Overcoming the Challenge of Support Surface Selection: Utilization of Standards.

ABSTRACT: Selecting the appropriate support surface for patients continues to challenge clinicians and facilities. The Support Surface Standards Committee has developed and published test methods that allow for informed comparisons among support surface characteristics. The first published standards address the performance characteristics of immersion/envelopment, shear/friction, and microclimate management. This article describes the full body support surface standards development and provides guidance on the use of the outcomes from those standard tests for clinicians and facilities to make more informed choices for patients and patient populations.

Comparing Pressure Injury Incidence Based on Repositioning Intervals and Support Surfaces in Acute Care Settings: A Quasi-Experimental Pragmatic Study.

OBJECTIVE: To compare pressure injury (PI) incidence based on repositioning intervals and support surfaces in acute care settings. METHODS: This pragmatic, quasi-experimental trial recruited a total of 251 critically ill patients who were at low or moderate risk for PI development. Participants were assigned to three interventions: a 2-hour repositioning interval using an air mattress, a 2-hour repositioning interval using a foam mattress, or a 3-hour repositioning interval using a foam mattress. Data were collected by nurses every shift over the course of 14 days. Pressure injury incidence was analyzed using a χ2 test. RESULTS: There were no statistically significant differences in PI incidence between the groups with a 2-hour repositioning interval. However, the PI incidence in the group using a foam mattress with a 3-hour repositioning interval was significantly lower than in the group using an air mattress with a 2-hour repositioning interval (odds ratio, 0.481; 95% confidence interval, 0.410-0.565). CONCLUSIONS: The findings showed that PIs decreased when the repositioning interval was extended from every 2 hours to every 3 hours while using foam mattresses. This study suggests that a 3-hour repositioning interval using a foam mattress could be applied to reduce the risk of PI development for patients at low or moderate risk.

Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries.

INTRODUCTION: Many hospital settings are adopting a zero-tolerance policy towards pressure injury (PI) development; this requires good planning and the implementation of care, as the incidence of PIs reflects the quality of care given in a hospital or facility. AIM: To identify common contributing factors towards the development of PIs in a geriatric rehabilitation hospital and improve patient safety through the reduction of hospital-acquired PIs. METHOD: This was done using root cause analysis (RCA). All patients who developed a Stage 3 or 4 deep tissue injuries or unstageable hospital-acquired PI between December 2017 and April 2018 PIs were investigated using RCA. The RCA was facilitated through the use of a contributing framework developed by the National Pressure Ulcer Advisory Panel which guides investigations of different areas of care. Qualitative and quantitative data was collected from several sources and placed in a timeline to reconstruct the series of events. The investigator then identified if the PI was avoidable or not by comparing the evidence with pre-set criteria. Content analysis was further used to analyse the themes retrieved. RESULTS: A variety of root causes were common amongst all the cases. These included both flaws in the system, such as poor equipment and inadequate educational programmes, as well as human factors such as a lack of basic routine care. No skin assessment was being performed (n = 0) apart from the assessment done on admission. Documentation of action planning when it comes to PI prevention was also missing (n = 0). It was identified that 7 patients were mobilized on admission while the others (n = 3) had a delay in mobilisation, due to some fragmentation in care. There was no documentation of patient and relative education on the prevention of PIs (n = 0). All the patients were provided with the right pressure redistributing mattress however, some mattresses were bottoming out. Some causes overlapped, with system defects like lack of protocols, equipment and tools pushing human errors to occur. This created a series of events leading to the adverse event. The identification of these factors helped to provide an understanding of the changes that are needed to reduce future harm and improve patient safety. CONCLUSION: Recommendations were proposed to reduce contributing factors to the development of hospital-acquired PIs. These include audits to reinforce adherence to hospital guidelines, streamlining of the documentation system, investment in new equipment and improvements to educational programmes. The recommendations implemented resulted in a decreased incidence rate of HAPIs.

Use of a Support Surface Standard to Test the Effects of a Turning and Positioning Device Versus Low-Air-Loss Therapy on Temperature and Humidity.

