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Background Pressure ulcers (also known as pressure injuries, pressure sores, decubitus ulcers and bed sores) are localised injuries to the skin or underlying soft tissue, or both, caused by unrelieved pressure, shear or friction. Beds, overlays or mattresses are widely used with the aim of treating pressure ulcers. Objectives To assess the effects of beds, overlays and mattresses on pressure ulcer healing in people with pressure ulcers of any stage, in any setting. Search methods In November 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In‐Process & Other Non‐Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta‐analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. Selection criteria We included randomised controlled trials that allocated participants of any age to pressure‐redistributing beds, overlays or mattresses. Comparators were any beds, overlays or mattresses that were applied for treating pressure ulcers. Data collection and analysis At least two review authors independently assessed studies using predetermined inclusion criteria. We carried out data extraction, 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool, and the certainty of the evidence assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology. Main results We included 13 studies (972 participants) in the review. Most studies were small (median study sample size: 72 participants). The average age of participants ranged from 64.0 to 86.5 years (median: 82.7 years) and all studies recruited people with existing pressure ulcers (the baseline ulcer area size ranging from 4.2 to 18.6 cm2,median 6.6 cm2). Participants were recruited from acute care settings (six studies) and community and long‐term care settings (seven studies). Of the 13 studies, three (224 participants) involved surfaces that were not well described and therefore could not be classified. Additionally, six (46.2%) of the 13 studies presented findings which were considered at high overall risk of bias. We synthesised data for four comparisons in the review: alternating pressure (active) air surfaces versus foam surfaces; reactive air surfaces versus foam surfaces; reactive water surfaces versus foam surfaces, and a comparison between two types of alternating pressure (active) air surfaces. We summarise key findings for these four comparisons below. (1) Alternating pressure (active) air surfaces versus foam surfaces: we are uncertain if there is a difference between alternating pressure (active) air surfaces and foam surfaces in the proportion of participants whose pressure ulcers completely healed (two studies with 132 participants; the reported risk ratio (RR) in one study was 0.97, 95% confidence interval (CI) 0.26 to 3.58). There is also uncertainty for the outcomes of patient comfort (one study with 83 participants) and adverse events (one study with 49 participants). These outcomes have very low‐certainty evidence. Included studies did not report time to complete ulcer healing, health‐related quality of life, or cost effectiveness. (2) Reactive air surfaces versus foam surfaces: it is uncertain if there is a difference in the proportion of participants with completely healed pressure ulcers between reactive air surfaces and foam surfaces (RR 1.32, 95% CI 0.96 to 1.80; I2 = 0%; 2 studies, 156 participants; low‐certainty evidence). When time to complete pressure ulcer healing is considered using a hazard ratio, data from one small study (84 participants) suggests a greater hazard for complete ulcer healing on reactive air surfaces (hazard ratio 2.66, 95% CI 1.34 to 5.17; low‐certainty evidence). These results are sensitive to the choice of outcome measure so should be interpreted as uncertain. We are also uncertain whether there is any difference between these surfaces in patient comfort responses (1 study, 72 participants; very low‐certainty evidence) and in adverse events (2 studies, 156 participants; low‐certainty evidence). There is low‐certainty evidence that reactive air surfaces may cost an extra 26 US dollars for every ulcer‐free day in the first year of use (1 study, 87 participants). Included studies did not report health‐related quality of life. (3) Reactive water surfaces versus foam surfaces: it is uncertain if there is a difference between reactive water surfaces and foam surfaces in the proportion of participants with healed pressure ulcers (RR 1.07, 95% CI 0.70 to 1.63; 1 study, 101 participants) and in adverse events (1 study, 120 participants). All these have very low‐certainty evidence. Included studies did not report time to complete ulcer healing, patient comfort, health‐related quality of