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      Support surfaces for treating pressure ulcers

      1 , 1 , 2 , 3 , 4 , 5

      Cochrane Wounds Group

      Cochrane Database of Systematic Reviews

      Wiley

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          Abstract

          Pressure ulcers are treated by reducing pressure on the areas of damaged skin. Special support surfaces (including beds, mattresses and cushions) designed to redistribute pressure, are widely used as treatments. The relative effects of different support surfaces are unclear. This is an update of an existing review. To assess the effects of pressure‐relieving support surfaces in the treatment of pressure ulcers. In September 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In‐Process & Other Non‐Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta‐analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. We included published or unpublished randomised controlled trials (RCTs), that assessed the effects of support surfaces for treating pressure ulcers, in any participant group or setting. Data extraction, assessment of 'Risk of bias' and GRADE assessments were performed independently by two review authors. Trials with similar participants, comparisons and outcomes were considered for meta‐analysis. Where meta‐analysis was inappropriate, we reported the results of the trials narratively. Where possible, we planned to report data as either risk ratio or mean difference as appropriate. For this update we identified one new trial of support surfaces for pressure ulcer treatment, bringing the total to 19 trials involving 3241 participants. Most trials were small, with sample sizes ranging from 20 to 1971, and were generally at high or unclear risk of bias. Primary outcome: healing of existing pressure ulcers Low‐tech constant pressure support surfaces It is uncertain whether profiling beds increase the proportion of pressure ulcer which heal compared with standard hospital beds as the evidence is of very low certainty: (RR 3.96, 95% CI 1.28 to 12.24), downgraded for serious risk of bias, serious imprecision and indirectness (1 study; 70 participants). There is currently no clear difference in ulcer healing between water‐filled support surfaces and foam replacement mattresses: (RR 0.93, 95% CI 0.63 to 1.37); low‐certainty evidence downgraded for serious risk of bias and serious imprecision (1 study; 120 participants). Further analysis could not be performed for polyester overlays versus gel overlays (1 study; 72 participants), non‐powered mattresses versus low‐air‐loss mattresses (1 study; 20 participants) or standard hospital mattresses with sheepskin overlays versus standard hospital mattresses (1 study; 36 participants). High‐tech pressure support surfaces It is currently unclear whether high‐tech pressure support surfaces (such as low‐air‐loss beds, air suspension beds, and alternating pressure surfaces) improve the healing of pressure ulcers (14 studies; 2923 participants) or which intervention may be more effective. The certainty of the evidence is generally low, downgraded mostly for risk of bias, indirectness and imprecision. Secondary outcomes No analyses were undertaken with respect to secondary outcomes including participant comfort and surface reliability and acceptability as reporting of these within the included trials was very limited. Overall, the evidence is of low to very low certainty and was primarily downgraded due to risk of bias and imprecision with some indirectness. Based on the current evidence, it is unclear whether any particular type of low‐ or high‐tech support surface is more effective at healing pressure ulcers than standard support surfaces. Support surfaces for treating pressure ulcers What is the aim of this review? The aim of this review was to find out whether different support surfaces such as specially‐designed beds, mattresses or cushions can help to treat pressure ulcers. Researchers from Cochrane collected and analysed all relevant studies (randomised controlled trials) to answer this question, and found 19 relevant studies. Key messages We cannot be certain which support surfaces are most effective for pressure ulcer treatment as the studies comparing them did not involve enough people and were not well designed. What was studied in the review? Pressure ulcers (also called pressure sores, decubitus ulcers and bed sores) are wounds to the skin and underlying tissue caused by pressure or rubbing. They typically form at points on the body which are bony or which bear weight or pressure, such as the hips, buttocks, heels and elbows. People who have mobility problems or who lie in bed for long periods are at risk of developing pressure ulcers. A range of treatments, including wound dressings and support surfaces like special mattresses and cushions, are used to treat pressure ulcers. Support surfaces for pressure ulcer treatment can include specially‐designed beds, mattresses, mattress overlays and cushions that are used to protect vulnerable parts of the body and distribute the surface pressure more evenly. Low‐tech support surfaces include mattresses filled with foam, fluid, beads or air; and alternative foam mattresses and overlays. High‐tech support surfaces include mattresses and overlays that are electrically powered to alternate the pressure within the surface, beds that are powered to have air mechanically circulated within them and low‐air‐loss beds that contain warm air moving within pockets inside the bed. Other support surfaces include sheepskins, cushions and operating table overlays. We wanted to find out which support surfaces were most effective in helping pressure ulcers to heal. We also wanted to compare different support surfaces in terms of cost, reliability, durability, and the benefits or harms for patients using them. What are the main results of the review? In September 2017, we searched for trials looking at support surfaces for treating pressure ulcers and which reported their effects on wound healing. We found 19 trials involving 3241 participants, all adults, the majority of whom were older people and bed‐bound in hospitals or nursing homes. In studies where participants' sex was reported, the majority were women. Not all studies reported their funding sources, but two of those who did were funded by device manufacturers. Five studies involving 318 participants compared low‐tech constant low‐pressure (CLP) support surfaces such as foam mattresses. We cannot be certain how these different support surfaces affect pressure ulcer healing as the evidence is mainly of low certainty. Fourteen studies involving 2923 participants compared different high‐tech support surfaces such as air‐fluidised beds. Again, we cannot be certain how these different support surfaces affect ulcer healing rates as the certainty of the evidence is mainly low. We are not able to draw firm conclusions about the effects of different support surfaces for treating pressure ulcers because the overall quality of the evidence is low to very low. Many of the studies included only small numbers of people, did not provide adequate information on their results, or were not well designed. Further, better conducted trials are necessary to determine which support surfaces are most effective in treating pressure ulcers. How up to date is this review? We searched for studies that had been published up to September 2017.

