Pressure redistributing devices

National Clinical Guideline Centre (UK)

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National Clinical Guideline Centre (UK). The Prevention and Management of Pressure Ulcers in Primary and Secondary Care. London: National Institute for Health and Care Excellence (NICE); 2014 Apr. (NICE Clinical Guidelines, No. 179.)

The Prevention and Management of Pressure Ulcers in Primary and Secondary Care.

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12Pressure redistributing devices

Pressure relieving and redistributing devices are widely accepted methods of trying to prevent the development of pressure ulcers for people considered as being at risk. The devices used include different types of mattresses, overlays, cushions and seating. These devices work by reducing or redistributing pressure, friction or shearing forces.

Selection of a device may depend on factors such as mobility of the individual, the results of skin assessment, the level of and site at risk, weight, staff availability and skill plus the general health and condition of the individual. It is also important that any device is able to be cleaned and decontaminated effectively. It is accepted that these devices should be used in conjunction with other preventative strategies such as repositioning.

Specific devices are available for certain at risk sites, for example, the heel. Pressure redistributing devices for heels are considered in Chapter 13.

The GDG were therefore interested in identifying whether the use of pressure redistributing devices, including both static and dynamic surfaces, are effective in the prevention of pressure ulcers.

12.1. Review question: What are the most clinically and cost-effective pressure re-distributing devices for the prevention of pressure ulcers?

For full details see review protocol in Appendix C.

12.1.1. Clinical evidence (adults)

A Cochrane review by McInnes et al (2011)¹²⁷ was identified from the search and was adapted for this review. The Cochrane review was quality assured and, as it was of very high quality and matched the majority of the protocol (see Appendix C), the information was used to populate this review for the summary of studies, forest plots and for the quality assessment of studies (see Appendix G-I). Fifty-three studies were included in the Cochrane review. Three studies were removed but used in the review on the use of pressure redistributing devices for the prevention of heel pressure ulcers²⁸^,⁷¹^,²⁰⁷ as they included devices which are specific to only heel ulcers (see Chapter 13). One study⁶⁰ was at high risk of bias and did not report outcomes clearly and was excluded (from our review and the Cochrane review). One other study (Economides, 1995)⁵⁸ was excluded as it looked at wound breakdown rather than incidence of pressure ulcers. Two other studies (Gentilello, 1988⁶⁹ and Summer, 1989¹⁹⁵) were excluded from this review as they were more relevant to the repositioning review (see Chapter 9). Eight other studies²⁷^,³⁰^,⁵⁴^,⁸²^,¹²⁵^,¹⁶³^,²⁰⁹^,²¹⁷ which were not included in the Cochrane review, were identified and included in this review (see Appendix G).

In total, 54 studies were included in this review ³^,⁶^,¹⁵^,³¹^,³³^,³⁵^,³⁸^-⁴⁰^,⁴²^,⁴⁸^,⁶¹^,⁶²^,⁷⁰^,⁷²^,⁷⁶^,⁷⁷^,⁸³^,⁸⁷^,⁹⁰^,⁹⁴^,¹⁰¹^,¹⁰³^,¹⁰⁴^,¹¹³^,¹¹⁴^,¹¹⁷^,¹²⁶^,¹³⁰^,¹⁴⁸^,¹⁴⁹ ²⁷^,³⁰^,⁵⁴^,⁶⁸^,⁸²^,¹²⁵^,¹⁶¹^,¹⁶³^-¹⁶⁵^,¹⁷²^,¹⁷⁴^,¹⁸⁰^,¹⁸⁵^,¹⁹²^,¹⁹⁸^-²⁰⁰^,²⁰⁹^,²¹⁴^,²¹⁷^,²¹⁸^,²²³. Evidence from these studies is summarised in the clinical GRADE evidence profiles below.

See also the study selection flow chart in Appendix D, forest plots in Appendix I, study evidence tables in Appendix G and exclusion list in Appendix J.

In the studies, various types of devices were used to redistribute pressure to prevent pressure ulcers. The Cochrane review categorised them as low-tech (non-powered) constant low pressure support surfaces, high-tech support surfaces and other support surfaces. The types of devices included are listed below;

‘Low-tech’ continuous low pressure (CLP) support surfaces:
- Standard foam mattresses.
- Alternative foam mattresses/overlays: conformable and aim to redistribute pressure over a larger contact area.
- Gel-filled mattresses/overlays: conformable and aim to redistribute pressure over a larger contact area.
- Fibre-filled mattresses/overlays: conformable and aim to redistribute pressure over a larger contact area.
- Air-filled mattresses/overlays: conformable and aim to redistribute pressure over a larger contact area.
- Water-filled mattresses/overlays: conformable and aim to redistribute pressure over a larger contact area.
- Bead-filled mattresses/overlays: conformable and aim to redistribute pressure over a larger contact area.
- Sheepskins
‘High-tech’ support surfaces:
- Alternating-pressure mattresses/overlays: air-filled sacs that inflate and deflate sequentially to relieve pressure at different anatomical sites for short periods; these may incorporate a pressure sensor
- Air-fluidised beds: warmed air circulates through fine ceramic beads covered by a permeable sheet; allowing support over a larger contact area (CLP)
- Low-air-loss beds: support provided by a series of air sacs through which warmed air passes (CLP)
Other support surfaces:
- Turning beds/frames: aides manual repositioning of the patient, or by motor driven turning and tilting.
- Operating table overlays: conformable and aim to redistribute pressure over a larger contact area.
- Wheelchair cushions: either conforming cushions that reduce contact pressures by increasing surface area in contact, or mechanical cushions which alternate pressure.
- Limb protectors: pads and cushions of different forms to protect bony prominences.
The Cochrane review considered all studies, regardless of whether grade 1 pressure ulcers were described separately, although the authors state that studies comparing the incidence of pressure ulcers of grade 2 or greater are more likely to be reliable. For the purposes of the current review, the GDG therefore chose to include pressure ulcers of grade 2 and above were.

Although the included studies used a range of grading systems, those which reported pressure ulcers of grade 2 and above separately, used the EPUAP or NPUAP classification system (see Table 50). For studies that did not use the EPUAP/NPUAP and reported grade of ulcer separately, the distinction was usually a break in the skin or blister.

Table 50

Glossary of terms (NPUAP 2007).

The Cochrane review reported that methods of measuring secondary outcomes such as comfort, durability, reliability and acceptability were not well developed. Where data were presented details were provided, but this was not incorporated into the analysis. As some of these outcomes were considered by the GDG to be critical for decision making, for the purposes of this review these outcomes have been included in the GRADE evidence tables (see Table 52).

The Cochrane review meta-analysed studies where there was more than 1 trial for an outcome which compared similar devices. The results were pooled using a fixed effect model, but if heterogeneity (I² = 50% or above and the p value was less than 0.10) was found, a random-effects model was used. The review states that it was assumed that the risk ratio remained constant for different lengths of follow-up and so results were pooled if participants were followed-up for different lengths of time.

No studies were found for standard or pressure-relieving chairs, tilt-in-space wheelchairs, postural support or limb protectors.

Summary of included studies

Table 51

Summary of included studies.

12.1.2. ‘Low-tech’ constant low-pressure (CLP) supports

The Cochrane review compared standard foam hospital mattresses with other low specification (‘low-tech’), constant low-pressure (CLP) supports. Sheepskin, static air-filled supports; water-filled supports; contoured or textured foam supports; gel-filled supports; bead-filled supports; fibre-filled supports, and alternative foam mattresses or overlays were considered to be low-tech CLP. However it is noted that there is not an international definition of what a standard foam mattress is. In addition the definition can change over time, within countries, and even within hospitals. If a description of the standard mattress was given it was included in the review, which is outlined in Table 51. The Cochrane review assumes that standard mattresses are likely to vary less within countries than between countries, and undertook subgroup analysis by country, although this intention was not pre-specified.

12.1.2.1. Standard foam hospital mattress compared with other “low-tech” CLP

Table 52

Clinical evidence profile: constant low-pressure supports (CLP) versus standard foam mattresses (SFM) for pressure ulcer prevention.

Table 53

Clinical evidence profile: constant low pressure support (inflated static overlay (ISO)) versus constant low pressure support (microfluid static overlay (MSO)) and alternating pressure support (low-air-loss dynamic mattress (LALDM)).

Table 54

Clinical evidence profile: alternative foam mattress versus standard foam mattress.

12.1.3. Comparisons between alternative foam mattresses

Table 55

Clinical evidence profile: comparisons between alternative foam supports.

12.1.4. Comparisons between ‘low-tech’ constant low-pressure supports

Table 56

Clinical evidence profile: comparisons between CLP supports.

12.1.5. ‘High-tech’ pressure supports

This section outlines 3 main groups of supportsL alternating pressure devices (AP), low-air loss beds and air-fluidised low beds.

12.1.5.1. Alternating-pressure compared with constant low pressure

Table 57

Clinical evidence profile: alternating-pressure versus standard foam mattress.

12.1.5.2. Alternating-pressure compared with constant low pressure

Table 58

Clinical evidence profile: alternating-pressure versus constant low-pressure.

Table 59

Clinical evidence profile: alternating pressure and constant low pressure in ICU/post ICU (factorial design).

Table 60

Clinical evidence profile: standard mattress in ICU/standard foam mattress post-ICU versus standard ICU/constant low pressure mattress (TEMPUR) post-ICU – grade 2 and above pressure ulcers.

Table 61

Clinical evidence profile: alternating pressure (NIMBUS) ICU/SFM post-ICU versus standard ICU/constant low pressure mattress (TEMPUR) post-ICU – grade 2 and above pressure ulcers.

Table 62

Clinical evidence profile: standard ICU/standard foam mattress post-ICU versus slternating pressure mattress (NIMBUS) ICU/constant low pressure mattress (TEMPUR)CLP post-ICU – grade 2 and above pressure ulcers.

Table 63

Clinical evidence profile: alternating pressure mattress (NIMBUS) ICU/standard foam mattress post-ICU versus alternating pressure mattress (NIMBUS) ICU/constant low pressure mattress (TEMPUR) post-ICU – grade 2 and above pressure ulcers.

