The provision of therapy mattresses
for pressure ulcer prevention
ABSTRACT
Preventing pressure ulcers is complex and involves skin care, the
provision of therapy mattresses, repositioning, the management
of incontinence and adequate nutritional support. This article
describes a model of therapy mattress provision that is based
on non-powered products. Evaluating the efficiency of this
model is challenging, due to the complexities of care, but Safety
Thermometer data and incidents reports offer reassurance that
non-powered therapy mattresses can provide adequate pressure
ulcer prevention. Therapy mattress provision is only one of the
five interventions and these are described in details to give readers
a fuller picture of the model used at the author’s trust.
Key words: Prevention ■ Complex intervention ■ Non-powered therapy
mattresses ■ Skin care ■ Repositioning ■ Incontinence
P
ressure ulcers are a key quality issue for the NHS.
The published results of the Safety Thermometer
data influences public perception of the quality of
care delivered by each trust. Pressure ulcers represent
a major burden to patients, carers and the healthcare system,
affecting approximately one in ten hospital and one in
twenty community patients (Nixon et al, 2016). They
impact on the physical, social and psychological wellbeing of
patients. In 2004, Bennet et al reported that pressure ulcers
cost an estimated £1.4-2.1 billion annually, equivalent to
4% of NHS expenditure; 4 years later, Riordan and Voegeli
(2009) estimated annual costs to be £2.64 billion. The cost
of treating a pressure ulcer in the UK ranges from £1214 to
£14 108 per year (Dealey et al, 2012).
The selection of therapy beds (or surfaces) is just one
aspect of preventative care, but the necessity to provide an
air-flow mattress for all patients who are at risk of developing
pressure ulcers has been questioned before (Pagnamenta,
2007). Evidence to support the use of such products is
limited (Nguyen et al, 2015) and has been recognised by the
Government, which is supporting the University of Leeds to
research this area. The results of a randomised controlled trial
to compare the effectiveness of high-specification foam and
Fania Pagnamenta, Nurse Consultant (Tissue Viability),
Newcastle upon Tyne Hospitals NHS Foundation Trust, Fania.
Pagnamenta@nuth.nhs.uk
Accepted for publication: January 2017
S28 
alternating pressure mattresses in pressure ulcer prevention
(‘PRESSURE 2’) are expected in 2018 (Nixon et al, 2016).
In the meantime, however, different models of therapy-
bed provision have been used in the UK, arguably with an
over-reliance on powered products, especially alternating
pressure-relieving mattress. These mattresses can be costly
when rented, and when purchased there are cost implications
for decontamination charges and repair. Both models (rental
or purchase) are costly in terms of manpower as nurses have
to place the product on a bedframe, inflate it and transfer the
patient onto the surface. Once the patient no longer requires
the mattress, it has to be deflated, rolled and placed into bags
ready for collection.
This article describes the Newcastle upon Tyne Hospitals
NHS Foundation Trust model for pressure-ulcer prevention
with a unique perspective on therapy-bed provision. This
model excludes bed and mattress provision in critical care.
Therapy-bed provision
The Newcastle upon Tyne Hospitals NHS Foundation
Trust is a large tertiary hospital with 98 wards over two
sites (1750 beds and 100 critical-care beds). Belonging to
the Shelford group of hospitals, it is a regional centre with
multiple specialties.
In 2005, the Trust, led by the tissue viability nurse
consultant, adopted a third model to pressure-ulcer
prevention; the non-powered approach. Over 250 gel
therapy mattresses (RIK Fluid Mattress, ArjoHuntleigh) were
purchased alongside high-quality foam mattresses, with no
change in prevalence. A very small number of low-air-loss
therapy mattresses (TheraKair Visio, ArjoHuntleigh) were
also used, but overall, the Trust was 98.6% non-powered.
This quality improvement programme was described in
Pagnamenta (2007).
The Newcastle approach
Preventing pressure ulcers is complex. Strategies for the
effective prevention of pressure ulcers are often presented
as a bundle of care that includes skin care, the appropriate
selection of surfaces, a strict repositioning regime, the
management of incontinence and finally a requirement to
address any nutritional deficits (Whitlock, 2013).
This model is multifaceted and reflects the complexities
that multiple interventions required for the effective
prevention of pressure ulcers. Each intervention has been
thoroughly detailed so that clinicians from other care
providers may find similarities and possible application of this
model to their setting.
British Journal of Nursing 2017, Vol 26, No 6: TISSUE VIABILITY SUPPLEMENT
Box 1. Plan of care for ‘at risk’ or ‘with existing damage’
■■ Inspect skin an on admission, transfer and discharge and at every positional
change
■■ Daily Braden Scale
■■ Commence ‘FOCUS’ (intentional rounding)
■■ Reposition every 2 hours
■■ Elevate heels while in bed
■■ Provide pressure-relieving cushion when seated
■■ Stand every hour when seated
■■ Minimise time spent in chair to 2–3 hours at a time
■■ Deliver skin care at every positional change
■■ Offer patient and carer a pressure ulcer prevention leaflet
Box 2. Data collection
■■ Safety Thermometer: the worst ulcer is reported as a new ‘harm’ (trust-acquired)
or old ‘harm’ (non-trust acquired) on one finite day of the month (true prevalence
data). Safety Thermometer data are collected on a monthly basis
■■ DATIX is the method by which staff report any category of ulcers. Moisture lesions
are also reported. The report highlights whether these ulcers are trust acquired
or non-trust acquired. These reports are the most accurate and useful to analyse.
The trend since January 2013 is a general reduction
Skin care
