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Background: Data on the prevention and treatment of pressure ulcers (PU's) among ICU patients is sparse., Objective: To compare PU outcomes in medial ICU patients nursed on either a reactive mattress overlay (ROHO, ROHO Inc, Belleville, IL, USA) or an active alternating pressure mattress (NIMBUS3, ArjoHuntleigh, Luton Bedfordshire, UK)., Design: Pilot prospective single blind randomised controlled clinical trial., Intervention: Two types of pressure redistributing mattress., Patients: Two groups of eight patients., Methods: Patients included in the study were those at high risk (Norton scale <8) or with a PU on admission., Results: The two groups had similar patient characteristics. However, the NIMBUS 3 group presented with more ulcers per patient on admission (62.5%) and more severe ulcers (20% category 3) while four patients (50%) presented with a single superficial ulcer in the ROHO group. HEALING: The progress of the ulcers showed significant decreases in PU surface area (p=0.05), total PUSH tool score (p=0.01) in the NIMBUS 3 group compared to the ROHO group. In the NIMBUS 3 group 82% of the ulcers improved versus none in the ROHO group (p=0.002) and 18% remained stable versus 33%. None of the ulcers deteriorated in the NIMBUS 3 group versus 67% in the ROHO group (p=0.006). Full thickness wounds (Category 3) were present in 22% of the NIMBUS 3 group versus 0% of the ROHO group on admission and in 0% versus 66.7% (p=0.008) respectively at the end of the pilot study., Prevention: Non-blanching erythema occurred equally in both arms at baseline; skin remained intact for the NIMBUS 3 group while 50% in the ROHO group worsened with superficial tissue loss., Conclusion: This small pilot study suggests that 'active' alternating therapy is a useful adjunct in the care of highly vulnerable patients, while the outcomes may be less favourable when using 'reactive', constant low pressure devices., (Copyright 2009 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.)