Full Body Support Surfaces for Prevention of Pressure Injuries (Part 2)

Changing from a Pressure Redistribution Foam (reactive) Full Body Support Surface

This subsection should be read in conjunction with the recommendations in Full Body Support Surfaces (Part 1), in particular recommendation SS3.

More information

SS4: Good Practice Statement

It is good practice to consider the following factors when selecting or changing the mattress, overlay or integrated bed support surface the individual’s:

  • overall risk of pressure injuries,

  • response of the skin and tissues,

  • independence, mobility and activity needs,

  • posture and sleeping position and their effects on pressure redistribution,

  • need for microclimate management and shear reduction features, and

  • preferences and care goals.

Implementation considerations

  • Consider the individual’s previous response to different full body support surfaces, where this information is available. This can inform the selection of the most appropriate full body support surface to meet the individual’s needs.

  • Document decisions that inform the selection of the full body support surface.

  • Continue regular skin and tissue assessments to identify early signs of skin and tissue damage (e.g., local erythema, hypo/hyperpigmentation in dark skin tones, local edema, increased skin temperature, etc.). If the individual’s response on the full body support surface is not as expected, re-evaluate the selection of the support surface and other aspects of the PI prevention plan, including repositioning frequency and effectiveness of various positions.

  • Consider the impact of the full body support surface the individual’s ability to re-position in the bed and safe egress from the bed.

  • Regularly re-evaluate the appropriateness of the selected full body support surface as the individual’s clinical condition changes. For example, when an individual transitions to rehabilitation care, the support surface should not be a barrier to increased self-mobilization.

Additional implementation considerations for special populations

    • Consider selecting a full body support surface with enhanced pressure redistribution, shear reduction and microclimate management features.

    • Select a full body support surface with consideration to the individual’s skin fragility and high risk of pressure injury development. Consider overall goals of care, including comfort.

Supporting Information

With a variety of full-body support surfaces available, different performance characteristics should be considered based on the clinical context. A pressure injury risk assessment helps identify specific risks for each individual and guides the selection of an appropriate full body support surface. Additionally, other clinical and functional needs, as well as the individual’s preferences, should be considered when making a choice. Ongoing skin and tissue assessments are required to evaluate the effectiveness of the full body support surface. Table 3 provides a general summary of some considerations when evaluating the different full body support surface options against the individual’s clinical needs.

Table 3: Summary of considerations in selecting a full body support surface

Features # Clinical considerations and preferences #
Pressure redistribution
Shear reduction *
Increased microclimate management
Requires continuous power source for a pump or motor
May impact ability to move in bed and/or egress the bed
May cause other discomfort (e.g. motion feeling)
May increase skin drying and dehydration
May increase warmth
May increase comfort
Pressure redistribution foam ✓ *
Powered air (reactive) (excluding low air loss) ✓ * ✓ ✓ ✓ ✓
Non-powered air (reactive) ✓ * ✓ ✓
Alternating pressure air (active) ✓ * ✓ ✓
Low air loss (with enhance microclimate features) ✓ * ✓ ✓ ✓ ✓ ✓
Medical grade sheepskin (reactive) ✓ * ✓ ✓
Air-fluidized (reactive) ✓ * ✓ ✓ ✓ ✓ ✓ ✓ ✓

# Indicative only, some full body support surfaces may have additional features. We recommend always reviewing manufacturers' information and standardized test results.
* Shear reduction capabilities are dependent on the design and materials of the full body support system

More information

SS5: Recommendation

We suggest using either air (reactive) full body support surfaces or pressure redistribution foam (reactive) full body support surfaces for individuals at risk of pressure injuries.

Conditional recommendation; very low certainty of evidence

Clinical question: Should air (reactive) full body support surfaces versus pressure redistribution foam (reactive) full body support surfaces be used to prevent PI occurrence for individuals at risk?

