The Impact of Using Pressure Mattresses in the Prevention of Pressure Ulcer in Acute Care Patients

This article discusses the impact of using pressure mattresses in the prevention of pressure ulcers in acute care patients. It explores the different types of pressure mattresses and their benefits in relieving pressure and preventing the development of sores on the body. The article also highlights the need for further research on the effectiveness of pressure mattresses and suggests recommendations for practice change and future research.

Running head: CLINICAL QUESTION 1
The impact of using pressure mattresses in the prevention of pressure ulcer in acute care patients
Outline of Clinical Issue
Pressure ulcers are localized injuries to the skin or the underlying tissue which develops
as a combination of pressure or shear. This problem affects the patient’s wellbeing and quality of
life to the patients while at the same time the cost associated with this problem in Australian
public hospitals has been estimated to exceed AU$1.8 billion per annum (Nguyen, Chaboye, &
Whitty, 2015). Despite the existence of evidence-based approaches for the management of
pressure ulcers, there are increased cases of pressure ulcers which call for the need to assess the
barriers faced by nurses during the implementation of evidence-based pressure ulcer prevention
strategies. There are different ways that nurses use to prevent pressure ulcers but the use of a
pressure mattress has been regarded as the best strategy for preventing pressure ulcers in acute
care patients.
According to Serraes & Beeckman (2016), pressure mattresses are specifically designed
to prevent bedsores and keep the patient healthy. The design of the mattress is to increase
comfort through high-level pressure support on different body parts. The mattresses contain air
pockets that place pressure on the main pressure points of the body to reduce the development of
sores. Two types of mattresses are used in clinical settings for prevention purposes, static/
reactive mattresses, alternating or active mattresses, and hybrid or combination mattresses. The
static mattress has multiple pressure-relieving foams that allow the distribution of the patient’s
weight over the surface lowering the pressure and reducing the risk of developing sores. On the
other hand, the airflow mattress has lateral air cells redistributes the pressure when the patient
lies on a dynamic surface. This study analyses the use of pressure mattresses in relieving
pressure and the development of sores on the body by creating comfort and distribution of the
body.
Clinical Question
The impact of using pressure mattresses in the prevention of pressure ulcer in acute care patients
Population: patients admitted in acute care situations who spend most of their time in bed or
wheelchair.
Intervention: use of pressure mattress
Comparison: effectiveness of using pressure mattress to prevent pressure ulcer
Outcome: pressure mattress in the prevention of pressure ulcers
Evidence Search
The purpose of this search was to find the best articles on the topic that were done using
the systematic review method or used randomized controlled trials since these are regarded as the
best sources of evidence for the study. Randomized controlled trials offer a good level of
evidence since they entail the use of two patient groups, one is the general group and the other is
a control group that is used to measure the effects of the treatment (Bhide, Shah, & Acharya,
2018). In most cases, the participants in the study are blinded to increase the efficiency and
reduce bias in the study. On the other hand, systematic reviews offer the highest level of
evidence that is developed from a review of previous studies that have been done on the topic
(Armstrong, Hall, Doyle, & Waters, 2011). By comparing the findings from different studies,
systematic reviews offer the highest level of evidence that can be used in any study.
The initial search revealed 739 items which included all the articles that were found on
the topic this gave a wide range of materials that needed to be refined. When the filters were
advanced to include article attributes for Medline journals and open access, the search led to 309