Table 64

Clinical evidence profile: standard ICU/constant low pressure mattress (TEMPUR) post-ICU versus alternating pressure mattress (NIMBUS) ICU/constant low pressure mattress (TEMPUR) post-ICU – grade 2 and above pressure ulcers.

12.1.6. Comparisons between different alternating-pressure devices

Table 65

Clinical evidence profile: comparisons between alternating-pressure devices.

12.1.7. Low-air-loss (LAL) beds

Three studies evaluated the use of low-air-loss beds. Such devices provide a flow of air that assists in controlling the microclimate of the person's skin (NPUAP 2007).²⁰ Two studies (Inman 1993 and Cobb 1997) were pooled as they included people in ICU.³³^,⁹³ A further study (Bennett) considered a low-air-loss hydrotherapy bed compared to a variety of mattresses which was not in people in ICU, and therefore was not pooled.¹⁴

12.1.7.1. Comparisons between LAL and other devices

Table 66

Clinical evidence profile: low air loss versus standard bed.

12.1.8. Other devices

12.1.8.1. Operating room mattress

Table 67

Clinical evidence profile: indentation load deflection (IDL) (25%) operating room foam mattress (density 1.3 cubic feet, IDL 30lb) versus operating room usual care (padding as required, including gel pads, foam mattresses, ring cushions).

12.1.8.2. Operating table overlay

Table 68

Clinical evidence profile: operating table overlay versus no overlay.

12.1.8.3. Face pillows in the operating theatre

Table 69

Clinical evidence profile: disposable polyurethane foam prone head positioner (OSI) versus neoprene air filled bladder (dry flotation) device (ROHO).

Table 70

Clinical evidence profile: disposable polyurethane foam prone head positioner (OSI) versus prone view protective helmet system with a disposable polyurethane foam prone head positioner (DUPACO).

Table 71

Clinical evidence profile: neoprene air filled bladder (dry flotation) device (ROHO) versus prone view protective helmet system with a disposable polyurethane foam prone head positioner (DUPACO).

Table 72

Clinical evidence profile: multi-cell pulsating dynamic mattress system (MICROPULSE) versus standard mattress for people undergoing surgery.

Table 73

Clinical evidence profile: viscoelastic foam (TEMPUR-PEDIC) A&E overlay and ward mattress versus standard A&E overlay and ward mattress.

12.1.9. Profiling beds

12.1.9.1. Comparison between profiling bed and flat-based bed

Table 74

Clinical evidence profile: profiling bed with a pressure-reducing foam mattress versus flat-based bed with a pressure-reducing mattress.

12.1.10. Seat cushions

12.1.10.1. Comparison between different cushions

Table 75

Clinical evidence profile: comparisons between different seat cushions.

12.1.11. Economic evidence (adults)

Published literature

Nine studies were included with relevant comparisons.⁶⁵^,⁹⁶^,¹¹⁵^,¹³¹^,¹⁴⁹^,¹⁵⁹^,¹⁶⁰^,¹⁶⁷^,²¹⁷ These are summarised in the economic evidence profiles below (Table 76 - Table 80). See also the study selection flow chart in Appendix D and study evidence tables in Appendix G.

Table 76

Economic evidence profile: alternating pressure verses alternative foam.

Table 77

Economic evidence profile: comparisons between alternating pressure devices.

Table 78

Economic evidence profile: high specification foam verses standard practice.

Table 79

Economic evidence profile: constant low pressure supports compared to standard care.

Table 80

Economic evidence profile: constant low pressure supports compared to standard care in operating theatre.

Four studies that met the inclusion criteria were selectively excluded due to methodological limitations and availability of more applicable evidence.¹³^,⁹²^,⁹³^,²⁰⁶ These are summarised in Appendix K, with reasons for exclusion given.

Six further studies were found which included devices for the prevention of pressure ulcers as part of more complex prevention strategies.¹²¹^,¹²⁴^,¹⁵³^,²⁰²^,²²⁶^,²²⁷ These studies were not included as they evaluated the cost-effectiveness of the prevention strategies as a whole, and did not provide information on the cost-effectiveness of the devices alone.

It is clear from Table 77 that 2 of the included studies⁶⁵^,¹⁴⁹ demonstrate conflicting results, despite both being conducted from the perspective of the UK NHS, with costs based on 2003 UK prices. Nixon and colleagues found that alternating pressure replacement mattresses (AR) dominate alternating pressure overlays (AO), whilst Fleurence found that AOs are cost effective. Both studies indicate that ARs have a greater effectiveness, with Nixon reporting greater time to pressure ulcer development and Fleurence a small increase in QALYs associated with an increase in pressure ulcer free days. However, the incremental pressure ulcer free days in Nixon are 10 times greater than those reported in Fleurence. This is most likely due to the different methods of collecting effectiveness data (Nixon is based on a within trial analysis whilst Fleurence is based on an estimation validated by experts) and the 2 different approaches to modelling (a regression analysis to calculate additional costs and pressure ulcer free days in Nixon, and a decision tree in Fleurence). Unit costs of devices presented in these 2 papers are almost identical, both obtained from Huntleigh Healthcare and reported in 2003 prices, yet Fleurence assumes a 2 year time horizon for overlays and an 8 year horizon for mattresses, whilst Nixon and colleagues assume a 2 year time horizon for both devices. Of note, a zero cost of pressure ulcer management is assumed in Nixon, whilst a value of £1,133 is used to represent this cost in Fleurence. There are also differences in assumptions surrounding the proportion of mattresses that were rented or purchased.

Unit costs

The following unit costs were presented to aid consideration of cost effectiveness (Table 81).

Table 81

Unit costs.

Note - these prices have been obtained directly from manufacturers, and represent the list price for the NHS. It is acknowledged that prices vary locally, therefore these prices are illustrative only. The devices included in the table are those identified by GDG members as being commonly used, and should not be interpreted as recommended devices.

12.1.12. Clinical evidence (neonates, infants, children and young people)

No RCTs or cohort studies were identified. Recommendations were developed using a modified Delphi consensus technique. Further details can be found in Appendix N.

12.1.13. Economic evidence (neonates, infants, children and young people)

Published literature

No relevant economic evaluations were identified.

Economic considerations

In the absence of economic evidence, the GDG considered relevant UK NHS unit costs of various mattresses and overlays (Table 82) These were considered alongside clinical evidence obtained from the Delphi consensus panel to inform qualitative judgement about cost-effectiveness.

Table 82

Unit costs.

12.1.14. Evidence statements

12.1.14.1. Clinical (adults)

12.1.14.1.1. Cubed foam mattress (COMFORTEX DECUBE) versus standard hospital mattress (standard polypropylene SG40)

One study (n=44) showed a cubed foam mattress is potentially more clinically effective at reducing the incidence of pressure ulcers (grade 2-4) when compared to a standard hospital mattress (very low quality).
One study (n=44) showed a cubed foam mattress is potentially more clinically effective at reducing the incidence of pressure ulcers (all grades) when compared to a standard hospital mattress (very low quality).
One study (n=44) reported medians for a cubed foam mattress and standard hospital mattress for length of stay in hospital. The median for a cubed foam mattress was 21 days (range 5-64) and 23 days (range 4-120) for the standard hospital mattress. No estimate for effect or precision could be derived (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Health-related quality of life

12.1.14.1.2. Bead filled mattress (BEAUFORT) versus standard hospital mattress

One study (n=75) showed a bead filled mattress is potentially more clinically effective at reducing the incidence of pressure ulcers (all grades) when compared to a standard foam mattress (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.3. Softform mattress versus standard 130mm NHS foam mattress

One study (n=170) showed a softform mattress is more clinically effective at reducing the incidence of pressure ulcers (grade 2-4) when compared to a standard 130mm NHS foam mattress (low quality).
One study (n=170) showed there is no clinical difference between a softform mattress and a standard 130mm NHS foam mattress for perception of comfort being very uncomfortable (low quality).
One study (n=170) showed there may be no clinical difference between a softform mattress and a standard 130mm NHS foam mattress for perception of comfort being uncomfortable, but the direction of the estimate of effect favoured the softform mattress (very low quality).
One study (n=170) showed a softform mattress is more clinically effective for perception of comfort being adequate when compared to a standard 130mm NHS foam mattress (low quality).
One study (n=170) showed a softform mattress is more clinically effective for perception of comfort being comfortable when compared to a standard 130mm NHS foam mattress (low quality).
One study (n=170) showed a softform mattress is more clinically effective for perception of comfort being very comfortable when compared to a standard 130mm NHS foam mattress (low quality).
No evidence was found for the following outcomes:
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.4. Water-filled mattress versus standard hospital mattress

One study (n=316) showed a water-filled mattress is potentially more clinically effective at reducing the incidence of pressure ulcers (all grades) when compared to a standard hospital mattress (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.5. Alternative foam pressure-reducing mattress (CLINIFLOAT, OMNIFORM, SOFTFORM, STM5, THERAREST, TRANSFOAM, VAPOURLUX) versus standard hospital mattress

Two studies (n=696) showed an alternative foam pressure-reducing mattress is more clinically effective at reducing the incidence of pressure ulcers (all grades) when compared to a standard hospital mattress (low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.6. High-specification foam mattress (visco-polymer energy absorbing foam mattress (CONFORM-ED) versus standard mattress (KING's FUND, LINKNURSE, SOFTFOAM, TRANSFOAM, KING's FUND MATTRESS with a SPENCO or PROPAD overlay)

One study (n=1166) showed there is potentially no clinical difference between a high-specification foam mattress and a standard mattress for reducing the incidence of pressure ulcers (all grades), the direction of the estimate of effect favoured the high-spec foam mattress (very low quality).
One study (n=706) showed there is no clinical difference between a high-specification foam mattress and a standard mattress for perception of comfort , the direction of the estimate of effect favoured the standard mattress (low quality).
No evidence was found for the following outcomes:
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.7. Inflated static overlay versus microfluid static overlay and low-air-loss dynamic mattress

One study (n=110) showed there may be a clinical benefit for a constant low-pressure support (inflated static overlay) compared to a constant low-pressure support (microfluid static overlay) and alternating-pressure support (low-air-loss dynamic mattress) for reducing the incidence of pressure ulcers (all grades) (very low quality).
One study (n=64) showed there is no clinical benefit of a constant low-pressure support (inflated static overlay) for patient acceptability (comfort) when compared with a constant low-pressure support (microfluid static overlay) and alternating-pressure support (low-air-loss dynamic mattress) (moderate quality).
No evidence was found for the following outcomes:
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.8. Alternative foam mattress versus standard foam mattress