Evidence Summary

A meta-analysis (15) was conducted of four RCTs (16, 17, 18, 19) exploring air (reactive) full body support surfaces, excluding studies on low air loss full body support surfaces.* The meta-analysis showed that air (reactive) full body support surfaces were associated with a statistically significantly lower rate of PIs (RR 0.42, 95% CI 0.18 to 0.96, p = 0.04) compared with pressure redistribution foam (reactive) full body support surfaces. This translated to 160 fewer per 1,000 individuals experiencing a PI (from 226 fewer individuals to 11 fewer individuals) when an air (reactive) full body support surface is used. However, both support surfaces demonstrated an effect in preventing PIs and the evidence was of very low certainty. Certainty of evidence was downgraded for the risk of bias, indirectness and inconsistency. The studies explored a range of air (reactive) full body support surfaces and compared them to different pressure redistribution foam (reactive) support surfaces (circa 1980 to 2013). (16, 17, 18, 19) Undesirable effects were equivocal in studies. The Expert and Consumer Panel Groups noted the risk of undetected deflation of air (reactive) surfaces that can lead to a PI. Some air (reactive) full body support surfaces may be more costly, require more carer time and resources to frequently check, and require a reliable electric supply. This may increase inequities for low resource settings.

The decision to use an air (reactive) full body support surface will depend on the PI risk of the individual, their level of independent mobility in bed, and other clinical needs, availability and feasibility in the specific context and personal preferences.

* Recommendation SS11 addresses use of low air loss full body support surfaces.

Data tables (Downloads)

  • Data extraction tables (coming soon)

  • Full evidence discussion (coming soon)

Certainty of Evidence

Certainty assessment No of patients Effect
Certainty
Importance
No of studies
Study design
Risk of bias
Inconsistency
Indirectness
Imprecision
Other considerations
air (reactive)
surfaces
Pressure
redistribution
(reactive) surfaces
Relative (95% CI)
Absolute (95% CI)
4 randomised
 Serious [a] Not
serious		 Serious [b] Serious [c] none 12/113
(10.6%)		 32/116
(27.6%)		 RR 0.42
(0.18 to
0.96)		 160 fewer
per 1,000
(from 226
fewer to
11 fewer)
Very Low
CRITICAL

[a] High or unclear risk of selection bias and high or unclear risk or performance bias across all studies, high or unclear risk of detection bias across 3 studies.
[b] Downgraded once for imprecision because despite the optimal information size being met, the confidence interval crossed GRADE minimum important differences value (0.75 and 1.25).
[c] Downgraded once because the interventions were pre-2013 and in one study, used in a non-traditional manner.

Evidence to Decision Framework

Problem:

Desirable Effects:

Undesirable Effects:

Certainty of Evidence:

Values:

Balance of Effects:

Resources Required:

Certainty of Evidence of Required Resources:

Summary of Judgements

Cost Effectiveness:

Inequity:

Acceptability:

Feasibility:

Yes

Large

Small

Very low

No important uncertainty or variability

Probably favors the intervention

Varies

No included studies

No included studies

Probably increased

Probably yes

Probably yes

More information

SS6: Recommendation

We suggest using either alternating pressure air (active) full body support surfaces or pressure redistribution foam (reactive) full body support surfaces for individuals at risk of pressure injuries.

Conditional recommendation; low certainty of evidence

Clinical question: Should alternating pressure (active) air full body support surfaces versus pressure-redistribution foam (reactive) full body support surfaces be used to prevent PI occurrence for individuals at risk?