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          Most cited references 81

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          Patient risk factors for pressure ulcer development: systematic review.

          To identify risk factors independently predictive of pressure ulcer development in adult patient populations? A systematic review of primary research was undertaken, based upon methods recommended for effectiveness questions but adapted to identify observational risk factor studies. Fourteen electronic databases were searched, each from inception until March 2010, with hand searching of specialist journals and conference proceedings; contact with experts and a citation search. There was no language restriction. Abstracts were screened, reviewed against the eligibility criteria, data extracted and quality appraised by at least one reviewer and checked by a second. Where necessary, statistical review was undertaken. We developed an assessment framework and quality classification based upon guidelines for assessing quality and methodological considerations in the analysis, meta-analysis and publication of observational studies. Studies were classified as high, moderate, low and very low quality. Risk factors were categorised into risk factor domains and sub-domains. Evidence tables were generated and a summary narrative synthesis by sub-domain and domain was undertaken. Of 5462 abstracts retrieved, 365 were identified as potentially eligible and 54 fulfilled the eligibility criteria. The 54 studies included 34,449 patients and acute and community patient populations. Seventeen studies were classified as high or moderate quality, whilst 37 studies (68.5%) had inadequate numbers of pressure ulcers and other methodological limitations. Risk factors emerging most frequently as independent predictors of pressure ulcer development included three primary domains of mobility/activity, perfusion (including diabetes) and skin/pressure ulcer status. Skin moisture, age, haematological measures, nutrition and general health status are also important, but did not emerge as frequently as the three main domains. Body temperature and immunity may be important but require further confirmatory research. There is limited evidence that either race or gender is important. Overall there is no single factor which can explain pressure ulcer risk, rather a complex interplay of factors which increase the probability of pressure ulcer development. The review highlights the limitations of over-interpretation of results from individual studies and the benefits of reviewing results from a number of studies to develop a more reliable overall assessment of factors which are important in affecting patient susceptibility. Copyright © 2012 Elsevier Ltd. All rights reserved.
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            The cost of pressure ulcers in the United Kingdom.

