Support surfaces for pressure ulcer prevention

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

doi:10.1002/14651858.CD001735.pub5

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Figure 1

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included trials.

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Analysis 1.1

Comparison 1 Constant low‐pressure supports (CLP) vs standard foam mattresses (SFM), Outcome 1 Pressure ulcer incidence.

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Analysis 2.1

Comparison 2 Alternative foam mattress vs standard foam mattress, Outcome 1 Pressure ulcer incidence.

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Analysis 2.2

Comparison 2 Alternative foam mattress vs 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 4.2

Comparison 4 Comparisons between CLP supports, Outcome 2 Pressure ulcer incidence.

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Analysis 5.1

Comparison 5 Alternating‐pressure vs standard foam mattress, Outcome 1 Pressure ulcer incidence.

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Analysis 6.1

Comparison 6 Alternating‐pressure (AP) vs constant low‐pressure, Outcome 1 Pressure ulcer incidence.

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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 vs standard bed, Outcome 1 Pressure ulcer incidence.

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Analysis 9.2

Comparison 9 Low Air Loss vs standard bed, Outcome 2 Pressure incidence pooled.

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Analysis 9.3

Comparison 9 Low Air Loss vs standard bed, Outcome 3 Incidence of patients developing multiple ulcers.

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Analysis 10.1

Comparison 10 Air‐Fluidised therapy vs dry flotation, Outcome 1 Rate of wound breakdown.

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Analysis 11.1

Comparison 11 Kinetic treatment table vs standard care, Outcome 1 Pressure ulcer incidence.

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Analysis 12.1

Comparison 12 Operating table overlay vs 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. Additional information on included studies

Trial	Clear inclusion & exclusion criteria	Sample size (arms)	A priori calculation	Grade 1 ulcer excluded	Intervention well documented
Andersen 1982	Yes	482 (3)	Yes	Yes	No
Aronovitch 1999	Yes	217 (2)	No	Yes	Yes
Bennett 1998	Yes	98 (2)	No	Yes	No
Brienza 2010	Yes	113/119 (2)	No	No	Yes
Cadue 2008	Yes	70/69 (2)	No	No	Yes
Cavicchioli 2007	Yes	170 (2)	No	No	Yes
Cobb 1997	Yes	123 (2)	No	No	Yes
Collier 1996	No	99 (9)	No	Not applicable	Yes
Conine 1990	Yes	187 (2)	No	Yes	No
Conine 1993	Yes	288 (2)	No	Yes	Yes
Conine 1994	Yes	163 (2)	No	Yes	Yes
Cooper 1998	Yes	100 (2)	No	Yes	Yes
Daechsel 1985	Yes	32 (2)	No	No	Yes
Demarre 2011	Yes	298/312 (2)	No	No	Yes
Donnelly 2011	Yes	120/119 (2)	No	No	Yes
Economides 1995	Yes	12 (2)	No	Yes	Yes
Ewing 1964	No	30 (2)	No	No	Yes
Exton‐Smith 1982	Yes	66 (2)	No	Yes	Yes
Feuchtinger 2006	Yes	175 (2)	Yes	No	Yes
Gebhardt 1996	Yes	43 (2)	No	Unclear	Yes
Gentilello 1988	Yes	65 (2)	No	No	Yes
Geyer 2001	Yes	32 (2)	No	Unclear	Yes
Gilcreast 2005	Yes	338 (2)	Yes	No	Yes
Goldstone 1982	Yes	75 (2)	No	No	Yes
Gray 1998	Yes	100 (2)	No	Yes	No
Gray 1994	Yes	170 (2)	No	Yes	Yes
Gunningberg 2000	Yes	101 (2)	Yes	Yes	Yes
Hampton 1997	Yes	75 (2)	No	No	Yes
Hofman 1994	Yes	44 (2)	Yes	Yes	Yes
Inman 1993	Yes	100 (2)	Yes	Yes	No
Jolley 2004	Yes	539 (2)	No	No	Yes
Kemp 1993	Yes	84 (2)	No	No	No
Keogh 2001	Yes	100 (2)	Yes	Yes	Yes
Laurent 1998	Yes	312 (4)	Yes	Yes	Yes
Lazzara 1991	Yes	74 (2)	No	Yes	No
Lim 1988	Yes	62 (2)	No	Yes	Yes
McGowan 2000	Yes	297 (2)	Yes	No	Yes
Mistiaen 2009	Yes	5434 (2)	Yes	No	Yes
Nixon 1998	Yes	446 (2)	Yes	Yes	Yes
Nixon 2006	Yes	1972 (2)	Yes	Yes	Yes
Price 1999	Yes	80 (2)	Yes	Yes	No
Ricci 2013	Yes	25 (2)	No	Yes	Yes
Russell 2000	Yes	198 (2)	No	No	Yes
Russell 2003	Yes	1166 (2)	Yes	No	Yes
Sanada 2003	Yes	103 (3)	Unclear	No	Yes
Santy 1994	Yes	505 (5)	Yes	No	Yes
Schultz 1999	Yes	413 (2)	Yes	No	No
Sideranko 1992	Yes	57 (3)	No	No	No
Stapleton 1986	Yes	100 (3)	No	Yes	No
Summer 1989	Yes	83 (2)	No	No	Yes
Takala 1996	Yes	40 (2)	Yes	Yes	Yes
Taylor 1999	Yes	44 (2)	Yes	No	Yes
Theaker 2005	Yes	62 (2)	Yes	Unclear	Yes
Tymec 1997	Yes	52 (2)	Yes	Yes	Yes
van Leen 2011	No	41/42 (2)	No	Yes	No
Vanderwee 2005	Yes	447 (2)	Yes	Yes	Yes
Vermette 2012	No	55 (2)	Yes	Unclear	Yes
Vyhlidal 1997	Yes	40 (2)	No	Yes	Yes
Whitney 1984	No	51 (2)	No	No	No

