Turning and Repositioning To Reduce Pressure Injuries
ohernzebagks
frequentrepositioning.pdf
Frequent manual repositioning and incidence of pressure ulcers among bed-bound elderly hip fracture patients
Shayna E. Rich, MA, PhD1; David Margolis, MD, PhD2; Michelle Shardell, PhD1; William G. Hawkes; PhD1; Ram R. Miller, MD1; Sania Amr, MD1; Mona Baumgarten, PhD1
1. Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, and
2. Departments of Epidemiology & Biostatistics, and Dermatology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
Reprint requests: Shayna Rich, MA, PhD, 121 South Fremont
Avenue, Apartment 431; Baltimore, MD
21201.
Tel: 11 443 604 6308;
Fax: 11 410 706 4433;
Email: [email protected]
Manuscript received: March 3, 2010
Accepted in final form: September 28, 2010
DOI:10.1111/j.1524-475X.2010.00644.x
ABSTRACT
Frequent manual repositioning is an established part of pressure ulcer prevention, but there is little evidence for its effectiveness. This study examined the association between repositioning and pressure ulcer incidence among bed-bound elderly hip fracture patients, using data from a 2004–2007 cohort study in nine Maryland and Pennsylvania hospitals. Eligible patients (n5269) were age�65 years, underwent hip fracture surgery, and were bed-bound at index study visits (during the first 5 days of hospitalization). Information about repositioning on the days of index vis- its was collected from patient charts; study nurses assessed presence of stage 21 pressure ulcers 2 days later. The association between frequent manual repositioning and pressure ulcer incidence was estimated, adjusting for pressure ulcer risk factors using generalized estimating equations and weighted estimating equations. Patients were frequently repositioned (at least every 2 hours) on only 53% (187/ 354) of index visit days. New pressure ulcers developed at 12% of visits following frequent repositioning vs. 10% following less frequent repositioning; the incidence rate of pressure ulcers per person-day did not differ between the two groups (inci- dence rate ratio 1.1, 95% confidence interval 0.5–2.4). No association was found be- tween frequent repositioning of bed-bound patients and lower pressure ulcer incidence, calling into question the allocation of resources for repositioning.
Pressure ulcers are a common complication of immobility among the elderly, resulting in substantial pain and suffering
1
and excess hospital costs with charges for associated hospital stays averaging > US$15,000.2 As of October 2008, Med- icare no longer reimburses hospitals for treatment of hos- pital-acquired stage 3 or 4 pressure ulcers.
3 This decision
was based on the designation of pressure ulcers as a ‘‘rea- sonably preventable condition,’’ i.e., it is assumed that pressure ulcers will generally not develop on patients re- ceiving care according to current evidence-based guide- lines. Unfortunately, although national and international clinical guidelines for pressure ulcer prevention recom- mend a wide range of measures, the evidence for the effec- tiveness of many of these measures is fairly weak.
4–6 To
ensure that the measures recommended by clinical guide- lines lead to a reduction in pressure ulcers, it is critical to confirm both that these measures are effective and that they are widely implemented.
One of the major methods for prevention of pressure ulcers is the frequent manual repositioning of patients with limited mobility. In particular, several clinical guidelines recommend that bed-bound patients be repositioned every 2 hours.
5,6 This recommendation is based primarily on
expert opinion, with few epidemiological studies and in- conclusive evidence that repositioning at this frequency is effective in preventing the development of pressure ulcers. Despite the dearth of evidence, repositioning bed-bound patients every 2 hours has become firmly established as the standard of care.
Confirming the effectiveness of frequent repositioning is an important goal, to ensure that the standard of care is appropriate and because the labor costs associated with this intervention are considerable. Indeed, repositioning and transferring patients take up the largest proportion of the time devoted to pressure ulcer prevention,
7 and in one
study cost of repositioning accounted for 73% of the total cost for pressure ulcer prevention.
8 Several studies have
also shown that manual repositioning increases health care workers’ risk for back pain and musculoskeletal inju- ries.
9,10 Given the shortage of both skilled and unskilled
nursing labor, the allocation of nursing time to patient re- positioning every 2 hours is only justified if this interven- tion is effective.
