 Völker MiS Activ. The active Micro-Stimulation-System for bedsore prophylaxis, mobilisation, pain reduction and the promotion of perception.

2 Meanwhile, Micro-Stimulation is a tried-and-tested concept for institutional nursing as well, with exceptional success in, for example, bedsore prophylaxis to boot. Now, Völker has developed its active Micro- Stimulation-System, Völker MiS Activ, as an ideal completion, for bedsore therapy too. Only at Völker: Hospital beds with Völker MiS and MiS Activ. Two years ago, at the ALTENPFLEGE 2003 in Nuremberg, Völker introduced the Micro- Stimulation-System as a new undersuspension. This made available a nursing aid directly integrated into Völker hospital beds which supports and completes basal stimulation in an appropriate manner and thus contributes to bedsore prophylaxis. There has been a compelling positive response and now 9 out of 10 beds are delivered with Völker MiS. The Micro-Stimulation-Systems principle is primarily based upon the theoretic foundations of basal stimulation, the Bobath concept and kinaesthetics. Micro-Stimulation-Systems promote and maintain the patients own movements and their perception through feedback between them and the system itself, which characteristically consists of the butterfly spring technology. This feedback supports the perception of one s own body and thus stimulates a patient s own movements. This, in turn, guarantees physiological blood circulation in the skin, which prevents the development of pressure ulcers (bedsores) or provides the right conditions for the healing of such wounds. At the same time, the Völker MiS Micro-Stimulation-System also meets mobilisation, promotion of perception and pain reduction requirements. MiS has thus become firmly established as a nursing aid which supports and completes basal stimulation in an appropriate manner. The classical Thevo-Adapt has been used for bedsore and pain patients with huge success, and for the past two years so has the Völker Micro-Stimulation-System in institutional healthcare (see page 12). After the results of a scientific long-term study have now been made available (see page 14 ff), Völker decided also to introduce active Micro-Stimulation in healthcare and hospital beds see page18). This brochure contains various articles which will give you general information about Micro- Stimulation in detail, especially about Thevo- Activ, the Völker Micro-Stimulation-System MiS and MiS Activ. The articles are taken from various publications. They may thus be a wee bit repetitive in terms of contents, but this makes the individual articles more intelligible. They are thus reprints of the originals.

3 Contents Issues and articles Contents Names and brands Only at Völker: Hospital beds with Völker MiS and MiS Activ...2 Contents...4 Andreas Fröhlich drew up the basal stimulation concept, Christel Bienstein implements it in nursing....4 Thomashilfen develops Thevo, Heinrich Völker implements MiS in institutional healthcare....6 Experts standard bedsore prophylaxis and the ongoing bedsore problem. The experts standard preamble....8 The experts standard s structure, process and result criteria....9 Völker MiS and MiS Activ. Why they are so important for nursing per cent fewer bedsores. The Meander Medisch Centrum s experiences...13 Test passed! The results of the long-term study Thevo-Activ The pros and cons of alternating pressure. The right bedsore therapy Thevo-Activ and Völker MiS Activ. Same operating mode, different drives Völker has something to fight bedsores. The new Völker MiS Activ How does Micro-Stimulation work? Völker MiS and Völker MiS Activ More than just pressure reduction: The new lying surface Völker MiS Activ Bienstein, Christel Head of expert working group bedsore prophylaxis, chair in healthcare science at Bremen University, Head of the Institut für Pflegewissenschaften an der Universität Witten/ Herdecke (a healthcare science faculty), co-editor of the standard textbook Dekubitus (Stuttgart 1997), lecturer on bedsore prophylaxis and therapy, kinaesthetics expert, basal stimulation coach Bobath-Konzept Neurophysiological treatment concept developed by the English physiotherapist B. Bobath ( ) Dorenbeck, Günther Völker Aktiengesellschaft s Development Manager Experts standard bedsore prophylaxis Presentation of the planning, development, general approval, implementation and evaluation of the national experts standard, Deutsches Netzwerk für Qualitätsentwicklung in der Pflege (German network for quality development in nursing), 2004 Fröhlich, Andreas developed basal > stimulation Heine, Heiko Head of ProScript!, Völker World Editor-in-Chief IGAP Institut für Innovationen im Gesundheitswesen und angewandte Pflegeforschung (institute for healthcare innovations and applied healthcare research), Bremervörde, Kinaesthetics Movement perception theory developed by the American psychologist L. Maletta and behaviour cyberneticist F. Hatch Lattoflex Thomas GmbH + Co. Sitz- und Liegemöbel KG, Bremervörde, > Winx bed systems Lubatsch, Heike Author of the specialist publication bedsore management on the basis of the national experts standard Micro-Stimulation-System A nursing concept for bedsore prophylaxis and therapy listed in the nursing aids register Osterbrink, Jürgen Prof. (FIU, Miami) Dr., project management of the study clinical evaluation of the efficacy of the Micro-Stimulations-Sytems Thevo-Activ, head of teaching centre, Klinikum Nürnberg, chair in healthcare science at Florida International University, Miami/USA Schröder, Gerhard Member of the expert working group bedsore prophylaxis, co-editor of the standard textbook Dekubitus (Stuttgart 1997), member of staff and reader ICW guideline bedsores, lecturer on bedsore prophylaxis and therapy: Test passed! The results of the long-term study Thevo-Activ. Simon, Sabrina Member of staff ProScript!, Völker World staff writer Stimulation, basale A concept for the personality development of physically and mentally handicapped children developed by Professor > Andreas Fröhlich Thomas, Gunnar Managing Director >Thomashilfen Thomashilfen Thomashilfen für Behinderte GmbH & Co. Medico KG, Bremervörde, Nursing aids and everyday aids with the objective of maintaining and stabilising a patient s individual energy through nursing measures within the framework of a holistic therapy approach. Thevo -Adapt, Thevo-Activ Micro-Stimulation-Systems distributed by the sanitary retail trade, registered trademarks of Thomashilfen, Bremervörde Völker AG Völker Aktiengesellschaft, Witten, Manufacturer of electrically driven healthcare and hospital beds, German market leader, global innovation leader Völker, Heinrich Chairman of the Board > Völker AG Völker MiS, Völker MiS Activ Micro-Stimulation-Systems for institutional healthcare, integrated in Völker healthcare and hospital beds, registered trademarks of > Völker Aktiengesellschaft, Witten Winx Micro-Stimulation-Systems distributed by the specialised bed trade, registered trademark of > Lattoflex Wolters, Matthijs Marketing Director of Völker BV, Netherlands Woltemade, Natascha Graduate in healthcare science, founded > IGAP in 1997 and there head of the healthcare science department 3