Five studies (n=2016) showed an alternative foam mattress is potentially more clinically effective at reducing the incidence of pressure ulcers (all grades) when compared to a standard foam mattress (very low quality).
Four UK studies (n=1980) showed an alternative foam mattress is potentially more clinically effective at reducing the incidence of pressure ulcers (all grades) when compared to a standard foam mattress (very low quality).
Two studies (n=206) showed an alternative foam mattress is more clinically effective at reducing the incidence of pressure ulcers (grade 2-4) when compared to a standard foam mattress (low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.9. Pressure redistributing mattress (CLINIFLOAT, OMNIFOAM, THERAREST, TRANSFOAM, VAPERM) versus standard NHS foam mattress (REYLON 150mm)

One study (n=505) showed a pressure redistributing mattress is more clinically effective at reducing the incidence of pressure ulcers (all grades) when compared to standard NHS foam mattress (low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.10. Foam mattress replacement (MAXIFLOAT) versus foam mattress overlay (IRIS 3000)

One study (n=40) showed a foam mattress replacement (Maxifloat) is potentially more clinically effective at reducing the incidence of pressure ulcers (all grades) when compared to a foam mattress overlay (very low quality).
One study (n=40) showed a foam mattress replacement (Maxifloat) is potentially more clinically effective at reducing the incidence of pressure ulcers (grade 2 and above) when compared to a foam mattress overlay (very low quality).
One study (n=40) reported means for a foam mattress replacement (Maxifloat) and foam mattress overlay for time to develop new pressure ulcers. The median for a foam mattress replacement (Maxifloat) was 9.2 days and 6.5 days (range 4-120) for the foam mattress overlay. No estimate for effect or precision could be derived. (very low quality)
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.11. Solid foam overlay versus convoluted foam overlay

One study (n=84) showed a solid foam overlay is potentially more clinically effective at reducing the incidence of pressure ulcers (all grades) when compared to a convoluted foam overlay (low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.12. Pressure-reducing foam mattress (TRANSFOAM) versus pressure-reducing foam mattress (TRANSFOAMWAVE)

One study (n=100) showed there may be no clinical difference between a pressure-reducing TRANSFOAM foam mattress and a pressure-reducing TRANSFOAMWAVE foam mattress for reducing the incidence of pressure ulcers (all grades), but the direction of the estimate of effect could favour either intervention (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.13. Constant low-pressure mattress (CARITAL OPTIMA) versus standard foam mattress (10cm thick foam density 35kg/m³)

One study (n=40) showed a constant low-pressure mattress is potentially more clinically effective at reducing the incidence of pressure ulcers (all grades) when compared to a standard foam mattress (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.14. Dry flotation mattress (SOFFLEX) versus dry flotation mattress (ROHO)

One study (n=84) showed there may be a clinical benefit for a SOFFLEX dry flotation mattress compared to a ROHO dry flotation mattress for reducing the incidence of pressure ulcers (all grades) (very low quality).
One study (n=84) showed that there may not be a clinical benefit of a ROHO dry flotation mattress compared to a SOFFLEX dry flotation mattress for reducing the incidence of pressure ulcers (grade 2 and above) (very low quality).
One study (n=84) showed there is no clinical difference between a SOFFLEX dry flotation mattress and a ROHO dry flotation mattress for patient acceptability (perception of comfort being very uncomfortable) (moderate quality).
One study (n=84) showed a SOFFLEX dry flotation mattress is potentially more clinically effective for patient acceptability (perception of comfort being uncomfortable) when compared to a ROHO dry flotation mattress (low quality).
One study (n=84) showed there may be no clinical difference between a SOFFLEX dry flotation mattress and a ROHO dry flotation mattress for patient acceptability (perception of comfort being adequate), but the direction of the estimate of effect could favour either intervention (very low quality).
One study (n=84) showed there may be no clinical difference between a SOFFLEX dry flotation mattress and a ROHO dry flotation mattress for patient acceptability (perception of comfort being comfortable), but the direction of the estimate of effect could favour either intervention (very low quality).
One study (n=84) showed there may be no clinical difference between a SOFFLEX dry flotation mattress and a ROHO dry flotation mattress for patient acceptability (perception of comfort being very comfortable), but the direction of the estimate of effect could favour either intervention (very low quality).
No evidence was found for the following outcomes:
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.15. Gel mattress versus air-filled overlay (SOFCARE)

One study (n=66) showed there may be a clinical benefit for a gel mattress compared to an air-filled overlay for reducing the incidence of pressure ulcers (all grades) (very low quality).
One study (n=66) showed there may be a clinical benefit for a gel mattress compared to an air-filled overlay for reducing the incidence of pressure ulcers (grade 2 and above) (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.16. Static air mattress (GAY MAR SOFCARE) versus water mattress (LOTUS PXM 3666)

One study (n=37) showed there may be a clinical benefit for a water mattress compared to a static air mattress for reducing the incidence of pressure ulcers (all grades) (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.17. Inflated static overlay (RIK or THERAKAIR) versus microfluid static overlay

One study (n=105) showed there may be a clinical benefit for an inflated static overlay compared to a microfluid static overlay for reducing the incidence of pressure ulcers (all grades) (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.18. Foam overlay versus Silicore overlay (SPENCO)

One study (n=68) showed there may be a clinical benefit of a Silicore overlay compared to a foam overlay for reducing the incidence of pressure ulcers (grade 2 and above) (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.19. Australian medical sheepskin versus no sheepskin

Three studies (n=1281) showed Australian medical sheepskin is more clinically effective at reducing the incidence of pressure ulcers (all grades) when compared to no sheepskin (very low quality).
Three studies (n=1281) showed there is potentially no clinical difference between an Australian medical sheepskin and no sheepskin for reducing the incidence of pressure ulcers (grade 2 and above), the direction of the estimate of effect favoured the Australian medical sheepskin (very low quality).
One study (n=539) reported 10 participants in the sheepskin group complained about its comfort. The clinical importance is unknown (very low quality).
One study (n=297) reported 6 participants in the sheepskin group withdrew before study completion due to the sheepskin causing irritation, was too hot or uncomfortable. The clinical importance is unknown (very low quality).
One study (n=539) reported a clinical benefit of Australian medical sheepskin when compared to no sheepskin for delaying the time to develop new pressure. The hazard ratio was 0.39 (95% CI 0.22 -0.69; p<0.001) (very low quality).
One study (n=543) reported a clinical benefit for Australian medical sheepskin when compared to no sheepskin for delaying the time to develop new pressure ulcers. The mean for Australian medical sheepskin was 12 days and 9 days for no sheepskin. No estimate of clinical effect or precision could be derived (very low quality).
No evidence was found for the following outcomes:
- Rates of development of pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.20. Static air overlay and cold foam mattress versus cold foam mattress alone

One study (n=74) showed a static air overlay and cold foam mattress is potentially more clinically effective at reducing the incidence of pressure ulcers (grade 2 and above) when compared to a cold foam mattress alone (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.21. 3D macroporous polyester overlay versus visco-elastic overlay

Two studies (n=122) showed there is potentially no clinical difference between a macroporous polyester overlay and a visco-elastic overlay for reducing the incidence of pressure ulcers, the direction of the estimate of effect favoured the macroporous polyester overlay (low quality).

12.1.14.1.22. Alternating-pressure versus standard foam mattress

Two studies (n=409) showed an alternating-pressure air mattress is more clinically effective at reducing the incidence of pressure ulcers (all grades) when compared to a standard foam mattress (low quality).
One study (n=82) showed an alternating-pressure air mattress is potentially more clinically effective at reducing the incidence of pressure ulcers (grade 2 and above) when compared to a standard foam mattress (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.23. Alternating-pressure versus constant low-pressure for pressure ulcer prevention

Eleven studies (n=1622) showed alternating-pressure is potentially more clinically effective at reducing the incidence of pressure ulcers (all grades) when compared to constant low-pressure (very low quality).
Six studies (n=826) showed alternating-pressure is potentially more clinically effective at reducing the incidence of pressure ulcers (grade 2 and above) when compared to constant low-pressure (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.24. Alternating pressure (various devices) versus constant low pressure (various devices)

One study (n=230) showed an alternating-pressure mattress is more clinically effective at reducing the incidence of pressure ulcers (all grades) when compared to a constant low-pressure mattress (low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.25. Alternating-pressure versus Silicore or foam overlay

Four studies (n=331) showed there is potentially no clinical difference between alternating-pressure and a Silicore or foam overlay for reducing the incidence of pressure ulcers (all grades), the direction of the estimate of effect favoured the alternating-pressure mattress (very low quality).
Two studies (n=180) showed that, for people with chronic neurological conditions, there is potentially no clinical difference between an alternating-pressure overlay and a silicore overlay for reducing the incidence of pressure ulcers (all grades), the direction of the estimate of effect favoured the alternating-pressure mattress (very low quality).
Two studies (n=151) showed that, for people without chronic neurological conditions, there may be no clinical difference between an alternating-pressure mattress and silicore or foam overlay for reducing the incidence of pressure ulcers (all grades) but the direction of the estimate of effect could favour either intervention (very low quality).
One study (n=187) showed that there may not be a clinical difference between a silicore overlay when compared to an alternating-pressure overlay for patient acceptability (drop out due to discomfort), but the direction of the estimate of effect could favour the silicore overlay (very low quality).
No evidence was found for the following outcomes:
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.26. Alternating-pressure versus water or static air mattress

Three studies (n=458) showed there may be no clinical difference between alternating-pressure and water or static air mattress for reducing the incidence of pressure ulcers (all grades) but the direction of the estimate of effect could favour the water or static air mattress (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.27. Alternating-pressure setting on mattress (DUO2) versus continuous low-pressure setting on mattress (DUO2)

