Running head: PRESSURE ULCERS AND PATIENT REPOSITIONING 1

Pressure Ulcers and Patient Repositioning

Jack Arnold
Ferris State University




PRESSURE ULCERS AND PATIENT REPOSITIONING 2

Abstract
Pressure ulcers and skin integrity are major concerns with limited mobility patients in health care
today. Current standard says a two hour time schedule for patient repositioning is best practice,
but this practice is based on professional opinion and limited data. The clinical question was
posed to see if the two hour time schedule could be lengthened to 4 hours without placing a
patient at risk. The research methodology is discussed giving details on how the research was
located. Three relevant articles were located and critiqued in an attempt to find evidence based
support, but, the evidence was inconclusive and limited to support such a change. Lastly, the
significance to nursing practice is discussed.

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Pressure Ulcers and Patient Repositioning
Pressure ulcers are a very real risk when working in health care. The purpose of this
paper is in hospitalized patients, how a two hour turn schedule checklist compared to greater than
a two hour turn schedule checklist affects the incidence of pressure ulcers.
Clinical Question
Pressure ulcers are reddened areas that typically develop over bony prominences. They
range in severity from a stage 1, reddened non-blanchable areas, to stage 4 full thickness tissue
loss with exposed bone, muscle or tendon (http://www.npuap.org/). They develop by pressure
against the skin that limits blood flow to the skin and surrounding tissue ("Mayo Clinic," 2014).
Limited mobility is one of the major contributing factors to pressure ulcers. Others include:
sustained pressure, when a person is in one position for too long such as in a bed or wheelchair.
Friction, when a patient is transferred from one surface to another and is essentially dragged
across a surface, and shear, this is when two surfaces move in opposite directions, like the
patients skin and the bed when the bed moves in one direction and the patients skin stays in place
("Mayo Clinic," 2014).
Hospital acquired pressure ulcers are not remittable by the insurance companies and cost
hospitals an average of forty-three thousand per incident for stage III and IV ulcers (Zaratkiewicz
et al., 2011). Pressure ulcers are preventable though. With regular positioning change and use of
support devices like heel boots and low air loss mattresses patients can be kept safe. While the
prevention of pressure ulcers is a multidisciplinary responsibility, it is ultimately the
responsibility of the nurse to prevent them.
As a nurse, the biggest defense against pressure ulcers is regular skin assessment and
repositioning, but what is the appropriate amount of time between position changes? According
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to Lyder and Ayello (2008) current guidelines date back to 1992 when the U.S. Agency for
Healthcare Research and Quality published clinical guidelines for preventing pressure ulcers.
Current guidelines call for manual repositioning of bedbound patients to be every two hours.
These guidelines were primarily based on level 3 evidence, expert opinion, and panel consensus.
So is this still the best practice guideline for nurses to follow today or has the evidence changed?
Methodology
The methodology used to search for data consisted of using several databases. These
databases included: CINAHL, PubMed, Cochrane Database of Systematic Reviews, and Google.
Key words and terms were used to generate the most effective return on usable articles. Some of
these terms included: pressure ulcer, bed sore, decubitus ulcer, repositioning, turn, reposition,
turn interval, turn frequency, immobile patient, and limited mobility.
Three articles were chosen from various search results. These articles were chosen
because the majority of the authors were registered nurses of some degree, bachelorette, master
or doctorate. While nursing only research was the goal of this paper, the results returned did not
provide such data. All the research obtained was of interdisciplinary collaboration involving
doctors and researchers also. Nursing research does not have to mean research only by nurses
though. Based on the definition by Nieswiadomy (2012), nursing research includes all studies
concerning nursing practice, nursing education, and nursing administration (p. 3) so the articles
chosen do apply to nursing practice and education and that is why they are relevant.
The level of evidence of the articles chosen varies only slightly. The level of evidence
measuring tool chosen was developed by the American Association of Critical Care Nurses
(AACN). The AACN uses a letter scale A-E and M. According to the Armola et al. (2009),
Level A evidence is the highest level consisting of meta-analysis of multiple controlled studies or
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qualitative studies down to Level E which is theory-based evidence from expert opinion or
multiple case reports (p. 72). Level M evidence consists of manufacturers recommendations
only. Most of the evidence presented in the three articles is of Level C thru E quality.
Literature Review
Article 1
At this time, based on the evidence presented in this systematic review, a
recommendation for a change to the policy that all patients at risk for pressure ulcers be placed
on a two hour time interval checklist between patient repositioning cannot be made. This
