1. Background
Healthcare-associated infection (HAI) is a significant threat to patient safety in healthcare settings, often stemming from poor hand hygiene and surface contamination (1). This global concern extends beyond hospitals to all healthcare settings, including home care, leading to thousands of patient injuries and deaths annually due to healthcare errors (2, 3).
The state of the art reveals that patients acquiring HAIs exhibit predictors that influence in-hospital mortality, necessitating the development and implementation of risk management policies. Researchers emphasize the significance of preventing and controlling these infections, which can escalate healthcare costs and directly impact patient safety. Consequently, immediate attention from health policymakers is underscored, urging the review of previous programs and standards and the implementation of evidence-based HAI control programs and health education to mitigate this health burden (4-6).
Annually, millions of residents in Long-Term Care Facilities (LTCFs) contract care-associated infections, influenced by population, environmental factors, and resource availability (1, 2). Environmental factors, including mattresses, contribute to microorganism spread, necessitating proper care and use, such as impermeable covers and regular inspections (7).
Brazilian guidelines recommend impermeable covers for healthcare mattresses, while international literature offers more comprehensive routines (8). Nursing plays a central role in patient care, making them key to ensuring mattress quality, comfort, and patient well-being. Establishing standards for mattress acquisition, handling, and maintenance is crucial in preventing complications and HAIs.
2. Objectives
This study evaluates hospital and LTCF mattresses, linking their physical condition to acquisition and maintenance processes to prevent HAIs, given the risks posed by inadequate mattresses and the lack of routine inspections across services.
3. Methods
3.1. Type of Study
This study is analytical and descriptive with a cross-sectional design, carried out from January to February 2021 in hospitals and Long-Term Care Facilities (LTCFs) for the elderly located in Campo Grande, Mato Grosso do Sul, Brazil.
3.2. Sample
The sample consisted of 267 mattresses, chosen from a total of 1,210 beds in hospitals and LTCFs. The response variable was the proportion of mattresses deemed adequate (33.5% ± 5%) with a significance level of 5%. Using proportional stratified sampling, the final sample size was adjusted to 278 mattresses to ensure a safety margin above the calculated threshold for evaluation. The study focused on mattresses used in pediatric, clinical, and surgical beds, excluding those in use by bedridden patients due to logistical constraints. For the purpose of random selection, mattresses were sequentially numbered, ensuring a sample size that exceeded the necessary minimum for evaluation.
3.3. Data Collection and Study Protocol
Data collection took place during scheduled visits to institutions in 2 phases. The first phase utilized a validated questionnaire (9) focused on mattress management practices within healthcare facilities, encompassing criteria for acquisition and maintenance. Structured interviews were conducted with personnel responsible for mattress management, typically involving members of the Hospital Infection Control Committee (HICC), Hospital Hospitality, or administrative staff. The second phase involved a physical assessment of mattresses using the "Audit of Physical Aspects of Mattresses" tool (10). This assessment covered an inspection for tears, fissures, leaks, stains, the condition of waterproof covers, labeling, foam quality, zipper functionality, structural integrity of the bed frame, and any signs of biological material contamination. Additionally, a water test was performed to evaluate the waterproof effectiveness of the cover and to check for potential contamination within the foam, applying a total of 11 criteria for evaluation.
3.4. Research Instrument Evaluation
The research instrument underwent face-content validation by 5 doctoral experts in the field, utilizing the Delphi method for its effectiveness in reaching expert consensus. The panel consisted of three nurses and 2 physicians, all holding doctoral degrees and selected for their scholarly publications. The assessment of the online questionnaire was conducted using the Likert scale to evaluate the significance of each item. After 2 rounds, consensus was reached. The Content Validity Index (CVI) was employed to measure agreement on the instrument's appearance, comprehension, and relevance, with a minimum agreement of 80% required for each item. This criterion was achieved for all items. The final CVI stood at 97%, reflecting a high level of expert consensus.
