The 30° tilt position vs the 90° lateral and supine positions in reducing the incidence of non- blanching erythema in a hospital inpatient population: a randomised controlled trial

Experience-based Modifications of the Bed Band ReAlised through Co-dEsign (EMBRACE)

BACKGROUND

Upper body limitations are a common disability in neurological conditions including stroke and multiple sclerosis. Care of patients with upper body limitations while in bed involves positioning techniques to maximise comfort and independence. The Bed Band is a nurse-led innovation to support people with limited mobility to maintain a comfortable position in bed, thereby promoting comfort and independence with activities of daily living.

AIM

To co-design and implement adaptations to the Bed Band prototype with recommendations for user instructions towards enhanced product design and future development.

METHODS

A co-design approach involving collaboration between academic and industry partners. Expert stakeholders provided feedback on the Bed Band via an online focus group before healthy volunteers tested the product in a healthcare simulation suite. Data were thematically analysed and findings sense checked by expert stakeholders who then prioritised adaptations to the Bed Band using a modified Delphi technique.

RESULTS

Three themes resulted from the analysis: (1) reaction to the Bed Band; (2) potential risks and mitigation; and (3) product adaptations. Simplicity was a strength of the innovation which easily enabled positional support. Adaptations to the Bed Band informed the development of an enhanced prototype for testing in future studies.

CONCLUSION

Co-design of the Bed Band prototype involving experts and healthy volunteers enabled early identification of potential risks with recommendations to mitigate them and priority adaptations. Further studies are required in hospital patients and community populations with upper mobility issues to determine the efficacy of the Bed Band and optimal duration of use.

Effect of various repositioning regimens on pressure wound ulcer occurrence in at-risk adult persons without existing pressure wound ulcers: A meta-analysis

Meta-analysis research was implemented to appraise the effect of various repositioning regimens (RRs) on pressure wound ulcer (PWU) occurrence in at-risk adult persons without existing PWUs. Inclusive literature research till April 2023 was done and 1197 interconnected researches were revised. The 15 picked researches, enclosed 8510 at-risk adult persons without existing PWUs persons were in the utilised researchers' starting point, 1002 of them were utilising repositioning, 1069 were control, 3443 were utilising 2-<4 h repositioning and 2994 were utilising 4-6 h repositioning. Odds ratio (OR) and 95% confidence intervals (CIs) were utilised to appraise the consequence of various RRs on PWU occurrence in at-risk adult persons without existing PWUs by the dichotomous approach and a fixed or random model. Repositioning had significantly lower PWU (OR, 0.49; 95% CI, 0.32-0.73, p < 0.001) compared to control in at-risk adult persons without existing PWUs persons. 2-<4 h repositioning had significantly lower PWU (OR, 0.62; 95% CI, 0.42-0.90, p = 0.01) compared to 4-6 h repositioning in at-risk adult persons without existing PWUs persons. Repositioning had significantly lower PWU compared to control in at-risk adult persons without existing PWU persons. 2-<4 h repositioning had significantly lower PWU compared to 4-6 h repositioning in at-risk adult persons without existing PWUs persons. However, caution needs to be taken when interacting with its values since there was a low sample size of some of the chosen research found for the comparisons in the meta-analysis.

Sacral interface pressure can be alleviated by repositioning with a small-angle change using an automated bed in patients with spinal cord injury

AIM OF THE STUDY

This study aimed to compare interface pressure and total contact area of the sacral region in different positions, including small-angle changes, in patients with spinal cord injury (SCI). Furthermore, we analyzed the clinical factors influencing pressure to identify the pressure injury (PI) high-risk group.

MATERIALS AND METHODS

An intervention was conducted for patients with paraplegia (n = 30) with SCI. In the first and second trials, interface pressure and total contact area of the sacral region were recorded from large- and small-angled positions using the automatic repositioning bed, which can change the angle of the back, lateral tilt, and knee.

RESULTS

Positions with back raised ≥45° showed significantly higher pressure on the sacrum than most other positions. The pressure and contact area differences were statistically insignificant for combinations of small-angled changes <30°. Additionally, the duration of injury (β = 0.51, p = 0.010) and neurological level of injury (NLI) (β = -0.47, p = 0.020) were significant independent predictors of average pressure. Similarly, the duration of injury (β = 0.64, p = 0.001), the Korean version of the spinal cord independence measure-III (β = -0.52, p = 0.017), and body mass index (BMI; β = -0.34, p = 0.041) were significant independent predictors of peak pressure.