BACKGROUND: Turning and repositioning devices (TRDs) help to reduce strain on caregivers, but clinicians question their effects on humidity and temperature (microclimate) at the skin surface that may increase risk of pressure ulcers. OBJECTIVE: To pilot the use of a standard test for support surfaces to compare microclimate at the skin surface in three scenarios: (1) on a low-air-loss (LAL) surface, (2) on a representative TRD with a basic underpad (TRDU) placed on a LAL surface, and (3) on a negative control with full occlusion. The results are designed to inform clinical decision-making in using a TRD on a LAL surface and the viability of using this test to study TRDs. DESIGN: Measuring humidity and temperature at the device-surface interface using a heated moisture-exuding bronze thermodynamic human model in a laboratory setting. MAIN OUTCOME MEASURE: Humidity and temperature levels across 3 hours 15 minutes of continuous loading with a 45-second complete unloading to simulate a position change at 3 hours. MAIN RESULTS: Relative humidity on the TRDU was below that on the LAL surface for the first 110 minutes and was markedly lower than the negative control for the remainder of humidity testing. Temperature on the TRDU was well below the negative control and negligibly higher than the surface alone throughout testing. The position change enhanced the effects of the TRDU. CONCLUSIONS: The support surface standard test appears useful in evaluating TRDs. This TRD along with the basic underpad is more comparable to a LAL surface than to full occlusion in managing the microclimate of the skin and pressure ulcer risk.

Reducing Waste in the Clinical Setting.

Nurses have the capacity and opportunity to alter their organization's environmental footprint. This article addresses how they can strengthen efficiency and environmental sustainability initiatives in their facilities by engaging in, monitoring, and supporting environmentally friendly clinical practices and programs at the point of care. Included are practical tips and examples of projects in which nurses identified sources of waste-the relaundering of unused linens; disposal of unused products; and improper sorting of pharmaceutical waste, recycling, and regulated medical waste-and realized significant cost savings as well as improved efficiency and environmental sustainability.

Comparing a patient positioning system to an overhead LIFT with pillows for impact on turning effectiveness.

BACKGROUND: Frequent patient handling activities present numerous challenges to healthcare workers. A variety of products are available to assist with in-bed positioning but few comparative studies have been completed to ascertain turning effectiveness. METHODS: The purpose of this study was to compare two turning devices (air-powered positioning system with wedges versus ceiling lift with pillows) for in-bed repositioning and turning effectiveness. The study took place at a large community hospital in the Midwestern USA and used a prospective, four-group crossover study design to compare devices. RESULTS: The two turning groups were not significantly different for any of the demographic variables. The use of an air-powered positioning system with wedges achieved a greater degree of turn and maintained that turn after an hour better than the lift device with pillows. There were no hospital acquired pressure injuries in either group. CONCLUSION: The devices used demonstrated significant differences in turn angle achieved and ability to maintain the turn at one hour. Future studies need to further delineate the ideal method for turning and compare devices to identify best practice and equipment. An effective turning method would integrate ease of use with the ability to achieve an optimal degree of turn in order to prevent hospital acquired pressure injuries while also decreasing caregiver injuries.

A Survey of Koreans on Sleep Habits and Sleeping Symptoms Relating to Pillow Comfort and Support.

The number of people who complain of sleep disturbances is steadily increasing. An understanding of sleep-related factors is required to address sleep problems. This survey study investigated the sleep habits and sleeping symptoms relating to the comfort and support characteristics of pillows and the relationship between sleep quality and pillow design factors. The study utilized data from 332 participating Korean adults aged 20-76 years (mean age ± SD: males, 40.4 ± 15.2; females, 42.9 ± 15.4). We developed a questionnaire that evaluated sleep habits (sleep duration, bedtime, wake-up time and sleeping position); sleeping symptoms (snoring or coughing, breathing and sleepiness during waking hours) based on the Korean version of the Pittsburgh Sleep Quality Index (PSQI-K) questionnaire; and pillow-related factors (support, comfort, fatigue, height and shape) from existing pillow studies. The average sleep duration was 6.8 h, with more than half (52%) of participants sleeping in the supine position. The overall score for sleep quality was considered poor (4.84 points on a seven-point Likert scale), with some degree of sleepiness during waking hours (4.4 points on a seven-point Likert scale). Females went to bed earlier than males and were more likely to sleep in the lateral position compared to males. The number of toss and turn or waking events during sleep increased with age, and older individuals went to sleep earlier and woke up earlier. Among the symptoms of fatigue, pain, discomfort with changing position, snoring, coughing and breathing discomfort, participants reported their highest levels of discomfort due to sleepiness after waking, and they experienced the least head pain. Participants who used a regular-type pillow had poorer satisfaction on multiple comfort and support factors (support, comfort, height suitability, shape suitability) compared with those who used a functional-type pillow. Less head fatigue, less neck fatigue and less shoulder pain had significant effects on sleep quality. To reduce neck fatigue and shoulder pain, designers should consider the height for neck support in the lateral position. To reduce neck fatigue, it is desirable to use materials like latex or memory foam that provide neck support, which can improve sleep quality. The findings of this study contribute to a better understanding of sleep habits and characteristics of pillow comfort and provide practical guidelines for better pillow designs.