Skin care described by Rees and Pagnamenta (2009) offers
a simple message (products listed are part of Trust guidance):
wash all skin with an emollient (Hydromol, Alliance
Pharmaceuticals Ltd), mixed in warm water, use a barrier
spray (Medi Derma-S spray, Medicareplus International Ltd)
for prevention or use a dimethicone-based skin protectant
(Proshield, H&R Healthcare) if the skin is broken.
Therapy mattresses
In 2012, the Trust adopted a zero-tolerance policy to pressure
ulcers. A task force group was established and the first task was
to audit existing stock of non-powered therapy mattresses. It
was established that the RIK mattresses were deteriorating
and it was no longer cost effective to replace them. The Trust
looked for another product that was manufactured in the UK
that would replace the RIK.
In 2012, the Trust purchased 419 Dyna-Form Static Air
mattress replacement systems (Direct Healthcare Services Ltd);
they combine the benefits of air displacement with high-
quality foam. Incorporating air and foam with a valves system
allows the pressures to readjust under the patient’s body weight
and movement. All component parts are interchangeable and
replaceable, maximising product life.
In the Trust, mattress audits had been undertaken yearly
until 2009 when these audits were increased to four times
per year. These audits involve a thorough check of the cover
and the patency of the foam to ensure they remain fit for
purpose. As old foam mattress failed, they were replaced with
Static Air mattresses.
While this mattress provided good pressure ulcer
redistribution, within 2 years, 107 covers needed replacing
(failure rate of 4.6% over 2 years). The rationale for the high
rate of cover failure appeared to be due to the membrane that
covered the foam in the middle of the mattress; under pressure,
for example when using moving and handling equipment to
move patients from bed to trolley, this would balloon and cause
the cover to stretch and tear. After feedback was provided to
S30 
the company, this product was further developed. The updated
design no longer includes the membrane in the middle of the
mattress so the cover is not subjected to additional forces.
In 2014, the Trust purchased 109 Dyna-Form Static Air HZ
(Direct Healthcare Services Ltd). The following year, a further
161 were purchased and in 2016, 149. The failure rate of the
cover dropped significantly, only 6 covers were replaced; a
failure rate of 1.4%, which had been previously deemed to be
an acceptable failure rate (Pagnamenta, 2013).
At the time of writing, the Trust holds 492 Dyna-Foam
Static Airs, 419 Dynafoam StaticAirs HZ, an estimated
40 remaining RIKs and approximately 800 high-quality foam
mattresses. These are permanently placed on the wards. With
intentional rounding, patients are asked ‘How comfortable
are you on this therapy mattress?’ and their answer forms part
of the decision as to which non-powered product is selected.
The tissue viability team in the Trust believes that the main
role of therapy mattresses is to provide comfort to patients
and to ensure rest and sleep is obtained while in the Trust’s
care. The objective is to allow patients more energy for self-
repositioning and/or to assist health professionals with their
programme of repositioning (Pagnamenta, 2009).
The Trust continues to hold between 20 and 25 low-
air-loss mattresses for patients who require a higher product
specification, namely burns patients, plastic surgery patients
and very thin, cachexic patients. At times, the non-powered
products may not provide sufficient comfort. These low-
air-loss mattresses are held in the equipment library and are
accessed through the tissue viability service via an online
request system. The 98.5% non-powered approach described
in Pagnamenta (2007) has been sustained over the last 10 years.
Repositioning
Risk assessment is undertaken using the Braden Scale
for Predicting Pressure Ulcer Risk. Braden is a pressure
ulcer scoring tool that aids clinicians with pressure ulcer
prevention (Pancorbo-Hidalgo et al, 2006). The risk is
assessed on admission and then daily for all patients at risk
(Braden <17). The plan of care that is expected for patients
who are at risk is detailed in Box 2.
Management of incontinence
Flat underpads have been removed from all clinical areas as
in the Trust. Clinical experience suggests that these products
may contribute to the development of pressure damage. The
recommendation to only use body-worn absorbent pads
with a pant system after a thorough continence assessment
has also been part of the programme. Bowel management
systems have also been introduced, first within critical care
and, with support, in other clinical areas, described in Rees
and Sharpe (2009).
Nutrition
All patients are screened using the Malunitrition Universal
Screening Tool (MUST) (Neelemaat et al, 2011) and referred
to dietetics if appropriate. Furthermore, all patients with
existing deep pressure ulcers are also referred. Currently,
there is not the resource in the tissue viability department
to provide dietetic input to patients at risk of developing
British Journal of Nursing 2017, Vol 26, No 6: TISSUE VIABILITY SUPPLEMENT
 140
pressure ulcers who do not score on the MUST or who have
developed superficial skin damage.
120
Monitoring
100 The prevalence of pressure ulcers is measured using two data
collection tools: Safety Thermometer (Power et al, 2012) and
80 through DATIX Software (See Box 2).
Reporting pressure ulcers varies in each establishment
60 (Tissue Viability Society, 2013). In order to provide a full
picture of the Trust’s model, it specifies that:
40 ■■ Pressure ulcers are hospital acquired if they are present on
admission. In line with currently recommendations (Tissue
20 Viability Society, 2012), the 72 hour rule is not used
■■ Pressure damage caused by medical devices is reported but
0
not included in the pressure ulcer data
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Jan 13

