Summary of best evidence for prevention and control of pressure ulcer on support surfaces

Abstract

The aim of this study was to summarise the best evidence for the prevention and control of pressure ulcer at the support surface based on the site and stage of the pressure ulcer in order to reduce the incidence of pressure ulcer and improve the quality of care. In accordance with the top‐down principle of the 6 S model of evidence‐based resources, evidence from domestic and international databases and websites on the prevention and control of pressure ulcer on support surfaces, including randomised controlled trials, systematic reviews, evidence‐based guidelines, and evidence summaries, was systematically searched for the period from January 2000 to July 2022. Evidence grading based on the Joanna Briggs Institute Evidence‐Based Health Care Centre Evidence Pre‐grading System (2014 version), Australia. The outcomes mainly embraced 12 papers, including three randomised controlled trials, three systematic reviews, three evidence‐based guidelines, and three evidence summaries. The best evidence summarised included a total of 19 recommendations in three areas: type of support surface selection assessment, use of support surfaces, and team management and quality control.

1. INTRODUCTION

A pressure ulcer is a localised injury caused by continuous pressure on the skin and/or subcutaneous soft tissues, usually located at a bony prominence, or involving a medical device or other instrument. ¹ Pressure redistribution is important in pressure ulcer prevention and control strategies, which include the use of support surfaces and postural management. Nursing staff have standardised and comprehensive care practices for postural management, but lack sufficient attention to support surfaces. Support surfaces 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. ² The results of the pressure ulcer prevention measures statistics show that only 61.81% of patients at risk of pressure ulcer use support surfaces, and mostly electric pressure inflatable mattresses, ³ the use rate is low and the appropriate support surface is not selected according to the stage of pressure ulcer or the site of occurrence. Currently, there is no separate summary and classification of support surfaces, and the evidence is scattered and lacks guidance from studies with high levels of evidence, ⁴ which weakens the overall prevention and control of pressure ulcer. Therefore, in this study, we systematically searched the literature related to the prevention and control of pressure ulcer with brace surfaces at home and abroad, evaluated, synthesised, and summarised the evidence using evidence‐based methods, classified the sites and stages of pressure ulcer occurrence, and finally formed a comprehensive evidence on the selection, use and management of brace surfaces in order to provide an evidence‐based basis for clinical practice.

2. MATERIALS AND METHODS

2.1. Search strategy

This study was searched in the following databases, Cochrane Library, Embase, PubMed, Wanfang, CNKI and China Biomedical Literature Database. The English search terms included “pressure ulcer/pressure ulcer/pressure sore/decubitus ulcer/bed sore/pressure sore” and “pressure relieving device/support surfaces/beds/mattress” and Chinese search terms include “pressure ulcer/pressure ulcer/pressure sore/pressure ulcer” and “support surfaces/airbeds/pressure‐relieving mattresses/gel mattresses/pressure‐relieving devices/support tools”. The comprehensive database was searched using a combination of subject terms and free words. The search time frame is from 2000 to 2022.

2.2. Criteria for considering studies

The inclusion criteria included: (a) study subjects were patients with pressure injuries using support surfaces or at‐risk groups; (b) intervention: use of support surfaces based on routine pressure ulcer care; (c) outcome indicators: 1 or more of pressure ulcer incidence and Branden score; (d) balanced consistency across studies, comparable baseline data between intervention and control groups; (e) study type. Randomised controlled trials, evidence‐based guidelines, systematic reviews, evidence summaries, expert consensus. Exclusion criteria: (a) literature types were guideline interpretations and plans; (b) repeatedly published or updated articles; (c) literature with incomplete information or inaccessible full text; (d) studies that failed the literature quality assessment.

