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Meta-Analysis
. 2021 May 6;5(5):CD013623.
doi: 10.1002/14651858.CD013623.pub2.

Alternative reactive support surfaces (non-foam and non-air-filled) for preventing pressure ulcers

Chunhu Shi  1 , Jo C Dumville  1 , Nicky Cullum  1 , Sarah Rhodes  2 , Elizabeth McInnes  3
Affiliations
Meta-Analysis

Alternative reactive support surfaces (non-foam and non-air-filled) for preventing pressure ulcers

Chunhu Shi et al. Cochrane Database Syst Rev. .

Abstract
in English, Spanish

Background: Pressure ulcers (also known as injuries, pressure sores, decubitus ulcers and bed sores) are localised injuries to the skin or underlying soft tissue, or both, caused by unrelieved pressure, shear or friction. Reactive surfaces that are not made of foam or air cells can be used for preventing pressure ulcers.

Objectives: To assess the effects of non-foam and non-air-filled reactive beds, mattresses or overlays compared with any other support surface on the incidence of pressure ulcers in any population in any setting.

Search methods: In November 2019, 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 We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional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 randomised controlled trials that allocated participants of any age to non-foam or non-air-filled reactive beds, overlays or mattresses. Comparators were any beds, overlays or mattresses used.

Data collection and analysis: At least two review authors independently assessed studies using predetermined inclusion criteria. We carried out data extraction, 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool, and the certainty of the evidence assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology. If a non-foam or non-air-filled surface was compared with surfaces that were not clearly specified, then the included study was recorded and described but not considered further in any data analyses.

Main results: We included 20 studies (4653 participants) in this review. Most studies were small (median study sample size: 198 participants). The average participant age ranged from 37.2 to 85.4 years (median: 72.5 years). Participants were recruited from a wide range of care settings but were mainly from acute care settings. Almost all studies were conducted in Europe and America. Of the 20 studies, 11 (2826 participants) included surfaces that were not well described and therefore could not be fully classified. We synthesised data for the following 12 comparisons: (1) reactive water surfaces versus alternating pressure (active) air surfaces (three studies with 414 participants), (2) reactive water surfaces versus foam surfaces (one study with 117 participants), (3) reactive water surfaces versus reactive air surfaces (one study with 37 participants), (4) reactive water surfaces versus reactive fibre surfaces (one study with 87 participants), (5) reactive fibre surfaces versus alternating pressure (active) air surfaces (four studies with 384 participants), (6) reactive fibre surfaces versus foam surfaces (two studies with 228 participants), (7) reactive gel surfaces on operating tables followed by foam surfaces on ward beds versus alternating pressure (active) air surfaces on operating tables and subsequently on ward beds (two studies with 415 participants), (8) reactive gel surfaces versus reactive air surfaces (one study with 74 participants), (9) reactive gel surfaces versus foam surfaces (one study with 135 participants), (10) reactive gel surfaces versus reactive gel surfaces (one study with 113 participants), (11) reactive foam and gel surfaces versus reactive gel surfaces (one study with 166 participants) and (12) reactive foam and gel surfaces versus foam surfaces (one study with 91 participants). Of the 20 studies, 16 (80%) presented findings which were considered to be at high overall risk of bias.

Primary outcome: Pressure ulcer incidence We did not find analysable data for two comparisons: reactive water surfaces versus foam surfaces, and reactive water surfaces versus reactive fibre surfaces. Reactive gel surfaces used on operating tables followed by foam surfaces applied on hospital beds (14/205 (6.8%)) may increase the proportion of people developing a new pressure ulcer compared with alternating pressure (active) air surfaces applied on both operating tables and hospital beds (3/210 (1.4%) (risk ratio 4.53, 95% confidence interval 1.31 to 15.65; 2 studies, 415 participants; I2 = 0%; low-certainty evidence). For all other comparisons, it is uncertain whether there is a difference in the proportion of participants developing new pressure ulcers as all data were of very low certainty. Included studies did not report time to pressure ulcer incidence for any comparison in this review. Secondary outcomes Support-surface-associated patient comfort: the included studies provide data on this outcome for one comparison. It is uncertain if there is a difference in patient comfort between alternating pressure (active) air surfaces and reactive fibre surfaces (one study with 187 participants; very low-certainty evidence). All reported adverse events: there is evidence on this outcome for one comparison. It is uncertain if there is a difference in adverse events between reactive gel surfaces followed by foam surfaces and alternating pressure (active) air surfaces applied on both operating tables and hospital beds (one study with 198 participants; very low-certainty evidence). We did not find any health-related quality of life or cost-effectiveness evidence for any comparison in this review.

Authors' conclusions: Current evidence is generally uncertain about the differences between non-foam and non-air-filled reactive surfaces and other surfaces in terms of pressure ulcer incidence, patient comfort, adverse effects, health-related quality of life and cost-effectiveness. Reactive gel surfaces used on operating tables followed by foam surfaces applied on hospital beds may increase the risk of having new pressure ulcers compared with alternating pressure (active) air surfaces applied on both operating tables and hospital beds. Future research in this area should consider evaluation of the most important support surfaces from the perspective of decision-makers. Time-to-event outcomes, careful assessment of adverse events and trial-level cost-effectiveness evaluation should be considered in future studies. Trials should be designed to minimise the risk of detection bias; for example, by using digital photography and adjudicators of the photographs being blinded to group allocation. Further review using network meta-analysis will add to the findings reported here.

Antecedentes: Las úlceras por presión (también conocidas como úlceras y escaras de decúbito) son lesiones localizadas en la piel o en los tejidos blandos subyacentes, o en ambos, causadas por la presión, el cizallamiento o la fricción no aliviados. Las superficies estáticas que no son de espuma o celdas de aire se pueden utilizar para prevenir las úlceras por presión.

