Full Body Support Surfaces: Support Surface Options for Individuals With a Pressure Injury (Part 3)
This subsection should be read in conjunction with the recommendations in Full Body Support Surfaces (Part 1).
The optimal environment in which a PI can heal includes complete offloading of pressure. Therefore, in a strict sense, if one assumes complete offloading is possible, the type of support surface should not directly influence pressure injury healing outcomes. However, it is not always possible to fully offload a pressure injury, particularly for individuals with a pressure injury at more than one anatomical location. Additionally, individuals with a pressure injury have a high risk for development of other new pressure injuries (47, 48, 49, 50, 51, 52). Therefore, the type of support surface should be reconsidered for individuals with an existing immobility-related (i.e., not device-related) PI.
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SS12: Good Practice Statement
It is good practice to re-evaluate the full body support surface for an individual who has experienced an immobility-related pressure injury. At a minimum, an individual with a pressure injury requires a pressure redistribution foam (reactive) support surface.
Clinical question: What are the general considerations when selecting or changing a full body support surface for individuals with a pressure injury?
Implementation considerations
Review and adjust the individual’s repositioning regimen before considering a change to the support surface. Refer to the guideline chapter on Repositioning and Mobilization.
Evaluate the effectiveness of previous and current prevention and treatment plans, and the individual’s care goals before changing the full body support surface.
Consider the anatomical location of the PI before changing the support surface. For example, completely changing the full body support surface may not be required if the individual has sustained a heel PI that could be managed with an appropriate offloading device.
Consider the previously outlined general considerations when selecting and changing a support surface. Refer to good practice statement SS2 and good practice statement SS4.
Consider changing the support surface when an individual with an existing PI:
Cannot be positioned off the PI,
Has a PI on two or more anatomical locations used for positioning (e.g., the sacrum and a greater trochanter),
Has a PI that is failing to heal despite a comprehensive PI management plan and optimal topical wound care, and/or
Is uncomfortable or bottoming out on the current support surface.
Supporting Information
Unless the individual’s clinical condition has changed (e.g., the individual has regained mobility, consciousness, and has adequate perfusion), the support surface on which a PI developed usually does not provide an appropriate environment for healing. A different support surface will usually be required to provide better pressure redistribution (i.e., envelopment and immersion) friction and shear force management and modification of the microclimate, thus reducing further ischemia or deformation-induced PIs. The properties of the support surfaces and other factors that might be considered when selecting a full body support surface are included in Table 3.
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SS13: Recommendation
We suggest using either pressure redistribution foam (reactive) full body support surfaces or alternating pressure air (active) full body support surfaces for individuals with Category/Stage 2—4 pressure injuries and unstageable pressure injuries.
Conditional recommendation; very low certainty of evidence
Clinical question: Should an alternating pressure (active) air full body support surface versus a pressure redistribution foam (reactive) full body support surface be used to promote pressure injury healing?
Evidence Summary
Two RCTs (53, 54) were included in the meta-analysis we conducted for this comparison. One study was conducted with individuals in a nursing home with Category/Stage 3–4 PIs who used a bed with both alternating pressure and low-air-loss features (53). The second study included individuals in community setting with Category/Stage II PIs using a range of different full body alternating pressure support surfaces (54). In one of the studies individuals with malnutrition, diabetes mellitus, wound infection or immune disorders were excluded (53). However, the second study included many individuals with malnutrition, incontinence, neurological conditions and/or diabetes mellitus (54). In the nursing home setting, the support surfaces were used in conjunction with two-hourly repositioning for 12 weeks (53). The community-based study noted that participants used an air flotation cushion when seated (54).
The meta-analysis showed no statistically significant difference between an alternating pressure (active) air full body support surface and a pressure redistribution foam (reactive) full body support surface for achieving complete healing of PIs (21.6% versus 25%, RR]0.97, 95% CI 0.27 to 3.53, p = 0.97). This translates to 8 fewer PIs per 1,000 healing completely with an alternating pressure (active) support surface. However, there is very little confidence in this effect estimate, and the true effect may be substantially different (ranging from 183 fewer to 633 more PIs healing). The evidence was downgraded for risk of bias due to a high risk of performance and attrition bias and was downgraded twice for imprecision due to a small sample size and a wide confidence interval that includes the null effect. A third RCT (55) conducted in an acute care setting for at least seven days had results that concurred with this analysis; however, the data was not appropriate for pooling. One study reported that there were no adverse events attributable to either type of support surface within a 12-week follow up (53). However, analysis in a Cochrane review (56) rated this evidence as being very low certainty due to a high risk of bias and having a small sample size. In the GGG’s expert opinion, the balance of effects favor neither intervention.