life, or cost effectiveness. (4) Comparison between two types of alternating pressure (active) air surfaces: it is uncertain if there is a difference between Nimbus and Pegasus alternating pressure (active) air surfaces in the proportion of participants with healed pressure ulcers, in patient comfort responses and in adverse events: each of these outcomes had four studies (256 participants) but very low‐certainty evidence. Included studies did not report time to complete ulcer healing, health‐related quality of life, or cost effectiveness. Authors' conclusions We are uncertain about the relative effects of most different pressure‐redistributing surfaces for pressure ulcer healing (types directly compared are alternating pressure air surfaces versus foam surfaces, reactive air surfaces versus foam surfaces, reactive water surfaces versus foam surfaces, and Nimbus versus Pegasus alternating pressure (active) air surfaces). There is also uncertainty regarding the effects of these different surfaces on the outcomes of comfort and adverse events. However, people using reactive air surfaces may be more likely to have pressure ulcers completely healed than those using foam surfaces over 37.5 days' follow‐up, and reactive air surfaces may cost more for each ulcer‐free day than foam surfaces. Future research in this area could consider the evaluation of alternating pressure air surfaces versus foam surfaces as a high priority. Time‐to‐event outcomes, careful assessment of adverse events and trial‐level cost‐effectiveness evaluation should be considered in future studies. Further review using network meta‐analysis will add to the findings reported here., Plain language summary What are the benefits and risks of different types of beds, mattresses and mattress toppers for treating pressure ulcers? Key messages Due to a lack of robust evidence, the benefits and risks of most types of beds, mattresses and mattress toppers for treating pressure ulcers are unclear. Beds with an air‐filled surface that apply constant pressure to the skin may be better than mattresses and toppers made of foam for ulcer healing if the evidence on the time needed to completely heal an ulcer is looked at, but may cost more. Future research in this area should focus on options and effects that are important to decision‐makers, such as: ‐ foam or air‐filled surfaces that redistribute pressure under the body; and ‐ unwanted effects and costs. What are pressure ulcers? Pressure ulcers are also known as pressure sores or bed sores. They are wounds to the skin and underlying tissue caused by prolonged pressure or rubbing. They often occur on bony parts of the body, such as heels, elbows, hips and the bottom of the spine. People who have mobility problems or who lie in bed for long periods are at risk of developing pressure ulcers. What did we want to find out? There are beds, mattresses and mattress toppers specifically designed for people with pressure ulcers. These can be made from a range of materials (such as foam, air cells or water bags) and are divided into two groups: ‐ reactive (static) surfaces that apply a constant pressure to the skin, unless a person moves or is repositioned; and ‐ active (alternating pressure) surfaces that regularly redistribute the pressure under the body. We wanted to find out if reactive and active surfaces: ‐ help ulcers to heal; ‐ are comfortable and improve people’s quality of life; ‐ have health benefits that outweigh their costs; and ‐ have any unwanted effects. What did we do? We searched the medical literature for studies that evaluated the effects of beds, mattresses and mattress toppers. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 13 studies (972 people, average age: 83 years) that lasted between seven days and 18 months (average: 37.5 days). In general, the studies did not provide sufficiently robust evidence for us to determine the effects of active and reactive surfaces. Evidence from two studies suggests that, when compared with mattresses and mattress toppers made of foam, beds with a reactive air‐filled surface may: ‐ improve chances of pressure ulcers healing if the data on the time needed to completely heal an ulcer is looked at (1 study, 84 people); ‐ cost an extra 26 US dollars per person for every ulcer‐free day in the first year of use (1 study, 87 people). The other benefits and risks of these and other surfaces are unclear. What limited our confidence in the evidence? Most studies were small (72 people on average) and nearly half of them (six studies) used methods likely to introduce errors in their results. How up‐to‐date is this review? The evidence in this Cochrane Review is current to November 2019.