4 4 Andreas Fröhlich konzipiert die Basale Stimulation Originally, basal > stimulation was a concept developed by Professor > Andreas Fröhlich in 1975 for the personality promotion and development of physically and mentally handicapped children. The term basal means that we want to use the most simple and elementary possibilities to reach out to people, to get in touch with them. It also means that we revert to the basis, i.e. the foundation of all human action. Stimulation means: A severely handicapped person is offered something positive, something that encourages him to get in touch with other people and his environment. Within the framework of the concept of basal stimulation, which is also based upon developmental physiology and psychology (cf. Piaget > Bobath in particular), Fröhlich offered the children perception experiences for which they didn t need to fulfil any requirements and which go back to very early, mostly prenatal experiences: Feeling one s own body, experiencing to be in motion, spatial position changes or discovering one s inside through vibrations (somatic, vestibular, vibratory experiences); listening closely, watching closely, oral and olfactory experiences, grasping one s environment (acoustic, visual, oral and olfactory plus tactile experiences). A. Fröhlich and his staff have successfully discovered that children responded within the bounds of their possibilities and have thus been able to develop a form of elementary communication which accompanies the children during their experiences and promotes their skills. Christel Bienstein implements basal stimulation in nursing Professor > Christel Bienstein and > Andreas Fröhlich have jointly transferred the afore-mentioned basic ideas of their concept to the nursing of adults and discovered that basal stimulation can just as well be applied to seriously ill adults. They found, for example, that apallic and comatose patients feel the same basic need for perception, movement and communication, while only having impaired faculties of experiencing them and running a risk of further damages if not stimulated in a targeted fashion. Basal stimulation in nursing tries to provide such people with the known, elementary experiences of perception in order to accompany them during such experiences and to promote their capabilities. The target group are all people with impaired capabilities of perception, movement and communication, e.g.: Unconscious, artificially respired, disorientated, somnolent, skull-brain traumatised people; dying people; patients with hypoxic brain damage, Morbus Alzheimer, hemiplegic, apallic or comatose syndrome; patients with a very limited mobility; the disabled and premature babies as well. All these people have in common that they need to be physically close to people in order to perceive them, that they need the one nursing them to let them feel their environment in the most simple way, to enable them to change their position or move and who will also nurse and feed them (cf. Fröhlich 1998). A. Fröhlich: Basale Stimulation. Das Konzept Düsseldorf 1998 A. Fröhlich: Wahrnehmungsstörungen und Wahrnehmungsförderung Universitätsverlag Winter, 2005 C. Bienstein, A. Fröhlich: Basale Stimulation in der Pflege Seelze/Velber 2003

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6 Thomashilfen (fig. Gunnar Thomas) develops Thevo. Heinrich Völker implements MiS in institutional healthcare. 6 At the end of the 1990s, > Thomashilfen used the concepts developed by Fröhlich and Bienstein for a new technological system, a > Micro- Stimulation-System, and called it > Thevo. The Micro-Stimulation-Systems principle is primarily based upon the theoretic foundations of basal stimulation, the Bobath concept and kinaesthetics. Micro-Stimulation-Systems promote and maintain the patients own movements and their perception through feedback between them and the system itself, which characteristically consists of the butterfly spring technology. This feedback supports the perception of one s own body and thus stimulates a patient s own movements. This, in turn, guarantees physiological blood circulation in the skin, which prevents the development of pressure ulcers (bedsores) or provides the right conditions for the healing of such wounds. If a human being has only a limited capability to move or perceive, he is no longer able to adequately respond to environmental stimuli. This lack of a patient s own movement is the reason for the development of pressure ulcers. A targeted therapeutic stimulation will promote the patient s perception and he is then able to move by himself, e.g. by shifting his weight. Here, > Thevo-Activ supports the therapeutically important somatic (physical) and vestibular stimulation. Micro-Stimulation s various modes of movement promote the physiological blood circulation in the affected areas or areas of risk. This microcirculation thus ensured supports the healing of the wound(s). > Völker is a licensee of > Thevo. While retaining the operating mode of Thevo, Völker, in a first step, developed the technical prerequisites for the use of a > Micro-Stimulation-System in institutional healthcare. The result is > Völker MiS. Since 2003, Völker healthcare and hospital beds have been equipped with this undersuspension, first optionally then as a standard feature, which is meanwhile demanded by almost all Völker customers at any rate. After the positive findings in a long-term study of the active system > Thevo-Activ, > Heinrich Völker decided to develop an active Micro- Stimulations-System for institutional healthcare, too. After one-and-a half-years, this work has now been concluded. This time was necessary to convert Thevo-Activ s drive to ensure an easy handling and a long service life when continuously operated under consideration of standards and guidelines and an inexpensive large-scale production. All experts have meanwhile recognised that while the high incidence of pressure ulcers has to be put down to a lack of mobility among patients, this mobility cannot really be achieved, not only for a lack of knowledge but primarily for a lack of available bedsore-prophylactic and therapeutic means. Since costs play an important role here, this can now be changed by using Völker MiS for bedsore prophylaxis and by simply exchanging it for Völker MiS Activ for bedsore therapy. Figure on the right: the development of lying surfaces for Völker hospital beds, from left: HPL surface, sprung aluminium profiles, undersuspension MiS (passive, standard in all Völker beds since 2003) Figure on the left: Micro-Stimulation- System Thevo-Adapt by Thomashilfen

7 Figure on the left: Völker lying surface with MiS Activ. Figure, top right: Design drawing Völker MiS (passive); the bracket profile is borne by a twochamber spring band. Figure, bottom right: Design drawing Völker MiS Activ; the bracket profile is integrated into the activator. Further specifications of both systems can be found on pages 22 and 23.