3.5. Data Analysis and Statistics
Data were organized using Google Forms, and statistical analyses were performed using Epi-info™ 7.2.4 (Centers for Disease Control and Prevention, Atlanta, Georgia, USA) and Bio Estat 5.3 (Mamirauá Society, Belém, Pará, Brazil). These software packages facilitated the automation of calculations, enhancing precision and reliability. Descriptive statistics encompassed absolute and relative frequencies, 95% confidence intervals, means, standard deviations, and the range of mattress evaluation scores. The Mann-Whitney Test was applied for comparison between 2 groups of scores, while the Kruskal-Wallis Test, followed by the Dunn Test, was utilized for comparisons among 3 or more groups. Multiple regression analysis was conducted with mattress scores as outcomes, selecting predictor variables based on statistical significance and employing the "backward selection" method. A significance level of 5% was established for the analyses.
3.6. Ethical Approval
In compliance with Resolution No. 466 of December 12, 2012, this research received approval from the Research Ethics Committee (REC) of the Federal University of Mato Grosso do Sul under Protocol No. 4,371,150/2010 (CAAE - 37772920.4.0000.0021).
4. Results
From the initial sample of 278 mattresses, 6 were excluded due to evaluation difficulties arising from patients being bed-bound, leaving 272 mattresses for assessment. All evaluated mattresses were foam-based. Based on the 11 criteria set for evaluation, with 6 being essential for mattress approval, only 27 mattresses met the approval criteria out of the total sample (n = 272), equating to 9.9% (95% CI: 6.4% to 13.5%). The evaluation scores varied from 2 to 11, with an average score of 6.75 (± 1.97 SD).
Table 1 illustrates the compliance rate of the sample with each evaluated criterion, highlighting the mandatory criteria in bold. The criterion with the least compliance was the presence of a label on the mattress, observed in only 11% of the sample (n = 272), whereas the criterion with the highest compliance was the presence of a waterproof cover, noted in 98.5% of the mattresses, serving to protect the foam. The thickness of the mattresses varied from 4 to 18 cm, averaging 11.3 cm (± 2.1 cm SD), with only 27.9% of mattresses meeting the minimum thickness requirement.
Table 1.Evaluation of Mattresses According to Presentation and Waterproofing Criteria, Campo Grande/Ms - 2021 (N = 272)
| Criteria | No (%) |
|---|---|
| The covering was waterproof a. | 268 (98.5) |
| The bed frame was free from contamination by blood or other bodily fluids | 242 (89.0) |
| No leaks a. | 201 (73.9) |
| The bed frame was solid but with holes | 194 (71.3) |
| Passed the support surface test (Foam) | 187 (68.8) |
| The mattress had a zipper | 185 (68.0) |
| No stains a. | 178 (65.4) |
| No tears or fissuresa. | 171 (62.9) |
| The mattress passed the water test a, b. | 103 (37.9) |
| Had a minimum thickness of 12.7 cm | 76 (27.9) |
| The mattress was labeled | 30 (11.0) |
a Mandatory Criteria
b Water testing was not conducted on 132 mattresses, as 83 of them lacked zippers, 4 lacked waterproof covering, 15 had tears or cracks, 13 were unsuitable due to not meeting minimum thickness requirements, 11 had leaks, 4 were stained, and 2 were classified as other reasons.
There was a lower percentage (4.8%) of approved mattresses in the surgical bed type (n = 83) compared to 11.2% in clinical beds (n = 169) and 20.0% in pediatric beds (n = 20). Surgical beds had the lowest average evaluation score (Table 2).