Table 1. Additional information on included studies

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Comparison 1. Constant low‐pressure supports (CLP) vs 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	2407	Risk Ratio (M‐H, Random, 95% CI)	0.38 [0.24, 0.61]

1.1 Cubed foam mattress	1	36	Risk Ratio (M‐H, Random, 95% CI)	0.34 [0.14, 0.85]
1.2 Bead‐filled mattress	1	75	Risk Ratio (M‐H, Random, 95% CI)	0.32 [0.14, 0.76]
1.3 Softform mattress	1	170	Risk Ratio (M‐H, Random, 95% CI)	0.20 [0.09, 0.45]
1.4 Water‐filled mattress	1	316	Risk Ratio (M‐H, Random, 95% CI)	0.35 [0.15, 0.79]
1.5 Alternative foam	2	644	Risk Ratio (M‐H, Random, 95% CI)	0.36 [0.22, 0.59]
1.6 Hi‐spec foam mattress/cushion	1	1166	Risk Ratio (M‐H, Random, 95% CI)	0.78 [0.55, 1.11]

Comparison 1. Constant low‐pressure supports (CLP) vs standard foam mattresses (SFM)

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Comparison 2. Alternative foam mattress vs 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 vs 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	5		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.1 Alternative foam vs standard foam	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Foam mattress vs foam overlay	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.3 Solid foam vs convoluted foam	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.4 Transfoam mattress vs Transfoamwave mattress	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.5 Cold foam mattress vs cold foam mattress and static air overlay	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	11	2138	Risk Ratio (M‐H, Fixed, 95% CI)	0.45 [0.36, 0.56]