8 Experts standard bedsore prophylaxis and the ongoing bedsore problem Preamble to the > experts standard 8 The bedsore issue has been one of the most important ones in nursing journals, nursing training, advanced vocational training, meetings and conferences for several years now. As a rule, these articles, however, focus on bedsore therapy and/or wound management of such a chronic wound. Bedsore prophylaxis as the preventive measure against the development of bedsores is rarely an issue in German specialist publications. National and international healthcare research has also dealt with this problem for quite some time. Its findings have led to the first national > experts standard for bedsore prophylaxis. This represents traditional measures like a risk assessment on the basis of standardised scales and appropriate skincare but also includes new concepts for skilled nursing. Shearing forcereducing positioning and transfer techniques, which are thus kind to the tissue, promotion of the patients self-mobilisation and instructions and training for the nursing staff are the main items in these concepts for medical care for this group of patients. But it is the prevention of this painful illness, so very expensive for the cost bearer, which should be paid much more attention to in times of tighter budgets. The prevention of pressure ulcers has to be objective of all efforts in nursing. After all, according to experts almost all pressure ulcers could indeed be prevented. Nursing experts in out-patient and long-term care facilities, in domestic care, among cost bearers and healthcare science institutes and manufacturers of nursing aids and dressing material try to tackle the bedsore problem and provide solutions. The strategies on offer have to be innovative and sound in terms of healthcare science. It is > Thomashilfen and > Völker s objective to meet these high standards and to improve such patients medical care. With innovative ideas, intensive research and interdisciplinary development, these two companies are the ones to contact when it comes to anti-bedsore systems. The experts standards make for changed requirements for anti-bedsore systems. Pressure reduction and shearing-force minimisation are still qualities not to be done without, but they do no longer suffice. Effective anti-bedsore systems have to be able to maintain and promote a patient s own movements. And they should have a positive impact on his "conception of his own body and its perception in order to avoid any negative influence on nursing measures and the patient s condition. Since people in danger of developing pressure ulcers are found in all facilities of the healthcare system, the (present) experts standard addresses geriatric nurses, nurses and paediatric nurses. (...) The experts standard is based upon a comprehensive analysis of the available national and international literature primarily a research of randomised controlled studies and the practice expertise of the members of the expert working group. The precept and result criterion define the prevention of bedsores as the central objective, since such a development can, as a rule, be counteracted. Nonetheless, this objective cannot be attained for all groups of people. There are limitations for those people whose medical condition does not allow a consistent application of prophylactic measures (e.g. in life-threatening situations), requires other priorities (e.g. people in their terminal stage) or precludes the prophylactic measures efficacy (e.g. serious blood circulation dysfunctions, perhaps when centralising drugs have been administered). The (present) standard s design in terms of contents and forms (a short and definite precept, measurable structure, process and result criteria) is based upon the tried-andtested international structure also used in the European network. The selected priorities focus on central aspects in order to avoid the standard being fraught with general statements(...). The general objective is an individual care, which also takes into account the patient s/relatives needs, if need be. The foundations for such an approach in nursing are, above all, a theory-based application of the nursing process method including an evaluation of the nursing success; an orientation along the patient s/the affected person s physical, social, emotional and spiritual needs; a meaningful documentation of the nursing process as an important data base for quality measurement; cooperation with other healthcare professions. The experts standard for bedsore prophylaxis presented in the following is the final version, drawn up by the expert working group in coordination with the DNQP s steering committee after the consensus conference. (...)

9 The experts standard bedsore prophylaxis in nursing. Struktur The qualified nurse Process The qualified nurse Result Precept: Every patient in danger of developing a bedsore receives a prophylactic treatment which will prevent the development of a bedsore. Reasons: A bedsore is one of the serious health risks run by patients/affected people in need of care or outside assistance. In view of the available knowledge on the extensive possibilities to prevent bedsores, the objective is a reduction to the minimum. It is of primary importance that qualified nursing staff ensure a systematic risk assessment, training of patients and affected people, mobility promotion, pressure reduction and a continual use of prophylactic measures. S1 has up-to-date knowledge of the development of bedsores and a risk assessment competence. S2 has a command of mobilising, positioning and transfer techniques kind to the skin and tissue. S3a has the competence to select appropriate pressurereducing aids. S3b has access to pressure-reducing aids (e.g. soft cushions and mattresses), special beds (e.g. aircushion beds) within 12 hours. S4 knows further appropriate intervention methods for bedsore prophylaxis deriving from the risk assessment besides mobility and promotion and pressure reduction. S5 has the skill, information and training material to instruct and advise the patients/affected people and their relatives on the promotion of self-mobility. S6 is employed in a facility which ensures that all staff participating in the nursing of patients/affected people know of the link between continual intervention and a successful prophylaxis. Information on the bedsore risk is transferred to external parties at all times. S7 has the competence to evaluate the efficacy of the prophylactic measures. P1 P2 P3 assesses the bedsore risk of all patients/affected people for which a risk cannot be excluded right at the beginning of the nursing process and then at intervals to be individually determined and also forthwith should there be any changes in mobility, activity and pressure and on the basis of a standardised assessment scale, e.g. by Braden, Waterlow or Norton, among other things. on the basis of an individual mobilising plan ensures immediate pressure relief through regular micro-movement. A low friction and shearing-force transfer promotes the patient s self-mobility as far as possible. uses the appropriate pressure-reducing aids if the patient s/the affected person s condition does not allow a sufficient mobility promotion and/or pressure relief. P4 on the basis of the risk assessment initiates further intervention methods for all identifiable risk factors, which may, for example, affect the maintenance and promotion of tissue tolerance. P5 P6 P7 explains the bedsore risk and the necessity of prophylactic measures and plans such with the patient/the affected person and his relatives. informs those involved in the care of patients/affected persons in danger of developing bedsores about the necessity of the continuation of the interventions (e.g. staff in doctor s practices, operation theatre and X-ray departments or transport services).. assesses the patient s/the affected person s skin condition at regular, individually determined intervals. R1 There is an up-to-date and systematic assessment of the bedsore risk. R2 There is an individual mobility plan. R3 The patient is put on a pressure-reducing surface adapted to his requirements forthwith, pressurereducing aids are used forthwith. R4 The implemented risk factor interventions are documented. R5 The patient/the affected person and his relatives now the reasons for the bedsore risk and the planned measures and cooperate on their implementation within the bounds of their possibilities. R6 All those involved in the patient s/the affected person s care know about the bedsore risk and the necessary measures. R7 The patient/the affected person does not suffer from bedsores. 9

