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Meta-Analysis
. 2015 Sep 3;2015(9):CD001735.
doi: 10.1002/14651858.CD001735.pub5.

Support surfaces for pressure ulcer prevention

Elizabeth McInnes  1 , Asmara Jammali-Blasi, Sally E M Bell-Syer, Jo C Dumville, Victoria Middleton, Nicky Cullum
Affiliations
Meta-Analysis

Support surfaces for pressure ulcer prevention

Elizabeth McInnes et al. Cochrane Database Syst Rev. .

Abstract

Background: Pressure ulcers (i.e. bedsores, pressure sores, pressure injuries, decubitus ulcers) are areas of localised damage to the skin and underlying tissue. They are common in the elderly and immobile, and costly in financial and human terms. Pressure-relieving support surfaces (i.e. beds, mattresses, seat cushions etc) are used to help prevent ulcer development.

Objectives: This systematic review seeks to establish:(1) the extent to which pressure-relieving support surfaces reduce the incidence of pressure ulcers compared with standard support surfaces, and,(2) their comparative effectiveness in ulcer prevention.

Search methods: In April 2015, for this fourth update we searched The Cochrane Wounds Group Specialised Register (searched 15 April 2015) which includes the results of regular searches of MEDLINE, EMBASE and CINAHL and The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 3).

Selection criteria: Randomised controlled trials (RCTs) and quasi-randomised trials, published or unpublished, that assessed the effects of any support surface for prevention of pressure ulcers, in any patient group or setting which measured pressure ulcer incidence. Trials reporting only proxy outcomes (e.g. interface pressure) were excluded. Two review authors independently selected trials.

Data collection and analysis: Data were extracted by one review author and checked by another. Where appropriate, estimates from similar trials were pooled for meta-analysis.

Main results: For this fourth update six new trials were included, bringing the total of included trials to 59.Foam alternatives to standard hospital foam mattresses reduce the incidence of pressure ulcers in people at risk (RR 0.40 95% CI 0.21 to 0.74). The relative merits of alternating- and constant low-pressure devices are unclear. One high-quality trial suggested that alternating-pressure mattresses may be more cost effective than alternating-pressure overlays in a UK context.Pressure-relieving overlays on the operating table reduce postoperative pressure ulcer incidence, although two trials indicated that foam overlays caused adverse skin changes. Meta-analysis of three trials suggest that Australian standard medical sheepskins prevent pressure ulcers (RR 0.56 95% CI 0.32 to 0.97).

Authors' conclusions: People at high risk of developing pressure ulcers should use higher-specification foam mattresses rather than standard hospital foam mattresses. The relative merits of higher-specification constant low-pressure and alternating-pressure support surfaces for preventing pressure ulcers are unclear, but alternating-pressure mattresses may be more cost effective than alternating-pressure overlays in a UK context. Medical grade sheepskins are associated with a decrease in pressure ulcer development. Organisations might consider the use of some forms of pressure relief for high risk patients in the operating theatre.

PubMed Disclaimer

Conflict of interest statement

Nicky Cullum was the Principal Investigator in the PRESSURE Trial, one of the trials included in this review (Nixon 2006), however, she was not involved in the data extraction or analysis for this trial. Kinetic Concepts Inc (KCI) supplied (free of charge) three VAC therapy units and starter packs for use in a pilot RCT of negative pressure wound therapy for pressure ulcers. They also provided product training, support and access to the KCI 24hr advice service for clinical and technical queries. However KCI had no input into the design, conduct, analysis or reporting of that research or this review which is not concerned with this technology. E McInnes: no interests declared. A Jammali‐Blasi: no interests declared. SEM Bell‐Syer: no interests declared. JC Dumville: no interests declared. V Middleton: was funded as research assistant by Nursing Research Institute (Australian Catholic University) to assist with this review.

