NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
National Clinical Guideline Centre (UK). The Prevention and Management of Pressure Ulcers in Primary and Secondary Care. London: National Institute for Health and Care Excellence (NICE); 2014 Apr. (NICE Clinical Guidelines, No. 179.)
9.1. Introduction
It is widely recognised that immobility and lack of sensation are significant risk factors affecting both the development and healing of pressure ulcers. Repositioning, that is a change in the individual's position whether by themselves or assisted (with or without the use of equipment) is an accepted method of pressure ulcer prevention. The aims of repositioning are to reduce or relieve the pressure on the area at risk, maintain muscle mass and general tissue integrity and ensure adequate blood supply to the at risk area. Despite frequent repositioning for people at risk of pressure ulcers being accepted best practice, there is a lack of published evidence in this area. Other guidelines and reviews have relied on consensus opinion of best practice.
This review focuses on identifying the most appropriate position for people who are at risk of developing a pressure ulcer, in order to reduce or relieve the pressure and prevent the development of a pressure ulcer. The review also aims to identify the optimum frequency at which people should be repositioned.
9.2. Review question: How and at what frequency should repositioning be undertaken for the prevention of pressure ulcers?
For full details see review protocol in Appendix C.
9.2.1. Clinical evidence (adults)
Six studies were included in the review.51 135 186 210 215 228Evidence from these are summarised in the clinical GRADE evidence profile below (Table 19). See also the study selection flow chart in Appendix D, forest plots in Appendix I, study evidence tables in Appendix G and exclusion list in Appendix J.
Table 19
Clinical evidence profile: repositioning (frequent turning or the use of pressure reducing mattress) versus no repositioning (standard care without turning).
For the purposes of the review, searches were conducted for RCT assessing effectiveness of repositioning for the prevention of pressure ulcers in people of all ages in any setting. Six RCTs (3 cluster RCTs 51 135 215 and 3 parallel RCTs 186 210 228) were identified.
The population varied from populations of older adults to individualsin intensive care units, all were assessed in different inpatient hospital settings. Four trials included older adults with a mean age of 80 years, 1 trial included acute inpatients with a mean age of 70 years. One trial included people admitted to an intensive care unit with a mean age of 63.9 years.210
Studies looked at different repositioning techniques applied at different time intervals. For the purpose of this review, the trials have been grouped and analysed in 4 different comparisons:
- Repositioning (frequent turning with or without the use of a pressure reducing mattress) versus no repositioning (standard care without turning).51
Trials reported the incidence of pressure ulcer (proportion of participants developing pressure ulcers (grade 1- 4) with 3 trials 135 215 228 giving a narrative report on ‘time to pressure ulcer development’ and tolerability. A narrative summary was included for studies where the outcome reported was not appropriate for GRADE. Included studies had varying time periods (ranging from 1 night to 5 weeks). Cluster RCTs have been analysed separately.
Summary of studies included in the review
| Study | Intervention/comparator | Population | Outcomes | Study length |
|---|---|---|---|---|
| Defloor 2005 51 | Participants either received a 2-hourly or a 3-hourly turning scheme on a standard institutional mattress or a 4-hourly or 6-hourly turning scheme on a pressure reducing mattress. The turning schemes consisted of alternating a semi-recumbent position with a lateral position. Standard care involving preventive nursing care based on clinical judgement of the nurses. Preventive measures used were water mattresses, alternating mattresses, sheepskins and gel cushions. Preventive care did not include turning. | People in a geriatric nursing home. Mean age: 84.4 (SD 8.33) years, The mean Braden score was 13.2 (SD 2.36) and the mean Norton score was 10.0 (SD 1.96). Participants were considered to be at risk of developing pressure ulcers. |
| 4 weeks. |
| Moore 2011 135 | Repositioning by using the 30° tilt (left side, back, right side, back) every 3 hours during the night. Repositioning every 6 hours at night, using 90° lateral rotation. Both groups were nursed during the day according to planned care. Pressure redistribution devises in current use on the bed and on the chair was continued. Participants positions were altered every 2-3 hours. | People from 12 long-term care of the older person hospital settings. Seventy-nine percent were women. Eighty-seven per cent were chair-fast and 77% had very limited activity. Participants were at risk of developing pressure ulcers (using the Braden pressure ulcer risk assessment scale). |
| 4 weeks |
| Smith 1990 186 | Small shift in body (adjusting the position of a limb or body part by placing a small rolled towel to designated areas). Shifts were completed in less than 1 minute. Sites for placement of rolled towel were under each arm, shoulder, hip, and leg. Both groups received normal, routine care and were turned every 2 hours. | Elderly adults. Participants ranged in age from 65 years to 91 years with a mean age of 80.55. Fourteen participants were women and five were men. |
| 2 weeks |
| Vanderwee 2007 215 | Four hours in a semi-recumbent 30° position and 2 hours in a lateral position 30°. Repositioning was the same as above but with equal time intervals of 4 hours in lateral 30° as in semi-recumbent 30° position. Participants in both groups were lying on a visco-elastic foam overlay mattress. | People in a geriatric nursing home. Mean age: 84.4 (SD 8.33) years, The mean Braden score was 13.2 (SD 2.36) and the mean Norton score was 10.0 (SD 1.96). |
| 5 weeks |
| Van Nieuwenhoven 2006 210 | Semi recumbent position. Aim was to achieve 45° position of the head and back. The 45° position was not achieved for 85% of the study time, and these participants more frequently changed position than supine positioned participants. Standard care (supine position). | 221 adults admitted to 4 ICUs in 3 university hospitals in the Netherlands. 112 randomised to semi recumbent positioning and 109 to supine positioning. Mean age of 63.9 years |
| 7 days |
| Young 2004 228 | 30° tilt position during the night. 90° side-lying position during the night. | Acute inpatient in a district general hospital. Mean age of 70.3 years. Participants were at risk of developing pressure ulcers (indicated by a Waterlow risk assessment score above 10). |
| One night |
Table 20
Clinical evidence profile: different frequencies of repositioning: 2 hourly turning on a standard institutional mattress versus 3 hourly turning on a standard institutional mattress.