Furthermore, it is unclear to what degree the recom- mendation for frequent manual repositioning is being im- plemented in US health care facilities. A study published in 2001 by the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) found that, in 1996, only 66% of bed- and chair-bound patients
CI Confidence interval
GEE Generalized estimating equations
IRR Incidence rate ratio
MMSE Mini-Mental State Examination
OR Odds ratio
PRSS Pressure-redistributing support surfaces
Wound Rep Reg (2011) 19 10–18 c� 2010 by the Wound Healing Society10
Wound Repair and Regeneration
were repositioned every 2 hours. 11
A study by Bates-Jen- sen et al.
12 in nursing homes in 2003 found that only 18 of
58 such patients were repositioned at least every 2 hours. No study since then has examined adherence to this rec- ommendation, although a few studies have examined the use of repositioning, but not its frequency, in preventing pressure ulcers.
13–15 There is some evidence that the ap-
propriate frequency of repositioning should vary with the support surface in use,
16 and guidelines differ in whether
patients using mattresses and overlays designed to redis- tribute pressure (i.e., pressure-redistributing support sur- faces, PRSS) can be repositioned less frequently than those using standard support surfaces.
5,6 Yet no studies have ex-
amined if the frequency of repositioning for patients using PRSS differs from that for patients using standard support surfaces. Thus, it is of interest to examine the degree of adherence to frequent manual repositioning recommenda- tions in bed-bound patients, particularly when considering the type of support surface in use.
Manual repositioning of bed-bound patients every 2 hours is an established part of the clinical guidelines for pressure ulcer prevention, but there is little evidence for its effectiveness and little is known about its implementation in the hospital setting. Thus, it is unclear what effect the recommendation for frequent manual repositioning has on clinical outcomes. In this study, we aimed to determine if manual repositioning every 2 hours is associated with a lower incidence of pressure ulcers among bed-bound elderly hip fracture patients and to examine the degree of adherence to recommendations for manual repositioning in these patients.
MATERIALS AND METHODS
Participants
Data for this study were collected as part of a prospective cohort study of patients aged 65 years or older who un- derwent surgery for hip fracture (ICD-9 code 820) between 2004 and 2007 in any of nine hospitals that participate in the Baltimore Hip Studies network. The methods for the parent study have been described previously.
17 Data for
the parent study were collected in the nine acute care hos- pitals and the 105 postacute facilities to which patients enrolled in this study were discharged; data for the current analysis were collected in the nine admission hospitals. All hospitals included in this analysis were voluntary non- profit acute care facilities, including four teaching hospi- tals. Seven of the study hospitals were in Maryland and two in Pennsylvania. The number of beds in each hospital ranged from 100 to 536 (median 253).
The parent study was approved by the Institutional Review Boards of each of the participating hospitals and the University of Maryland Baltimore; the latter also ap- proved the current study. Permission to contact patients for screening and recruitment was obtained from attending physicians. If the patient had a Mini-Mental State Exam- ination (MMSE)
18 score of 20 or greater, the patient’s writ-
ten consent was obtained; otherwise the patient’s verbal assent and a proxy’s written consent were obtained. Proxy consent was also obtained for patients who were uncon- scious or noncommunicative. A total of 1,167 patients were
screened for eligibility, of whom 1,055 were eligible (90% of screened), and 658 patients enrolled (62% of eligible).
Data about repositioning frequency were collected for the first 5 days of each patient’s initial hospitalization. Thus, patients who did not have any study visits during the first 5 days of hospitalization (n5103) were excluded from the current study. Because national clinical guidelines only recommend repositioning for bed-bound patients, patients were also excluded from the current study if they were not bed-bound according to the activity item of the Braden scale
19 during at least one study visit in the first 5 days of
hospitalization (n5286), leaving a sample of 269 patients.
Measures
Repositioning
Data about repositioning were collected from the nursing flowsheet by a specially trained chart abstractor or a reg- istered nurse experienced in medical record review. This information included the number of times that the patient was manually repositioned on each of the first 5 days of the patient’s initial hospital stay. If the nursing flowsheet indi- cated only the frequency of turning rather than the number of times the patient was turned (e.g., ‘‘q2h’’ to indicate turning every 2 hours), the corresponding number of turns was recorded in the daily total. Repositioning was classi- fied as frequent if there were 12 or more turns per hospital day, corresponding to an average frequency of every 2 hours, as recommended in several clinical guidelines for the prevention of pressure ulcers.