Evidence summary

The meta-analysis (20) of four RCTs (21, 22, 23, 24) showed that alternating pressure (active) air full body support surfaces are associated with a statistically non-significant lower rate of PI occurrence (RR 0.63, 95% CI 0.34 to 1.17, p = 0.14). This translated to 39 fewer per 1,000 individuals expected to experience a PI if an alternating pressure air surface is used compared to a pressure redistribution foam (reactive) full body support surface. However, certainty of evidence is low, and the true effect could vary from 69 fewer individuals to 18 more individuals experiencing a PI if an alternating pressure air (active) support surface is used. The evidence was downgraded for risk of bias and imprecision. One RCT (24) determined that alternating pressure air (active) full body support surfaces are probably modestly cost effective compared with pressure redistribution foam (reactive) full body support surfaces when the cost of an individual acquiring a full-thickness PIs was considered. However, certainty of this evidence is very low due to the risk of bias and imprecision. Pressure redistribution foam (reactive) full body support surfaces are effective in preventing PIs in individuals with moderate and high risk in long term care settings when repositioned at regular intervals (25, 26) (very low certainty of evidence) and are therefore an acceptable support surface in all settings. The cost of the support surface and availability of a reliable electricity supply may limit the use of powered air surfaces in low resource settings and in some clinical settings (e.g., in the community). In these settings a pressure redistribution foam (reactive) support surface may be used.

Where available, alternating pressure air (active) surfaces may be more clinically effective and cost effective for individuals at the highest PI risk (e.g., individuals in critical care) or for those seeking an alternative support surface option for comfort or when less frequent repositioning is the individual’s preferred option (e.g., palliative or end-of-life care).

Data tables (Downloads)

  • Process document (includes meta-analysis)

  • Data extraction tables (coming soon)

  • Full evidence discussion (coming soon)

Certainty of Evidence

Certainty assessment No of patients Effect
Certainty
Importance
No of studies
Study design
Risk of bias
Inconsistency
Indirectness
Imprecision
Other considerations
alternating
pressure (active)
air surfaces
pressure
redistributing
foam (reactive)
surfaces
Relative (95% CI)
Absolute (95% CI)
4 randomized
trials		 Serious [a] Not
serious		 Not
serious		 Serious [b] none 83/1225
(7.4%)		 117/1122
(10.4%)		 RR 0.63
(0.34 to
1.17)		 39 fewer
per 1,000
(from 69
fewer to
18 more)
Low
CRITICAL

[a] Downgraded twice due to high risk of bias in more than one category and high overall risk of bias
[b] Downgraded once for small sample size and number of events

Evidence to Decision Framework

Problem:

Desirable Effects:

Undesirable Effects:

Certainty of Evidence:

Values:

Balance of Effects:

Resources Required:

Certainty of Evidence of Required Resources:

Summary of Judgements

Cost Effectiveness:

Inequity:

Acceptability:

Feasibility:

Yes

Moderate

Small

Low

No important uncertainty or variability

Don’t know

Varies

Very low

Probably favors the intervention

Probably increased

Probably yes

Probably yes

More information

SS7: Recommendation

We suggest using either alternating pressure (active) air or air (reactive) full body support surfaces for individuals at risk of pressure injuries.

Conditional recommendation; very low certainty of evidence

Clinical question: Should alternating pressure air (active) full body support surfaces versus air (reactive) full body support surfaces be used to prevent PI occurrence for individuals at risk?

Implementation considerations

  • Consider the individual’s clinical needs for pressure redistribution, shear management and microclimate management when selecting between air (reactive) or alternating pressure (active) air full body support surfaces.

  • Follow the manufacturer’s guidance on minimal and maximum weight and dimensions for the individual when using air (reactive or active) full body support surfaces.

  • Inspect the air inflated full body support surfaces before use to ensure proper functioning, including being inflated to a pressure that is appropriate to the weight and shape of the individual based on the manufacturer’s instructions. (33) Check the full body support surface for bottoming out. Regularly reinspect the air inflated full body support surface as it may require reinflation or adjustment.

  • For powered full body support surfaces, regularly check that the power source is connected, turned on and operating.

  • Consider reserving alternating pressure (active) air or air (reactive) full body support surfaces for individuals at higher risk or deteriorating clinical condition or skin condition.

