WCJC #12, Repositioning frequency
Repositioning for pressure injury prevention in adults (Review)
Cochrane Database of Systemic Reviews 2020, Issue 6: CD009958
Gillespie BM, Walker RM, Latimer SL, Thalib L, Whitty JA, McInnes E, Chaboyer WP
For as long as I have been in practice, most clinicians have taken it for granted that data must show that repositioning every two hours is beneficial in preventing pressure injury (PI). Otherwise, there would be a different repositioning recommendation. I recall during residency that one of my professors, who was a firm believer in evidence-based medicine, stated that 80% of what we do does not have objective evidence.
I have previously read a Cochrane Library article regarding repositioning for pressure injury prevention back in 2015. It stated there was not sufficient evidence to recommend any specific repositioning protocol. When I saw this more recent update, I knew I had to read it and post a review about it.
The Cochrane Library is well known for performing well done systematic reviews that help in making guidelines for evidence-based practice. For this study, they identified all randomized controlled trials (RCT) that assessed the effects of any repositioning schedule or different patient positions and measured pressure injury incidence in adults in any setting. Although facility acquired pressure injury is well recognized enough to be on the CMS list of "Never Events," only eight trials were found that were of sufficient quality to be included in the study.
Three RCTs with a total of 1074 participants were evaluated to compare 2-hourly repositioning on any support surface to 4-hourly repositioning. The comparative risk for developing any PI was 116 per 1000 patients for the 4-hourly group compared to 117 per 1000 patients for the 2 -hourly group. These results represent no significant difference between either protocol.
The authors were unable to pool data comparing 2-hourly to 3-hourly repositioning due to high statistical heterogeneity.
Other RCTs were identified comparing repositioning 3-hourly to 4-hourly and comparing 4-hourly to 6-hourly, but the authors felt the certainty of the evidence was too low.
Two RCTs with a total of 252 patients compared 30º tilts at 3-hourly with 90º tilts overnight. The rate of PI was 111 per 1000 for the 90º tilt patients compared to 51 per 1000 for the 30º tilt patients with a relative risk of 0.62, but the confidence intervals and P values were not statistically significant, and therefore the evidence was graded as "Very low."
The authors concluded that "there is currently insufficient evidence to recommend one repositioning schedule/regimen in preference to another." They noted that the most recent clinical practice guideline from the National Pressure Injury Advisory Panel (NPIAP) in 2019 no longer advocated repositioning patients every 2 hours. They discussed that there is a need for a high-quality multicenter trial to evaluate the clinical and cost-effectiveness of repositioning regimens on the prevention of PI.
Pressure injuries continue to be a recognized complication found during hospitalization and stays in nursing facilities. Due to the national attention from being listed as a "Never Event," there has been increasing attention paid by facilities and providers to decrease the incidence of PI. Despite this, they continue to be a frequent occurrence during hospitalizations and nursing facility stays. Clinical practice guidelines attempt to use the best available evidence to improve the care of patients at risk of developing PI, yet they continue.
Repositioning protocols almost universally recommend repositioning every 2 hours; however, the evidence does not yet exist to support that or any other time-based repositioning. The most recent NPIAP 2019 guidelines recommend individualizing the repositioning schedule based on the patient's physical, cognitive, and psychological condition as well as the type of support surface. The patient's level of activity and the ability to reposition independently is to be considered. Given the evidence, this is a reasonable recommendation for the guideline. Still, the reality is that this much subjectivity in determining when to reposition a patient is difficult to implement in actual practice. If a lawsuit is filed, because of the difficulty in explaining why a specific individualized program that includes anything less than 2-hourly was selected, I expect most hospitals and nursing facilities will continue to include 2-hourly repositioning in their protocols for patients identified at risk for PI.
While I understand the legal concerns, repositioning is not without risks. Disruption of sleep lengthens recovery, suppresses immune function, and predisposes to infection. Repositioning may also cause patients pain. Large well-controlled studies that could answer the question about the ideal reposition protocol and methods, taking into account everything that affects the patient, would be ideal but are unlikely to be performed soon and even less likely to address the issue of sleep disruption, so for the foreseeable future, the 2-hour protocol will remain.