Table 21
Clinical evidence profile: different frequencies of repositioning: 2 hourly turning on a standard institutional mattress versus 4 hourly turning plus pressure reducing mattress.
Table 22
Clinical evidence profile: different frequencies of repositioning: 2 hourly turning on a standard institutional mattress versus 6 hourly turning plus pressure reducing mattress.
Table 23
Clinical evidence profile: different frequencies of repositioning: 3 hourly turning on a standard institutional mattress versus 4 hourly turning plus pressure reducing mattress.
Table 24
Clinical evidence profile: different frequencies of repositioning: 3 hourly turning on a standard institutional mattress versus 6 hourly turning plus pressure reducing mattress.
Table 25
Clinical evidence profile: different frequencies of repositioning: 4 hourly turning plus pressure reducing mattress versus 6 hourly turning plus pressure reducing mattress.
Table 26
Clinical evidence profile: different frequencies of repositioning: turning 2 hourly in a lateral and 4 hourly in a supine position versus repositioning 4 hourly.
Table 27
Clinical evidence profile: different frequencies of repositioning: unscheduled small shifts in body position versus 2-hourly turning.
Table 28
Clinical evidence profile: different positions for repositioning – 30° tilt position versus 90° lateral and supine position (control).
Table 29
Clinical evidence profile: different positions for repositioning – semi recumbent position (45° position of the head and back) versus standard care (supine position).
9.2.1.1. Comparison between kinetic beds and conventional beds
Table 30
Clinical evidence profile: kinetic treatment table versus standard care for pressure ulcer prevention.
9.2.1.2. RCT Narrative summary
The following study is summarised as a narrative because the outcomes were not appropriate for GRADE due to incomplete outcome reporting:
One study 228 examining the effects of the 30° tilt position (experimental arm) in reducing the incidence of non-blanching erythema (grade 1 pressure ulcer)compared to the use of 90° lateral and supine position (control arm) reported that 5(22%) out of 23 participants in the experimental arm were unable to tolerate the intervention. No data was provided for the individuals in the control arm.
9.2.2. Economic evidence (adults)
Published literature
One economic evaluation was identified with a relevant comparison and has been included in this review.133 This is summarised in the economic evidence profile below (Table 31) and the economic evidence table in Appendix H.
Table 31
Economic evidence profile: Repositioning schedules.
Ten studies were found which included repositioning as part of more complex prevention strategies. 13,121,124,153,181,190,202,225-227 These studies were not included as they evaluated the cost-effectiveness of these more complex prevention strategies as a whole, and did not provide information on the cost-effectiveness of repositioning alone.
See also the economic article selection flow diagram in Appendix D.
New cost-effectiveness analysis
Repositioning was identified by the GDG as a priority area for new economic analysis. An overview of the methods and results of the analysis are presented here, with full details reported in Appendix L The analysis is also summarised in the economic evidence profile above (Table 31).
The model was based on a key randomised trial identified in the systematic review of clinical literature.215 This approach was taken because none of the studies identified in the clinical review had common comparators, and the majority had different populations and different follow up times, thus the interventions could not be reliably compared across the trials.
Costs were considered from a UK NHS and personal social services perspective and health outcomes expressed as quality adjusted life years (QALYs) in accordance with the NICE reference case.140 The time horizon of the model was duration of the trial, or until healing of pressure ulcer. Discounting was not undertaken due to the short time horizon.
Overview of analysis
The population and interventions were dictated by the trial and are summarised below; full details are provided in the evidence table in Appendix L
Population: Residents of Belgian elder care nursing homes who had non-blanchable erythema in a pressure area. The mean age was 84 years.
Intervention 1: Four hours in a semi-Fowler 30° position and 4 hours in a lateral position 30°. The semi-Fowler position consisted of a 30° elevation of the head end and the foot end of the bed. In a lateral position, the position, the individual was rotated 30°, with their back supported with an ordinary pillow.
Intervention 2: Repositioning was the same as above but with 4 hours spent in the semi-Fowler 30° position, and 2 hours in lateral 30° position.
Individuals in the model received intervention 1 or intervention 2. The key clinical outcome was the incidence of pressure ulcers. The proportion of people developing pressure ulcers in each trial arm determined the magnitude of the incremental QALYs. The costs were calculated based on the cost of the repositioning strategies themselves, plus the cost of treating the number of pressure ulcers which developed. Where possible, the model was built probabilistically to take account of the uncertainty around input parameter point estimates. Deterministic sensitivities analyses were also undertaken (for full details see Appendix L).
Model inputs
Model inputs were based on clinical evidence identified in the systematic review undertaken for the guideline, supplemented by additional data sources as required. Model inputs were validated with clinical members of the GDG. A summary of the model inputs used in the base-case analyses is provided in Table 32. Full details about sources, calculations and rationale for selection can be found in Appendix L.
Table 32
Overview of parameters and parameter distributions used in the model.
Aspects of preventative care other than staff time for repositioning, for example nutritional strategies or pressure redistributing devices, were not included in the analysis. These were assumed to be constant between the groups, and would therefore not impact the incremental analysis.
Computations
The model was constructed in Microsoft Excel.
Let UPU represent the utility loss associated with a pressure ulcer, and TPU represent the time spent with a pressure ulcer. PUs avoided is the incremental number of pressure ulcers between the two trial arms. Then, incremental QALYs were calculated as follows:
For costs, let staffi represent the total cost of staff time for intervention i (i=1,2), nurse cost is the cost of nurse time per minute, and minutesi is the number of minutes required per day to implement intervention i. days is the number of days in the time horizon. Then:
Now let pi represent the probability of developing a pressure ulcer when receiving intervention i, and let costPU represent the cost of a pressure ulcer. Then total cost for strategy i is computed as follows:
Sensitivity analyses
Sensitivity analyses were undertaken to explore the effect of different parameter inputs and assumptions on the results of the model. Analyses included varying the staff time required for repositioning, using clinical support workers instead of nurses to reposition people, and varying the cost of a pressure ulcer. Full details of all sensitivity analyses can be found in Appendix L
Results
Table 33 shows the results of the probabilistic base case analysis. Intervention 2 is more costly than intervention 1, and also leads to a greater health benefit. However, the incremental QALY gains are small, and as such, intervention 2 has not been found to be cost-effective at the £20,000 per QALY gained threshold. These results are shown graphically in Table 33. Probabilistic sensitivity analysis revealed that intervention 2 has a probability of being cost-effective of just 3.2%, when compared to intervention 1.