Additional implementation considerations for special populations

    • Consider the use of an alternating pressure air (active) surface for individuals in the palliative or end-of life-care settings where this meets their overall goals of care, including comfort.

    • Consider the impact of increased noise of powered air full body support surfaces.

    • Consider the impact of the cyclic action of alternating pressure (active) air full body support surfaces. The cyclic action may cause waves of high stress concentration in soft tissue, stimulating local nociceptors to signal increase in inflammatory pain.(34, 35)

    • For powered full body support surfaces, instruct the individual and their informal cares to regularly check that the power source is connected, turned on and operating. Ensure there is an action plan for managing power outages.

    • Non-powered options should be preferred in regional areas with unreliable or inconsistent power resources.

    • Do not use an air (reactive or active) full body support surface for neonates and young children.

    • Follow the manufacturer’s guidance on minimal weight and dimension requirements for air (reactive or active) full body support surfaces. There is no evidence on using (reactive or active) full body support surface for preventing PIs in children, and in most situations, this is not recommended. It may be appropriate for some older adolescents if they meet the minimal weight and dimension requirements.

Evidence summary

A meta-analysis of five RCTs (27, 28, 29, 30, 31, 32) showed that alternating pressure air (active) full body support surfaces are associated with a statistically significant higher rate of PI occurrence (RR 1.81, 95% CI 1.00 to 3.27, p = 0.05) than air (reactive) full body support surfaces. Using an air (reactive) full body support surface (n.b., excluding low air loss full body support surfaces) might reduce the proportion of individuals who develop a new PI compared to an alternating pressure (active) air support surface). The analysis translated to 19 per 1,000 individuals more experiencing a PI with an alternating pressure (active) air full body support surface (from 0 fewer to 52 more). The evidence is very uncertain and was downgraded for the risk of bias and imprecision. There was no data available on potential serious undesirable effects. Comfort level is reported as similar for alternating pressure (active) and air (reactive) full body support surfaces. (27, 28, 29) Powered air support surfaces (either active or reactive) require an initial investment cost and a reliable electricity source, which vary widely across different clinical and geographic contexts. Both alternating pressure (active) and air (reactive) full body surfaces require very regular inspections for function (e.g., checking for deflation) and ongoing maintenance. In addition to resource requirements, the ease with which the individual can reposition and get in and out of the bed, their comfort and preferences, and the care setting should all be considered when making a choice between these two support surface options. Refer to recommendation SS4 for more guidance on considerations when selecting between different full body support surface options. Pressure redistribution foam (reactive) full body support surfaces are often adequate for many individuals at risk of pressure injuries. Alternating pressure (active) air or air (reactive) full body support surfaces are usually reserved for individuals at higher risk or deteriorating skin condition or clinical condition.

Data tables (Downloads)

  • Process document (includes meta-analysis)

  • Data extraction tables (coming soon)

  • Full evidence discussion (coming soon)

Certainty of Evidence

Certainty assessment No of patients Effect
Certainty
Importance
No of studies
Study design
Risk of bias
Inconsistency
Indirectness
Imprecision
Other considerations
alternating pressure
(active) air
surfaces
air (reactive)
surfaces
Relative (95% CI)
Absolute (95% CI)
5 randomised
trials		 Very
Serious [a]		 Not
serious		 Not
serious		 Serious [b] none 32/780
(4.1%)		 19/828
(2.3%)		 RR 1.81
(1.00 to
3.27)		 19 more
per 1,000
(from 0
fewer to
52 more)
Very Low
CRITICAL

[a] Downgraded twice for risk of bias in domains other than performance bias in 3 studies with more than 54% analysis weight.
[b] Downgraded once for imprecision because the confidence interval for imprecision because the confidence interval crossed GRADE minimum important differences value (0.75 and 1.25)

Evidence to Decision Framework

Problem:

Desirable Effects:

Undesirable Effects:

Certainty of Evidence:

Values:

Balance of Effects:

Resources Required:

Certainty of Evidence of Required Resources:

Summary of Judgements

Cost Effectiveness:

Inequity:

Acceptability:

Feasibility:

Yes

Trivial (favors the comparator, air reactive)

Don’t know

Very low

No important uncertainty or variability

Don’t know

Varies

No included studies

No included studies

Probably increased

Probably yes

Probably yes

More information

SS8: Recommendation

We suggest a medical grade sheepskin could be used for individuals at risk of pressure injuries where geographically available. If used, consider the potential impact on the full body support surface.

