NSG 502: Advanced Nursing Research: Evidence-Based Project Part II
The Use of Alternating Pressure Air Mattresses to Prevent Pressure Ulcers
Pressure ulcers are serious patient safety issues in healthcare and can lead to detrimental health impacts when not properly addressed. Pressure ulcers have continued to remain an old global public health problem despite all advances in health care (Gaspar et al., 2019). These health conditions are also called pressure injuries. They are defined as sin injuries and/or localized underlying tissue damage over a bony area, as a result of pressure force and/or pressure and shear combined.
In most cases, pressure ulcers are predictable and preventable when proper evidence-based interventions are put in place. The use of alternating-pressure air mattresses is one of the strategies that can be employed to prevent this health condition. These special mattresses work by allowing proper pressure redistribution to prevent pressure injuries (Lavender et al., 2022). Regarding this, assesses whether alternating pressure air mattresses are effective in preventing pressure ulcers in hospitalized patients. The paper will cover background, significance, problem statement, purpose statement, and the PICOT question.
Background
Pressure ulcers are tissue damage that occurs as a result of external factors such as shear force, continuous pressure, and friction. This condition is an important aspect of nursing care in terms of the maintenance of skin integrity. According to Shi et al. (2020), pressure ulcer severity is classified using the National Pressure Injury Advisory Panel (NPIAP) system. Stage 1 includes intact skin with a local appearance of non-blanchable erythema. Stage 2 is partial-thickness skin loss and exposed dermis.
Stage 3 includes full-thickness skin loss (Shi et al., 2020). Stage 4 is full-thickness skin and tissue loss with visible muscle, tendon, fascia, ligament, cartilage, or bone. The next stage is unsaleable pressure injury, which is marked by full-thickness skin and tissue loss that is obscured by slough or eschar so that the severity of the injury cannot be confirmed (Shi et al., 2020). The last but not least stage is the deep tissue injury. This is described as a localized injury of persistent non-blanch-able deep red, purple, or maroon discoloration or epidermal separation indicating a dark wound bed or blood-filled blister.
Pressure ulcers affect people globally across all healthcare settings. According to Shi et al. (2020), the estimated number of people affected by pressure injuries or bed sores in the USA, UK, Ireland, and Sweden is between 5.6 to 2300 per 10,000 based on the nature of the population surveyed. However, these incidents are preventable. Källman et al. (2022) described a study whose aim was to identify the prevalence and prevention strategies for pressure ulcers in Sweden.
The study showed that the implementation of a national patient safety program has had a positive impact on pressure injury prevalence and the occurrence of prevention strategies. According to Shi et al. (2020), alternating pressure mattresses have been proven helpful in reducing the proportion of patients developing new pressure ulcers. Meaume & Marty (2018) also carried out a study to investigate the effectiveness of alternating pressure ulcers. The authors reiterated that in high-risk patients using a motorized alternating-pressure air mattress in the prevention group, only one in 30 patients developed pressure ulcers.
Significance
There are several reasons why this topic is important to patients, the healthcare system, and the entire community. The condition has detrimental health effects on the patients that need serious attention. Pressure ulcers can result in discomfort or pain due to tissue damage or ischemia (Kim & Shin, 2021). Pressure ulcers also cause physical problems that may lead to complications. This incident also leads to poor clinical outcomes, social problems, and psychological problems resulting from increased health costs. Källman et al. (2022) also state that pressure ulcers bring great suffering to people affected, as well as, a high cost to society.
The shear and pressures often deform soft tissues and may result in cell death. Pressure ulcers lead to a prolonged hospital stay and poor patient prognosis. These health, social, and financial problems associated with pressure injuries make it a topic worth researching.
This information is important to nursing practice to improve patient safety and outcomes. A pressure ulcer is a nursing issue that indicates poor nursing strategies. Consequently, reducing the occurrence of these issues will improve nursing care and patient outcomes. Nurses will gain knowledge and apply evidence-based practice to improve patient care and outcomes. According to Kim & Shin (2021), practical guidelines and methods for preventing pressure injuries include skin assessment, changing position, and use of support surfaces such as alternating pressure air mattresses.
The aim of nursing care is also to improve patient experience in terms of cost of care, length of hospital stay, pain relief, and others. Pressure ulcer prevention takes care of these areas by avoiding the high cost of care associated with the condition, improving the general patient experience, and avoiding unnecessary pain associated with pressure injuries (Kim & Shin, 2021). Therefore, this information promotes quality nursing practices. If this problem is not addressed, patients will have a bad experience, increased costs of care, prolonged hospital stay, and increased pain related to pressure injuries.