5,6
Pressure ulcer status
Specially trained research nurses assessed pressure ulcer status at study visits that occurred at baseline (as soon as possible after hospital admission) and on alternating days for 21 days. The presence and stage of pressure ulcers were determined at each study visit by a whole-body skin exam- ination conducted according to standard wound assess- ment practice.
20 Standard definitions of pressure ulcer
stages 21
were used: stage 1 (alteration of intact skin with persistent redness), stage 2 (partial thickness dermal loss or serum-filled blister), and stages 3 and 4 (full-thickness tis- sue loss without/with exposed bone, tendon, or muscle). The study outcome was development of one or more new pressure ulcers stage 2 or higher at the visit following the day for which repositioning frequency was recorded. Re- sults were similar when the study outcome was restricted to stage 2 pressure ulcers. Because only 16 of the pressure ulcers observed in the study ever reached stages 3 or 4, it was not possible to perform an analysis restricting the study outcome to stage 3 and 4 pressure ulcers. Patients with pressure ulcers continued to be considered at risk for additional pressure ulcers. Results were virtually identical when patients with pressure ulcers present at hospital admission were excluded from the analysis.
Covariates
At each assessment, the research nurse recorded the patient’s Braden scale score,
19,22 based on observation
Wound Rep Reg (2011) 19 10–18 c� 2010 by the Wound Healing Society 11
Frequent repositioning and pressure ulcer incidenceRich et al.
and discussion with clinical staff. The Braden scale com- prises six items: mobility, activity, sensory perception, ex- posure to friction and shear forces, skin moisture, and nutritional status. The ‘‘friction and shear’’ item is rated on a three-point scale; each of the other five items is rated on a four-point scale. The values for each item are summed to provide a score ranging from six to 23, with lower scores indicating a higher risk for pressure ulcer development. A cut-off point of 16 is commonly used to indicate ‘‘at-risk’’ patients.
23
Acute mental status was also assessed at each visit by counting the number of orientations to person, place, and time. Incontinence status was based primarily on the research nurses’ observation of skin moisture and/or soil- ing with stool during the skin assessment and secondarily on the four-point incontinence item of the Norton scale of pressure ulcer risk.
24 Information about use of PRSS was
recorded by the research nurses on a structured form at each study visit. PRSS were considered to be in use if any overlays were observed to be on the patient’s bed or if the mattress on the patient’s bed was made of any materials other than standard foam and spring. For pressure ulcer preventive devices other than PRSS, cushions were con- sidered in use if they were on the patient’s chair or wheel- chair, even if the patient was not seated at the time of the assessment, whereas heel protectors, elbow protectors, and positioning pillows/wedges were only recorded as being in use if they were observed to be on, or supporting, the patient at the time of assessment.
Data about all other covariates were obtained by clini- cal observation at the baseline study visit, by patient or proxy interview, or by chart review. At the baseline visit, research nurses used the Subjective Global Assessment of Nutritional Status
25 to classify individuals as being at low,
moderate, or high risk of nutrition-associated complica- tions. Arterial insufficiency, defined as absence of pedal pulses or ankle brachial index < 1, was also determined at the baseline visit. Weight and height were obtained from the medical chart or, when missing, from patient or proxy interview; this information was used to calculate the pa- tient’s body mass index (weight [kg]/height[m]
2 ). Standard
definitions 26
were used to define weight status: under- weight (body mass index < 18.5), normal weight (body mass index518.5–24.9), and overweight/obese (body mass index�25.0). Severity of illness was measured on the Rand Sickness at Admission Scale (hip fracture version)
27 and
comorbidity by the Charlson Comorbidity Index, 28
both of which use information from the medical chart. The number of days since hospital admission was determined according to the information in the medical chart.
Analysis
To describe the study population, the distributions of the patients’ characteristics noted at the baseline visit were compared for those repositioned frequently (at least every 2 hours) on the day of the baseline visit and those reposi- tioned less frequently. We used simple counts and propor- tions for categorical variables, and means with standard deviations for continuous variables. p-values were obtained by chi-square test for categorical variables or by two-sample t-test for continuous variables.
