Clinical question
Should a low friction fabric product versus no low friction fabric product be used to prevent PI occurrence in individuals at risk?
Context
Population:
Intervention:
Comparison:
Main Outcomes:
Setting:
Conflicts on Interest:
People at risk of pressure injuries
Low friction fabric
Usual care with cotton blend fabric
Any clinical setting
Pressure injury (PI) occurrence
None
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
Large
Don’t know
Very low
No important uncertainty or variability
Probably favors the intervention
Varies
No included studies
No included studies
Probably increased
Varies
Varies
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 local interventions to prevent promote skin integrity (e.g. interventions that manage moisture or friction) as being the highest priority (median ranking 5/5, where 5 is the highest priority).
In an earlier survey conducted by the previous Guideline Governance Group in 2018(Haesler, Pittman et al. 2022), 90.10% (304/337) of individuals with or at risk of PIs and 87.52% (603/689) of informal carers rated receiving information on skin care as important or very important.
2. Desirable Effects:
How substantial are the desirable anticipated effects?
JUDGEMENT
Trivial
Small
Moderate
Large
Varies
Don’t Know
RESEARCH EVIDENCE
| Outcome | Heel offloading device |
Fluid filled bag | Difference | Relative effect |
|---|---|---|---|---|
| PI occurrence | 158/3089 (5.1%) | 380/3497 (10.8%) | 73 fewer per 1,000 (from 90 fewer to 41 fewer) |
RR 0.33 (0.17-0.62) |
Outcome 1: PI Occurrence
The meta-analysis included six studies (one randomized (Cleves, Ivins et al. 2022) and five non-randomized (Smith and Ingram 2010, Coladonato, Smith et al. 2012, Smith, McNichol et al. 2013, Freeman, Smith et al. 2017, van Leen, van Ratingen et al. 2022)) that compared using silk-like linen with a low co-efficient of friction compared with cotton blend fabric for reducing PI occurrence. Most of the studies used a full bed linen set with patient gowns,(Smith and Ingram 2010, Coladonato, Smith et al. 2012, Smith, McNichol et al. 2013, Freeman, Smith et al. 2017, van Leen, van Ratingen et al. 2022) and one study focussed on low friction fabric bootees to prevent heel PIs (Cleves, Ivins et al. 2022). The studies were conducted in care homes,(van Leen, van Ratingen et al. 2022) medical units (Smith and Ingram 2010, Coladonato, Smith et al. 2012, Smith, McNichol et al. 2013, Cleves, Ivins et al. 2022), orthopedic wards (Smith and Ingram 2010) and intensive care settings (Coladonato, Smith et al. 2012, Smith, McNichol et al. 2013, Freeman, Smith et al. 2017)for between 5 days and six weeks (most studies for a maximum of two weeks).
The meta-analysis showed a significantly lower rate of PI occurrence was associated with using low friction fabrics compared to usual (cotton blend) linen (5.1% versus 10.8%, RR 0.33, 95% CI 0.17 to 0.62, p = 0.0007). This translated to a difference of 73 fewer per 1,000 experiencing a device-related PI when a preventive dressing is used. However, the evidence was of very low quality. It is uncertain if the result represents a true effect; the true effect lies between 90 fewer people and 41 fewer people experiencing a PI with low friction fabrics compared with no low friction fabric.
3. Undesirable Effects:
How substantial are the undesirable anticipated effects?
JUDGEMENT
Trivial
Small
Moderate
Large
Varies
Don’t Know
RESEARCH EVIDENCE
In a study that was exploring low friction bootees to prevent heel PIs, people whose risk of falls changed during the study follow up period were withdrawn from the study because the low friction fabric bootees could have further increased falls risk (Cleves, Ivins et al. 2022).
No other undesirable effects were explored or reported in the studies.
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
| Outcome | Relative Importance | Certainty of Evidence |
|---|---|---|
| PI occurrence | CRITICAL | VERY LOW |
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).
Outcome 1: PI occurrence
The certainty of evidence is very low. The evidence was downgraded twice for risk of bias due to serious overall risk of bias in the majority of studies. The evidence was also downgraded twice for inconsistency because of considerable variation in point estimates and high heterogeneity.
5. Values:
Is there important uncertainty about or variability in how much people value the main outcomes?
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 or the comparison?
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
The desirable effects are large, demonstrated by a relative risk of 0.33 (95% confidence interval 0.17 to 0.62), and the undesirable effects have not been adequately explored. In the Guideline Governance Group’s evaluation, the balance of effects probably favors the intervention.
7. Resources Required:
How large are resource requirements (costs) of the intervention?