Objetivos: Evaluar los efectos de las camas, los colchones o los sobrecolchones estáticos sin espuma y sin aire en comparación con cualquier otra superficie especial para el manejo de la presión (SEMP) o sobre la incidencia de las úlceras por presión en cualquier población y en cualquier contexto. MÉTODOS DE BÚSQUEDA: En noviembre de 2019 se hicieron búsquedas en el Registro especializado del Grupo Cochrane de Heridas (Cochrane Wounds), en el Registro Cochrane central de ensayos controlados (Cochrane Central Register of Controlled Trials, CENTRAL); Ovid MEDLINE (incluido In‐Process & Other Non‐Indexed Citations); Ovid Embase y EBSCO CINAHL Plus. También se buscaron estudios en curso y no publicados en los registros de ensayos clínicos, y se examinaron las listas de referencias de los estudios incluidos pertinentes, así como de las revisiones, los metanálisis y los informes de tecnología sanitaria para identificar estudios adicionales. No hubo restricciones en cuanto al idioma, la fecha de publicación ni el contexto de los estudios. CRITERIOS DE SELECCIÓN: Se incluyeron los ensayos controlados aleatorizados que asignaron a participantes de cualquier edad a camas, colchones o sobrecolchones estáticos sin espuma y sin aire. Los comparadores fueron todas las camas, sobrecolchones o colchones utilizados. OBTENCIÓN Y ANÁLISIS DE LOS DATOS: Al menos dos autores de la revisión evaluaron de forma independiente los ensayos según criterios de inclusión predeterminados. Se realizó la extracción de los datos, la evaluación del riesgo de sesgo mediante la herramienta Cochrane "Risk of bias" y la evaluación de la certeza de la evidencia según el método Grading of Recommendations, Assessment, Development and Evaluations. Si se comparaba una superficie sin espuma o sin aire con superficies que no estaban claramente especificadas, se registraba y describía el estudio incluido, pero no se tenía en cuenta en ningún análisis de datos.

Resultados principales: En esta revisión se incluyeron 20 estudios (4653 participantes). La mayoría de los estudios eran pequeños (mediana del tamaño muestral de los estudios: 198 participantes). La edad promedio de los participantes varió entre 37,2 y 85,4 años (mediana: 72,5 años). Los participantes se reclutaron en una amplia variedad de ámbitos asistenciales, pero principalmente en ámbitos de cuidados intensivos y de agudos. Casi todos los estudios se realizaron en Europa y América. De los 20 estudios, 11 (2826 participantes) incluían superficies que no estaban bien descritas y, por lo tanto, no se podían clasificar completamente. Se resumieron los datos de las 12 comparaciones siguientes: (1) superficies de agua estáticas versus superficies de aire de presión alternante (activas) (tres estudios con 414 participantes), (2) superficies de agua estáticas versus superficies de espuma (un estudio con 117 participantes), (3) superficies de agua estáticas versus superficies de aire estáticas (un estudio con 37 participantes), (4) superficies de agua estáticas versus superficies de fibras estáticas (un estudio con 87 participantes), (5) superficies de fibras estáticas versus superficies de aire de presión alternante (activas) (cuatro estudios con 384 participantes), (6) superficies de fibras estáticas versus superficies de espuma (dos estudios con 228 participantes), (7) superficies de gel estáticas en las mesas de operaciones, seguidas de superficies de espuma en las camas de las salas, versus superficies de aire de presión alternante (activas) en las mesas de operaciones y posteriormente en las camas de las salas (dos estudios con 415 participantes), (8) superficies de gel estáticas versus superficies de aire estáticas (un estudio con 74 participantes) (9) superficies de gel estáticas versus superficies de espuma (un estudio con 135 participantes), (10) superficies de gel estáticas versus superficies de gel estáticas (un estudio con 113 participantes), (11) superficies de espuma y gel estáticas versus superficies de gel estáticas (un estudio con 166 participantes) y (12) superficies de espuma y gel estáticas versus superficies de espuma (un estudio con 91 participantes). De los 20 estudios, 16 (80%) presentaron resultados que se consideraron con alto riesgo general de sesgo. Desenlace principal: incidencia de las úlceras por presión No se encontraron datos analizables para dos comparaciones: superficies de agua estáticas versus superficies de espuma, ni superficies de agua estáticas versus superficies de fibras estáticas. Las superficies de gel estáticas utilizadas en las mesas de operaciones seguidas de las superficies de espuma aplicadas en las camas de hospital (14/205 [6,8%]) podrían aumentar la proporción de personas que presentan una nueva úlcera por presión en comparación con las superficies de aire de presión alternante (activas) aplicadas en las mesas de operaciones y en las camas de hospital (3/210 [1,4%]) (razón de riesgos 4,53; intervalo de confianza del 95%: 1,31 a 15,65; dos estudios, 415 participantes; I2 = 0%; evidencia de certeza baja). Para todas las demás comparaciones, no hay certeza de que haya una diferencia en la proporción de participantes que presentan nuevas úlceras por presión, ya que todos los datos eran de certeza muy baja. Los estudios incluidos no informaron el tiempo hasta la incidencia de las úlceras por presión para ninguna comparación en esta revisión. Desenlaces secundarios Comodidad del paciente asociada con la SEMP: los estudios incluidos proporcionan datos sobre este desenlace para una comparación. No está claro si existe una diferencia en la comodidad del paciente entre las superficies de aire de presión alternante (activas) y las superficies de fibras estáticas (un estudio con 187 participantes; evidencia de certeza muy baja). Todos los eventos adversos informados: hay evidencia sobre este desenlace para una comparación. No se sabe si existe una diferencia en los eventos adversos entre las superficies de gel estáticas seguidas de superficies de espuma y las superficies de aire de presión alternante (activas) aplicadas tanto en las mesas de operaciones como en las camas de hospital (un estudio con 198 participantes; evidencia de certeza muy baja). No se encontró evidencia acerca de la calidad de vida relacionada con la salud ni de la coste‐efectividad para ninguna comparación en esta revisión.

