Prevention of pressure ulcers with a static air support surface: A systematic review.

The aims of this study were to identify, assess, and summarise available evidence about the effectiveness of static air mattress overlays to prevent pressure ulcers. The primary outcome was the incidence of pressure ulcers. Secondary outcomes included costs and patient comfort. This study was a systematic review. Six electronic databases were consulted: Cochrane Library, EMBASE, PubMed (Medline), CINAHL (EBSCOhost interface), Science direct, and Web of Science. In addition, a hand search through reviews, conference proceedings, and the reference lists of the included studies was performed to identify additional studies. Potential studies were reviewed and assessed by 2 independent authors based on the title and abstract. Decisions regarding inclusion or exclusion of the studies were based on a consensus between the authors. Studies were included if the following criteria were met: reporting an original study; the outcome was the incidence of pressure ulcer categories I to IV when using a static air mattress overlay and/or in comparison with other pressure-redistribution device(s); and studies published in English, French, and Dutch. No limitation was set on study setting, design, and date of publication. The methodological quality assessment was evaluated using the Critical Appraisal Skills Program Tool. Results were reported in a descriptive way to reflect the exploratory nature of the review. The searches included 13 studies: randomised controlled trials (n = 11) and cohort studies (n = 2). The mean pressure ulcer incidence figures found in the different settings were, respectively, 7.8% pressure ulcers of categories II to IV in nursing homes, 9.06% pressure ulcers of categories I to IV in intensive care settings, and 12% pressure ulcers of categories I to IV in orthopaedic wards. Seven comparative studies reported a lower incidence in the groups of patients on a static air mattress overlay. Three studies reported a statistical (P < .1) lower incidence compared with a standard hospital mattress (10 cm thick, density 35 kg/m3 ), a foam mattress (15 cm thick), and a viscoelastic foam mattress (15 cm thick). No significant difference in incidence, purchase costs, and patient comfort was found compared with dynamic air mattresses. This review focused on the effectiveness of static air mattress overlays to prevent pressure ulcers. There are indications that these mattress overlays are more effective in preventing pressure ulcers compared with the use of a standard mattress or a pressure-reducing foam mattress in nursing homes and intensive care settings. However, interpretation of the evidence should be performed with caution due to the wide variety of methodological and/or reporting quality levels of the included studies.

Preventive Effect of a Microclimate-Regulating System on Pressure Ulcer Development: A Prospective, Randomized Controlled Trial in Dutch Nursing Homes.

OBJECTIVE: Prevention of pressure ulcers (PrUs) is based on relieving pressure, diminishing shear stress, and controlling the skin's microclimate. Based on the recommendations in the most recent guideline for prevention of PrUs, a pressure-relieving, shear stress-diminishing, and microclimate-controlling skin interface multilayer support system (Bedcare; Sense Textile, 's-Hertogenbosch, the Netherlands) has been developed for use on top of a viscoelastic foam mattress (Formafoam, Kabelfabriek Eupen, Belgium). The aim of this study was to test the PrU preventive effect of this system compared with a viscoelastic foam mattress alone. METHODS: A multicenter, prospective, randomized controlled trial was executed in 21 nursing homes in the Netherlands. Residents with a Braden score less than 16, a life expectancy of more than 3 months, and no PrUs during the last 3 months were asked to participate and included after informed consent. Residents were divided into 2 groups. The control group received a new high-quality viscoelastic foam mattress covered with a cotton sheet. The intervention group received the same new mattress, in combination with the newly developed multilayer system. Research nurses followed the participating residents for 12 weeks. The outcome parameter was the development of PrUs. RESULTS: Two hundred six residents participated in the study. Both groups had comparable demographics (eg, age, Braden score, care dependency, incontinence). In the control group, 5% of the residents developed a category 2, 3, or 4 PrU, and 9% in the intervention group did. These results were not statistically significant. CONCLUSIONS: This study shows that the multilayer system (Mini Overlay System, barrier mattress cover, and Stay and Transfer Sheet), when used as an integral system and in combination with a viscoelastic foam mattress, has no added value over the viscoelastic foam mattress/cotton sheet.

A Secondary Analysis of Longitudinal Prevalence Data to Determine the Use of Pressure Ulcer Preventive Measures in Dutch Nursing Homes, 2005-2014.