Study visits at which patients in the study sample were bed-bound during the first 5 days of hospitalization (354 person-visits) were designated as index visits. Because some patients had multiple index visits, generalized esti- mating equations (GEE) analysis
29 with an exchangeable
working correlation matrix was used to account for within-patient correlation. GEE models with a log link, Poisson working model, and offset of log number of days between visits (to account for differing amounts of patient follow-up) were fit to determine the association between repositioning frequency on the day of an index visit and incidence of pressure ulcers stage 2 or higher at the following visit. Estimates of incidence rate ratios (IRR) and 95% confidence intervals (CI) were reported, both unadjusted and adjusted for covariates. The number of days since hospital admission was included in the adjusted model as a continuous variable using a linear spline with a knot at hospital day 2, and some admission hospitals with few outcomes were combined in the adjusted model. To determine whether the association between repositioning frequency and pressure ulcer incidence was modified by pressure ulcer risk status, another adjusted model was fit with additional covariates for the patient’s Braden scale score (dichotomized at the sample’s median) at the index visit and a term for the interaction between Braden scale score and repositioning frequency.
Because repositioning data and covariate data were missing for 10% (37/354) and 9% (33/354) of index visits, respectively, weighted estimating equations analysis
30 was
used to account for possible selection bias due to missing data. To compute the weights for this analysis, the prob- ability of having observed (nonmissing) repositioning data was estimated using a GEE model with a logit link, bino- mial working model, and predictor variables (admission hospital, severity of illness, use of pressure ulcer preventive devices other than PRSS, pressure ulcer incidence before or at the index visit, linear spline of days since hospital admission, and completeness of other covariate data). The probability of having complete covariate data was esti- mated in a similar way with admission hospital as the predictor variable. Weights were then estimated as the product of the inverse probability of having complete cov- ariate data and the inverse probability of having observed repositioning data.
GEE models were fit with a binomial distribution and identity link to determine estimates and 95% CI for the proportion of index visit days on which patients were fre- quently repositioned, for the whole study sample, for sub- groups of patients using each type of support surface, and for subgroups of patients in each admission hospital. GEE models with a logit link and binomial working model were fit to determine whether PRSS use on a given day was associated with frequent repositioning on the same day. Estimates of prevalence odds ratios (OR) and 95% CI are reported, both unadjusted and adjusted for covariates. To avoid overfitting, age, sex, acute mental status, comorbid- ity, arterial insufficiency, use of preventive devices other than PRSS, and presence of a pressure ulcer at the index visit were eliminated from the model, after it was deter- mined that these variables did not change the estimate of the coefficient of interest by > 10%. Because the use of frequent repositioning and PRSS were expected to vary
Wound Rep Reg (2011) 19 10–18 c� 2010 by the Wound Healing Society12
Frequent repositioning and pressure ulcer incidence Rich et al.
based on hospital policy and resources, it was expected that there may be important clustering effects by admis- sion hospital. To examine these effects, additional models were fit that adjusted for admission hospital using indica- tor variables. All analyses were performed using SAS 9.1 (SAS Institute Inc., Cary, NC).
RESULTS
Study sample
Patients’ baseline characteristics, by repositioning frequency on the day of the baseline visit, are shown in Table 1.
