Clinical question
Should two hourly repositioning vs. three hourly repositioning be used for people at risk of pressure injuries?
Context
Population:
Intervention:
Comparison:
Main Outcomes:
Setting:
Background:
Conflicts on Interest:
People at risk of pressure injuries
Two hourly repositioning regimen
Three hourly repositioning regimen
Any clinical setting
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
Varies
Trivial (favors comparator)
Very low
No important uncertainty or variability
Does not favor either the intervention or the comparison
Varies
Very low
Varies
Increased
Varies
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 (favours comparator)
Small
Moderate
Large
Varies
Don’t Know
RESEARCH EVIDENCE
| Outcome | With 2 hourly repositioning | With 3 hourly repositioning | Difference | Relative effect |
|---|---|---|---|---|
| PI occurrence | 8/640 (1.3%) | 2/649 (0.3%) | 9 more PIs per 1,000 (from 0 fewer to 55 more) |
RR 4.06 (0.87-18.98) |
Outcome 1: Reduction in PI Occurrence
The meta-analysis included two randomized controlled trials (RCTs) (Bergstrom, Horn et al. 2013, Yap, Horn et al. 2022) that compared a two hourly repositioning regimen to a three hourly regimen for older adults in long term care with a moderate or high risk of PIs (as measured on the Braden scale) who were followed for four weeks. In both studies, repositioning regimens were conducted in conjunction with a pressure redistribution support surface described as a high-density foam mattress. In one of the studies (Yap, Horn et al. 2022) no PIs were reported for people receiving either two hourly repositioning or three hourly repositioning. A risk ratio estimating the effect that the intervention might have had in preventing PI occurrence was unable to be calculated for this study because no events occurred; however, the meta-analysis includes the participants from the trial. In the second study (Bergstrom, Horn et al. 2013) no Category/Stage 3 or 4 PIs were reported. The analysis showed that two hourly repositioning was associated with a higher rate of PI occurrence (RR = 4.06, 95% CI 0.87 to 18.98, p=0.07).
3. Undesirable Effects:
How substantial are the undesirable anticipated effects?
JUDGEMENT
Trivial
Small
Moderate
Large
Varies
Don’t Know
RESEARCH EVIDENCE
Quantitative data on undesirable effects was not reported in any of the included studies. A recent Cochrane review (Gillespie, Walker et al. 2020) highlighted the following negative outcomes associated with repositioning, noting that when repositioning frequency increases, the risk of these outcomes increases:
Disruption to the individual’s sleep. Noting the sleep cycle occurs every 90 minutes, more frequent repositioning is likely to lead to sleep fragmentation that has been associated with longer recovery from illness, suppressed immune function and increased predisposition to infection, as well as negative psychosocial impact (Carskadon and Dement 2005, Humphries 2008, Gillespie, Walker et al. 2020).
Pain (e.g. joint and bone pain, discomfort for wounds) (Gillespie, Walker et al. 2020).
Staff injuries associated with manual handling. Back pain and injury have been associated with more frequent repositioning. In Australia, this was quantified as over AUD $4.3 million in 2005-2006 (Safe Work Australia 2012, Gillespie, Walker et al. 2020).
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
The certainty of evidence is very low. The evidence was downgraded once for risk of bias. The two included studies (Bergstrom, Horn et al. 2013, Yap, Horn et al. 2022) had a high risk of performance bias and unclear risk of selection bias (Avsar, Moore et al. 2020). Certainty was also downgraded once for imprecision due to a wide confidence interval that also crossed 1.25.
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 outcomes et for PI prevention trials, the outcome of PI occurrence was rated as being of critical 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 GGG considered the low certainty of desirable effects and the available information on undesirable effects in making its decision.
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 conducted using data collected in a nursing home setting found that repositioning every 3 hours versus every 2 hours saved approximately $12,146 (USD in 2023) (Padula, Crawford et al. 2024).
Cost analysis is 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 available cost analysis considered nursing time for repositioning, continence care, skin care and other preventive care, costs of equipment (e.g. support surfaces), training costs, variable costs (e.g. cleaning solutions, topical products, repositioning devices) and costs of treating a PI (Padula, Crawford et al. 2024).
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 analysis conducted using data collected in a nursing home setting found that reducing repositioning intervals from 2 hourly to 3 or 4 hourly represents reduces costs without sacrificing value of preventive care or jeopardizing resident safety. Repositioning every 3 hours versus every 2 hours saved approximately $12,146 (USD in 2023) at an average loss of 0.18 quality adjusted life years (QALYs)/resident. This translates to a 100-bed nursing saving approximately $1.2 million annually, with a small increase in exposure to PI risk (Padula, Crawford et al. 2024).