Table 2.Number and Percentage of Approved Mattresses, Mean, Standard Deviation (SD), Minimum and Maximum Values (Min-Max) of Mattress Evaluation Scores According to the Characteristics of the Institutions, Campo Grande/Ms - 2021 (N = 272)
| Variables | n | No. % of Approved | Mean ± SD a | Min-Max | P-Value b |
|---|---|---|---|---|---|
| Type of institution | 0.012 | ||||
| Long-Term Care Facility | 53 | 10 (18.9) | 7.4 ± 2.1 c | 4 - 11 | |
| Hospital | 219 | 17 (7.8) | 6.6 ± 1.9 a | 2 – 11 | |
| Type of management | < 0.001 | ||||
| Private | 69 | 14 (20.3) | 7.6 ± 1.5 c | 5 - 11 | |
| Public | 47 | 5 (10.6) | 6.6 ± 2.0 a | 3 - 10 | |
| Philanthropic | 156 | 8 (5.1) | 6.4 ± 2.0 a | 2 - 11 | |
| Number of beds | < 0.001 | ||||
| Up to 49 beds | 13 | 4 (30.8) | 8.5 ± 1.5 c | 6 - 11 | |
| 50 to 99 beds | 118 | 11 (9.3) | 7.1 ± 1.7 a | 3 - 10 | |
| 100 beds or more | 141 | 12 (8.5) | 6.3 ± 2.1 a | 2 - 11 | |
| Type of bed | 0.003 | ||||
| Pediatric | 20 | 4 (20.0) | 7.0 ± 2.1 c | 3 - 10 | |
| Medical/surgical | 169 | 19 (11.2) | 7.0 ± 1.9 c | 2 - 11 | |
| Surgical | 83 | 4 (4.8) | 6.1 ± 1.9 a | 2 - 10 |
a The Mann-Whitney Test was used to compare 2 groups, and the Kruskal-Wallis Test, followed by the Dunn Test, was used for 3 groups.
b P-values indicate statistically significant differences.
c Different letters indicate statistically significant differences.
Among the beds evaluated, no approved mattresses were identified in institutions that replace mattresses based on necessity or that were unable to specify the frequency of replacement. The largest proportion of approved mattresses (18.2%) and the highest average evaluation score were observed in the facilities (n = 121) that replaced mattresses every 1 to 5 years. Notably, while 5.8% of mattresses were approved in the cohort (n = 86) of institutions with a replacement cycle of less than one year, this group exhibited a lower average score based on the evaluation criteria (see Table 3).
Table 3.Number and Percentage of Approved Mattresses of Mattress Evaluation Scores According to the Management Characteristics, Campo Grande/Ms - 2021 (N = 272)
| Variables | n | No. % of Approved | Mean ± SD a | Min-Max | P-Value |
|---|---|---|---|---|---|
| Acquisition of mattresses b | 0.181 | ||||
| Bidding | 54 | 6 (11.1) | 6.8 ± 1.9 b | 3 - 10 | |
| Direct purchase | 250 | 22 (8.8) | 6.8 ± 2.0 b | 2 - 11 | |
| Donation | 66 | 5 (7.6) | 7.3 ± 1.9 b | 3 - 11 | |
| Parliamentary amendment | 54 | 4 (7.4) | 6.5 ± 2.0 b | 4 - 10 | |
| Frequency of mattress replacement | < 0.001 c | ||||
| Less than 1 year | 86 | 5 (5.8) | 5.8 ± 2.0 b | 2 - 10 | |
| From 1 to 5 years | 121 | 22 (18.2) | 7.3 ± 1.9 a | 4 - 11 | |
| Necessity | 59 | - | 7.0 ± 1.3 a | 3 - 9 | |
| Couldn't provide information | 6 | - | 6.5 ± 2.6 b | 3 - 9 | |
| Reason for choosing the mattress b | < 0.001 c | ||||
| Mattress cleaning process | 49 | 10 (20.4) | 6.8 ± 2.3 b | 3 - 10 | |
| User comfort | 101 | 17 (16.8) | 7.3 ± 2.0 b | 3 - 11 | |
| Material resistance | 113 | 18 (15.9) | 7.0 ± 2.1 b | 3 - 11 | |
| Price | 56 | 5 (8.9) | 6.9 ± 1.6 b | 3 - 10 | |
| Not optional | 73 | 5 (6.8) | 6.9 ± 1.6 b | 3 - 10 | |