CLINICAL QUESTION 2
articles on the topic. The refinement was further done narrowing down to only studies that dealt
with pressure ulcer prevention using mechanical forms which led to 65 studies. From these
studies, 22 studies were found on the topic which had to be reviewed one by one using their
abstract to determine the method of study which led to 7 articles that entailed the use of pressure
mattresses to prevent pressure ulcers. This has been shown in the PRISMA table in the appendix.
Literature Synthesis of Best Evidence
Malbrain, et al. (2010) study presented the importance of pressure redistribution support
surfaces to prevent pressure ulcer in critical care patients. The mechanism of the mattress allows
distribution of the body on the surface of the mattress allowing the loading and off-loading the
tissues of the body allowing body pressure to be reduced which allows the patient to feel better.
Since pressure healing only occurs when the pressure on the affected area is reduced or
eliminated, then the role of the mattress is to allow equal perfusion of the body. Meaume &
Marty (2018) study also reported that for patients lying for over 15 hours, it is important to use
support surfaces that offer the best comfort for the patient which will allow distribution of
pressure in the body. Just turning the patient regularly to prevent the accumulation of pressure, it
is important to ensure that the patient achieves maximum comfort. The design of the mattress is
to provide comfort from the specific body parts that can easily develop sores from body
pressure.
Shi, Dumville, & Cullum (2018) study reports that the use of pressure mattresses reports
a significant decrease in pressure ulcer surfaces in most patients. This is because the design of
the mattress allows the ulcers to improve by providing and balancing pressures on the surface.
The mechanism of healing is through reducing the pressure that the body exerts on the damaged
skin area. The design of the mattress is to specifically offer relief to the patient. Pressure
mattresses are designed with air cells that deflate and inflate on different parts of the body to
allow the sores to heal by themselves. This design is similar to the mechanical movement of the
patient while sleeping on the mattress which provides comfort to reduce the development of
sores. This leads to reduced pressure in body parts with less padding like shoulders, elbows,
heels, and hips. Further, Colin, et al. (2012) add that these mattresses offer a support surface that
allows and increases air circulation which prevents the development of sores. The mattress is
designed to offer quality sleep for the patient which is an important component of preventing
pressure sores. This leads to optimal immune function which addresses the response of the body
to pressure ulcers. There are different types of pressure mattresses which have all been designed
to provide comfort and relieve pressure to the patient.
According to the study by Nixon, et al. (2016) pressure mattresses offer an effective way
of preventing and treating pressure ulcers but there are different types of mattresses that exist
which require different use and patient monitoring methods. In this case, the nature of the patient
setting determines the pressure ulcer challenges that they face which requires the need for
assessing the limitations in different kinds of literature on the use of mattresses. This is because
there are different risk factors like diabetes that can exacerbate the likelihood of the patient
developing pressure ulcers. In most cases, these mattresses have been used to offer the best
comfort to the patient that allows pressure distribution and even healing of existing pressure
ulcers. This has been supported by Meaume & Marty (2018) who argued that the pressure
mattress use in clinical situations is the best way based on the findings of this study which
reported a low incidence of pressure ulcers in high-risk patients.
In addition to that Tsuchiya, et al. (2016) suggests that the selection of the pressure-
relieving mattress depends on factors like mobility, results of the skin assessment and the level of