Background Pressure ulcers (also known as pressure injuries, pressure sores, decubitus ulcers and bed sores) are localised injuries to the skin or underlying soft tissue, or both, caused by unrelieved pressure, shear or friction. Alternating pressure (active) air surfaces are widely used with the aim of preventing pressure ulcers. Objectives To assess the effects of alternating pressure (active) air surfaces (beds, mattresses or overlays) compared with any support surface on the incidence of pressure ulcers in any population in any setting. Search methods In November 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In‐Process & Other Non‐Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta‐analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. Selection criteria We included randomised controlled trials that allocated participants of any age to alternating pressure (active) air beds, overlays or mattresses. Comparators were any beds, overlays or mattresses. Data collection and analysis At least two review authors independently assessed studies using predetermined inclusion criteria. We carried out data extraction, 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool, and the certainty of the evidence assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology. Main results We included 32 studies (9058 participants) in the review. Most studies were small (median study sample size: 83 participants). The average age of participants ranged from 37.2 to 87.0 years (median: 69.1 years). Participants were largely from acute care settings (including accident and emergency departments). We synthesised data for six comparisons in the review: alternating pressure (active) air surfaces versus: foam surfaces, reactive air surfaces, reactive water surfaces, reactive fibre surfaces, reactive gel surfaces used in the operating room followed by foam surfaces used on the ward bed, and another type of alternating pressure air surface. Of the 32 included studies, 25 (78.1%) presented findings which were considered at high overall risk of bias. Primary outcome: pressure ulcer incidence Alternating pressure (active) air surfaces may reduce the proportion of participants developing a new pressure ulcer compared with foam surfaces (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.34 to 1.17; I2 = 63%; 4 studies, 2247 participants; low‐certainty evidence). Alternating pressure (active) air surfaces applied on both operating tables and hospital beds may reduce the proportion of people developing a new pressure ulcer compared with reactive gel surfaces used on operating tables followed by foam surfaces applied on hospital beds (RR 0.22, 95% CI 0.06 to 0.76; I2 = 0%; 2 studies, 415 participants; low‐certainty evidence). It is uncertain whether there is a difference in the proportion of people developing new pressure ulcers between alternating pressure (active) air surfaces and the following surfaces, as all these comparisons have very low‐certainty evidence: (1) reactive water surfaces; (2) reactive fibre surfaces; and (3) reactive air surfaces. The comparisons between different types of alternating pressure air surfaces are presented narratively. Overall, all comparisons suggest little to no difference between these surfaces in pressure ulcer incidence (7 studies, 2833 participants; low‐certainty evidence). Included studies have data on time to pressure ulcer incidence for three comparisons. When time to pressure ulcer development is considered using a hazard ratio (HR), it is uncertain whether there is a difference in the risk of developing new pressure ulcers, over 90 days' follow‐up, between alternating pressure (active) air surfaces and foam surfaces (HR 0.41, 95% CI 0.10 to 1.64; I2 = 86%; 2 studies, 2105 participants; very low‐certainty evidence). For the comparison with reactive air surfaces, there is low‐certainty evidence that people treated with alternating pressure (active) air surfaces may have a higher risk of developing an incident pressure ulcer than those treated with reactive air surfaces over 14 days' follow‐up (HR 2.25, 95% CI 1.05 to 4.83; 1 study, 308 participants). Neither of the two studies with time to ulcer incidence data suggested a difference in the risk of developing an incident pressure ulcer over 60 days' follow‐up between different types of alternating pressure air surfaces. Secondary outcomes The included studies have data on (1) support‐surface‐associated patient comfort for comparisons involving foam surfaces, reactive air surfaces, reactive fibre surfaces and alternating pressure (active) air surfaces; (2) adverse events for comparisons involving foam surfaces, reactive gel surfaces and alternating pressure (active) air surfaces; and (3) health‐related quality of life outcomes for the comparison involving foam surfaces. However, all these outcomes and comparisons have low or very low‐certainty evidence and it is uncertain whether there are any differences in these outcomes. Included studies have data on cost effectiveness for two comparisons. Moderate‐certainty evidence suggests that alternating pressure (active) air surfaces are probably more cost‐effective than foam surfaces (1 study, 2029 participants) and that alternating pressure (active) air mattresses are probably more cost‐effective than overlay versions of this technology for people in acute care settings (1 study, 1971 participants). Authors' conclusions Current evidence is uncertain about the difference in pressure ulcer incidence between using alternating pressure (active) air surfaces and other surfaces (reactive water surfaces, reactive fibre surfaces and reactive air surfaces). Alternating pressure (active) air surfaces may reduce pressure ulcer risk compared with foam surfaces and reactive gel surfaces used on operating tables followed by foam surfaces applied on hospital beds. People using alternating pressure (active) air surfaces may be more likely to develop new pressure ulcers over 14 days' follow‐up than those treated with reactive air surfaces in the nursing home setting; but as the result is sensitive to the choice of outcome measure it should be interpreted cautiously. Alternating pressure (active) air surfaces are probably more cost‐effective