Repositioning for pressure injury prevention in adults (Review)
Gillespie, B. M., Walker, R. M., Latimer, S. L., Thalib, L., Whitty, J. A., McInnes, E. and Chaboyer, W. P.. (2020) Repositioning for pressure injury prevention in adults (Review). Cochrane Database of Systematic Reviews. Issue 6, p. CD009958. https://doi.org/10.1002/14651858.CD009958.pub3
|Authors||Gillespie, B. M., Walker, R. M., Latimer, S. L., Thalib, L., Whitty, J. A., McInnes, E. and Chaboyer, W. P.|
Data collection and analysis
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.
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.
No studies reported health‐related quality of life utility scores, procedural pain, or patient satisfaction.
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).
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.
|Keywords||beds; cost-benefit analysis; patient positioning; pressure ulcer; randomized controlled trials as topic; time factors|
|Journal||Cochrane Database of Systematic Reviews|
|Journal citation||Issue 6, p. CD009958|
|Publisher||John Wiley & Sons|
|Digital Object Identifier (DOI)||https://doi.org/10.1002/14651858.CD009958.pub3|
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File Access Level
|Online||02 Jun 2020|
|Publication process dates|
|Deposited||11 Jun 2021|
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