CONCLUSIONS

For repositioning, combinations of small-angle changes <30° effectively reduce pressure on the sacral region in patients with SCI. Lower BMI, longer duration of injury, lower functioning score, and NLI ≥ T7 are predictors of high sacral pressures, which increase the risk for PI. Therefore, patients with these predictors require strict management.

Turning and Repositioning Frequency to Prevent Hospital-Acquired Pressure Injuries Among Adult Patients: Systematic Review

Turning and repositioning is considered one of the strategies to reduce the incidence of pressure injuries (PIs) among hospitalized patients, as it helps to redistribute and minimize direct pressure on the targeted skin and enhance blood perfusion in the affected areas. The frequency of turning and repositioning is generally uniform across clinical settings, with most clinical guidelines recommending a substantial change in a patient's position according to their health status. Notably, the optimal time interval between the position changes has not yet been established. Therefore, this study aimed to review the current literature in relation to the frequency of turning and repositioning adult patients to prevent PIs. The author used a systematic review following Whittemore and Knafl's review strategy. The author used the following databases: CINAHL, Scopus, PubMed, ProQuest, Ovid, MedLine, Web of Science, and Google Scholar. During the search, Boolean logic operators, MeSH terms, and keywords were utilized. The researcher followed the Johns Hopkins Nursing Evidence-based Practice Grading Scale to evaluate the quality of selected studies. The search yielded 723 articles, of which 10 were included in this review. These 10 articles revealed several frequency intervals for comparison purposes: 2-hourly, 3-hourly, 4-hourly, and 6-hourly depending on the healthcare setting, with a combination of supine, 30° tilt, or 90° tilt. This review shows that the optimal frequency of turning and repositioning to prevent PIs remains unclear and further investigation is necessary. Considering the varying nature of clinical settings, there is a lack of clarity regarding a golden standard for the same. Therefore, patients' health conditions should be considered when choosing the proper frequency to prevent PIs.

Effect of changing the lying posture angle by changing the bed posture on the average pressure, maximum pressure, and pressure area in the hip region

BACKGROUND: An electric bed can easily change posture from a lying position and was effective in preventing pressure ulcer. OBJECTIVE: This study aimed to identify the optimal posture for the prevention of pressure ulcers by analyzing pressure changes applied to the pelvic region. METHODS: Pressure changes resulting from lateral rotations of the body using an electronic adjustable bed and changes in the posture and angles of the trunk and knees were assessed. Twelve conditions with varying angles of the trunk and knees (15–35∘ in 5∘ increments) and varying lateral angles (20–35∘ in 5∘ increments) were tested. The pressure (maximum and average) and contact area in the pelvic region of 20 individuals without disabilities were calculated. RESULTS: The conditions in which the average and maximum pressures did not increase according to the increase in angle were 25∘ for the upper body and knee angles and 35∘ for the side. CONCLUSIONS: The body pressure changed according to the posture rather than according to physical characteristics. Lateral rotation combined with changes in the angles of the trunk and knees effectively prevented pressure ulcers. Changes in the posture at various angles prevented an increased pressure on the body.

Repositioning mattress: how a lateral tilt position reshapes the prevention of pressure ulcers in bedridden patients

Pressure ulcers have been part of tissue damage without effectiveness in medical, surgical, and intensive care units. This study aims to focus on developing lateral tilt positions for effective pressure ulcer relief for bedridden patients. A repositioning mattress was placed in the side-lying left lateral tilt position (15°, 30°, 45°), sheering (0.680, 1.323, 1.870), interface pressure (2.550, 2.290, 2.830), and placed at 1.5 m long piece of polyethylene rubber. The design strength was set at 6000 N and 2100 mm x 1105 mm (σt,0,d = 42, σc,0,d = 34). The design shows the greatest supine position at 30°, 1.323, 2.290, pressure load (Δp0 = 1.125 (1820) ≈ 2050 psi, Δp3000 = 1.125 (620) ≈ 700 psi), tensile stress (σt,0,d (MPa) = 42), compressive stress (σc,0,d (MPa) = 34), and FOS (σt,0,d = 42, σc,0,d = 34). The factor of safety illustrated that the 30° lateral tilt position is more consistent in repositioning for pressure ulcer prevention compared to the supine-to-tilt region. Further, an application of repositioning mattresses was developed to test in bedridden patients with tissue ulcers in nursing homes.