Conclusiones de los autores: Por lo general no se desconoce la evidencia actual sobre las diferencias entre las superficies estáticas sin espuma y sin aire y otras superficies en términos de la incidencia de las úlceras por presión, la comodidad del paciente, los efectos adversos, la calidad de vida relacionada con la salud y la coste‐efectividad. Las superficies de gel estáticas utilizadas en las mesas de operaciones, seguidas de las superficies de espuma aplicadas en las camas de hospital, podrían aumentar el riesgo de aparición de nuevas úlceras por presión en comparación con las superficies de aire de presión alternante (activas) aplicadas en las mesas de operaciones y en las camas de hospital. Los estudios de investigación futuros en este campo deberían considerar la evaluación de las SEMP más importantes desde la perspectiva de aquellos que toman decisiones. En los estudios futuros se deben considerar los desenlaces de tiempo hasta el evento, la evaluación cuidadosa de los eventos adversos y la evaluación de la coste‐efectividad a nivel de ensayo. Los ensayos deben estar diseñados para minimizar el riesgo de sesgo de detección; por ejemplo, con el uso de fotografía digital y el cegamiento de los adjudicatarios de las fotografías a la asignación a los grupos. Una revisión posterior mediante metanálisis en red ampliará los resultados aquí proporcionados.

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Conflict of interest statement

Chunhu Shi: I received research funding from the National Institute for Health Research (NIHR) (Research for Patient Benefit, Evidence synthesis for pressure ulcer prevention and treatment, PB‐PG‐1217‐20006). I received support from the Tissue Viability Society to attend conferences unrelated to this work. The Doctoral Scholar Awards Scholarship and Doctoral Academy Conference Support Fund (University of Manchester) also supported a PhD and conference attendance respectively, both were unrelated to this work.

Jo Dumville: I am Chief Investigator on a National Institute for Health Research grant that funded the conduct of this review (Research for Patient Benefit, Evidence synthesis for pressure ulcer prevention and treatment, PB‐PG‐1217‐20006). This research was co‐funded by the National Institute for Health Research Manchester Biomedical Research Centre and partly funded by the National Institute for Health Research Applied Research Collaboration Greater Manchester.

Nicky Cullum: I am Co‐investigator on a National Institute for Health Research grant that funded the conduct of this review (Research for Patient Benefit, Evidence synthesis for pressure ulcer prevention and treatment, PB‐PG‐1217‐20006). This research was co‐funded by the National Institute for Health Research Manchester Biomedical Research Centre, and partly funded by the National Institute for Health Research Applied Research Collaboration Greater Manchester.

My previous and current employers received research grant funding from the NHS Research and Development programme and subsequently the NIHR for previous versions of this review. The funders had no role in the conduct of the review. My previous employer received research grant funding from the NIHR for an RCT comparing different alternating pressure air surfaces for pressure ulcer prevention. This RCT (for which I was the Chief Investigator) was not eligible for inclusion in this review.

Sarah Rhodes: my salary is funded from three NIHR grants and a grant from Greater Manchester Cancer.

Elizabeth McInnes: none known.