One study (n=140) showed there may be no clinical difference between a continuous low-pressure setting on mattress and an alternating-pressure setting on mattress for reducing the incidence of pressure ulcers (all grades), the direction of the estimate of effect favoured continuous low-pressure setting on mattress (very low quality).
One study (n=170) reported that there was no difference in length of stay related to pressure ulcer development among people at high-risk placed on the intervention or control mattresses. The clinical importance is unknown. (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.28. Alternating-pressure air mattress (ALPHA-X-CELL) versus visco-elastic foam mattress (TEMPUR)

One study (n=447) showed there may be no clinical difference between alternating-pressure air mattress and visco-elastic foam mattress for the incidence of pressure ulcers (all grades) but the direction of the estimate of effect could favour the visco-elastic foam mattress (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.29. Alternating-pressure mattress (NIMBUS 3) versus dry flotation mattress overlay (ROHO)

One study (n=16) showed there may be no clinical difference between an alternating-pressure mattress and a dry flotation mattress overlay for reducing the incidence of pressure ulcers (all grades), but the direction of the estimate of effect could favour either intervention (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.30. Dynamic flotation mattress (NIMBUS2) and alternating-pressure cushion versus low-pressure inflatable mattress (REPOSE SYSTEM) and cushion (polyurethane)

One study (n=50) showed there may be no clinical difference between dynamic flotation mattress with alternating-pressure cushion and low-pressure inflatable mattress and cushion for reducing the incidence of pressure ulcers (grade 2 and above), but the direction of the estimate of effect could favour either intervention (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.31. Standard foam mattress in ICU/Standard foam mattress post-ICU versus Alternating-pressure mattress (NIMBUS) in ICU/Standard foam mattress post-ICU

One study (n=160) showed no clinical difference between a standard foam mattress in ICU followed by a standard foam mattress post-ICU and an alternating-pressure mattress in ICU followed by a standard foam mattress post-ICU for reducing the incidence of pressure ulcers (all grades), the direction of the estimate of effect favoured the standard foam mattress in ICU followed by a standard foam mattress post-ICU (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.32. Standard mattress in ICU/Standard foam mattress post-ICU versus Standard foam mattress ICU/constant low-pressure mattress (TEMPUR) post-ICU

One study (n=155) showed there may be no clinical difference between a standard foam mattress in ICU followed by a constant low-pressure mattress post-ICU and a standard foam mattress in ICU followed by a standard foam mattress post-ICU for reducing the incidence of pressure ulcers (all grades), the direction of the estimate of effect favoured standard foam mattress in ICU followed by a constant low-pressure mattress post-ICU (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.33. Alternating-pressure mattress (NIMBUS) in ICU/Standard foam mattress post-ICU versus Standard foam mattress ICU/constant low-pressure mattress (TEMPUR) post-ICU

One study (n=155) showed there may be no clinical difference between an alternating-pressure mattress in ICU followed by a standard foam mattress post-ICU and a standard foam mattress in ICU followed by a constant low-pressure mattress post-ICU for reducing the incidence of pressure ulcers (all grades), the direction of the estimate of effect favoured the alternating-pressure mattress in ICU (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.34. Standard foam mattress in ICU/Standard foam mattress post-ICU versus Alternating-pressure mattress (NIMBUS) in ICU/ constant low-pressure mattress (TEMPUR) post-ICU

One study (n=157) showed there may be no clinical difference for a standard foam mattress in ICU followed by a standard foam mattress post-ICU and an alternating-pressure mattress in ICU followed by a constant low-pressure mattress post-ICU for reducing the incidence of pressure ulcers (all grades), the direction of the estimate of effect favoured the standard foam mattress in ICU followed by a standard foam mattress post-ICU (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.35. Alternating-pressure mattress (NIMBUS) in ICU/Standard foam mattress post-ICU versus alternating-pressure mattress (NIMBUS) in ICU/constant low-pressure mattress (TEMPUR) post-ICU

One study (n=157) showed there may be no difference for an alternating-pressure mattress in ICU followed by a standard foam mattress post-ICU compared to an alternating-pressure mattress in ICU followed by a constant low-pressure mattress post-ICU for reducing the incidence of pressure ulcers (all grades) (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.36. Standard foam mattress ICU/constant low-pressure mattress (TEMPUR) post-ICU versus alternating-pressure mattress (NIMBUS) in ICU/ constant low-pressure mattress (TEMPUR) post-ICU

One study (n=142) showed there may be no clinical difference for a standard foam mattress in ICU followed by a constant low-pressure mattress post-ICU compared to an alternating-pressure mattress in ICU followed by a constant low-pressure mattress post-ICU for reducing the incidence of pressure ulcers (all grades) (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.37. Alternating-pressure mattress with 2 layers of air cells (PEGASUS AIRWAVE SYSTEM) versus alternating-pressure large cell ripple mattress

One study (n=62) showed an alternating-pressure mattress with 2 layers of air cells is potentially more clinically effective at reducing the incidence of pressure ulcers (grade 2 and above) when compared to an alternating-pressure large cell ripple mattress (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.38. Alternating-pressure mattress (PEGASUS AIRWAVE SYSTEM) versus alternating-pressure mattress (PEGASUS CAREWAVE SYSTEM)

One study (n=75) showed there is no clinical difference between a Pegasus airwaves alternating-pressure mattress system and a Pegasus care wave alternating-pressure mattress system for reducing the incidence of pressure ulcers (grade 2 and above) (low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.39. Alternating-pressure mattress (TRINOVA) versus control

One study (n=44) showed there may be a clinical benefit for a Trinova alternating-pressure mattress compared to a control for reducing the incidence of pressure ulcers (all grades) (very low or moderate quality).
One study (n=44) showed there may be a clinical benefit for a Trinova alternating-pressure mattress compared to a control for reducing the incidence of pressure ulcers (grade 2 and above) (very low quality).
One study (n=44) reported data for the Trinova alternating-pressure mattress for patient acceptability (comfort). 11/18 participant thought the mattress was comfortable, 10/18 participants thought that the mattress was acceptable and 5/18 found the mattress comfort unacceptable. No estimate of effect or precision could be derived (very low quality).
No evidence was found for the following outcomes:
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.40. Alternating-pressure overlay versus alternating-pressure mattress

One study (n=1971) showed there is potentially no difference for an alternating-pressure mattress alternating-pressure overlay compared to for reducing the incidence of pressure ulcers (grade 2 and above) (low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.41. Alternating-pressure bed (THERAPULSE) versus alternating-pressure mattress (HILL-ROM DUO)

One study (n=62) showed there may be a clinical benefit for an alternating-pressure THERAPULSE bed compared to an alternating-pressure (HILL-ROM DUO) mattress for reducing the incidence of pressure ulcers (grade 2 and above) (very low quality).
One study (n=62) reported means for an alternating-pressure THERAPULSE bed and an alternating-pressure (HILL-ROM DUO) mattress for length of stay in hospital for people who developed a pressure ulcer. The mean for an alternating-pressure (HILL-ROM DUO) mattress was 26 days (range 23-37.3) and 24 days (range 13-59) for an alternating-pressure (HILL-ROM DUO) mattress. No estimate for effect or precision could be derived (very low quality).
One study (n=62) reported means for an alternating-pressure THERAPULSE bed and an alternating-pressure (HILL-ROM DUO) mattress for length of stay in hospital for people who did not develop a pressure ulcer. The mean for an alternating-pressure (HILL-ROM DUO) mattress was 18 days (range 5-127) and 20 days (range 5-49) for an alternating-pressure (HILL-ROM DUO) mattress. No estimate for effect or precision could be derived (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Health related quality of life

12.1.14.1.42. Alternating low-pressure air mattress with multi-stage inflation and deflation of air cells versus standard (CLINACTIV, HILLROM) alternating low-pressure air mattress with single-stage inflation and deflation of air cells

One study (n=610) showed there is potentially no clinical difference between an alternating low-pressure air mattress with single-stage inflation and deflation of air cells compared to an alternating low-pressure air mattress with multi-stage inflation and deflation of air cells for reducing the incidence of pressure ulcers (all grades), the direction of the estimate of effect favoured the low-pressure air mattress with single-stage inflation and deflation of air cells (very low quality).
One study (n=610) showed there may be no clinical difference between an alternating low-pressure air mattress with multi-stage inflation and deflation of air cells and an alternating low-pressure air mattress with single-stage inflation and deflation of air cells for reducing the incidence of pressure ulcers (grade 2 and above), but the direction of the estimate of effect could favour either intervention (very low quality).
One study (n=610) showed there may be a clinical benefit for an alternating low-pressure air mattress with multi-stage inflation and deflation of air cells compared to an alternating low-pressure air mattress with single-stage inflation and deflation of air cells for patient acceptability (withdrawal due to discomfort) (very low quality).
One study (n=610) reported a benefit for an alternating low-pressure air mattress with multi-stage inflation and deflation of air cells compared to an alternating low-pressure air mattress with single-stage inflation and deflation of air cells for time to develop a new pressure ulcer. The medians for an alternating low-pressure air mattress with multi-stage inflation and deflation of air cells was 5.0 days (Interquartile range 3.0-8.5) and 8 days (interquartile range 3.0 8.5) for an alternating low-pressure air mattress with single-stage inflation and deflation of air cells. No estimate of clinical effect or precision could be derived (very low quality).
No evidence was found for the following outcomes:
- Rates of development of pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.43. Low-air-loss bed (KINAIR/THERAKAIR) versus static air mattress overlay/inflated static overlay (EHOB WAFFLE) or standard ICU bed

