Improving Best Practices in Assessing the Usage Conditions of Hospital and Long-Term Care Mattresses

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.

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.

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.

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).

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).

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.

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.

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).