Effectiveness of interventions to prevent pressure injury in adults admitted to acute hospital settings: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Hospital-acquired pressure injuries cause significant harm to afflicted individuals, and financially burden hospitals. Most pressure injuries are avoidable with the use of preventative interventions. However, within acute hospital settings the effectiveness of pressure injury preventative interventions, as demonstrated by high-level evidence, requires examination.

OBJECTIVE

Analyse the effectiveness of interventions to prevent pressure injury in adults admitted to acute hospital settings.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

CINAHL, MEDLINE, Scopus, Web of Science and Embase were searched in May/June 2019. In April 2020, searches were updated to the end of 2019.

METHODS

Randomised controlled trials which investigated the effectiveness of pressure injury preventative interventions on pressure injury incidence, within adults admitted to acute hospital settings, were included. Trials limited to pressure injury treatment or specialty areas, and non-English reports, were excluded. Screening, extraction and risk-of-bias assessment were undertaken independently by two reviewers, with a third as arbitrator. Included studies were grouped by intervention type. Studies were synthesised narratively, and meta-analysis was undertaken where study interventions were similar. Using a random-effects model, primary meta-analyses were undertaken using intention-to-treat data.

RESULTS

Of 2000 records, 45 studies were included in the systematic review which investigated nine different intervention types: continence management, heel protection devices, medication, nutrition, positioning, prophylactic dressings, support surfaces, topical preparations and bundled interventions. All studies were judged to be at unclear or high risk-of-bias. Several meta-analyses were undertaken, pooled by intervention type. Most pooled samples were heterogeneous. Based on intention-to-treat data, only one intervention demonstrated a statistically significant effect: Australian medical sheepskin surfaces compared to other standard care surfaces (risk ratio 0.42, p = 0.006, I² = 36%), but included studies were limited by bias and age. Following per protocol meta-analyses, only two intervention types demonstrated a significant effect: support surfaces (active versus other comparison [risk ratio = 0.54, p = 0.005, I² = 43%] and standard surfaces [risk ratio = 0.31, p < 0.001, I² = 0%]; and reactive versus other comparison surfaces [risk ratio = 0.53, p = 0.03, I² = 64%]) and heel protection devices versus standard care (risk ratio = 0.38, p < 0.001, I² = 36%).

CONCLUSIONS

Only one intervention was supported by intention-to-treat meta-analysis. Significantly, all trials were at unclear or high risk-of-bias; and there were several limitations regarding heterogeneity across trials and trial outcomes. Further large-scale, high-quality trials testing pressure injury preventative interventions are required to establish effectiveness within acute hospital settings. Attention should be paid to true intention-to-treat analysis, and acute and intensive care settings should be reported separately. PROSPERO registration number:CRD42019129556.

Repositioning for pressure injury prevention in adults: An abridged Cochrane systematic review and meta-analysis

BACKGROUND

A pressure injury is an area of localised damage to the skin and underlying tissues. Patient repositioning is an important prevention strategy, as those with limited mobility are at increased risk of developing pressure injury.

OBJECTIVES

To assess the clinical and cost-effectiveness of repositioning schedules on the prevention of pressure injury in adults.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

The Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials; MEDLINE (Ovid); Embase (Ovid) and Cumulative Index of Nursing and Allied Health Literature Plus (EBSCO) were searched in February 2019. No restrictions were applied to language or date of publication.

REVIEW METHODS

Studies were eligible if they were randomised controlled trials including cluster trials, published or unpublished, and undertaken in any healthcare setting that assessed the clinical and/or cost effectiveness of repositioning schedules for prevention of pressure injury in adults. Methodological quality of the studies was independently assessed by three authors. Heterogeneity between studies was assessed using the I² statistic, and the pooled risk ratios along with their 95% confidence intervals were estimated using either fixed and random effects models, as indicated. Grading of Recommendations Assessment, Development and Evaluation was used to appraise the certainty of evidence.