One study (n=123) showed a low-air-loss bed is potentially more clinically effective at reducing the incidence of pressure ulcers (all grades) when compared to a static air mattress overlay (very low quality).
Two studies (n=183) showed there may be a clinical benefit for a low-air-loss bed compared to static air mattress overlay/inflated static overlay for reducing the incidence of pressure ulcers (all grades) (very low quality).
Two studies (n=221) showed a low-air-loss bed is more clinically effective at reducing the incidence of pressure ulcers (grade 2and above)when compared to a static air mattress overlay or standard ICU bed (low quality).
One study (n=98) showed a low air loss hydrotherapy bed is more clinically effective at reducing the incidence of people developing multiple ulcers when compared to a standard care (standard bed or foam, air or alternating-pressure mattress) (low quality).
Three studies (n=319) showed a low-air-loss bed is more clinically effective at reducing the incidence of pressure ulcers (grade 2 and above) when compared to static air mattress overlay/standard ICU bed or standard care (standard bed or foam, air or alternating-pressure mattress) (low quality).
One study (n=98) reported some information about patient acceptability (comfort) for the low air loss hydrotherapy mattress. 10/42 provided information about comfort, of these 5/10 participants though it was comfortable and 4/10 participants thought it was uncomfortable. The clinical importance is unknown (very low quality).
One study (n=98) reported some information about patient acceptability (withdrawal from the study) for the low air loss hydrotherapy mattress compared with standard care (standard bed or foam, air or alternating-pressure mattress). In the low air loss hydrotherapy mattress group, 24/48 participantstients withdrew from the study, 6 on the first day of the study because a participant or family member complained about the bed (wet, cold or uncomfortable). In the standard care group 2/58 participants withdrew from the study. The clinical importance is unknown (very low quality).
No evidence was found for the following outcomes:
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.44. Indentation load deflection (IDL) (25%) operating room foam mattress (density 1.3 cubic feet, IDL 30lb) versus operating room usual care (padding as required, including gel pads, foam mattresses, ring cushions (donuts))

One study (n=413) showed an indentation load deflection operating room foam mattress has a potential for clinical harm at reducing the incidence of pressure ulcers (all grades) when compared to operating room usual care (low quality).
One study (n=413) showed that there was potentially no clinical difference of an indentation load deflection operating room foam mattress compared to operating room usual care for reducing the incidence of pressure ulcers (grade 2 and above), but the direction of the estimate of effect favoured usual care (very low quality).
One study (n=413) reported that participants on the indentation load deflection operating room foam mattress were significantly more likely to have skin changes than those on the usual care operating room table. The clinical importance is unknown (very low quality).
No evidence was found for the following outcomes:
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.45. Viscoelastic polymer pad versus no overlay

One study (n=416) showed a viscoelastic polymer pad is potentially more clinically effective at reducing the incidence of pressure ulcers (all grades of pressure ulcers) when compared to no overlay (low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.46. Viscoelastic foam overlay versus no overlay

One study (n=175) showed there may be no clinical difference for a viscoelastic foam overlay compared to no overlay for reducing the incidence of pressure ulcers (all grades), the direction of the estimate of effect favoured the viscoelastic foam overlay (very low quality).
One study (n=175) showed there may be no clinical difference between viscoelastic foam overlay and no overlay for reducing the incidence of pressure ulcers (grade 2 and above), but the direction of the estimate of effect could favour either intervention (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.47. Neoprene air filled bladder (dry flotation) device compared to a disposable polyurethane foam prone head positioner

One study (n=44) showed there is potentially a clinical benefit for a neoprene air filled bladder (dry flotation) device compared to a disposable polyurethane foam prone head positioner for reducing the incidence of pressure ulcers (all grades) (very low quality).
One study (n=44) showed there may be a clinical benefit for a neoprene air filled bladder (dry flotation) device compared to a disposable polyurethane foam prone head positioner for reducing the incidence of pressure ulcers (grade 2and above) (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.48. A prone view protective helmet system with a disposable polyurethane foam prone head positioner versus a disposable polyurethane foam prone head positioner

One study (n=44) showed a prone view protective helmet system with a disposable polyurethane foam prone head positioner has a potential for clinical benefit for reducing the incidence of pressure ulcers (all grades) when compared to a disposable polyurethane foam prone head positioner (very low quality).
One study (n=44) showed there may be a clinical benefit for a prone view protective helmet system with a disposable polyurethane foam prone head positioner compared to a disposable polyurethane foam prone head positioner for reducing the incidence of pressure ulcers (grade 2 and above) (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.49. A neoprene air filled bladder (dry flotation) device versus a prone view protective helmet system with a disposable polyurethane foam prone head positioner

One study (n=44) showed there is no clinical difference between a neoprene air filled bladder (dry flotation) device and a prone view protective helmet system with a disposable polyurethane foam prone head positioner for reducing the incidence of pressure ulcers (all grades) (low quality).
One study (n=44) showed there is no clinical difference between a neoprene air filled bladder (dry flotation) device and a prone view protective helmet system with a disposable polyurethane foam prone head positioner for reducing the incidence of pressure ulcers (grade 2 and above) (low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.1.50. A multi-cell pulsating dynamic mattress versus a standard mattress

Two studies (n=368) showed that for people undergoing surgery, a multi-cell pulsating dynamic mattress system is more clinically effective at reducing the incidence of pressure ulcers (all grades) when compared to a standard mattress (low quality).
One study (n=170) showed that for people undergoing surgery, a multi-cell pulsating dynamic mattress system is potentially more clinically effective at reducing the incidence of pressure ulcers (grade 2 and above) when compared to a standard mattress (very low quality).
One study (n=170) reported information about the length of stay in hospital for people who developed pressure ulcers. The average length of stay for those developing pressure ulcers was 14 days. Six of the 8 people who developed ulcers had a length of stay longer than average for the specific diagnosis. The clinical importance is unknown (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Health related quality of life

12.1.14.1.51. A visco-elastic foam accident and emergency (A&E) overlay and ward mattress versus standard A&E overlay and ward mattress

One study (n=101) showed there may be a clinical benefit for visco-elastic foam A&E overlay and ward mattress compared to a standard A&E overlay and ward mattress for reducing the incidence of pressure ulcers (grade 2 and above) (very low quality).
One study (n=101) showed there may be a clinical benefit for visco-elastic foam A&E overlay and ward mattress compared to standard A&E overlay and ward mattress for reducing the incidence of pressure ulcers (all grades) (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.2. Wheelchair cushions

12.1.14.2.1. Slab foam cushion versus bespoke contoured foam cushion

Two studies (n=300) showed there is no clinical difference between a slab foam cushion when compared with a bespoke contoured foam cushion for reducing the incidence of pressure ulcers (all grades) (low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.2.2. Gel cushion with foam base (JAY) versus foam cushion

One study (n=141) showed a gel cushion with foam base is potentially more clinically effective at reducing the incidence of pressure ulcers (all grades of pressure ulcers) when compared to a foam cushion (low quality).
One study (n=163) showed there may be a clinical benefit for a gel cushion with foam base compared to a foam cushion for patient acceptability (withdrawal due to discomfort) (very low quality).
No evidence was found for the following outcomes:
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.2.3. Pressure reducing cushion (not specified – chosen by nurse based on the individual) versus standard 3 inch convoluted foam cushion (EGGRATE)

One study (n=32) showed there may be a clinical benefit for a pressure reducing cushion compared to a standard 3 inch convoluted foam cushion for reducing the incidence of pressure ulcers (all grades), (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.2.4. Skin protection cushion versus segmented foam cushion

One study (n=232) showed a skin protection cushion is potentially more clinically effective at reducing the incidence of sitting related ischial tuberosities when compared to a segmented foam cushion (very low quality).
One study (n=232) showed a skin protection cushion is potentially more clinically effective at reducing the incidence of pressure ulcers of the combined ischial tuberosities and sacral/coccyx areas when compared to a segmented foam cushion (very low quality).
No evidence was found for the following outcomes:
- Patient acceptability
- Rates of development of pressure ulcers
- Time to develop new pressure ulcers
- Time in hospital or NHS care
- Health related quality of life

12.1.14.3. Economic (adults)

12.1.14.3.1. Alternating pressure verses alternative foam

One cost–utility analysis found that alternating pressure overlays and alternating pressure mattress replacements dominate (less costly and more effective) high specification foam mattresses in the prevention of pressure ulcers. This analysis was assessed as partially applicable with potentially serious limitations.

12.1.14.3.2. Comparisons between alternating pressure devices

One cost–utility analysis found that alternating pressure mattress replacements were not cost effective compared to alternating pressure overlays for the prevention of pressure ulcers (ICER: £253,000 per QALY gained). This analysis was assessed as partially applicable with potentially serious limitations.
Conversely, 1 cost-effectiveness analysis found alternating pressure mattress replacements dominate alternating overlays, with a longer time to pressure ulcer development and reduced costs. This analysis was assessed as partially applicable with potentially serious limitations.

12.1.14.3.3. High specification foam verses standard practice

One cost–effectiveness analysis found that high specification foam mattresses dominate standard mattresses in the prevention of pressure ulcers, with a reduced incidence of pressure ulcers at a lower cost. This analysis was assessed as partially applicable with minor limitations.
One cost–utility analysis found that use of pressure redistribution foam mattresses (for all residents) dominates standard practice in the prevention of pressure ulcers, with an increase in QALYs at a lower cost. This analysis was assessed as partially applicable with potentially serious limitations
One cost-effectiveness analysis found that visco-polymer energy absorbing foam mattresses dominate standard mattresses, with reduced costs and reduced incidence of pressure ulcer. This analysis was assessed as partially applicable with minor limitations.

12.1.14.3.4. Constant low pressure supports compared to standard care

One cost–effectiveness analysis found that usual care plus Australian medical sheepskin was more costly and more effective than usual care alone (ICER: £2,298 per sacral pressure ulcer avoided). This analysis was assessed as partially applicable with potentially serious limitations.
One cost–effectiveness analysis found that a preventative treatment protocol and use of a Clinitron Rite-Hite Air Fluidised Therapy bed dominates standard care on an ICU bed (reduction in pressure ulcer incidence and reduced costs). This analysis was assessed as partially applicable with potentially serious limitations.
One cost–effectiveness analysis found that use of an inflated static overlay dominated (reduction in pressure ulcer incidence and reduced costs) standard care in the prevention of pressure ulcers. This analysis was assessed as partially applicable with potentially serious limitations.

12.1.14.3.5. Constant low pressure supports compared to standard care in operating theatre

One cost–utility analysis found that use of viscoelastic polymer overlays on operating tables (for people undergoing surgery expected to last ≥90 minutes) dominates current practice, yielding higher QALYs at a lower cost. This analysis was assessed as partially applicable with minor limitations.

