Clinical question
Should a medical grade sheepskin support surface vs. any other support surface be used to reduce pressure injury occurrence in people at risk?
Context
Population:
Intervention:
Comparison:
Main Outcomes:
Setting:
Background:
Conflicts on Interest:
Individuals at risk of pressure injuries
Medical grade sheepskin support surface
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
Small
Moderate
Very low
No important uncertainty or variability
Don’t know
Don’t know
No included studies
No included studies
Probably no impact
Probably yes
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 | Medical grade sheepskin support surfaces | Any other support surfaces | Difference | Relative effect |
|---|---|---|---|---|
| PI occurrence | 18/720 (2.5%) | 33/704 (4.7%)0.59 | 19 fewer PIs per 1,000 (from 0 fewer to 2 more) |
RR 0.59 (0.33-1.05) |
Outcome 1: Reduction in PI Occurrence
The meta-analysis (McInnes, Jammali-Blasi et al. 2015) included three randomized controlled trials (RCTs) (McGowan, Montgomery et al. 2000, Jolley, Wright et al. 2004, Mistiaen, Achterberg et al. 2010) that compared medical grade sheepskins to pressure redistribution support surfaces, standard vinyl mattress and un-defined comparators. Medical grade sheepskin supports were associated a lower rate of PI occurrence effect size (RR = 0.59, 95% CI 0.33 to 1.05. It is uncertain if using medical grade sheepskin surfaces versus any other support surfaces would prevent a new Category/Stage 1 or greater PI (McInnes, Jammali-Blasi et al. 2015).
** 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
There was no evidence about serious adverse events. In consideration of the lack of published cases, and in the expert opinion of the Panel Group, serious adverse events are unlikely to be associated with a sheepskin support surface. In one study (Mistiaen, Achterberg et al. 2010) 33% of participants reported medical grade sheepskin was too warm and this contributed to some people requesting a change of surface. About 5% of 218 individuals in a second study (Jolley, Wright et al. 2004) reported the sheepskin was not acceptable due to being too hot, too uncomfortable of due to wool sensitivity.
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 low. The evidence was downgraded once for risk of bias. all studies had high risk of performance bias, plus two studies with approximately 90% of weight in the analysis had another domain at high risk of bias (McInnes, Jammali-Blasi et al. 2015). Evidence was downgraded because the comparator surfaces were either reported to be surfaces that are no longer considered standard care (e.g. vinyl mattresses) or were not reported. 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 evidence on desirable and desirable effects is very low certainty.
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 on resources required.
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 required.
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 medical grade sheepskins are already used in lower resources countries and communities. They are commonly used in some countries under heel (usually on top of a pressure redistribution surface).
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 (Mistiaen, Achterberg et al. 2010), 52% of the 209 individuals stated they would recommend a sheepskin surface. In the Guideline Governance Group’s opinion, there is varied acceptability; it is not uncommon for people to experience a medical grade sheepskin support surface as too warm.
12. Feasibility:
Is the intervention feasible to implement?
JUDGEMENT
No
Probably no
Probably yes
Yes
Varies
Don’t know
RESEARCH EVIDENCE
Medical sheepskins require specialist laundering to achieve thermal disinfection. This may reduce their feasibility for use in some clinical settings and for some individuals (e.g., individuals who are incontinent or those with a heavily exuding wound) (Jolley, Wright et al. 2004).