HEALTHTECH PROGRAMME

Slide sheets are used to help move or reposition people. This is an essential and necessary part of care in both hospitals and the community. They are widely used in the NHS by a range of carers for a variety of moving and repositioning tasks, but most commonly to reposition someone in bed or to move them from one surface to another. There may be many reasons for moving or repositioning someone. The person may have various comorbidities, which can affect their ability to assist, how frail they are, continence and the risk of pressure damage. The committee acknowledged that all these factors have an impact on deciding which type of slide sheet is most appropriate.

Slide sheets may not be suitable for people who are particularly frail, critically ill or have severe skin conditions. A limited understanding of the English language, mental health conditions or learning disabilities can also affect the person's ability to assist during the moving or repositioning task. This increases the musculoskeletal burden experienced by the carer. Clinical experts explained that carers may also be at higher risk of sustaining injury if they are above or below average height. Some slide sheets may have features that are beneficial in such cases (see sections 3.5 and 3.8). The committee concluded that the characteristics and preferences of the carer and the person who is being moved or repositioned should be considered when choosing a slide sheet.

The evidence base for slide sheets is limited and of low quality. The EAG identified 7 studies directly related to the decision problem in its evidence review. All studies had quasi-experimental designs. Most of the studies did not have adequate sample sizes, and the studies varied in the type of repositioning task, setting, participants, outcomes reported and description of the interventions. Many studies were not done in a clinical setting, some used mannequins or volunteers, and 4 studies were not done in the NHS. A specialist committee member highlighted that the studies did not control for many important confounders, such as the physical characteristics of the carer and the time needed for moving or repositioning. The committee concluded that the comparability and generalisability of the findings were limited. It also noted that there was no published evidence on a number of additional relevant outcomes outlined in the final scope.

Only one study's primary aim was to compare slide sheets with and without additional features. So, it was not possible to conclude from the published evidence whether any specific feature had an impact on outcomes. There was also no published evidence available for several of the features in the final scope.

Clinical experts noted that some features can have an impact on the effectiveness of slide sheets. Single-patient-use slide sheets are usually preferred because washable slide sheets can lose their friction-reducing properties over time. The experts also noted that disposable slide sheets are usually made from lower-quality materials and can be less effective and more difficult to use. This can negatively affect the person being moved or repositioned.

The committee discussed the implications of laundering washable slide sheets. The clinical experts explained that if there are no effective laundry services available, slide sheets can get lost or damaged, for example they can be returned to the wrong ward. The committee heard that many NHS trusts do not have effective laundry services, and external contracting of laundering is common. But the committee also heard that some NHS trusts with onsite laundry facilities have successfully implemented washable slide sheets. The committee noted that this can also reduce waste.

The committee discussed in situ slide sheets, which are designed to remain under the person who is being moved or repositioned. Clinical and patient experts said that these can reduce discomfort from frequent insertion and removal of a slide sheet and help preserve dignity. The EAG identified 1 non-peer-reviewed study that compared the use of in situ slide sheets with washable flat slide sheets in the community. The study found that fewer carers were needed to perform handling tasks for some patients with an in situ slide sheet. The clinical experts added that in situ slide sheets can reduce the time required for repositioning and agreed that they can allow some repositioning tasks to be done by a single carer. But they noted that there can be laundering issues with in situ slide sheets (see section 3.6).

The clinical experts also highlighted that some potentially innovative features of slide sheets, such as straps, handles, top clip loops and hook-and-loop fasteners, may have disadvantages. They explained that handles can encourage lifting rather than sliding, which substantially increases the risk of accidents and musculoskeletal injuries. The committee also heard that some of these features can affect infection control. The committee concluded that the usefulness of these features depends on the carer and the person being moved or repositioned. These features are only likely to be of value in some situations, for example to avoid overreaching when moving or repositioning someone with overweight or obesity.

The committee discussed whether clinical equivalence between slide sheets with or without a particular feature(s) can be established. It recalled that the published evidence was limited, but some features were likely to have an impact on the effectiveness of slide sheets (see sections 3.4 to 3.8). The clinical experts added that the quality of the material used will affect both the durability of the slide sheet (including the impact of laundering) and its friction-reducing properties. So, even though some slide sheets have the same features, they may not be equivalent. But, the committee agreed this could be less apparent when comparing new slide sheets, and it would be reasonable to assume clinical equivalence in some cases, such as for single-patient-use slide sheets used over shorter periods.