2.3. Studies selection, data extraction, and quality assessment

Two authors (Lijun Huang, Yuan Liao) scanned the titles and abstracts of all records identified through the search strategy independently. The full text of potentially relevant articles was obtained and assessed independently by two authors (Lijun Huang, Yuan Liao) in accordance with inclusion and exclusion criteria. Any differences of opinion were resolved through discussion with a senior author (Yimin Huang) Data were collected using a standardised form to include first author, publication year, baseline characteristics of participants, sample sizes, type of support surfaces, type of intervention, details of comparison, and incidence of pressure ulcer. Two authors (Lijun Huang, Yimin Huang) independently assessed the risk of bias using the UK's 2017 updated clinical guidelines research and evaluation system (Appraisal of Guidelines for Research and Evaluation II,AGREE II), ⁵ the Assessment of Multiple Systematic Reviews 2 (AMSTAR 2). Systematic evaluations were performed using the Assessment of Multiple Systematic Reviews 2 (AMSTAR 2). ⁶ Randomised controlled trials were evaluated using the evaluation criteria of the Australian JBI Centre for Evidence‐Based Health Care (2016). ⁷ The extracted evidence was evaluated in this study using the Johns Hopkins Centre for Evidence‐Based Care evidence grading system, ⁸ Under the guidance of FAMA structure, combined with the JBI recommendation strength grading principle of the evidence, the research team determined the strength of the evidence recommendation, that is, A‐level recommendation (strong recommendation) and B‐level recommendation (weak recommendation).

3. RESULTS

3.1. General characteristics of the included literature

A total of 635 publications were included, and after excluding duplicates and those that did not meet the requirements after reading the title, abstract, and full text, a total of 12 publications were finally included, including three randomised controlled trials, three systematic reviews, three evidence‐based guidelines, and three best evidence summaries. The basic characteristics of the included literature are shown in Table 1.

TABLE 1.

Basic characteristics of the included literature.

Inclusion in the literature	Literature name	Literature sources	Nature of literature
Qu Xiaolong et al. 9	Comparison of the effectiveness of dynamic and static air mattresses in preventing pressure injuries in bedridden neurology patients	Wanfang	Randomised controlled experiments
Luo Qiaofang et al. 10	Effectiveness of static mattress combined with turning to prevent pressure ulcer in elderly bedridden patients	China Knowledge Network	Randomised controlled experiments
Bueno et al. 11	The effect of support surfaces on the incidence of stress injury in critically ill patients: a randomised clinical trial.	Cochrane	Randomised controlled experiments
Sun Xin et al. 12	Meta‐analysis of the effectiveness of air cushion beds in preventing and treating pressure‐related injuries	Wanfang	System evaluation
McInnes, E, et al. 13	Support surfaces for preventing pressure damage	Cochrane	System evaluation
Shi, C Dumville, J C et al. 14	Alternative reactive support surfaces (non‐foam and non‐inflatable) for pressure ulcer prevention	Cochrane	System evaluation
Collins F et al. 15	A practical guide to providing mattresses and cushions to relieve stress	CINAHL	Evidence‐Based Guidelines
Colin, D. et al. 16	As of 2012, what is the best surface of support for prevention and treatment for patients at risk and/or suffering from pressure‐related injuries?	Pubmed	Evidence‐Based Guidelines
Emily Haesler 2	Quick Reference Guide for Clinical Management of Pressure Ulcers/Injuries	EPUAP official website	Evidence‐Based Guidelines
Emily Haesler et al. 17	Evidence Summary: Active Support Surfaces for the Prevention and Treatment of Pressure Injuries for the Treatment of Pressure‐Related Injuries	CINAHL	Evidence Summary
Yang Ting etc. 18	Evidence summary for the prevention and management of pressure injuries of the heel	Wanfang	Evidence Summary
Zhou Qing etc. 19	Summary of best evidence for intraoperative pressure injury prevention	Wanfang	Evidence Summary

3.2. Evaluation results of the quality of the included literature

3.2.1. Quality evaluation results of the guidelines

Three guidelines were included in this study with high inter‐rater agreement, and the results of the standardised scores for each domain and the overall quality evaluation of the guidelines are shown in Table 2.

TABLE 2.

Results of the quality evaluation of the guidelines.

