Clinical question
Should 30 degree lateral positioning vs. greater than 30 degree lateral positioning be used for people at risk of pressure injuries?
Context
Population:
Intervention:
Comparison:
Main Outcomes:
Setting:
Conflicts on Interest:
People at risk of pressure injuries
30 degree lateral positioning
greater than 30 degree lateral positioning
Any clinical setting
Pressure Injury occurrence
No Guideline Governance Group members of Core Review Group members had a conflict of interest
Evidence to Decision Framework
(Click on the individual judgements for more information)
Summary of Judgements
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Yes
Moderate
Trivial
Very low
No important uncertainty or variability
Favors the intervention
Negliible costs and savings
Low
Varies
Varies
Probably yes
Varies
1. Problem:
Is the problem (pressure injuries) a priority?
JUDGEMENT
No
Probably No
Probably Yes
Yes
Varies
Don’t Know
RESEARCH EVIDENCE
The problem of preventing pressure injuries is a significant priority to healthcare in most clinical settings. In a stakeholder survey conducted by the Guideline Governance Group in 2021, the target audiences for the guideline, including individuals with or at risk of PIs, their informal carers and health professionals, all identified that receiving clinical guidance on repositioning in a bed or chair is of the highest priority (median ranking 5/5, where 5 is the highest priority).In an earlier survey conducted by the previous Guideline Governance Group in 2018 (Haesler, Pittman et al. 2022), 76.2% (292/383) of individuals with or at risk of PIs and 69.8% (593/850) of informal carers rated receiving information on repositioning as important or very important. The median (inter quartile range [IQR]) priority ranking for receiving information on support surfaces was 4 (1) for individuals with or at risk of PIs and 5 (1) for informal carers (possible score range 1 to 5).
2. Desirable Effects:
How substantial are the desirable anticipated effects?
JUDGEMENT
Trivial
Small
Moderate
Large
Varies
Don’t Know
RESEARCH EVIDENCE
| Outcome | With 30 degree lateral tilt positioning |
With greater than 30 degree lateral tilt positioning |
Difference | Relative effect |
|---|---|---|---|---|
| PI occurrence | 6/117 (5.1%) | 15/135 (11.1%) | 42 fewer PIs per 1,000 (from 100 fewer to 330 more) |
RR 0.62 (0.10-3.97) |
Outcome 1: PI Occurrence
The meta-analysis (Gillespie, Walker et al. 2020) included two randomized controlled trials (RCTs) (Young 2004, Moore, Cowman et al. 2011) that compared 30 degree lateral positioning versus greater than 30 degree lateral positioning for people at risk of PIs (as measured on the activity/mobility sub-scale of the Braden scale or the Waterlow score). One study conducted in an acute medical ward followed participants for 24 hours (Young 2004). The second study was conducted in long term aged care and followed participants for four weeks (Moore, Cowman et al. 2011). In both studies repositioning was conducted on a pressure redistribution surface described as low air loss mattresses (Young 2004), alternating pressure (active) air mattresses (Young 2004) or powered devices (Moore, Cowman et al. 2011). In one study, repositioning was conducted every 2-3 hours for all participants (Young 2004); in the second study 30 degree positioning was conducted every three hours and greater than 30 degree positioning was conducted every six hours (Moore, Cowman et al. 2011, Moore, Cowman et al. 2013). No participants in either study experienced a Category/Stage 3 or 4 PI (Young 2004, Moore, Cowman et al. 2011). The meta-analysis (Gillespie, Walker et al. 2020) showed that 42 fewer people (between 100 fewer and 330 more) might experience a PI when a 30 degree lateral tilt is used (RR = 0.62, 95% CI 0.10 to3.97, p = 0.62).
3. Undesirable Effects:
How substantial are the undesirable anticipated effects?
JUDGEMENT
Trivial
Small
Moderate
Large
Varies
Don’t Know
RESEARCH EVIDENCE
| Outcome | With 30 degree lateral tilt positioning |
With greater than 30 degree lateral tilt positioning |
Difference | Relative effect |
|---|---|---|---|---|
| Any adverse event | None reported | None reported | unknown | unknown |
Mortality
Neither of the studies (Young 2004, Moore, Cowman et al. 2011) included adverse or undesirable effects in reporting. In the absence of any reporting on serious adverse events, and based on the GGG’s experience, the undesirable effects of positioning at 30 degrees laterally are trivial
4. Overall certainty of evidence: What is the overall certainty of the evidence of effects?
JUDGEMENT
Very low
Low
Moderate
High
No included studies
RESEARCH EVIDENCE
| Outcome | Relative Importance | Certainty of Evidence |
|---|---|---|
| PI occurrence | CRITICAL | VERY LOW |
Outcome 1: PI occurrence
In a Delphi survey (Lechner, Coleman et al. 2022) that developed a core outcome set for PI prevention trials, the main outcome, PI occurrence, was rated as being a critically important (score of 7-9). The certainty of evidence is very low (Gillespie, Walker et al. 2020).