Manejo seguro de la ropa e higiene de la piel en pacientes y profesionales sanitarios frente al Covid-19: scoping review / Safe handling of clothing and hygiene of patients and health professionals: Scoping Review

INTRODUCCIÓN: En enero de 2020 aparece en China un brote de neumonía causada por un virus zoonótico (SARS-CoV-2). Se considera que la ruta principal de transmisión es por inhalación de grandes gotas respiratorias, por deposición en las mucosas y las manos o los fómites contaminados. El objetivo es identificar las intervenciones a realizar durante la hospitalización para un manejo correcto y seguro de la ropa e higiene de los pacientes y profesionales sanitarios. MÉTODO: Scoping review realizada sin delimitación cronológica ni de idioma en las bases de datos PUBMED y Cochrane. Rastreo de normas y recomendaciones de entidades gubernamentales nacionales e internacionales para responder a la pregunta de investigación sobre el manejo seguro de la ropa y la higiene de la piel en pacientes y en profesionales sanitarios para evitar el contagio por Covid-19. El análisis de los datos fue realizado en dos etapas: en la primera, identificación y categorización de los estudios, y en la segunda, análisis de contenido como criterio informativo y clasificatorio. RESULTADOS: Se han seleccionado 14 documentos, principalmente de entidades gubernamentales. Las recomendaciones se estructuran en 5 epígrafes sobre manejo de ropa e higiene de la piel de pacientes infectados y profesionales sanitarios en el ámbito hospitalario. CONCLUSIÓN: La ropa de los pacientes y del personal sanitario son vehículos transmisores de la enfermedad. Su correcto tratamiento ayuda a mejorar el control de la misma y a una correcta utilización de los recursos disponibles en estos momentos. La adecuada higiene de la piel, en especial la limpieza de las manos, constituye uno de los pilares básicos para la prevención y el control de la infección. Destacamos la semejanza de algunas de las pautas recogidas y proporcionadas por los diferentes organismos consultados

INTRODUCTION: In January 2020, an outbreak of pneumonia caused by a zoonotic virus (SARS-CoV-2) appeared in China. The main route of transmission is considered to be the inhalation of large respiratory drops, by deposition in the mucosa and hands or contaminated fomites. The objective is to identify the interventions to be performed during hospitalization for the correct and safe handling of clothing and hygiene of patients and health professionals. METHOD: Scoping review carried out without chronological or language delimitation in the PUBMED and Cochrane databases. Tracking standards and recommendations of national and international government entities to answer the research question on the safe handling of clothing and skin hygiene in patients and in health professionals to avoid Covid-19 infection. The data analysis was carried out in two stages: in the first, identification and categorization of the studies, and in the second, content analysis as an informative and classifying criterion. RESULTS: 14 documents have been selected, mainly from government entities. The recommendations are structured in 5 sections on the management of clothing and skin hygiene of infected patients and health professionals in the hospital setting. CONCLUSION: The clothing of patients and healthcare personnel are transmitting vehicles of the disease. Its correct treatment helps to improve the control of the same and the correct use of the resources available at the moment. Proper skin hygiene, especially hand cleansing, is one of the basic pillars for infection prevention and control.We highlight the similarity of some of the guidelines collected and provided by the different agencies consulted

Preventing Inadvertent Hypothermia in Patients Undergoing Major Spinal Surgery: A Nonrandomized Controlled Study of Two Different Methods of Preoperative and Intraoperative Warming.