Conditional recommendation; very low certainty of evidence

Clarifiers:

  • A medical grade sheepskin is not recommended when there is a full body support surface with pressure redistribution properties available.

  • Only medical grade sheepskins should be used. Non-medical grade sheepskins do not have the same microclimate management properties and may increase the risk of PIs.

  • Ensure that medical grade sheepskin overlays do not interfere with the pressure redistribution properties of the full body support surface.

Clinical question: Should medical grade sheepskins versus any other support surface be used to reduce pressure injury occurrence for individuals at risk?

Implementation considerations

  • Use only medical grade sheepskins manufactured to Australian Standard AS 4480.1. Synthetic products do not have the same density, uniformity and resilience for laundering.

  • Consider the clinical context when deciding if a medical-grade sheepskin is appropriate. Medical grade sheepskins require specialist laundering. This means they might not be practical in clinical situations where frequent laundering is expected (e.g., for incontinent individuals or for individuals with heavily exuding wounds).(37)

  • Consider the potential negative impact of a medical grade sheepskin on the function of the full body support surface. A sheepskin could create surface tension (sometimes referred to as hammocking) that decreases the envelopment, immersion and microclimate management properties of the support surface.

  • Regularly assess the individual to evaluate the choice to use a medical grade sheepskin. Medical grade sheepskins are reported to be particularly warm. (37, 39) This might reduce acceptability for some individuals. It also might change the microclimate in such a way as to increase the risk of PIs (e.g., increased temperature and moisture).

  • Medical grade sheepskins are a single patient/individual use only device.

  • Be aware that medical grade sheepskins are an animal-based product and may not be acceptable to all individuals.

  • Review the guideline section on Preventing Heel Pressure Injuries before considering the use of a medical grade sheepskin as a support surface under the heels.

Additional implementation considerations for special populations

    • In general, medical grade sheepskins are not appropriate for use with neonates and young children. A medical grade sheepskin support surface requires specialist laundering and is not appropriate for children requiring continence management. A medical grade sheepskin can increase heat and warmth and is not consistent with safe sleeping guidelines.

Evidence summary

A meta-analysis (36) of three RCTs (37, 38, 39) showed that medical grade sheepskins are associated with a non-significant lower rate of PI occurrence (RR 0.59, 95% CI 0.33 to 1.05, p = 0.074) compared with other support surfaces. In the included studies, (37, 38, 39) the comparator support surfaces were either not specified or were vinyl mattresses without pressure redistribution properties. Using a medical grade sheepskin might reduce the proportion of individuals who develop a new PI compared to a mattress or overlay without pressure re-distribution features. The analysis translated to 19 per 1,000 individuals fewer experiencing a PI with a medical grade sheepskin (from 31 fewer to 2 more). The evidence is very uncertain and was downgraded for the risk of bias, indirectness and imprecision. No data was available on serious undesirable effects; the literature (37, 39) and expert opinion from the Panel Group suggested that undesirable effects are related to discomfort from the warmth of the sheepskin. Medical grade sheepskins are often used in low resource settings, but the costs are not reported and there are no analyses of cost effectiveness. The choice to use a medical grade sheepskin in addition to a support surface with pressure redistribution features should be made in consideration of the access to medical grade products and appropriate laundering facilities, (37) the individual’s clinical needs and response to the surface (particularly with respect to microclimate management), and whether the medical grade sheepskin is comfortable and acceptable to in the individual.