Inclusion in the literature	Standardised score for each field (%)						Number of fields with ≥60% (one)	≤30% of the number of areas (one)	Overall Quality
	Scope purpose	Participants	Rigour	Clarity	Applicability	Independence
Collins 15	72.22	44.44	50.00	72.22	64.58	66.67	4	0	5
Colin, D 16	83.33	61.11	71.87	83.73	72.92	87.50	6	0	6
Emily, H 2	97.22	91.66	68.68	64.58	60.41	91.66	6	0	6

3.2.2. Results of the quality evaluation of the systematic review

Three systematic reviews were included in this study, one from the Wanfang database and two from the cochrane database. Sun Xin et al. ¹² For the study of Sun Xin et al. in the study, entry 2 “Whether the study method of the systematic evaluation was determined before the implementation of the systematic evaluation. Were inconsistencies with the study protocol explained?”, entry 7 “Did the authors of the systematic evaluation provide a list of excluded literature and the reasons for their exclusion?”, entry 10 “Do the authors of the systematic evaluation report the sources of funding for the inclusion of individual studies?”, entry 16 “Do the systematic evaluation authors report all sources of potential conflicts of interest, including any grants received for the production of the systematic evaluation?” Evaluated as no, entry 4 “Did the systematic evaluation authors use a comprehensive search strategy?”, entry 8 “Did the systematic evaluation authors describe the included studies in detail?”, and entry 9 “Did the systematic evaluation authors use appropriate tools to assess the risk of bias for each included study?” The results were partially yes and yes for all other entries; McInnes, E et al. ¹³ For the study by McInnes, E et al., entry 2 “Were study methods determined prior to systematic evaluation? Are inconsistencies in protocols explained?” and entry 10 “Do the authors of the systematic evaluation report the source of funding for each study included?” The evaluation result was no, while all other entries were yes; ShiC et al. ¹⁴ studies, all entries were evaluated as yes. The study design was relatively complete, and the overall quality was moderate, and was included after discussion by the study team.

3.2.3. Quality evaluation results of the evidence summary

Three evidence summaries from CINAHL and Wanfang, which followed the evidence development process and criteria and met the inclusion criteria for this study, were included in this study.

3.2.4. Quality evaluation of randomised controlled trials

A total of three randomised controlled trials were included in this study. Among them, the study by Qu et al. ⁹ the evaluation result was no, entry 6 “Was the outcome assessor blinded?” and entry 7 “Did the groups receive the same measures other than the intervention to be validated?” All entries were evaluated as yes, except for entry 6, “Was the outcome measure blinded?” and entry 7, “Did the groups receive the same measures except for the intervention to be validated?”, which were evaluated as unclear. The study by Luo Qiaofang et al. ¹⁰ was evaluated as high quality, except for entry 5, “Was the intervention blinded?” The evaluation result was no, and entry 7 “Apart from the intervention to be validated, were the other measures received by each group the same?” The study by Bueno et al. ¹¹ was evaluated as yes, except for entry 5, “Was the intervention blinded?”, which was evaluated as no. All entries were evaluated as yes, and the quality of the literature was high.

3.3. Evidence aggregation and generation

The researchers extracted relevant evidence from the 12 included papers to form the first draft of the evidence summary, and a total of 35 pieces of evidence were obtained. This research team combined the evidence with the same formulation, and conflicting evidence was selected with high evidence level and newer chronology. Discussions were held by two (Lijun Huang, Yuan Liao), and the final evidence summary was conducted in three areas: selection assessment of support surfaces, use of support surfaces, and team management and quality control, resulting in 19 best evidence summaries, which are shown in Table 3. The Australian JBI evidence‐based health care centre evidence pregrading and evidence recommendation level system (2014) was used to determine the grading of included evidence.

TABLE 3.

Summary of best evidence for support surfaces to reduce and manage pressure ulcer.

