Clinical question
Should air fluidized full body support surfaces versus any other surface be used to prevent PI occurrence in for individuals at risk?
Context
Population:
Intervention:
Comparison:
Main Outcomes:
Setting:
Background:
Conflicts on Interest:
Individuals at risk of pressure injuries
Air fluidized full body support surfaces
Any other support surfaces
Any clinical setting
Pressure Injury occurrence
No Guideline Governance Group members or 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
Moderate
Small
Very low
No important uncertainty or variability
Don’t know
Large costs
Low
No included studies
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 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 | Air fluidized support surfaces | Any other support surfaces | Difference | Relative effect |
|---|---|---|---|---|
| PI occurrence | 9/52 (17.3%) | 15/53 (28.3%) | 96 fewer PIs per 1,000 (from 187 fewer to 79 more) |
RR 0.66 (0.34-1.28) |
Outcome 1: Reduction in PI Occurrence
The meta-analysis included two RCTs (Allman, Walker et al. 1987, Finnegan, Gazzerro et al. 2008) that explored an air fluidized support surface compared to another support surface (an alternating pressure (active) air mattress in one study and an alternating therapy surface in the second study).** The meta-analysis showed that air fluidized support surfaces are associated with a lower rate of PI occurrence (RR = 0.66, 95% CI 0.34 to 1.28). Based on the wide confidence interval, and the low certainty of evidence, together with one study reporting no events, the GGG judged the desirable effects as small.
** 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
One of the studies(Allman, Walker et al. 1987) reported the death rate was similar between using an air fluidized surface (n= 8/31) and a pressure redistribution foam (reactive) mattress placed on top of an alternating pressure (active) air mattress (n = 7/34). The certainty of this evidence is low due to unclear risk of bias and the small sample size(Shi, Dumville et al. 2021).
In one of the RCTs (Finnegan, Gazzerro et al. 2008), about 39% (7/18) of individuals using an air fluidized surface described the surface as uncomfortable compared to about 13% (2/15) of the individuals using the comparator surface (a specialized alternating pressure [active] air surface).
In the Guideline Governance Group’s expert opinion, the risk of dehydration for individuals using an air fluidized is well-recognized.
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 |
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 very low certainty. The evidence was downgraded twice for risk of bias based on critical appraisal in existing reviews (Shi, Dumville et al. 2021, Shi, Dumville et al. 2021) The two studies were either at high or unclear risk of performance bias and ALSO at unclear risk of selection bias. Certainty was downgraded once for inconsistency because one study reported no PI events (Finnegan, Gazzerro et al. 2008) while the second study (Allman, Walker et al. 1987) reported event rates of almost 37% across the study population. Certainty was also downgraded for imprecision.
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 were small given the wide confidence interval and very low certainty of evidence. The undesirable effects were considered moderate. However, the analysis is based on two very small studies, one of which experienced no events.
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
In the Panel Group and Guideline Governance Group’s expert opinion, air fluidized surfaces have low accessibility in most geographic and clinical contexts due to their high financial cost of surfaces and energy.
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
There are no published studies, but the costs of air fluidized surfaces are acknowledged to be significant in the majority of clinical settings.
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
There was no evidence on cost-effectiveness of the options.
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
The Panel Group noted that an air fluidized surface is not available in many clinical contexts, even in high resource settings. The Guideline Governance Group believe that inequity would be greater if air fluidized surfaces were recommended.
11. Acceptability:
Is the intervention acceptable to key stakeholders?
JUDGEMENT
No
Probably no
Probably yes
yes
Varies
Don’t know
RESEARCH EVIDENCE
In an RCT (Allman, Walker et al. 1987) set in a post-operative setting (n=65), health professionals adhered more closely to a pressure prevention protocol that included an air fluidized support surface compared to a protocol that included an alternating air pressure (active) surface (p<0.05) (Allman, Walker et al. 1987).
In the Guideline Governance Group’s expert experience, acceptability may be reduced because bed mobility and egress is more difficult, and people sometimes experience disorientation. Health professionals sometimes have difficulty in repositioning an individual on an air fluidized support surface.
12. Feasibility:
Is the intervention feasible to implement?
JUDGEMENT
No
Probably no
Probably yes
Yes
Varies
Don’t know
RESEARCH EVIDENCE
A small case series (n = 10) suggested that using air fluidized surfaces was feasible in the acute care setting (Arnold, Yanez et al. 2020). However in the Guideline Governance Group’s expert opinion, feasibility is limited in many clinical settings. The bed is expensive, heavy (not suitable for home structures) and requires electricity to continuously operate, reducing its feasibility in low resource and home settings.