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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: Pressure ulcers are treated by reducing pressure on the areas of damaged skin. Special support surfaces (including beds, mattresses and cushions) designed to redistribute pressure, are widely used as treatments. The relative effects of different support surfaces are unclear. Objectives: To assess the effects of pressure‐relieving support surfaces in the treatment of pressure ulcers. Search methods: We searched: The Cochrane Wounds Group Specialised Register (searched 15 July 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3); Ovid MEDLINE (2007 to July Week 1 2011); Ovid MEDLINE (In‐Process & Other Non‐Indexed Citations, July 14, 2011); Ovid EMBASE (2007 to 2011 Week 27); EBSCO CINAHL (2007 to 14 July 2011). The reference sections of included studies were also searched. Selection criteria: We included published or unpublished randomised controlled trials (RCTs), that assessed the effects of support surfaces for treating pressure ulcers, in any patient group or setting, that reported an objective measure of wound healing. Data collection and analysis: Data extraction and assessment of risk of bias were performed independently by two review authors. Trials with similar patients, comparisons and outcomes were considered for pooled analysis. Where pooling was inappropriate the results of the trials were reported narratively. Where possible, the risk ratio or mean difference was calculated for the results of individual studies. Main results: We identified 18 trials of support surfaces for pressure ulcer treatment, involving 1309 participants with samples sizes that ranged from 14 to 160. Of three trials comparing air‐fluidized devices with conventional therapy, two reported significant reductions in pressure ulcer size associated with air‐fluidized devices. Due to lack of reported variance data we could not replicate the analyses. In relation to three of the trials that reported significant reductions in pressure ulcer size favouring low air loss devices compared with foam alternatives, we found no significant differences. A small trial found that sheepskin placed under the legs significantly reduced redness and similarly a small subgroup analysis favoured a profiling bed compared with a standard bed in terms of the healing of existing grade 1 pressure ulcers. Poor reporting, clinical heterogeneity, lack of variance data and methodological limitations in the eligible trials meant that no pooled comparisons were undertaken. Authors' conclusions: There is no conclusive evidence about the superiority of any support surface for the treatment of existing pressure ulcers. Methodological issues included variations in outcomes measured, sample sizes and comparison groups. Many studies had small sample sizes and often there was inadequate description of the intervention, standard care and co‐interventions. Individual study results were often inadequately reported, with failure to report variance data common, thus hindering the calculation of mean differences. Some studies did not report P values when reporting on differences in outcomes. In addition, the age of some trials (some being 20 years old), means that other technologies may have superseded those investigated. Further and rigorous studies are required to address these concerns and to improve the evidence base before firm conclusions can be drawn about the most effective support surfaces to treat pressure ulcers.

Background: Pressure ulcers (i.e. bedsores, pressure sores, decubitus ulcers) are areas of localised damage to the skin and underlying tissue. They are common in the elderly and immobile, and costly in financial and human terms. Pressure‐relieving support surfaces (i.e. beds, mattresses, seat cushions etc) are used to help prevent ulcer development. Objectives: This systematic review seeks to establish: (1) the extent to which pressure‐relieving support surfaces reduce the incidence of pressure ulcers compared with standard support surfaces, and, (2) their comparative effectiveness in ulcer prevention. Search methods: For this third update we searched: the Cochrane Wounds Group Specialised Register (searched 8 December 2010), The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 4); Ovid MEDLINE (1950 to November Week 3 2010); Ovid MEDLINE (In‐Process & Other Non‐Indexed Citations December 07, 2010); Ovid EMBASE (1980 to 2010 Week 48); EBSCO CINAHL (1982 to 3 December 2010), and the reference sections of included studies. Selection criteria: Randomised controlled trials (RCTs) and quasi‐randomised studies, published or unpublished, that assessed the effects of any support surface for prevention of pressure ulcers, in any patient group or setting which measured pressure ulcer incidence.Studies reporting only proxy outcomes (e.g. interface pressure) were excluded. Two review authors independently selected studies. Data collection and analysis: Data were extracted by one author and checked by another. Where appropriate, estimates from similar studies were pooled for meta‐analysis. Main results: One new trial was included, bringing the total of included studies to 53. Foam alternatives to standard hospital foam mattresses reduce the incidence of pressure ulcers in people at risk (RR 0.40 95% CI 0.21 to 0.74). The relative merits of alternating‐ and constant low‐pressure devices are unclear. One high‐quality trial suggested that alternating‐pressure mattresses may be more cost effective than alternating‐pressure overlays in a UK context. Pressure‐relieving overlays on the operating table reduce postoperative pressure ulcer incidence, although two studies indicated that foam overlays caused adverse skin changes. Meta‐analysis of three trials indicated that Australian standard medical sheepskins prevent pressure ulcers (RR 0.56 95% CI 0.32 to 0.97). Authors' conclusions: People at high risk of developing pressure ulcers should use higher‐specification foam mattresses rather than standard hospital foam mattresses. The relative merits of higher‐specification constant low‐pressure and alternating‐pressure support surfaces for preventing pressure ulcers are unclear, but alternating‐pressure mattresses may be more cost effective than alternating‐pressure overlays in a UK context. Medical grade sheepskins are associated with a decrease in pressure ulcer development. Organisations might consider the use of some forms of pressure relief for high risk patients in the operating theatre.