Table 33
Base case results (probabilistic).
Figure 3
Cost-effectiveness plane.
Overall, sensitivity analyses demonstrated that the results of this analysis were largely robust to changes in key assumptions, costs, and frequency of dressing change. See Appendix L for details.
Discussion
This analysis found that 2 and 4 hourly repositioning is not cost-effective compared to 4 hourly repositioning in elderly people in a nursing home with non-blanchable erythema. This conclusion was robust to a range of sensitivity analyses, demonstrating that although uncertainty surrounds model inputs, variation within reasonable ranges does not change the results.
The results above are based on 1 trial, comparing just 2 possible repositioning strategies. Based on this, we cannot conclude that intervention 1 compared to all possible alternatives, but rather that it is cost-effective compared to intervention 2. Ideally, clinical evidence would have allowed a full comparison of all feasible strategies against each other; however this was not possible in this case.
This economic evaluation considered different interventions to those included in the analysis presented by Moore and colleagues,133 and therefore the results of the 2 studies cannot be compared directly. See Appendix L for full discussion.
9.2.3. Clinical evidence (children and young people)
One study was included in this review. 64Evidence from this study is summarised in the clinical GRADE evidence profile below (Table 34). See also the study selection flow chart in Appendix D, forest plots in Appendix I, study evidence tables in Appendix G and exclusion list in Appendix G.
Table 34
Clinical evidence profile: critically ill infants and children: different positions for repositioning – prone positioning versus control supine positioning (control).
The study identified was a parallel randomised trial including infants and children and looked at different positions for repositioning prone or semi-recumbent versus control supine positioning.
Summary of studies included in the review
| Study | Intervention/comparison | Population | Outcomes | Study length |
|---|---|---|---|---|
| Fineman 2006 64 | Prone positioning: a 2 hourly cyclic rotation from full prone to right lateral/prone to full prone to left lateral/prone and then to full prone. Supine positioning. All participants were maintained on standard hospital beds. Individually sized head, chest, pelvic, distal femoral and lower limb cushions were created using pressure-relieving material. | One hundred and two children with acute lung injury. |
| 28-days |
9.2.4. Economic evidence (children and young people)
Published literature
No relevant economic evaluations were identified.
New cost-effectiveness analysis
The results of the new cost-effectiveness analysis presented above were not intended to be generalisable to people under the age of 18.
Economic considerations
In the absence of economic evidence for this review question, the GDG considered relevant UK NHS unit costs. These were considered alongside clinical evidence obtained from the Delphi consensus panel to inform qualitative judgement about cost-effectiveness.
The ease of repositioning depends on the weight of the child and how stable they are. Small, light children can be repositioned by a nurse or carer in a couple of minutes. Heavier, immobile children, or those in an unstable condition, may require 2 nurses or healthcare support workers for up to 10 minutes (costing an estimated £7.00-11.6047). Repositioning equipment may also be required.
The GDG estimated that patient hoists cost £500 - £1,500, but noted that cheaper equipment is also available, such as repositioning sheets (or slide sheets). Example repositioning sheets include the Disposaglide tubular patient specific slide sheet 100cm × 120cm, which costs £80.04 for 10 disposable sheets, and the Laundraglide tubular washable slide sheet 100cm × 120cm, which costs £57.77 for 5 reusable sheets.
Play experts can also be used to encourage children to move around. The GDG expected most play experts to be NHS Band 4, thus 1 hour of play expert time could be estimated to cost £26 (calculated based on annual costs of Band 4 healthcare professionals, including for example, overheads and capital costs, divided by the annual hours worked by a hospital nurse [1,573]47).
9.2.4.1. Clinical (adults)
9.2.4.1.1. Repositioning compared to no repositioning
- One study (n= 574) showed there is no clinical difference between frequent turning (2 hourly) compared to standard care for reducing the incidence of pressure ulcers (all grades), the direction of effect favoured 2 hour turning (very low quality).
- One study (n=569) showed there is no clinical difference between frequent turning (3 hourly) and standard care for reducing the incidence of pressure ulcers (all grades), the direction of the effect favoured the standard hospital mattress (very low quality).
- One study (n= 577) showed a pressure reducing mattress in combination with less frequent turning (4 hourly) was more clinically effective than standard care for the incidence of pressure ulcers (all grades)(very low quality).
- One study (n=578) showed there is no clinical difference between a pressure-reducing mattress in combination with less frequent turning (6 hourly) and standard care for the incidence of pressure ulcers (all grades), the direction of the effect favoured the pressure-reducing mattress and less frequent turning (low quality).
- One study (n=574) showed there is no clinical difference between frequent turning (2 hourly) and standard care for the incidence of pressure ulcers (grade 2 and above) (very low quality).
- One study (n= 574) showed there is no clinical difference between frequent turning (3 hourly) and standard care for the incidence of pressure ulcers (grade 2 and above) (very low quality).
- One study (n=569) showed that the use of a pressure reducing mattress in combination with less frequent turning (4 hourly) is clinically effective at reducing the incidence of pressure ulcers (grade 2 and above) compared to standard care (low quality).
- One study (n=577) showed there is no clinical difference between a pressure reducing mattress in combination with less frequent turning (6 hourly) and standard for the incidence of pressure ulcers (grade 2 and above) (very low quality).
- No evidence was found for the following outcomes:
- Acceptability of treatment
- Rate of development of pressure ulcers
- Time to development of pressure ulcers
- Time in hospital or NHS care
- Health-related quality of life
9.2.4.1.2. Different frequencies of repositioning
- One study (n=121) showed there is potentially a clinical benefit of frequent turning (2 hourly) when compared to frequent turning (3 hourly) for the incidence of pressure ulcer (all grades)(very low quality).
- One study (n=121) showed there may be a clinical benefit of frequent turning (2 hourly) when compared to frequent turning (3 hourly) for the incidence of pressure ulcer (grade 2 and above)(very low quality).