12.1.14.4. Clinical (neonates, infants, children and young people)

No evidence was identified

12.1.14.5. Economic (neonates, infants, children and young people)

No evidence was identified

12.2. Recommendations and link to evidence

12.2.1. Adults

Recommendations	30. Use a high-specification foam mattress for adults who are: admitted to secondary care assessed as being at high risk of developing a pressure ulcer in primary and community care settings 31. Consider a high-specification foam theatre mattress or an equivalent pressure redistributing surface for all adults who are undergoing surgery. 32. Consider the seating needs of people at risk of developing a pressure ulcer who are sitting for prolonged periods. 33. Consider a high-specification foam or equivalent pressure redistributing cushion for adults who use a wheelchair or who sit for prolonged periods.
Relative values of different outcomes	The GDG identified that the proportion of people developing new pressure ulcers and patient acceptability were the most critical outcomes to inform decision making, given that the primary goal of pressure ulcer prevention was to limit the number of new pressure ulcers. Acceptability was identified as being critical from the perspective of the patient, as it was noted that this could have a significant impact upon quality of life. Rate of development of new pressure ulcers, time to develop new pressure ulcers, time in hospital or NHS care and health related quality of life were considered important outcomes to inform decision making.
Trade-off between clinical benefits and harms	There was low to very low quality evidence to suggest that high specification foam mattresses were better than standard foam mattress for preventing pressure ulcers. All studies showed a clinical benefit of higher specification foam mattresses (cubed foam mattress, soft foam mattress, pressure redistributing foam mattress), in reducing the incidence of pressure ulcers when compared to standard hospital mattresses (standard polypropylene SG40, standard 130mm NHS foam mattress, standard 150mm NHS foam mattress). A study published in 2003 which included a visco-polymer energy absorbing foam mattress compared to a standard mattress or cushion (which was a variety of foam mattresses or overlays), showed no clinical difference for the prevention of pressure ulcers or comfort of surface. The softfoam mattress was judged to be adequate to very comfortable in comparison to the standard 130mm NHS foam mattress. The GDG recognised that the standard hospital mattress used in the studies was likely to have varied yearly and by hospital. Current standard hospital mattresses are likely to be higher specification foam mattresses than those included in the studies (as the majority of the studies were undertaken greater than 10 years ago). The GDG further acknowledged that the type of mattress used in community settings will vary. Both a bead-filled mattress and a water-filled mattress showed a clinical benefit for reducing the incidence of pressure ulcers when compared to standard hospital mattresses (type not specified). However these studies were published in 1982 and the type of standard hospital mattress used in the study is unlikely to be representative of the mattress used in current clinical practice. One small study found a foam mattress to be of clinical benefit in reducing the incidence of pressure ulcers compared to a foam overlay. Another small study found solid foam to be clinically beneficial for reducing the incidence of pressure ulcers compared to convoluted foam. Sheepskin overlay was found to be of clinical benefit compared to no sheepskin overlay for preventing all grades of pressure ulcers (using the AHCPR classification) but this did not follow for pressure ulcers of grade 2 and above. The sheepskin overlay had comfort issues that were specific to the nature of the sheepskin, such as irritation and being too hot. The following were clinically beneficial for reducing the incidence of pressure ulcers; a constant low pressure mattress compared to a standard foam mattress, an alternating pressure mattress compared to a standard foam mattress, various types of alternating pressure mattresses compared to various constant low pressure mattresses, and a variety of alternating-pressure devices compared to other alternating-pressure devices. A mattress with a single-stage inflation system delayed the onset until the development of pressure ulcers compared to a multi-stage inflation system. In 3 studies low air loss beds were found to be of clinical benefit for reducing the incidence of pressure ulcers when compared to a standard bed. In addition, a static air overlay on a cold foam (a form of polyurethane) mattress was of clinical benefit compared to no overlay on a cold foam mattress, a gel mattress was found to be more clinically beneficial than an air-filled overlay, an inflated static overlay was more clinically beneficial than a microfluid static overlay and a silicore overlay was more beneficial than a foam overlay, for reducing incidence of pressure ulcers. No clinical benefit was found for an alternating-pressure compared to silicore or foam overlay. Operating theatre A viscoelastic polymer pad was clinically beneficial for reducing the incidence of pressure ulcers compared to no overlay. A pressure redistributing (indentation load deflection) operating room foam mattress was not beneficial in comparison to operating room usual care (using padding, gel pads, foam mattresses and ring cushions) for reducing the incidence of all grades of pressure ulcers (grade 1 and above). However grade 2 and above pressure ulcers demonstrated no clinical difference. A multi-cell pulsating dynamic mattress system was more beneficial than the standard mattress (gel pad or standard pad in operating room or a replacement mattress postoperatively or a standard hospital mattress with a 6 inch or 4 inch overlay) for reducing the incidence of all grades of pressure ulcer and, in particular, grade 2 and above. The GDG considered that for people in the operating theatre, a high specification foam theatre mattress should be given as a minimum, as people undergoing surgery were likely to be at risk of developing a pressure ulcer. The group also recognised that in some operating theatres, equivalent pressure redistributing surfaces may be used and that these may provide similar benefits. Therefore a separate recommendation for people undergoing surgery (in the operating theatre) was developed. Accident and Emergency A visco-elastic overlay was more beneficial than the standard Accident and Emergency overlay for reducing the incidence of pressure ulcers. The GDG wished to highlight that individuals awaiting admission in Accident and Emergency, particularly those on trolleys, should be provided with high specification foam mattresses as a minimum, in line with those who have been admitted to secondary care, as these individuals may be at risk of developing pressure ulcers. Intensive care There was no clinical benefit of alternating pressure or constant low pressure mattresses for the prevention of pressure ulcers in people in intensive care. The GDG considered that for these individuals, a high specification foam mattress, provided on admission to intensive care, should be given as a minimum. Wheelchair cushions Two studies suggest no clinical difference between a high specification foam cushion and a slab foam cushion. A gel filled pad and a pressure-reducing cushion (designed to improve tissue tolerance in sitting by providing more surface area and reducing peak pressure) were clinically beneficial compared to foam cushions for reducing the incidence of pressure ulcers in people who use a wheelchair. A skin protection cushion was clinically beneficial compared to a segmented foam cushion for reducing the incidence of pressure ulcers. Fewer people in the pre-contoured foam plus gel filled pad group withdrew due to discomfort than in the foam cushion group. The GDG highlighted that people who use wheelchairs were likely to be at risk of developing pressure ulcers and that pressure redistribution was likely to be needed. The GDG noted that the evidence suggested a benefit of high specification foam cushions. The GDG therefore developed a recommendation for this population to emphasise the need to provide high specification foam cushions to prevent pressure ulcers. The following comparisons were not thought to inform the recommendation: alternative foam mattress versus standard foam mattress, pressure-reducing foam mattress compared to a pressure-reducing foam mattress or a dry flotation mattress compared to dry flotation mattress The GDG discussed the needs of individuals who are likely to be sitting for long periods of time. Although limited evidence was identified specifically in this population, the GDG felt that these individuals were likely to have similar pressure redistributing requirements as adults who use a wheelchair. The GDG therefore chose to develop a recommendation highlight that the needs of these individuals should be considered and to further recommend that these people are provided with a pressure redistributing cushion. Primary and community care settings The GDG noted that there was limited evidence available focusing on people in primary and community care settings such as nursing homes. The GDG considered that this group of people were likely to be at risk of developing pressure ulcers and would benefit from specific preventative care. Despite the lack of evidence, the GDG considered that the benefits of high specification foam mattresses were likely to be applicable to this population, in line with those being admitted to secondary care. People in primary and community care settings were therefore included in the recommendation to highlight that this population should be provided with a high specification foam mattress to prevent the development of pressure ulcers. Summary Given the available evidence, the GDG noted that the provision of a high-specification foam mattress was likely to significantly reduce the risk of pressure ulcer development. No potential harms for the provision of high-specification foam mattresses were identified. As such, the GDG agreed that all individuals considered at risk of developing pressure ulcers should be considered for a high-specification foam mattress, including the specific populations outlined above. The GDG noted that this was likely to include all individuals admitted to secondary care, dependent upon individual characteristics (for example, their clinical condition), as well as people requiring ongoing care in primary care settings, people with significant limited mobility and all other individuals considered at risk of developing pressure ulcers. The GDG considered the use of overlays as an alternative to the provision of a high specification mattress. Although there was evidence to suggest that there was some benefit of using an overlay such as sheepskin in some scenarios, the provision of high specification foam mattresses was considered to be adequate as a minimum. Any further benefit from the use of an overlay in addition to a high specification mattress was unclear.
Economic considerations	The GDG considered evidence from 9 economic evaluations, alongside relevant UK unit costs of devices. Three economic evaluations found high specification foam to dominate standard practice, as they reduce the incidence of pressure ulcers and reduces costs. The GDG therefore agreed that the use of high specification foam would be cost-effective and potentially cost saving, compared to standard mattresses, for the population outlined in the recommendation above. The GDG did not consider the evidence (either clinical or economic) to be clear enough to make a recommendation in favour of other types of support surface, over the use of high specification foam, for the prevention of pressure ulcers in these people. Note that at present high specification foam is generally considered to be standard care in the UK NHS, thus this recommendation is not expected to have a large impact on resources. One cost-utility analysis found that the use of viscoelastic polymer overlays on operating tables led to an increase in QALYs and a reduction in costs. The clinical evidence also showed that the use of support surfaces reduces the incidence of pressure ulcers in theatre, which implies an increase in quality of life and a reduction in treatment costs. The GDG therefore felt that the use of high specification foam theatre mattresses or equivalent pressure redistributing surfaces would be cost effective, and may even be cost-saving, for people who are undergoing surgery. No economic evidence was identified specifically relating to pressure redistributing cushions for people who use a wheelchair. The GDG noted that the clinical evidence showed clinical benefit (reduction in incidence of pressure ulcers) when pre-contoured foam plus a gel filled pad and a pressure -reducing cushion were used in this population, compared to foam cushions. The clinical benefit of these cushions indicates that they prevent pressure ulcer related reductions in quality of life, and that they reduce treatment costs. The GDG agreed that the use of high specification foam, or other pressure redistributing cushions, would be highly likely to be cost-effective, and may even be cost saving, for people who use a wheelchair.
Quality of evidence	There was low to very low quality evidence for high specification foam mattresses compared to standard foam mattresses for the prevention of pressure ulcers. The type of mattresses included in the studies (both as intervention and comparison) were highly variable. Studies of other types of mattresses, overlays, beds and cushions had low to very low quality evidence. Most of the studies had serious to very serious imprecision and risk of bias. Only limited evidence was identified for people who were in primary care or community care settings such as nursing homes.
Other considerations	The GDG highlighted that all people in secondary care are considered to be at risk of developing a pressure ulcer and should therefore receive a high specification foam mattress.