Figures

1
1
Study flow diagram
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
1.1
1.1. Analysis
Comparison 1: Reactive water surfaces compared with alternating pressure (active) air surfaces, Outcome 1: Proportion of participants developing a new pressure ulcer
2.1
2.1. Analysis
Comparison 2: Reactive water surfaces compared with reactive air surfaces, Outcome 1: Proportion of participants developing a new pressure ulcer
3.1
3.1. Analysis
Comparison 3: Reactive fibre surfaces compared with alternating pressure (active) air surfaces, Outcome 1: Proportion of participants developing a new pressure ulcer
4.1
4.1. Analysis
Comparison 4: Reactive fibre surfaces compared with foam surfaces, Outcome 1: Proportion of participants developing a new pressure ulcer
5.1
5.1. Analysis
Comparison 5: Reactive gel surfaces followed by foam surfaces compared with alternating pressure (active) air surfaces, Outcome 1: Proportion of participants developing a new pressure ulcer
6.1
6.1. Analysis
Comparison 6: Reactive gel surfaces compared with reactive air surfaces, Outcome 1: Proportion of participants developing a new pressure ulcer
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    1. Branom R, Rappl LM. "Constant force technology" versus low-air-loss therapy in the treatment of pressure ulcers. Ostomy/Wound Management 2001;47(9):38-46. [PMID: ] - PubMed
Brown 2001 {published data only}
    1. Brown SJ. Bed surfaces and pressure sore prevention: an abridged report. Orthopedic Nursing 2001;20(4):38-40. [PMID: ] - PubMed
Bueno de Camargo 2018 {published data only}
    1. Bueno de Camargo WH, Pereira RD, Tanita MT, Heko L, Grion IC, Festti J, et al. The effect of support surfaces on the incidence of pressure injuries in critically ill patients: a randomized clinical trial. Critical Care Research and Practice 2018;2018:Article ID 3712067. - PMC - PubMed
    1. NCT02844166. Support surfaces to prevent pressure injuries. clinicaltrials.gov/show/NCT02844166.
Cadue 2008 {published data only}
    1. Cadue JF, Karolewicz S, Tardy C, Barrault C, Robert R, Pourrat O. Prevention of heel pressure sores with a foam body-support device. A randomized controlled trial in a medical intensive care unit [Efficacite de supports anatomiques en mousse pour la prevention des escarres de talons. Etude controlee randomisee en reanimation medicale]. Presse Medicale (Paris, France: 1983) 2008;37(1 Pt 1):30-6. [PMID: ] - PubMed
Caley 1994 {published data only}
    1. Caley L, Jones S, Freer J, Muller JS. Randomized prospective trial: treatment outcomes and cost-effectiveness of two types of low-air-loss therapy. Proceedings of the 9th Annual Clinical Symposium on Pressure Ulcer and Wound Management 1994:1-2.
Cassino 2013b {published data only}
    1. Cassino R, Ippolito AM, Cuffaro C, Corsi A, Ricci E. A controlled, randomized study on the effectiveness of two overlays in the treatment of decubitus ulcers. Minerva Chirurgica 2013;68(1):105-16. - PubMed
Cavicchioli 2007 {published data only}
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    1. Chaloner D, Cave J. Should weaker study designs ever be preferred over randomised controlled trials. Journal of Tissue Viability 2000;10(3 su):7-9. [PMID: ] - PubMed
ChiCTR1800017466 {published data only}
    1. ChiCTR1800017466. The study on the application of fluidized positioner in preventing intraoperative pressure injury. www.who.int/trialsearch/Trial2.aspx?TrialID=ChiCTR1800017466 2018.
Chou 2013 {published data only}
    1. Chou R, Dana T, Bougatsos C, Blazina I, Starmer AJ, Reitel K, et al. Pressure ulcer risk assessment and prevention: a systematic comparative effectiveness review. Annals of Internal Medicine 2013;159(1):28-38. [PMID: ] - PubMed
Cobb 1997 {unpublished data only}
    1. Cobb GA, Yoder LH, Warren JB. Pressure ulcers: patient outcomes on a KinAir bed or EHOB waffle mattress. TriService Nursing Research Program (TSNRP) 1997.
Collier 1996 {published data only}
    1. Collier ME. Pressure-reducing mattresses. Journal of Wound Care 1996;5(5):207-11. [PMID: ] - PubMed
Cooper 1998 {published data only}
    1. Cooper PJ, Gray DG, Mollison J. A randomised controlled trial of two pressure-reducing surfaces. Journal of Wound Care 1998;7(8):374-6. [PMID: ] - PubMed
Cummins 2019 {published data only}
    1. Cummins KA, Watters R, Leming-Lee T. Reducing pressure injuries in the pediatric intensive care unit. Nursing Clinics of North America 2019;54(1):127-40. [PMID: ] - PubMed
Day 1993 {published data only}
    1. Day A, Leonard F. Seeking quality care for patients with pressure ulcers. Decubitus 1993;6(1):32-43. [PMID: ] - PubMed
Defloor 2005 {published data only}
    1. Defloor T, De Bacquer D, Grypdonck MH. The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers. International Journal of Nursing Studies 2005;42(1):37-46. [PMID: ] - PubMed
Demarre 2012 {published data only}
    1. Demarre L, Beeckman D, Vanderwee K, Defloor T, Grypdonck M, Verhaeghe S. Multi-stage versus single-stage inflation and deflation cycle for alternating low pressure air mattresses to prevent pressure ulcers in hospitalised patients: a randomised-controlled clinical trial. International Journal of Nursing Studies 2012;49(4):416-26. [PMID: ] - PubMed
    1. Demarre L, Vanderwee K, Beeckman D, Defloor T. Pressure ulcer prevention: randomized controlled trail comparing the effect of a standard alternating pressure air mattress and a alternating low pressure air mattress with gradual inflation and deflation. EWMA Journal 2010;10(2):44.
    1. Demarre L, Vanderwee K, Beeckman D, Defloor T. The effectiveness of a multistage low pressure air mattress in pressure ulcer prevention: an RCT Fourth European Nursing Congress. Journal of Clinical Nursing 2010;19:41.
