The effect of multiple layers of linens on surface interface pressure: results of a laboratory study

Underpads and layers of linens are frequently placed under patients who are incontinent, have other moisture-related issues, and/or are immobile and cannot reposition independently. Many of these patients are also at risk for pressure ulcers and placed on pressure-redistribution surfaces. The purpose of this study was to measure the effects of linens and incontinence pads on interface pressure. Interface sacral pressures were measured (mm Hg) using a mannequinlike pelvic indenter that has pressure transducers integrated into the unit and is covered with a soft flesh-like elastomer. The indenter was loaded to simulate a median-weight male (80 kg/176 lb), and the testing was performed at head-of bed (HOB) angles of 0°, 30°, and 45°. Two different surfaces, a high performance low-air-loss support (LAL) surface and a standard foam support surface, were used and covered with a fitted sheet (FS) only or a combination of the FS and various incontinence pads and transfer sheets. Linen combinations typically used for relatively immobile patients (n = 4), moisture management (n = 4), and moisture management and immobility (n = 1) were tested, as was the heavy use of linens/pads (nine layers, n = 1). All combinations were tested 10 times at HOB angles of 0°, 30°, and 45°. The highest pressure observed was recorded (peak pressure). Ninety five percent (95%) confidence interval (CI) surrounding the mean of the 10 trials for each combination was calculated using the t-distribution; differences between means for all surface combinations were determined using one-way ANOVA with follow-up Fisher Hayter test. Results indicated that each incontinence pad, transfer sheet, or combination of linens significantly increased the mean peak sacral pressure when compared to a single FS on both the low-air-loss surface and the foam surface, regardless of the head-of-bed angle. The magnitude of peak sacral interface pressure increase for the LAL surface at 30° head-of-bed angle was 20% to 64% depending on the linen combination. At 30°, the foam surface showed increases 6% to 29% (P <0.0001) compared with a FS baseline. If linens were wet, peak interface sacral pressures were equivalent to or less than pressures measured on the same pads when measured dry. The presence of linens on both surface types adversely affected the pressure redistribution capabilities of the surfaces; added layers increased pressure proportionally. The effect on interface pressure from the linen layers was more pronounced on the LAL than the foam surface. The study results illustrate that significant increases in peak interface pressure occur in a laboratory setting when linen layers are added to pressure redistribution surfaces. Results also indicated wetting incontinence pads on a support surface did not significantly increase interface pressure. Although additional preclinical and clinical studies are needed to guide practice, excessive linen usage for patients on therapeutic support surfaces should be discouraged.