Figures

1
1
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included trials.
1.1
1.1. Analysis
Comparison 1 Constant low‐pressure supports (CLP) vs standard foam mattresses (SFM), Outcome 1 Pressure ulcer incidence.
2.1
2.1. Analysis
Comparison 2 Alternative foam mattress vs standard foam mattress, Outcome 1 Pressure ulcer incidence.
2.2
2.2. Analysis
Comparison 2 Alternative foam mattress vs standard foam mattress, Outcome 2 Pressure ulcer incidence UK studies only.
3.1
3.1. Analysis
Comparison 3 Comparisons between alternative foam supports, Outcome 1 Pressure ulcer incidence.
4.1
4.1. Analysis
Comparison 4 Comparisons between CLP supports, Outcome 1 Pressure ulcer incidence.
4.2
4.2. Analysis
Comparison 4 Comparisons between CLP supports, Outcome 2 Pressure ulcer incidence.
5.1
5.1. Analysis
Comparison 5 Alternating‐pressure vs standard foam mattress, Outcome 1 Pressure ulcer incidence.
6.1
6.1. Analysis
Comparison 6 Alternating‐pressure (AP) vs constant low‐pressure, Outcome 1 Pressure ulcer incidence.
7.1
7.1. Analysis
Comparison 7 AP and CLP in ICU/post ICU (factorial design), Outcome 1 Pressure ulcer incidence.
8.1
8.1. Analysis
Comparison 8 Comparisons between alternating‐pressure devices, Outcome 1 Pressure ulcer incidence.
9.1
9.1. Analysis
Comparison 9 Low Air Loss vs standard bed, Outcome 1 Pressure ulcer incidence.
9.2
9.2. Analysis
Comparison 9 Low Air Loss vs standard bed, Outcome 2 Pressure incidence pooled.
9.3
9.3. Analysis
Comparison 9 Low Air Loss vs standard bed, Outcome 3 Incidence of patients developing multiple ulcers.
10.1
10.1. Analysis
Comparison 10 Air‐Fluidised therapy vs dry flotation, Outcome 1 Rate of wound breakdown.
11.1
11.1. Analysis
Comparison 11 Kinetic treatment table vs standard care, Outcome 1 Pressure ulcer incidence.
12.1
12.1. Analysis
Comparison 12 Operating table overlay vs no overlay, Outcome 1 Pressure ulcer incidence.
13.1
13.1. Analysis
Comparison 13 Micropulse System for surgical patients, Outcome 1 Pressure ulcer incidence.
14.1
14.1. Analysis
Comparison 14 Seat cushions, Outcome 1 Pressure ulcer incidence.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Andersen 1982 {published data only}
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Hampton 1997 {published and unpublished data}
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Hofman 1994 {published data only}
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Jolley 2004 {published data only}
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Kemp 1993 {published data only}
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Keogh 2001 {published data only}
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Lazzara 1991 {published data only}
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Lim 1988 {published data only}
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McGowan 2000 {published data only}
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Mistiaen 2009 {published data only}
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Nixon 1998 {published data only}
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Nixon 2006 {published data only}
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Ricci 2013 {published data only}
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Russell 2003 {published data only}
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Sanada 2003 {published data only}
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Takala 1996 {published data only}
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References to studies excluded from this review