Problem Statement
The problem identified in this proposal is the increasing rates of pressure ulcers within the healthcare facility. This is a serious health concern that must be addressed with the urgency it deserves (Lavender et al., 2022). In the identified care facility, more than 5 percent of the hospitalized patients had developed pressure ulcers. Without proper intervention, these incidences tend to get worse while the rates keep increasing. As mentioned above, Pressure ulcers are associated with detrimental health effects, including social and psychological problems (Lavender et al., 2022). Pressure ulcers are associated with an increased financial burden, prolonged hospital stay, pain, and generally bad patient experience.
Purpose Statement
The purpose of this proposal is to examine the effectiveness of alternating pressure air mattresses in preventing pressure ulcers in hospitalized patients.
PICOT Question
The PICOT question is: in hospitalized patients with limited mobility (P), how does the use of alternating pressure air mattresses (I) compared to no intervention (C) affect the rates of pressure ulcers (O) within six months (T)?
ALSO READ: NSG 502: Advanced Nursing Research: Evidence-Based Project Part III
Literature Review
Search Strategies
This study is based on credible and reliable sources of evidence. Peer-reviewed articles were searched using keywords such as pressure ulcers, alternating pressure air mattress, pressure ulcer prevention, pressure ulcer interventions, and support air surfaces. Various types of research studies were selected for review, including systematic review of randomized control trials, quasi-experimental studies, and randomized controlled trials.
Ten of these studies were searched from various online databases. These databases include Google Scholar, CINAHL Ultimate, Cochrane Library, PubMed Central, SAGE Journals, and ScienceDirect. These studies were published in different journals, including International wound journal, international journal of environment research ad public health, military medicine, journal of wound care, Cochrane Database of Systematic Reviews and others. A literature review matrix table is provided in the appendix.
Review
Ahtiala et al. (2020) carried out a research study whose purpose was to investigate the effects of different types of mattresses on Pressure ulcer prevention. The authors retrospectively investigated the effect of mattresses on the development of pressure ulcers (PUs). The researcher included 8,956 ICU patients into the clinical observational study that lasted over a 6-year period. Sampling was conducted purposively based on certain characteristics.
This was a quasi-experimental study design. Four types of mattresses used include e foam, alternating air, dynamic and low-pressure mattress system, and the computerized, individually and precisely adaptive minimum pressure air mattress system (MPA). The study results showed that PU incidences reduced from 11.1% to 3.7%. There was a significant reduction in PU incidences for foam and alternating air mattresses.
Ezeamuzie et al. (2019) aimed to assess the effectiveness of low profile alternating pressure (AP) overlay in preventing the operating room associated pressure injuries. The researchers conducted a prospective case control study in the operating room. Participants included patients undergoing neurosurgery for at least 2 hours in supine position. Participants were assigned to receive the AP overlay. 212 patients were selected for the study (104 in the AP system). The study results indicated that there was no adverse reaction in the AP overlays. In addition, significant reduction in PU incidences was noted in the intervention group.
The purpose of the study conducted by Gaspar et al. (2019) aimed to evaluate the effective approaches to pressure ulcer prevention in hospitalized patients. This was a systematic review of randomized controlled trials. The researchers included 26 studies with adult patients admitted in hospital wards/units. The study results showed that multiple intervention programmes in compliance with advanced practice wound nurse’s regulation are more effective in decreasing PU incidences.
Meaume & Marty (2018) carried out a study whose objective was to assess the incidence of pressure ulcer in high-risk patients lying down between 15 and 20 hours per day on an alternating pressure matress overlay (APMO). This was a prospective observational study carried out in three rehabilitation centers and two nursing homes between 2016 and 2017. Included were patients who did not have PU at baseline. The study results showed a low PU incidence in participating patients.
Sauvage et al. (2017) had a purpose of comparing e Axtair one, an alternating pressure air mattress (APAM), with a viscoelastic foam mattress (VFM) in elderly patients at moderate to high risk of developing pressure ulcers (PUs). This study was a randomized, controlled, supersity, multicenter study. This study lasted between 2012 and 2015. The researcher randomized 76 patients and assigned 39 in the APAM group and 37 in the VFM group. The study result showed that APAM was superior to a VFM for preventing PUs.
Synthesis
Most of the studies summarized above have indicated that alternating pressure air mattresses and other reactive support surfaces are effective in preventing pressure ulcers. All the studies showed that alternating-pressure air mattresses are effective in reducing the incidences of pressure ulcers (Ahtiala et al., 2020; Ezeamuzie, 2019; Gaspar et al., 2019; Meaume & Marty, 2018; Sauvage et al., 2017).