| Durability | 109 | 7 (6.4) | 6.0 ± 2.1 a | 2 - 10 | |
| Frequency of mattress evaluation | 0.200 | ||||
| Daily | 183 | 18 (9.8) | 7.0 ± 2.0 b | 2 - 11 | |
| Weekly | 63 | 7 (11.1) | 7.0 ± 1.9 b | 3 - 10 | |
| Monthly | 7 | 2 (28.6) | 8.0 ± 1.6 b | 6 - 10 | |
| Not done | 19 | - | 7.0 ± 1.6 b | 3 - 9 | |
| Method of mattress evaluation b | < 0.001 c | ||||
| During concurrent cleaning | 119 | 17 (14.3) | 7.0 ± 1.9 b | 4 - 11 | |
| During bed-making | 89 | 15 (16.8) | 7.0 ± 2.0 b | 3 - 11 | |
| During terminal cleaning | 152 | 13 (8.5) | 6.0 ± 1.9 a | 2 - 10 | |
| During specific evaluation routine | 46 | 9 (19.6) | 8.0 ± 2.0 c | 3 - 11 | |
| Nursing spontaneous evaluation | 3 | - | 7.0 ± 1.5 b | 6 - 9 | |
| Only when the covering is damaged | 19 | - | 7.0 ± 1.6 b | 3 - 9 |
a Different capital letters indicate statistically significant differences.
b The Kruskal-Wallis Test, followed by the Dunn Test, was used to compare 4 or more groups.
c P ≤ 0.05 indicates statistically significant differences.
According to Table 4, there were no significant differences in the median evaluation scores between mattresses covered with napa and those covered with corvin material. Similarly, the percentage of mattresses that met approval criteria was comparable for both types of covering materials.
Table 4.The Number and Percentage of Mattresses That Were Approved, Alongside the Mean, Standard Deviation (SD), and the Minimum and Maximum Values (Min-Max) of Mattress Evaluation Scores, Categorized by the Type of Mattress Covering Material Used in Campo Grande/Ms - 2021 (N = 272)
| Variables | n | No. % of Approved a | Mean ± SD | Min-Max | P-Value |
|---|---|---|---|---|---|
| Material of the mattress covering b | 0.099 | ||||
| Vinyl | 195 | 19 (9.7) | 7.0 ± 1.8 b | 3 - 11 | |
| Corvin | 198 | 20 (10.1) | 7.0 ± 2.1 b | 2 - 11 | |
| Reason for choosing the mattress covering b | < 0.001c | ||||
| Material resistance | 122 | 9 (7.4) | 6.0 ± 2.1 b | 2 - 10 | |
| User comfort | 97 | 6 (6.2) | 6.0 ± 2.1 b | 2 - 11 | |
| Durability | 121 | 14 (11.6) | 7.0 ± 2.0 a | 3 - 11 | |
| Mattress cleaning process | 176 | 24 (13.6) | 7.0 ± 1.9 a | 3 - 11 | |
| Non-optional | 35 | 3 (8.6) | 7.0 ± 1.6 a | 4 - 10 | |
| Price | 18 | 5 (27.8 | 8.0 ± 1.6 c | 5 - 10 | |
| Impermeability | 13 | 1 (7.7) | 7.5 ± 1.7 a | 4 - 10 | |
| Frequency of mattress covering evaluation | 0.254 | ||||
| Daily | 240 | 25 (10.4) | 7.0 ± 2.0 b | 2 - 11 | |
| Weekly | 25 | - | 7.0 ± 1.5 b | 3 - 9 | |
| Monthly | 7 | 2 (28.6) | 7.9 ± 1.6 b | 6 - 10 | |
| Method of evaluating the integrity of the mattress covering b | 0.001 c | ||||
| During concurrent cleaning | 141 | 18 (12.8) | 7.0 ± 2.0 b | 3 - 11 | |
| During bed-making | 89 | 15 (16.8) | 7.0 ± 2.0 b | 3 - 11 | |
| During terminal cleaning | 155 | 13 (8.4) | 6.0 ± 1.9a | 2 - 10 | |
| During specific evaluation routine | 43 | 8 (18.6) | 7.0 ± 2.0 b | 3 - 11 | |
| Nursing spontaneous evaluation | 3 | - | 7.0 ± 1.5 b | 6 - 9 | |
| Mattress covering replacement | < 0.001 c | ||||
| Yes | 178 | 27 (15.2) | 7.0 ± 2.0 b | 3 - 11 | |
| No, replace the mattress | 69 | - | 6.0 ± 2.0a | 2 - 10 | |
| No | 25 | - | 6.0 ± 2.0a | 3 - 9 | |
| Professional b | 0.021 c | ||||