CLINICAL QUESTION 3
the site at risk. This means that clinical settings will have different types of pressure mattresses
which can yield different results. McInnes, Jammali-Blasia, Bell-Syerb, Dumville, & Cullum
(2012) study also reported that there is a range of different low-pressure mattresses that can be
used in the treatment of pressure ulcers. This means that there is a need for further research to
determine the way these mattresses can be used to completely treat pressure ulcers. This study
reports that few studies offer evidence-based guidelines on the effectiveness of using the
pressure mattress. This is because the increasing number of patients at the risk of developing
pressure ulcers has gone up due to the varying number of patients who are admitted in clinical
settings. This is also seen in Malbrain et al. (2010) study which highlighted that despite the
preventive care being implemented, ICU patients still develop pressure injuries. The varying
nature of studies on the use of pressure mattress to prevent pressure mattress shows that they are
effective in offering support surfaces that reduce the effects of pressure on the body. The role of
the mattress is to achieve equal distribution of the body and allow airflow in specific parts that
can lead to the development of pressure ulcers.
Recommendations for practice change and research
Despite the fact the innovation of pressure mattresses offers the best therapeutic
conditions for patients who spend most of their time in one position, it is evident that there is still
a high number of patients suffering from pressure ulcers. This calls for the need for research on
the clear role that reactive support surfaces like mattresses offer. This is because different studies
have proposed different ways of preventing pressure ulcers in critical patients (Tsuchiya, et al.,
2016). This is because the level of evidence in most studies that have been done of the topic is
relatively weak which means that there are no strong assumptions on the topic that can be used to
draw specific conclusions. Thus thorough research needs to be done on a larger number of
patient populations to capture the different challenges in the implementation of the study
method.
Another issue is the limited existence of the pressure mattresses on the market, which
creates the gap of availability and affordability. In this case, most patients may lack the ability to
afford this mattress while the studies that have been done may have failed to capture varying
demographic profiles of patients. This implies that it can be easier if alternative forms of
pressure-relieving surfaces can be proposed which are easy to afford so that most patients can
benefit from the process.
Further, there are other pressure ulcer prevention methods like fluidized therapy which
are effective in reducing the sores. From the studies, McInnes, Jammali-Blasia, Bell-Syerb,
Dumville, & Cullum (2012) suggests that there is no comparison of the effectiveness of pressure
mattresses with other methods so that their effectiveness can be ranked on a scale. This implies
that even though they are effective, there is a need for proper research to adequately compare
their effectiveness with other study methods to propose the best method using an evidence-based
approach.
Malbrain, et al. (2010), Nixon, et al. (2016) and Colin, et al. (2012) studies have also
raised the need to analyze the relative merits of different interventions that relate to the use of
pressure mattresses in pressure ulcer prevention. Thus future research needs to focus on
addressing the deficiencies that are reported in the studies. Further, these studies relied heavily
on previous studies which had several limitations. Thus further research will be effective in
assessing the challenges of using pressure mattresses and how this can be addressed to improve
clinical outcomes.

CLINICAL QUESTION 4
Therefore, pressure mattresses offer an alternative way of preventing and treating
pressure ulcers among patients in critical care situations. The pressure mattress acts by relieving
the body from the pressure that it exerts on specific points that create the sores. This mattress
offers mechanical therapy options that replacing turning the patient around creating comfort to
the patient. However, there is limited literature on the effectiveness of the mattresses since most
of them are not widely available in the market. This review calls for the need for further research
to address the limitations of different studies on the topic.

CLINICAL QUESTION 5
References
Armstrong, R., Hall, B. J., Doyle, J., & Waters, E. (2011). Scoping the scope’ of a cochrane
review. Journal of Public Health, 33(1), 147–150.
Bhide, A., Shah, P. S., & Acharya, G. (2018). A simplified guide to randomized controlled trials.
Acta Obstetricia et Gynecologica Scandinavic, 97(4).
Colin, D., Rochet, J.-M., Ribinik, P., Barrois, B., Passadorid, Y., & Michelea, J.-M. (2012).
What is the best support surface in prevention and treatment, as of 2012, for a patient at
risk and/ or suffering from pressure ulcer sore? Developing French guidelines for clinical
practice. Annals of Physical and Regabilitation Medicine, 55, 446-481.
Malbrain, M., Hendriks, B., Wijnands, P., Denie, D., Jans, A., Vanpellicom, J., & De-Keulenaer,
B. (2010). A pilot randomised controlled trial comparing reactive air and active
alternating pressure mattresses in the prevention and treatment of pressure ulcers among
medical ICU patients. Journal of Tissue Viability, 19(1), 7-15.
McInnes, E., Jammali-Blasia, A., Bell-Syerb, S., Dumville, J., & Cullum, N. (2012). Preventing
pressure ulcers—Are pressure-redistributing support surfaces effective?A Cochrane
systematic review and meta-analysis. International Journal of Nursing Studies, 49, 345-
359.
Meaume, S., & Marty, M. (2018). Pressure ulcer prevention using an alternating-pressure
mattress overlay: the MATCARP project. Journal of Wound Care, 27(8).
doi:https://doi.org/10.12968/jowc.2018.27.8.488
Nguyen, K.-H., Chaboye, W., & Whitty, J. A. (2015). Pressure injury in Australian public
hospitals: a cost-of-illness study. Australian Health Review, 39, 329–336.
doi:http://dx.doi.org/10.1071/AH14088
Nixon, J., Cranny, G., Iglesias, C., Nelson, E. A., Hawkins, K., Mason, A. P., & Cullum, N.
(2016). Randomised, controlled trial of alternating pressure mattresses compared with
alternating pressure overlays for the prevention of pressure ulcers: PRESSURE (pressure
relieving support surfaces) trial. Journal of Wound Care, 1-5.
doi::10.1136/bmj.38849.478299.7C (publ
Serraes, B., & Beeckman, D. (2016). Static air support surfaces to prevent pressure injuries: a
multicenter Cohort study in Belgian nursing homes. , 43(4),. Journal of Wound Ostomy
Continued Nursing, 43(4), 375-378.
Shi, C., Dumville, J. C., & Cullum, N. (2018). Support surfaces for pressure ulcer prevention: A
network meta-analysis. PLoS ONE, 13(2).
Tsuchiya, S., Sato, A., Azuma, E., Urushidan, H., Osawa, M., Kadoya, K., . . . Sugama, J.
(2016). The effectiveness of small changes for pressure redistribution; using the air
mattress for small changes. Journal of Tissue Viability, 25, 135-142.