than reactive foam surfaces in preventing new pressure ulcers. Future studies should include time‐to‐event outcomes and assessment of adverse events and trial‐level cost‐effectiveness. Further review using network meta‐analysis will add to the findings reported here., Plain language summary Do beds, mattresses and mattress toppers with air‐filled surfaces that regularly redistribute pressure under the body prevent pressure ulcers? Key messages Beds, mattresses and mattress toppers that regularly redistribute pressure under the body may reduce the chance of pressure ulcers developing when compared with surfaces that: ‐ apply a constant pressure to the skin; and ‐ are made of foam or gel. However, they may increase the risk of pressure ulcers developing among nursing home residents when compared with air surfaces that apply constant pressure. More research is needed to strengthen the evidence that compares air‐filled and other surfaces. Future studies should focus on effects that are important to decision‐makers, including: ‐ whether and when pressure ulcers develop; ‐ unwanted effects; and ‐ costs. What are pressure ulcers? Pressure ulcers are also known as pressure sores or bed sores. They are wounds to the skin and underlying tissue caused by prolonged pressure or rubbing. They often occur on bony parts of the body, such as heels, elbows, hips and the bottom of the spine. People who have mobility problems or who lie in bed for long periods are at risk of developing pressure ulcers. What did we want to find out? There are beds, mattresses and mattress toppers specifically designed for people at risk of pressure ulcers. These can be made of a range of materials (such as foam, air cells or water bags) and are divided into two groups: ‐ reactive (static) surfaces that apply a constant pressure to the skin, unless a person moves or is repositioned; and ‐ active (alternating pressure) surfaces that regularly redistribute the pressure under the body. We wanted to find out if active, air‐filled surfaces: ‐ prevent pressure ulcers; ‐ are comfortable and improve people’s quality of life; ‐ have health benefits that outweigh their costs (cost‐effectiveness); and ‐ have any unwanted effects. What did we do? We searched the medical literature for studies that evaluated the effects of beds, mattresses and mattress toppers with an active, air‐filled surface. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 32 studies (9058 people, average age: 69 years) that lasted between three and 180 days (average: 14 days). The studies compared active, air‐filled surfaces with: ‐ foam, fibre, water‐filled or gel surfaces; and ‐ other air‐filled surfaces. Pressure ulcer prevention The evidence suggests that active, air‐filled surfaces may reduce the risk of pressure ulcers developing when compared with: ‐ foam surfaces; ‐ gel surfaces used on operating tables followed by foam surfaces used on hospitals beds, for people who undergo surgery. However, active, air‐filled surfaces may increase the risk of pressure ulcers developing when compared with reactive air surfaces (1 study, 308 nursing home residents, duration: 14 days). It is unclear if active air‐filled surfaces prevent pressure ulcers compared with surfaces other than reactive foam, gel or air‐filled surfaces. The type of active, air‐filled surface used may make little to no difference for preventing pressure ulcers. Other effects Active, air‐filled surfaces are probably more cost‐effective than foam. Mattresses with an active, air‐filled surface are probably more cost‐effective than mattress toppers with the same surface. We did not find sufficiently robust and clear evidence to determine how active, air‐filled surfaces affect comfort, quality of life and unwanted effects. What limited our confidence in the evidence? Most studies were small (83 people on average) and more than two‐thirds of them (25) used methods likely to introduce errors in their results. How up‐to‐date is this review? The evidence in this Cochrane Review is current to November 2019.

Background The Quality in Acute Stroke Care (QASC) trial evaluated systematic implementation of clinical treatment protocols to manage fever, sugar, and swallow (FeSS protocols) in acute stroke care. This cluster-randomised controlled trial was conducted in 19 stroke units in Australia. Aim To describe perceived barriers and enablers preimplementation to the introduction of the FeSS protocols and, postimplementation, to determine which of these barriers eventuated as actual barriers. Methods Preimplementation: Workshops were held at the intervention stroke units (n = 10). The first workshop involved senior clinicians who identified perceived barriers and enablers to implementation of the protocols, the second workshop involved bedside clinicians. Postimplementation, an online survey with stroke champions from intervention sites was conducted. Results A total of 111 clinicians attended the preimplementation workshops, identifying 22 barriers covering four main themes: (a) need for new policies, (b) limited workforce (capacity), (c) lack of equipment, and (d) education and logistics of training staff. Preimplementation enablers identified were: support by clinical champions, medical staff, nursing management and allied health staff; easy adaptation of current protocols, care-plans, and local policies; and presence of specialist stroke unit staff. Postimplementation, only five of the 22 barriers identified preimplementation were reported as actual barriers to adoption of the FeSS protocols, namely, no previous use of insulin infusions; hyperglycaemic protocols could not be commenced without written orders; medical staff reluctance to use the ASSIST swallowing screening tool; poor level of engagement of medical staff; and doctors' unawareness of the trial. Linking Evidence to Action The process of identifying barriers and enablers preimplementation allowed staff to take ownership and to address barriers and plan for change. As only five of the 22 barriers identified preimplementation were reported to be actual barriers at completion of the trial, this suggests that barriers are often overcome whilst some are only ever perceived rather than actual barriers.

