Repositioning for pressure injury prevention in adults

Abstract

Background: A pressure injury (PI), also referred to as a 'pressure ulcer', or 'bedsore', is an area of localised tissue damage caused by unrelieved pressure, friction, or shearing on any part of the body. Immobility is a major risk factor and manual repositioning a common prevention strategy. This is an update of a review first published in 2014.

Objectives: To assess the clinical and cost effectiveness of repositioning regimens(i.e. repositioning schedules and patient positions) on the prevention of PI in adults regardless of risk in any setting.

Search methods: We searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase, and EBSCO CINAHL Plus on 12 February 2019. We also searched clinical trials registries for ongoing and unpublished studies, and scanned the reference lists of included studies as well as reviews, meta-analyses, and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication, or study setting.

Selection criteria: Randomised controlled trials (RCTs), including cluster-randomised trials (c-RCTs), published or unpublished, that assessed the effects of any repositioning schedule or different patient positions and measured PI incidence in adults in any setting.

Data collection and analysis: Three review authors independently performed study selection, 'Risk of bias' assessment, and data extraction. We assessed the certainty of the evidence using GRADE.

Main results: We identified five additional trials and one economic substudy in this update, resulting in the inclusion of a total of eight trials involving 3941 participants from acute and long-term care settings and two economic substudies in the review. Six studies reported the proportion of participants developing PI of any stage. Two of the eight trials reported within-trial cost evaluations. Follow-up periods were short (24 hours to 21 days). All studies were at high risk of bias. Funding sources were reported in five trials. Primary outcomes: proportion of new PI of any stage Repositioning frequencies: three trials compared different repositioning frequencies We pooled data from three trials (1074 participants) comparing 2-hourly with 4-hourly repositioning frequencies (fixed-effect; I² = 45%; pooled risk ratio (RR) 1.06, 95% confidence interval (CI) 0.80 to 1.41). It is uncertain whether 2-hourly repositioning compared with 4-hourly repositioning used in conjunction with any support surface increases or decreases the incidence of PI. The certainty of the evidence is very low due to high risk of bias, downgraded twice for risk of bias, and once for imprecision. One of these trials had three arms (967 participants) comparing 2-hourly, 3-hourly, and 4-hourly repositioning regimens on high-density mattresses; data for one comparison was included in the pooled analysis. Another comparison was based on 2-hourly versus 3-hourly repositioning. The RR for PI incidence was 4.06 (95% CI 0.87 to 18.98). The third study comparison was based on 3-hourly versus 4-hourly repositioning (RR 0.20, 95% CI 0.04 to 0.92). The certainty of the evidence is low due to risk of bias and imprecision. In one c-RCT, 262 participants in 32 ward clusters were randomised between 2-hourly and 3-hourly repositioning on standard mattresses and 4-hourly and 6-hourly repositioning on viscoelastic mattresses. The RR for PI with 2-hourly repositioning compared with 3-hourly repositioning on standard mattress is imprecise (RR 0.90, 95% CI 0.69 to 1.16; very low-certainty evidence). The CI for PI include both a large reduction and no difference for the comparison of 4-hourly and 6-hourly repositioning on viscoelastic foam (RR 0.73, 95% CI 0.53 to 1.02). The certainty of the evidence is very low, downgraded twice due to high risk of bias, and once for imprecision. Positioning regimens: four trials compared different tilt positions We pooled data from two trials (252 participants) that compared a 30° tilt with a 90° tilt (random-effects; I² = 69%). There was no clear difference in the incidence of stage 1 or 2 PI. The effect of tilt is uncertain because the certainty of evidence is very low (pooled RR 0.62, 95% CI 0.10 to 3.97), downgraded due to serious design limitations and very serious imprecision. One trial involving 120 participants compared 30° tilt and 45° tilt with 'usual care' and reported no occurrence of PI events (low certainty evidence). Another trial involving 116 ICU patients compared prone with the usual supine positioning for PI. Reporting was incomplete and this is low certainty evidence. Secondary outcomes No studies reported health-related quality of life utility scores, procedural pain, or patient satisfaction. Cost analysis Two included trials also performed economic analyses. A cost-minimisation analysis compared the costs of 3-hourly and 4-hourly repositioning with 2-hourly repositioning schedule amongst nursing home residents. The cost of repositioning was estimated at CAD 11.05 and CAD 16.74 less per resident per day for the 3-hourly or 4-hourly regimen, respectively, compared with the 2-hourly regimen. The estimates of economic benefit were driven mostly by the value of freed nursing time. The analysis assumed that 2-, 3-, or 4-hourly repositioning is associated with a similar incidence of PI, as no difference in incidence was observed. A second study compared the nursing time cost of 3-hourly repositioning using a 30° tilt with standard care (6-hourly repositioning with a 90° lateral rotation) amongst nursing home residents. The intervention was reported to be cost-saving compared with standard care (nursing time cost per patient EUR 206.60 versus EUR 253.10, incremental difference EUR -46.50, 95% CI EUR -1.25 to EUR -74.60).