10 Völker MiS and MiS Activ. Why they are so important for nursing. Heiko Heine Head of ProScript!, Völker Wörld Editor-in Chief The > experts standard bedsore prophylaxis in nursing (see also pages 8,9) was published by the DNQP in August One would expect a lot to have happened since then. After all, a huge range of anti-bedsore mattresses and various prophylactic systems is available. And any lying surface of hospital or healthcare beds featuring a small and flexible part is advertised as an effective preventive measure. This statement on bedsore prophylaxis by a major manufacturer s expert at an exhibition stand is thus no real surprise: "We refer our customers asking about this problem to our anti-bedsore mattresses. After all, you don t feel plastic suspension elements anyway!" 10 Nursing staff, willing to prevent bedsore, often feel unsure of themselfes, because of the amount of informations. And, let s face it, he is not totally wrong. In fact, irritating developments in nursing are certainly on the increase. And the incidence of bedsores has not gone down. It is all still about nipping it in the buds. Thus, the precept of the experts standard reads: "Every patient in danger of developing a bedsore receives a prophylactic treatment which will prevent the development of a bedsore. Nursing staff are able to do that because they are up-to-date on the development of bedsores and able to assess the risk (see experts standard S1). And according to the experts standard, nursing staff have also mastered mobilising, positioning and transfer techniques gentle to the skin and tissue (see experts standard S2) and have the competence to select suitable pressure-reducing aids available within 12 hours, e.g. air cushion beds (see experts standard S3a, b). And there is the rub. After all, it is not all about knowledge and competence but about the availability of such means and considerable expenditure, too. The measures required by the experts standard often fail for a lack of suitable aids. For prophylactic treatment has to be provided in accordance with an individual exercise plan. This includes immediate pressure relief through regular mobilisation of the patient, e.g. 30 laying, micromovement, low-friction and gravity transfer and, as far as possible, the patient s self- mobilisation. If the patient s condition does not allow sufficient mobilisation or pressure relief, suitable pressure-reducing aids have to be used. The result according to the experts standard: The patient is put on a pressure-reducing surface adapted to his requirements forthwith, pressure-reducing aids are used forthwith. A 100 per cent prevention of bedsores would require appropriate aids for 450,000 healthcare beds. People in danger of developing bedsores need an immediate prophylactic treatment, mobilisation above all, once the danger has been recognised. Insiders estimate the risk of developing bedsores in hospitals at 30 per cent, in geriatric

11 nursing homes at 50 per cent or more. There are about 500,000 beds in hospitals, and about 600,000 in nursing homes. In plain language, this means the initiation of appropriate measures and an availability of appropriate aids for 150,000 plus 300,000 beds, if 100 per cent of bedsores are supposed to be prevented. And with regard to hospitals we only speak of their number of beds, not of the annual number of about 4.5 m patients, out of the total of 15 m, in danger of developing bedsores. People responsible for bedsore management point out that rendering medical care and funding medical care are two sides of the same coin. While experience teaches us that money does not equal quality, we can also see that there is no such thing as a free quality lunch (> Heike Lubatsch, Dekubitusmanagement, Schlütersche, Hannover 2004). Bedsore therapy costs about Euro 3.2 bn p.a. And the costs are huge. But the exact figures are as hard to come by as exact data on the bedsore risk and incidence and reliable estimates. Stiftung Pflege (a healthcare foundation) estimates the costs for the German healthcare system to come in at at least Euro 3.2 bn. Bedsore management in hospitals is thus often a continuous struggle with the financial department. These examples indicate insufficient medical care: demands for lower rents for bedsore mattresses, orders being placed without any consideration of nursing criteria, the procurement of 20 foam pads and 25 foam mattresses for bedsore prophylaxis and 10 for bedsore therapy, an additional 200 positioning cushions, and all this for a 550-bed facility. Bedsores develop unexpectedly. They are already there when you see them. Bedsores arrive by stealth. The human body s weight exerts pressure on the lying surface which in turn exerts counterpressure on the affected area of the skin. A bedsore will develop if a person moves only insufficiently and the pressure thus caused damages the blood circulation in the tissue for too long. A clamping of the venous capillaries is enough to bring about this reduced blood circulation and lack of oxygen. The body responds by a warning pressure pain, which in mobile persons will trigger a change of posture and thus a relief of the compressed areas of skin. Small movements will suffice. But if someone is no longer able to perceive the pressure pain or to move on his own in response to that pain, the skin will remain compressed and waste products will build up in the tissue, which will then lead to acidosis. This, in turn, causes an outflow of water from the capillaries into the tissue. The oedema thus formed will grow the longer the pressure is being exerted. The increasingly reduced blood circulation causes the skin cells to die and a bedsore is formed. Why there is such a bedsore incidence. Bedsores are an avoidable ailment because there is sufficient support and knowledge available. The causes are a lack of treatment or an inadequate treatment and insufficient information for the patients, says Professor > Christel Bienstein. The NPUAP (National Pressure Ulcer Advisory Panel) even calls bedsores a national tragedy because they make the affected patients suffer while at the same time being avoidable. And all this despite the fact that both in Germany and the USA various prophylactic and therapeutic means, some even state-of-the-art, are available. According to experts, the fact that the incidence of bedsores is not reduced despite the broad range of therapeutic systems available is due to their complicated, but also their frequently incorrect handling. On the other hand, the original problem, insufficient movement of the patient, is not, or only to a small extent, addressed, even when it comes to hightech beds. Nip it in the bud. With the Völker Micro-Stimulation-System. Inspired by the process of professionalisation in German nursing, some nursing concepts developed which allowed a holistic view and care of patients. basal > stimulation developed by Professor > Andreas Fröhlich in 1975 was one of them. During the 1980s, this principle was applied to nursing by Professor > Christel Bienstein. At the end of the 1990s, Thomashilfen developed under consideration of basal stimulation, by > Bobath and including > kinaesthetic principles a mattress undersuspension which was called > Micro- Stimulation-System (see also page 6). In 2002, > Heinrich Völker developed this undersuspension into a laying system for bedsore prophylaxis in institutional care (see also page 6). As with all microstimulation systems, the basic idea was that movement is only likely to occur when there is prior sensory perception. These stimuli are processed by the central nervous system and turned into movement in response to the stimuli. This physical activity makes for permanent pressure alterations also among those regions of the H. Lubatsch: Dekubitusmanagement auf der Basis des Nationalen Expertenstandards Schlütersche/