Background and Purpose— Implementation of nurse-initiated protocols to manage fever, hyperglycemia, and swallowing dysfunction decreased death and disability 90 days poststroke in the QASC trial (Quality in Acute Stroke Care) conducted in 19 Australian acute stroke units (2005–2010). We now examine long-term all-cause mortality. Methods— Mortality was ascertained using Australia’s National Death Index. Cox proportional hazards regression compared time to death adjusting for correlation within stroke units using the cluster sandwich (Huber–White estimator) method. Primary analyses included treatment group only unadjusted for covariates. Secondary analysis adjusted for age, sex, marital status, education, and stroke severity using multiple imputation for missing covariates. Results— One thousand and seventy-six participants (intervention n=600; control n=476) were followed for a median of 4.1 years (minimum 0.3 to maximum 70 months), of whom 264 (24.5%) had died. Baseline demographic and clinical characteristics were generally well balanced by group. The QASC intervention group had improved long-term survival (>20%), but this was only statistically significant in adjusted analyses (unadjusted hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.58–1.07; P =0.13; adjusted HR, 0.77; 95% CI, 0.59–0.99; P =0.045). Older age (75–84 years; HR, 4.9; 95% CI, 2.8–8.7; P P P =0.042) was associated with increased likelihood of survival. Cardiovascular disease (including stroke) was listed either as the primary or secondary cause of death in 80% (211/264) of all deaths. Conclusions— Our results demonstrate the potential long-term and sustained benefit of nurse-initiated multidisciplinary protocols for management of fever, hyperglycemia, and swallowing dysfunction. These protocols should be a routine part of acute stroke care. Clinical Trial Registration— URL: http://www.anzctr.org.au . Unique identifier: ACTRN12608000563369.

Introduction Hand hygiene best practice compliance rates are low in acute care settings despite investment in strategies in the acute care setting to improve hand hygiene practice. Knowledge of local influences such as health professionals' views on current strategies and influential factors is required to develop effective and sustainable interventions. Methods A single-centre cross-sectional survey was conducted to identify the views of 300 randomly sampled acute care health professionals from a tertiary referral teaching hospital, on the factors that they believe influence hand hygiene practice, and their views on strategies to improve compliance. Data were collected using a 19-question self-administered questionnaire and were analysed using descriptive statistics and chi-square tests to analyse differences between the clinical disciplines. Results The sample response rate was 39% (n = 118). Doctors were significantly less likely to report receiving hand hygiene education (p < 0.01) or familiarity with the five moments for hand hygiene (p < 0.01). Overall, respondents regarded organisational strategies more favourably than clinician or patient-focused strategies. Medical staff were less likely to agree with clinical area hand hygiene performance feedback (p = 0.03) while nursing staff were more likely to be agreeable to regular hand hygiene assessment (p = 0.02). Conclusion Hand hygiene education may require targeting of particular groups of health professionals to ensure that all clinical disciplines receive hand hygiene education. Hand hygiene strategies should be based on local needs and take into account contextual factors.

Objectives To undertake a systematic review of the effectiveness of pressure redistributing support surfaces in the prevention of pressure ulcers. Design Systematic review and meta-analysis. Data sources Cochrane Wound Group Specialised Register, The Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid EMBASE and EBSCO CINAHL. The reference sections of included trials were searched for further trials. Review methods Randomised controlled trials and quasi-randomised trials, published or unpublished, which assessed the effects of support surfaces in preventing pressure ulcers (of any grade), in any patient group, in any setting compared to any other support surface, were sought. Two reviewers extracted and summarised details of eligible trials using a standardised form and assessed the methodological quality of each trial using the Cochrane risk of bias tool. Results Fifty-three eligible trials were identified with a total of 16,285 study participants. Overall the risk of bias in the included trials was high. Pooled analysis showed that: (i) foam alternatives to the standard hospital foam mattress reduce the incidence of pressure ulcers in people at risk (RR 0.40, 95% CI 0.21–0.74) and Australian standard medical sheepskins prevent pressure ulcers compared to standard care (RR 0.48, 95% CI 0.31–0.74). Pressure-redistributing overlays on the operating table compared to standard care reduce postoperative pressure ulcer incidence (RR 0.53, 95% CI 0.33–0.85). Conclusions While there is good evidence that higher specification foam mattresses, sheepskins, and that some overlays in the operative setting are effective in preventing pressure ulcers, there is insufficient evidence to draw conclusions on the value of seat cushions, limb protectors and various constant low pressure devices. The relative merits of higher-tech constant low pressure and alternating pressure for prevention are unclear. More robust trials are required to address these research gaps.