There were several quasi experimental studies in the study (Ahtiala et al., 2020; Ezeamuzie, 2019; Meaume & Marty, 2018) are quasi-experimental studies. Sauvage et al. (2017) is a randomized controlled trial and Gaspar et al. (2019) is a systematic review. All the five articles are high sources of evidence. All of them are relevant to the topic of study because they all tend to assess the effective approaches to prevent PUs. Furthermore, all the articles included alternating pressure air mattresses as part of interventions under study. Therefore, these studies will provide useful information to help understand the topic.
Critical Appraisal
Strengths and Weaknesses
Ahtiala et al. (2020) included a large number of participants (9,965 adult patients) into the study making it a high quality study. In addition, it used credible statistical methods of analysis such as Chi-squared test, mean, SD. A Cox proportional hazards model and others. However, the study lack random sampling because of quasi-experimental design. Ezeamuzie et al. (2019) also recruited a large sample of participants (212 participants).
In addition, this study used various forms of credible statistical analysis methods. Study weakness include quasi-experimental design that lack random assignment of samples. Gaspar et al. (2019) is a level I source of evidence because it is a systematic review of RCTs. It used the evidence-based librarianship (EBL) Critical Appraisal tool to evaluate and select quality studies for review. The weakness of this study is that all the studies included had heterogeneity, cause mainly by issues surrounding the study populations, settings, and interventions under investigation.
Sauvage et al. (2017) presented a clear methodology of the study. The study was a RCT that provided high level of evidence. It used randomized method of sampling. Weakness of the study is that the results are more valid for patients benefiting from a repositioning protocol similar to that observed.
Knowledge Gained from Review
These is quite a lot to learn from this literature review. The very basic knowledge is that pressure ulcers are preventable when proper measures are put in place. The most important knowledge gained, based on this research study, is that alternating pressure air mattresses are effective in preventing pressure ulcers. All these studies have hinted at the efficacy of the intervention (Ahtiala et al., 2020; Ezeamuzie, 2019; Gaspar et al., 2019; Meaume & Marty, 2018; Sauvage et al., 2017). The information included in the study that is not related to the PICOT question is that multiple intervention programs are more effective than single intervention programs in reducing PU incidences.
Gaps in Knowledge
The knowledge gap is the cost effectiveness of alternating pressure air mattresses compared to other interventions. None of the articles analyzed have informed about cost effectiveness of this intervention. Cost is an essential aspect of a quality improvement research to prevent pressure ulcer incidences.
Conclusion
This paper provided a proposal for a project that would assess the effectiveness of alternating pressure air mattresses to prevent pressure ulcer injuries among hospitalized patients. Pressure ulcers are injuries of the tissue due to pressure force and/or shear on the bony areas of the body. Pressure ulcers have detrimental health impacts on patients. They also cause social and psychological problems resulting from financial burdens and other factors.
This information is significant to nursing practice because when used it can improve patient experience and outcomes. This paper covered the background, significance, problem statement, purpose statement, and the PICOT question. The literature review section covered a lot. The entire five peer reviewed articles indicated effectiveness of alternating pressure air mattresses to prevent pressure ulcers.
The articles presented high level of evidence (quasi-experimental, systematic reviews, and randomized controlled trials). Majority of the studies presented clear study methodology. They used large study sample making them valid and generalizable. Cost effectiveness of alternating pressure air mattresses is a knowledge gap that should be considered in the future research.