RESULTS

Eight eligible trials involving 3,941 participants published between 2004 and 2018 were identified. Trials compared either different repositioning frequencies or positioning regimens. Three trials (1074 participants) compared 2-hourly with 4-hourly repositioning (risk ratio 1.06, 95% confidence interval 0.80 to 1.41; I² = 45%). Two other trials (252 participants) compared a 30-degree tilt with a 90-degree tilt (risk ratio0.62, 95% confidence interval 0.10 to 3.97; I² =69%). Only two trials included economic analyses, both amongst nursing home residents. One study estimated the costs of repositioning to be Canadian dollars $11.05 and Canadian dollars $16.74 less per resident per day for the 3-hourly or 4-hourly regimens, respectively, when compared to 2-hourly regimen. The second study reported 3-hourly repositioning using a 30-degree tilt to cost €46.50 (95% confidence interval €1.25 to €74.60) less per patient in nursing time compared with 6-hourly repositioning with a 90-degree lateral rotation.

CONCLUSION

It remains unclear which repositioning frequencies or positions are most effective in preventing pressure injury in adults. There is limited evidence to support the cost effectiveness of repositioning frequencies and positions. Registration: Cochrane protocol published in 2012.

Repositioning for preventing pressure ulcers: a systematic review and meta-analysis

Objective:

The aim of this systematic review was to assess the effects of different repositioning regimens on pressure ulcer (PU) incidence in at-risk adult individuals without existing PUs.

Method:

Using systematic review methodology, randomised controlled trials (RCTs), including cluster-RCTs, prospective non-RCTs, pre–post-studies and interrupted-time-series studies were considered. Specifically explored was the impact of the frequency of repositioning, use of repositioning systems and use of turning teams. The search was conducted in January 2019, using PubMed, CINAHL, SCOPUS, Cochrane and EMBASE databases. Data were extracted using a pre-designed extraction tool and analysis was undertaken using RevMan.

Results:

A total of 530 records were returned, of which 16 met the inclusion criteria. Half of studies were conducted in intensive care units (50%). The mean sample size was 629±604 participants. Frequency of repositioning was explored in nine studies. PU incidence was 8% (n=221/2834) for repositioning every 2–3 hours, versus 13% (n=398/3050) for repositioning every 4–6 hours. The odds ratio (OR) was 0.75 (95% confidence interval (CI): 0.61–0.90, p=0.03), suggesting that there is a 25% reduction in the odds of PU development in favour of more frequent repositioning. Use of a repositioning system was explored in three studies. PU incidence was 2% (17/865) for the repositioning system, versus 5.5% (51/926) for care without using the repositioning system. The OR was 0.26 (95% CI: 0.05–1.29, p=0.10); this finding was not statistically significant. Use of a turning team was explored in two studies. PU incidence was 11% (n=22/200) with use of a turning team versus 20% (n=40/200) for usual care. The OR was 0.49 (95% CI: 0.27–0.86, p=0.01) suggesting that there is a 51% reduction in the odds of PU development in favour of use of a turning team. Using GRADE appraisal, the certainty of the evidence was assessed as low.

Conclusion:

The results of this systematic review indicate that more frequent repositioning and use of a turning team reduce PU incidence. However, given the low certainty of evidence, results should be interpreted with caution.

Repositioning for pressure injury prevention in adults

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.

Wheelchair Pressure Ulcer Prevention Using FBG Based Sensing Devices

In this work, a fiber Bragg grating (FBG) based sensing system for wheelchair pressure ulcer prevention was developed. Six FBGs were strategically positioned in a wheelchair to monitor the more prominent bone areas, namely scapulas (right (SR) and left (SL)), ischiatic zone (right (IR) and left (IL)), and heels (right (HR) and left (HL)). The sensing architecture was tested by a female user during pressure relief exercises, to verify its effectiveness on pressure monitoring. The proposed system proves to be a compact and reliable solution for wheelchair pressure ulcer prevention, making it a suitable alternative to existing conventional electronic sensors, with the advantage of being immune to electromagnetic interferences and usable in humid environments. In addition to the pressure, the breathing rate was also monitored. By combining the proposed sensing architecture with a wheelchair user detection software, it is possible to create alerts for the user to know when a new position should be adopted, in order to relieve the pressure in a specific area, thus avoiding one of the biggest problems for such patients, pressure ulcers.

How consistent and effective are current repositioning strategies for pressure ulcer prevention?

AIM

To examine the inter-practitioner variability of repositioning for pressure ulcer prevention, the effectiveness of the intervention, and whether the provision of written guidance influenced the repositioning technique.