    1. Demarre L, Verhaeghe S, Van Hecke A, Grypdonck M, Clays E, Vanderwee K, et al. The effectiveness of three types of alternating pressure air mattresses in the prevention of pressure ulcers in Belgian hospitals. Research in Nursing & Health 2013;36(5):439-52. [PMID: ] - PubMed
De Oliveira 2017 {published data only}
    1. De Oliveira KF, Nascimento KG, Nicolussi AC, Chavaglia SR, De Araujo CA, Barbosa MH. Support surfaces in the prevention of pressure ulcers in surgical patients: an integrative review. International Journal of Nursing Practice (John Wiley & Sons, Inc.) 2017;23(4):doi: 10.1111/ijn.12553. - PubMed
Devine 1995 {published data only}
    1. Devine B. Alternating pressure air mattresses in the management of established pressure sores. Journal of Tissue Viability 1995;5(3):94-8.
Economides 1995 {published data only}
    1. Economides NG, Skoutakis VA, Carter CA, Smith VH. Evaluation of the effectiveness of two support surfaces following myocutaneous flap surgery. Advances in Wound Care 1995;8(1):49-53. [PMID: ] - PubMed
Evans 2000 {published data only}
    1. Evans D, Land L, Geary A. A clinical evaluation of the Nimbus 3 alternating pressure mattress replacement system. Journal of Wound Care 2000;9(4):181-6. [PMID: ] - PubMed
Exton‐Smith 1982 {published data only}
    1. Exton-Smith AN, Overstall PW, Wedgwood J, Wallace G. Use of the 'air wave system' to prevent pressure sores in hospital. Lancet (London, England) 1982;1(8284):1288-90. [PMID: ] - PubMed
Ferrell 1993 {published data only}
    1. Ferrell BA, Osterweil D, Christenson P. A randomized trial of low-air-loss beds for treatment of pressure ulcers. JAMA 1993;269(4):494-7. [PMID: ] - PubMed
Ferrell 1995 {published data only}
    1. Ferrell BA, Keeler E, Siu AL, Ahn SH, Osterweil D. Cost-effectiveness of low-air-loss beds for treatment of pressure ulcers. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 1995;50(3):M141-6. [PMID: ] - PubMed
Feuchtinger 2006 {published data only}
    1. Feuchtinger J, De Bie R, Dassen T, Halfens R. A 4-cm thermoactive viscoelastic foam pad on the operating room table to prevent pressure ulcer during cardiac surgery. Journal of Clinical Nursing 2006;15(2):162-7. [PMID: ] - PubMed
    1. Feuchtinger J. Preventing decubitus ulcer in heart surgery interventions: visco-elastic foam layer on the operating room table--a study [Dekubituspravention wahrend kardiochirurgischer Eingriffe: Viskoelastische Schaumstoffauflage auf dem Operationstisch--eine Studie]. Pflege Zeitschrift 2006;59(8):498-501. [PMID: ] - PubMed
Finnegan 2008 {published data only}
    1. Finnegan MJ, Gazzerro L, Finnegan JO, Lo P. Comparing the effectiveness of a specialized alternating air pressure mattress replacement system and an air-fluidized integrated bed in the management of post-operative flap patients: a randomized controlled pilot study. Journal of Tissue Viability 2008;17(1):2-9. - PubMed
Fleischer 1997 {published data only}
    1. Fleischer I, Bryant D. Evaluating replacement mattresses. Nursing Management 1997;28(8):38-41. [PMID: ] - PubMed
García Fernández 2004 {published data only}
    1. García Fernández FP, Pancorbo Hidalgo PL, Rodríguez Torres M. Utility and cost-effectiveness of air suspension bed in the prevention of pressure ulcers. Gerokomos 2004;15(3):162-7.
Gazzerro 2008 {published data only}
    1. Gazzerro L, Finnegan M. Comparing the effectiveness of alternating air pressure mattress replacement systems and air fluidized integrated beds in the management of flap and graft patients: ten case studies. Scientific and Clinical Abstracts from the 40th Annual Wound, Ostomy and Continence Nurses Annual Conference. Journal of Wound, Ostomy, and Continence Nursing 2008;35(3):S63.
Gebhardt 1994a {published data only}
    1. Gebhardt K, Bliss MR. A controlled study to compare the efficacy, practicability and cost of pressure relieving supports to prevent and heal pressure sores. In: 2nd European Conference on Advances in Wound Management; 1992 October 20-23; Harrogate (UK). 1993:166.
    1. Gebhardt K. A randomized trial of alternating pressure (AP) and constant low pressure (CLP) supports for the prevention of pressure sores. Journal of Tissue Viability 1994;4(3):93.
Gebhardt 1994b {published data only}
    1. Gebhardt KS, Bliss MR, Winwright PL. A randomised controlled trial to compare the efficacy of alternating and constant low pressure supports for preventing pressure sores in an intensive care unit (ICU). Clinical Science 1994;86(S30):39P.
Gebhardt 1996 {published data only}
    1. Gebhardt KS, Bliss MR, Winwright PL, Thomas J. Pressure-relieving supports in an ICU. Journal of Wound Care 1996;5(3):116-21. - PubMed
Geelkerken 1994 {published data only}
    1. Geelkerken RH, Breslau PJ, Hermans J, Wille J, Hofman A, Hamming JJ. Anti-decubitus mattress [Anti-decubitusmatrassen]. Nederlands Tijdschrift voor Geneeskunde 1994;138(36):1834; author reply 1834-5. [PMID: ] - PubMed
Goldstone 1982 {published data only}
    1. Goldstone LA, Norris M, O'Reilly M, White J. A clinical trial of a bead bed system for the prevention of pressure sores in elderly orthopaedic patients. Journal of Advanced Nursing 1982;7(6):545-8. [PMID: ] - PubMed
Gray 1994 {published data only}
    1. Gray D. A randomised clinical trial of two foam mattresses. Aberdeen Royal Hospitals NHS Trust. Medical Support System 1994.
    1. Gray D. A randomised controlled trial of two foam mattresses. Journal of Tissue Viability 1994;4(3):92.
    1. Gray DG, Campbell M. A randomised clinical trial of two types of foam mattresses. Journal of Tissue Viability 1994;4(4):128-32.
    1. Gray DG, Cooper PJ, Campbell M. A study of the performance of a pressure reducing foam mattress after three years of use. Journal of Tissue Viability 1998;8(3):9-13. [PMID: ] - PubMed
Gray 2000 {published data only}
    1. Gray D, Smith M. A randomized controlled trial of two pressure-reducing foam mattresses. In: European Wound Management Association Conference; 1998 November; Harrogate (UK). 1998:4.