There was no recent evidence on the cost effectiveness of these support surfaces when used for promoting PI healing. The GGG noted that there is significant inequity across different health settings and geographic regions in access to resources such as an alternating pressure (active) air support surface. For those individuals with access, several clinical trials (23, 26, 54, 55) and observational studies (57, 58, 59, 60, 61) established that individuals experience easy bed movement and less pain with an alternating pressure (active) air support surface and reported that health professionals also found these support surfaces easy to use (58, 59). A Cochrane meta-analysis (56) showed no significant difference between an alternating pressure (active) air surface and a pressure redistributing foam support surface with respect to comfort (mean difference 0.40, 95% CI –0.42 to 1.22, n = 1 study (55)), but there was very low certainty in the evidence.
There was no evidence available comparing these support surfaces for healing suspected deep tissue injuries (DTPIs).
Certainty of Evidence (Outcome 1: Time to complete healing)
| Certainty assessment | No of patients | Effect | Certainty |
Importance |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
No of studies |
Study design |
Risk of bias |
Inconsistency |
Indirectness |
Imprecision |
Other considerations |
alternating pressure air (active) surfaces |
Pressureredistribution (reactive) surfaces |
Relative (95% CI) |
Absolute (95% CI) |
||
| 1 | RCT |
Serious [a] | Not serious |
Not serious |
Very serious[b] |
none | mean time to healing 16.54 days |
mean time to healing 29.2 days |
MD -12.66 (-54.9 to 28.97) |
mean difference 12.6 days fewer (from 54.29 fewer to 28.97 fewer) |
Very Low |
CRITICAL |
[a] Downgraded once due to high risk of bias from high risk of performance and attrition bias.
[b] Downgraded twice due to very sample size and very wide confidence interval that included the null effect.
Evidence to Decision Framework
Problem:
Desirable Effects:
Undesirable Effects:
Certainty of Evidence:
Values:
Balance of Effects:
Resources Required:
Certainty of Evidence of Required Resources:
Summary of Judgements
Cost Effectiveness:
Inequity:
Acceptability:
Feasibility:
Yes
Small
Trivial
Very low
No important uncertainty or variability
Does not favor either the intervention or the comparison
Varies
No included studies
No included studies
Probably increased
Probably yes
Probably yes
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SS14: Recommendation
We suggest using either pressure redistribution foam (reactive) full body support surfaces or water filled (reactive) full body support surfaces for individuals with Category/Stage 2—4 and unstageable pressure injuries.
Conditional recommendation; very low certainty of evidence
Clinical question: Should a water filled (reactive) full body support surface versus a pressure redistributing foam (reactive) full body support surfaces be used to promote pressure injury healing?
Evidence summary
The analysis (56) included only one RCT (62) comparing a water filled (reactive) support surface and a pressure redistribution foam (reactive) support surface. The study was conducted for four weeks in individuals in nursing homes with Category/Stage 2—4 PIs. The support surfaces were used in conjunction with 2—3-hourly repositioning.(62) The analysis (56) showed there was no significant difference between the support surfaces for achieving complete healing of PIs (48.07% versus 44.9%, risk ratio [RR] 1.07, 95% CI 0.70 to 1.63, p = 0.75). This translated to 31 more PIs per 1,000 healing with a water filled (reactive) support surface. However, there is very little confidence in this effect estimate and true effect may be substantially different (from 135 fewer to 283 more healed PIs). The evidence was downgraded twice for risk of bias and downgraded twice for imprecision.
The RCT (62) reported several undesirable effects that were not serious, and were also not substantial different between the different support surface types. The incidence of maceration and the incidence of pain were both 4.1% for the pressure redistribution foam surface and 3.8% for the water filled surface (56). No evidence was available on the resource requirements, cost-effectiveness, acceptability or feasibility. Stakeholders report that water-filled full body support surfaces might be challenging to handle and maintain because they often require precise water-level management to avoid bottoming out, have a risk of leaking and can be extremely heavy.
Certainty of Evidence: Outcome 1 (Percent PI completely healed)
| Certainty assessment | No of patients | Effect | Certainty |
Importance |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
No of studies |
Study design |
Risk of bias |
Inconsistency |
Indirectness |
Imprecision |
Other considerations |
water filled(reactive) full body support surface |
pressure redistributing foam (reactive) surfaces |
Relative (95% CI) |
Absolute (95% CI) |
||
| 1 | RCT | Very serious [a] |
Not serious |
Not serious |
Very serious [b] |
none | 25/52 (48.07%) |
22/49 (44.9%) |
RR 1.07 (0.70 to 1.63) |
31 more healed per 1,000 (from 135 fewer to 283 more) |
Very low |
CRITICAL |
[a] Downgraded twice due to high risk of bias from high risk of detection bias and unclear risk of selection and performance bias (Shi, Dumville et al. 2021).