PURPOSE: To evaluate if a Full Access Underbody (FAU) blanket used preoperatively and intraoperatively in patients undergoing major spinal surgery prevents hypothermia compared with current practice and to explore patients' experiences of comfort. DESIGN: A nonrandomized controlled trial. METHODS: Sixty patients were included, 30 in each group. Temperature was assessed on arrival, after connecting to the bladder catheter, and at the start and end of surgery. In the FAU group, comfort was evaluated at arrival and after 10 minutes of prewarming. FINDINGS: The incidence of hypothermia at the start of surgery was significantly lower (relative risk [95% confidence interval], 0.28 [0.13 to 0.59]). Before prewarming, 77% felt comfortable, 20% cold, and 3% hot. After prewarming 60% felt comfortable, 37% hot, and 3% very hot. CONCLUSIONS: Patients using the FAU blanket had a 72% lower incidence of hypothermia at the start of the operation. Attention to thermal comfort during surgery is important.

Thermal Suit or Forced Air Warming in Prevention of Perioperative Hypothermia: A Randomized Controlled Trial.

PURPOSE: To prevent perioperative hypothermia, forced air warming blanket was compared with a passive insulation suit. DESIGN: Prospective, open, randomized controlled trial. METHODS: Thirty patients were scheduled for orthopedic spinal surgery. The intervention group (group TS) received the thermal suit T-Balance before premedication and throughout the perioperative period, whereas the control group (group C) received forced air warming (FAW) during surgery. FINDINGS: No statistically significant difference (ns) was found between the groups for core temperature 30 minutes after induction of general anesthesia. Perioperative hypothermia occurred in 10 (66.7%) patients in group TS and 6 (40%) in group C (ns). For hypothermic patients, re-establishment of normothermia took significantly longer in group TS, mean 108 ± 111 minutes, than in group C, 33 ± 59.5 minutes (P = .03). CONCLUSIONS: The thermal suit did not prevent hypothermia in this study. FAW was significantly more efficient in re-establishing normothermia.

Evaluation of Warming Effectiveness on Physiological Indices of Patients Undergoing Laparoscopic Cholecystectomy Surgery: A Randomized Controlled Clinical Trial.

PURPOSE: The present study aimed to evaluate the impact of warming on physiological indices of patients undergoing laparoscopic cholecystectomy. DESIGN: The study was a three-group randomized controlled clinical trial. METHODS: In the present study, 96 patients were assigned to three groups: forced-air warming system group; warmed intravenous fluid group; and control group. The intervention was performed immediately after the anesthesia induction. Physiological indices (core body temperature, blood pressure, and heart rate) were evaluated at 15-minute intervals, and postoperative shivering was also recorded. FINDINGS: The mean systolic blood pressure and the mean heart rate were significantly different in each warming group before, during, and after surgery, but the three groups had no significant differences in terms of physiological indices at any time (P > .05). Postoperative shivering was not seen in any group. CONCLUSIONS: Both interventions had similar effects on physiological indices. Therefore, the recommendation is to use the warming method according to patient's other conditions.

How Clean Is the Linen at My Hospital? The Mucorales on Unclean Linen Discovery Study of Large United States Transplant and Cancer Centers.

Mucormycosis outbreaks have been linked to contaminated linen. We performed fungal cultures on freshly-laundered linens at 15 transplant and cancer hospitals. At 33% of hospitals, the linens were visibly unclean. At 20%, Mucorales were recovered from >10% of linens. Studies are needed to understand the clinical significance of our findings.

Support surfaces for treating pressure ulcers.

