Clinical question
Should air (reactive) full body support surfaces vs. pressure redistribution foam (reactive) full body support surfaces be used for people at risk of pressure injuries?
Context
Population:
Intervention:
Comparison:
Main Outcomes:
Setting:
Conflicts of Interest:
Individuals at risk of pressure injuries
Air (reactive) full body support surfaces
Pressure redistribution foam (reactive) full body 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
Small
Large
Very low
No important uncertainty or variability
Probably favors the intervention
Varies
No included studies
No included studies
Probably increased
Probably yes
Probably es
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 (reactive) support surfaces | Pressure redistribution foam (reactive) foam support surface | Difference | Relative effect |
|---|---|---|---|---|
| PI occurrence | 12/113 (10.6%) | 32/116 (27.6%) | 160 fewer PIs per 1,000 (from 226 fewer to 11 fewer) |
RR 0.42 (0.189-0.96) |
Outcome 1: Reduction in PI Occurrence
The meta-analysis(Shi, Dumville et al. 2021) included four RCTs (Allman, Walker et al. 1987, Takala, Varmavuo et al. 1996, van Leen, Hovius et al. 2011, Van Leen, Hovius et al. 2013) that explored support surfaces directly relevant to the clinical question based on categorization by the authors/researchers at the time the research was undertaken.** The meta-analysis showed that air (reactive) support surfaces are associated with a lower rate of PI occurrence (RR = 0.42, 95% CI 0.18 to 0.96, p=0.04). Using air (reactive) support surfaces might reduce the proportion of people who develop a new PI compared to pressure redistribution foam (reactive) support surfaces, but the confidence interval is very wide and the evidence is uncertain (Shi, Dumville et al. 2021).
Comfort
One of the studies (Allman, Walker et al. 1987) reported comfort rated on a 4-point scale. Statistically more people using a pressure redistribution foam mattress placed on top of an alternating pressure (active) air mattress rated it as comfortable or very comfortable compared to those using an air (reactive) surface (p = 0.04). This data was considered to be indirect as the support surface was used in a non-traditional manner.
** 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
| Outcome | Pressure redistribution foam (reactive) support surfaces | Air (reactive) support surfaces | Difference | Relative effect |
|---|---|---|---|---|
| Death (Allman, Walker, et al, 1987) | Explored, but the specific event rate was not reported | Explored, but the specific event rate was not reported) | Reported to be no difference between the options, but statistical analysis was not reported | Not calculable |
| Other adverse events (Allman, Walker, et al, 1987) | Explored, but the specific event rate was not reported | Explored, but the specific event rate was not reported) | Reported to be no difference between the options, but statistical analysis was not reported | Not calculable |
Outcome 1: Serious adverse events: death
One of the studies (Allman, Walker et al. 1987) reported the death rate was similar between using a reactive (air) surface (n = 8/31) and using a pressure redistribution foam 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).
Outcomes 2: Other adverse events
One of the studies (Allman, Walker et al. 1987) reported adverse events were similar between using a reactive (air) surface versus a pressure redistribution foam support surface a placed on top of an alternating pressure (active) air mattress. The reported events included pneumonia, urinary tract infections, sepsis, fever and heart failure (Allman, Walker et al. 1987) and appeared unlikely to be related to the support surface being used.
The Consumer Panel Group noted that deflation of air support surfaces is a risk that can lead to developing a PI. Vigilance is required to ensure that deflation of a support surface is identified and addressed promptly.
In the GGGs expert opinion, the rate of adverse events from using either type of support surface are small. This is supported by the rate of adverse events reported with these support surfaces in studies making other comparisons.(Price, Bale et al. 1999, Cavicchioli and Carella 2007, Jiang, Li et al. 2014, Sauvage, Touflet et al. 2017, Nixon, Brown et al. 2019)
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 downgraded once for risk of bias (Shi, Dumville et al. 2021). Two studies with approximately 50% of weight in the analysis had either one domain other than performance bias at high risk of bias, or all domains at unclear risk of bias. The other two studies had domains other than performance bias at unclear risk of bias. Certainty was also downgraded once for imprecision because even though the optimal information size (OIS) was met, the confidence interval crossed 0.75 (Shi, Dumville et al. 2021). The Guideline Governance Group additionally downgraded the evidence for directness due to the interventions being older support surfaces (all studies published pre-2014) and one study used a reactive overlay over an active surface.
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
Both undesirable and desirable effects are small, the data is dated and the comparator in one study was not a traditional way of using a support surface. However, all studies favored 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
In the Panel Group’s expert opinion, a powered (reactive) air surface can increase the time health workers and informal carers spend managing and maintaining support surfaces (e.g. checking power, settings and inspecting the integrity of the surface). Access to a cost feasible electrical supply (for powered air surfaces) is highly variable. Unpowered (reactive) air surfaces may require less management but will still require inspection and maintenance.
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 was no evidence on the costs of required 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 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
In the Panel Group’s expert opinion, accessibility of air (reactive) surfaces is highly variable depending upon geographic and clinical context. In high resource countries, air (reactive) surfaces are generally accessible in in-patient and community settings and might be funded through government disability or veteran schemes for people at higher risk of PIs.
The Panel Group noted that people from low economic backgrounds in all geographic regions, including people who are homeless, have reduced access to support surfaces. The Panel Group noted that the rising costs of power could increase the costs of using powered support surfaces and reduce access.
11. Acceptability:
Is the intervention acceptable to key stakeholders?
JUDGEMENT
No
Probably no
Probably yes
yes
Varies
Don’t know
RESEARCH EVIDENCE
There is no evidence on how acceptable the support surfaces options are to key stakeholders.
12. Feasibility:
Is the intervention feasible to implement?
JUDGEMENT
No
Probably no
Probably yes
Yes
Varies
Don’t know
RESEARCH EVIDENCE
Ease of use
In studies conducted in aged care, caregivers and older adults rated transferring in and out of a bed with an air (reactive) surface as easy (Zwaenepoel, Van Hecke et al. 2020, Meaume and Marty 2023). This finding was duplicated in another study in aged care in which caregivers rated an air (reactive) surface as easy to assist older adults into and out of bed and to reposition horizontally and vertically in the bed (Raepsaet, Zwaenepoel et al. 2021). One of these studies reported that 100% of staff respondents found an air mattress easy to clean, and more than 95% found it easy to implement (Meaume and Marty 2023).
Patient experience
Some studies reported quantitative(Zwaenepoel, Van Hecke et al. 2020, Raepsaet, Zwaenepoel et al. 2021) and qualitative (Serraes and Beeckman 2016, Meaume and Marty 2023) evaluations of air (reactive) surfaces by people in aged care settings and their care providers and informal caregivers. Median ratings of comfort for an air (reactive) surface were 8-9 out of 10 (Raepsaet, Zwaenepoel et al. 2021).
Although air (reactive) surfaces are historically recognized as potentially noisy (Serraes and Beeckman 2016), in recent studies (Serraes and Beeckman 2016, Zwaenepoel, Van Hecke et al. 2020, Raepsaet, Zwaenepoel et al. 2021) people using air (reactive) surfaces and/or their caregivers indicated that the noise did not disrupt their sleep. An older study (Serraes and Beeckman 2016) reported that individuals had equivalent levels of comfort on different types of air (reactive) surfaces. I The Consumer Panel Group noted that deflation of support surfaces is a risk that can lead to developing a PI. Vigilance is required to ensure that deflation of a support surface is identified and addressed promptly. In the Panel Group’s expert opinion, some health services have ceased using air (reactive) surfaces because of this risk.