Guest Editorial: The NPUAP Support Surface Standards Initiative

    Support surfaces are widely accepted as some of the most important tools used to help prevent the development of pressure ulcers and to help heal existing ulcers. Yet, deciding which support surface- which mattress, bed, overlay or cushion - to rent or buy is a challenge because information comparing merits of these products is difficult to find.

    Manufacturers use a variety of methods to test basic performance characteristics of their beds, mattresses, overlays, and cushions, and often use different terminology to describe features and performances. As a result, clinicians do not have enough clear information from which to make an informed decision about the most appropriate surface. To this day, calls to standardize support surface information have largely been ignored and efforts to advance the scientific body of knowledge in this area have been slow to emerge.^1,2 In an effort to remedy this situation, the National Pressure Ulcer Advisory Panel (NPUAP) has been coordinating the development of uniform terminology, test methods, and reporting standards for support surfaces. This initiative - the Support Surface Standards Initiative (S3I) - will provide an objective means for evaluating and comparing support surface characteristics.

    The outcome of this endeavor will have numerous positive effects. Clinicians, patients, and other users will have product information, test data, and labeling that is consistent and comparable. Manufacturers will be afforded guidelines to develop products according to established standards. Quality assurance in the manufacturing process will be enhanced.

    Researchers will be able to relate the validated test methods to clinical outcomes. In the meantime, awareness of S3I activities will encourage end-users to ask the right questions when buying or renting support surfaces.

    Because many have a stake in the development of these standards, an equal chance to participate is paramount; S3I membership has been open to anyone interested in working on this initiative. The NPUAP also is collaborating with the European Pressure Ulcer Advisory Panel. Even though 250 individuals are registered participants, far fewer participate in the process. Additional members, especially clinicians who are best suited to provide clinical perspectives of proposed test methods, are welcome. Three working groups address the following S31 specific topic areas: Terms and Definitions, Tissue Integrity, and Lifespan Evaluation. Results of workgroup efforts to date illustrate why making an informed support surface purchase decision is so difficult.

    For example, the Terms and Definitions work group is charged with developing standardized nomenclature, terms, and definitions. In reviewing various terms, they recognized that some are physical or engineering terms while others appear to have developed or evolved within the support surface industry. Regardless of origin, all terms must be clearly defined and understood. The mission of the Tissue Integrity workgroup is to define test methods for support surface characteristics that affect tissue integrity. These tests measure variables including pressure, friction, shear, and microclimate. Many people have tested support surfaces using these or similar variables, but because a wide range of test methods have been used (eg, human volunteers, mannequins, and patients), meaningful comparisons cannot be made. The Lifespan Evaluation working group's goal is to help clinicians answer the question: Is the support surface in good working condition? All support surfaces have a finite usable life. However, because their performance characteristics change incrementally over time, degradation is often hard to discern. At the very least, clinicians and users should be informed about how a support surface fails; the owner's manual should describe situations that dictate replacement or repair. For powered systems, this might involve the loss of a visual indicator that informs the user the surface is working properly. For non-powered systems, the challenge is more difficult. Foam incrementally degrades but never actually fails over time. One can envision that lifespan evaluation may impact support surface warranties or the definition of a "useful life."

    The stakes are high. Pressure ulcers are painful, costly, and a potential liability. The products designed to help prevent or heal these ulcers are also costly. Standards to help clinicians make informed purchase decisions are long overdue. The success of the S3I is dependent on participation from all stakeholder groups.* In the meantime, acknowledging concerns may prompt those who need to make support surface purchase decisions to ask the right questions.

* Additional information about the workgroups and how to join can be obtained from the website, www.npuap.org or by sending an e-mail to s3i@npuap.org.

1. Krouskop TA, van Rijswijk L. Standardizing performance-based criteria for support surfaces. Ostomy/Wound Management. 1995;41(1):34-45.

2. Maklebust, JA. An update on horizontal patient support surfaces. Ostomy/Wound Management. 1999;45(suppl. 1A):70S-77S.