statement is based on a systematic review (Krapfl & Gray, 2008) evaluating several studies
regarding regular repositioning of patients to prevent pressure ulcers from a peer-reviewed
journal (Journal of Wound, Ostomy and Continence Nursing, 2008). The main subject reviewed
the evidence on the value of repositioning as a pressure ulcer prevention method. The purpose of
this study was to determine the best positioning schedule and lateral position for patients at risk
for pressure ulcers. Since current clinical guidelines are based on level 3 evidence and expert
opinion dating back to 1992, a need was found to conduct this study. The problem investigated
was to determine if 4 hour time schedule and degree of lateral position was just as effective as a
2 hour time schedule at preventing pressure ulcers. The sample population varied between the
studies ranging from health patients to long-term and acute care facility patients. The design of
the study was a systematic review of databases MEDLINE and CINAHL with level C evidence
support based on the American Association of Critical-Care Nurses (AACN) scale (Armola et
al., 2009) of randomized control trials with inconsistent results. Statistical analyses were limited
to mean scores and nominal level of measure which are appropriate.
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Results were highly varying and inconclusive. With all the variation between studies, the
results are valid, but threats to validity are present. One study supported the current
recommendations while another stated there was no difference in pressure ulcer incidence
between a 2 hour and 4 hour positioning schedule. Another study stated that positioning time
interval in not as important as using pressure redistribution surfaces and frequent repositioning
(less than two hours) might be more effective. These inconclusive results are subject to multiple
threats to validity. These threats include: time frame of study, high level of patient dropout rate
(attrition), incidence of spontaneous repositioning (extraneous variable) and type of mattress
(instrumentation) and selection bias (Nieswiadomy, 2012). With these reasons in mind, the
original question of proper time frame interval of repositioning remains unanswered. Based on
this systemic review, any change to current guidelines would be unadvisable and potentially
placing patients at risk. Until more conclusive evidence can be obtained, a recommendation to
change current policy cannot be given.
Article 2
At this time, based on the evidence presented in this systematic review, a
recommendation for a change to the policy that all patients at risk for pressure ulcers be placed
on a two hour time interval checklist between patient repositioning cannot be made. This
statement is based on a study (Wong, 2011) measuring various components of pressure ulcer
formation from a peer-reviewed journal (Journal of Wound, Ostomy and Continence Nursing,
2011). The subject of the study is skin perfusion, temperature change, and hyperemic response
in long-term care residents. Since current clinical guidelines are based on level 3 evidence and
expert opinion dating back to 1992, a need was found to conduct this study. The problem
investigated was to determine if there was a difference in transcutaneous oxygen level over time
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in heels, trochanters, and sacral region. The purpose was to examine the changes in
transcutaneous oxygen, skin temperature, and hyperemic response in the heels, sacrum, and
trochanters in a 2 hour loading-unloading condition (Wong, 2011, p. 529) while positioned in
supine and lateral positions. The sample population was 9 nursing home residents used in a 1-
group, prospective, repeated-measures non-invasive pilot study design. The level D evidence
support based on the American Association of Critical-Care Nurses (AACN) scale (Armola et
al., 2009) used Freidman test and median values for statistical analyses. The ratio and nominal
level of measure is appropriate for this study (Nieswiadomy, 2012).
Results showed no statistical difference in oxygen level of the skin or skin temperature on
the sacrum, heels or trochanter and only one-third showed an elevated oxygen level at the end of
the 2 hour interval. The results are conclusive and clear and answer the question poised, if there
are changes in transcutaneous oxygen, skin temperature, and hyperemic response in the heels,
sacrum, and trochanters in 2-hour loading-unloading schedule (Wong, 2011, p. 529). Although
the results appear valid, threats to validity exist. They include: instrumentation, small subject
group, selection bias, testing (a 10 question mental status questionnaire was administered prior to
selection) which could affect selection bias. Since similar studies were not located, a comparison
of the results could not be conducted at this time. Based on this study alone, no recommendation
can be made at this time for a change in current guidelines of a 2 hour repositioning regimen.
Article 3
At this time, based on the evidence presented in this systematic review, a
recommendation for a change to the policy that all patients at risk for pressure ulcers be placed
on a two hour time interval checklist between patient repositioning cannot be made. This
statement is based on a systematic review (Gillespie et al., 2013) evaluating several studies
PRESSURE ULCERS AND PATIENT REPOSITIONING 8