1.1 Optima vs SFM	1	40	Risk Ratio (M‐H, Fixed, 95% CI)	0.06 [0.00, 0.99]
1.2 Sofflex vs ROHO	1	84	Risk Ratio (M‐H, Fixed, 95% CI)	0.63 [0.16, 2.47]
1.3 Gel mattress vs air‐filled overlay	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.8 [0.24, 2.72]
1.4 Static air mattress vs water mattress	1	37	Risk Ratio (M‐H, Fixed, 95% CI)	0.43 [0.04, 4.29]
1.5 Foam overlay vs Silicore overlay	1	68	Risk Ratio (M‐H, Fixed, 95% CI)	1.17 [0.64, 2.14]
1.6 Sheepskin vs no sheepskin (Including all pressure ulcers regardless of Grade)	3	1424	Risk Ratio (M‐H, Fixed, 95% CI)	0.48 [0.36, 0.64]
1.7 Foam support surface vs no support	1	70	Risk Ratio (M‐H, Fixed, 95% CI)	0.16 [0.05, 0.49]
1.8 Heel‐lift suspension boot and various support surfaces vs support surfaces alone	1	239	Risk Ratio (M‐H, Fixed, 95% CI)	0.26 [0.12, 0.53]
1.9 Inflated static overlay vs microfluid static overlay or LAL dyname mattress	1	110	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.07, 1.58]
2 Pressure ulcer incidence Show forest plot	3	1424	Risk Ratio (M‐H, Random, 95% CI)	0.59 [0.33, 1.05]

2.1 Sheepskin vs no sheepskin (grade 2 + pressure ulcers only)	3	1424	Risk Ratio (M‐H, Random, 95% CI)	0.59 [0.33, 1.05]

Comparison 4. Comparisons between CLP supports

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Comparison 5. Alternating‐pressure vs 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 vs standard foam mattress

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Comparison 6. Alternating‐pressure (AP) vs 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) vs CLP (various)	1	230	Risk Ratio (M‐H, Random, 95% CI)	0.38 [0.22, 0.66]
1.2 AP vs Silicore or foam overlay	4	331	Risk Ratio (M‐H, Random, 95% CI)	0.91 [0.72, 1.16]
1.3 AP vs water or static air mattress	3	458	Risk Ratio (M‐H, Random, 95% CI)	1.31 [0.51, 3.35]
1.4 AP vs continuous low pressure mattress	1	140	Risk Ratio (M‐H, Random, 95% CI)	2.06 [0.19, 22.18]
1.5 AP vs visco‐elastic foam mattress	1	447	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.64, 1.52]

Comparison 6. Alternating‐pressure (AP) vs 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 Standard ICU/SFM post‐ICU vs Nimbus AP ICU/SFM post‐ICU	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Standard ICU/SFM post‐ICU vs standard 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 vs standard ICU/Tempur CLP post‐ICU	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.4 Standard ICU/SFM post‐ICU vs 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 vs Nimbus ICU/Tempur post‐ICU	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.6 Standard ICU/Tempur post‐ICU vs 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	6		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.1 Airwave vs Large Cell Ripple	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Airwave vs Pegasus Carewave	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.3 Trinova vs control	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.4 AP overlay vs AP mattress	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.5 TheraPulse vs Duo	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.6 AP mattress (single stage inflation) vs AP mattress (multi stage inflation)	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 vs 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 ulcers Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 9. Low Air Loss vs standard bed

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Comparison 10. Air‐Fluidised therapy vs 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		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 10. Air‐Fluidised therapy vs dry flotation

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Comparison 11. Kinetic treatment table vs standard care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pressure ulcer incidence Show forest plot	2	151	Risk Ratio (M‐H, Fixed, 95% CI)	1.23 [0.57, 2.65]

Comparison 11. Kinetic treatment table vs standard care

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Comparison 12. Operating table overlay vs 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 vs no overlay	1	416	Risk Ratio (M‐H, Random, 95% CI)	0.53 [0.33, 0.85]
1.2 Viscoelastic foam overlay vs no overlay	1	175	Risk Ratio (M‐H, Random, 95% CI)	1.53 [0.69, 3.39]

Comparison 12. Operating table overlay vs 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	5		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]
1.4 Skin protection cushion with segmented foam cushion	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 14. Seat cushions

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