Support surfaces for pressure ulcer prevention

Elizabeth McInnes; Nicky A Cullum; Sally EM Bell‐Syer; Jo C Dumville; Asmara Jammali‐Blasi

doi:10.1002/14651858.CD001735.pub3

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Analysis 1.1

Comparison 1 Constant low pressure supports v Standard foam mattresses (SFM), Outcome 1 Pressure ulcer incidence.

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Analysis 2.1

Comparison 2 Alternative Foam Mattress v Standard Foam Mattress, Outcome 1 Pressure ulcer incidence.

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Analysis 2.2

Comparison 2 Alternative Foam Mattress v Standard Foam Mattress, Outcome 2 Pressure ulcer incidence UK studies only.

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Analysis 3.1

Comparison 3 Comparisons Between Alternative Foam Supports, Outcome 1 Pressure ulcer incidence.

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Analysis 4.1

Comparison 4 Comparisons Between CLP Supports, Outcome 1 Pressure ulcer incidence.

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Analysis 5.1

Comparison 5 Alternating Pressure v Standard Foam Mattress, Outcome 1 Pressure ulcer incidence.

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Analysis 6.1

Comparison 6 Alternating Pressure v Constant Low Pressure, Outcome 1 Pressure ulcer incidence.

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Analysis 6.2

Comparison 6 Alternating Pressure v Constant Low Pressure, Outcome 2 AP devices versus silicore or foam overlay.

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Analysis 6.3

Comparison 6 Alternating Pressure v Constant Low Pressure, Outcome 3 AP devices versus water or static air mattress.

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Analysis 7.1

Comparison 7 AP and CLP in ICU/Post ICU (Factorial Design), Outcome 1 Pressure ulcer incidence.

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Analysis 8.1

Comparison 8 Comparisons Between Alternating Pressure Devices, Outcome 1 Pressure ulcer incidence.

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Analysis 9.1

Comparison 9 Low Air Loss v Standard Bed, Outcome 1 Pressure ulcer incidence.

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Analysis 9.2

Comparison 9 Low Air Loss v Standard Bed, Outcome 2 Pressure incidence pooled.

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Analysis 9.3

Comparison 9 Low Air Loss v Standard Bed, Outcome 3 Incidence of patients developing multiple sores.

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Analysis 10.1

Comparison 10 Air‐Fluidised Therapy v Dry Flotation, Outcome 1 Rate of wound breakdown.

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Analysis 11.1

Comparison 11 Kinetic Treatment Table v Standard, Outcome 1 Pressure ulcer incidence.

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Analysis 12.1

Comparison 12 Operating Table Overlay v No Overlay, Outcome 1 Pressure ulcer incidence.

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Analysis 13.1

Comparison 13 Micropulse System for Surgical Patients, Outcome 1 Pressure ulcer incidence.

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Analysis 14.1

Comparison 14 Seat Cushions, Outcome 1 Pressure ulcer incidence.

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Table 1. Quality Assessment of Included Studies and sample sizes