- One study (n= 129) showed there is potentially a clinical benefit of a pressure reducing mattress in combination with less frequent turning (4 hourly) when compared to frequent turning (2 hourly) for the incidence of pressure ulcers (all grades) (very low quality).
- One study (n= 129) showed there is potentially a clinical benefit of a pressure reducing mattress in combination with less frequent turning (4 hourly) when compared to frequent turning (2 hourly) for the incidence of pressure ulcers (grade 2 and above) (very low quality).
- One study (n= 126) showed there is no clinical difference between frequent turning (2 hourly) compared to a pressure reducing mattress in combination with less frequent turning (6 hourly) for reducing the incidence of pressure ulcers, but the direction of the estimate of effect could favour either intervention (all grades) (low quality).
- One study (n= 126) showed there may be no clinical difference between frequent turning (2 hourly) compared to a pressure reducing mattress in combination with less frequent turning (6 hourly) for reducing the incidence of pressure ulcers, but the direction of the estimate of effect could favour either intervention (grade2 and above) (very low quality).
- One study (n=124) showed that less frequent turning (4 hourly) was more clinically effective when compared to a pressure reducing mattress in combination with frequent turning (3 hourly) for reducing the incidence of pressure ulcers (all grades) (very low quality).
- One study (n=124) showed that less frequent turning (4 hourly) may be more clinically effective when compared to a pressure reducing mattress in combination with frequent turning (3 hourly) for reducing the incidence of pressure ulcers (grade 2 and above) (low quality).
- One study (n= 121) showed there is potentially a clinical benefit of less frequent turning (6 hourly) compared to a pressure reducing mattress in combination with frequent turning (3 hourly) for reducing the incidence of pressure ulcer (all grades) (very low quality).
- One study (n= 121) showed there may be a clinical benefit of less frequent turning (6 hourly) compared to a pressure reducing mattress in combination with frequent turning (3 hourly) for reducing the incidence of pressure ulcer (grade 2 and above) (very low quality).
- One study (n=129) showed there is potentially a clinical benefit of a pressure reducing mattress in combination with more frequent turning (4 hourly) compared to a pressure reducing mattress in combination with less frequent turning ( 6 hourly) for reducing the incidence of pressure ulcers (all grades) (very low quality).
- One study (n=129) showed there is potentially a clinical benefit of a pressure reducing mattress in combination with more frequent turning (4 hourly) compared to a pressure reducing mattress in combination with less frequent turning ( 6 hourly) for reducing the incidence of pressure ulcers (grade 2 and above) (very low quality).
- One study (n= 235) showed there may be no clinical difference between repositioning with unequal time interval (2 hours in a lateral position and 4 hours in a supine position) compared to repositioning with equal time interval (4 hourly) for reducing the incidence of pressure ulcers (grade 2 and above) but the direction of the estimate of effect could favour either intervention (very low quality).
- One study (n= 235) reported that there may be no difference between repositioning on a pressure reducing mattress alternately for 2 hours in a lateral position and 4 hours in a supine position compared with repositioning every 4 hours for the time to develop a pressure ulcer. The clinical importance and imprecision is unknown (very low quality).
- One study (n=19) showed there may be no clinical difference between repositioning with unequal time intervals (small unscheduled shifts) compared to repositioning with equal time intervals (2 hourly) at 2 weeks follow up for the incidence of pressure ulcers (grade 2 and above), but the direction of the estimate of effect could favour either intervention (very low quality).
- No evidence was found for the following outcomes:
- Acceptability of treatment
- Rate of development of pressure ulcers
- Time to development of pressure ulcers
- Time in hospital or NHS care
- Health-related quality of life
9.2.4.1.3. Different positions for repositioning
- One study (n= 213) showed that repositioning using the 30° tilt (3 hourly at night) is potentially more clinically effective at reducing pressure ulcers (grade 1-4) when compared to the 90° lateral position (6 hourly at night) (very low quality).
- One study (n=46) showed that the 90° lateral position (at night) may be more clinically effective at reducing the incidence of pressure ulcers (grade l: non-blanching erythema) when compared to the 30° tilt over 1 night (very low quality).
- One study (n=46) reported a mean time to pressure ulcer development of 26 days (range 3 days) for the 30° tilt group and 17 days (range 24 days) with the a 90° lateral rotation. The clinical importance and imprecision is unknown (very low quality).
- One study (n= 221) showed there may be no clinical difference between the semi recumbent positioning (45° position of the head and back) when compared to supine positioning (standard care) for reducing the incidence of pressure ulcers (grade 1-4), but the direction of the estimate of effect could favour either intervention (low quality).
- No evidence was found for the following outcomes:
- Acceptability of treatment
- Rate of development of pressure ulcers
- Time to development of pressure ulcers
- Time in hospital or NHS care
- Health-related quality of life
9.2.4.1.4. Turning tables
- Two studies (n=151) showed there may be no clinical difference between a kinetic treatment table and standard care for reducing the incidence of pressure ulcers (all grades), but the direction of the estimate of effect could favour either intervention (very low quality).
- One study (n=86) reported evidence for a kinetic treatment table and standard care for the time in hospital. The number of days in hospital was reported. The clinical importance and imprecision is unknown.
- No evidence was found for the following outcomes:
- Acceptability of treatment
- Rate of development of pressure ulcers
- Time to development of pressure ulcers
- Time in hospital or NHS care
- Health-related quality of life
9.2.4.2. Economic (adults)
- One cost-effectiveness analysis found that repositioning using a 30° tilt every 3 hours during the night dominates repositioning every 6 hours at night using 90° lateral rotation in people in long term care. This analysis was assessed as partially applicable with minor limitations.
- One cost-utility analysis found that repositioning every 4 and 2 hours (alternatively) was not cost-effective compared to repositioning every 4 hours (ICER = £1,854,070) in people in long term care with non-blanchable erythema. This analysis was assessed as directly applicable with minor limitations.
9.2.4.3. Clinical (neonates, infants, children and young people)
9.2.4.3.1. Critically ill infants and children: different positions for repositions (prone positioning) versus control (supine positioning)
Proportion of people developing pressure ulcers
- One study (n=102) showed supine positioning (2 hour cyclic rotation) may be more clinically effective at reducing pressure ulcers (grade 2 and above) when compared to prone positioning (very low quality).
