Foam mattresses: improving protection

The Newcastle-upon-Tyne Hospitals NHS Foundation Trust (NUTH) consists of two main acute hospitals offering regional tertiary care as well as providing community services to the population of Newcastle. In common with many other Trusts in the UK, in 2010 it highlighted foam mattresses being a risk of infection as the covers allowed ingress of bodily fluid onto the foam. It soon became clear that the yearly mattress audit was no longer sufficient and mattresses were then checked after each patient episode. In response to these issues of poor durability and performance of high-quality foam mattress covers, NUTH started to work alongside industry to develop a new cover material. Since 2010, a number of different types of cover materials were clinically tested, none of which satisfied the requirement of a cover that could withstand the rigours of acute care with its stringent cleaning regime and continue to offer pressure redistribution. However, since September of 2011, a new type of cover* material was introduced. To date, 270 covers (n=270) have been trialled in acute wards and clinical areas throughout the Trust, replacing failed covers. Over this extended period there have been no product failures due to delamination and subsequent fluid ingress.

Potential risk to patients

The Hospital Infection Society stated that at up to 9% of hospitalised patients are potentially at risk of acquiring an infection related to their hospital stay.1 This underlined the importance of strict decontamination and cleaning regimes in hospitals which includes all mattresses and therapy beds. When a mattress cover is breached, the inside can very quickly become contaminated following episodes of incontinence, bleeding or any other loss of bodily fluids. Bacteria held within the mattress can multiply and cause infection to the patient laying on it. Hypochlorites are the most commonly used disinfectants to decontaminate mattresses as they have a broad spectrum of antimicrobial activity and are inexpensive. Concentrations of 1:1000 are used to clean spillages of bodily fluids and, if not rinsed appropriately and then dried, it can cause ‘delamination’ of mattress covers, which over time, allow for strikethrough of fluids. Mattresses are cleaned in between each patient and, at times, the same mattress could be cleaned three or four times per day – sometimes even more depending on patient turnover. Manufacturers of mattresses, just like clinicians, were slow to realise the daily assault mattress covers were subjected to from this new decontamination regime. Ironically, the very act of decontaminating mattresses made them porous to bodily fluids, increasing the risks of contaminating patients with infections. Large amounts of hospital mattresses began to fail due to strikethrough; leaking bodily fluid through the outer cover without the aid of any puncture or obvious traumatic damage, placing patients at risk of cross infection from fluid ingress into the core of the mattresses.2 Manufacturers struggled with the amount of complaints and guarantee breaches. A less than open culture among the industry fuelled recrimination and accusations until finally it became clear that it was the change in decontamination practices that had caused the problem. Unfortunately, the industry was not ready to provide a cover that was fit for the new cleaning regimes. In January 2010, a Medical Device Alert was released (MDA/2010/002) regarding the failing of the covers. The British Healthcare Trades Association (BHTA) responded on behalf of the industry with the recommendations that, if mattresses were to be cleaned with chlorine solution, the solution had to be rinsed off and the cover thoroughly dried.3 However, this three-stage application is labour intensive and timeconstraining, especially given the pressure of an acute ward environment. The two main NUTH acute hospitals offer regional tertiary care as well as providing community services to the population of Newcastle. The Trust has over 1,800 beds. Mattresses are replaced if the foam becomes contaminated, otherwise only the cover is replaced. The Trust had a robust yearly audit and replacement process; as the Medicines and Healthcare products Regulatory Agency (MHRA) guidance (2010) was released, these checks were increased to quarterly intervals. However, as more covers were failing, it became clear that these checks were not sufficient. Since 2011, all foam mattresses are checked after each patient episode, resulting in some mattresses being checked up to five times per day. This was unsustainable and a better quality cover was required to allow for a return to quarterly checks which are deemed as an acceptable time span. It was not just a question of swapping suppliers, because all suppliers of foam mattresses were in the same situation. Having very quickly understood the predicament of the industry, NUTH believed that the best way forward was to collaborate with industry to develop a cover that would be fit for purpose and withstand the regimes of acute care decontamination. To achieve this goal, it started to work with Direct Healthcare Services. During the course of 2010, a number of different covers were trialled – all of which failed. Some covers were too soft and scratched easily, allowing bodily fluids to ingress; others stained when in contact with Iodine Povodone, becoming unsightly and looking dirty. Finally, in March 2011, a new batch of covers were trialled that seemed to offer a solution. These new covers are made with a fabric that has three layers of high-quality polyurethane laminated to a robust, ‘stretch engineered’ textile. Traditionally, polyurethane swells when exposed to moisture, especially when the cover is washed with chlorine and the material becomes less resistant to scratches. However, the new cover uses a textile combined with a higher modulus matt surface polyurethane coating, which increases its waterproofing performance. This combination reduces polyurethane swell. Therefore, when exposed to moisture, surface friction is reduced and, ultimately, the likelihood of snagging or surface damage is also reduced. Adopting the BHTA recommendations, in March 2012, the Trust’s local infection control policies introduced the ‘Wash, Rinse and Dry’ regime. ‘Mattress Champions’ attended a teaching session to reinforce this change in policy. This cover is slightly tougher with less stretch but it retains pressure redistribution qualities and pressure mapping of the new cover were surprising and unexpected. The pressures were improved compared to the more stretchy ordinary cover, possibly because with the old cover, its stretchiness caused an increased ‘hammocking’ effect compared to the less stretchy material.