12.2.2. Neonates, infants, children and young people

Recommendations	34. Use a high-specification foam cot mattress or overlay for all neonates and infants who have been identified as being at high risk of developing a pressure ulcer as part of their individualised care plan. 35. Use a high-specification foam mattress or overlay for all children and young people who have been assessed as being at high risk of developing a pressure ulcer as part of their individualised care plan.
Relative values of different outcomes	The GDG identified that the proportion of people developing new pressure ulcers and patient acceptability were the most critical outcomes to inform decision making, given that the primary goal of pressure ulcer prevention was to limit the number of new ulcers. Acceptability was identified as being critical from the perspective of the patient, as it was noted that this could have a significant impact upon quality of life. Rate of development of new pressure ulcers, time to develop new pressure ulcers, time in hospital or NHS care and health related quality of life were considered important outcomes to inform decision making.
Trade-off between clinical benefits and harms	The GDG used 2 statements from the Delphi consensus survey to inform the recommendations on the use of pressure redistributing devices for the prevention of pressure ulcers. The statement was ‘Healthcare professionals should use a high specification cot mattress for all neonates and infants, or a high specification foam mattress for all children and young people’. In developing the recommendation, the GDG also considered evidence from the statement ‘Healthcare professionals should use a high specification pressure redistributing overlay for all neonates, infants, children and young people at risk of developing a pressure ulcer’. Both statements were accepted by the Delphi consensus panel. Further detail on the Delphi consensus survey can be found in Appendix N. The statement on mattresses was included in Round 1 of the Delphi consensus survey. A number of comments from panel members suggested that the provision of pressure redistributing mattresses would be dependent upon the risk of the individual, following risk assessment. Further responses suggested that there may be potential harms when providing a high specification mattress, notably that these mattresses can limit the child's ability to move which may affect rehabilitation. A large proportion of comments highlighted the need to ensure that care is tailored to the individual. For example, 1 panel member emphasised that the need for a pressure redistributing mattress would be dependent upon the child's clinical condition, the length of stay, risk level and mobility. The statement on overlays was included in Round 1 of the Delphi consensus survey. A number of comments from panel members suggested that the use of mattresses was generally preferable to overlays, however there were specific situations in which overlays could provide a benefit. Panel members iilustrated this with the example of a delay in the provision of a high specification mattress which could result in potential harm (namely, the development of a pressure ulcer), or in community or home settings. However, some panel members also highlighted specific harms of using an overlay in place of a mattress. For example, panel members emphasised that some overlays could raise a child above the bed rails resulting in a falling hazard. Other comments noted that the weight of a child (particularly for neonates) should be considered when using specific pressure redistributing devices. Another comment noted that there were issues relating to cleaning and decontamination with regards to overlays. The GDG discussed the statement on mattresses and agreed that a recommendation should be developed. On further reflection and consideration of the qualitative comments received, the group agreed that pressure redistributing mattresses should be provided to all neonates, infants, children and young people who would be considered to be at significant risk of developing a pressure ulcer in a hospital setting. The GDG felt that those in community settings who required a pressure redistributing mattress were likely to be neonates, infants, children and young people at significant risk of developing a pressure ulcer. Further discussion on the statement on overlays from the GDG took into account the potential harms raised by the consensus panel. The GDG however, felt that the use of overlays for neonates and infants was common place and agreed that for these populations, the use of a high specification cot overlay might be an option in place of a high specification cot mattress. The GDG felt that the benefits of recommending pressure redistribution in the form of a high specification mattress were likely to be substantial in the subsequent prevention of pressure ulcer development, particularly in such a large population. Although potential harms were identified by the consensus panel in the use of cot and bed mattresses (for example, by limiting movement and potentially preventing rehabilitation) and cot overlays the GDG considered that these were likely to be outweighed by a significant benefit in pressure ulcer prevention.
Economic considerations	There are costs associated with high specification foam cot and bed mattresses, and overlays. The estimated purchase costs are £50-£199 (typical products identified by GDG members), and the devices can be used over a number of years, therefore the expected cost per patient is low. The GDG considered these costs likely to be offset by the benefits of the intervention in terms of improvement in the person's quality of life, and reduction in future treatment costs through reduction in pressure ulcer incidence. The GDG felt there was insufficient evidence to recommend the use of more expensive dynamic support surfaces for prevention of pressure ulcers in this population.
Quality of evidence	No RCTs or cohort studies were identified for neonates, infants, children or young people. Formal consensus using a modified Delphi was therefore used to develop the recommendation. To inform the recommendation, the GDG used 2 statements which were included in Round 1 of the Delphi consensus survey and both reached 83% consensus agreement. Further details can be found in Appendix N.
Other considerations	There were no other considerations.

Recommendations	36. Offer infants, children and young people who are long-term wheelchair users, regular wheelchair assessments and provide pressure relief or redistribution.
Relative values of different outcomes	The GDG identified that the proportion of people developing new pressure ulcers and patient acceptability were the most critical outcomes to inform decision making, given that the primary goal of pressure ulcer prevention was to limit the number of new pressure ulcers. Acceptability was identified as being critical from the perspective of the patient, as it was noted that this could have a significant impact upon quality of life. Rate of development of new pressure ulcers, time to develop new pressure ulcers, time in hospital or NHS care and health related quality of life were considered important outcomes to inform decision making.
Trade-off between clinical benefits and harms	The GDG used 1 statement from the Delphi consensus panel to develop the recommendation. The statement was ‘Healthcare professionals should offer infants, children and young people who are long term wheel chair users appropriate wheelchair assessments.’ The statement was accepted by the GDG in Round 1 of the survey. Further detail on the Delphi consensus survey can be found in Appendix N. The statement was included in Round 1 of the Delphi consensus. Qualitative responses gathered from panel members suggested that there were a variety of methods for assessing the pressure ulcer development in people who use wheelchairs (for example, pressure mapping) and that it was important to ensure that infants, children and young people who use wheelchairs received education in the importance of pressure ulcer prevention. A number of panel members highlighted the importance of ensuring that the assessments took place regularly because the growth of children may affect the appropriateness of their wheelchair size and the need to consider wheel chair cushions. There is also the potential for rapid change in clinical condition in these children. One comment identified that assessment should be carried out by a healthcare professional who is appropriately trained in carrying out assessment. A second comment suggested that this would be in co-ordination with paediatric occupational therapists/physiotherapists. One panel member noted that there is a lack of paediatric occupational therapists available in their area. There were also comments from panel members regarding difficulty in providing timely wheel chair assessments in their area. One panel member noted that this was often due to wheel chair users travelling from outside of their local area to access services, whilst a second stated that this would be because of the lack of paediatric occupational therapists available. The GDG discussed the statement and agreed that a recommendation should be developed. The GDG felt that there were likely to be a range of benefits, including but not limited to the prevention of pressure ulcer development, from providing infants, children and young people with regular wheelchair assessments and that doing so represented good practice. The group felt that this was supported by qualitative comments received identifying that these individuals often changed physical and clinical state rapidly (for example, they were likely to grow or their clinical condition may change quickly) meaning that regular assessment was important. The GDG acknowledged that there may be some areas in which the lack of paediatric occupational therapists, or occupational therapists with experience of working with children may be limited. The GDG therefore did not wish to recommend who should be carrying out the assessment, as it was acknowledged that this was likely to vary across the UK.
Economic considerations	There are costs associated with wheelchair assessments and provision of pressure redistribution. The GDG noted that this is a very high risk population, and provision of pressure redistribution is crucial. The GDG considered the likely cost implications (for example the cost of a paediatric pressure relieving cushion, £185), and concluded that the benefits of the intervention in terms of improvement in quality of life and reduction in future treatment costs (through reduction in incidence of pressure ulcers) are likely to far outweigh the costs.
Quality of evidence	No RCTs or cohort studies were identified for neonates, infants, children or young people. Formal consensus using a modified Delphi was therefore used to develop the recommendation. To inform the recommendation, the GDG used 1 statement which was included in Round 1 of the Delphi consensus survey and reached 97% consensus agreement. Further details can be found in Appendix N.
Other considerations	There were no other considerations.

Recommendations	37. Offer neonates, infants, children and young people at risk of developing an occipital pressure ulcer an appropriate pressure redistributing surface (for example, a suitable pillow or pressure redistributing pad).
Relative values of different outcomes	The GDG identified that the proportion of people developing new pressure ulcers and patient acceptability were the most critical outcomes to inform decision making, given that the primary goal of pressure ulcer prevention was to limit the number of new ulcers. Acceptability was identified as being critical from the perspective of the patient, as it was noted that this could have a significant impact upon quality of life. Rate of development of new pressure ulcers, time to develop new pressure ulcers, time in hospital or NHS care and health related quality of life were considered important outcomes to inform decision making.
Trade-off between clinical benefits and harms	The GDG used 1 statement from the Delphi consensus panel to develop the recommendation. The statement was ‘Pressure redistributing surfaces should be used to prevent occipital pressure ulcers in neonates / infants / children / young people at risk of developing pressure ulcers.’ During Round 1 of the Delphi consensus panel, qualitative feedback to a number of statements on the prevention of pressure ulcers highlighted that the sites at risk from pressure damage were different in neonates, infants, children and young people, those in adults. For these populations members of the panel considered the occiput to be a site at great risk of pressure ulcer development. As such, the GDG felt that a statement should be developed for the use of specific pressure redistributing devices for the prevention of occipital pressure ulcers for inclusion in Round 2 of the survey. The statement ‘Pressure redistributing surfaces should be used to prevent occipital pressure ulcers in neonates / infants / children / young people at risk of developing pressure ulcers’ was therefore developed. The statement was accepted by the Delphi panel in Round 2 of the survey. Further detail on the Delphi consensus survey can be found in Appendix N. During Round 2 of the Delphi consensus survey, qualitative responses gathered highlighted that the clinical condition of the child may prevent the use of pressure redistributing devices for the prevention of occipital pressure ulcers (for example, those with a cervical spine injury may have their head mobilised in skull traction). Other comments suggested that the method of pressure redistribution may come from the use of repositioning strategies, or devices such as gel pads or cushions. The GDG discussed the statement and the qualitative responses received and agreed that a recommendation should be developed. The GDG felt that responses received from the panel were helpful and agreed that the recommendation should reflect that the exact pressure redistributing strategy employed would need to be tailored to the individual, accounting for factors such as clinical condition. The GDG therefore developed a recommendation to reflect that any neonates, infants, children and young people considered at risk of developing an occipital pressure ulcer should be provided with a pressure redistributing surface. The GDG agreed that the benefits of preventing occipital ulcers, that were to come from the provision of a pressure redistributing surface, were likely to outweigh any possible harms (for example, the possibility of increasing pressure on other sites).
Economic considerations	The GDG acknowledged that there would be cost implications of providing occipital pressure redistributing surface. The GDG considered the example of a gel pillow which costs £6.83. This device could be used by a number of patients; therefore the cost per patient would be small. Prevention of pressure ulcers prevents detrainments to quality of life, and future treatment costs. The GDG therefore agreed that provision of an appropriate pressure redistribution surface was highly likely to be cost-effective for people at risk of developing occipital pressure ulcers.
Quality of evidence	No RCTs or cohort studies were identified for neonates, infants, children or young people. Formal consensus using a modified Delphi was therefore used to develop the recommendation. To inform the recommendation, the GDG used 1 statement which was included in Round 2 of the Delphi consensus survey and reached 76% consensus agreement. Further details can be found in Appendix N.