Data tables (Downloads)

  • Process document (includes meta-analysis)

  • Data extraction tables (coming soon)

  • Full evidence discussion (coming soon)

Certainty of Evidence

Certainty assessment No of patients Effect
Certainty
Importance
No of studies
Study design
Risk of bias
Inconsistency
Indirectness
Imprecision
Other considerations
medical grade sheepskin
support surface
any other
support surfaces
Relative (95% CI)
Absolute (95% CI)
3 randomised
trials		 Serious [a] Not
serious		 Serious [b] Serious [c] none 18/720
(2.5%)		 33/704
(4.7%)		 RR 0.59
(0.33 to
1.05)		 19 fewer
per 1,000
(from 31
fewer to
2 more)
Very Low
CRITICAL

[a] Downgraded once due to two studies with approximately 90% of weight in the analysis had either one domain other than performance bias at high risk of bias and all studies had performance bias at high risk of bias.
[b] Downgraded because comparators are surfaces no longer in use (e.g. vinyl mattress) or not reported
[c] Downgraded once for a 95% confidence interval that crossed GRADE minimum important differences value (0.75 and 1.25).

Evidence to Decision Framework

Problem:

Desirable Effects:

Undesirable Effects:

Certainty of Evidence:

Values:

Balance of Effects:

Resources Required:

Certainty of Evidence of Required Resources:

Summary of Judgements

Cost Effectiveness:

Inequity:

Acceptability:

Feasibility:

Yes

Moderate

Small

Very low

No important uncertainty or variability

Don’t know

Don’t know

No included studies

No included studies

Probably no impact

Varies

Probably yes

More information

SS9: Recommendation

We suggest a fiber support surface is not used to prevent pressure injuries in individuals at risk in settings where a pressure redistribution foam (reactive) full body support surface is available.

Conditional recommendation; very low certainty of evidence

Clinical question: Should fiber surfaces versus pressure redistribution foam (reactive) full body surfaces be used to prevent PI occurrence for individuals at risk?

Evidence summary

The meta-analysis (40) included one RCT (22) that compared a fiber pad/surface to a pressure redistribution foam pad/surface. The meta-analysis showed that fiber surfaces were associated with a non-significant lower rate of PI occurrence (RR 0.86, 95% CI 0.18 to 0.96, p = 0.62) that translated to 58 fewer individuals per 1,000 experiencing a PI with a fiber support surface (from 218 fewer to 235 more individuals 1,000 individuals). (40) However, the evidence is very uncertain and was downgraded for the risk of bias and imprecision. The evidence is also from the 1980s and may not reflect ant currently available fiber support surfaces. No evidence was available on resources and cost effectiveness. Based on the very low certainty of evidence and the low acceptability and feasibility, the Guideline Governance group suggests not to use fiber support surfaces when there is an option to use a pressure redistribution foam (reactive) support surface.

If there are no other options, a fiber support surface does provide pressure redistribution.

Data tables (Downloads)

  • Process document (includes meta-analysis)

  • Data extraction tables (coming soon)

  • Full evidence discussion (coming soon)

Certainty of Evidence

Certainty assessment No of patients Effect
Certainty
Importance
No of studies
Study design
Risk of bias
Inconsistency
Indirectness
Imprecision
Other considerations
fiber (reactive)
surfaces
Pressure redistribution
foam (reactive)
surfaces
Relative (95% CI)
Absolute (95% CI)
1 randomized
trials		 Very
Serious [a]		 Not
serious		 Not
serious		 Serious [b] none 12/34
(35.3%)		 14/34
(41.2%)		 RR 0.86
(0.47 to
1.57)		 58 fewer
per 1,000
(from 218
fewer to
235 more)
Very Low
CRITICAL

[a] Downgraded twice for unclear risk of bias across all domains.
[b] Downgraded twice for imprecision due to a small sample size, a small number of events and a wide 95% confidence interval that crossed GRADE minimum important differences value (0.75 and 1.25).