Table 1. Baseline characteristics of study participants, by repositioning frequency on day of baseline visit
Characteristics
Patients repositioned at
least every 2 hours
(N5139)
Patients repositioned less
frequently than every 2 hours
(N5130)n All patients
(N5269) w
p-value z
n (%)
Age �85 years 68 (48.9) 71 (54.6) 139 (51.7) 0.35 Male sex 36 (25.9) 32 (24.6) 68 (25.3) 0.81
White race 137 (98.6) 128 (98.5) 265 (98.5) 0.95
Community resident before
admission
83 (59.7) 86 (66.2) 169 (62.8) 0.27
Medicaid payor 12 (8.6) 6 (4.6) 18 (6.7) 0.19
Trochanteric fracture 53 (38.1) 57 (43.9) 110 (40.9) 0.34
Partial or total arthroplasty 58 (41.7) 56 (43.1) 114 (42.4) 0.82
Albumin < 3.0 g/dL 48 (34.5) 45 (34.6) 93 (34.6) 0.99
Not fully oriented to person,
place, and time
61 (45.9) 46 (36.2) 107 (41.2) 0.11
High risk of nutrition-related
complications
22 (16.3) 11 (8.5) 33 (12.5) 0.06
Incontinence 0.97
None 95 (68.8) 91 (70.0) 186 (69.4)
Urinary only 28 (20.3) 26 (20.0) 54 (20.2)
Fecal with or without urinary 15 (10.9) 13 (10.0) 28 (10.5)
Arterial insufficiency 56 (40.3) 62 (47.7) 118 (43.9) 0.22
Braden scale score �16 129 (94.9) 119 (93.7) 248 (94.3) 0.69 Pressure ulcers present at
baseline visit
25 (20.2) 9 (7.8) 34 (14.2) 0.006
Mean (standard deviation)
Mean age (years) 83.9 (6.4) 84.0 (6.5) 84.0 (6.5) 0.90
Mean Rand Sickness at
Admission score
13.6 (7.5) 12.9 (6.3) 13.3 (6.9) 0.40
Mean Charlson Comorbidity
Index
1.5 (1.5) 1.5 (1.5) 1.5 (1.5) 0.67
Mean MMSE score 15.8 (11.1) 17.5 (10.8) 16.6 (11.0) 0.21
Mean BMI (weight [kg]/height
[m] 2 )
23.4 (5.3) 24.2 (4.7) 23.8 (5.0) 0.24
Mean Braden scale score 13.8 (1.7) 14.2 (1.6) 14.0 (1.7) 0.07
Mean length of hospital stay
(days)
6.0 (2.7) 5.7 (3.1) 5.9 (2.9) 0.35
Mean interval between admission
and baseline visit (days)
1.8 (1.1) 1.6 (1.1) 1.7 (1.1) 0.15
nIncludes patients with missing repositioning data and two study participants who did not have a baseline visit in the first 5 days of
hospitalization at which the patient was bed-bound. w Because of missing data, N for individual items ranges from 240 to 269. z p-value determined by two-sample t-test for continuous variables or chi-square for categorical variables.
MMSE, Mini-Mental State Examination. BMI, body mass index.
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Frequent repositioning and pressure ulcer incidenceRich et al.
Patients repositioned frequently (at least 12 times/day or every 2 hours on average) were more likely than those repo- sitioned less frequently to have a pressure ulcer at the base- line visit (p50.006). Those repositioned frequently were also more likely to have a high risk of nutrition-related compli- cations (p50.06) and to have a lower mean Braden scale score (p50.07) than patients repositioned less frequently.
Effect of frequent repositioning on incidence of pressure ulcers
Patients in the study sample had an incident pressure ulcer stage 2 or higher at 11% (38/354) of visits following an index visit; the proportion was 12% (22/187) for visits following days on which patients were frequently reposi- tioned and 10% (16/167) following days on which patients were repositioned less frequently (Table 2). The rate of incident pressure ulcers stage 2 or higher at the visit following an index visit per person-day of follow-up was similar whether or not the patient was repositioned frequently on the day of the index visit (unadjusted IRR 1.22, 95% CI 0.65–2.30; covariate-adjusted IRR 1.12, 95% CI 0.52–2.42).
The effect of frequent repositioning on pressure ulcer incidence varied somewhat (p for the interaction50.07 in adjusted model) according to whether or not the patient was at high risk of pressure ulcers, as indicated by a Braden scale score less than the study sample median value of 14. Among the higher risk patients, the incidence rate of pressure ulcers per person-day of follow-up was lower for those frequently repositioned on the day of the index visit compared with those repositioned less frequently (adjusted IRR 0.39, 95% CI 0.08–1.84), whereas in lower risk patients, the incidence rate of pressure ulcers for those repositioned frequently was higher than for those repositioned less frequently (adjusted IRR 2.19, 95% CI 0.73–6.60).
Relationship between use of PRSS and frequent repositioning
Patients were repositioned frequently on 53% of the days on which an index visit occurred (95% CI 47–58%); the proportion was 54% (78/145) among patients using PRSS and 52% (106/204) among patients using standard mat- tresses. The proportion of days with frequent repositioning according to type of support surface ranged from 42 to 66% (Figure 1). The use of frequent repositioning also differed substantially by admission hospital; the hospital- specific proportion of days on which frequent repositioning was in use ranged from 23 to 77%. Examining the role of admission hospital in detail, we found that hospitals with more PRSS use tended to have less use of frequent reposi- tioning and vice versa, indicating that admission hospital was a negative confounder of the association between PRSS use and frequent repositioning. Thus, although there was no association between using PRSS and frequent repositioning in models not accounting for admission hos- pital (unadjusted OR 1.14, 95% CI 0.74–1.75; covariate- adjusted OR 1.06, 95% CI 0.67–1.70), the odds of frequent repositioning in patients using PRSS were more than twice as high as the odds in patients using standard mattresses in models accounting for admission hospital (hospital- adjusted OR 2.08, 95% CI 1.10–3.92; fully adjusted OR 2.28, 95% CI 1.15–4.54).