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Brienza 2001 {published data only}
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Colin 1996 {published data only}
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Defloor 2005 {published data only}
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Flam 1995 {published data only}
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Fleischer 1997 {published data only}
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Geelkerken 1994 {published data only}
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Gil Agudo 2009 {published data only}
    1. Gil‐Agudo A, Peña‐González A, Ama‐Espinosa A, Pérez‐Rizo E, Díaz‐Domínguez E, Sánchez‐Ramos A. Comparative study of pressure distribution at the user‐cushion interface with different cushions in a population with spinal cord injury. Clinical Biomechanics 2009;24(7):558‐63. - PubMed
Gray 2008 {published data only}
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Grindley 1996 {published data only}
    1. Grindley A, Acres J. Alternating pressure mattresses: comfort and quality of sleep. British Journal of Nursing 1996;5(21):1303‐10. - PubMed
Grisell 2008 {published data only}
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Gunningberg 1998 {published data only}
    1. Gunningberg L, Lindholm C, Carlsson M, Sjoden PO. Patients with hip fracture: risk for pressure ulcers. A prospective, controlled study of 124 patients in Uppsala, Sweden. European Wound Management Association and Journal of Wound Care Autumn Conference; 1998 November; Harrogate, UK. 1998:10.
Haalboom 1994 {published data only}
    1. Haalboom J R. Anti‐decubitus mattresses. Nederlands Tijdschrift voor Geneeskunde 1994;138(26):1309‐10. - PubMed
Hampton 1998 {published data only}
    1. Hampton S. Can electric beds aid pressure sore prevention in hospitals?. British Journal of Nursing 1998;7(17):1010‐7. - PubMed
Hawkins 1997 {published data only}
    1. Hawkins JE. The effectiveness of pressure‐reducing table pads as an intervention to reduce the risk of intraoperatively acquired pressure sores. Military Medicine 1997;162:759‐61. - PubMed
Heyneman 2009 {published data only}
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Holzgreve 1993 {published data only}
    1. Holzgreve A, Waldner M, Waldner PW, Hohlbach G. Bed sore prophylaxis in patients with chronic arterial occlusive disease with a new thermoactive pressure alternating mattress. Langenbecks Archiv fur Chirurgie 1993;Suppl Kongessbericht:1117.
Huang 2009 {published data only}
    1. Huang TT, Tseng CE, Lee TM, Yeh JY, Lai YY. Preventing pressure sores of the nasal ala after nasotracheal tube intubation: from animal model to clinical application. Journal of Oral and Maxillofacial Surgery 2009;67(3):543‐51. - PubMed
Huang 2013 {published data only}
    1. Huang HY, Chen HL, Xu XJ. Pressure‐redistribution surfaces for prevention of surgery‐related pressure ulcers: A meta‐analysis. Ostomy/Wound Management 2013;59(4):36‐48. - PubMed
Inman 1999 {published data only}
    1. Inman KJ, Dymock K, Fysh N, Robbins B, Rutledge FS, Sibbald WJ. Pressure ulcer prevention: a randomized controlled trial of 2 risk‐directed strategies for patient surface assignment. Advances in Wound Care 1999;12(2):72‐80. - PubMed
Jacksich 1997 {published data only}
    1. Jacksich BB. Pressure ulcer prevalence and prevention of nosocomial development: one hospital's experience. Ostomy/Wound Management 1997;43(3):32‐4, 36, 38‐40. - PubMed
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Jesurum 1996 {published data only}
    1. Jesurum J, Joseph K, Davis JM. Balloons, beds and breakdown. Effects of low air loss therapy on the development of pressure ulcers in cardiovascular surgical patients with intra‐aortic balloon pump support. Critical Care Nursing Clinics of North America 1996;8(4):423‐40. - PubMed
Koo 1995 {published data only}
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Marchand 1993 {published data only}
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Nakahara 2012 {published data only}
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Neander 1996 {published data only}
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Ooka 1995 {published data only}
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Pham 2011a {published data only}
    1. Pham B, Stern A, Chen W, Sander B, John‐Baptiste A, Thein HH, Gomes T, Wodchis WP, Bayoumi A, Machado M, Carcone S, Krahn M. Preventing pressure ulcers in long‐term care: A cost‐effectiveness analysis. Archives of Internal Medicine 2011;171(20):1839‐47.. - PubMed
Pham 2011b {published data only}
    1. Pham B, Teague L, Mahoney J, Goodman L, Paulden M, Poss J, Li J, Ieraci L, Carcone S, Krahn M. Early prevention of pressure ulcers among elderly patients admitted through emergency departments: a cost‐effectiveness analysis. Annals of emergency medicine 2011;58(5):468‐478. e3. - PubMed
Phillips 1999 {published data only}
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Reynolds 1994 {published data only}
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Takala 1994 {published data only}
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Thomas 1994 {published data only}
    1. Thomas J. Support surface evaluation methodological and statistical considerations. Journal of Tissue Viability 1994;4(3):93.
Timmons 2008 {published data only}
    1. Timmons J, Bertram M. The use of micro‐stimulation in pressure ulcer prevention. Wounds UK 2008;4(4):120‐3.
Torra i Bou 2002 {published data only}
    1. Torra i Bou JE, Rueda López J, Camañes G, Herrero Narváez E, Blanco Blanco J, Martínez‐Esparza EH, et al. Heel pressure ulcers. Comparative study between heel protective bandage and hydrocellular dressing with special form for the heel. Revista de Enfermeria 2002;25(5):50‐6. - PubMed
Turnage‐Carrier 2008 {published data only}
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Vanderwee 2007 {published data only}
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Vanderwee 2008 {published data only}
    1. Vanderwee K, Grypdonck M, Defloor T. Alternating pressure air mattresses as prevention for pressure ulcers: a literature review. International Journal of Nursing Studies 2008;45(5):784‐801. - PubMed
Wells 1984 {published data only}
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Wu 2011 {published data only}
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References to studies awaiting assessment

Allegretti 2008 {unpublished data only}
    1. Allegretti A. Factors associated with clinical decisions and pressure ulcer development in long term care residents. University of Pittsburgh.
Mastrangelo 2010 {published data only}
    1. Mastrangelo D, Farina E, Gallicchio V, Anna D, Bresadola F, FArina MA. Initial analyses of the prospective study randomized on the anti‐decubitis lesion mattress cover. SAWC Spring: The Symposium on Advanced Wounds Care and the Wound Healing Society; 2010, April 17‐20; Orlando, Florida. 2010:S32, Abstract CR‐053.
Mayer 2008 {published data only}
    1. Mayer H, Schröder G, Osterbrink J. Clinical evaluation of the efficiency of the micro‐stimulation‐system thevo‐activ: Final report [Klinische Evaluation der Wirksamkeit des MiS Micro‐Stimulations‐Systems Thevo‐Activ]. Florida International University 2008.
Rafter 2011 {published data only}
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