| Nurse | 216 | 24 (11.1) | 7.0 ± 2.0 b | 2 - 11 | |
| Nursing technician/assistant | 168 | 9 (5.4) | 7.0 ± 2.0 b | 2 - 10 | |
| Hygiene Assistant | 98 | 5 (5.1) | 6.0 ± 1.9a | 2 - 10 | |
| Caregiver | 22 | 1 (4.5) | 6.5 ± 2.4a | 4 - 11 | |
| Administrator | 7 | 2 (28.6) | 7.9 ± 1.6c | 6 - 10 | |
| Nursing intern | 11 | - | 7.9 ± 1.1c | 6 - 9 | |
| Housekeeper | 11 | - | 6.8 ± 1.3 b | 5 - 9 |
a Different capital letters indicate statistically significant differences.
b The Mann-Whitney Test was used to compare 2 groups. The Kruskal-Wallis Test, followed by the Dunn Test (We used standard practices with letters for indicating significant differences), was used for 3 or more groups.
c P ≤ 0.05 indicate statistically significant differences.
The Multiple Linear Regression analysis presented in Table 5 sheds light on the determinants influencing mattress evaluation scores in healthcare environments. Significantly impactful variables include the involvement of nurses in the assessment of mattresses and coverings, which is strongly associated with better scores, as evidenced by a partial regression coefficient of 1.680 (P < 0.001). The frequency of replacing mattress coverings is inversely related to evaluation scores (P < 0.001). Additionally, the form of administrative management (P < 0.001), the rigor of inspections for mattress and covering integrity during bed preparation (P = 0.009), and the type of institution (P = 0.044) are also significant predictors of mattress evaluation outcomes. These findings underscore the importance of management practices and the responsibilities of staff in upholding the quality of mattresses in healthcare settings.
Table 5.Multiple Linear Regression between the Mattress Approval Criteria Score (Outcome) and the Characteristics of the Institutions and Management, Campo Grande/Ms - 2021 (N = 272) a
| Variables | Partial Regression Coefficient | P-Value |
|---|---|---|
| The nurse is the person responsible for the mattress and covering evaluation | 1.680 | < 0.001b |
| Mattress covering replacement | -1.069 | < 0.001 b |
| Type of administration | 0.632 | < 0.001 b |
| Integrity evaluation of mattress and covering during bed-making | -0.896 | 0.009 b |
| Type of institution | 0.946 | 0.044 b |
| Type of bed | 0.344 | 0.089 |
| Frequency of mattress replacement | -0.277 | 0.095 |
| Number of beds | 0.243 | 0.495 |
a The predictor variables were chosen using the "backward selection" method.
b P ≤ 0.05 indicates a statistically significant association.
5. Discussion
In our study, we assessed the physical conditions of 272 mattresses based on 11 criteria. The results revealed varying compliance scores, with an average of 6.75. Approximately 61% of the criteria were met, and only 27 mattresses were approved. Even a single failure in one of the six mandatory criteria resulted in disapproval. The mattress approval rate was higher in facilities with fewer beds and those under private management. This suggests that institutions with robust management practices tend to perform better in terms of mattress compliance, which can have a positive impact on financial performance and process quality (11, 12).