12 Continuation body in danger of developing bedsores or affected by them. It is exactly these basic ideas which were realised in the development of the laying system > Völker MiS. The use of active systems is required when immobile patients with bedsores up to stage IV have to receive therapeutic treatment. Here, Völker MiS Activ is a real and cheap alternative. 12 "Völker MiS is now standard in Völker beds. The (passive) Micro-Stimulation-System has been a standard feature of all Völker beds since This means there is prophylactic treatment from the very first day of hospitalisation, and there are no additional costs, no additional handling. It has been proven that Völker MiS prevents the development of 34 per cent of all bedsores, as was found in the long-term study by Meander Medisch Centrum, Amersfoort/NL (2003/2004, see page 13). These results of the passive MiS encouraged Heinrich Völker to complement the passive system with an active one. Again, for this system Thomashilfen developed prototypes, under the name > Thevo-Activ, which were then tested in a long-term study (see also page 13). This study leaves no doubt whatsoever that the system is suitable for patients with pressure ulcers (bedsores) at predisposed regions of the body. This system was then further developed for institutional care and is now in its production stage. The advantages for an effective bedsore management: it is cheap and can easily be exchanged for the passive Standard MiS in Völker beds. It conforms with the standard dimensions of hospital beds, has a long servicelife when continuously operated, is easily connected, can be operated continuously and patterns of movement can be programmed in accordance with the patient s indication (see page 22). Heiko Heine First published in Völker Wörld (VöWö) 20/2005

13 34 per cent fewer bedsores. The Meander Medisch Centrum s experiences. Matthijs Wolters Managing Director Völker BV, Netherlands The long-term study s findings: MiS (passive), Meander Medisch Centrum, Amersfoort/NL, 2003/2004 Völker MiS reduced bedsore incidence in stages 2, 3 and 4 by 34 %. Völker MiS reduced the use of air lying systems by 57 %. The Meander Medisch Centrum was able to reduce the used systems by 42 %. The Meander Medisch Centrum was able to reduce the period of bed confinement by 52 %. The Meander Medisch Centrum (MMC) in Amersfoort, Netherlands (figure bottom left) opted for hospital beds with > Völker MiS for both bedsore prophylaxis and therapy. What are their experiences and how does the Völker system compare with the previously used alternating pressure systems? > Matthijs Wolters of Völker Netherlands interviewed Hennie Luchtenberg of the MMC. M. Wolters: How many patients and staff does the MMC have and what is your number of beds? H. Luchtenberg: " We have a staff of 3,200, 200 medical consultants and a lot of voluntary workers. We have an annual intake of about 52,000 in-patients and 370,000 out-patients. Our number of beds is 982, 600 thereof in operation. M. Wolters: What made you opt for Völker beds and what is your experience with this system? H. Luchtenberg: We opted for Völker beds because they met our basic requirements best: functionality, the safety of patients (electrically and mechanically), bedsore prophylaxis and hygiene, easy handling and use, comfort and patients self-help (adjustments and two-part side rails), the company s expertise and service, the product s image. M. Wolters: What did the patients say of these beds? H. Luchtenberg: We got a lot of positive feedback. They are very satisfied with their lying comfort, adjustments and the fact that they can get into bed and out of it without outside assistance and without being hindered by side rails. Some patients said it was the first time they had slept well in a hospital bed. M. Wolters: You had a project comparing the efficacy of Völker MiS with an air lying system. Bedsore incidence aside, what other parameters were important? H. Luchtenberg: The reduction of the bedsore incidence was at the forefront. It is tied to the quality of nursing. This aside, the stress caused by the very frequent changes of mattresses and the costs incurred by bedsores though longer periods of bed confinement also played their part. Within the framework of a programme run by the health ministry our objective was to reduce bedsore prevalence below 5 %. A continuous registration of prevalence and incidence is part of the project. We registered the number of patients on the wards, the number of patients with bedsores and the number of the air lying systems used. The 2004 results with Völker MiS are these: a reduction in the number of patients with bedsores of 34 % for all stages 2,3 and 4; a reduction in the use of air lying systems of 57 %. We also checked the use of air lying systems and their period of use. We compared their average use in 2002 and 2003 with the period March June 2004 after we had started to use Völker beds with MiS. The use of air lying systems was lowered by 57 %, bed confinement by 52 %. Since we do not know the exact number of patients with bedsores in the MMC as a whole, we have no results on different bedsore incidence in different departments. Still, it is clear that by reducing the use of air lying systems by 42 % we were also able to reduce the number of days of hospitalisation by half. It seems we shall be able to attain our target figure of a 75 % reduction by using the new Völker MiS lying surface. The good cooperation with Völker AG provides us with a win-win situation and I hope we are going to establish a permanent relationship. After all, it s all about high-quality capital goods, which are supposed to have a long service-life. Interview: Matthijs Wolters First published in Völker Wörld (VöWö) 17/