9.2.4.4. Economic (neonates, infants, children and young people)
- No relevant economic evaluations were identified.
9.3. Recommendations and link to evidence
9.3.1. Adults
| Recommendations |
|
|---|---|
| Relative values of different outcomes | The GDG identified that the proportion of people developing new pressure ulcers and patient acceptability were the most critical outcomes to inform decision making, given that the primary goal of pressure ulcer prevention was to limit the number of new pressure ulcers. Acceptability was identified as being critical from the perspective of the patient, as it was noted that frequency of repositioning could have a significant impact upon quality of life. Rate of development of new pressure ulcers, time to develop new pressure ulcers, time in hospital or NHS care and health related quality of life were considered important outcomes to inform decision making. |
| Trade-off between clinical benefits and harms | The GDG considered that relieving pressure by repositioning people at risk of pressure ulcers is fundamental to the prevention of pressure ulcers and is current best practice. The GDG therefore used the evidence identified to ascertain the optimal repositioning strategy (including frequency and position) to prevent pressure ulcers. The evidence for frequency of repositioning came from 1 study. There was a clinical benefit of 4 hour turning (the intervention included a pressure-reducing mattress) compared to standard care for reduction in incidence of grade 2 and above pressure ulcers, and for all grades of pressure ulcers. When comparing the differing turning schemes for reducing the incidence of pressure ulcers there was a clinical benefit for 2 hour turning compared to 3 hour for grade 2 pressure ulcers. There was a clinical benefit of 4 compared to 2 hours (all grades, grade 2 and above) but no clinical benefit of 6 hours compared to 2 hours (all grades, grade 2 and above), and 4 and 6 hours compared to 3 hours (all grades, grade 2 and above) but this was confounded by the fact that the 4 and 6 hour intervention had a pressure-reducing mattress. For grade 1 pressure ulcers and grade 2 and above, 4 hour turning plus a pressure-reducing mattress was more clinically beneficial for reducing grade 1 pressure ulcers than 6 hour turning plus a pressure-reducing mattress. Three studies looked at the differing positions and frequency of positioning. There was no clinical difference between 2 hours lateral and 4 hours supine positioning compared to repositioning at 4 hours, prone compared to supine positioning or small unscheduled shifts in position in comparison to 2 hour turning. There was a clinical benefit of 30 degree tilt (3 hourly at night) compared to 90 degree tilt (6 hourly at night) for grade 1 to 4 ulcers. There was no difference between 45 degree position of head and back compared to supine position for grade 1 to 4. No differences were found in time to develop a pressure ulcer. Another study found no clinical difference between a kinetic treatment table (which turns people) compared to a standard bed for incidence of pressure ulcers and time in hospital. No data was identified on patient acceptability. The GDG wished to highlight patient acceptability was likely to be impacted by frequent repositioning, particularly during the night time. The GDG also felt that many people who are at risk of developing a pressure ulcer are likely to be unable to tolerate lying in 1 position for a signigifcant period of time and in these situations, healthcare professionals should discuss tolerability and preferences with the person at risk. The evidence identified suggested that a lower frequency of repositioning (4 hour hour) was beneficial yet this was confounded by the use of a pressure redistributing mattress. However, the GDG considered that people at risk would be provided with a high specification mattress (in line with recommendation 29). The results were inconclusive for other frequencies of repositioning however the GDG felt that any patients who have the chance of developing a pressure ulcer should be turned at least every 6 hours. The evidence was extrapolated for patients in hospital populations to those in the community as the outcome of reducing pressure ulcer development should be the same and that the benefits of repositioning was important enough to be extended to this population. The GDG acknowledged that there were challenges in doing this in the community but that the impact of avoiding a pressure ulcer was likely to have a large impact on quality of life. Care packages should allow for this frequency of repositioning. The GDG emphasised that where a person is able to reposition themselves, they should be encouraged to do so, as this was likely to be more acceptable to the individual and require fewer resources. However, it was acknowledged that there are situations in which people would not be able to reposition themselves and in these scenarios, healthcare professionals should reposition individuals manually. No evidence was identified on the use of repositioning equipment (for example, hoists or slide sheets) however the GDG felt that the use of this equipment may be essential in repositioning some individuals (for example people who are obese) and therefore the recommendation highlighted the possible use of such devices. The GDG highlighted that where equipment was used for the repositioning of people at risk or high risk of developing a pressure ulcer, appropriate equipment should be used, in discussion with the individual. |
| Economic considerations | An original economic model was developed based on the best available clinical evidence. The primary clinical outcome included in the model was the development of a pressure ulcer, the probability of which varied according to each repositioning schedule. The probability data was taken from 1 key RCT identified in the clinical review.215 Costs were calculated from an NHS and social services perspective, and the impact on quality of life was included for the proportion of individuals who developed a pressure ulcer. 4 hours in a semi-Fowler 30° position (the individual lies on their back with upper body high by 30⁰) and 4 hours in a lateral position 30°, was found to be cost-effective compared to 4 hours in a semi-Fowler 30° position and 2 hours in a lateral position 30° (ICER = £1,864,070). The population was people at high risk, and the majority were lying on pressure reducing devices (as per recommendation 29). The model was robust to the majority of sensitivity analyses surrounding key assumptions and data used to inform the model. However, the model did reveal that if the cost of treating a pressure ulcer is £11,584 (compared to £5,672 in the base case), repositioning every 3 hours during the night would be cost-effective compared to repositioning every 6 hours. The GDG did not think that this was an unrealistic scenario, as people at high risk are likely to develop more severe pressure ulcers which take a long time to heal and could feasibly cost this much to treat. No additional economic evidence was identified. The GDG felt that the evidence was not strong enough to pinpoint an exact time interval at which individuals should be repositioned, as the benefits, and therefore the economic impact, varied greatly between individuals. The GDG considered the evidence presented, and agreed that it would most likely be cost effective to reposition adults at the frequencies identified in the recommendation above. The GDG noted that the resource implications may be higher in a community setting, but agreed that the benefits were likely to be such that repositioning at the specified intervals was still likely to be cost-effective. In many situations repositioning would be undertaken during contact with a health care professional for other reasons and the additional resources required for repositioning would be small. Also note that it was assumed in the model that all adults required 2 members of staff to change their position, whereas many adults are able to reposition themselves, and in such cases the economic impact will be greatly reduced. |
