Clinical question
Should time limited (two hours) sitting out of bed versus unlimited sitting out of bed duration for use for individuals at risk of PIs who are seated?
Context
Population:
Intervention:
Comparison:
Main Outcomes:
Setting:
Background:
Conflicts on Interest:
Individuals at risk of pressure injuries who are seated out of bed
Limiting time sitting out of bed to two hours
Unlimited sitting out of bed duration
Any clinical setting
Pressure Injury (PI) 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
Large
Small
Very low
No important uncertainty or variability
Favors the intervention
Don’t know
No included studies
No included studies
Probably no impact
Varies
Probably 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 | Limited SOOB time to a max 2 hrs |
No limited duration for SOOB |
Difference | Relative effect |
|---|---|---|---|---|
| Reduction in PI occurrence | 2/30 (6.7%) | 17/27 (63%) | 560 fewer PIs per 1,000 (from 611 fewer to 365 more) |
RR 0.11 (0.03-0.42) |
Outcome 1: Reduction in PI Occurrence
The meta-analysis included one RCT (Gebhardt and Bliss 1994) that compared a repositioning regimen that restricted sitting out of bed to two hours per day to no limitation on sitting out of bed. The participants were older adults admitted to an orthopedic ward for management of fractures or major orthopedic surgery of the lower body. In the intervention group (limited time sitting out of bed), 83% of sitting sessions were two hours or shorter and only and 8% were longer than three hours. In the comparator group (unlimited SOOB), 18% of sitting sessions were two hours or shorter, 73% were longer than three hours and 21% were longer than nine hours.(Gebhardt and Bliss 1994) Limiting the time seated out of bed to two hours was associated with a statistically significant reduction in PI occurrence (6.7% versus 63%, RR 0.11, 95% CI 0.03 to 0.42, p=0.001). This translated to 560 fewer people per 1,000 compared to not limiting time spent sitting in chair (from 611 fewer to 365 fewer).
3. Undesirable Effects:
How substantial are the undesirable anticipated effects?
JUDGEMENT
Trivial
Small
Moderate
Large
Varies
Don’t Know
RESEARCH EVIDENCE
In the RCT, (Gebhardt and Bliss 1994) no participants in either group developed a deep vein thrombosis; one person in the intervention group developed a pulmonary embolus but this was during the complete bedrest phase immediately post operatively. The rate of chest infection was higher (11% versus 3%) in the comparison (no limitation on sitting out of bed) group compared to the frequent repositioning (2 hour sit out of bed, intervention group).(Gebhardt and Bliss 1994)
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
Relative importance of main outcome measures
| 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 twice for risk of bias because there was a high risk of bias in most domains and an overall high risk of bias. One downgrade was made for imprecision due small number of events and small sample sizes.
5. Values:
Is there important uncertainty about or variability in how much people value the main outcomes (reduction in PI occurence)?
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 (limiting sitting time) or the comparison (unlimited sitting time)?
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
Given the large desirable effects and small undesirable effects, the balance of effects probably favors limiting time seated out of bed.
7. Resources Required:
How large are resource requirements (costs) of the intervention (limiting sitting time)?
JUDGEMENT
Large costs
Moderate costs
Negligible costs and savings
Moderate savings
Large savings
Varies
Don’t know
RESEARCH EVIDENCE
There is no evidence available on resources required.
8. Certainty of evidence of required resources:
What is the certainty of evidence of resource requirements (costs) of the intervention (limiting sitting time)?
JUDGEMENT
Very low
Low
Moderate
High
No included studies
RESEARCH EVIDENCE
Full evaluation of the costs has not been conducted.
9. Cost Effectiveness: Does the cost-effectiveness of the intervention favour the intervention (limiting sitting time) or the comparison (unlimited sitting time)?
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
There are no cost effectiveness studies.
10. Inequity:
What would be the impact of recommending the intervention (limiting sitting time) on health inequity?
JUDGEMENT
Reduced
Probably reduced
Probably no impact
Probably increased
Increased
Varies
Don’t know
RESEARCH EVIDENCE
Limiting time sitting out of bed is unlikely to impact health equity.
11. Acceptability:
Is the intervention (limiting sitting time) acceptable to key stakeholders?
JUDGEMENT
No
Probably no
Probably yes
yes
Varies
Don’t know
RESEARCH EVIDENCE
The Consumer Panel Group indicated that for a person using a wheelchair for the long term, or anyone with a long term PI risk, limiting time seated out of bed is not compatible with having a high quality of life or participating in society. Patient consumers were confined to bed only throughout necessity (e.g. healing an active PI). However, for short durations (e.g. post operatively), limiting time seated out of bed might be acceptable.
12. Feasibility:
Is the intervention (limiting sitting time) feasible to implement?
JUDGEMENT
No
Probably no
Probably yes
yes
Varies
Don’t know
RESEARCH EVIDENCE
It is generally feasible to limit time seated out of bed.
