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hen examining equipment expenditures in long-term care, especially in regard to seating and positioning, many providers shutter to think of the costs that are associated with providing mobility equipment and ancillary products, such as wheelchair cushions and postural support devices. However, these pieces of equipment can play a vital role in facilities' success at maintaining the long-term health and function of their residents. It is an area that is often overlooked but deserves serious consideration.
       Statistics from the Administration on Aging1 show that over 50 percent of individuals over the age of 65 report having disability. As the population of citizens over 65 skyrockets (it is estimated that this population will grow from 35 million in 2000 to 39 million in 2010 and to 54 million by 2020), the percentage of individuals with disabilities requiring long-term care services will also increase. Administrators and facilities need to prepare for these numbers and invest in quality equipment that can be adjusted to suit a variety of clinical needs.
       The acquisition of seating and positioning devices should be considered an investment. Products should be examined carefully and not chosen just on price alone. While it is true that wheelchairs can be acquired in the $400 to $2,000 range, it is important to weigh the cost-benefit ratio of these purchases and determine which features will have the most impact. First, durability should be examined. While it is common to purchase standard "depot wheelchairs," a study from the University of Pittsburgh2 indicates that the durability of depot chairs (as defined by Medicare descriptions) is significantly lower than that of lightweight chairs. For example, in standard laboratory testing of durability, depot chairs tested had a total of 295 percent more class 1 and class 2 failures than lightweight chairs. Class 1 and 2 failures encompass most minor repairs and adjustments that can be done by a technician. Lightweight chairs may also provide other benefits, such as fostering independent mobility for a client with decreased muscle strength and endurance and decreasing employee risk of injury from handling heavy equipment. While lightweight chairs are shown to be more durable, the facility must also have realistic maintenance expectations. Developing a program for maintenance will prolong the life of the equipment and ensure maximal function for residents. Besides general cleaning, attention must be given to tire pressure and/or wear, position, and function of wheel locks and replacement or tightening of sling seat and back upholstery. The maintenance of sling seat and back upholstery is an area often overlooked. This area is critical to maintain adequate postural support for residents and prevent orthopedic deformities, such as scoliosis, kyphosis, or internal rotation and adduction of the femurs. This will improve comfort and address postural issues impacting swallowing, communication, alertness, and function.
       Also problematic is the notion that "one size fits all." It is important to offer wheelchairs in a variety of sizes that will at least approximate the residents' needs. Proper fit of a wheelchair will have a direct impact on function, mobility, and safety. For example, if a resident is sitting in a wheelchair that is too wide, it may be difficult or impossible for the client to reach the rear wheels for self propulsion. Now the wheelchair has become a dependent transport device and provides little opportunity for independence within the facility. Also, if a resident propels the wheelchair with his/her feet, the seat-to-floor height must be adequate to achieve heel strike and follow through. If too high, the resident will be ineffective and may be observed sliding too far out of the chair to make contact with the floor. With this scenario, adjustability is also a key, as equipment may be used to meet the needs of a variety of clients over time.
       While width and seat depth are usually fixed options, consideration should be given to adjustable leg rests and armrest height. If both are adjusted properly, they will enhance pressure distribution and seated comfort. Also, look for swing away or swing back arm rests. These armrests do not need to be removed completely from the chair yet provide an added safety benefit during transfers. Neither the staff nor the residents need to transfer over or in front of the armrests to safely move from one surface to another. While the adjustability and fit of the chair contribute to safety and postural support, it is also necessary to recognize the importance of a stable and therapeutic seated support surface or wheelchair cushion.
       The seat-chair interface is critical for many reasons, yet quality wheelchair cushions are extremely underutilized in long-term care. If a resident is seated for an extended period of time, he or she needs to be protected. The common use of pillows and towels for seated comfort does not provide the postural support or protection needed and may actually contribute to postural dysfunction and impaired skin integrity. The cushion should provide postural support, protect skin integrity, contribute to maximal function, and be cost effective. It is also important to look at cost effectiveness over time. Do not just look at the initial price tag. Consider the life expectancy of the cushion, the therapeutic advantages, reparability, and the ability to recycle the product between residents. A standard two-inch foam cushion may be affordable, but it will need to be replaced frequently and cannot be adequately cleaned for multiresident use. Look carefully at cushion mediums. Most products are combinations of gel, foam, viscous fluid, and air. They provide varying amounts of postural support and pressure relief. Where skin integrity is concerned, high-end air and fluid products typically out perform gel and foam in a variety of clinical studies. As with wheelchairs, correct size and adjustability is important to ensure maximal function, support, and pressure relief.
       Examine wheelchair cushions critically. Read the instruction manuals, ask for equipment trials from manufacturers' representatives, and offer a variety of cushions that will meet the unique needs of individual residents. If utilizing wheelchair cushions for pressure relief, be consistent with surface selection and maintain adequate protection even after the problem area has healed to closure. The tissue in that area is, at best, 75 to 80 percent the original strength; therefore, vulnerable areas are at higher risk. Comfort and postural support from wheelchair cushions may also contribute to limiting restraints, increasing alertness, and decreasing pain. The benefits of a therapeutic seating surface and properly fitting wheelchair can far outweigh the initial expenditures.
       While budgets are limited, it is important to consider the long-term costs associated with incorrect or ill-fitting seating and positioning devices. Seating and positioning should be considered part of continuity of care and need to be viewed as one part of a holistic assessment and intervention strategy. The benefits of a properly fitting seating and positioning system are many and include prevention of postural deformity, maintenance of skin integrity, pain reduction, independent mobility, maximization of functional potential, minimization of restraints, and increased alertness and communication. While these costs may seem daunting, the functional, psychological, anatomical, and physiological benefits can actually mean future savings. When you consider that the cost of healing one pressure ulcer can reach upward of $70,000, the cost of a properly fitting seating system that may contribute to prevention seems minuscule. When selecting equipment, consider a team approach. Utilize the knowledge of allied health professionals who specialize in equipment and postural evaluation and justify the long-term benefits of purchasing high quality versus inexpensive wheelchairs and cushions. Remember to examine equipment critically and look for quality, adjustability, durability, and clinical effectiveness. Matching the equipment to the resident will benefit the staff and the resident by ensuring optimal function, limiting chronic secondary complications, and decreasing the overall cost of care.