Clinical Question
Should a pressure redistribution seating surface/cushion versus a non-pressure redistribution seating surface be used to prevent PI occurrence in individuals at risk?
Context
Population:
Intervention:
Comparison:
Main Outcomes:
Setting:
Background:
Conflicts of Interest:
Individuals at risk of pressure injuries
Pressure redistribution seating surface
Non-pressure redistribution seating surface
Any clinical setting
Pressure Injury (PI) occurrence
No Guideline Governance Group members of Core Review Group members had a conflict of interest
Evidence to Decision Framework
(Click on the Individual judgements for more information)
Summary of Judgements
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Yes
Small
Trivial
Moderate
No important uncertainty or variability
Probably favors the intervention
Varies
No included studies
No included studies
Probably increased
Probably yes
Probably yes
1. Problem:
Is the problem (pressure injuries) a priority?
JUDGEMENT
No
Probably No
Probably Yes
Yes
Varies
Don’t Know
RESEARCH EVIDENCE
The problem of preventing pressure injuries is a significant priority to healthcare in most clinical settings. In a stakeholder survey conducted by the Guideline Governance Group in 2021, the target audiences for the guideline, including individuals with or at risk of PIs, their informal carers and health professionals, all identified that receiving clinical guidance on selection of support surfaces is of the highest priority (median ranking 5/5).
In an earlier survey conducted by the International Pressure Injury Guideline, Guideline Governance Group (Haesler, Pittman et al. 2022), 68.6% (263/383) of individuals with or at risk of PIs and 61.5% (523/850) of informal carers rated receiving information on support surfaces to use as important or very important. The median priority ranking for receiving information on support surfaces was 4/5 for both individuals with or at risk of PIs of informal carers (Haesler, Pittman et al. 2022).
2. Desirable Effects:
How substantial are the desirable anticipated effects?
JUDGEMENT
Trivial
Small
Moderate
Large
Varies
Don’t Know
RESEARCH EVIDENCE
| Outcome | Pressure redistribution seating surfaces |
Non-pressure redistribution seating surfaces |
Difference | Relative effect |
|---|---|---|---|---|
| PI occurrence | 139/347 (40.1%) | 163/358 (45.5%) | 64 fewer PIs per 1,000 (from 118 fewer to 5 more) |
RR 0.86 (0.74-1.01) |
Outcome 1: PI Occurrence
The meta-analysis included five randomized controlled trials (RCTs) (Lim, Sirett et al. 1988, Conine, Daechsel et al. 1993, Conine, Hershler et al. 1994, Geyer, Brienza et al. 2001, Brienza, Kelsey et al. 2010) that compared a cushion with pressure redistribution characteristics (including contoured foam, a gel cushion, and a skin protection cushion) with a comparator foam cushion without pressure redistribution characteristics for people in seated positions.** Participants in four of the five included studies (Conine, Daechsel et al. 1993, Conine, Hershler et al. 1994, Geyer, Brienza et al. 2001, Brienza, Kelsey et al. 2010) were older adults using cushions for wheelchair seating; in the fifth study (Lim, Sirett et al. 1988) the participants were older adults using a cushion on any seat. The meta-analysis showed that using a pressure redistribution cushion in a seated position is associated with a lower rate of PIs compared to using a cushion without pressure redistribution characteristics (RR = 0.86, 95% CI 0.74 to 1.01). There is moderate certainty that using a pressure redistribution cushion when seated could prevent a new Category/Stage 1 or greater PIs versus a non-pressure redistribution cushion.
** Support surfaces reported in the research were considered in this Guideline based on their categorization by the researchers (at the time the research was undertaken). Where available, the product name and characteristics were included in the data extraction tables. Product names/technology may have changed. Due to advances in technology, currently available support surfaces in the same category may have different performance characteristics.
3. Undesirable Effects:
How substantial are the undesirable anticipated effects?
JUDGEMENT
Trivial
Small
Moderate
Large
Varies
Don’t Know
RESEARCH EVIDENCE
The Panel Group noted that there is a risk of reduced functionality or other adverse events (e.g. pressure injuries, instability or falls) if the selected pressure redistribution cushion is not appropriately fitted to the individual and the seat. The pressure redistribution cushions used in most of the studies were made-to-measure/fitted to individuals and their seats and adverse events were not reported. Based on available evidence and the Guideline Governance Group’s experience, no significant undesirable effects are associated with a seating cushion if it has pressure redistribution properties and is used according to manufacturer’s instructions.
4. Overall certainty of evidence:
What is the overall certainty of the evidence of effects?