■■ Moisture lesions are included in the data, as the author’s

Trust views these equally as harm that should be prevented
Figure 1. Trust-acquired category, 2, 3 and 4 (Jan 2013–January 2017) ■■ All patients who have developed hospital-acquired
pressure ulcers or moisture lesions are reviewed by the
400 tissue viability team
■■ It is the Trust’s view that all pressure ulcers are avoidable as it
350 is recognised that the delivery of ‘perfect’ care is not always
300
achievable in a dynamic care environment and therefore
some gaps in care are likely to occur.
250 Figure 1 reports categories 1, 2 and 3 pressure ulcers and
moisture lesions since January 2013, the data demonstrates a
200
slow reduction in pressure ulcers and moisture lesions. Figure 2
150
demonstrates that the number of DATIX submitted has
increased during the same period by 38.5%.The Trust’s position
100 in the Safety Thermometer data compares favourably to the
national average (Figure 3; NHS, 2013).
50

0
Discussion and conclusion
The Newcastle upon Tyne Hospitals NHS Foundation
Jan 13

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Jan 15

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Trust has adopted a non-powered model for pressure ulcer

Trust acquired Non-Trust acquired Totals prevention, which has been embedded in practice for the last
10 years. Analysis of the data tells a story of a slow reduction
Figure 2. Incident reporting: trust- and non-trust acquired (category 2, 3, 4) in trust-acquired pressure ulcers and moisture lesions, but also
of a substantial increase in reporting, which makes it difficult
120
to measure the efficacy of this approach. Nevertheless, the data
NHS Pressure ulcer prevalence Value
Upper level
offer reassurance that this approach is efficient in delivering
100 Lower level
quality care. Pressure ulcers and moisture lesions remain a
priority and the Trust is determined to reduce this further by
embedding the guidance in everyday practice.
80
Preventing pressure ulcers is complex and requires a number
of interventions.The two most important aspects are ensuring
Harm per 1000

60 a repositioning regime is in place and a consistent approach

to skin care. Repositioning patients every hour (if in a chair)
or 2-hourly (if in bed) is time consuming and necessitates
40
leadership, team work and coordination of care. Furthermore, it
necessitates manpower and the Trust is not alone in describing
20 nursing staff shortages. Powered mattresses do not replace
manpower and it is the Trust’s experience that using non-
powered mattress has saved the Trust money in terms of rental
0 costs or decontamination costs, as well as staffing time as non-
0 1000 2000 3000 4000 5000 6000 7000
powered mattresses are ready for use.This article has described
Number of patients the Trust’s model of care for pressure ulcer prevention and each
Figure 3. NHS ‘Classic’ Safety Thermometer: red dot is Newcastle (correct at time key intervention, offering as much detail as possible.This model
of publication) of care may be applicable to many other acute trusts.  BJN