regarding regular repositioning of patients to prevent pressure ulcers from a peer-reviewed
journal (The Cochrane Collaboration, 2014). The main subject of the study was to determine the
best time interval for patient repositioning. Based on the background research data available and
that current recommendation is based on professional opinion and inconclusive research, a need
was supported to conduct this research. The problem investigated was the occurrence of
pressure ulcers in limited mobility patients. The purpose was to assess the effects of
repositioning on the prevention of pressure ulcers in adults regardless of risk or in-patient setting,
determine the most effective repositioning schedules for preventing pressure ulcers in adults, and
establish the incremental resource consequences and costs associated with implementing
different repositioning regimens compared with alternate schedules or standard practice
(Gillespie et al., 2014, p. 1). The sample population consisted of geriatric patients of in-patient
hospital and long-term care facilities that were free of pressure ulcers before start of the trials.
Three study designs were utilized, that included: 2 and 5-armed cluster random controlled trial
with a 4 week follow-up period and a random controlled trial with 24 hour follow-up period.
These studies consisted of Level C evidence based on the American Association of Critical-Care
Nurses (AACN) scale using risk ratio, confidence level, and random effects model statistical
analyses. Based on the nominal and ratio level of measure, the statistical analyses methods are
appropriate since there can be a true zero (Nieswiadomy, 2012).
Results of the three studies used in this systematic review show support on the use of
repositioning to prevent pressure ulcers is low in volume and quality and the need for further
research to measure the effects of repositioning on pressure ulcer development is needed.
Results are clear, but are unable to answer the question of proper time interval for patient
repositioning. Validity was threatened based on selection bias, performance bias and detection
PRESSURE ULCERS AND PATIENT REPOSITIONING 9

bias. The findings of this systematic review are consistent with other reviews in the fact that
they have all been inconclusive on time interval intervention for repositioning and all state
further evidence is needed to make accurate conclusion, and all revert back to current guidelines
for repositioning. Based on this systemic review, no recommendation can be made to change
current policy of a two hour time interval schedule on patient repositioning.
Significance to Nursing
Based on todays guidelines, a two hour repositioning schedule is the current standard of
practice. Newest guidelines recommend performing regular skin assessments and developing an
individualized turn schedule based on the patients Braiden risk score, care goals, vulnerable skin
areas, and type of support surfaces and devices being utilized (National Guideline Clearinghouse,
2013). Most hospitals and care facilities follow current guidelines of the two hour turn schedule
even though evidence based practice cannot support this task.
Very few articles exist on the topic of pressure ulcers and patient repositioning that agree
with each other. There are three things that all these articles do agree upon: first, the evidence is
inconclusive on time frame positioning of patients. Second, repositioning of patients for
pressure ulcer prevention works, and third, more research needs to be conducted.
Based on the articles reviewed and critiqued for this paper, a recommendation for
changing the current policy regarding a two hour repositioning schedule cannot be given.
Current practice dictates we reposition our patients every two hours, but as a nurse, you need to
remember to perform regular skin assessments on your patients and make a plan to protect their
skin integrity and keep them safe


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References
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