    1. Gray DG, Smith M. Comparison of a new foam mattress with the standard hospital mattress. Journal of Wound Care 2000;9(1):29-31. [PMID: ] - PubMed
Gray 2008 {published data only}
    1. Gray D, Cooper P, Bertram M, Duguid K, Pirie G. A clinical audit of the Softform Premier Active™ mattress in two acute care of the elderly wards. Wounds UK 2008;4(4):124-8.
Greer 1988 {published data only}
    1. Greer DM, Morris J, Walsh NE, Glenn AM, Keppler J. Cost-effectiveness and efficacy of air-fluidized therapy in the treatment of pressure ulcers. Journal of Enterostomal Therapy 1988;15(6):247-51. [PMID: ] - PubMed
Grindley 1996 {published data only}
    1. Grindley A, Acres J. Alternating pressure mattresses: comfort and quality of sleep. British Journal of Nursing (Mark Allen Publishing) 1996;5(21):1303-10. [PMID: ] - PubMed
Groen 1999 {published data only}
    1. Groen HW, Groenier KH, Schuling J. Comparative study of a foam mattress and a water mattress. Journal of Wound Care 1999;8(7):333-5. - PubMed
Gunningberg 2000 {published data only}
    1. Gunningberg L, Lindholm C, Carlsson M, Sjoden PO. Effect of visco-elastic foam mattresses on the development of pressure ulcers in patients with hip fractures. Journal of Wound Care 2000;9(10):455-60. [PMID: ] - PubMed
Gunningberg 2001 {published data only}
    1. Gunningberg L, Lindholm C, Carlsson M, Sjoden PO. Reduced incidence of pressure ulcers in patients with hip fractures: a 2-year follow-up of quality indicators. International Journal for Quality in Health Care 2001;13(5):399-407. [PMID: ] - PubMed
Haalboom 1994 {published data only}
    1. Haalboom JR. Anti-decubitus mattresses [Anti-decubitusmatrassen.]. Nederlands Tijdschrift voor Geneeskunde 1994;138(26):1309-10. [PMID: ] - PubMed
Hale 1990 {published data only}
    1. Hale JS, Smith SH. Pressure reduction mattresses versus pressure reduction overlays: a cost analysis. Journal of Enterostomal Therapy 1990;17(6):241-3. [PMID: ] - PubMed
Hampton 1997 {published data only}
    1. Hampton S. Evaluation of the new Cairwave Therapy System in one hospital trust. British Journal of Nursing (Mark Allen Publishing) 1997;6(3):167-70. [PMID: ] - PubMed
Hampton 1998 {published data only}
    1. Hampton S. Can electric beds aid pressure sore prevention in hospitals? British Journal of Nursing (Mark Allen Publishing) 1998;7(17):1010-7. [PMID: ] - PubMed
Hampton 1999 {published data only}
    1. Hampton S. Efficacy and cost-effectiveness of the Thermo contour mattress. British Journal of Nursing (Mark Allen Publishing) 1999;8(15):990-6. - 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(11):759-61. [PMID: ] - PubMed
Hofman 1994 {published data only}
    1. Hofman A, Geelkerken RH, Wille J, Hamming JJ, Hermans J, Breslau PJ. Pressure sores and pressure-decreasing mattresses: controlled clinical trial. Lancet (London, England) 1994;343(8897):568-71. [PMID: ] - PubMed
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 1993:1117.
Hommel 2008 {published data only}
    1. Hommel A, Thorngre KG, Ulander K. How to prevent patients with a hip fracture from developing pressure ulcers. EWMA Journal 2008;8(2):157.
Hoskins 2007a {published data only}
    1. Hoskins A. Alternating pressure mattresses were more cost effective than alternating pressure overlays for preventing pressure ulcers. Evidence-Based Nursing 2007;10(1):23. [PMID: ] - PubMed
Hoskins 2007b {published data only}
    1. Hoskins A. Similar proportions of patients developed pressure ulcers on alternating pressure overlays and alternating pressure mattresses. Evidence-Based Nursing 2007;10(1):22. [PMID: ] - 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):36-8, 42, 44, 46, 48. [PMID: ] - PubMed
Huang 2018 {published data only}
    1. Huang W, Zhu Y, Qu H. Use of an alternating inflatable head pad in patients undergoing open heart surgery. Medical Science Monitor 2018;24:970-6. [PMID: ] - PMC - PubMed
Hungerford 1998 {published data only}
    1. Hungerford K. A specially designed foam mattress replacement reduced pressure ulcers in nursing home residents. Evidence-Based Nursing 1998;1(2):51.
Iglesias 2006 {published data only}
    1. Iglesias C, Nixon J, Cranny G, Nelson EA, Hawkins K, Phillips A, et al. Pressure relieving support surfaces (PRESSURE) trial: cost effectiveness analysis. BMJ 2006;332(7555):1416-8. - PMC - PubMed
    1. Iglesias CP, Nixon J, Cranny G, Nelson A, Hawkins K, Philips A, et al. The NHS Health Technology Assessment Programme. Pressure trial: cost effectiveness analysis of two alternating pressure surfaces for the prevention of pressure ulcers. EWMA Journal 2006;6(1):38.
    1. Iglesias CP, Nixon J, Cranny G. Pressure trial: cost effectiveness analysis of two alternating pressure surfaces for the prevention of pressure ulcers. In: European Wound Management Association Conference; 2005 September 15-17; Stuttgart (Germany). 2005:156.
Inman 1993 {published data only}
    1. Inman KJ, Sibbald WJ, Rutledge FS, Clark BJ. Clinical utility and cost-effectiveness of an air suspension bed in the prevention of pressure ulcers. JAMA 1993;269(9):1139-43. [PMID: ] - PubMed
IRCT2016091129781N1 {published data only}
    1. IRCT2016091129781N1. Comparison gum gel and foam cushions to prevent bedsores. www.who.int/trialsearch/Trial2.aspx?TrialID=IRCT2016091129781N1.
Ismail 2001 {published data only}
    1. Ismail ZBM. Comparative study between the use of a pressure relieving overlay mattress and other mattresses commonly used by homebound patients in the community. Singapore Nursing Journal 2001;28(2):13-6.
Jiang 2014 {published data only}
    1. Jiang Q, Li X, Zhang A, Guo Y, Liu Y, Liu H, et al. Multicenter comparison of the efficacy on prevention of pressure ulcer in postoperative patients between two types of pressure-relieving mattresses in China. International Journal of Clinical and Experimental Medicine 2014;7(9):2820-7. [PMID: ] - PMC - PubMed