14 Test passed! The results of the long-term study Thevo-Activ. 14 Professor Jürgen Osterbrink Project manager of the study Klinische Evaluation der Wirksamkeit des MiS Micro-Stimulations-Sytems Thevo-Activ Gerhard Schröder Member of the expert working group bedsore prophylaxis Long-term study: Klinische Evaluation der Wirksamkeit des MiS Micro-Stimulations- Systems Thevo-Activ (Project management: Dr Herbert Mayer, Gerhard Schröder, Professor Jürgen Osterbrink). How does a bedsore develop and what can one do to fight it? A bedsore will develop if a person moves only insufficiently and the pressure thus caused damages the blood circulation in the tissue for too long. A clamping of the venous capillaries is enough to bring about this reduced blood circulation and lack of oxygen. The body responds by a warning pressure pain, which in mobile persons will trigger a change of posture and thus a relief of the compressed areas of skin. Small movements will suffice. But if someone is no longer able to perceive the pressure pain or to move on his own in response to that pain, the skin will remain compressed and waste products will build up in the tissue, which will then lead to acidosis. This, in turn, causes an outflow of water from the capillaries into the tissue. The oedema thus formed will grow the longer the pressure is being exerted. When the oedema is so big that it will clamp the capillaries, we talk of bedsore stage 1. Stage 1 can be diagnosed by applying the finger test: press the finger into the red spot and withdraw it quickly. If the spot turns white, the blood could be pressed away. Should it stay red, there is the afore-mentioned compression, i.e. bedsore stage I (see page 15). Movement means prevention The duration of the exertion of pressure is the decisive factor in the development of bedsores, which means that movement is the best preventive measure. Therefore, the national > experts standard bedsore prophylaxis in nursing (www.dnqp.de) also calls for mobility promotion by means of a mobility plan as a prophylactic pillar. If, however, the patient s passive movement no longer suffices, as can be diagnosed by applying the finger test, or the affected person is no longer able to move, the pressure has to be reduced. Soft mattresses will not resolve the problem, however. Clinical observations have shown that the very low pressure on soft mattresses can have side effects (Knobel 1996). The lower the pressure or the softer the mattress the more immobile the patient gets. This may well lead to an even higher risk of developing bedsores. But what might even be worse: The lower pressure on the soft mattress will make the patient lose his/her conception of his/her own body. This results in even less movement and more difficult mobilisation. We know this problem from hemiplegic patients. This mis- or non-conception of one s own body (see figure below) can also negatively influence disorientation so that some patients on soft mattresses appear even more confused. And finally, we know of some side effects caused by alternating pressure mattresses: The higher pressure exerted on a regular basis may let sensitive patients feel additional pain (see page 17). A solution is on the horizon This called for a new system avoiding the aforementioned side effects. Some years ago, experts started to develop an entirely new laying system. Pressure reduction aside, the result is an additionally stimulating system, based upon the principles of basal > stimulation, a concept developed by Professor > Andreas Fröhlich for severely handicapped children and patients with an impaired perception, which was then applied to nursing by Professor > Christel Bienstein. Vibratory, acoustic, visual stimuli make for means of communication. The newly developed system is called > Micro-Stimulation-System (MiS ) and has been tested in an extensive, multi-centred study. Extensive clinical study confirms success The preparation of the first clinical study started in There had been no previous studies of such a kind, so it was rather a new frontier. We, the authors > Gerhard Schröder and Professor > Jürgen Osterbrink and Dr Herbert Mayer, renowned experts in clinical healthcare research, were commissioned to conduct the study. The bedsore-therapeutic efficacy aside, the study was also about whether the system would bring about a reduction of pain, an improved orientation among normally disorientated patients, a promotion of self-mobility and about whether the affected people find the system comfortable and agreeable. Hospitals, domestic care services and geriatric care facilities participated in this study. After all, in the latter facilities the monitoring period for individual patients is much longer than in hospitals. The study was conducted in accordance with a randomised, comparative and explorative study design. The factors favouring a development or healing of bedsores could not be the same for all patients. Therefore, it was drawn by lot what patient would form part of the test or control group. Patient recruitment involved those who had one

15 Figure above: The diagram clearly demonstrates the Activ -system s superiority in the category The wound has healed. or more pressure ulcers of stage 2 to 4 on which their lying position still had an influence. The monitoring period was four weeks, during which comprehensive healthcare-scientific tools were employed,.e.g. the Bradden scale to assess the bedsore risk, wound photography and a standardised wound documentation sheet, the visual analogue scale to determine the degree of pain, a mobility measurement we had developed ourselves, the Glasgow-Coma- Scale and the Confusion-Rating Scale and a comfort scale surveying the patient s subjective impressions when lying in bed. The results are definite and are going to change nursing practice. The 47 concluded measurements made for a monitoring period of 1,224 days. 27 patients were laid on the new system, 16 patients, the control group, on another bedsore-therapeutic aid like small and large-cell alternating pressure systems, and in addition 4 patients were laid on the new MiS. This, however, remained switched off, so there was no stimulation. Among 74 % of the patients laid onto the new system, the healing of wounds was good or very good. Among 33 % they even healed completely. In terms of the "healing of pressure ulcers the new system was superior to smallcell alternating pressure systems and equal to large-cell systems. In some cases there was a marked improvement in orientation, in some others it was not quite so marked. It was likewise with mobilisation, but this factor was very hard to analyse since some measuring equipment errors made for only a small number of results to be analysed. This shall serve as an example: One female patient of 77 years suffers from Morbus Alzheimer and vascular encephalopathy and is very confused. There are no longer any clear phases, especially with regard to communication. Suffering from a number of diseases (osteoporosis, hypertension, Parkinson, cardiac insufficiency), she is bedridden. Dependent upon her state of confusion, she moves by herself and is partly very restless in motor terms. Thitherto she had been laid on a normal mattress. Attempts on a large-cell system failed because her motor restlessness only increased on such a system. When spoken to, the patient was able to open her eyes but unable to move actively (e.g. to raise her arm) in a targeted fashion or give details concerning time, place or her own person. Within the framework of the study, she was put onto the new system. After 7 days of stimulation, there was a huge improvement in her state of confusion: The evaluation criteria "inadequate behaviour and "inadequate communication previously both rated 2 on the Confusion-Rating Scale, over the following 3 weeks improved to 0 (0 = no such behaviour; 1 = slight manifestation of such At an international level, the increase in the development of pressure ulcers (bedsores) is broken down into stages I IV. Stage I is a skin reddening of intact skin which cannot be pressed away. At stage II, there is a partial loss of skin; the epidermis and parts of the corium are damaged; the pressure damage is superficial and may clinically manifest itself as a blister, a graze or a flat ulcer. Stage III includes the loss of all skin layers and damage to or a necrosis of all subcutaneous tissue, which may affect the underlying fascia. Clinically, the bedsore is a deep, open ulcer. Stage IV means loss of all skin layers including extensive damage, tissue necrosis or damage to muscles, bones or supporting structures like sinews or joint capsules. 15