| Quality of evidence | The evidence was graded as low to very low. The evidence either had serious or very serious imprecision and the studies had risk of bias. Studies used different repositioning regimens and some of them used repositioning in combination with different pressure redistributing devices. There were differences between studies in the use of risk assessment tools for identifying people who were at high risk. Some studies used standard care which did not include repositioning. The GDG did not consider this to be representative of the standard care provided within the NHS. The majority of evidence was based in different settings for example, ICU, nursing homes, geriatric wards. Older studies may have used adjunctive pressure redistributing devices of a different standard to those used in current practice. GDG consensus was used to develop the recommendation on repositioning those assessed to be at risk at least every 6 hours, as they thought this necessary as a minimum preventional strategy. |
| Other considerations | The GDG felt that it was important to consider an individuals' preference when offering repositioning, particularly when this takes place during the night-time. The GDG highlighted that the needs and preferences of each individual should be considered by the healthcare professional, emphasising that it is important that every person at risk understands the benefits of being repositioned. The GDG also highlighted that less frequent repositioning may impact upon an individual's comfort and tolerability and that this should also be considered when identifying the optimum frequency of repositioning. For example, some people who are at risk of developing a pressure ulcer are likely to be unable to tolerate lying in 1 position for a significant period of time and in these situations, healthcare professionals should discuss tolerability with the person at risk. The GDG referred to anecdotal evidence which suggested that there were often difficulties in obtaining access to repositioning equipment and therefore delays in accomplishing repositioning of an individual at risk may occur as a result. The GDG thus amended the recommendation to highlight that repositioning equipment should be made readily available and that healthcare professionals should ensure that the timing of access to equipment is considered when planning a prevention strategy. |
9.3.2. Neonates, infants, children and young people
| Recommendations |
|
|---|---|
| Relative values of different outcomes | The GDG identified that the proportion of people developing new pressure ulcers and patient acceptability were the most critical outcomes to inform decision making, given that the primary goal of pressure ulcer prevention was to limit the number of new pressure ulcers. Acceptability was identified as being critical from the perspective of the patient, as it was noted that this could have a significant impact upon quality of life. Rate of development of new pressure ulcers, time to develop new pressure ulcers, time in hospital or NHS care and health related quality of life were considered important outcomes to inform decision making. |
| Trade-off between clinical benefits and harms | One RCT was identified, which included critically ill infants and children. Only 1 relevant outcome was included; incidence of pressure ulcers (grade 2 and above), which showed no clinical benefit for the prone position compared to the supine position. There were no studies identified for neonates, infants, children or young people which considered the frequency of repositioning therefore formal consensus using a modified Delphi was used to develop the recommendation.. The GDG used 1 statement from the Delphi consensus survey to inform the recommendation. The statement was ‘Healthcare professionals should ensure that neonates, infants, children and young people at high risk of developing a pressure ulcer are repositioned at least every 4 hours’. The statement was accepted by the Delphi consensus panel. Further detail on the Delphi consensus survey can be found in Appendix N. The GDG discussed the statement and agreed that a recommendation should be developed. Qualitative comments gathered from the Delphi consensus panel suggested that there are situations in which there may be benefits from more frequent repositioning, particularly for people considered to be at high risk of developing a pressure ulcer. Additionally, the GDG felt that it was likely that benefits in pressure ulcer prevention gained by the adult population and identified in the evidence was likely to be applicable to the paediatric population. Additional comments from the panel also highlighted that there may be some cases in which the benefits of frequent repositioning are outweighed by the harms. For example, for some children the clinical condition may prevent frequent repositioning and in these cases, alternative strategies for achieving pressure reduction should be considered. The group also noted that there are some situations in which less frequent repositioning may be considered for example, those nearing the end of life for which repositioning is carried out for comfort. Given the potential benefits in the prevention of pressure ulcers, the GDG decided to amend the final recommendation to reflect these benefits, to favour repositioning every 4 hours. In addition, qualitative comments from the GDG highlighted the importance of ensuring that the frequency of repositioning is tailored to the needs of the individual. The panel and the GDG felt that some individuals at high risk of developing a pressure ulcer, including for example, children with a spinal cord injury or with neurological disease, may require more frequent repositioning and that this should be considered on an individual basis. The GDG therefore developed a recommendation to reflect the need for more frequent repositioning in high risk populations. Qualitative comments from the Delphi panel also identified that there was a need to ensure that processes were in place to ensure that healthcare professionals caring for a neonate, infant, child or young person were aware of the need for more frequent repositioning. Panel members suggested that this process may involve documenting an individualised care pathway, including the process for repositioning or a pathway outlining the times repositioning was required. The GDG did not feel that it was possible to recommend a specific method for documenting the need for increased repositioning because of the variety of examples suggested and the lack of evidence identified,. However, the group agreed that as the benefits of doing so were likely to outweigh harms in terms of the additional resource required, the need to document increased frequency of repositioning should be recommended. |
| Economic considerations | There are some costs associated with repositioning. Small children can be repositioned by nurses or carers in a few minutes, whereas heavier, immobile children may need 2 nurses or health care support workers for up to 10 minutes, at an estimated cost of £7-£12. The GDG noted that repositioning is crucial for pressure redistribution, and its benefit is supported by evidence from the Delphi consensus panel. The GDG considered the economic implications and concluded that repositioning will improve the quality of life of those with pressure ulcers, as well as reduce future treatment costs by preventing pressure ulcers. The improvement in quality of life and reduction in future treatment costs were considered likely to outweigh the costs. |
| Quality of evidence | One RCT was identified for critically ill infants and children. The study had only 1 relevant outcome, which was graded according to GRADE criteria, very low due to serious risk of bias and very serious imprecision. No RCTs or cohort studies were identified for neonates, infants, children or young people for frequency of repositioning. Formal consensus using a modified Delphi was therefore used to develop the recommendation. To inform the recommendation, the GDG used 1 statement which was included in Round 1 of the Delphi consensus survey and reached 77% consensus agreement. Further details can be found in Appendix N. |