JPRN‐UMIN000029680 {published data only}
    1. JPRN-UMIN000029680. Effects of robotic mattress on pressure ulcer healing, comfort level among pressure ulcer patients, and nursing work load: a randomized controlled trial. www.who.int/trialsearch/Trial2.aspx?TrialID=JPRN-UMIN000029680.
Kemp 1993 {published data only}
    1. Kemp MG, Kopanke D, Tordecilla L, Fogg L, Shott S, Matthiesen V, et al. The role of support surfaces and patient attributes in preventing pressure ulcers in elderly patients. Research in Nursing & Health 1993;16(2):89-96. [PMID: ] - PubMed
Keogh 2001 {published data only}
    1. Keogh A, Dealey C. Profiling beds versus standard hospital beds: effects on pressure ulcer incidence outcomes. Journal of Wound Care 2001;10(2):15-9. [PMID: ] - PubMed
Klein 1989 {published data only}
    1. Klein L, Gilroy K. Evaluating mattress overlays and pressure relieving systems: a question of perception or reality? Journal of Enterostomal Therapy 1989;16(2):58-60. [PMID: ] - PubMed
Laurent 1998 {published data only}
    1. Laurent S. Effectiveness of pressure decreasing mattresses in cardiovascular surgery patients: a controlled clinical trial. In: 3rd European Conference for Nurse Managers; 1997 Oct; Brussels (Belgium). 1998.
Lee 1974 {published data only}
    1. Lee EOK, Kim MJ. A comparative study on the effect of gel pad, sheepskin and sponge on prevention and treatment of decubitus ulcers. Journal of Nurses Academic Society 1974;4(3):93-104.
Maklebust 1988 {published data only}
    1. Maklebust J, Brunckhorst L, Cracchiolo-Caraway A, Ducharme MA, Dundon R, Panfilli R, et al. Pressure ulcer incidence in high-risk patients managed on a special three-layered air cushion. Decubitus 1988;1(4):30-40. [PMID: ] - PubMed
Malbrain 2010 {published data only}
    1. Malbrain M, Hendriks B, Wijnands P, Denie D, Jans A, Vanpellicom J, et al. A pilot randomised controlled trial comparing reactive air and active alternating pressure mattresses in the prevention and treatment of pressure ulcers among medical ICU patients. Journal of Tissue Viability 2010;19(1):7-15. [PMID: ] - PubMed
Marutani 2019 {published data only}
    1. JPRN-UMIN000035568. Evaluation of pressure ulcer prevention and QOL for using dual-fit-air-cell-mattresses. www.who.int/trialsearch/Trial2.aspx?TrialID=JPRN-UMIN000035568.
    1. Marutani A, Okuwa M, Sugama J. Use of 2 types of air-cell mattresses for pressure ulcer prevention and comfort among patients with advanced-stage cancer receiving palliative care: an interventional study. Ostomy Wound Management 2019;65(5):24-32. - PubMed
Mastrangelo 2010a {published data only}
    1. Mastrangelo D, Farina E, Gallicchio V, De Anna D, Bresadola F. Observational study of the use of antidecubitus mattress covers in the prevention and care of pressure ulcers. Acta Vulnologica 2010;8(2):87-92.
McGinnis 2011 {published data only}
    1. McGinnis E, Stubbs N. Pressure-relieving devices for treating heel pressure ulcers. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No: CD005485. [DOI: 10.1002/14651858.CD005485.pub2] - DOI - PubMed
McInnes 2015 {published data only}
    1. McInnes E, Jammali-Blasi A, Bell-Syer SE, Dumville JC, Middleton V, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No: CD001735. [DOI: 10.1002/14651858.CD001735.pub5] - DOI - PMC - PubMed
McInnes 2018 {published data only}
    1. McInnes E, Jammali-Blasi A, Bell-Syer SE, Leung V. Support surfaces for treating pressure ulcers. Cochrane Database of Systematic Reviews 2018, Issue 10. Art. No: CD009490. [DOI: 10.1002/14651858.CD009490.pub2] - DOI - PMC - PubMed
Mendoza 2019 {published data only}
    1. Mendoza RA, Lorusso GA, Ferrer DA, Helenowski IB, Liu J, Soriano RH, et al. A prospective, randomised controlled trial evaluating the effectiveness of the fluid immersion simulation system vs an air-fluidised bed system in the acute postoperative management of pressure ulcers: a midpoint study analysis. International Wound Journal 2019;16(4):989-99. - PMC - PubMed
Mistiaen 2010a {published data only}
    1. Mistiaen P, Jolley D, McGowan S, Hickey M, Spreeuwenberg P, Francke A. The Australian Medical Sheepskin prevents pressure ulcers: a combined multilevel analysis of three RCTs. Fourth European Nursing Congress. Journal of Clinical Nursing 2010;19:20.
    1. Mistiaen P, Jolley DJ, McGowan S, Hickey MB, Spreeuwenberg P, Francke AL. 'Australian Medical Sheepskin' in the prevention of decubitus: meta-analysis with individual patient data shows efficacy ['Australische Medische Schapenvacht' ter preventie van decubitus: meta-analyse met individuele patientendata toont effectiviteit]. Nederlands Tijdschrift voor Geneeskunde 2011;155(15):686-91. [PMID: ] - PubMed
    1. Mistiaen P, Jolley DJ, McGowan S, Hickey MB, Spreeuwenberg P, Francke AL. Australian Medical Sheepskin for prevention of pressure ulcers: individual patient data meta-analysis shows effectiveness ['Australische Medische Schapenvacht' ter preventie van decubitus: meta-analyse met individuele patientendata toont effectiviteit]. Nederlands Tijdschrift voor Geneeskunde 2011;155(18):A3034. [PMID: ] - PubMed
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Nakahara 2012 {published data only}
    1. Nakahara R, Ohto S, Kato H. Treating pressure ulcers using alternating pressure replacement mattresses. In: 4th Congress of the World Union of Wound Healing Societies; 2012 September 2-6; Yokohama (Japan). 2012.
NCT01402765 {published data only}
    1. NCT01402765. Interface pressure measures for mattresses: Nimbus 3 versus Summit. clinicaltrials.gov/show/NCT01402765.
NCT02565797 {published data only}
    1. NCT02565797. Comparative prevention-effectiveness trial of DabirAIR overlay system. ClinicalTrials.gov/show/NCT02565797.
NCT02634892 {published data only}