Evidence items	Evidence content	Level of evidence	Recommended level
Evaluation of the type of support surface selection	Assessment of prone support surfaces. ① The degree of mobility and activity restriction. ② the need for controlled microenvironment and shear reduction. ③ The patient's body size and weight. ④ The number, severity, and location of existing pressure injuries, and the risk of new pressure injuries. ⑤ acute onset of illness, serious illness, diabetes, major surgery, or spinal cord injury. ⑥Patient comfort and satisfaction, economic conditions and cost investment. 2 , 9 , 15 , 19	Level 5c	A
	2 Assessment of seated support surfaces. ①Body type and physique ②The effect of posture and deformity on pressure redistribution ③Activity and lifestyle needs 16	Level 5c	A
	3 Assessment of the heel support surface (satisfying any of the following conditions). ①braden score ≤13, or subentry with activity and/or mobility ≤2 ②Lower limb mobility loss, inability to lift legs, muscle strength below grade 3 ③ Presence of a pressure ulcer to the heel 18	Level 5c	A
	4 Intraoperative evaluation of the support surface. ①Surgery duration ②Surgical position ③Specific requirements for instrumentation and stability of the surgical area 19	Level 5b	B
Use of support surfaces
Pressure ulcer Preventive use	5For patients at risk of pressure‐related injury, including preoperative, intraoperative, and postoperative, use a high‐specification induction single‐layer foam mattress or bedspread instead of a non‐high‐specification specific foam mattress 2 , 19	Level 5c	A
	6Intraoperatively in the prone position, it is recommended to use pressure redistribution support surfaces (eg, facial pads, chest pads) or place postural devices to relieve pressure points on the face and body 19	Level 1b	A
	7Pressure redistribution cushions are recommended for the prevention of pressure injuries in high‐risk patients who require prolonged chair or wheelchair use, especially those who are unable to perform pressure reduction 2	Level 5c	A
	8It is recommended to use a heel support device designed to relieve pressure on the heel, such as a heel suspension boot, a long foam pad 18	Level 1b	B
	9For patients for whom regular pressure repositioning is not possible, it is recommended to use alternating pressure mattresses to shorten the local pressure time on the skin, reduce friction, and shear force, and improve blood circulation to the local pressure area 13 , 17	Level 5b	B
	10In the absence of power supply and low cost investment, it is recommended to use static air mattress and every four hours turn the combination of measures, can effectively disperse the pressure of the mattress on the body, the local skin to play a protective cushioning effect, conducive to enhance the bed comfort and ease of operation. 9 , 10	Level 1b	A
	11Air‐jet airbeds are not recommended as they are not easy to control the air pressure and need to be used strictly according to the patient's weight 10	Level 1c	B
	12Foam rings and donut‐type support surfaces are not recommended for intraoperative prone position 19	Level 1b	A
pressure ulcer managed use	13For patients with early pressure ulcer, it is recommended to use dynamic alternating decompression inflatable mattresses to change the alternating pressure between the body and the support surface to promote blood circulation and speed up the healing process. 12 , 19	Level 1b	B
	14For stage II pressure ulcer patients, high specification reactive foam mattresses, non‐dynamic pressure redistribution mattresses or viscoelastic foam mattresses are recommended, while viscoelastic foam mattresses can also be used for surgical procedures in the operating room 11 , 13 , 14	Level 1b	A
	15For patients with class III or IV/stage pressure injuries, an air flow bed or low air loss mattress is recommended to promote healing while reducing the relative benefits of skin temperature and excessive hydration 2 , 17	Level 5c	A
	16Alternating pressure cushions are recommended to promote pressure ulcer healing in patients with pressure ulcer who are chair or wheelchair bound for long periods of time, especially those who are unable to perform pressure reduction 2	Level 5c	A
	17For patients at risk of heel pressure ulcer and/or with Stage I or II pressure ulcer, it is recommended that the heel be elevated with a specially designed heel support device or pillow/foam pad that allows the weight of the leg to be distributed along the lower leg, completely relieving pressure on the heel and avoiding compression of the Achilles tendon and popliteal vein 2	Level 5c	A
Team management and quality control	18 Pressure ulcer and support surface knowledge education ①Target of education: caregivers and family caregivers in medical institutions and elderly care institutions ②Education content: training on knowledge and skills such as the use of support surfaces, skin assessment, the use and judgement of risk assessment scales, and the use of pressure monitoring systems ③Education method: multimedia explanation, one‐on‐one training method 2 , 9 , 13 , 14	Level 1a	A
	19Limitations of the use of support surfaces 20Pressure ulcer prevention and control should be based on a comprehensive, holistic assessment and treatment, and it is important to note that the support surface is only a tool for pressure ulcer prevention and reduction, and its use must be within the framework of a holistic patient management strategy that emphasises stress targeting and nutritional care 15 , 16	Level 5b	A