DISCUSSION
In this study of bed-bound elderly hip fracture patients, we did not find that repositioning patients at least every 2 hours is associated with a decreased incidence of pressure ulcers, suggesting that manual repositioning at this fre- quency may not effectively prevent pressure ulcers. Previ- ous studies of frequent repositioning for pressure ulcer prevention have yielded inconsistent results. Although a
Table 2. Unadjusted and adjusted incidence rate ratios for developing a pressure ulcer stage 2 or higher at the following visit, by
frequency of repositioning on the day of an index visit
Repositioning frequency Number of visits
% who developed �1 IPU at following visit
Unadjusted
IRR (95% CI)
Fully adjustedn
IRR (95% CI)
Among all patients
Less than every 2 hours 167 10 Reference —
At least every 2 hours 187 12 1.22 (0.65, 2.30) 1.12 (0.52, 2.42)
Among patients at higher risk of pressure ulcers (Braden scale score <14)
Less than every 2 hours 60 13 Reference —
At least every 2 hours 80 6 0.51 (0.20, 1.26) 0.39 (0.08, 1.84)
Among patients at lower risk of pressure ulcers (Braden scale score �14) Less than every 2 hours 107 7 Reference —
At least every 2 hours 107 16 2.11 (0.92, 4.87) 2.19 (0.73, 6.60)
All models account for within-patient correlation by generalized estimating equations using an exchangeable structure for the work-
ing correlation matrix. nAccounts for missing repositioning and missing covariate data using weighted estimating equations, and adjusts for age, sex, acute
mental status, risk of nutrition-related complications, weight status, incontinence status, arterial insufficiency, severity of illness,
comorbidity, use of pressure-redistributing support surfaces, use of any other pressure ulcer preventive device, admission hospital,
prior pressure ulcer of any stage, and number of days since hospital admission.
IPU, incident pressure ulcer stage 2 or higher; IRR, incidence rate ratio; CI, confidence interval.
Wound Rep Reg (2011) 19 10–18 c� 2010 by the Wound Healing Society14
Frequent repositioning and pressure ulcer incidence Rich et al.
randomized trial 16
found a lower incidence of pressure ulcers for patients repositioned every 2 hours than for those repositioned every 3 hours among patients using a standard mattress, the same group
31 found no significant
difference in pressure ulcer incidence when they compared groups under two repositioning-interval regimens (2 hours in a lateral position and 4 hours in a supine position vs. 4 hours in each position). Observational studies in humans have only shown that the duration of pressure likely to result in pressure ulcers falls within a range of 1–6 hours.
32,33 Finally, studies in humans using surrogate
endpoints (skin temperature and redness, and contact pressure) and animal studies and in vitro tissue studies suggest that even a 2-hour interval of repositioning might be insufficient to prevent tissue damage.
34–36 Thus, the
evidence for an optimal repositioning interval is inconclu- sive, with biological plausibility for an interval < 2 hours but little difference in clinical outcomes between this inter- val and longer intervals. Taken together, the published literature and the present study findings suggest that the clinical recommendations for manual repositioning with a specified interval are not well-founded.
Recent guidelines have recognized the limitations of the evidence for manual repositioning, and these guidelines have recommended that frequency of manual reposition- ing should be tailored to each patient based on character- istics such as mobility and general medical condition.
37
Given the substantial costs and burden of repositioning every 2 hours, it is important to target this intervention to patients who are most likely to benefit. In this study, there was some suggestion that the effect of repositioning was modified by the patient’s pressure ulcer risk status. Among patients at high risk of pressure ulcers (as indicated by low Braden scale scores), those repositioned at least every 2 hours had a lower rate of incident pressure ulcers than those repositioned less frequently; among patients at low risk of pressure ulcers, those repositioned at least every
2 hours had a higher rate of incident pressure ulcers than those repositioned less frequently, although neither differ- ence was statistically significant. If confirmed in future studies, these findings suggest that, even among bed- bound patients, repositioning may only be effective as a prevention measure for those at particularly high risk of pressure ulcers, and patients at high risk according to Braden scale score may be a population of particular in- terest. Additional studies should examine if frequent repo- sitioning is only effective in this patient population.