    1. NCT02634892. Pressure redistributing overlay with targeted cooling technology (PRO-TECT) for pressure ulcer prevention. ClinicalTrials.gov/show/NCT02634892.
NCT02735135 {published data only}
    1. NCT02735135. Comparison of 2 mattresses for the prevention of bedsores by measuring skin pressure in the sacral area. clinicaltrials.gov/show/NCT02735135.
NCT03048357 {published data only}
    1. NCT03048357. Effectiveness of Freedom Bed compared to manual turning in prevention of pressure injuries in persons with limited mobility due to traumatic brain injury and/or spinal cord injury. clinicaltrials.gov/show/NCT03048357.
NCT03211910 {published data only}
    1. NCT03211910. Sacral Savers: study of prevention and enhanced healing of sacral and trochenteric ulcers. ClinicalTrials.gov/show/NCT03211910.
NCT03351049 {published data only}
    1. NCT03351049. An RCT on support surfaces for pressure ulcer prevention. ClinicalTrials.gov/show/NCT03351049.
Nixon 2006 {published data only}
    1. ISRCTN78646179. Randomised controlled trial comparing alternating pressure overlays with alternating pressure mattresses for pressure sore prevention and treatment. isrctn.com/ISRCTN78646179.
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    1. Nixon J, Cranny G, Iglesias C, Nelson EA, Hawkins K, Phillips A, et al. Randomised, controlled trial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pressure ulcers: PRESSURE (pressure relieving support surfaces) trial. BMJ 2006;332(7555):1413-5. - PMC - PubMed
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    1. Nixon J, Cranny G, Nelson A, Iglesias C, Phillips A, Hawkins K, et al. The NHS Health Technology Assessment Programme. Pressure trial clinical and patient outcomes. EWMA Journal 2006;6(1):38.
Nixon 2019 {published data only}
    1. Brown S, Smith I, Brown J, Hulme C, Nixon J. Pressure relieving support surfaces: a randomised evaluation 2 (PRESSURE 2). Trials 2013;14(Suppl 1):P68.
    1. Brown S, Smith IL, Brown JM, Hulme C, McGinnis E, Stubbs N, et al. Pressure RElieving Support SUrfaces: a Randomised Evaluation 2 (PRESSURE 2): study protocol for a randomised controlled trial. Trials 2016;17(1):604. [PMID: ] - PMC - PubMed
    1. ISRCTN01151335. Pressure RElieving Support SUrfaces: a Randomised Evaluation 2. isrctn.com/ISRCTN01151335.
    1. McGinnis E, Brown S, Collier H, Faulks P, Gilberts R, Greenwood C, et al. Pressure RElieving Support SUrfaces: a Randomised Evaluation 2 (PRESSURE 2) photographic validation sub-study: study protocol for a randomised controlled trial. Trials 2017;18(1):132. [PMID: ] - PMC - PubMed
    1. Nixon J, Brown S, Smith IL, McGinnis E, Vargas-Palacios A, Nelson EA, et al. Comparing alternating pressure mattresses and high-specification foam mattresses to prevent pressure ulcers in high-risk patients: the PRESSURE 2 RCT. Health Technology Assessment (Winchester, England) 2019;23(52):1-176. [PMID: ] - PMC - PubMed
Ooka 1995 {published data only}
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Osterbrink 2005 {published data only}
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Ozyurek 2015 {published data only}
    1. Ozyurek P, Yavuz M. Prevention of pressure ulcers in the intensive care unit: a randomized trial of 2 viscoelastic foam support surfaces. Clinical Nurse Specialist CNS 2015;29(4):210-7. [PMID: ] - PubMed
Park 2017 {published data only}
    1. Park KH, Park J. The efficacy of a viscoelastic foam overlay on prevention of pressure injury in acutely ill patients: a prospective randomized controlled trial. Journal of Wound, Ostomy, and Continence Nursing 2017;44(5):440-4. [PMID: ] - PubMed
Phillips 1999 {published data only}
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Price 1999 {published data only}
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Pring 1998 {published data only}
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Rae 2018 {published data only}
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Rafter 2011 {published data only}
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Reddy 2006 {published data only}
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Reddy 2008 {published data only}
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Ricci 2013a {published data only}
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Rithalia 1995 {published data only}
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Rosenthal 2003 {published data only}
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Russell 1999 {published data only}
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Russell 2000b {published data only}
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Russell 2000c {published data only}
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Russell 2003a {published data only}
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Russell 2003b {published data only}
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Sanada 2003 {published data only}
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Santy 1994 {published data only}
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Santy 1995 {published data only}
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Sauvage 2017 {published data only}
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Serraes 2018 {published data only}
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Shakibamehr 2019 {published data only}
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Sharp 2007 {published data only}
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Shi 2018a {published data only}
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References to studies awaiting assessment

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References to other published versions of this review

Shi 2020
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Publication types