Clinical question
Should two hourly repositioning versus four, five or six 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
Four, five or six hourly repositioning
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
Small
Don’t know
Very low
No important uncertainty or variability
Does not favor either the intervention or the comparison
Moderate costs
Moderate
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
Small
Moderate
Large
Varies
Don’t Know
RESEARCH EVIDENCE
| Outcome | Nutritional supp. | No nutritional supp. | Difference | Relative effect |
|---|---|---|---|---|
| Reduction in PI occurrence | 56/1525 (3.6%) | 67/1518 (4.4%) | 6 fewer PIs per 1,000 (from 31 fewer to 41 more) |
RR 0.89 (0.46-1.71) |
Reduction in PI Occurrence
The meta-analysis included five randomized controlled trials (RCTs)(Vanderwee, Grypdonck et al. 2007, Bergstrom, Horn et al. 2013, Manzano, Colmenero et al. 2014, Jiang, Liu et al. 2020, Yap, Horn et al. 2022) that compared a two hourly repositioning regimen to a four- five or six hourly regimen for people assessed as being at high risk of PIs (assessed using either the Braden scale and/or being immobile). The studies were conducted either in long term aged care (Vanderwee, Grypdonck et al. 2007, Bergstrom, Horn et al. 2013, Yap, Horn et al. 2022) or intensive care units (ICUs)(Manzano, Colmenero et al. 2014, Jiang, Liu et al. 2020). In one of the studies (Yap, Horn et al. 2022) no PIs were reported for people in either study group. 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 counts the participants from the trial. A range of different support surfaces were used in the studies, including air (reactive) mattresses(Jiang, Liu et al. 2020), pressure redistribution foam (reactive) mattresses or overlays (Vanderwee, Grypdonck et al. 2007, Bergstrom, Horn et al. 2013, Jiang, Liu et al. 2020, Yap, Horn et al. 2022) and alternating pressure (active) air mattresses (Manzano, Colmenero et al. 2014). The meta-analysis showed that a two hourly repositioning regimen was associated with a non-significant lower rate of PI occurrence (RR = 0.89, 95% CI 0.46 to 1.71, p=0.73). The true value may be from 31 fewer PIs with 2 hourly repositioning regimens to 41 more.
3. Undesirable Effects:
How substantial are the undesirable anticipated effects?
JUDGEMENT
Trivial
Small
Moderate
Large
Varies
Don’t Know
RESEARCH EVIDENCE
| Outcome | With 2 hourly repositioning | With 4, 5, or 6 hourly repositioning | Difference | Relative effect |
|---|---|---|---|---|
| Any adverse event (Jiang, Liu, et al. 2020) | 0/1525 | 0/1872 | No difference | Not estimable |
| Mortality (Manzano, Colmenero et al, 2014) | explored | explored | No precise figure (data) provided but authors report no difference between groups | -- |
| Median duration of mechanical ventilation (Manzano, Colmenero et al, 2014) | explored | explored | No precise figure (data) provided but authors report no difference between groups | -- |
| Length of ICU stay (Manzano, Colmenero et al, 2014) | explored | explored | No precise figure (data) provided but authors report no difference between groups | -- |
Limited data on adverse events was reported in the literature and meta-analyses were not performed. The studies that reported adverse events focused on ICU settings and reported no differences in event rates between two hourly repositioning and four, five or six hourly repositioning (Manzano, Colmenero et al. 2014, Jiang, Liu et al. 2020)
A 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
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 importance (score of 7-9).
The certainty of evidence is very low. The evidence was downgraded once for risk of bias because most studies had a high risk of performance bias and about half the studies also had a high risk of detection and selection bias (Avsar, Moore et al. 2020). Certainty was also downgraded once for inconsistency and 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
There was a small effect size for reducing PI occurrence with a very low certainty of evidence. Details on potential adverse events were minimally reported. The GGG determined that the balance of effects did not favor either two hourly or four plus hourly repositioning.
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 (Padula, Crawford et al. 2024) conducted using data collected in a nursing home setting found that repositioning every 4 hours versus every 2 hours saved approximately $17,756 (USD in 2023) per resident (Padula, Crawford et al. 2024).
Another study (Manzano, Colmenero et al. 2014) reported that the daily nursing workload was twice as high when repositioning people every two hours compared to repositioning less frequently (21 mins/patient/day [IQR 14-27] versus 11 mins/patient/day [IQR 8-15], p < 0.001) (Manzano, Colmenero et al. 2014).
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 identified 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 (Padula, Crawford et al. 2024) 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 4 hours versus every 2 hours saved approximately $17,756/resident (USD in 2023) at an average loss of 0.26 quality adjusted life years (QALYs)/resident. This translates to a 100-bed nursing home saving approximately $1.8 million per year if increasing the repositioning interval to every 4 hours. The sensitivity analysis showed 40% of simulations favored 4-h repositioning, and approximately 25% of simulations favored 2-h repositioning intervals(Padula, Crawford et al. 2024). Cost effectiveness data is limited to aged care settings and may vary in other clinical 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 it generally available, staffing is variable and some people at risk of PIs 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.
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 Consumer and Expert Panel Groups 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.
For independent wheelchair users, monitoring their own skin tolerance and assessing repositioning every 2 hours as not required.
12. Feasibility:
Is the intervention feasible to implement?
JUDGEMENT
No
Probably no
Probably yes
yes
Varies
Don’t know
RESEARCH EVIDENCE
One study (Manzano, Colmenero et al. 2014) noted that in people for whom there was a higher adherence to the repositioning regimen, there was a lower rate of PI occurrence regardless of the repositioning regimen to which they were assigned. 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 Consumer and Expert Panel Groups 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.