METHODS

A pre-test post-test study design was utilised. Descriptive data regarding the work history of participants was collected. Participants were invited to reposition a healthy volunteer before and after reviewing guidance detailing the 30° side-lying technique. The researchers measured the resulting turn angles and assessed offloading of bony prominences.

RESULTS

The repositioning technique varied considerably in the sample of nurse participants. Turn angles decreased following the guidance, but offloading of body sites vulnerable to pressure damage remained sporadic.

CONCLUSION

Pressure ulcer prevention training should include practical demonstrations of repositioning. Clear guidance regarding the optimal repositioning technique for pressure ulcer prevention is needed.

Identifying and prioritizing topics for evidence-based geriatric nursing practice guidelines in Korea

BACKGROUND

Despite the increasing population of elderly individuals in Korea, there are no evidence-based geriatric nursing practice guidelines.

AIM

This study aimed to identify and prioritize topics related to the development of evidence-based geriatric nursing practice guidelines in long-term care facilities in Korea.

METHODS

To identify potential topics, 89 nurses responded to a questionnaire on activities that require further evidence and/or standardization in the long-term care facility setting. To prioritize these topics, 14 geriatric nursing experts completed surveys to prioritize five categories.

RESULTS

The collected data included 240 clinical topics, which were classified into 41 subcategories and 18 main categories. According to topic prioritization by the geriatric nursing experts, the following were the most heavily weighted categories: fall prevention, position change and prevention of pressure ulcers.

CONCLUSIONS

The development of standardized guidelines based on these results may help improve the quality of geriatric care and quality of life of older individuals. The small number of respondents may be a limitation of this study, and further study is needed to expand the population.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

The development of evidence-based nursing guidelines based on the present findings will help improve the quality of nursing in long-term care facilities. Additionally, health policies and systems, such as introduction of a fee for nursing services for older individuals based on the evidence, are worth considering.

Could lateral tilt mattresses be the answer to pressure ulcer prevention and management?

Pressure ulcers have been part of illness for thousands of years and are not reducing in number. Traditionally, since the Crimean War, patients have been ritually repositioned every 2 hours, regardless of the individual need. Pressure ulcers occur mainly on bony prominences, and so it makes sense to reposition into the 30 degree tilt, off of bony prominences. Nevertheless, this still takes time in order to reposition on a regular basis. It is time to look at automatic repositioning, reducing nursing time, increasing patient comfort and releasing carers to provide more social support to the patients.

Effects of a continuous lateral turning device on pressure relief

[Purpose] The purpose of this study was to examine the pressure-relieving effects of a continuous lateral turning device on common pressure ulcer sites. [Subjects] Twenty-four healthy adults participated. [Methods] The design of our continuous lateral turning device was motivated by the need for an adequate pressure-relieving device for immobile and/or elderly people. The procedure of manual repositioning is embodied in our continuous lateral turning device. The interface pressure and time were measured, and comfort grade was evaluated during sessions of continuous lateral turning at 0°, 15°, 30°, and 45°. We quantified the pressure-relieving effect using peak pressure, mean pressure, and pressure time integration. [Results] Participants demonstrated pressure time integration values below the pressure-time threshold at 15°, 30°, and 45° at all the common pressure ulcer sites. Moreover, the most effective angles for pressure relief at the common pressure ulcer sites were 30° at the occiput, 15° at the left scapula, 45° at the right scapula, 45° at the sacrum, 15° at the right heel, and 30° at the left heel. However, angles greater than 30° induced discomfort. [Conclusion] Continuous lateral turning with our specially designed device effectively relieved the pressure of targeted sites. Moreover, the suggested angles of continuous lateral turning can be used to relieve pressure at targeted sites.