CLINICAL QUESTION 6

CLINICAL QUESTION 7
APPENDIX A: 1PRISMA diagram
The impact of using pressure mattresses in the
prevention of pressure ulcer in acute care
patients
CINAHL MEDLINE BJI GOOGLE
SCHOLAR
739 units of analysis found
309 Units of analysis when
parameters of the year 2010-
2018 were put in place
65 Unit of analysis after
duplicates were removed, only
full texts were considered and
only texts in English used.
22 Units of analysis after abstract
of title were read
7 Units of analysis included after
reading the remaining 30 units
430 units excluded
244 units excluded
15 units excluded

CLINICAL QUESTION 8
Appendix B. Evidence Summary Table
Appendix B. Evidence Summary Table
SEARCH QUESTION/TOPIC: Challenges faced by nurses in the implementation of evidence-based methods Clinical situations
Author (s)
(date)
Study Design
Question
Domain
Key
information
Validity Check
(eg bias)
Author’s
Results/Findings
Author’s
Conclusions
Reviewer
Comments
(Your appraisal)
Evidence Source
Colin, D.,
Rochet, J.-M.,
Ribinik, P.,
Barrois, B.,
Passadorid, Y.,
& Michelea, J.-
M. (2012).
Purpose: define
the best support
surfaces for
prevention of
pressure ulcers.
Design:
systematic review
Level: II
Domain: review
of RCTs
P: pressure
ulcer
I: use of
alternative
prevention
measures
C: pressure
mattress
O: Reduced
pressure
Bias was reduced
through use of
external
reviewers.
There are
different support
surfaces used in
the reduction of
pressure ulcer.
The need for
further research
to assess the
effectiveness of
pressure support
surfaces
The strength of
this study lies in
the findings and
recommendations
for the study.

CLINICAL QUESTION 9
Evidence Source
Malbrain, M.,
Hendriks, B.,
Wijnands, P.,
Denie, D., Jans,
A.,
Vanpellicom,
J., & De-
Keulenaer, B.
(2010)
Purpose:
comparison of the
relevance of suing
pressure
mattresses in
pressure ulcer
Design: Pilot
prospective single
blind RCT
Level: II
Domain: Blinded
respondents
P: Pressure
ulcer
I: use of
pressure
mattress
C: alternative
therapy
O: Reduced
pressure
. The validity of
the study is based
on blinding of
patients in
clinical study.
There was high
benefits in
preventing and
healing of
pressure ulcers
Alternating
mattress therapy
reduces the risk
of pressure
ulcers
The use of
pressure mattress
or alternative
therapy increases
pressure
distribution
reducing ulcers.

