2014 Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline

News and Statements

Nov 2016 World Stop Pressure Ulcer Day 2016
Jun 2016 NPUAP Staging System revision
Jan 2016 Small Cell Technology in Alternating Pressure Mattresses
Nov 2015 World Stop Pressure Ulcer Day 2015

World Stop Pressure Ulcer Day 2016

November 2016

To celebrate World Stop Pressure Ulcer/Injury Day, a 25% discount will apply to all purchases of the Guideline from November 17th.

Visit the online shop to order your copy of the Guideline.

NPuAP Staging System revision

June 2016

The National Pressure Ulcer Advisory Panel (NPUAP) recently released the NPUAP Pressure Injury Staging System based on a review of the literature, stakeholder comments and the results of a consensus conference involving 400 participants. Additional information can be found at www.npuap.org. The International Guideline Development Group (including representatives from the EPUAP, PPPIA and NPUAP) have reviewed the work of the NPUAP and determined that the International Pressure Ulcer Classification System published in the 2014 International Guideline is still valid. Although the NPUAP altered some terms and clarified definitions, there have been no substantive conceptual changes to the 2014 International Pressure Ulcer Classification System. What clinicians have always classified as a "Category/Stage I" is still a "Category/Stage 1". A "Category/Stage II" is still a "Category/Stage 2". Et cetera.

The International Guideline Development Group congratulates their colleagues in the NPUAP and looks forward to further validation of the new NPUAP Pressure Injury Staging System and its impact on education, practice, research and public policy. Revisions to the International Pressure Ulcer Classification System will be considered for the next guideline update using our established guideline methodology. The international pressure ulcer guideline methodology is designed to ensure that all new research has been systematically reviewed and evaluated; small working groups with international representation have reviewed available evidence before making changes and the input of a broad range of international stakeholders has been considered.

Small Cell Technology in Alternating Pressure Mattresses

January 2016

The International Guideline Development Group (GDG) has reviewed the evidence on small cell technology in alternating pressure mattresses. The recommendation to avoid using small cell alternating pressure mattresses and overlays has been retracted by the guideline development team.

In one older study (Bliss, McLaren et al., 1966) pressure ulcers occurred more frequently in individuals who received a small cell mattress (diameter 1.5 to 2 inches or 3.8 to 5.1 cm) compared with a large cell mattress (diameter 6 inches or 15.25 cm). However, both the mattresses trialled in this study used technology and materials that are outdated and the results cannot be extrapolated to contemporary technologies.

When selecting a mattress or overlay with alternating pressure features the choice should be individualized according to pressure ulcer risk, comfort of the individual and effectiveness determined through regular skin assessments. Clinical evaluation of an alternating pressure support surface should include assessment of the individual using the surface in supine, lateral and sitting positions, and the potential for the support surface to redistribute pressure without "bottoming out". The individual's body shape, size, weight distribution, and any asymmetrical bony prominences may influence the performance of an alternating pressure support surface.

A range of factors and combinations of other features in the design of mattresses and overlays with alternating pressure features likely contribute to their effectiveness in reducing the incidence of pressure ulcers. The diameter, height, length and width of the air bladders may all be important in the effectiveness of mattress designs. The internal pressures of air bladders, the layout of the cells, the way in which the cells are connected to the system, and the alternating pressure cycle amplitude and frequency are also factors that are likely to contribute to effectiveness. Earlier mattresses with alternating pressure such as those used in the Bliss, McLaren et al. (1966) study had high internal bladder pressures (up to 100mmHg) and were constructed of stiff plastic materials. The cells were arranged in rows through which pressure alternated in a "ripple wave" (Bliss, McLaren et al., 1966) and it was noted that incidence of pressure ulcers were higher in individuals considered to be more bony. Following the study by Bliss (1966) the small cell design of alternating pressure mattress was abandoned in favour of the large cell design (Bliss, 1978). However, the pressure ulcer incidence rate noted for the large cell design ripple mattress used in Bliss' study was still high (33% in high-risk individuals who were pressure ulcer free at commencement) (Bliss, McLaren et al., 1966) and ongoing concerns regarding the functionality of this large cell ripple mattress design, for example its easily displaced or kinked tubing and high maintenance requirements, were documented by Bliss in 1978 (Bliss, 1978). Health professionals in geographic regions that still have access to the old small cell ripple mattress designs should be aware that smaller cell diameters have been associated with significantly higher risk of pressure ulcers compared to large cell mattress designs (Bliss 1966). Health professionals should also be aware that some large cell alternating pressure ripple mattresses are also associated with high pressure ulcer incidence (Bliss, McLaren et al., 1966); (Manzano, Pérez et al., 2013) and should work toward acquiring contemporary alternating pressure mattresses or overlays for individuals at high risk of pressure ulcers.

Contemporary alternating pressure mattresses are manufactured with layers of material (often with a second layer of air cells or foam bottom layer) and generally use a combination of cell sizes in their design. Many contemporary alternating pressure mattresses have internal sensors with feedback loops that adjust for high internal pressure. In a study by Nixon, Cranny et al. (2006) comparing two contemporary alternating pressure mattresses/overlays, there was no significant difference in incidence of new pressure ulcers between an alternating pressure overlay with a cell height of 8.5 cm to 12.25 cm and an alternating pressure mattress with a cell height of 19.6 cm to 29.4 cm (10% overlay vs 9.3% replacement mattress; p=0.58). In a study by Manzano, Pérez et al. (2013) significant differences were noted in development of Category/Stage 3 and 4 pressure ulcers between an alternating pressure overlay reported as having a maximum cell height of 6.5 cm and an alternating pressure mattress reported as having cells of 13.5cm height. However, the "small cell" overlay referred to in this study had a shorter alternating pressure cycle than most contemporary alternating pressure mattresses, used ripple wave technology and the reported cell heights for both mattresses was not consistent with manufacturer information.

Evaluation of the effectiveness of alternating pressure mattresses and overlays is made more difficult by the failure of researchers to adequately and accurately report the specifications of the products used in trials, as well as the many specifications that vary between products (i.e. cell height/width/diameter, bladder pressure, cell construction, inflation/deflation cycle amplitude and frequency and various safety features). These factors appear to influence the ability of the alternating pressure mattress to attain effective loading and unloading.


  • Bliss, M. (1978). "The use of Ripple beds." Age and Ageing 7(25):25-7.
  • Bliss, M.R., R. McLaren and A.N. Exton-Smith. (1966). "Mattresses for preventing pressure sores in geriatric patients." Medical Bulletin of the Ministry of Health 25:238-67.
  • Manzano, F., A.M. Pérez, M. Colmenero, et al. (2013). "Comparison of alternating pressure mattresses and overlays for prevention of pressure ulcers in ventilated intensive care patients: A quasi-experimental study." Journal of Advanced Nursing Epub 2013 Jan 24.
  • Nixon, J., G. Cranny, C. Iglesias, et al. (2006). "Randomised, controlled trial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pressure ulcers: PRESSURE (pressure relieving support surfaces) trial." British Medical Journal 332(7555):1413-.

World Stop Pressure Ulcer Day 2015

November 2015

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