| Other considerations | Qualitative comments from the Delphi consensus panel highlighted the importance of ensuring that any special considerations relating to settings in which a child may require repositioning were considered for example, in school. Other comments identified that many neonates and infants were likely to be repositioned frequently through their standard care, for example, when they are picked up and held or their nappy is changed. |
| Recommendations |
|
|---|---|
| Relative values of different outcomes | The GDG identified that the proportion of people developing new pressure ulcers and patient acceptability were the most critical outcomes to inform decision making, given that the primary goal of pressure ulcer prevention was to limit the number of new pressure ulcers. Acceptability was identified as being critical from the perspective of the patient, as it was noted that this may have a significant impact upon quality of life. Rate of development of new pressure ulcers, time to develop new pressure ulcers, time in hospital or NHS care and health related quality of life were considered important outcomes to inform decision making. |
| Trade-off between clinical benefits and harms | One RCT was identified, which included critically ill infants and children. Only 1 relevant outcome was included; incidence of pressure ulcers (grade 2 and above), which showed no clinical benefit for the prone position compared to the supine position. There were no studies identified for neonates, infants, children or young people regarding repositioning equipment therefore formal consensus using a modified Delphi was used to develop the recommendation. The GDG used 1 statement from the Delphi consensus survey to inform the recommendation; ‘Healthcare professionals should ensure that repositioning equipment is made available to aid repositioning of young people, where clinically indicated’. The statement was accepted by the Delphi consensus panel in Round 1 of the Delphi consensus survey. Further detail on the Delphi consensus survey can be found in Appendix N. The GDG discussed the statement and agreed that a recommendation should be developed. Qualitative responses gathered from the Delphi consensus panel reported that there were often difficulties in obtaining access to repositioning equipment, despite benefits to both the individual and the healthcare professional. The GDG acknowledged that not all individuals within the paediatric population would require the use of repositioning equipment. However it was clear that the possible benefits gained from preventing pressure ulcers by facilitating repositioning were likely to be high and as such, outweigh any possible harm. Hence the GDG developed a recommendation to highlight that this equipment should be readily available for use by healthcare professionals in repositioning children and young people. Qualitative responses also highlighted the need to ensure that healthcare professionals were trained in the use of this equipment, so that it is used safely. The GDG agreed that this was important and developed a recommendation to reflect this need. |
| Economic considerations | There are some costs associated with repositioning equipment and associated training. Hoists are available in the majority of hospitals and are estimated to cost around £500-£1,500. Repositioning sheets can also be used in some cases, and can be obtained at a much lower cost of £12 for a reusable sheet (based on £57.77 for 5 Laundraglidesheets), or £8 for a disposable sheet (based on £80.04 for 10 Disposaglide sheets). The GDG has considered the economic implications of the use of repositioning equipment, and concluded that these interventions will improve the safety and quality of life of the individual who needs to be repositioned. In addition, upfront costs will be mitigated through reductions in future treatment costs. The improvement in quality of life and reduction in future costs were considered likely to outweigh the costs. Qualitative responses also highlighted the need to ensure that healthcare professionals were trained in the use of this equipment, so that it is used safely. The GDG agreed that this was important and developed a recommendation to reflect this need. |
| Quality of evidence | One RCT was identified for critically ill infants and children. The study had only 1 relevant outcome, which was graded very low due to serious risk of bias and very serious imprecision. No RCTs or cohort studies were identified for neonates, infants, children or young people for repositioning equipment. Formal consensus using a modified Delphi was therefore used to develop the recommendation. To inform the recommendation, the GDG used 1 statement which was included in Round 1 of the Delphi consensus survey and reached 95% consensus agreement. Further details can be found in Appendix N. |
| Other considerations | There were no other considerations. |
| Recommendations |
|
|---|---|
| Relative values of different outcomes | The GDG identified that the proportion of people developing new pressure ulcers and patient acceptability were the most critical outcomes to inform decision making, given that the primary goal of pressure ulcer prevention was to limit the number of new ulcers. Acceptability was identified as being critical from the perspective of the patient, as it was noted that this could have a significant impact upon quality of life. Rate of development of new pressure ulcers, time to develop new pressure ulcers, time in hospital or NHS care and health related quality of life were considered important outcomes to inform decision making. |
| Trade-off between clinical benefits and harms | One RCT was identified, which included critically ill infants and children. Only 1 relevant outcome was included which was incidence of pressure ulcers (grade 2 and above), which showed no clinical benefit for the prone position compared to the supine position. There were no studies identified for neonates, infants, children or young people for reasons for repositioning therefore the GDG used formal consensus using a modified Delphi to develop the recommendation. The GDG used 1 statement from the Delphi consensus survey to inform the recommendation. The statement was ‘In children and young people, who refuse repositioning, healthcare professionals should ensure that patients and carers understand the reasons for repositioning’. The statement was accepted by the Delphi consensus panel. Further detail on the Delphi consensus survey can be found in Appendix N. The GDG discussed the statement and agreed that a recommendation should be developed. Qualitative responses from the Delphi consensus panel discussed methods of ensuring that the need for repositioning is well understood by children and their parents or carers. Specifically, comments identified that pictures can be beneficial in providing information, particularly for individuals in whom English is not their first language. The GDG did not feel that it was possible to recommend a method by which the reasons for repositioning should be explained as the needs of each individual should be considered by the healthcare professional in identifying the best approach. The GDG did not identify any possible harms in ensuring that the reasons for repositioning were explained, particularly as it was felt that this was part of obtaining informed consent. However, the GDG felt that an increase in understanding was likely to result in the prevention of a greater number of pressure ulcers, due to the associated increase in the rates of repositioning. A recommendation was therefore developed to highlight the need to ensure that the reasons for repositioning were well understood. A number of comments from the panel also identified that the use of the word ‘decline’ was more appropriate than ‘refuse’. Other comments identified that parents and carers may decline repositioning on behalf of their child and therefore, the recommendation should also include these individuals. The recommendation was suitably amended to incorporate these changes. |
| Economic considerations | No economic considerations. |