Trial	Clear inc & excl	Sample size(arms)	A priori calc	True RCT	Baseline comp	Blind outcome assess	Grade 1 sore exclude	Intervent well docum
Andersen 1982	yes	482(3)	yes	no	yes	no	yes	no
Aronovitch 1999	yes	217(2)	no	no	yes	yes	yes	yes
Bennett 1998	yes	98(2)	no	no	yes	no	yes	no
Cadue 2008	yes	70/69 (2)	no	yes	yes	unclear	no	yes
Cavicchioli 2007	yes	170 (2)	no	unclear	yes	yes	no	yes
Cobb 1997	yes	123 (2)	no	yes	no	unclear	no	yes
Collier 1996	no	99(9)	no	yes	no	no	n/a	yes
Conine 1990	yes	187(2)	no	no	yes	yes	yes	no
Conine 1993	yes	288(2)	no	unclear	yes	yes	unclear	yes
Conine 1994	yes	163(2)	no	no	yes	yes	yes	yes
Cooper 1998	yes	100(2)	no	yes	yes	no	yes	yes
Daechsel 1985	yes	32(2)	no	no	yes	no	no	yes
Economides 1995	yes	12(2)	no	yes	yes	no	yes	yes
Ewing 1964	no	30(2)	no	no	no	no	no	yes
Exton‐Smith 1982	yes	66(2)	no	on	yes	no	yes	yes
Feuchtinger 2006	yes	175 (2)	yes	Unclear	yes	yes	no	yes
Gebhardt 1994	yes	230(2)	no	no	yes	no	yes	yes
Gentilello 1988	yes	65(2)	no	yes	yes	no	no	yes
Geyer 2001	yes	32 (2)	no	yes	yes	yes	unclear	yes
Gilcreast 2005	yes	338 (2)	yes	yes	no	unclear	no	yes
Goldstone 1982	yes	75(2)	no	no	yes	no	no	yes
Gray 1994b	yes	100(2)	no	yes	yes	yes	yes	no
Gray 1994a	yes	170(2)	no	yes	yes	no	yes	yes
Gunningberg 2000	yes	101(2)	yes	yes	yes	yes	yes	yes
Hampton 1997	yes	75(2)	no	no	no	no	no	yes
Hofman 1994	yes	44(2)	yes	no	yes	no	yes	yes
Inman 1993	yes	100(2)	yes	no	yes	no	yes	no
Jolley 2004	yes	539 (2)	Unclear	yes	yes	no	no	yes
Kemp 1993	yes	84(2)	no	yes	yes	yes	no	no
Keogh 2001	yes	100(2)	yes	yes	yes	unclear	unclear	yes
Laurent 1997	yes	312(4)	yes	no	yes	no	yes	yes
Lazzara 1991	yes	74(2)	no	yes	no	no	yes	no
Lim 1988	yes	62(2)	no	no	yes	yes	yes	yes
McGowan 2000	yes	297(2)	yes	no	yes	no	no	yes
Nixon 1998	yes	446(2)	yes	yes	yes	yes	yes	yes
Nixon 2006	yes	1972 (2)	yes	yes	yes	no	yes	yes
Price 1999	yes	80(2)	yes	yes	yes	no	yes	no
Russell 2000	yes	198(2)	no	yes	yes	no	no	yes
Russell 2002	yes	1166(2)	yes	yes	yes	no	no	yes
Sanada 2003	yes	103 (3)	Unclear	yes	yes	no	no	yes
Santy 1994	yes	505(5)	yes	yes	yes	no	no	yes
Schultz 1999	yes	413(2)	yes	yes	yes	yes	no	no
Sideranko 1992	yes	57(3)	no	no	yes	no	no	no
Stapleton 1986	yes	100(3)	no	no	no	no	yes	no
Summer 1989	yes	83(2)	no	no	yes	no	no	yes
Takala 1996	yes	40(2)	yes	no	yes	no	yes	yes
Taylor 1999	yes	44(2)	yes	unclear	yes	unclear	no	yes
Theaker 2005	yes	62 (2)	yes	yes	yes	no	Unclear	yes
Tymec 1997	yes	52(2)	yes	no	no	no	yes	yes
Vanderwee 2005	yes	447 (2)	yes	yes	yes	no	yes	yes
Vyhlidal 1997	yes	40(2)	no	no	yes	no	yes	yes
Whitney 1984	no	51(2)	no	no	no	no	no	no

Table 1. Quality Assessment of Included Studies and sample sizes

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Comparison 1. Constant low pressure supports v Standard foam mattresses (SFM)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pressure ulcer incidence Show forest plot	7		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

1.1 Water	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 Bead Bed	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
1.3 Comfortex DeCube mattress	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
1.4 Softform mattress	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
1.5 Alternative foam	2		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
1.6 Hi spec foam mattress/cushion	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 1. Constant low pressure supports v Standard foam mattresses (SFM)

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Comparison 2. Alternative Foam Mattress v Standard Foam Mattress

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pressure ulcer incidence Show forest plot	5	2016	Risk Ratio (M‐H, Random, 95% CI)	0.40 [0.21, 0.74]

1.1 Various alternatives (pooled)	5	2016	Risk Ratio (M‐H, Random, 95% CI)	0.40 [0.21, 0.74]
2 Pressure ulcer incidence UK studies only Show forest plot	4	1980	Risk Ratio (M‐H, Random, 95% CI)	0.41 [0.19, 0.87]

Comparison 2. Alternative Foam Mattress v Standard Foam Mattress

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Comparison 3. Comparisons Between Alternative Foam Supports

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pressure ulcer incidence Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.1 alternative foam v standard foam	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Maxifloat Foam Mattress v Iris Foam Overlay	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.3 Solid Foam v Convoluted Foam	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 3. Comparisons Between Alternative Foam Supports

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Comparison 4. Comparisons Between CLP Supports

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pressure ulcer incidence Show forest plot	8		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 Sofflex v ROHO	1	84	Risk Ratio (M‐H, Random, 95% CI)	0.63 [0.16, 2.47]
1.2 Optima v SFM	1	40	Risk Ratio (M‐H, Random, 95% CI)	0.06 [0.00, 0.99]
1.3 Gel Mattress v Air‐filled Overlay	1	66	Risk Ratio (M‐H, Random, 95% CI)	0.8 [0.24, 2.72]
1.4 Static Air Mattress v Water Mattress	1	37	Risk Ratio (M‐H, Random, 95% CI)	0.42 [0.04, 4.29]
1.5 Foam Overlay v Silicore Overlay	1	68	Risk Ratio (M‐H, Random, 95% CI)	1.17 [0.64, 2.14]
1.6 Sheepskin v no sheepskin	2	738	Risk Ratio (M‐H, Random, 95% CI)	0.42 [0.22, 0.81]
1.7 Foam support surface v no support	1	69	Risk Ratio (M‐H, Random, 95% CI)	0.15 [0.05, 0.47]