Evidence to Decision Framework

Problem:

Desirable Effects:

Undesirable Effects:

Certainty of Evidence:

Values:

Balance of Effects:

Resources Required:

Certainty of Evidence of Required Resources:

Summary of Judgements

Cost Effectiveness:

Inequity:

Acceptability:

Feasibility:

Yes

Small

Don’t know

Very low

No important uncertainty or variability

Don’t know

Don’t know

No included studies

No included studies

Don’t know

Probably no

Probably no

More information

SS10: Recommendation

We suggest an air fluidized full body support surface is not routinely used to prevent pressure injuries in individuals at risk.

Conditional recommendation; very low certainty of evidence

Clarifiers:

  • An air fluidized full body support surface might be considered for individuals at very high pressure injury risk (e.g., those who are immobilized with extensive burns) or who have previously experienced a full thickness pressure injury on a different full body support surface.

  • Air fluidized full body support surfaces might be used for individuals with existing full thickness pressure injuries or following surgical reconstruction with flaps/grafts.

Clinical question: Should air fluidized full body support surfaces versus any other support surfaces be used to prevent pressure injuries for individuals at risk?

Evidence summary

A meta-analysis of two RCTs (16, 41) showed that air fluidized full body support surfaces are associated with a non-significant lower rate of PI occurrence compared to pressure redistribution foam (reactive) and alternating pressure air (active) full body support surfaces (RR 0.66; 95% CI 0.34 to 1.28, p = 0.22). This translated to 96 fewer individuals per 1,000 (from 187 fewer to 79 more) experiencing a PI when using an air fluidized full body support surface. However, the evidence was of very low certainty and was downgraded for the risk of bias, indirectness and imprecision. The desirable effects were considered small due to the wide confidence interval, and were heavily outweighed by relatively large costs, resource requirements (e.g., reliable electrical supply), feasibility (space and architectural support for a large heavy bed, carer burden), and undesirable effects (drying/dehydration, difficulties with self or assisted repositioning on the surface, disorientation). Although newer designs of air fluidized surfaces may have fewer disadvantages, the costs generally outweigh benefits when other appropriate full body support surfaces are available. As noted in the clarifiers, there are clinical situations in which an air fluidized bed might be appropriate for an individual at risk of PIs, including those who are highly immobile and critically ill, those who have previously experienced a PI on a pressure redistribution full body support surface, and to prevent new PIs following surgical reconstruction of a previous PI.

Data tables (Downloads)

  • Process document (includes meta-analysis)

  • Data extraction tables (coming soon)

  • Full evidence discussion (coming soon)

Certainty of Evidence

Certainty assessment No of patients Effect
Certainty
Importance
No of studies
Study design
Risk of bias
Inconsistency
Indirectness
Imprecision
Other considerations
Air fluidized
surfaces
Any other support
surface
Relative (95% CI)
Absolute (95% CI)
2 RCTs Very
serious [a]
Serious [b]		 Not
Serious		 Very
Serious[c]		 None 9/52
(17.3%)		 15/53
(28/3%)		 RR 0.66
(0.04 to
1.28)		 96 fewer
per 1,000
(from 187
fewer to
79 more)
Very Low
CRITICAL

[a] Downgraded twice due to high or unclear risk of detection bias; unclear risk of selection bias
[b] Downgraded once because one study experienced no PI events
[c] Small sample and event size, wide 95% CI that that crossed GRADE minimum important differences value (0.75 and 1.25).

Evidence to Decision Framework

Problem:

Desirable Effects:

Undesirable Effects:

Certainty of Evidence:

Values:

Balance of Effects:

Resources Required:

Certainty of Evidence of Required Resources:

Summary of Judgements

Cost Effectiveness:

Inequity:

Acceptability:

Feasibility:

Yes

Moderate

Moderate

Very low

No important uncertainty or variability

Don’t know

Large costs

Low

No included studies

Increased

Varies

Varies

More information

SS11: Recommendation

We suggest a low air loss (reactive) full body support surface could be used for individuals at risk of pressure injuries, especially when moisture and heat at the skin-surface interface are contributing factors.