We found limited adherence to the recommendation for frequent manual repositioning despite the fact that the study population, bed-bound elderly hip fracture patients, is recognized as being at high risk of pressure ulcers.
7,38 It
is reassuring that patients who were repositioned fre- quently were more likely than those who were repositioned less frequently to have a lower Braden scale score. Overall, though, patients were repositioned at least every 2 hours on only 53% of days. This finding is consistent with several previous studies showing a low prevalence of reposition- ing, although the prevalence may vary substantially by hospital unit.
11,13 In one study, staff members did not
reposition patients as regularly as prescribed despite knowledge that repositioning should be done,
39 and sev-
eral studies have found that the main reasons cited for not regularly repositioning patients include lack of time and lack of staff, rather than a lack of knowledge of turning protocols.
40 Thus, despite indications that repositioning
is widely accepted as standard care for pressure ulcer prevention, repositioning does not appear to be fully implemented.
The prevalence of frequent repositioning was higher among patients using PRSS when compared with patients on standard support surfaces, allaying concerns that use of a PRSS reduces frequent repositioning. These results sug- gest that providers are using these preventive measures together for high-risk patients, as is appropriate under
43%
53%
42%
55%
66%
52%
0%
25%
50%
75%
100%
Standard (n=206)
Static air overlay (n=52)
Alternating pressure
overlay (n=26)
Static air mattress (n=28)
Alternating pressure mattress (n=18)
Other PRSS (n=23)
Type of Support Surface
P ro
p o
rt io
n o
f d
a y s (
% )
45%
64%
22%
77%
29%
62%
22%
79%
59%
52%
35%
75%
Figure 1. Proportion of days (and 95% confidence intervals) on which patients were repositioned at least every 2 hours (�12 times/ day), by type of support surface.
Wound Rep Reg (2011) 19 10–18 c� 2010 by the Wound Healing Society 15
Frequent repositioning and pressure ulcer incidenceRich et al.
current guidelines, rather than using PRSS alone. The presence of a PRSS may also be a cue to remind providers to frequently reposition patients. However, we found sub- stantial variation in the prevalence of frequent reposition- ing and PRSS use by hospital, indicating that differences in resource availability or facility policies, such as the pres- ence of quality improvement initiatives, may play major roles in the implementation of pressure ulcer prevention guidelines.
An important limitation of this study is its observational design; randomized studies are required to provide strong evidence regarding the effectiveness of this intervention. However, given that repositioning every 2 hours is the cur- rent standard of care, it would be difficult and possibly unethical to perform experimental studies where patients are randomized to less frequent intervals of repositioning. To strengthen the inferences drawn from this study, we adjusted for many known confounders of the association of interest, but bias due to unmeasured confounders can- not be excluded. Also, there may be errors in the informa- tion about frequency of repositioning obtained from medical records. This limitation is particularly salient as the prior study by Bates-Jensen et al.
12 found a wide dis-
crepancy between actual repositioning practices and med- ical record documentation, with documentation rates much higher than repositioning rates measured by thigh monitors. As such errors are probably equally likely among patients who do and do not develop pressure ulcers, the errors tend to bias results toward the null. An- other limitation of this study was the relatively small sam- ple size which limited the power to test the associations of interest. Finally, our study population was limited to hip fracture patients age 65 years or older, and results may not be generalizable to other patients at risk for pressure ulcers. However, because hip fracture patients are fre- quently bed-bound for long periods of time in the periop- erative period, pressure ulcers are a common complication of immobility among these patients.
17 Thus, elderly hip
fracture patients represent an excellent population in which to examine repositioning as an intervention to pre- vent pressure ulcers, and there is no known reason that the effect of frequent repositioning in this population would differ from that in other populations at risk for pressure ulcers. The high incidence of pressure ulcers seen in this study may be due to the choice of elderly hip fracture patients (a particularly high-risk group) as the study sam- ple, but it may also be linked to infrequent repositioning practices in study facilities. Unfortunately, data were not available to examine facility polices, practices, or resources related to repositioning; the contribution of these factors to pressure ulcer incidence may be an important future area of study.