The evidence was downgraded twice for risk of bias. Both studies had a high risk of performance bias, one was at high risk of detection bias and the other was at high risk of attrition bias. Certainty was also downgraded once for imprecision and once for inconsistency (Gillespie, Walker et al. 2020).
5. Values:
Is there important uncertainty about or variability in how much people value the main outcomes?
JUDGEMENT
Important uncertainty or variability
Possibly important uncertainty or variability
Probably no important uncertainty or variability
No important uncertainty or variability
RESEARCH EVIDENCE
In a Delphi survey (Lechner, Coleman et al. 2022) that developed a core outcome set for PI prevention trials, the main outcome, PI occurrence, was rated as being a critically important (score of 7-9) by all types of stakeholders (health professionals, people with or at risk of a PI and their informal carers, industry representatives and researchers). Greater than 90% of the 158 participants rated this outcome measure as critically important (Lechner, Coleman et al. 2022).
6. Balance of Effects:
Does the balance between desirable and undesirable effects favour the intervention or the comparison?
JUDGEMENT
Favors the comparison
Probably favors the comparison
Does not favor either the intervention or the comparison
Probably favors the intervention
Favors the intervention
Varies
Don’t know
RESEARCH EVIDENCE
The balance of effects favors the intervention based on the lower rate of PIs associated with the 30 degree tilt, together with trivial undesirable effects.
7. Resources Required:
How large are resource requirements (costs) of the intervention?
JUDGEMENT
Large costs
Moderate costs
Negligible costs and savings
Moderate savings
Large savings
Varies
Don’t know
RESEARCH EVIDENCE
A cost-analysis (Moore, Cowman et al. 2013) that was based on the study by Moore et. al. 2011 reported that implementing a 30° tilt 3-hourly regimen instead of a 90°-tilt 6-hourly regimen (standard care) for people at risk of PI due to mobility limitation was associated with an annual cost difference favouring the intervention of EUR 512,800, equivalent to 21,462 hours of nurse time. However, in the second study (Young 2004), two nurses were required to position all people in a 30 degree lateral position. About 17% of people only required one nurse to position at a greater than 30 degree lateral position, 4% required more than two nurses and most required two nurses. Cost analysis was limited to aged care settings
8. Certainty of evidence of required resources:
What is the certainty of evidence of resource requirements (costs) of the intervention?
JUDGEMENT
Very low
Low
Moderate
High
No included studies
RESEARCH EVIDENCE
The cost effectiveness assessed by Moore et al. 2013 that was based on the study by Moore et. al. 2011 considered the incremental cost per patient free of ulcer and the incremental cost per ulcer avoided. The modelling considered the cost of nursing time and wound dressings (Moore, Cowman et al. 2013).
9. Cost Effectiveness: Does the cost-effectiveness of the intervention favour the intervention or the comparison?
JUDGEMENT
Favors the comparison
Probably favors the comparison
Does not favor either the intervention or the comparison
Probably favors the intervention
Varies
No included studies
RESEARCH EVIDENCE
A cost effective analysis (Moore, Cowman et al. 2013) was conducted based on the findings of one of the studies (Moore, Cowman et al. 2011). Using the 30 degree lateral positioning every three hours was reported to be cost-saving in nurse time compared with using greater than 30 degree lateral positioning (mean nurse time cost per patient EUR 206.60 versus EUR 253.10, incremental difference EUR −46.50, 95% confidence interval [CI] EUR −1.25 to EUR −74.60). There was lower nurse time cost for implementing 30 degree lateral positioning despite the repositioning being conducted more frequently because fewer nurses were required for each turn in the study by Moore et al. 2013, which was in contrast to the findings in the second study (Young 2004). Cost analysis was limited to aged care settings
10. Inequity:
What would be the impact of recommending the intervention on health inequity?
JUDGEMENT
Reduced
Probably reduced
Probably no impact
Probably increased
Increased
Varies
Don’t know
RESEARCH EVIDENCE
The Panel Group reported that there is inequity in access to the resources required to implement repositioning because access to the staff and equipment required to achieve this is variable based on clinical setting. The Panel Group noted some potential inequity in access to this intervention:
People in community settings in most geographic regions do not have access to the resources required to perform repositioning. Many people in these settings rely on their own ability, or that of informal carers to reposition. Without appropriate manual handling equipment or training, achieving a 30 degree tilt is difficult.
Achieving and maintaining a 30 degree tilt is difficult for individuals who have obesity or significant overweight.
Positioning devices can assist in achieving and maintaining a 30 degree tilt, but these are not accessible for all people at risk of pressure injuries, particularly those living in the community.