References
Ahtiala, M., Kivimäki, R., Laitio, R., & Soppi, E. (2020). Effect of mattress deployment on pressure ulcer development: A real-world observational cohort experience. Wounds International, 11(1), 0-7. https://www.directhealthcaregroup.com/app/uploads/effect-of-mattress-deployment-on-pressure-ulcer-development-a-realworld-observational-cohort-experience-1.pdf
Ezeamuzie, O., Darian, V., Katiyar, U., & Siddiqui, A. (2019). Intraoperative use of low-profile alternating pressure mattress for prevention of hospital acquired pressure injury. Perioperative Care and Operating Room Management, 17, 100080. https://doi.org/10.1016/j.pcorm.2019.100080
Gaspar, S., Peralta, M., Marques, A., Budri, A., & Gaspar de Matos, M. (2019). Effectiveness on hospital‐acquired pressure ulcers prevention: a systematic review. International wound journal, 16(5), 1087-1102. https://doi.org/10.1111/iwj.13147
Kim, S. Y., & Shin, Y. S. (2021). A Comparative Study of 2-Hour Interface Pressure in Different Angles of Laterally Inclined, Supine, and Fowler’s Position. International Journal of Environmental Research and Public Health, 18(19), 9992. https://doi.org/10.3390/ijerph18199992
Källman, U., Hommel, A., Borgstedt Risberg, M., Gunningberg, L., Sving, E., & Bååth, C. (2022). Pressure ulcer prevalence and prevention interventions–A ten‐year nationwide survey in Sweden. International wound journal, 1-12. https://doi.org/10.1111/iwj.13779
Lavender, S. A., Kachlan, A., Pennells, S. E., & Spence, D. (2022). Evaluating the Efficacy of a New Alternating Pressure Air Mattress Aimed at Reducing Pressure Injuries During the Transport of Combat Casualties. Military Medicine, 0(1). https://doi.org/10.1093/milmed/usac113
Meaume, S., & Marty, M. (2018). Pressure ulcer prevention using an alternating-pressure mattress overlay: The MATCARP project. Journal of wound care, 27(8), 488-494. https://doi.org/10.12968/jowc.2018.27.8.488
Shi, C., Dumville, J. C., Cullum, N., Rhodes, S., & McInnes, E. (2020). Alternating pressure (active) air surfaces for preventing pressure ulcers. The Cochrane Database of Systematic Reviews, 2020(5). https://doi.org/10.1002/14651858.CD013620
Sauvage, P., Touflet, M., Pradere, C., Portalier, F., Michel, J. M., Charru, P., & Scherrer, B. (2017). Pressure ulcers prevention efficacy of an alternating pressure air mattress in elderly patients: E²MAO a randomised study. Journal of Wound Care, 26(6), 304-312. https://doi.org/10.12968/jowc.2017.26.6.304
Appendix
Appendix A: A Literature Review Matrix Table.
| Author/
Date/Journal (should be peer-reviewed sources only) |
Problem statement; purpose statement; research/PICOT question; hypotheses | Literature Review: Levels of Evidence | Study Design | Key Variables | Population/
Sampling/Ethics (IRB) |
Analysis Methods used (Statistics) &
Findings |
Conclusions: Discussion and Limitations | Implications
For practice |
|
| 1 | Gaspar et al. /2019/ International wound journal. | To evaluate the effective approaches to pressure ulcer prevention in hospitalized patients. | Level I | Systematic review of RCTs | Dependent: PU incidences
Independent: Approaches to PU prevention. |
Population were adults over 18 years. 26 studies were reviewed. No information on IRB approval | The evidence-based librarianship (EBL) Critical Appraisal checklist was used for analysis. The overall validity (global rating) of the studies was determined based on the “Yes” scores ≥75% or “No/Unclear” scores ≤25%. Multiple intervention programmes in compliance with advanced practice wound nurse’s regulation are more effective in decreasing PU incidences. | Multiple intervention programs should be applied in together with advanced nurses practice regulations to reduce PU incidences. | This information can be used in healthcare settings to help reduce PU incidences. |
| 2 | Kim, S. Y., & Shin, Y. S. /2021/ International Journal of Environmental Research and Public Health. | To compare the peak pressure, risk area ratio, and pressure ulcer (PU) threshold pressure time among patients in laterally inclined, supine with head-of-bed, and Fowler’s with 30◦ leg elevation positions. | Level II | RCT | Dependent: peak pressure, risk area ratio, and pressure ulcer (PU) threshold pressure time
Independent: Positions (laterally inclined supine with head-of-bed, and Fowler’s with 30◦ leg elevation). |
Study included 64 adults. Sampling was randomized. The study was approved by IRB of Hanyang University | Mean, median, standard deviation, numbers, percentages, Chi-square and independent t-test, and ANOVA. Results: position changes are required every 2 h in the 30◦ tilting position, every 1.5 to 2 h at 0◦ supine, and at least every 1.5 h for all the other positions. | To prevent pressure ulcers, position changes are required every 2 h in the 30◦ tilting position, every 1.5 to 2 h at 0◦ supine, and at least every 1.5 h for all the other positions. | This information can be used to educate care providers about positions to |
| 3 | Shi et al. /2020/ The Cochrane Database of Systematic Reviews. | To evaluate the effects of alternating pressure air surfaces compared with any support surface on PU incidences. | Level I | Systematic review of RCTs | Dependent: PU incidences
Independent: alternating pressure air surfaces, other surfaces. |