BACKGROUND: Pressure ulcers are treated by reducing pressure on the areas of damaged skin. Special support surfaces (including beds, mattresses and cushions) designed to redistribute pressure, are widely used as treatments. The relative effects of different support surfaces are unclear. This is an update of an existing review. OBJECTIVES: To assess the effects of pressure-relieving support surfaces in the treatment of pressure ulcers. SEARCH METHODS: In September 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA: We included published or unpublished randomised controlled trials (RCTs), that assessed the effects of support surfaces for treating pressure ulcers, in any participant group or setting. DATA COLLECTION AND ANALYSIS: Data extraction, assessment of 'Risk of bias' and GRADE assessments were performed independently by two review authors. Trials with similar participants, comparisons and outcomes were considered for meta-analysis. Where meta-analysis was inappropriate, we reported the results of the trials narratively. Where possible, we planned to report data as either risk ratio or mean difference as appropriate. MAIN RESULTS: For this update we identified one new trial of support surfaces for pressure ulcer treatment, bringing the total to 19 trials involving 3241 participants. Most trials were small, with sample sizes ranging from 20 to 1971, and were generally at high or unclear risk of bias. PRIMARY OUTCOME: healing of existing pressure ulcersLow-tech constant pressure support surfacesIt is uncertain whether profiling beds increase the proportion of pressure ulcer which heal compared with standard hospital beds as the evidence is of very low certainty: (RR 3.96, 95% CI 1.28 to 12.24), downgraded for serious risk of bias, serious imprecision and indirectness (1 study; 70 participants).There is currently no clear difference in ulcer healing between water-filled support surfaces and foam replacement mattresses: (RR 0.93, 95% CI 0.63 to 1.37); low-certainty evidence downgraded for serious risk of bias and serious imprecision (1 study; 120 participants).Further analysis could not be performed for polyester overlays versus gel overlays (1 study; 72 participants), non-powered mattresses versus low-air-loss mattresses (1 study; 20 participants) or standard hospital mattresses with sheepskin overlays versus standard hospital mattresses (1 study; 36 participants).High-tech pressure support surfacesIt is currently unclear whether high-tech pressure support surfaces (such as low-air-loss beds, air suspension beds, and alternating pressure surfaces) improve the healing of pressure ulcers (14 studies; 2923 participants) or which intervention may be more effective. The certainty of the evidence is generally low, downgraded mostly for risk of bias, indirectness and imprecision.Secondary outcomesNo analyses were undertaken with respect to secondary outcomes including participant comfort and surface reliability and acceptability as reporting of these within the included trials was very limited.Overall, the evidence is of low to very low certainty and was primarily downgraded due to risk of bias and imprecision with some indirectness. AUTHORS' CONCLUSIONS: Based on the current evidence, it is unclear whether any particular type of low- or high-tech support surface is more effective at healing pressure ulcers than standard support surfaces.

Forces involved when sliding a patient up in bed.

BACKGROUND: This study investigated the effects of 3 different types of slide sheets upon hand forces while sliding a patient up in bed. METHODS: The sheets used included the reusable Arjo Maxislide, the McAuley disposable sheet, and a standard cotton sheet. Hand forces were measured from 38 male and female participants as they slid a 'patient' up in bed. A repeated measures ANOVA with 5 levels to the repeated factor (number of sheets and sheet type) was used, along with post-hoc repeated measures contrasts to compare differences between each condition. RESULTS: A significant reduction in required force occurred when using the friction reducing sheets as compared to the cotton sheets when used according to manufacturer recommendations, as well as a reduction in one of the single friction reducing sheet categories compared to the cotton. However, it is important to note that there was still substantial force being placed on the participants. CONCLUSIONS: This study illustrates the importance of using friction reducing slide sheets while engaging in manual patient handling. Future research should investigate the forces involved with other friction reducing materials and methods as well as the possibility of combining said materials and methods.

The Efficacy of a Viscoelastic Foam Overlay on Prevention of Pressure Injury in Acutely Ill Patients: A Prospective Randomized Controlled Trial.