Pressure ulcers (PUs) are an important and distressing problem in Dutch nursing homes. A secondary analysis of longitudinal data from the Dutch National Prevalence Measurement of Care Problems (LPZ) - an annual, multicenter, point-prevalence survey - was conducted for the years 2005-2014 to determine the use of specific recommended PU preventive measures from the European Pressure Ulcer Advisory Panel 1998, the National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel 2009, and the 2002 and 2011 Dutch PU guidelines. Preventive care was investigated among nursing home residents at risk for PUs and included skin care (moisturization); nutritional and hydration status assessment and optimization; and pressure redistribution involving mattresses, cushions, and heel pressure-relieving strategies and devices. Following abstraction from the study database, data for 3 at-risk groups were distinguished: 1) residents with a Braden score of 17, 18, or 19; 2) residents with a Braden score below 17; and 3) residents with a PU. Data were aggregated at the institutional level. Differences were tested with multiple regression analyses. The mean number of residents over the study period was 5435, the mean age was 82.8 years, and the mean Braden score was 15.3. None of the recommended preventive measures from the guidelines consulted was applied 100% of the time: preventive skin care measures were used in 25.1% to 63.8% of cases and dehydration and/or malnutrition were identified and managed in 27.8% to 65.6% of patients. Pressure redistribution with special types of mattresses was used in 85.2% of patients, cushions in (wheel)chairs were used in 64.8% of patients, and heels were offloaded in 57.8% of patients. The results regarding repositioning for the 3 groups, respectively, showed a maximum use of 9.7%, 30.3%, and 65.6%; the higher the PU risk, the more preventive measures were used. Although the results show a decrease in the percent of category 2 through category 4 PUs from 16.6% to 5.5% and a trend toward increased use of preventive measures (more skin care, attention for dehydration/malnutrition, use of floating heels/heel devices, and pressure-relieving systems when a PU was present), the reason why measurements were suboptimally used remains unclear. Further research to address the application of guidelines in daily practice is needed.

Pressure Relief, Visco-Elastic Foam with Inflated Air? A Pilot Study in a Dutch Nursing Home.

OBJECTIVE: There is still little evidence regarding the type of mattress that is the best for preventing pressure ulcers (PUs). In a Dutch nursing home, a new type of overlay mattress (air inflated visco-elastic foam) was tested to analyze the opportunity for replacement of the normally used static air overlay mattress in its three-step PU prevention protocol In this small pilot the outcome measures were: healing of a category one pressure ulcer, new development or deterioration of a category one PU and need for repositioning. METHODS: We included 20 nursing home residents with a new category one pressure ulcer, existing for no longer than 48 h following a consecutive sampling technic. All residents were staying for more than 30 days in the nursing home and were lying on a visco-elastic foam mattress without repositioning (step one of the 3-step protocol) at the start of the pilot study. They had not suffered from a PU in the month before. The intervention involved use of an air inflated foam overlay instead of a static air overlay (normally step 2 of the 3-step protocol). At the start; the following data were registered: age; gender; main diagnosis and presence of incontinence. Thereafter; all participating residents were checked weekly for PU healing tendency; deterioration of PUs; new PUs and need of repositioning. Only when residents showed still a category one PU after 48 h or deterioration of an existing pressure ulcer or if there was development of a new pressure ulcer, repositioning was put into practice (step 3 of the PU protocol). All residents participated during 8 weeks. RESULTS: Seven residents developed a new pressure ulcer category one and still had a category one pressure ulcer at the end of the study period. One resident developed a pressure ulcer category 2. Fifteen residents needed repositioning from one week after start of the study until the end of the study. CONCLUSIONS: Overall 40% of the residents developed a pressure ulcer. Seventy five percent of the residents started with repositioning because there was no healing tendency of their category one PU diagnosed at the start of the pilot. Because this new type of overlay mattress resulted in an increased PU incidence, and almost standard need of repositioning with accompanied high costs, this type of overlay mattress gives no benefit above the traditional visco-elastic foam mattresses in combination with the originally used static air overlay.

The effect of a simple 3-step pressure relieving strategy for preventing pressure ulcers: an explorative longitudinal study from 2002-2011.

OBJECTIVE: Pressure ulcers (PUs) still form an important and distressing problem in Dutch nursing homes. Pressure ulcer prevention protocols are generally based on current guidelines. The authors developed an alternative 3-step protocol to help prevent pressure ulcers. The effects of this new 3-step protocol on the prevalence of pressure ulcers in patients at risk of developing PUs in the Avoord nursing homes in Etten-Leur/Zundert (Netherlands) were calculated. In addition, the protocol's general cost effects were explored. METHOD: Data on the prevalence of PUs and the use of preventive measures were derived from the annual independent International Prevalence Measurement of Care Problems of Maastricht University (Landelijke prevalentiemeting Zorgproblemen [LPZ]). This annual measurement was implemented in 1998 and measures care problems such as the prevalence of PUs and related preventive measures. Data on patients at risk of developing PUs at the Avoord nursing homes in Etten- Leur/Zundert (Netherlands) were analyzed and compared with national data between 2002 and 2011. RESULTS: The introduction of the 3-step protocol resulted in a significant reduction of the nosocomial prevalence of category 2-4 PUs. The prevalence was reduced from 8.7% to 0.5% during the first year and remained stable at about 2% throughout the rest of the study period. The prevalence at the national level also decreased during this period, but not as much, and was still significantly higher in 2011. The use of alternated systems decreased to almost 1%. Use of static air mattresses showed an almost linear rise in the Avoord nursing homes from the start of the implementation of the protocol, while the trend for both types of mattresses remained stable on a national level. Introducing the static air mattress instead of the more expensive alternating mattresses helped to reduce the mean daily costs of mattresses at the Avoord nursing homes by more than 70% compared to national figures. The workload of the nursing staff decreased as well due to the reduction of repositioning. CONCLUSION: The introduction of the 3-step protocol showed to be effective. The prevalence of PUs and the mean daily costs were reduced to, and have been sustained at, a significantly lower level. .