Mobilização corporal para prevenção de úlceras por pressão: custo direto com pessoal

RESUMOObjetivo:calcular o custo total médio (CTM) relativo à mão de obra direta (MOD) de profissionais de enfermagem para a mobilização corporal de pacientes visando à prevenção de úlceras por pressão.Método:estudo de caso quantitativo, exploratório-descritivo. Observou-se a realização de 656 mobilizações preventivas e calculou-se o custo multiplicando-se o tempo despendido pelos profissionais pelo custo unitário da MOD.Resultados:o CTM com MOD por Unidade correspondeu a: Clínica Médica R$ 5,38 por mudança de decúbito, R$ 5,26 por posicionamento em poltrona, R$ 5,55 por auxílio deambulação; Clínica Cirúrgica R$ 2,42 por mudança de decúbito, R$ 2,30 por posicionamento em poltrona, R$ 2,96 por auxílio deambulação e Unidade de Terapia Intensiva R$ 8,15 por mudança de decúbito, R$ 7,57 por posicionamentos em poltrona, R$ 15,32 por auxílio deambulação.Conclusão:o conhecimento gerado poderá subsidiar o gerenciamento de custos relacionados aos recursos humanos necessários ao cuidado de enfermagem eficiente e eficaz.

Positioning bedridden patients to reduce interface pressures over the sacrum and great trochanter

OBJECTIVE

In this study, we evaluated the effect of hip-joint rotation on the interface pressure over the sacrum and greater trochanter with a new protocol for positioning of bedridden elderly patients.

METHOD

The interface pressure values over the sacrum and greater trochanter in bedridden patients were evaluated. These were collected in the supine position, 90° lateral position, and 30° and 40° laterally inclined positions with external rotation or neutral positioning of the hip joint. Each interface pressure was assessed with a device measuring pressure distribution, after which, the peak pressure index (PPI) was calculated.

RESULTS

In the 17 patients examined, the PPI over the sacrum in the supine position was significantly greater than that in other positions. In the 30° and 40° laterally inclined positions, the PPIs over the greater trochanter were significantly lower in the neutral position of the hip joint compared with those in the external rotation position.

CONCLUSION

Our findings revealed the effects of hip-joint rotation on the interface pressure for the greater trochanter, possibly due to the increased distance between the greater trochanter and the sacrum caused by neutral position of the hip joint. The results demonstrate that it is to best place the hip joint in a neutral position when the legs are in contact with the bed in order to distribute the pressure over the greater trochanter in the 30° and 40° laterally inclined positions. These results can be applied to the clinical setting to improve patient positioning and decrease pressure ulcers.

DECLARATION OF INTEREST

The authors declare that they have no competing financial interests.

The repositioning of hospitalized patients with reduced mobility: a prospective study

AIM

To determine the frequency of patient repositioning across three consecutive nursing shifts (day, evening and night) and to identify predictors of repositioning frequency.

BACKGROUND

Patient repositioning is a frequently implemented pressure injury prevention strategy. Yet, little is known about how often it should be implemented, or the frequency of movement among hospitalized patients with reduced mobility.

DESIGN

An observational prospective study.

METHODS

Chart audits were used to gather clinical and demographic data. Semi-structured observations were conducted every 30 minutes for a continuous 24-hour period. Observational data included the patient's body position, the frequency of repositioning, assistance require to reposition and the use of support surfaces.

RESULTS

Patients were repositioned frequently during the day and evening and least at night time. Elevation of the head of the bed (1-45°) was the most frequently adopted position. The independent predictors of repositioning frequency were age and gender, with older patients and males repositioned less frequently.

Nursing staff induced repositionings and immobile patients' spontaneous movements in nursing care

The aim of this study was to investigate nursing staff induced repositionings and the patients' spontaneous movements during the day and night among older immobile patients in nursing care. Furthermore, the aim was to identify factors associated with the nursing staff induced repositionings and the patients' spontaneous movement frequency. An observational cross-sectional design was used. Spontaneous movements among patients (n = 52) were registered continuously using the MovinSense monitoring system. The nursing staff documented each time they repositioned the patient. Patients spontaneous movements were compared with nursing staff induced repositionings. There were large variations in the patients' spontaneous repositioning frequency during both days and nights, which shows that, although immobilised, some patients frequently reposition themselves. Analgesics were positively related to the movement frequency and psycholeptics were negatively related. The nursing staff more often repositioned the patients who were assessed as high risk than those assessed as low risk, but the patients' spontaneous movement frequency was not correlated to the risk score. This may be important when planning repositioning schedules. A monitoring system may be useful in decision making with regard to planning repositioning and positions used in the prevention of pressure ulcers among elderly immobile patients.

Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians

DESCRIPTION

The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations based on the comparative effectiveness of risk assessment scales and preventive interventions for pressure ulcers.