Conditional recommendation; very low certainty of evidence

Clinical question: We suggest a low air loss (reactive) full body support surface could be used for individuals at risk of pressure injuries, especially when moisture and heat at the skin-surface interface are contributing factors.

In this Guideline, a low air loss (reactive) support surface refers to a support surface construction that uses a flow of air to assist in pressure redistribution. Low air loss (reactive) support surfaces may also assist in managing heat and humidity (microclimate) of the skin.

Implementation considerations

  • Assess and maintain skin moisture and overall hydration to reduce the known drying effects of a support surface with enhanced microclimate management properties (e.g., a low air loss surface).

  • Evaluate the individual’s ability to move in and egress from a low air loss bed. If self-repositioning and mobilization is difficult, consider using a different full body support surface as so as mobility is becoming re-established.

  • A full body support surface with micromanagement properties is not required to manage increased moisture associated with heavily exuding wounds or incontinence.

Evidence summary

A meta-analysis of three RCTs (23, 42, 43) exploring low air loss (reactive) full body support surfaces was conducted. For the purposes of this analysis, low air loss (reactive) full body support surfaces were considered as distinct and separate from other reactive air constructions. The analysis showed that low air loss (reactive) full body support surfaces are associated with a non-significant lower rate of PI occurrence (RR 0.76, 95% CI 0.06 to 9.13, p = 0.83). This translated to 30 individuals fewer per 1,000 who might experience a PI if a flow air loss (reactive) full body support surface is selected (from 118 fewer to 1,000 more). However, the certainty of evidence is very low, and the evidence was downgraded for the risk of bias, inconsistency and imprecision. The comparator support surfaces in the studies (23, 42, 43) were an alternating pressure (active) air mattress, a medium density polyurethane pressure redistribution foam (reactive) mattress and a “standard” (vinyl) hospital mattress. No serious adverse events were reported in any of the studies. Due to the moderate resource requirements, low air loss (reactive) full body support surfaces may be more appropriate for individuals at very high risk of PIs and may be indicated for moisture management in individuals with exposure to excess moisture. Access to low air loss (reactive) full body support surfaces is limited in many geographic and clinical settings.

Data tables (Downloads)

  • Process document (includes meta-analysis)

  • Data extraction tables (coming soon)

  • Full evidence discussion (coming soon)

Certainty of Evidence

Certainty assessment No of patients Effect
Certainty
Importance
No of studies
Study design
Risk of bias
Inconsistency
Indirectness
Imprecision
Other considerations
Low air loss
support surfaces
Any other
support surface
Relative (95% CI)
Absolute (95% CI)
3 RCTs Serious [a] Very
serious [b]		 Not
serious		 Extremely serious [c] none 11/129
(8.5%)		 18/143
(12.6%)		 RR 0.76
(0.06 to
9.13)		 30 fewer
per 1,000
(from 118
fewer to
1,000 more)
Very Low
CRITICAL

[a] Unclear risk of selection, performance and detection bias in all studies
[b] Very serious heterogeneity
[c] Small sample and event size, very wide 95% CI that crossed GRADE minimum important differences value (0.75 and 1.25).

Evidence to Decision Framework

Problem:

Desirable Effects:

Undesirable Effects:

Certainty of Evidence:

Values:

Balance of Effects:

Resources Required:

Certainty of Evidence of Required Resources:

Summary of Judgements

Cost Effectiveness:

Inequity:

Acceptability:

Feasibility:

Yes

Moderate

Varies

Very low

No important uncertainty or variability

Don’t know

Moderate costs

No included studies

No included studies

Probably increased

Varies

Varies