JUDGEMENT
Large costs
Moderate costs
Negligible costs and savings
Moderate savings
Large savings
Varies
Don’t know
RESEARCH EVIDENCE
Although none of the studies reported resource requirements in detail, there is a requirement to purchase the low friction linen for this intervention. The costs are likely to vary based on location, accessibility, and the size of the facility.
8. Certainty of evidence of required resources:
What is the certainty of evidence of resource requirements (costs) of the intervention?
JUDGEMENT
Very low
Low
Moderate
High
No included studies
RESEARCH EVIDENCE
No included studies.
9. Cost Effectiveness: Does the cost-effectiveness of the intervention favour the intervention or the comparison?
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
An analysis that calculated costs as a comparison of patient throughput suggested that the savings associated with preventing PI outweighed the cost. The base-case model indicated a saving of more than £63,000 per 100 at-risk patients (UK in 2010) (Smith and Ingram 2010). However, it was unclear whether all relevant cost data were included, and the data represented only one UK Trust (Centre for Reviews and Dissemination 2017). The cost-effectiveness analysis was at high risk of bias (Centre for Reviews and Dissemination 2017).
10. Inequity:
What would be the impact of recommending the intervention on health inequity?
JUDGEMENT
Reduced
Probably reduced
Probably no impact
Probably increased
Increased
Varies
Don’t know
RESEARCH EVIDENCE
In the Guideline Governance Group’s evaluation, recommending the use of low friction fabrics would probably increase inequity, because access and affordability to the intervention is variable.
11. Acceptability:
Is the intervention acceptable to key stakeholders?
JUDGEMENT
No
Probably no
Probably yes
yes
Varies
Don’t know
RESEARCH EVIDENCE
In one of the studies, compliance with using low friction bootees was 75-100% of participants (Cleves, Ivins et al. 2022).
12. Feasibility:
Is the intervention feasible to implement?
JUDGEMENT
No
Probably no
Probably yes
yes
Varies
Don’t know
RESEARCH EVIDENCE
One of the studies reported that low friction bottom sheets could not be used on some highly specialized mattresses that have their own covers (Smith, McNichol et al. 2013).
Feasibility in practice is varied.
References
Centre for Reviews and Dissemination (2017). NHS Economic Evaluation Database (NHS EED), University of York.
Cleves, A., N. Ivins, M. Clark, G. Carolan-Rees, N. Jones, J. White and R. Morris (2022). "Parafricta bootees compared with standard care to prevent heel pressure ulcers: a multicentre pragmatic randomised controlled trial." Wounds UK 18(2): 30-37.
Coladonato, J., A. Smith, N. Watson, A. T. Brown, L. McNichol, A. Clegg, T. Griffin, L. McPhail and T. G. Montgomery (2012). " Prospective, nonrandomized controlled trials to compare the effect of a silk-like fabric to standard hospital linens on the rate of hospital-acquired pressure ulcers." Ostomy Wound Manage 58(10): 14-31.
Freeman, R., A. Smith, S. Dickinson, D. Tschannen, S. James and C. Friedman (2017). "Specialty linens and pressure injuries in high-risk patients in the intensive care unit." American Journal of Critical Care 26(6): 474-481.
Haesler, E., J. Pittman, J. Cuddigan, S. Law, Y. Y. Chang, K. Balzer, D. Berlowitz, K. Carville, J. Kottner, M. Litchford, Z. Moore, P. Mitchell and D. Sigaudo-Roussel (2022). "An exploration of the perspectives of individuals and their caregivers on pressure ulcer/injury prevention and management to inform the development of a clinical guideline." J Tissue Viability 31(1): 1-10.
Lechner, A., S. Coleman, K. Balzer, J. J. Kirkham, D. Muir, J. Nixon and J. Kottner (2022). "Core outcomes for pressure ulcer prevention trials: results of an international consensus study." Br J Dermatol 187(5): 743-752.
Smith, A., L. L. McNichol, M. A. Amos, G. Mueller, T. Griffin, J. Davis, L. McPhail and T. G. Montgomery (2013). "A retrospective, nonrandomized, before and after study of the effect of linens constructed of synthetic silk-like fabric on pressure ulcer incidence." Ostomy Wound Management 59(4): 28-34.
Smith, G. and A. Ingram (2010). "Clinical and cost effectiveness evaluation of low friction and shear garments." Journal of Wound Care 19(12): 535-542.
van Leen, M., W. van Ratingen and J. Schols (2022). "Effects of a breathable silk-like, 3-layer ventilating mattress sheet on self-repositioning, repositioning support and pressure ulcer incidence; a pragmatic observational study." Wounds Int 13(1): 38-45.