METHODS

This guideline is based on published literature on this topic that was identified by using MEDLINE (1946 through February 2014), CINAHL (1998 through February 2014), the Cochrane Library, clinical trials registries, and reference lists. Searches were limited to English-language publications. The outcomes evaluated for this guideline include pressure ulcer incidence and severity, resource use, diagnostic accuracy, measures of risk, and harms. This guideline grades the quality of evidence and strength of recommendations by using ACP's clinical practice guidelines grading system. The target audience for this guideline includes all clinicians, and the target patient population is patients at risk for pressure ulcers.

RECOMMENDATION 1

ACP recommends that clinicians should perform a risk assessment to identify patients who are at risk of developing pressure ulcers. (Grade: weak recommendation, low-quality evidence).

RECOMMENDATION 2

ACP recommends that clinicians should choose advanced static mattresses or advanced static overlays in patients who are at an increased risk of developing pressure ulcers. (Grade: strong recommendation, moderate-quality evidence).

RECOMMENDATION 3

ACP recommends against using alternating-air mattresses or alternating-air overlays in patients who are at an increased risk of developing pressure ulcers. (Grade: weak recommendation, moderate-quality evidence).

Pressure Ulcer Risk Assessment and Prevention for the Family Physician

Pressure ulcers are common and result in serious medical complications, prolonged hospital stay and frequent readmissions. With a rapidly ageing population and increasing chronic disease burden in Singapore, the prevalence of pressure ulcers will increase further. Family physicians will encounter more pressure ulcers in their practices in the primary, intermediate and long term care settings. We conducted a comprehensive literature review on established evidence on pressure ulcer risk assessment and prevention, and also reviewed current hospital protocols in Singapore. We found that many studies on pressure ulcer risk assessment and prevention lacked methodological quality to provide robust evidence and conclusions. Consequently, many of the recommendations in major international guidelines and protocols of major hospitals in Singapore are based on a combination of best available evidence, best practices and consensus opinion. We provided a summary of key recommendations for family physicians, based on the Strength of Recommendation Taxonomy (SORT) framework. We also hope to stimulate interest in regular updates of local guidelines and major hospital protocols in Singapore to reflect the latest evidence based strategies on risk assessment and prevention of pressure ulcers.

Repositioning for pressure ulcer prevention in adults

BACKGROUND

A pressure ulcer (PU), also referred to as a 'pressure injury', 'pressure sore', or 'bedsore' is defined as an area of localised tissue damage that is caused by unrelieved pressure, friction or shearing forces on any part of the body. PUs commonly occur in patients who are elderly and less mobile, and carry significant human and economic impacts. Immobility and physical inactivity are considered to be major risk factors for PU development and the manual repositioning of patients in hospital or long-term care is a common pressure ulcer prevention strategy.

OBJECTIVES

The objectives of this review were to:1) assess the effects of repositioning on the prevention of PUs in adults, regardless of risk or in-patient setting;2) ascertain the most effective repositioning schedules for preventing PUs in adults; and3) ascertain the incremental resource consequences and costs associated with implementing different repositioning regimens compared with alternate schedules or standard practice.

SEARCH METHODS

We searched the following electronic databases to identify reports of the relevant randomised controlled trials: the Cochrane Wounds Group Specialised Register (searched 06 September 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 8); Ovid MEDLINE (1948 to August, Week 4, 2013); Ovid EMBASE (1974 to 2013, Week 35); EBESCO CINAHL (1982 to 30 August 2013); and the reference sections of studies that were included in the review.

SELECTION CRITERIA

Randomised controlled trials (RCTs), published or unpublished, that assessed the effects of any repositioning schedule or different patient positions and measured PU incidence in adults in any setting.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction.