A second cost-utility analysis reported on costs of different repositioning regimens based on data from Canadian aged care setting. The estimated lifetime costs were CAN $5,425 (95% credible interval $922–12,166) less per resident with 3-hour repositioning versus 2-hour repositioning. The gain in expected quality adjusted life years (QALYs) of using a 3- hour positioning regimen versus a 2-hour repositioning strategy was 0.008 (95% CrI 0.005–0.016) (Pechlivanoglou, Paulden et al. 2018).
Note: Cost analysis is 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 significant inequity in access to the resources required to implement more frequent (2 hourly) repositioning because access to the staff and equipment required to achieve this is variable based on clinical setting:
The Panel Group reported that in intensive care (ICU) settings, staff and manual handling resources are generally available in most geographic regions to perform more frequent (2 hourly) repositioning.
The Panel Group reported that in other in-patient care settings (e.g. aged care and acute medical or surgical settings), although manual handling equipment is generally available, staffing is variable and some people at risk of pressure injuries may not receive strict two hourly repositioning.
The Panel Group members reported that in community settings in most geographic regions people at risk of pressure injuries do not have access to the resources required to perform regular repositioning at more frequent (two hourly) intervals. In most regions, people living in the community do not have appropriate access to health workers required to perform repositioning because this service requires funding that is either not available or difficult to access. While some people will have an informal carer available to assist, this informal carer may not have the physical ability or equipment to assist with repositioning and is unlikely to be able to conduct frequent repositioning around the clock in an ongoing capacity.
The Panel Group reported that there might be inequity in access to regular repositioning for people with obesity or significant overweight due to the additional staffing and specialized equipment required to perform repositioning for these individuals.
In the Guideline Governance Group’s expert opinion, recommending 2-hourly repositioning would likely increase health inequity. There are barriers to accessing repositioning for many people depending on their geographic location and the clinical context.
11. Acceptability:
Is the intervention acceptable to key stakeholders?
JUDGEMENT
No
Probably no
Probably yes
yes
Varies
Don’t know
RESEARCH EVIDENCE
A scoping review reported that patients are more accepting of repositioning regimens that have less frequent repositioning (e.g. every 3-4 hours) because they have better sleep quality, comfort and overall quality of life (Langemo, Anderson et al. 2022). More frequent repositioning has potential to disturb the person, especially if they are sleeping. The Panel Group supported this finding and noted that two hourly repositioning can be stressful for people with or at risk of PI, particularly at night when it may disrupt sleep. One study (Vanderwee, Grypdonck et al. 2007) reported that only 4/235 (1.7%) of people in a repositioning trial set in aged care reported that repositioning was disruptive; however, these results conflict with the recent literature (Langemo, Anderson et al. 2022) and expert experience, and may underestimate the impact.
The Panel Group reported that acceptability of more frequent (2 hourly) repositioning is variable amongst health workers, informal carers and people at risk of pressure injuries. The following factors reduce the acceptability to key stakeholders of more frequent (2 hourly) repositioning:
Access to health workers or informal carers to assist with repositioning, particularly in community care settings
Sustainability of informal carers performing two hourly repositioning, particularly at night
Work burden in clinical settings with insufficient staffing
Staff injuries (particularly associated with frequently repositioning people with overweight or obesity)
Risks associated with more frequent repositioning in hemodynamically unstable individuals in ICU settings
Preferences of people receiving end-of-life care.
In the Guideline Governance Group’s expert opinion, recommending 2-hourly repositioning would not be acceptable to many key stakeholders.
12. Feasibility:
Is the intervention feasible to implement?
JUDGEMENT
No
Probably no
Probably yes
yes
Varies
Don’t know
RESEARCH EVIDENCE
For people in any clinical setting, feasibility of repositioning regimens depends on the individualized plan. Plans with less frequent repositioning are considered by health professionals to be more feasible and efficient (Langemo, Anderson et al. 2022).
For people in the community at risk of PIs (e.g. people with SCI), ongoing reinforcement may be required to encourage people to maintain a regular repositioning program over time. One study found people with SCI reduced their repositioning behavior over time (Eren, DeLuca et al. 2022). Reasons for not regularly repositioned included no longer considering it important, and not having appropriate assistance available (Eren, DeLuca et al. 2022).
The Panel Group reported that feasibility of more frequent (2 hourly) repositioning is variable across clinical settings and geographic regions. The following factors reduce the feasibility of implementing more frequent (2 hourly) repositioning:
Access to health workers or informal carers to assist with repositioning, particularly in community care settings.
Sustainability of informal carers performing two hourly repositioning, particularly at night.
Work burden in clinical settings with insufficient staffing.
In the Guideline Governance Group’s expert opinion, the feasibility of 2-hourly repositioning is variable across geographic and clinical setting based on available resources.