Clinical question
Should 30-degree head of bed elevation versus 45-degree head of bed elevation be used in individuals at risk of pressure injuries?
Context
Population:
Intervention:
Comparison:
Main Outcomes:
Setting:
Background:
Conflicts on Interest:
People at risk of pressure injuries
45 degree semi-recumbent
30 degree semi-recumbent
any clinical settings
Pressure Injury occurrence
none
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
Large
Very low
No important uncertainty or variability
Does not favor either the intervention or the comparison
Negligible costs and savings
No included studies
No included studies
Probably no impact
Varies
Yes
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 | 30 degree semi recumbent | 45 degree semi recumbent | Difference | Relative effect |
|---|---|---|---|---|
| PI occurrence (a prevention of PI) | 21/189 (11.1%) | 36/190 (18.9%) | 68 fewer PIs per 1,000 (from 112 fewer to 5 fewer) |
RR 0.59 (0.36-0.97) |
Outcome 1: PI Occurrence
The meta-analysis(Zhuo, Pan et al. 2021) included four randomized controlled trials (RCTs).(Li 2015, Schallom, Dykeman et al. 2015, Jiang, Liu et al. 2016, Ghezeljeh, Kalhor et al. 2017) The meta-analysis compared the effect of increasing the head of bed elevation to 45-degree semi-recumbent positioning for ICU patients (primarily mechanically ventilated people), with PIs reported as an undesirable effect of the intervention. The results were re-analyzed to explore 30-degree head of bed elevation as the intervention versus 45-degree head of bed elevation. The new meta-analysis showed that if the head of bed elevation is restricted to 30-degrees, 68 fewer people per 1,000 (between 112 fewer and 5 fewer) might experience a PI (OR 0.59, 95% CI 0.36 to 0.97). The studies were conducted over durations of one week or less.
3. Undesirable Effects:
How substantial are the undesirable anticipated effects?
JUDGEMENT
Trivial
Small
Moderate
Large
Varies
Don’t Know
RESEARCH EVIDENCE
| Outcome | 30 degree semi recumbent | 45 degree semi recumbent | Difference | Relative effect |
|---|---|---|---|---|
| Gastric reflux (Zhuo, Pan et al. 2021) | 29/235 (12.3%) | 16/239 (6.7%) | 50 more per 1,000 (from 2 more to 124 more) |
OR 1.85 (1.04 to 3.3) |
| Ventilated assisted pneumonia (Zhuo, Pan et al. 2021). | 42/318 (13.2%) | 23/322 (7.1%) | 70 more per 1,000 (from 16 more to 151 more) |
OR 2.15 (1.24 to 3.72) |
Undesirable effects were higher when the head of bed was kept lower (i.e. adverse events happened more frequently with the intervention). A meta-analysis(Zhuo, Pan et al. 2021) presented results from six RCTs(van Nieuwenhoven, Vandenbroucke-Grauls et al. 2006, Li 2015, Schallom, Dykeman et al. 2015, Jiang, Liu et al. 2016, Ghezeljeh, Kalhor et al. 2017). The results were re-analyzed based on 30-degree elevation as the intervention. The new meta-analysis showed that keeping the head of the bed at 30-degree elevation significantly increases the rate of ventilated assisted pneumonia compared with elevating the bed to 5-degrees elevation (OR 2.15, 95% CI 1.24 to 3.72, p=0.007). A difference of 70 more per 1,000 (from 16 more to 151 more) might experience VAP if the head of bed is kept at 30-degree elevation.
A meta-analysis(Zhuo, Pan et al. 2021) reported results from three RCTs(van Nieuwenhoven, Vandenbroucke-Grauls et al. 2006, Li 2015, Schallom, Dykeman et al. 2015). The results were re-analyzed with the 30-degree elevation being the intervention. This analysis showed that keeping the head of bed at 30-degree elevation significantly increases the risk of gastric reflux when compared to head of bed at 45- degree elevation. If the head of bed is kept at 30-degrees, 50 more people per 1,000 (from 2 more to 124 more) might experience gastric reflux (OR 1.85, 95% CI 1.04 to 3.3, p=0.04).
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 low. The evidence was downgraded once for risk of bias. Half the studies making up more than 90% of the weight had unclear performance bias. Certainty was also downgraded once for imprecision.
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
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
Changing the head of bed elevation would generally not require increased resources in in-patient facilities. However, for people living in the community without a specialist bed, adjusting the body’s elevation is more difficult and requires appropriate assistance and support wedges/pillows etc.
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
There are no formal studies on resources required to change the head of bed elevation.
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
Favors the intervention
Varies
No included studies
RESEARCH EVIDENCE
There are no cost effectiveness studies.
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
Changing the head of bed elevation is not likely to influence health equity.
11. Acceptability:
Is the intervention acceptable to key stakeholders?
JUDGEMENT
No
Probably no
Probably yes
yes
Varies
Don’t know
RESEARCH EVIDENCE
The Consumer Panel Group and Guideline Governance Group noted that head of bed elevation influences the individual’s quality of life and comfort. If the bed is maintained at a lower elevation to prevent PIs, this can increase discomfort and ability to engage in activity. This might influence the acceptability of individuals to changing the bed position.
12. Feasibility:
Is the intervention feasible to implement?
JUDGEMENT
No
Probably no
Probably yes
Yes
Varies
Don’t know
RESEARCH EVIDENCE
It is feasible in in-patient settings to change head of bed elevation. If the head of bed is maintained lower and/or flat, this is feasible in community settings.