S32  British Journal of Nursing 2017, Vol 26, No 6: TISSUE VIABILITY SUPPLEMENT
 PRESSURE ULCERS

Figure 3 reproduced with kind permission from the Safety

Thermometer Support Team KEY POINTS
■■ Prevention of pressure ulcers is complex
Declaration of interest: none ■■ Evaluating efficacy of any interventions is challenging
■■ The Newcastle model of therapy mattress provision is based on non-
Author’s note: the therapy mattresses mentioned in this article are powered therapy mattresses
currently used in the Trust: similar products may be used instead.
■■ Skin care and repositioning are the two main interventions in the
The skin products mentioned in this article are currently listed on
prevention of pressure ulcers
the Trust Formulary; similar products may be used instead.
Pagnamenta F (2007) Is fluid filled mattress technology compatible with NICE
Bennett G, Dealey C, Posnett J (2004) The cost of pressure ulcers in the UK. Age guidance? Br J Community Nurs 12(12): S35-S8
and Ageing 33(3): 230-5. doi: https://dx.doi.org/10.1093/ageing/afh086 Pagnamenta F (2009) Patient satisfaction and comfort assessed. Clinical Services
Dealey C, Posnett J, Walker A (2012) The cost of pressure ulcers in the Journal 8: 49-52
United Kingdom. Journal of Wound Care 21(6): 261–6. doi: https://dx.doi. Pagnamenta F (2013) Foam mattresses: improving protection. The Clinical Services
org/10.12968/jowc.2012.21.6.261 Journal 4: 21-24
Neelemaat F, Meijers J, Kruizenga H, van Ballegooijen H, van Bokhorstde van Power M, Stewart K, Brotherton A (2012) What is the NHS
der Schueren M (2011) Comparison of five malnutrition screening tools in Safety Thermometer? Clin Risk 18(5): 163-9. https://dx.doi.
one hospital inpatient sample. J Clin Nurs 20(15-16): 2144-52. doi: https:// org/10.1258%2Fcr.2012.012038 (accessed 22 February 2017)
dx.doi.org/10.1111/j.1365-2702.2010.03667.x Rees J, Pagnamenta F (2009) Best practice guidelines for the prevention and
Nguyen KH, Chaboyer W, Whitty JA (2015) Pressure injury in Australian public management of incontinence dermatitis. Nurs Times 105(36): 24-6
hospitals: a cost-of-illness study. Aust Health Rev 39(3): 329–3. doi: https:// Rees J, Sharpe A (2009) The use of bowel management systems in the high-
dx.doi.org/10.1071/AH14088 dependency setting Br Journal Nurs 18(7): S19-S24. doi: http://dx.doi.
NHS (2013) NHS Safety Thermometer. It’s not just counting ... It’s caring. org/10.12968/bjon.2009.18.Sup3.41665
http://tinyurl.com/zf9ef35 (accessed 9 March 2017) Riordan J,Voegeli D (2009) Prevention and treatment of pressure ulcers. Br J
Nixon J (2016) PRESSURE 2. University of Leeds, Leeds. http://tinyurl.com/ Nursing 18(20 Suppl): 20-7. doi: http://dx.doi.org/10.12968/bjon.2015.24.
hxznxvu (accessed 16 February 2017) Sup6.S30
Pancorbo-Hidalgo PL, Garcia-Fernandez FP; Lopez-Medina IM, Alvarez-Nieto Tissue Viability Society (2012) Achieving Consensus in Pressure Ulcer Reporting.
C (2006) Risk assessment scales for pressure ulcer prevention: a systematic http://tinyurl.com/qye4csl (accessed 16 February 2017)
review. J Adv Nurs 54(1): 94–110. doi: https://dx.doi.org/10.1111/j.1365- Whitlock J (2013) SSKIN bundle: preventing pressure damage across the health-
2648.2006.03794.x care community, Br J Community Nurs 18(9 Suppl): S32-9

CPD reflective questions

■■ What sets of intervention do you use in your clinical setting to prevent pressure ulcers?
■■ Reflect on the role of the nurse in preventing pressure ulcers and that of the other members of the multidisciplinary
team: how do you maximise efficiency when planning turning regimes for your patients?
■■ Does your trust have a skin guidance and if so, does it differ from the one in this article?

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