PURPOSE: The purpose of this study was to compare a viscoelastic foam overlay (VEFO) to a standard hospital mattress for pressure injury (PI) prevention. We also compared interface pressures (IPs) of the VEFO to our facility's standard hospital mattress. DESIGN: Prospective, randomized controlled trial. SUBJECTS AND SETTING: Data analysis was based on 110 participants (55 in each group) who were 19 years or older, had a Braden Scale for Pressure Sore Risk score of 16 or less, and were cared for on a neurology, oncology, or pulmonology inpatient care unit. The research setting was the Samsung Medical Center in Seoul, South Korea. METHODS: Participants were divided into 2 groups: the experimental group were based on a VEFO on top of the standard hospital mattress used in our facility. Participants in the control group were placed on a standard hospital mattress with/without air overlay. All patients were given standard nursing care for prevention of PI. Skin assessments were completed daily over a period of 2 weeks. In addition, we compared IPs of the standard hospital mattress and the VEFO in participants randomly allocated to the intervention group. Interface pressure was measured over the sacral/coccygeal area with subjects in the supine position. Pressures were measured immediately before and immediately following placement of the VEFO and just before data collection began. Data were collected between October 2013 and November 2014. Pressure injury incidence was compared between groups using the χ test, and IPs were compared using the paired t test. INSTRUMENTS: Pressure injury development was determined using the staging system described in guidelines from the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance in 2014. Interface pressure was measured using a device manufactured for this purpose. RESULTS: The incidence of PI development was significantly lower in subjects assigned to the experimental group as compared to those in the control group (3.6%-27.3% over the 2-week data collection period; P = .001). The maximum IP was significantly lower on the VEFO with standard hospital mattress than on the standard hospital mattress (paired t = 8.87, P < .001). CONCLUSIONS: Patients managed with a VEFO had a significantly lower incidence of PI than those managed with a standard hospital mattress. Additional research is needed to further characterize the efficacy of the VEFO, its effect on PI healing, and its effect of PI prevention in high-risk populations such as critically ill patients.

An evaluation of a novel alternating mattress and cushion technology.

Pressure ulcer prevention and management remain a challenge across all health-care settings, and the incidence and prevalence of pressure ulcers in nursing homes and residential homes continues to remain unknown. The use of suitable support surfaces has been found to be beneficial in the prevention and management of pressure ulcers. Carrying out a holistic assessment of the patient and recording the patient's at-risk score would help the clinician to determine the most suitable pressure-relieving surface for the patient. The clinician's clinical experience and judgment are also important. The Domus Auto (by APEX) mattress system and Dynamic Seat Cushion (by APEX) are effective dynamic, support surfaces in the prevention and management of pressure ulceration. They meet the recommendations by both national and international guidelines; they also partly fulfil the SSKIN bundle. From a four-week evaluation carried out in a nursing home, it has been demonstrated that, together with regular assessments and repositioning of the patients, these devices are useful tools in preventing patients' risk of tissue damage and improving the patients' quality of life.

Effect of sand and rubber surface on the lying behavior of lame dairy cows in hospital pens.

Housing lame cows in designated hospital pens with a soft surface may lessen the pain the animals feel when lying and changing position. This study investigated the effect of the lying surface on the behavior of lame cows in hospital pens. Thirty-two lame dairy cows were kept in individual hospital pens, provided with either 30-cm deep-bedded sand or 24-mm rubber mats during 24 h in a crossover design. On each surface, the lying behavior of each cow was recorded during 18 h. On deep-bedded sand, cows lay down more and changed position more often than when housed on the rubber surface. Furthermore, a shorter duration of lying down and getting up movements and a shorter duration of lying intention movements were observed. These results suggest that lame dairy cows are more reluctant to change position on rubber compared with sand, and that sand is more comfortable to lie on. Thus, deep bedding such as sand may provide better lying comfort for lame cows than an unbedded rubber surface.

Ergonomic approach for pillow concept design.

Sleep quality is an essential factor to human beings for health. The current paper conducted four studies to provide a suitable pillow for promoting sleep quality. Study 1 investigated the natural positions of 40 subjects during sleep to derive key-points for a pillow design. The results suggested that the supine and lateral positions were alternatively 24 times a night, and the current pillows were too high for the supine position and too low for lateral positions. Study 2 measured body dimensions related to pillow design of 40 subjects to determine pillow sizes. The results suggested that the pillow height were quite different in supine position and lateral position and needed to take into consideration for a pillow design. Study 3 created a pillow design based on the results of above studies. The pillow was a U-form in the front of view in which the pillow height in the middle area was lower for the supine position, and both sides were higher for the lateral positions. Study 4 assessed sleep quality of 6 subjects by using the proposed pillows and the current pillows. The results showed that the newly designed pillow led to significantly higher sleep quality, and the new design received an innovation patent.