JUDGEMENT
Very low
Low
Moderate
High
No included studies
RESEARCH EVIDENCE
Relative importance of main outcome measures
| Outcome | Relative Importance | Certainty of Evidence |
|---|---|---|
| PI occurrence | CRITICAL | MODERATE |
Outcome 1: PI occurrence
In a Delphi survey (Lechner, Coleman et al. 2022) that developed a core outcomes et for PI prevention trials, the outcome of PI occurrence was rated as being of critical importance (score of 7-9). The evidence was of moderate certainty. The evidence was downgraded once for risk of bias based on critical appraisal reported in a previous meta-analysis (McInnes, Jammali-Blasi et al. 2015). Three of the studies were at unclear risk of selection, performance, detection and attrition bias.
5. Values:
Is there important uncertainty about or variability in how much people value the main outcomes (PI occurence)?
JUDGEMENT
Important uncertainty or variability
Possibly important uncertainty or variability
Probably no important uncertainty or variability
No important uncertainty or variability
RESEARCH EVIDENCE
In a Delphi survey (Lechner, Coleman et al. 2022) that developed a core outcomes et for PI prevention trials, the outcome of PI occurrence was rated as being of critical important (score of 7-9) by all types of stakeholders (health professionals, people with or at risk of a PI and their informal carers, industry representatives and researchers). Greater than 90% of the 158 participants rated this outcome measure as critically important (Lechner, Coleman et al. 2022).
6. Balance of Effects:
Does the balance between desirable and undesirable effects favour the intervention (pressure-redistribution surface) or the comparison (non-pressure redistribution surface)?
JUDGEMENT
Favors the comparison
Probably favors the comparison
Does not favor either the intervention or the comparison
Probably favors the intervention
Favors the intervention
Varies
Don’t know
RESEARCH EVIDENCE
Undesirable effects were trivial in the available RCTs and not reported as a concern throughout the literature.
7. Resources Required:
How large are resource requirements (costs) of the intervention (pressure redistribution support surface)?
JUDGEMENT
Large costs
Moderate costs
Negligible costs and savings
Moderate savings
Large savings
Varies
Don’t know
RESEARCH EVIDENCE
There was no evidence on the financial resources of seating cushions. Many of the cushions reported in the study were individualized to the user. This requires access to people with the skills to assess the individual, and measure and produce the individualized product. However, in the Panel Group’s experience a non-individualized pressure redistribution cushion is accessible in many clinical settings.
8. Certainty of evidence of required resources:
What is the certainty of evidence of resource requirements (costs) of the intervention (pressure redistribution support surface)?
JUDGEMENT
Very low
Low
Moderate
High
No included studies
RESEARCH EVIDENCE
There is no evidence on resources.
9. Cost Effectiveness:
Does the cost-effectiveness of the intervention favour the intervention (pressure redistribution surface) or the comparison (non-pressure redistribution surface)?
JUDGEMENT
Favors the comparison
Probably favors the comparison
Does not favor either the intervention or the comparison
Probably favors the intervention
Varies
No included studies
RESEARCH EVIDENCE
There was no evidence on cost-effectiveness.
10. Inequity:
What would be the impact of recommending the intervention (pressure redistribution surface) on health inequity?
JUDGEMENT
Reduced
Probably reduced
Probably no impact
Probably increased
Increased
Varies
Don’t know
RESEARCH EVIDENCE
Financial cost might limit accessibility of pressure redistribution cushions in some clinical and geographic regions, particularly with respect to specialist alternating pressure cushions (Makhsous, Lin et al. 2009).
The Expert Panel Group indicated that accessibility to pressure redistribution cushions in low in resource poor geographic locations, particularly to more advanced products such as alternating pressure (active) cushions is limited. Additionally, in many geographic and clinical settings, access to cushions designed for specific populations (e.g. people who with overweight or obesity) is limited.
11. Acceptability:
Is the intervention (pressure redistribution surface) acceptable to key stakeholders?
JUDGEMENT
No
Probably no
Probably yes
yes
Varies
Don’t know
RESEARCH EVIDENCE
An observational study (Garcia-Molina, Casasus et al. 2021) involving healthy volunteers (n = 23) reported that ratings of comfort and fit to body were high for a range of different pressure redistribution seating cushion designs. In this study, the rating for comfort did not correlate to performance in reducing peak interface pressure or temperature range (Garcia-Molina, Casasus et al. 2021). In another observational study in healthy volunteers (n = 7), the least discomfort was associated with the most contoured seating cushions. In the Guideline Governance Group’s expert opinion, when the pressure redistribution cushion is correctly selected and fitted to the individual, the increase in comfort and independence is likely to mean the intervention is acceptable.
12. Feasibility:
Is the intervention (pressure redistribution surface) feasible to implement?
JUDGEMENT
No
Probably no
Probably yes
yes
Varies
Don’t know
RESEARCH EVIDENCE
In the Guideline Group’s expert opinion, it is feasible that a pressure redistribution cushion be used for most people at risk of pressure injuries.