11. Acceptability:
Is the intervention acceptable to key stakeholders?
JUDGEMENT
No
Probably no
Probably yes
yes
Varies
Don’t know
RESEARCH EVIDENCE
The Panel Group reported that lateral tilt positions can be uncomfortable for some people due to the positioning of their shoulder, but this is also an issue for other positions.
12. Feasibility:
Is the intervention feasible to implement?
JUDGEMENT
No
Probably no
Probably yes
yes
Varies
Don’t know
RESEARCH EVIDENCE
Some studies have reported that a considerable number of people who are repositioned laterally change to a supine position in between repositioning intervals (Vanderwee, Grypdonck et al. 2007).
In one study (Young 2004), 61% of people positioned in 30 degree lateral position and 52% of people positioned in greater than 30 degree lateral position independently repositioned at least once during a 24 hour period, despite using pillows to assist positioning. More people were assessed as having an inability to get into 30 degree lateral position compared with greater than 30 degree lateral positioning (35% versus 2%), and to stay in position (26% versus 0%). Reasons for these difficulties included joint stiffness, pain and anxiety (Young 2004).
Studies have shown that using repositioning devices, including fluidized positioners, foam wedges and pillows can assist in effectively maintaining the 30 degree lateral position for up to two hours in immobile people (Kapp, Gerdtz et al. 2019, Sousa, Kapp et al. 2020).
An exploration of the repositioning practice of nurses showed that there was high level of variability in the way they position people in the 30 degree lateral position, and offloading of bony prominences was not always achieved, even when nurses are provided with written guidance. This suggests that the 30 degree lateral position may be difficult to achieve accurately (Woodhouse, Worsley et al. 2019).
References
Defloor, T. (2000). "The effect of position and mattress on interface pressure." Appl Nurs Res 13(1): 2-11.
Gillespie, B. M., R. M. Walker, S. L. Latimer, L. Thalib, J. A. Whitty, E. McInnes and W. P. Chaboyer (2020). "Repositioning for pressure injury prevention in adults." Cochrane Database Syst Rev 2020 (6) (no pagination)(CD009958).
Haesler, E., J. Pittman, J. Cuddigan, S. Law, Y. Y. Chang, K. Balzer, D. Berlowitz, K. Carville, J. Kottner, M. Litchford, Z. Moore, P. Mitchell and D. Sigaudo-Roussel (2022). "An exploration of the perspectives of individuals and their caregivers on pressure ulcer/injury prevention and management to inform the development of a clinical guideline." J Tissue Viability 31(1): 1-10.
Källman, U., M. Engstrom, S. Bergstrand, A. C. Ek, M. Fredrikson, L. G. Lindberg and M. Lindgren (2015). "The effects of different lying positions on interface pressure, skin temperature, and tissue blood flow in nursing home residents." Biol Res Nurs 17(2).
Kapp, S., M. Gerdtz, A. Gefen, R. Prematunga and N. Santamaria (2019). "An observational study of the maintenance of the 30° side-lying lateral tilt position among aged care residents at risk of developing pressure injuries when using the standard care pillow and a purpose-designed positioning device." Int Wound J 16(5): 1080-1086.
Lechner, A., S. Coleman, K. Balzer, J. J. Kirkham, D. Muir, J. Nixon and J. Kottner (2022). "Core outcomes for pressure ulcer prevention trials: results of an international consensus study." Br J Dermatol 187(5): 743-752.
Moore, Z., S. Cowman and R. M. Conroy (2011). "A randomised controlled clinical trial of repositioning, using the 30° tilt, for the prevention of pressure ulcers." J Clin Nurs 20(17/18): 2633-2644.
Moore, Z., S. Cowman and J. Posnett (2013). "An economic analysis of repositioning for the prevention of pressure ulcers." J Clin Nurs 22(15-16): 2354-2360.
Sousa, I., S. Kapp and N. Santamaria (2020). "Positioning immobile critically ill patients who are at risk of pressure injuries using a purpose-designed positioning device and usual care equipment: An observational feasibility study." International Wound Journal 17(4): 1028-1038.
Vanderwee, K., M. H. Grypdonck, B. D. De and T. Defloor (2007). "Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions." J Adv Nurs 57(1): 59-68.
Woodhouse, M., P. R. Worsley, D. Voegeli, L. Schoonhoven and D. L. Bader (2019). "How consistent and effective are current repositioning strategies for pressure ulcer prevention?" Appl Nurs Res 48: 58-62.
Young, T. (2004). "The 30 degree tilt position vs the 90 degree lateral and supine positions in reducing the incidence of non-blanching erythema in a hospital inpatient population: A randomised controlled trial." J Tissue Viability 14(3): 88, 90, 92-86.