[b] Downgraded twice due to very wide confidence interval that included the null effect and due to the criteria for optimal information size being unmet (Shi, Dumville et al. 2021).
Evidence to Decision Framework
Problem:
Desirable Effects:
Undesirable Effects:
Certainty of Evidence:
Values:
Balance of Effects:
Resources Required:
Certainty of Evidence of Required Resources:
Summary of Judgements
Cost Effectiveness:
Inequity:
Acceptability:
Feasibility:
Yes
Trivial
Small
Very low
No important uncertainty or variability
Does not favour either the intervention or the comparator
Don’t know
No included studies
No included studies
Probably no impact
Don’t know
Don’t know
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SS15: Recommendation
We suggest using low air loss full body support surfaces for individuals with Category/Stage 2–4 and unstageable pressure injuries.
Conditional recommendation; very low certainty of evidence
Clinical question: Should a low air loss support surface versus any other support surface be used to promote pressure injury healing?
Evidence summary
The analysis of one RCT (63) showed there was no statistically significant difference between a low air loss support surface and a 3.9 inch (10 cm) convoluted foam mattress overlying a regular hospital mattress# for achieving complete healing of Category/Stage 2–4 PIs (46.30% versus 60.50%, RR 1.30, 95% CI 0.87 to 1.96, p = 0.20). This translated to 139 more PIs per 1,000 healing. However, there is very little confidence in this estimate; the true effect may be substantially different (from 60 fewer to 445 more PIs healing). The evidence was downgraded twice for risk of bias and downgraded once for imprecision. The study was conducted in individuals in nursing homes who were repositioned two hourly (63). There was no evidence available on potential adverse events. Resources required for a low air loss support surface were estimated to be a moderate cost. Cost effectiveness was estimated from an investigation with 87 participants conducted in nursing homes in the US in the early 1990s. The analysis found that using a low air loss support surface cost an additional $26 (USD in 1993) for every PI-free day in the first year of treatment compared with a combined air-foam mattress (64). This evidence was rated as low certainty(56) and may not reflect contemporary costs. There was no evidence available comparing these support surfaces for healing suspected DTPIs.
# Product names may have changed, study conducted >20 years ago.
Certainty of Evidence: Outcome 1 PIs completely healed
| Certainty assessment | No of patients | Effect | Certainty |
Importance |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
No of studies |
Study design |
Risk of bias |
Inconsistency |
Indirectness |
Imprecision |
Other considerations |
low air loss (active)support surfaces |
any other pressure management support surface |
Relative (95% CI) |
Absolute (95% CI) |
||
| 1 | RCT |
Very Serious [a] |
Not serious |
Not serious |
Serious [b] | none | 19/41 (46.30%) |
26/43 (60.5%) |
RR 1.30 (0.87 to 1.96) |
139 more PI healed per 1,000 (from 60 fewer to 445 more) |
Very Low |
CRITICAL |
[a] Downgraded twice due to high of performance and detection bias and unclear risk of selection bias.
[b] Downgraded once due to confidence interval that included the null effect
Evidence to Decision Framework
Problem:
Desirable Effects:
Undesirable Effects:
Certainty of Evidence:
Values:
Balance of Effects:
Resources Required:
Certainty of Evidence of Required Resources:
Summary of Judgements
Cost Effectiveness:
Inequity:
Acceptability:
Feasibility:
Yes
Moderate
Don’t know
Very low
No important uncertainty or variability
Don’t know
Moderate costs
No included studies
No included studies
Probably increased
Probably yes
Probably yes
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S16: Recommendation
We suggest using air fluidized full body support surfaces for individuals with Category/Stage 2–4 pressure injuries, unstageable pressure injuries and suspected deep tissue pressure injuries.
Conditional recommendation; very low certainty of evidence
Clinical question: Should an air fluidized support surface versus any other support surface be used to promote pressure injury healing?
Clinical question: Should an air fluidized support surface versus any other support surface be used to promote healing of suspected deep tissue pressure injuries?
