Clinical question
Should a support surface with microclimate management properties (e.g., low air loss) versus any other surface be used in individuals at risk of pressure injuries?
Context
Population:
Intervention:
Comparison:
Main Outcomes:
Setting:
Background:
Conflicts on Interest:
Individuals at risk of pressure injuries
Low air loss 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
Varies
Small
Very low
No important uncertainty or variability
Don’t know
Moderate costs
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 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 | Low air loss surfaces | Any other support surfaces | Difference | Relative effect |
|---|---|---|---|---|
| PI occurrence | 11/129 (8.5%) | 18/143 (12.6%) | 30 fewer PIs per 1,000 (from 118 fewer to 1,000 more) |
RR 0.76 (0.06-9.13) |
Outcome 1: Reduction in PI Occurrence
The meta-analysis included three RCTs (Inman, Sibbald et al. 1993, Bennett, Baran et al. 1998, Rosenthal, Felton et al. 2003) that compared low air loss support surfaces to another support surface (comparators were an alternating pressure [active] air mattress, a medium density polyurethane pressure redistribution [reactive] foam mattress and a standard hospital mattress. **
The meta-analysis showed that low air loss support surfaces are associated with a lower rate of PI occurrence (RR = 0.76, 95% CI 0.06 to 9.13) However, there is very high uncertainty as to whether using a low air loss support surface reduces the occurrence of a new Category/Stage 1 or greater PIs.
** 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
Serious adverse events
No serious adverse events occurred in the studies exploring low air loss surfaces.
Discomfort
Of the 10 individuals in one RCT who evaluated a low air loss bed, 50% rated the bed as comfortable and 40% rated the bed as uncomfortable (Bennett, Baran et al. 1998).
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 certainty of evidence was very low. The evidence was downgraded once for risk of bias based on critical appraisal in existing reviews (Shi, Dumville et al. 2021, Shi, Dumville et al. 2021). All studies were at unclear risk of selection, performance and detection bias. Certainty was downgraded twice for inconsistency and was also downgraded three times 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 undesirable effects are unclear.
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
There is no evidence available on the resource requirements for using low air loss bed systems; however, the Panel Group noted that bed purchase or hire costs are likely to be substantial.
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 is no evidence on resources.
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.
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 low air loss surfaces are a support surface and not available in many clinical contexts, even in high resource settings
11. Acceptability:
Is the intervention acceptable to key stakeholders?
JUDGEMENT
No
Probably no
Probably yes
yes
Varies
Don’t know
RESEARCH EVIDENCE
In the Panel Group’s expert opinion, acceptability of low air loss support surfaces varies. Some people find a low air loss support surface to be noisy, make the skin very dry, feel “boggy” and/or difficult to move around on.
12. Feasibility:
Is the intervention feasible to implement?
JUDGEMENT
No
Probably no
Probably yes
Yes
Varies
Don’t know
RESEARCH EVIDENCE
In one RCT, 65% of the 47 nurses who cared for an individual in a low air loss bed rated learning how to use the bed as easy and 21% of the nurses were overall satisfied with using a low air loss bed (Bennett, Baran et al. 1998).
In the Panel Group’s expert opinion, access to low air loss beds is limited in many clinical settings and geographic locations.
In the Panel Group’s expert opinion, a low air loss bed can be a barrier to early and regular mobility because it is hard for people to move on the surface, and to get in and out of bed. This means the feasibility of using the surface is lower for people who have some mobility.