| Quality of evidence | One RCT was identified for critically ill infants and children. The study had only1 relevant outcome, which was graded very low due to serious risk of bias and very serious imprecision. No RCTs or cohort studies were identified for neonates, infants, children or young people for understanding the reasons for repositioning. Formal consensus using a modified Delphi was therefore used to develop the recommendation. To inform the recommendation, the GDG used 1 statement which was included in Round 1 of the Delphi consensus survey and reached 100% consensus agreement. Further details can be found in Appendix N. |
| Other considerations | Panel members identified that where children, parents or carers decline repositioning, the reasons for repositioning should be clearly documented in the child's notes. |
| Recommendations |
|
|---|---|
| Relative values of different outcomes | The GDG identified that the proportion of people developing new pressure ulcers and patient acceptability were the most critical outcomes to inform decision making, given that the primary goal of pressure ulcer prevention was to limit the number of new ulcers. Acceptability was identified as being critical from the perspective of the patient, as it was noted that this could have a significant impact upon quality of life. Rate of development of new pressure ulcers, time to develop new pressure ulcers, time in hospital or NHS care and health related quality of life were considered important outcomes to inform decision making. |
| Trade-off between clinical benefits and harms | One RCT was identified, which included critically ill infants and children. Only 1 relevant outcome was included which was incidence of pressure ulcers (grade 2 and above), which showed no clinical benefit for the prone position compared to the supine position. There were no studies identified for neonates, infants, children or young people for the use of a play expert to encourage repositioning therefore the GDG used formal consensus using a modified Delphi to develop the recommendation. The GDG used 1 statement from the Delphi consensus survey to inform the recommendation. The statement was ‘Healthcare professionals should consider the use of play experts to encourage repositioning in children who have difficulty with compliance.’ The statement was accepted by the Delphi consensus panel. Further detail on the Delphi consensus survey can be found in Appendix N. The GDG discussed the statement and agreed that a recommendation should be developed. Qualitative comments received from members of the Delphi consensus panel focused on methods which the play expert may use to encourage repositioning. The GDG agreed that the use of play specialists to increase compliance with repositioning was likely to result in benefits in the prevention of pressure ulcers from an increase in rates of repositioning. The group felt that these benefits were likely to outweigh any harms in terms of resources and developed a recommendation to suggest that the use of a play expert should be considered. |
| Economic considerations | There are costs associated with the use of a play expert. The estimated cost per hour for a band 4-5 play expert is £26 (typical salary band identified by GDG members). The GDG considered these costs likely to be offset by the benefits of the intervention in terms of improvement in the person's quality of life and reductions in future treatment costs through the prevention of pressure ulcers. |
| Quality of evidence | One RCT was identified for critically ill infants and children. The study had only 1 relevant outcome, which was graded very low due to serious risk of bias and very serious imprecision. No RCTs or cohort studies were identified for neonates, infants, children or young people for use of a play expert to encourage repositioning. Formal consensus using a modified Delphi was therefore used to develop the recommendation. To inform the recommendation, the GDG used 1 statement which was included in Round 1 of the Delphi consensus survey and reached 97% consensus agreement. Further details can be found in Appendix N. |
| Other considerations | There are no other considerations. |
| Recommendations |
|
|---|---|
| Relative values of different outcomes | The GDG identified that the proportion of people developing new pressure ulcers and patient acceptability were the most critical outcomes to inform decision making, given that the primary goal of pressure ulcer prevention was to limit the number of new ulcers. Acceptability was identified as being critical from the perspective of the patient, as it was noted that this could have a significant impact upon quality of life. Rate of development of new pressure ulcers, time to develop new pressure ulcers, time in hospital or NHS care and health related quality of life were considered important outcomes to inform decision making. |
| Trade-off between clinical benefits and harms | One RCT was identified, which included critically ill infants and children. Only 1 relevant outcome was included which was incidence of pressure ulcers (grade 2 and above), which showed no clinical benefit for the prone position compared to the supine position. There were no studies identified for neonates, infants, children or young people for the relieving of scalp and head pressure when repositioning therefore the GDG used formal consensus using a modified Delphi to develop the recommendation. The GDG used 1 statement from the Delphi consensus survey to inform the recommendation. The statement was ‘Repositioning neonates, infants, children and young people at risk of developing pressure ulcers should include ensuring that pressure on areas of the scalp of the head is also relieved.’ The statement was included in Round 2 of the Delphi consensus survey after being identified as a relevant area for inclusion in qualitative comments gathered during Round 1. The statement was accepted by the Delphi consensus panel. Further detail on the Delphi consensus survey can be found in Appendix N. The GDG discussed the statement and agreed that a recommendation should be developed. The GDG felt that the benefits of recommending pressure redistribution were likely to be substantial in the subsequent prevention of pressure ulcer development and that the scalp and head were areas that neonates, infants, children and young people were likely to be at risk of developing pressure ulcers. The GDG could not identify any likely harms of relieving pressure in these areas and therefore a recommendation was developed to ensure that pressure redistribution in these areas was achieved to prevent the development of pressure ulcers. |
| Economic considerations | No additional economic considerations further to those discussed for repositioning. |
| Quality of evidence | One RCT was identified for critically ill infants and children. The study had only 1 relevant outcome, which was graded very low due to serious risk of bias and very serious imprecision. No RCTs or cohort studies were identified for neonates, infants, children or young people for the relieving of head and scalp pressure when repositioning. Formal consensus using a modified Delphi was therefore used to develop the recommendation. To inform the recommendation, the GDG used 1 statement which was included in Round 2 of the Delphi consensus survey and reached 96% consensus agreement. Further details can be found in Appendix N. |
| Other considerations | Qualitative comments from the Delphi consensus panel identified that there were other at risk areas which should be considered when repositioning this population for example, the scalp, and that any repositioning regimen should take into account and inspect all areas which may be at risk of developing a pressure ulcer. Recommendations on the provision of pressure redistributing devices for the prevention of occipital pressure ulcers in neonates, infants, children and young people can be found in Chapter 10. |
- Repositioning - The Prevention and Management of Pressure Ulcers in Primary and ...Repositioning - The Prevention and Management of Pressure Ulcers in Primary and Secondary Care
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