            To provide an estimate of the costs of treating pressure ulcers in the UK at August 2011 prices, as a means of highlighting the importance of pressure ulcer prevention. Resource use was derived from a bottom-up methodology, based on the daily resources required to deliver protocols of care reflecting good clinical practice, with prices reflecting costs to the health and social care system in the UK. This approach was used to estimate treatment costs per episode of care and per patient for ulcers of different severity and level of complications. The cost of treating a pressure ulcer varies from £1,214 (category 1) to £14,108 (category IV). Costs increase with ulcer severity because the time to heal is longer and the incidence of complications is higher in more severe cases. Pressure ulcers represent a significant cost burden in the UK, both to patients and to health-care providers. Without concerted effort, this cost is likely to increase in the future as the population ages. The estimates reported here provide a basis for assessment of the cost-effectiveness of measures to reduce the incidence of hospital-acquired ulcers. Heron Evidence Development Ltd. was funded for this work by Mölnlycke Health Care (UK). The authors have no other conflicts of interest to declare.
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              Treatment of pressure ulcers: a systematic review.

              Many treatments for pressure ulcers are promoted, but their relative efficacy is unclear. To systematically review published randomized controlled trials (RCTs) evaluating therapies for pressure ulcers. The databases of MEDLINE, EMBASE, and CINAHL were searched (from inception through August 23, 2008) to identify relevant RCTs published in the English language. Methodological characteristics and outcomes were extracted by 3 investigators. A total of 103 RCTs met inclusion criteria. Of these, 83 did not provide sufficient information about authors' potential financial conflicts of interest. Methodological quality was variable. Most trials were conducted in acute care (38 [37%]), mixed care (25 [24%]), or long-term care (22 [21%]) settings. Among 12 RCTs evaluating support surfaces, no clear evidence favored one support surface over another. No trials compared a specialized support surface with a standard mattress and repositioning. Among 7 RCTs evaluating nutritional supplements, 1 higher-quality trial found that protein supplementation of long-term care residents improved wound healing compared with placebo (improvement in Pressure Ulcer Scale for Healing mean [SD] score of 3.55 [4.66] vs 3.22 [4.11], respectively; P < .05). Other nutritional supplement RCTs showed mixed results. Among 54 RCTs evaluating absorbent wound dressings, 1 found calcium alginate dressings improved healing compared with dextranomer paste (mean wound surface area reduction per week, 2.39 cm(2) vs 0.27 cm(2), respectively; P<.001). No other dressing was superior to alternatives. Among 9 RCTs evaluating biological agents, several trials reported benefits with different topical growth factors. However, the incremental benefit of these biological agents over less expensive standard wound care remains uncertain. No clear benefit was identified in 21 RCTs evaluating adjunctive therapies including electric current, ultrasound, light therapy, and vacuum therapy. Little evidence supports the use of a specific support surface or dressing over other alternatives. Similarly, there is little evidence to support routine nutritional supplementation or adjunctive therapies compared with standard care.
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                Author and article information

                Journal
                Cochrane Database of Systematic Reviews
                Wiley
                14651858
                October 11 2018
                Affiliations
                [1 ]School of Nursing, Midwifery and Paramedicine, Australian Catholic University; Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University (ACU); Executive Suite, Level 5 DeLacy Building St Vincent's Hospital, 390 Victoria Road Darlinghurst New South Wales Australia 2010
                [2 ]Cochrane; Cochrane Editorial Unit; St Albans House 57-59 Haymarket London UK SW1Y 4QX
                [3 ]Sydney Eye Hospital; Kensington Sydney NSW Australia 2052
                [4 ]The University of Sydney; Reserve Road Sydney NSW Australia 2065
                [5 ]The University of New South Wales; Reserve Road Sydney NSW Australia 2065
                Article
                10.1002/14651858.CD009490.pub2
                6517160
                30307602
                © 2018
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