Evidence summary
In the first analysis, data from one RCT (18) showed the effectiveness of an air fluidized support surface compared with any other type of support surface* for supporting Category/Stage II–IV PIs to complete healing. The comparator surface in the included study was a vinyl air mattress that was manufactured with a 0.75 inch (19 mm) foam pad cover. The study was conducted in individuals in a primary care medical center who were repositioned two-hourly for the study duration of 13 days.(18) The analysis showed there was no statistically significant difference between the support surfaces for achieving complete healing of PIs (55.60% versus 41.70%, RR 1.33, 95% CI 0.82 to 2.16, p = 0.24). This translated to 138 more PIs per 1,000 healing with an air fluidized support surface. However, there is very little confidence in this estimate; the true effect may be substantially different (from 75 fewer to 483 more PIs healing). This evidence was downgraded once for risk of bias, once for directness and once for imprecision. In a second analysis there was a mean decrease of 1.2 cm2 (–38 to 15.5) for PIs in individuals using the air-fluidized bed, while the control group had a mean increase in PI size of 0.5cm2 (–55.1 to 94.2) (18). The effect size was inestimable and there was low certainty in the result (downgraded once for risk of bias, once for directness and once for imprecision).
Another study (65) also reported improvements in healing of Category/Stage 3–4 PIs for individuals in a nursing home who used an air fluidized support surface. The PIs healed at a faster rate (mean 3.1 cm2/week) compared to PIs for individuals using static overlays and replacement mattresses (mean = 0.6 cm2/week) and compared to individuals who used low air loss or alternating pressure air (active) full body support surfaces (mean = 0.7 cm2/week) (65).
When considering healing of suspected DTPIs only one non-randomized comparative study(66) was identified that investigated effectiveness of air fluidized support surfaces compared with any other type of support surface.# The comparator in the study was a low air loss support surface. The study reported a retrospective cohort analysis using data from medical records over three years in a trauma center, with the primary outcome being mean change in surface area (cm2) of torso suspected DTPIs (heels excluded), calculated as the final size minus the initial size. The analysis showed a statistically significant mean difference in surface area change of 12.5cm2, favoring the air fluidized support surface (p=0.0178) (66). However, there is very little confidence in this estimate. The evidence was downgraded twice for risk of bias and downgraded twice for imprecision, noting this was a very small study (n=18 total participants) that excluded suspected DTPI of the heel.
There was no evidence on the resources of cost effectiveness of using an air fluidized support surface for treating PIs. This type of support surface is not available in all geographic or clinical contexts, and may not be feasible for all individuals because of the difficulty in repositioning and transferring in and out of bed (18). Although some individuals have reported more comfort and reduced pain when using an air fluidized support surface, it is uncertain if this finding translates to individuals with existing PIs. Additionally, issues that might influence acceptability, such as drying/dehydration, difficulties with self or assisted repositioning on the surface have been reported.
* Product names may have changed, study conducted >25 years ago.
# Product names may have changed.
Certainty of Evidence
| Certainty assessment | No of patients | Effect | Certainty |
Importance |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
No of studies |
Study design |
Risk of bias |
Inconsistency |
Indirectness |
Imprecision |
Other considerations |
air fluidized support surface |
any other support surfaces |
Relative (95% CI) |
Absolute (95% CI) |
||
| 1 | RCT reporting PI healing |
Serious [a] | Not serious |
Serious [b] | Serious [c] | none | 18/720 (2.5%) |
33/704 (4.7%) |
RR 1.33 (0.82 to 2.16) |
138 more PI healed per 1,000 (from 75 fewer to 283 more) |
Very Low |
CRITICAL |
| 1 | non-RCT reporting change in DTPI surface area |
Very Serious [d] |
Not serious |
Not Serious |
Very Serious [e] |
none | -7.4cm2 (-16.5 to -3.7) |
5.1cm2 (1.85 to 25.8) |
12.5cm2 |
-- |
Very Low |
CRITICAL |
[a] Downgrade once due to unclear risk of bias in at least two domains.
[b] Downgraded because comparator may not reflect contemporary support surface.
Downgraded because confidence interval that included the range between recommending or not recommending
[c] Downgraded because confidence interval that included the range between recommending or not recommending
a treatment.
[d] Downgraded twice due to non-randomized design, lack of blinding, missing data, and potential confounding.
[e] Downgraded twice due to small sample size and absence of confidence intervals for median differences.
Evidence to Decision Framework
Problem:
Desirable Effects:
Undesirable Effects:
Certainty of Evidence:
Values:
Balance of Effects:
Resources Required:
Certainty of Evidence of Required Resources:
Summary of Judgements
Cost Effectiveness:
Inequity:
Acceptability:
Feasibility:
Yes
Small for PI, Moderate for DTPI
Small for PI, Don’t know for DTPI
Very low
No important uncertainty or variability
Don’t know
Don’t know
No included studies
No included studies
Probably increased
Varies
Probably yes or varies
Return to the support surfaces chapter and references.