3.4. Summary and analysis of best evidence

After a rigorous literature search, quality evaluation, and evidence grading, 19 pieces of evidence were finally included in this study, which were divided into three areas, of which 12 were recommended at level A and 7 at level B. The details are shown in Table 3.

4. DISCUSSION

Through evidence extraction and integration, the evidence for support surfaces to prevent and manage stressful injuries included three major areas of support surface type selection assessment, support surface use, and team management and quality control, with a total of 19 pieces of evidence, as shown in Table 3.

4.1. Support surface prevention and treatment of pressure ulcer has received attention, and the benefits of some support surfaces remain controversial

The treatment of pressure ulcer is complex, which not only increases patient pain and prolongs hospital stay, but also increases the consumption of medical resources. ²⁰ Therefore, standardised, scientific and effective prevention and treatment are particularly important to reduce the incidence of pressure ulcer. In recent years, the prevention and treatment of pressure ulcer has received attention from health care professionals worldwide, and Emily Haesler ² is one of the most authoritative guidelines currently developed by the European Pressure Ulcer Advisory Panel (EPUAP), the Pressure Injury Advisory Panel of the United States (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA), which is revised every five years, with the first edition published in The 2019 edition adopts the latest methodological theories, summarises and evaluates research evidence using an evidence‐based decision‐making framework, and enriches the evidence description section with more comprehensive and detailed recommendations and evidence discussions. In addition, the guidelines provide implementation considerations for the recommendations, making the new guidelines more scientific, readable, and actionable, and of great importance to clinical practice.

Emily Haesler ² added to the recommendations for the use of support surfaces by adding a new section on special populations to the transport population. Patients are at a higher risk of pressure ulcer because of the prolonged restriction of movement during travel to and from clinical care settings (eg, in an ambulance or waiting in an emergency department). In addition, the incidence of pressure injury for patients with suspected cervical spine injuries who remained on a hardboard in the spine for four hours was 28.3%. ²¹ It is recommended that patients be transferred from the spinal rigid board or posterior board to acute care equipment as soon as possible after consultation with medical staff. Pressure ulcer may also occur in patients during transfer, which has been less studied in China and should be taken seriously by clinical practitioners.

The new guidelines make more specific recommendations for new types of support surfaces, but the strength of evidence and strength of recommendation for this part of the opinion is low and needs to be supported by more high‐quality research. The effectiveness of alternating pressure inflatable mattresses compared with other mattresses for the management of pre‐existing pressure injuries is controversial in current research, and the available evidence on these types of support surfaces is limited and conflicting. Nevertheless, this paper recommends the use of alternating pressure inflatable mattresses in patients at risk of developing pressure‐related injuries and for whom pressure repositioning is not possible versus patients with prolonged chair or wheelchair‐based pre‐existing pressure ulcer, as more quality literature (Emily Haesler, ² Colin D ¹⁶ ) recommends the use of alternating pressure inflatable mattresses and their greater cost‐effectiveness in Adverse events (eg, falls) are uncommon. Therefore, the relative benefits of using alternating pressure inflatable mattresses for individuals at risk of pressure‐related injury need to be evaluated on a case‐by‐case clinical basis.