CLINICAL QUESTION 10
Evidence Source
McInnes, E.,
Jammali-Blasia,
A., Bell-Syerb,
S., Dumville, J.,
& Cullum, N.
(2012)
Purpose: review
the effectiveness
of pressure
redistributing
support surfaces
to prevent ulcers
Design:
systematic review
Level: I
Domain: use of
randomized
control trials to
evaluate research
outcomes.
P: pressure
ulcer
I: use of
support
surfaces
C: support
surfaces
O: Reduced
pressure
ulcers
Two reviewers
were used to
assess the articles
to reduce bias
Pressure
mattresses are
effective in
reducing pressure
ulcer
Support surfaces
offer the best
solution for
reducing the
development pf
pressure ulcer
this study can be
generalized to
clinical settings.

CLINICAL QUESTION 11
Evidence Source
Meaume, S., &
Marty, M.
(2018)
Purpose:
assessing the
incidence of
pressure ulcer in
high risk patients.
Design:
prospective
observational study
Level:
Domain:
Investigation of
the relevance of
pressure ulcer
P: pressure
ulcer
I: Pressure
ulcer
mattress
C: use of
alternative
forms
O: reduced
pressure
the study reported
a confidence level
of 95%
there were high
benefits in the use
of the mattress
Pressure
mattresses are
recommended as
reducing the
incidence of
pressure ulcer
The validity of the
study is important
in the application
of pressure ulcer
prevention.
Evidence Source
Nixon, J.,
Cranny, G.,
Iglesias, C.,
Nelson, E. A.,
Hawkins, K.,
Mason, A. P.,
& Cullum, N.
(2016)
Purpose:
comparing the
difference
between pressure
mattresses
Design: Pragmatic, open,
multicenter, randomized
controlled trial
Level
Domain:
investigation of
pressure mattress
P: pressure
ulcer
I: pressure
mattress
C: use of
pressure
mattress
O: Reduced
pressure
The patients were
blinded in the
study to increase
validity of the
findings
the study reported
that the pressure
mattress relieved
pressure in
patients
Pressure ulcers
can be reduced
through the use
of pressure
mattress
This study is
highly
representative of
the patient
population.

CLINICAL QUESTION 12
Author (date): include all authors and date of publication
Study design: include purpose, study design , domain, and level of
evidence (LOE) using JBI
Key information: include population/patients (P), intervention (I),
comparison (C), outcomes measured (O)
Validity check: include issues with methodology, rigour, potential for
bias –eg validity, reliability
Results/Findings: include generally favourable or
unfavourable, specific outcomes of interest, estimates of
experimental effect, if appropriate
Author Conclusions: author’s interpretation of findings;
include limitations, implication for practice and research) if
appropriate
Reviewer Comments: include potential for bias,
weaknesses and strengths of study design, applicability
SEARCH QUESTION/TOPIC:
Author (s)
(date)
Key
information
Validity Check
(eg bias)
Author’s
Results/Findings
Author’s
Conclusions
Reviewer’
Comments
(Your appraisal)
Evidence Source
Shi, C.,
Dumville, J. C.,
& Cullum, N.
(2018)
Purpose:
determining
effect of support
surfaces in
prevention of
pressure ulcer
Design systematic
review
Level: II
Domain:
Investigation of
pressure ulcer
P: pressure
ulcer
I: Pressure
mattress
C: support
surfaces
O: reduced
ulcers
Criteria for
inclusion was
RCT studies
Support surfaces
offer relief and
assist in
distribution of
pressure
Pressure
mattresses
reduce the
incidence of
pressure ulcers
The findings of
this study can be
generalized to the
field of study.