The criterion with the highest compliance rate (98.5%) concerning the presence of a waterproof covering on the mattresses, as well as higher approval rates in services where they are regularly replaced, is related to the function of the external protective cover. This cover prevents the absorption of blood and bodily fluids and facilitates cleaning and hygiene (12).
Similar results were found in studies conducted in the United States (11-13), indicating that little importance is given to the analysis of hospital mattresses. Higher approvals were also observed in services that have a specific routine for the mattress and covering evaluation and perform it during bed-making. Institutions that evaluate only during terminal cleaning had a lower percentage of approved mattresses, probably because this procedure is not as frequent as bed-making.
Services that periodically change mattresses, typically every one to five years, also achieved higher scores. Both the mattress (foam block) and the covering have a finite lifespan, which varies depending on the manufacturer, typically ranging from 1 to 7 years, depending on their characteristics (12).
In this context, some aspects are essential in mattress evaluation for acquisition, such as the cleaning process. Services that consider this factor had higher approval rates. During the cleaning process of the mattress and other bed structures, various factors become obstacles, including the team's lack of awareness of the risk of infection from inadequately cleaned and disinfected mattresses, as well as incorrect execution of cleaning, use of improper products, or incorrect concentrations, among other factors (14, 15).
It is recommended to clean mattresses between each patient admission, in addition to the daily routine during bed-making. This should consider the manufacturer's guidelines and the type of contamination to choose the appropriate product. It's crucial to mention that certain products can cause drying of the covering, leading to the appearance of fissures that reduce the product's lifespan. Similarly, it's impossible to perform effective cleaning and disinfection of a damaged mattress with damp foam (1, 16).
Another factor directly related to the quality of mattresses in use is that when the evaluation is conducted by nurses or administrators, approval rates tend to be higher. This is likely due to their decision-making authority and governance to solve problems related to patient beds, which is not observed in other mid-level professionals.
When assessing mattress permeability, both sides of the covering and foam should be inspected, as well as any loss of color. It's essential to consider the characteristics of the patient using the mattress, such as age, bedridden status, any type of incontinence, admission to an endemic area for certain microorganisms, and other factors (14).
5.1. Implications of the Study for Nursing Practice
Nurses are central to patient care, making mattresses a key component in ensuring patient comfort and preventing complications such as pressure ulcers and skin injuries. Recognizing the significance of mattress quality and integrity is vital for nurses in delivering safe and comfortable care.
Nurses can take a leading role in advocating for and instituting standardized practices concerning mattress selection, maintenance, and assessment. Their active involvement in evaluating mattresses to ascertain compliance with quality standards is crucial for enhancing patient well-being and averting potential health issues.
This study identified differences in mattress approval rates depending on the healthcare facility type. Nurses in various environments, including hospitals and long-term care facilities, must understand these discrepancies and tailor their practices to ensure optimal care delivery.
5.2. Limitations
It is important to note the limitations of this study, particularly that it was conducted during the COVID-19 pandemic. This period saw many institutions having to adjust their routines, leading to a decline in participation, most notably among long-term care facilities. Consequently, conducting new research focused on mattress auditing for the prevention of HAIs would be of significant value.
5.3. Conclusions
This study demonstrates that only 9.9% of the examined sample had mattresses that met the required standards, primarily due to the inadequate physical characteristics of the mattresses used in hospitals and long-term care facilities (ILPI). Additionally, there is an absence of standardized protocols for the procurement, maintenance, and replacement of these items to guarantee patient safety. Despite the introduction of recent national legislation, there remains a substantial discrepancy between sanitary regulations and the actual practices of healthcare services in terms of maintaining suitable bedding. This discrepancy underscores the necessity for policy development focused on the standardization of mattresses within healthcare settings, given their extensive physical contact with patients and the current lack of regulation in most institutions.