16 Continuation 16 behaviour; 2 = marked manifestation of such behaviour). After the 4-week monitoring period the patient was put back on a normal mattress. After 3 days she relapsed into her former state of confusion which then remained unchanged. The change was so massive that her relatives, who were also her guardians, demanded she was to be put back onto the new system, which indeed she was for another 3 weeks. Her confusion was gone again, i.e. after 3 days clear communication with this patient was possible. Unfortunately, after this second monitoring period the patient had to be hospitalised due to her general condition. Among the mostly disorientated patients, the rate of pain over the four weeks, which was to be assessed by the patients themselves, was also very hard to evaluate, but there were positive results among some patients. Patients rated the lying comfort from "very good to good. It is especially gratifying that the new system got a very positive rating because of its lack of noise. For what patients is the new MiS -System suitable? On he basis of the results of the study, the new system is suitable for patients with bedsores but also for bedsore prophylaxis. The advantages of the new stimulation seem to have a positive impact on patients with an impaired perception, a lack of mobility, pain and disorientation. We were, however, unable to ascertain this impact throughout and in all areas and in all patients. Further development, consistent monitoring and studies should be able to determine the exact group of suitable patients. It must be said, though, that the new system has led to no deterioration or even complication whatsoever. G. Schröder, Professor J. Osterbrink Figure above: wound healing evaluation criteria. Figure above: healing success vs. positioning aids, the results of the study in detail.

17 The pros and cons of alternating pressure. The right bedsore therapy. Natascha Woltemade Graduate in healthcare science, Head of IGAP Formerly, air lying systems were deemed the ultimate in bedsore therapy. On the basis of recent results of healthcare research this has now changed. Bedsore prophylaxis and therapy is one issue the Institut für Innovationen im Gesundheitswesen und angewandte Pflegeforschung focuses on. In daily practice it is often hard to find an effective anti-bedsore system which also meets the patient s requirements. Remember: There is no operating mode which would lead to the best possible therapeutic results for all patients. Alternating pressure systems have long since been established in anti-bedsore nursing. However, on the basis of more recent findings and observations in nursing and medicine their uniform use should now be questioned. Inspired by the process of professionalisation in German nursing, nursing concepts developed, incl. Aktivitas, kinaesthetics or old and scientifically proven concepts like > basal stimulation, which were then applied to nursing. The resultant skills made for a holistic view and care of patients. Bedsores are now also being viewed differently. While a few years ago, pressure ulcers were deemed the mere consequence of pressure and shearing forces, we know now that psychosocial factors also have an impact. As a result, earlier anti-bedsore product developments focused on a reduction of pressure and shearing forces to the exclusion of other factors. Today we know that the selection of positioning systems also has to take account of the underlying illness. It is especially among patients with an impaired perception, e.g. stroke or Alzheimer patients, that alternating pressure systems may have serious negative side effects. The following changes in patients on alternating pressure systems have been observed: degenerative habituation because of repetitive, uniform stimuli; a body conception and perception dysfunction; coordination disorders; a potential misinterpretation of environmental stimuli, spatial and temporal disorientation; communication disorders; behavioural disorders; emotional disorders; pain symptoms aggravated by lifting movements and temporary pressure cones; low quality of sleep through noises, vibrations and a physiologically detrimental lying position; negative changes in the skin and bed climate; restricted mobility, resulting in contractions; spasm of the muscles possible; negative impact on the patient s well-being through the system s deficient adjustability. Nursing staff may also find it difficult to use alternating pressure systems: positioning and mobilising the patient is made difficult; there are problems in the transfer of patients; many systems are liable to malfunction; they can t be repaired (by the nursing staff); the result may be a total system breakdown. It is thus clear that a suitable anti-bedsore system has to be selected by responsible nursing staff and doctors on the basis of the patient s individual needs. Natascha Woltemade, IGAP 17