CLINICAL QUESTION 13
Evidence Source
Tsuchiya, S.,
Sato, A.,
Azuma, E.,
Urushidan, H.,
Osawa, M.,
Kadoya, K., . . .
Sugama, J.
(2016).
Purpose: to assess
the effectiveness
of pressure
redistribution
surfaces in
preventing
pressure ulcer
Design:
randomized
control trial
Level: II
Domain:
Experimental
analysis
P: pressure
ulcer patients
I: Pressure
redistribution
C:
effectiveness
in reducing
pressure
O:
distribution
of body
pressure
validity of the
study was based
on the confidence
level of the study
There was
reduced risk of
developing
pressure ulcers
when the
mattresses were
used.
The use of
support surfaces
reduces
disruptions in
alignment of the
body to reduce
the risk of
pressure ulcer.
The findings of
this study can be
replicated into
other studies.
Author (date): include all authors and date of publication
Study design: include purpose, study design , domain, and level of
evidence (LOE) using JBI
Key information: include population/patients (P), intervention (I),
comparison (C), outcomes measured (O)
Validity check: include issues with methodology, rigor, potential for
bias
Results/Findings: include generally favourable or
unfavourable, specific outcomes of interest, estimates of
experimental effect, if appropriate
Author Conclusions: author’s interpretation of findings;
include limitations, implication for practice and research) if
appropriate
Reviewer Comments: include potential for bias,
weaknesses and strengths of study design

CLINICAL QUESTION 14

CLINICAL QUESTION 15
Appendix C. Links to five best evidence sources
Colin, D., Rochet, J.-M., Ribinik, P., Barrois, B., Passadorid, Y., & Michelea, J.-M. (2012). What is the best support surface in
prevention and treatment, as of 2012, for a patient at risk and/ or suffering from pressure ulcer sore? Developing French
guidelines for clinical practice. Annals of Physical and Regabilitation Medicine, 55, 446-481.
http://dx.doi.org/10.1016/j.rehab.2012.08.002
Malbrain, M., Hendriks, B., Wijnands, P., Denie, D., Jans, A., Vanpellicom, J., & De-Keulenaer, B. (2010). A pilot randomised
controlled trial comparing reactive air and active alternating pressure mattresses in the prevention and treatment of pressure
ulcers among medical ICU patients. Journal of Tissue Viability, 19(1), 7-15. https://doi.org/10.1016/j.jtv.2009.12.001
McInnes, E., Jammali-Blasia, A., Bell-Syerb, S., Dumville, J., & Cullum, N. (2012). Preventing pressure ulcers—Are pressure-
redistributing support surfaces effective?A Cochrane systematic review and meta-analysis. International Journal of Nursing
Studies, 49, 345-359. doi: oi:10.1016/j.ijnurstu.2011.10.014
Meaume, S., & Marty, M. (2018). Pressure ulcer prevention using an alternating-pressure mattress overlay: the MATCARP project.
Journal of Wound Care, 27(8). doi:https://doi.org/10.12968/jowc.2018.27.8.488.
Nixon, J., Cranny, G., Iglesias, C., Nelson, E. A., Hawkins, K., Mason, A. P., & Cullum, N. (2016). Randomised, controlled trial of
alternating pressure mattresses compared with alternating pressure overlays for the prevention of pressure ulcers:
PRESSURE (pressure relieving support surfaces) trial. Journal of Wound Care, 1-5. doi::10.1136/bmj.38849.478299.7C.
Retrieved from https://www.bmj.com/content/bmj/332/7555/1413.full.pdf
Shi, C., Dumville, J. C., & Cullum, N. (2018). Support surfaces for pressure ulcer prevention: A network meta-analysis. PLoS ONE,
13(2).https://doi.org/10.1371/journal.pone.0192707
Tsuchiya, S., Sato, A., Azuma, E., Urushidan, H., Osawa, M., Kadoya, K., . . . Sugama, J. (2016). The effectiveness of small changes for
pressure redistribution; using the air mattress for small changes. Journal of Tissue Viability, 25, 135-142.
http://dx.doi.org/10.1016/j.jtv.2015.1

CLINICAL QUESTION 16
Appendix D. completed Critical appraisal of highest level of evidence