Authors' conclusions: Despite the addition of five trials, the results of this update are consistent with our earlier review, with the evidence judged to be of low or very low certainty. There remains a lack of robust evaluations of repositioning frequency and positioning for PI prevention and uncertainty about their effectiveness. Since all comparisons were underpowered, there is a high level of uncertainty in the evidence base. Given the limited data from economic evaluations, it remains unclear whether repositioning every three hours using the 30° tilt versus "usual care" (90° tilt) or repositioning 3-to-4-hourly versus 2-hourly is less costly relative to nursing time.

Conflict of interest statement

Brigid Gillespie: none known.

Rachel Walker: none known.

Sharon Latimer: none known.

Lukman Thalib: none known.

Jennifer Whitty: none known.

Elizabeth McInnes: none known.

Wendy Chaboyer: none known.

Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Figures

1

Study flow diagram for clinical studies.

2

Study flow diagram for economic studies.

3

Risk of bias summary: review authors' judgements about each risk of bias item for each included clinical study.

4

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included clinical studies.

1.1. Analysis

Comparison 1: 2‐hourly repositioning versus 4‐hourly repositioning on any type of support surface, Outcome 1: Pressure injury occurrence (stage 1 to 4)

2.1. Analysis

Comparison 2: 30° tilt 3‐hourly overnight versus 90° tilt overnight, Outcome 1: Pressure injury occurrence (stage 1 to 4)

References

References to studies included in this review Bergstrom 2013 {published data only}

Defloor 2005 {published data only} Ghezeljeh 2017 {published data only} Manzano 2014 {published data only} Moore 2011 {published data only (unpublished sought but not used)} Pickham 2018 {published data only} Young 2004 {published data only} Zhou 2014 {published data only} References to studies excluded from this review Beuret 2002 {published data only} Girard 2014 {published data only} Su 2015 {published data only} Taccone 2009 {published data only} Vanderwee 2007 {published data only} Voggenreiter 2005 {published data only} References to ongoing studies NCT02479425 {published data only} NCT02690753 {published data only} NCT02996331 {published data only} NCT03048357 {published data only} NCT03454230 {published data only} Additional references Australian Institute of Health and Welfare 2009 Beeckman 2014 Beeckman 2016 Bennett 2004 Bergstrom 2014 Braden 1987 Braden 2005 Bureau of Labor Statistics 2016 Carskadon 2005 Catania 2007 Chaboyer 2016 Chew 2017 CONSORT 2010 CRD 2013 Cumming 2008 Dawson 2007 Deeks 2002 Deeks 2011 EPUAP 1998 EPUAP/NPUAP 2009 Exton‐Smith 1961 Gillespie 2014a Higgins 2011a Higgins 2011b Higgins 2011c Humphries 2008 Husereau 2013 Institute for Healthcare Improvement 2008 Jalali 2005 Lefebvre 2011 Lindgren 2004 Manorama 2010 McInnes 2011 McInnes 2015 Moore 2013a Moore 2013b Mulligan 2011 Nguyen 2015 NIH 2018 Norton 1962 NPIAP 2019 NPUAP 2007 NPUAP 2016 NPUAP/EPUAP/PPPIA 2014 Palmen 1987 Paulden 2014 Pickham 2016 Polit 2010 Queensland Health 2017 Raymond 2004 Reddy 2006 Review Manager 2014 [Computer program] Ryan 2016 Safe Work Australia 2012 Schuurman 2009 Schünemann 2017 Schünemann 2011 Shemilt 2010 Shemilt 2011 SIGN 2018 Smith 1990 Sterne 2011 Thompson 2005 Trinkoff 2001 Vieira 2009 Yap 2018 References to other published versions of this review Gillespie 2014b