The EAG's regression analysis, using data from NHS Supply Chain, found that 63% of the price variation between different slide sheets was attributed to 4 features (reusability, type of slide sheet, presence of handles, and size of slide sheet). Slide sheets with handles and washable slide sheets had a statistically significantly higher price. But, a visual comparison of the prices for all features indicated considerable overlap between prices. Only some features could be reliably identified from the available data to include in the analysis. The committee acknowledged that the price of slide sheets may be driven by other potentially innovative features that were not included in the regression analysis. It also highlighted that the pricing of slide sheets may be driven by factors unrelated to features, such as manufacturing costs or competitive pricing models.

The EAG developed 2 economic models. The first compared washable with disposable or single-patient-use slide sheets, and the second compared removable with in situ slide sheets. The EAG assumed clinical equivalence between slide sheets. The committee recalled that clinical equivalence in practice is unlikely, especially if slide sheets are used for a long time (see section 3.9). But, because of the lack of published evidence, it agreed this was a reasonable assumption (see sections 3.4 to 3.8).

The economic model comparing washable with disposable or single-patient-use slide sheets included 4 clinical scenarios to capture a variety of settings of slide sheet use. The scenarios were outpatient, ambulance or emergency care use; acute hospital ward use; longer-term hospital use; and community care use. The committee welcomed this approach and agreed the model covered the range of scenarios that are likely to be seen in the NHS.

The EAG's models included resource use and cost parameters related to purchase, reprocessing (including washing and transportation) and disposal of slide sheets. The committee noted that all key resource use parameters were sourced from 1 non-peer-reviewed study or through expert elicitation, which led to substantial parameter uncertainty. The committee noted that the model comparing washable with disposable or single-patient-use slide sheets may have underestimated losses of slide sheets during laundering, especially if laundering is provided externally (see section 3.6). The committee acknowledged that the lack of clinical evidence available to inform modelling of differences in clinical efficacy, manual handling injury outcomes or patient experience was a significant limitation (see section 3.3).

The models' costs for slide sheets were based on weighted averages from sales data provided by NHS Supply Chain for 2023 to 2024. Most slide sheets in the NHS are bought through NHS Supply Chain. A representative from NHS Supply Chain explained that NHS trusts can buy slide sheets directly from manufacturers and negotiate discounts, but these prices are likely to be similar to those from NHS Supply Chain. The committee concluded that the costs used in the EAG's models are appropriate.

The economic model comparing washable, disposable and single-patient-use slide sheets estimated that washable slide sheets were the least expensive option in almost all scenarios. The committee noted that the model may have underestimated some losses during laundering. The EAG clarified that some implementation issues could not be fully captured in the model. The committee concluded that the model's results were subject to parameter uncertainty, but washable slide sheets are likely to represent a cost-saving option if there is an effective laundering service. The committee also noted the sustainability benefits of using washable slide sheets if they were implemented successfully.

The economic model comparing in situ slide sheets with washable slide sheets in the community estimated that in situ slide sheets could save money because fewer care workers would be needed for some handling tasks. The committee noted that this was based on 1 non-peer-reviewed study (see section 3.13). A clinical expert observed that the model did not include time savings for handling tasks using an in situ slide sheet, so the results may be an underestimate. The committee concluded that, although the model results were subject to parameter uncertainty, in situ slide sheets are likely to represent a cost-saving option for long-term care in the community.

The committee considered an exploratory analysis that included the cost and utility impact of pressure ulcer reduction from using in situ slide sheets, and acknowledged that this increased the benefit of in situ slide sheets. The committee also discussed an exploratory analysis that investigated the potential value of using in situ slide sheets in acute care. The clinical experts explained that implementing in situ slide sheets in acute care across the NHS would require significant infrastructure changes, guidance and training.

The committee considered a hypothetical scenario that modelled the financial impact of shifting towards using washable slide sheets. It concluded that this could result in overall cost savings for the system, but the results are uncertain. The committee recalled that there may have been uncaptured benefits relating to sustainability (see section 3.15).

The committee discussed evidence from a user preference assessment. This aimed to explore which features of a slide sheet are most important to users when choosing a slide sheet. The top 2 criteria related to the quality of the slide sheet material. But, there was no consensus on how a higher-quality material could be defined or measured. The committee noted that there was no published evidence on the clinical and economic impact of different materials, and slide sheet material was not included in the regression analysis (see sections 3.3, 3.5 and 3.10). They recalled that the clinical experts advised that the quality of the material can affect durability and the experience of the person being moved or repositioned, and concluded that the quality of the material may be more important when slide sheets are used over longer periods. The committee recognised that slide sheets are available in a range of sizes. Clinical expert feedback stated that the range of sizes is too large, and in practice having a standard and plus size are sufficient to address most clinical scenarios.