This study investigated patients’ 90-day outcomes poststroke following an admission to one Australian metropolitan Acute Stroke Unit (ASU) and examined premorbid risk factors associated with these outcomes. Data from patients consecutively admitted from January 2006 to July 2007 (n = 54) to an acute stroke unit within 48 hours of onset of symptoms were linked with the Quality in Acute Stroke Care research project data and were analyzed to identify associations between premorbid risk factors (atrial fibrillation, hypertension, high cholesterol, smoking and diabetes); demographic, clinical and stroke characteristics; and death, disability (modified Rankin Score ≥ 2), dependency (Barthel Index score ≥ 95) and health status (SF-36) poststroke. Within 90 days, 4 participants had died and 45.5% were classified as dependent. Of the total participants, 56.8% were classified as disabled. The SF-36 mean scores indicated that the cohort had less than optimal physical health (46.7, SD = 9.8) and mental health (46.4, SD = 13.1). Analysis of baseline variables showed that participants with atrial fibrillation were more likely to have a severe stroke (p = 0.037). Patients presenting with intracerebral haemorrhage (p = 0.017) and those with subsequent strokes (p = 0.000) had significantly lower Barthel Index scores. A lower SF-36 physical component score at 90 days was significantly associated with intracerebral haemorrhages (p = 0.018) and subsequent strokes (p = 0.026). Although most patients were alive at 90 days poststroke, there were variable levels of morbidity-associated stroke type, subsequent strokes and premorbid risk factors, particularly atrial fibrillation. The findings provide insight into the 90-day outcomes of patients discharged from an ASU, which may be of use to plan appropriate postdischarge support for this group. In particular, aggressive management of stroke risk factors to prevent recurrent stroke is warranted.

Objectives To examine the effects on healing of pressure relieving support surfaces in the treatment of pressure injury. Design Systematic review. Data sources Cochrane Wound Group Specialised Register, The Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid EMBASE and EBSCO CINAHL. The reference sections of included trials were searched for further trials. Review methods Randomised controlled trials, published or unpublished, assessing the effect of support surfaces in treating all pressure injuries were sought. All included studies had to have reported objective measures of pressure injury healing. Where possible, findings from individual trials were calculated using risk ratio estimates or mean difference with 95% confidence intervals. Results Eighteen eligible trials involving 1309 participants were identified. There was no statistically significant effect on pressure injury size with low air loss devices compared with foam alternatives. One small trial at high risk of bias found that sheepskin positioned under the legs significantly reduced redness and a very small subgroup analysis favoured a profiling bed when compared with a standard bed in terms of the healing of grade 1 pressure injuries. Conclusions Overall, there was an absence of good evidence to support the superiority of any pressure relieving device in the treatment of pressure injuries. This review highlights that the current evidence base requires improving by undertaking robust trials to ascertain which support surfaces are most effective for the treatment of pressure injuries.

Background Clinical networks have been established to improve patient outcomes and processes of care by implementing a range of innovations and undertaking projects based on the needs of local health services. Given the significant investment in clinical networks internationally, it is important to assess their effectiveness and sustainability. This qualitative study investigated the views of stakeholders on the factors they thought were influential in terms of overall network success. Method Ten participants were interviewed using face-to-face, audio-recorded semi-structured interviews about critical factors for networks’ successes over the study period 2006–2008. Respondents were purposively selected from two stakeholder groups: i) chairs of networks during the study period of 2006–2008 from high- moderate- and low-impact networks (as previously determined by an independent review panel) and ii) experts in the clinical field of the network who had a connection to the network but who were not network members. Participants were blind to the performance of the network they were interviewed about. Transcribed data were coded and analysed to generate themes relating to the study aims. Results Themes relating to influential factors critical to network success were: network model principles; leadership; formal organisational structures and processes; nature of network projects; external relationships; profile and credibility of the network. Conclusions This study provides clinical networks with guidance on essential factors for maximising optimal network outcomes and that may assist networks to move from being a ’low-impact’ to ‘high-impact’ network. Important ingredients for successful clinical networks were visionary and strategic leadership with strong links to external stakeholders; and having formal infrastructure and processes to enable the development and management of work plans aligned with health priorities.