Comparison 4. Comparisons Between CLP Supports

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Comparison 5. Alternating Pressure v Standard Foam Mattress

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pressure ulcer incidence Show forest plot	2	409	Risk Ratio (M‐H, Fixed, 95% CI)	0.31 [0.17, 0.58]

Comparison 5. Alternating Pressure v Standard Foam Mattress

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Comparison 6. Alternating Pressure v Constant Low Pressure

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pressure ulcer incidence Show forest plot	10	1606	Risk Ratio (M‐H, Random, 95% CI)	0.85 [0.64, 1.13]

1.1 AP (various) v CLP (various)	1	230	Risk Ratio (M‐H, Random, 95% CI)	0.38 [0.22, 0.66]
1.2 AP v Silicore or Foam Overlay	4	331	Risk Ratio (M‐H, Random, 95% CI)	0.91 [0.72, 1.16]
1.3 AP v Water or Static Air Mattress	3	458	Risk Ratio (M‐H, Random, 95% CI)	1.31 [0.51, 3.35]
1.4 AP v continuous low pressure mattress	1	140	Risk Ratio (M‐H, Random, 95% CI)	2.06 [0.19, 22.18]
1.5 AP v Visco‐elastic foam mattress	1	447	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.64, 1.52]
2 AP devices versus silicore or foam overlay Show forest plot	4	331	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.71, 1.17]

3 AP devices versus water or static air mattress Show forest plot	3	458	Risk Ratio (M‐H, Random, 95% CI)	1.31 [0.51, 3.35]

Comparison 6. Alternating Pressure v Constant Low Pressure

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Comparison 7. AP and CLP in ICU/Post ICU (Factorial Design)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pressure ulcer incidence Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.1 Std ICU/SFM post‐ICU v Nimbus AP ICU/SFM post‐ICU	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Std ICU/SFM post‐ICU v Std ICU/Tempur CLP post‐ICU	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.3 Nimbus AP ICU/SFM post‐ICU v Std ICU/Tempur CLP post‐ICU	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.4 Std ICU/SFM post‐ICU v Nimbus AP ICU/Tempur CLP post‐ICU	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.5 Nimbus AP ICU/SFM post‐ICU v Nimbus ICU/Tempur post‐ICU	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.6 Std ICU/Tempur post‐ICU v Nimbus ICU/Tempur post‐ICU	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 7. AP and CLP in ICU/Post ICU (Factorial Design)

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Comparison 8. Comparisons Between Alternating Pressure Devices

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pressure ulcer incidence Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.1 Airwave v Large Cell Ripple	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Airwave v Pegasus Carewave	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.3 Trinova v control	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.4 AP Overlay v AP Mattress	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.5 TheraPulse v Duo	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 8. Comparisons Between Alternating Pressure Devices

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Comparison 9. Low Air Loss v Standard Bed

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pressure ulcer incidence Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2 Pressure incidence pooled Show forest plot	2	221	Risk Ratio (M‐H, Random, 95% CI)	0.33 [0.16, 0.67]

3 Incidence of patients developing multiple sores Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 9. Low Air Loss v Standard Bed

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Comparison 10. Air‐Fluidised Therapy v Dry Flotation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Rate of wound breakdown Show forest plot	1	12	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.20, 4.95]

Comparison 10. Air‐Fluidised Therapy v Dry Flotation

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Comparison 11. Kinetic Treatment Table v Standard

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pressure ulcer incidence Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 11. Kinetic Treatment Table v Standard

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Comparison 12. Operating Table Overlay v No Overlay

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pressure ulcer incidence Show forest plot	2		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 Viscoelastic polymer pad v No overlay	1	416	Risk Ratio (M‐H, Random, 95% CI)	0.53 [0.33, 0.85]
1.2 Viscoelastic foam overlay v No overlay	1	175	Risk Ratio (M‐H, Random, 95% CI)	1.53 [0.69, 3.39]

Comparison 12. Operating Table Overlay v No Overlay

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Comparison 13. Micropulse System for Surgical Patients

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pressure ulcer incidence Show forest plot	2	368	Risk Ratio (M‐H, Fixed, 95% CI)	0.21 [0.06, 0.70]

Comparison 13. Micropulse System for Surgical Patients

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Comparison 14. Seat Cushions

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pressure ulcer incidence Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.1 Slab Foam v Bespoke Contoured Foam	2		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Jay Gel Cushion v Foam	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.3 Pressure reducing cushion v standard foam cushion	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 14. Seat Cushions

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