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National Clinical Guideline Centre (UK). The Prevention and Management of Pressure Ulcers in Primary and Secondary Care. London: National Institute for Health and Care Excellence (NICE); 2014 Apr. (NICE Clinical Guidelines, No. 179.) 12, Pressure redistributing devices.
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Review question: What are the most clinically and cost-effective pressure re-distributing devices for the prevention of pressure ulcers?
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The Prevention and Management of Pressure Ulcers in Primary and Secondary Care.

12Pressure redistributing devices

12.1. Review question: What are the most clinically and cost-effective pressure re-distributing devices for the prevention of pressure ulcers?

12.1.1. Clinical evidence (adults)

Summary of included studies

12.1.2. ‘Low-tech’ constant low-pressure (CLP) supports

12.1.2.1. Standard foam hospital mattress compared with other “low-tech” CLP

12.1.3. Comparisons between alternative foam mattresses

12.1.4. Comparisons between ‘low-tech’ constant low-pressure supports

12.1.5. ‘High-tech’ pressure supports

12.1.5.1. Alternating-pressure compared with constant low pressure

12.1.5.2. Alternating-pressure compared with constant low pressure

12.1.6. Comparisons between different alternating-pressure devices

12.1.7. Low-air-loss (LAL) beds

12.1.7.1. Comparisons between LAL and other devices

12.1.8. Other devices

12.1.8.1. Operating room mattress

12.1.8.2. Operating table overlay

12.1.8.3. Face pillows in the operating theatre

12.1.9. Profiling beds

12.1.9.1. Comparison between profiling bed and flat-based bed

12.1.10. Seat cushions

12.1.10.1. Comparison between different cushions

12.1.11. Economic evidence (adults)

Published literature

Unit costs

12.1.12. Clinical evidence (neonates, infants, children and young people)

12.1.13. Economic evidence (neonates, infants, children and young people)

Published literature

Economic considerations

12.1.14. Evidence statements

12.1.14.1. Clinical (adults)

12.1.14.1.1. Cubed foam mattress (COMFORTEX DECUBE) versus standard hospital mattress (standard polypropylene SG40)

12.1.14.1.2. Bead filled mattress (BEAUFORT) versus standard hospital mattress

12.1.14.1.3. Softform mattress versus standard 130mm NHS foam mattress

12.1.14.1.4. Water-filled mattress versus standard hospital mattress

12.1.14.1.5. Alternative foam pressure-reducing mattress (CLINIFLOAT, OMNIFORM, SOFTFORM, STM5, THERAREST, TRANSFOAM, VAPOURLUX) versus standard hospital mattress

12.1.14.1.6. High-specification foam mattress (visco-polymer energy absorbing foam mattress (CONFORM-ED) versus standard mattress (KING's FUND, LINKNURSE, SOFTFOAM, TRANSFOAM, KING's FUND MATTRESS with a SPENCO or PROPAD overlay)

12.1.14.1.7. Inflated static overlay versus microfluid static overlay and low-air-loss dynamic mattress

12.1.14.1.8. Alternative foam mattress versus standard foam mattress

12.1.14.1.9. Pressure redistributing mattress (CLINIFLOAT, OMNIFOAM, THERAREST, TRANSFOAM, VAPERM) versus standard NHS foam mattress (REYLON 150mm)

12.1.14.1.10. Foam mattress replacement (MAXIFLOAT) versus foam mattress overlay (IRIS 3000)

12.1.14.1.11. Solid foam overlay versus convoluted foam overlay

12.1.14.1.12. Pressure-reducing foam mattress (TRANSFOAM) versus pressure-reducing foam mattress (TRANSFOAMWAVE)

12.1.14.1.13. Constant low-pressure mattress (CARITAL OPTIMA) versus standard foam mattress (10cm thick foam density 35kg/m3)

12.1.14.1.14. Dry flotation mattress (SOFFLEX) versus dry flotation mattress (ROHO)

12.1.14.1.15. Gel mattress versus air-filled overlay (SOFCARE)

12.1.14.1.16. Static air mattress (GAY MAR SOFCARE) versus water mattress (LOTUS PXM 3666)

12.1.14.1.17. Inflated static overlay (RIK or THERAKAIR) versus microfluid static overlay

12.1.14.1.18. Foam overlay versus Silicore overlay (SPENCO)

12.1.14.1.19. Australian medical sheepskin versus no sheepskin

12.1.14.1.20. Static air overlay and cold foam mattress versus cold foam mattress alone

12.1.14.1.21. 3D macroporous polyester overlay versus visco-elastic overlay

12.1.14.1.22. Alternating-pressure versus standard foam mattress

12.1.14.1.23. Alternating-pressure versus constant low-pressure for pressure ulcer prevention

12.1.14.1.24. Alternating pressure (various devices) versus constant low pressure (various devices)

12.1.14.1.25. Alternating-pressure versus Silicore or foam overlay

12.1.14.1.26. Alternating-pressure versus water or static air mattress

12.1.14.1.27. Alternating-pressure setting on mattress (DUO2) versus continuous low-pressure setting on mattress (DUO2)

12.1.14.1.28. Alternating-pressure air mattress (ALPHA-X-CELL) versus visco-elastic foam mattress (TEMPUR)

12.1.14.1.29. Alternating-pressure mattress (NIMBUS 3) versus dry flotation mattress overlay (ROHO)

12.1.14.1.30. Dynamic flotation mattress (NIMBUS2) and alternating-pressure cushion versus low-pressure inflatable mattress (REPOSE SYSTEM) and cushion (polyurethane)

12.1.14.1.31. Standard foam mattress in ICU/Standard foam mattress post-ICU versus Alternating-pressure mattress (NIMBUS) in ICU/Standard foam mattress post-ICU

12.1.14.1.32. Standard mattress in ICU/Standard foam mattress post-ICU versus Standard foam mattress ICU/constant low-pressure mattress (TEMPUR) post-ICU

12.1.14.1.33. Alternating-pressure mattress (NIMBUS) in ICU/Standard foam mattress post-ICU versus Standard foam mattress ICU/constant low-pressure mattress (TEMPUR) post-ICU

12.1.14.1.34. Standard foam mattress in ICU/Standard foam mattress post-ICU versus Alternating-pressure mattress (NIMBUS) in ICU/ constant low-pressure mattress (TEMPUR) post-ICU

12.1.14.1.35. Alternating-pressure mattress (NIMBUS) in ICU/Standard foam mattress post-ICU versus alternating-pressure mattress (NIMBUS) in ICU/constant low-pressure mattress (TEMPUR) post-ICU

12.1.14.1.36. Standard foam mattress ICU/constant low-pressure mattress (TEMPUR) post-ICU versus alternating-pressure mattress (NIMBUS) in ICU/ constant low-pressure mattress (TEMPUR) post-ICU

12.1.14.1.37. Alternating-pressure mattress with 2 layers of air cells (PEGASUS AIRWAVE SYSTEM) versus alternating-pressure large cell ripple mattress

12.1.14.1.38. Alternating-pressure mattress (PEGASUS AIRWAVE SYSTEM) versus alternating-pressure mattress (PEGASUS CAREWAVE SYSTEM)

12.1.14.1.39. Alternating-pressure mattress (TRINOVA) versus control

12.1.14.1.40. Alternating-pressure overlay versus alternating-pressure mattress

12.1.14.1.41. Alternating-pressure bed (THERAPULSE) versus alternating-pressure mattress (HILL-ROM DUO)

12.1.14.1.42. Alternating low-pressure air mattress with multi-stage inflation and deflation of air cells versus standard (CLINACTIV, HILLROM) alternating low-pressure air mattress with single-stage inflation and deflation of air cells

12.1.14.1.43. Low-air-loss bed (KINAIR/THERAKAIR) versus static air mattress overlay/inflated static overlay (EHOB WAFFLE) or standard ICU bed

12.1.14.1.44. Indentation load deflection (IDL) (25%) operating room foam mattress (density 1.3 cubic feet, IDL 30lb) versus operating room usual care (padding as required, including gel pads, foam mattresses, ring cushions (donuts))

12.1.14.1.45. Viscoelastic polymer pad versus no overlay

12.1.14.1.46. Viscoelastic foam overlay versus no overlay

12.1.14.1.47. Neoprene air filled bladder (dry flotation) device compared to a disposable polyurethane foam prone head positioner

12.1.14.1.48. A prone view protective helmet system with a disposable polyurethane foam prone head positioner versus a disposable polyurethane foam prone head positioner

12.1.14.1.13. Constant low-pressure mattress (CARITAL OPTIMA) versus standard foam mattress (10cm thick foam density 35kg/m³)