Pressure relief with visco-elastic foam or with combined static air overlay? A prospective, crossover randomized clinical trial in a dutch nursing home.

OBJECTIVE: Evidence of the best mattress for preventing pressure ulcers is not conclusive. In a single center, prospective, crossover trial on pressure ulcer incidence in nursing home residents, a static air overlay mattress, without a pump, on top of a visco-elastic foam mattress was compared with a visco-elastic foam mattress alone. METHODS: The study was performed using a randomized crossover design. Forty-one patients with a score of 19 or lower on the Braden scale, but with no pressure ulcer at the start, were divided into 2 groups; 21 patients received a visco-elastic foam mattress (control group) and 20 patients a static air overlay on top of a visco-elastic foam mattress (intervention group) for a period of 6 months. In the second (crossover) period of 6 months, 19 patients participated in each group. Patients were checked weekly and, only when signs of development of a pressure ulcer were present was treatment altered to reposition patients according to the nursing home pressure ulcer protocol. No statistically significant differences were noted between the 2 groups with regard to age, gender, or Braden scale score. RESULTS: Of 41 patients, 3 died and were unable to participate in the crossover period, 8 patients (22.2%) developed a category 2 or higher pressure ulcer on a visco-elastic foam mattress (control group) and 2 (5.2%) on a static air mattress (intervention group)(P = 0.087). There was a difference regarding pressure ulcer incidence between patients with a very low Braden score between 6 and 12, and patients with a mean score between 13-19. Out of 8 patients, in the 2(25%) who developed a pressure ulcer on a foam mattress, the ulcers showed no signs of healing. In the static air group all pressure ulcers healed by normal treatment according to a standardized pressure ulcer treatment protocol. CONCLUSIONS: In this small study, static air overlay mattresses provided a better prevention than visco-elastic foam mattresses alone (5.2% vs 22.2%). The Braden scores of the patients in both groups did not change during the 6-month test. The decision to use repositioning only when there were signs of a pressure ulcer is acceptable when a static air overlay is in position. The 22.2% incidence of pressure ulcers in the foam group, however, may stress the need to continue repositioning when using this type of mattress. .

Pressure relief, cold foam or static air? A single center, prospective, controlled randomized clinical trial in a Dutch nursing home.

OBJECTIVE: At present, the evidence regarding the type of mattress that is the best for preventing pressure ulcers is not convincing. In a single center, prospective, controlled trial we compared a static air overlay mattress (no electric pump needed) on top of a cold foam mattress with a cold foam mattress alone on pressure ulcer incidence in nursing home residents. METHODS: 83 Patients were included in the study with a score lower than 12 points on the Norton scale and no pressure ulcer at the start of the study. 42 Patients received a cold foam mattress and 41 patients received a static air overlay on top of that cold foam mattress. Out of bed we standardized the pressure reduction in sitting position by using a static air cushion in both groups. Patients were checked weekly in both groups for pressure ulcers. Only when there were signs of developing a pressure ulcer grade 2 or higher, repositioning by our nursing home pressure ulcer protocol (PU protocol) was put into practice. RESULTS: Seven patients (17.1%) on a cold foam mattress and two (4.8%) on a static air mattress developed a pressure ulcer grade 2 or more. There was no difference regarding pressure ulcer incidence between patients with a high risk (Norton 5-8) and patients with a medium risk (Norton 9-12). In 5 out of 7 patients who developed a pressure ulcer on a foam mattress the ulcers showed no healing using our PU protocol. In the static air group all pressure ulcers healed by regular treatment according to our PU protocol. CONCLUSIONS: In this study, static air overlay mattresses provided a better prevention than cold foam mattresses alone (4.8% versus 17.1%). The Norton scores of the patients in both groups did not change during the 6 month trial period. Our decision to use repositioning only when there were signs of a pressure ulcer seems to be acceptable when a static air overlay is in position. However, the score of 17.1% development (incidence) of pressure ulcers in the foam group may stress the need of repositioning when using only this type of mattress.