18 Thevo-Activ and Völker MiS Activ. Same operating mode, different drives. Sabrina Simon interviews > Heinrich Völker, Völker AG. Sabrina Simon Völker Wörld staff writer S. Simon: Mr Völker, why have you, as a licensee of Thevo-Adapt and Thevo-Activ, decided to participate in the development of microstimulation systems? 18 A springing behaviour comparison. Left: a conventional slatted frame, which practically absorbs kinetic energy; right: Winx bed systems return the kinetic momentum. H. Völker: It may sound a bit immodest but Völker healthcare and hospital beds have many advantages which you do not find in other beds and certainly not in this combination and variety. That starts with the telescope lift and doesn t stop at our two-part side rails. But we used to have difficulties with the lying surface. We asked ourselves, what is the use of an ergonomic quartering and mattress retraction under > kinaesthetic aspects when patients or residents lie on a kind of "stiff board, be it made of aluminium or HPL. The bedsore problem cannot be resolved by an anti-bedsore mattress or flexible elements on a rigid surface. And we had to find out that a later use of positioning aids for therapy is never an ideal solution. In short, we were looking for a really efficient, simple and cheap system that manufacturers can integrate into each and every bed. And which, in an optimised form, can also be used for therapy. When looking for such a system, we kind of had to work with > Thomashilfen and > Thevo-Adapt. S. Simon: We know that Thomashilfen are known for many an aid. But why does this name also embody such a system? H. Völker: Thomashilfen has been associated with > Lattoflex for decades now. With Lattoflex, there was here a very good undersuspension, which was then enormously improved by the so-called Winx systems. Conventional slatted frames practically absorb movement. Winx systems, however, respond to natural movements in sleep and gently return this momentum to the body. I thought this was the first step in the right direction." S. Simon: "Why this difference? And where is the difference between Winx and Thevo?" H. Völker: Firstly, in contrast to all other systems where, if at all, disc elements rest on rigid bracket profiles, the Winx system has three different suspension levels. While with a rigid undersuspension with a low point elasticity there will be pressure cones, Winx has the effect of a balanced pressure distribution without such cones. S. Simon: And now for Thevo. H. Völker: "Thevo, distributed by Thomashilfen via the specialised sanitary trade, is the professional realisation of Winx, which is distributed by Lattoflex via the specialised bed trade." S. Simon: Well, you call the system installed in Völker beds Völker MiS, that is Völker Micro-

19 Stimulation-System. Why didn t you stick with Thevo? H. Völker: "Because > Völker MiS is not the same as Thevo. Our consumers in institutional healthcare, i.e. hospitals and nursing homes, have higher standards. These have to be met for the patients and residents and for the nursing staff, too. And not least for HVAC and bed supply. While the operating mode is exactly the same, the system had to be adapted to the afore-mentioned requirements." S. Simon: "The success of microstimulation systems has been published. You yourself point to results like Völker hospital beds with MiS having reduced the incidence rate of bedsores by 34 per cent and the use of air-surface systems by 57 per cent. There is similar success in other facilities." H. Völker: Yes, that is right. Meanwhile we deliver 90 per cent of our beds with MiS, which we now call "standard lying surface. That means, MiS is included in a bed s price, there is no surcharge at all. The mere fact that with no additional expenditure 30 per cent of all costs previously incurred annually - experts even give an estimate of 50 per cent, which is up to Euro 2 bn - can now be saved fully justifies the following bold statement: Given the ensuing cost savings, if half of all hospital and healthcare beds were to be replaced by Völker beds with MiS all at once, this expenditure would fully pay off within only one year. S. Simon: Why then do we also have Völker MiS Activ? H. Völker: "Even if we were to see a 100 per cent prevention by using Völker MiS beds at a rate of 100 per cent, the bedsore incidence could not be reduced down to zero. But with an integrated MiS, we are able to provide patients/residents with an effective system for bedsore prophylaxis which minimises the risk from their very first day of hospitalisation. For the bedsore incidence rate remaining, we have no developed Völker MiS Activ." S. Simon: Within the framework of a long-term study, Thevo-Activ has been rated very positively. Völker is a licensee and still develops its own system? H. Völker: Not our own system. Again, the operating mode is the same as Thevo-Activ s, only the drive is different. In Thevo-Activ, valve activators, as they are normally called, trigger the desired pattern of movement. These activators are controlled by air, more or less of which, as is needed, is supplied by the system s hoses. This pneumatic drive, an alternating pressure drive as it were, is in some ways disadvantageous. Thevo-Activ has to be put on an existing lying surface. This means, the system will exceed a minimum height, also construction-related, and applicable standards cannot be complied with. And the huge number of cables and hoses and connections makes handling somewhat difficult, and we really wanted to avoid that. S. Simon: "So, its operating mode is identical with Thevo-Activ s, but it has a different drive." H. Völker: "Yes, an electromotive drive. Where Thevo uses valves, we use motors. This modification we thought was necessary because in our experience in institutional healthcare on the one hand and for Völker beds on the other, certain requirements have to be met. Our active system is supposed to be compatible with the passive system. This means, the standard MiS can be replaced by the active MiS system, if need be. The active system has thus to be an integrated component of the lying surface, at the same level at that. Furthermore, for Völker MiS Activ we had to develop a drive which is able to endure under professional conditions. This drive had to have a control by which various patterns of movement for various indications or any pattern can be programmed (see also page 27). An electric drive should use low-voltage and DC to preclude alternating voltage fields. And MiS Activ has to see large-scale production at a price which will justify, in terms of profitability considerations, that a sufficient number of them is held available at hospitals." Figure above: Exerted pressure, incl. pressure cones, on a rigid undersuspension. Figure below: An even pressure distribution without pressure cones by so-called Winx. 19

20 Continuation S. Simon: Völker MiS Activ meets all these requirements? H. Völker: Indeed it does! The technical development has been concluded, as has the patent application. The operating mode as as a licensee we would take for granted at any rate is that of the study now conducted in cooperation with Thevo-Activ. Regardless of this study, we will commission our own study in We will present the first Völker beds equipped MiS Activ at the Medica 2005 in Düsseldorf. We will start large-scale production at the beginning of 2006." 11,1% bad healing of wounds 11,1% very bad healing of wounds 33,3% complete healing of wounds 20 S. Simon: Mr Völker, we wish you every success with the launch of MiS Activ, also for all those affected by bedsores, who may then be no longer affected after all. Interview: Sabrina Simon First published in Völker Wörld (VöWö) 20/ ,2% good healing of wounds 22,3% very good healing of wounds Results of the MiS Thevo- Activ long-term study: 77 % marked improvement, 33 % thereof a complete healing of wounds. Quelle: MiS Studie, Thomashilfen

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