Population were 9058 adults over 18 years. 31 studies were reviewed. No information on IRB approval | Review manager 5.4. Forest plots. RR with 95% CI. Alternating pressure (active) air surfaces may reduce pressure ulcer risk compared with foam surfaces and reactive gel surfaces. | Alternating pressure (active) air surfaces are effective than other surfaced in reducing PU incidences. | This information can be used to prevent PUs. |
| 4 | Källman et al. /2022/ International wound journal | To describe pressure ulcer prevalence and prevention interventions in hospital care in Sweden based on nationwide surveys conducted over a 10-year period. | Level III | Quasi experimental | Dependent: PU prevalence
Independent: PU interventions Independent: alternating-pressure mattress overlay |
More than 130 000 patients were included. Purposive sampling. Study is IRB approved. | Logistic regression model. Pressure-reducing mattresses, sliding sheets, heel protection, and repositioning plans reduced PU incidences. | These approaches to PU prevention are effective. | This study can educate care providers about approaches to PU prevention. |
| 5 | Lavender et al. /2022/ Military Medicine. | To investigate the potential for potential for a new intervention, an air-inflated insulating mattress pad (IMP) | Level III | Quasi experimental | Dependent: PU incidences
Independent: air-inflated insulating mattress pads (IMPs) |
Study included 12 participants. Convenience sampling. IRB approved. | SD, ANOVA, mean, and slope function. All pad conditions showed a positive result on reducing PU incidences. | The IMP with alternating cell pressurizations are effective in reducing PU incidences. | The interventions can improve military medical care services. |
| 6 | Meaume, S., & Marty, M. /2018/ Journal of wound care. | To assess of effect of alternating pressure mattress overlay in preventing PU. | Level III | Quasi experimental | Dependent: PU incidences
Independent; alternating-pressure mattress overlay |
83 patients were included in the study. Convenience sampling. IRB approved. | Percentages and the exact 95% CI were calculated. . Over the study period, 1.2% (1/83) (95% confidence interval (CI): 0.03 to 6.53) of patients developed a PU. | Alternating pressure mattress overlay is effective in reducing PU incidences. | Informs the effectiveness of alternating pressure mattress overlay to reduce PU incidences. |
| 7 | Ahtiala et al. /2020/ Wounds International. | To investigate the effects of different types of mattresses on PU prevention. | Level III | Quasi experimental | Dependent: PU incidence
Independent: types of mattresses. |
Study included 9,965 adult patients. Purposive sampling. IRB of the Hospital District of Southwest Finland | Chi-squared test, mean, SD. A Cox proportional hazards model with mJ/C score. Both the mJ/C score (P=0.0002) and the type of first mattress (P<0.0001). | The incident of PUs among patients on MPAs was significantly lower than on any of the other mattresses. | Informs the effectiveness of MPAs on reducing PUs. |
| 8 | Sauvage et al. /2017/ Journal of Wound Care. | To compare Axtair One, an alternating pressure air mattress (APAM), with a viscoelastic foam mattress (VFM) in elderly patients at moderate to high risk of developing pressure ulcers (PUs). | Level II | RCTs | Dependent: Risk of PU
Independent: Axtair One, an alternating pressure air mattress (APAM), a viscoelastic foam mattress (VFM) |
Patients were aged 70 and over and 76 patients were included. Randomized sampling. IRB approved. | Percentages, A sequential test, 80% with an alpha risk of 5%, 95% confidence interval (CI). The cumulative risk of PUs was estimated at 6.46% [95% confidence interval (CI): 1.64; 23.66] in the APAM group and at 38.91% [95% CI: 24.66; 57.59] in the VFM group | The APAM was superior to a VFM for preventing PUs in elderly patients | Informs the efficacy of APAM compared to VFM. |
| 9 | McInnes, et al. /2018/Cochrane Database of Systematic Reviews. | To assess the effects of pressure-relieving support surfaces in the treatment of pressure ulcers. | Level I | Systematic review of RCTs | Dependent: healing of existing pressure ulcers independent: pressure-relieving support surfaces | Population included about 100 people. 19 RCTs were reviewed. No IRB approval | RR with 95% CI, mean.
There is 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 |
Informs effectiveness of both water-filled support surfaces and foam replacement mattresses in preventing PU incidences. | |
| 10 | Ezeamuzie et al. /2019/ Perioperative Care and Operating Room Management | To study the efficacy of a low profile alternating pressure (AP) overlay to prevent operating room associated pressure injuries | Level III | Quasi experimental | Dependent: PU incidences
Independent: the efficacy of a low profile alternating pressure (AP) overlay |
212 patients were enrolled into the study. Convenience sampling. IRB approved. | A chi-squared test. SAS 9.2 software (SAS Institute Inc., Cary, NC) and statistical significance was set at P less than .05.
There were no adverse events or unintended consequences resulting from use of the AP overlays |
Low Profile Alternating Pressure mats are a safe and effective way to prevent hospital acquired pressure injuries. | Informs the effectiveness of Low Profile Alternating Pressure mats. |