4.2. Different parts and stages should be selected to correspond to the support surface to facilitate the extension of the turning interval

The different support surfaces are designed to relieve pressure and are used to cushion vulnerable areas of the body and distribute surface pressure more evenly. ¹³ Support surfaces are mainly divided into total body support surfaces and local support surfaces. Domestic and international research on support surfaces has focused on systemic support surfaces, especially mattresses, mainly to relieve pressure in the sacrococcygeal region, the most common site of pressure ulcer. Clinically reported systemic support surfaces in China mainly include foam mattresses, gel foam mattresses, static air mattresses, water mattresses, fluctuating inflatable mattresses, and alternating pressure‐reducing mattresses. Fewer local support surfaces have been reported, mainly including cotton pillow cores, air loops, water loops, sponge pads, gel pads, celiac pads, etc. There are various forms of support surfaces, and there is a lack of high evidence‐based level of evidence guiding the selection of support surfaces by nursing staff, so the blind selection of support surfaces during nursing care may lead to problems such as over‐care or difficulty in controlling the development of pressure injury, which may affect the patient's pressure ulcer control effect. In this study, we categorised different sites and different stages of PI and compiled the recommended evidence for the corresponding support surfaces. Because there are some differences in symptoms, risks, and control measures for pressure ulcer in different stages and sites, it suggests that we should develop care plans for different sites and stages according to PI stages and sites, and select support surfaces of corresponding levels to facilitate patients’ access to targeted care interventions.

Studies have shown that ¹⁰ the support surface can prolong the turning interval without increasing the incidence of pressure ulcer. Turning is an effective method of pressure reduction to help prevent pressure ulcer, but frequent turning in clinical practice tends to increase patient discomfort, interfere with the patient's resting state, and increase nursing workload. Based on this, domestic and international scholars have turned their research focus to the support surface to find a more effective support surface to extend the turning interval for people at risk of pressure ulcer. ²² A study by Luo Qiaofang ¹⁰ showed that a static air mattress has a better pressure sore prevention effect than a conventional pressure‐reducing mattress and has some therapeutic effect on pressure ulcer. ²³ Moreover, the static air mattress has moderate softness and good touch, which can effectively disperse the pressure of the mattress on the body, reduce the friction and shear force generated by the process of body position movement, and can prolong the turning interval of patients. Therefore, this study recommends the use of this support surface to extend the turning interval time, but at present, the specific turning interval time after using the support surface still needs to be decided according to the patient's disease condition and the characteristics of the support surface, and the turning interval time of patients after using a specific model of support surface can be studied in depth in future, and the turning interval time of patients in a specific place (such as ICU) after using the pressure‐reducing mattress can also be studied. ²⁴

4.3. Enhanced assessment and support surface research in heel pressure ulcer to facilitate heel pressure ulcer prevention

Domestic and international literature. ²⁵ It is reported that the heel is the second most prevalent site after the sacrococcygeal region, and its incidence accounts for 9.6% to 33.3% of the total incidence of pressure injuries. If the heel pressure ulcer continues to worsen, it will lead to local tissue necrosis, bone exposure, increased risk of osteomyelitis, and even amputation in severe cases, reducing the quality of life of patients and increasing the consumption of health care resources. ¹⁸ Therefore, this study included heel pressure ulcer as a special site in the prone situation. Colin D, ¹⁶ Emily Haesler, ² and Yang Ting ¹⁸ showed that the ideal way to prevent heel pressure ulcer is to ensure that the heel does not touch the bed to avoid all pressure, that is, to keep the heel in a “floating” position. ²⁶ This means keeping the heel “floating”. For patients with established pressure ulcer and those who are bedridden, heel support devices are recommended, but there are many different types, such as heel suspension boots, long foam pads, and their composition, materials, and performance need to be considered when choosing one. There is insufficient evidence to determine which support surface is most effective in preventing and treating heel pressure ulcer. At the same time, many scholars ²⁷ , ²⁸ are of the opinion that heel pressure ulcer risk assessment should not be limited to existing scale entries, but needs to consider other high‐risk factors, but there is no PI‐specific risk assessment tool for the foot among the widely used pressure ulcer assessment tools at home and abroad, and it is necessary to develop a specific tool for heel pressure ulcer risk assessment in the future.