Pressure ulcers have been recognized as an important indicator of quality of care, particularly since the identifi- cation of stage 3 or 4 pressure ulcers as one of the hospital- acquired conditions for which the Centers for Medicare and Medicaid Services will not provide reimbursement. Clinical practice guidelines for pressure ulcer prevention recommend the use of frequent manual repositioning in bed-bound patients, but this study found that the imple- mentation of this intervention was suboptimal. The imple- mentation also varied substantially by hospital, indicating that factors other than patient need influence the choice of
pressure ulcer prevention methods and that the quality of care for pressure ulcer prevention may differ by facility. However, the results of this study and others indicate that we do not yet have evidence for the efficacy of frequent re- positioning for pressure ulcer prevention. Additional study is needed to determine if there is a standard interval at which manual repositioning is effective at preventing pressure ulcers, or if manual repositioning is only effective in a subpopulation of bed-bound patients. In the absence of this information, it is unclear if the variations in care demonstrated in this study translate into a difference in patient outcomes, or if decreasing the frequency of reposi- tioning might reduce the cost and burden of this interven- tion without increasing the incidence of pressure ulcers. The current findings call into question the efficacy of turn- ing as a pressure ulcer prevention strategy, but it is pre- mature to suggest that frequent manual repositioning is unnecessary. Repositioning may be more important for patients at higher risk (i.e., lower scores) by the Braden scale, but further research is required.
ACKNOWLEDGMENTS
Supported by grants from the National Institute on Aging (T32 AG000262 and F30 AG034008); National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01 AR47711); University of Maryland General Clinical Re- search Center Grant, General Clinical Research Centers Program, National Center for Research Resources (M01 RR16500); National Institute on Aging Claude D. Pepper Older Americans Independence Center (P30 AG028747); and National Institute of Child Health and Human Devel- opment (K12 HD043489).
Preliminary results from this study were presented as a poster at the 2009 Annual Scientific Meeting of the Amer- ican Geriatrics Society, Chicago, IL, April 30, 2009, and at the 61st Annual Meeting of the Gerontological Society of America, National Harbor, MD, November 19, 2008. Fi- nal results from this study were presented at the 137th An- nual Meeting of the American Public Health Association, Philadelphia, PA, November 10, 2009.
Data from this study have been the subject of other analyses, the results of which have been previously pub- lished. The publications are as follows: (a) Baumgarten, M., Margolis, D.J., Orwig, D.L., Shardell, M.D., Hawkes, W.G., Langenberg, P., Palmer, M.H., Jones, P.S., McAr- dle, P.F., Sterling, R., Kinosian, B.P., Rich, S.E., Sowin- ski, J., and Magaziner, J. 2009. ‘‘Pressure Ulcers in Elderly Patients with Hip Fracture Across the Continuum of Care.’’ Journal of the American Geriatrics Society. 57(5): 863–70. (b) Baumgarten, M., Margolis, D., Orwig, D., Hawkes, W., Rich, S., Langenberg, P., Shardell, M., Palmer, M.H., McArdle, P., Sterling, R., Jones, P.S., and Magaziner, J. 2010. ‘‘Use of Pressure-Redistributing Sup- port Surfaces Among Elderly Hip Fracture Patients Across the Continuum of Care: Adherence to Pressure Ul- cer Prevention Guidelines.’’ Gerontologist. 50:253–62. Nei- ther of these previously published articles have examined the hypotheses that are addressed in this article.
The authors have no potential conflicts of interest. Dr. Rich had full access of the data in the study and takes
Wound Rep Reg (2011) 19 10–18 c� 2010 by the Wound Healing Society16
Frequent repositioning and pressure ulcer incidence Rich et al.
responsibility for the integrity of the data and the accuracy of the data analysis.
Author contributions: Study concept and design: Rich, Margolis, Amr, Miller, Baumgarten. Data acquisition: Rich, Shardell, Hawkes, Margolis, Baumgarten. Data management and analysis: Rich, Shardell, Hawkes. Data interpretation and preparation of manuscript: Rich, Shardell, Hawkes, Margolis, Amr, Miller, Baumgarten.
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