MAIN RESULTS

We included three RCTs and one economic study representing a total of 502 randomised participants from acute and long-term care settings. Two trials compared the 30º and 90º tilt positions using similar repositioning frequencies (there was a small difference in frequency of overnight repositioning in the 90º tilt groups between the trials). The third RCT compared alternative repositioning frequencies.All three studies reported the proportion of patients developing PU of any grade, stage or category. None of the trials reported on pain, or quality of life, and only one reported on cost. All three trials were at high risk of bias.The two trials of 30º tilt vs. 90º were pooled using a random effects model (I² = 69%) (252 participants). The risk ratio for developing a PU in the 30º tilt and the standard 90º position was very imprecise (pooled RR 0.62, 95% CI 0.10 to 3.97, P=0.62, very low quality evidence). This comparison is underpowered and at risk of a Type 2 error (only 21 events).In the third study, a cluster randomised trial, participants were randomised between 2-hourly and 3-hourly repositioning on standard hospital mattresses and 4 hourly and 6 hourly repositioning on viscoelastic foam mattresses. This study was also underpowered and at high risk of bias. The risk ratio for pressure ulcers (any category) with 2-hourly repositioning compared with 3-hourly repositioning on a standard mattress was imprecise (RR 0.90, 95% CI 0.69 to 1.16, very low quality evidence). The risk ratio for pressure ulcers (any category) was compatible with a large reduction and no difference between 4-hourly repositioning and 6-hourly repositioning on viscoelastic foam (RR 0.73, 95% CI 0.53 to 1.02, very low quality evidence).A cost-effectiveness analysis based on data derived from one of the included parallel RCTs compared 3-hourly repositioning using the 30º tilt overnight with standard care consisting of 6-hourly repositioning using the 90º lateral rotation overnight. In this evaluation the only included cost was nursing time. The intervention was reported to be cost saving compared with standard care (nurse time cost per patient €206.6 vs €253.1, incremental difference €-46.5; 95%CI: €-1.25 to €-74.60).

AUTHORS' CONCLUSIONS

Repositioning is an integral component of pressure ulcer prevention and treatment; it has a sound theoretical rationale, and is widely recommended and used in practice. The lack of robust evaluations of repositioning frequency and position for pressure ulcer prevention mean that great uncertainty remains but it does not mean these interventions are ineffective since all comparisons are grossly underpowered. Current evidence is small in volume and at risk of bias and there is currently no strong evidence of a reduction in pressure ulcers with the 30° tilt compared with the standard 90º position or good evidence of an effect of repositioning frequency. There is a clear need for high-quality, adequately-powered trials to assess the effects of position and optimal frequency of repositioning on pressure ulcer incidence.The limited data derived from one economic evaluation means it remains unclear whether repositioning every 3 hours using the 30º tilt is less costly in terms of nursing time and more effective than standard care involving repositioning every 6 hours using a 90º tilt.

Targeted preventive care may be needed for adults with congenital spine anomalies

OBJECTIVE

To compare hospitalizations caused by spina bifida-sensitive conditions, ambulatory care-sensitive conditions in adults with spina bifida and in the general population, our aim was to provide information about whether preventive health efforts already underway in the hospitalized general population are adequate for preventive care in spina bifida and congenital spine anomalies.

DESIGN

Retrospective secondary data analysis.

PATIENTS (OR PARTICIPANTS)

Records of hospitalized individuals who were 18 years of age and older.

METHODS

Comparison between individuals hospitalized with spina bifida and the general population using data from the California State Inpatient Database from the Healthcare Cost and Utilization Project for 2004 of adults.

MAIN OUTCOME MEASUREMENTS

Prevalence of spina bifida-sensitive conditions and ambulatory care-sensitive conditions as reason for hospitalization and 30-day readmission.

RESULTS

As compared with the general population, persons with spina bifida who were hospitalized in 2004 had a significantly greater number of hospitalizations, number of hospitalizations associated with both spina bifida-sensitive conditions and ambulatory care-sensitive conditions, and number of 30-day readmissions. Stratification by age shows that the admissions for spina bifida sensitive conditions were greater in persons with spina bifida than in the general population for all age groups. In contrast, only in the youngest age group did those with spina bifida experience greater hospitalizations for ambulatory care-sensitive conditions.

CONCLUSIONS

This study provides further evidence that persons with spina bifida have hospitalizations that are beyond what the general population experiences. These conditions may be potentially preventable with appropriate ambulatory care. This group also had a greater risk for readmission within 30 days of discharge from their last hospitalization. More research is needed on the efficacy of programs aimed at prevention of these conditions.

Intensive Session: New Approaches to Medical Issues in Long-Term Care

This article, based on a series of presentations at the American Medical Directors Association, briefly highlights new advances in medical areas of interest to long-term care physicians. The areas discussed are heart failure, vitamin D, falls, new treatments for diabetes mellitus, blood pressure measurement, anemia, clinical nutrition, pressure ulcers, Clostridium difficile, insomnia, and antipsychotic therapy.