4.4. Raising nursing staff awareness of support surfaces facilitates the reduction of pressure ulcer incidence

Foreign studies have shown that nurses' knowledge of stress injuries is still lacking. ²⁵ The increase in the prevalence of pressure injuries is related to the lack of awareness of risk factors and inadequate protective measures among nurses. ²⁹ For example, clinical nursing staff often use posture devices instead of support devices. When patients are at risk of pressure ulcer, nursing staff often consciously use air rings, cotton pillows, or R‐shaped turning pillows to turn them, and consider this measure as a preventive measure for pressure ulcer. However, R‐shaped pillows, although they have certain support functions, are essentially postural placement devices, so confusing the two functions is not conducive to the effective prevention of pressure ulcer. ³⁰ The confusion between the two is not conducive to the prevention of pressure ulcer.

Therefore, hospital administrators should pay attention to the promotion of knowledge related to pressure ulcer guidelines and strengthen the study and assessment of updated guidelines by health care personnel. Also introduce current advanced support surfaces and standardise the use of support surfaces. The training of nurses should be emphasised, and centralised education and face‐to‐face lectures can be used to improve the ability to use it, skills and techniques so that the support surface can better play a role in preventing pressure injuries in the clinic. ³¹ Medical and nursing staff should enhance their learning, deepen their understanding of the support surface, and use the pressure ulcer assessment tool for individualised assessment. Combine with the causes of pressure ulcer in our department, early support surface intervention, and adhere to the principle of prevention in the first place. At the same time, we should master new advances in pressure ulcer assessment tools, continuously innovate new techniques and methods in clinical work, and improve the clinical use of brace surfaces. The clinical use of brace surfaces should be improved. Starting from the clinical needs, avoiding harm, continuously strengthening the development and improvement of the support surface, and fully considering the economic acceptability of patients and the principle of nursing staff saving labour to design the support surface with good safety, high comfort and practicality. ³⁰ The support surfaces are designed with good safety, comfort, and practicality in mind.

5. SUMMARY

This study summarises the current best evidence on the use of bracing surfaces in the prevention and management of pressure ulcer, with the aim of providing clinical caregivers with a reference for the selection of appropriate bracing surfaces to prevent and manage the occurrence of pressure ulcer and improve quality of life and reduce health care costs, depending on the site and stage of the pressure ulcer. However, there is a lack of high‐quality experimental studies on support surfaces. In future studies, outcomes should also be carefully selected, and adverse events should be carefully assessed and reported in studies to generate meaningful data. Similarly, patient comfort, quality of life, and cost analysis are important outcomes that are not currently clearly defined or reported. ¹⁴ Finally, with respect to potential bias, it is important that all future studies be designed to the highest possible standard of the randomised control principle. Although avoiding the risk of performance bias in support surface trials is challenging because it is difficult to blind participants and researchers, we need to adequately describe common interventions and ensure that intervention protocols accurately carry out these measures in different trial groups. In addition, the risk of detection bias can also be minimised by using digital photography and by researchers masking the support surfaces in photographs. Finally, it is recommended that the clinical translation process be evaluated in the context of different cultural backgrounds, relevant infrastructure and care settings, and that a comprehensive cost and benefit analysis be conducted to apply the evidence to the clinic and maximise patient benefit.

6. LIMITATIONS

This evidence summary only includes published studies in Chinese and English, and articles in other languages could be included to form a better evidence summary. The search for this study may lack comprehensiveness, and literature with guidelines that are more than twenty years old, pre‐updated guidelines, and consensus were excluded, which may have some bias, and this study did not include special and rare support surfaces. This study included mostly foreign literature, taking into account differences in ethnicity, perceptions, and values, as well as geographical and cultural differences in health care delivery systems. Further consideration of the clinical context is needed during the application of the evidence to develop a localised practice plan. Future clinical reviews will be conducted to assess any barriers to the application of the evidence.

FUNDING INFORMATION

None.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.

Huang L, Yan Y, Huang Y, et al. Summary of best evidence for prevention and control of pressure ulcer on support surfaces. Int Wound J. 2023;20(6):2276‐2285. doi: 10.1111/iwj.14109

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are openly available in [figshare”] at http://doi.org[doi], reference number [reference number].