Turning And Repositioning To Reduce Pressure Injuries

The guidelines and formatting for this paper is attached as well as 4 articles being used. Below is the PICOT question that is used.

P : Hospitalized patients

I : Turning and repositioning

C (OPTIONAL) : N/A

0 : Reduce pressure injuries

T (OPTIONAL) : N/A

Clinical Question:

In hospitalized patients, does turning and repositioning reduce the risk of pressure injuries?
Gwynedd Mercy University

Frances M. Maguire School of Nursing and Health Professions

NUR 231 Evidence-Based Practice in Nursing

Evidence-Based Practice Paper Guidelines

EBP requires nurses to continuously cultivate a spirit of inquiry. Nurses must identify and appraise the most relevant and best evidence to integrate the evidence into clinical practice. Students will identify and discuss suggested best practice related to an identified clinical issue/problem.

1. Students may work individually or with a partner on this assignment (limit to one partner). One paper submitted per partnership.

2. Using the PICOT question developed in class, perform a search for research studies from professional, scholarly journals (nursing journals preferred) and/or best-practice guidelines from professional organizations.

3. Select at least four studies or guidelines that discuss evidence-based practice related to the specific PICOT question, published within the past 10 years. Do not use an article that is a literature review, synthesis or meta-analysis (consult with Professor Lynn or the research librarian if you have questions or need assistance).

4. Complete the Literature Review Template for the selected sources. This information will form the basis of the written assignment.

Paper:

5. Introduce the nursing problem. Provide a clear and concise description of the clinical practice issue/problem. Discuss the reason this topic is important to nursing practice (significance).

6. Translate the clinical nursing practice issue/problem into an investigational question. Identify each component of the PICOT question. The question must include all PICOT components.

7. Provide a discussion of each article, including the clinical problem and relevant background for the focus of the study/guideline.

a. If the source discusses a research study, include the research question (purpose), type of study (quantitative or qualitative) and results/conclusions (suggested strategies).

b. If the source discusses an evidence-based practice guideline, summarize the guideline (suggested strategies).

8. Describe potential barriers to implementing the research/guideline suggestions.

9. Identify potential strategies to address the barriers.

10. This paper must be written following APA guidelines, Times New Roman 12 double spaced. Include a reference list. Proper grammar, spelling and professional word choice is mandatory.

11. The body of the paper is not to exceed 6 pages.

12. Papers will be submitted through SafeAssign in Blackboard.

13. Refer to the Grading Criteria Rubric posted in Blackboard and the Course Polices in the syllabus.

Evidence-Based Practice Paper Format

· Title Page

· Abstract: Brief summary of the key points of the paper. No need for keywords.

· Introduction: Provide a clear and concise description of the clinical practice issue/problem and background. Discuss the reason this topic is important to nursing practice (significance) and include a minimum of one reference for your reasoning. Identify the PICOT question at the end of the Introduction, , including all PI(C)O(T) components.

· Review of Literature: Address the required content for each study/guideline. Try to make use of transitional sentences between the discussion of each resource.

· Summary of suggested best practices as identified by authors.

· Barriers: Identify potential barriers to implementation of the best-practice recommendations in the articles.

· Strategies: Identify potential strategies to address the barriers.

· Conclusion

· References

APA format: Make use of the library resources! See APA Style Guide and sample paper on the library’s webpage.

Headings are optional, but if you decide to use them, be certain to consult the APA Style Guide.

No first person, no pronouns.

Citations for a direct quote must have page number.

Example: “Donuts make people happy” (Lynn, 2017, p. 3).

Tone of writing: Do not refer to authors by first names, and do not identify the title of the article. That is what the reference page is for.

Example: Lynn (2017) examined the relationship between eating donuts and being happy.
Cochrane Database of Systematic Reviews

Repositioning for pressure ulcer prevention in adults (Review)

Gillespie BM, Chaboyer WP, McInnes E, Kent B, Whitty JA, Thalib L

Gillespie BM, Chaboyer WP, McInnes E, Kent B, Whitty JA, Thalib L.

Repositioning for pressure ulcer prevention in adults.

Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD009958.

DOI: 10.1002/14651858.CD009958.pub2.

www.cochranelibrary.com

Repositioning for pressure ulcer prevention in adults (Review)

http://www.cochranelibrary.com
T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

18DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

33DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 1.1. Comparison 1 2h versus 3h repositioning on standard hospital mattresses, Outcome 1 Pressure ulcer risk

(category 1 to 4). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Analysis 1.2. Comparison 1 2h versus 3h repositioning on standard hospital mattresses, Outcome 2 Pressure ulcer risk

(category 2 to 4). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Analysis 2.1. Comparison 2 4h versus 6h repositioning on viscoelastic foam mattresses, Outcome 1 Pressure ulcer risk

(category 1 to 4). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Analysis 2.2. Comparison 2 4h versus 6h repositioning on viscoelastic foam mattresses, Outcome 2 Pressure ulcer risk

(category 2 to 4). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Analysis 3.1. Comparison 3 30o tilt 3-hourly overnight versus 90o tilt overnight, Outcome 1 Pressure ulcer risk (category 1

to 4). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

36APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

41WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

42CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

42DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

42SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

43DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .

43INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iRepositioning for pressure ulcer prevention in adults (Review)

[Intervention Review]

Repositioning for pressure ulcer prevention in adults

Brigid M Gillespie1, Wendy P Chaboyer1, Elizabeth McInnes2 , Bridie Kent3, Jennifer A Whitty4, Lukman Thalib5

1NHMRC Centre of Research Excellence in Nursing, Centre for Health Practice Innovation, Menzies Health Institute Queensland,

Griffith University, Brisbane, Australia. 2Nursing Research Institute, St Vincent’s Health Australia (Sydney) and Australian Catholic

University (ACU), School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Darlinghurst, Australia. 3School

of Nursing and Midwifery, Deakin Centre for Quality and Risk Management, Deakin University, Melbourne, Burwood, Australia. 4School of Pharmacy, The University of Queensland, Brisbane, Australia. 5Department of Community Medicine, Kuwait University,

Safat, Kuwait

Contact address: Wendy P Chaboyer, NHMRC Centre of Research Excellence in Nursing, Centre for Health Practice Innovation,

Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia. w.chaboyer@griffith.edu.au.

Editorial group: Cochrane Wounds Group.

Publication status and date: New, published in Issue 4, 2014.

Review content assessed as up-to-date: 6 September 2013.

Citation: Gillespie BM, Chaboyer WP, McInnes E, Kent B, Whitty JA, Thalib L. Repositioning for pressure ulcer prevention in adults.

Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD009958. DOI: 10.1002/14651858.CD009958.pub2.

A B S T R A C T

Background

A pressure ulcer (PU), also referred to as a ’pressure injury’, ’pressure sore’, or ’bedsore’ is defined as an area of localised tissue damage

that is caused by unrelieved pressure, friction or shearing forces on any part of the body. PUs commonly occur in patients who are

elderly and less mobile, and carry significant human and economic impacts. Immobility and physical inactivity are considered to be

major risk factors for PU development and the manual repositioning of patients in hospital or long-term care is a common pressure

ulcer prevention strategy.

Objectives

The objectives of this review were to:

1) assess the effects of repositioning on the prevention of PUs in adults, regardless of risk or in-patient setting;

2) ascertain the most effective repositioning schedules for preventing PUs in adults; and

3) ascertain the incremental resource consequences and costs associated with implementing different repositioning regimens compared

with alternate schedules or standard practice.

Search methods

We searched the following electronic databases to identify reports of the relevant randomised controlled trials: the Cochrane Wounds

Group Specialised Register (searched 06 September 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (2013,

Issue 8); Ovid MEDLINE (1948 to August, Week 4, 2013); Ovid EMBASE (1974 to 2013, Week 35); EBESCO CINAHL (1982 to

30 August 2013); and the reference sections of studies that were included in the review.

Selection criteria

Randomised controlled trials (RCTs), published or unpublished, that assessed the effects of any repositioning schedule or different

patient positions and measured PU incidence in adults in any setting.

1Repositioning for pressure ulcer prevention in adults (Review)

mailto:w.chaboyer@griffith.edu.au
Data collection and analysis

Two review authors independently performed study selection, risk of bias assessment and data extraction.

Main results

We included three RCTs and one economic study representing a total of 502 randomised participants from acute and long-term care

settings. Two trials compared the 30º and 90º tilt positions using similar repositioning frequencies (there was a small difference in

frequency of overnight repositioning in the 90º tilt groups between the trials). The third RCT compared alternative repositioning

frequencies.

All three studies reported the proportion of patients developing PU of any grade, stage or category. None of the trials reported on pain,

or quality of life, and only one reported on cost. All three trials were at high risk of bias.

The two trials of 30º tilt vs. 90º were pooled using a random effects model (I² = 69%) (252 participants). The risk ratio for developing

a PU in the 30º tilt and the standard 90º position was very imprecise (pooled RR 0.62, 95% CI 0.10 to 3.97, P=0.62, very low quality

evidence). This comparison is underpowered and at risk of a Type 2 error (only 21 events).

In the third study, a cluster randomised trial, participants were randomised between 2-hourly and 3-hourly repositioning on standard

hospital mattresses and 4 hourly and 6 hourly repositioning on viscoelastic foam mattresses. This study was also underpowered and at

high risk of bias. The risk ratio for pressure ulcers (any category) with 2-hourly repositioning compared with 3-hourly repositioning

on a standard mattress was imprecise (RR 0.90, 95% CI 0.69 to 1.16, very low quality evidence). The risk ratio for pressure ulcers

(any category) was compatible with a large reduction and no difference between 4-hourly repositioning and 6-hourly repositioning on

viscoelastic foam (RR 0.73, 95% CI 0.53 to 1.02, very low quality evidence).

A cost-effectiveness analysis based on data derived from one of the included parallel RCTs compared 3-hourly repositioning using the

30º tilt overnight with standard care consisting of 6-hourly repositioning using the 90º lateral rotation overnight. In this evaluation

the only included cost was nursing time. The intervention was reported to be cost saving compared with standard care (nurse time cost

per patient EURO206.6 vs EURO253.1, incremental difference EURO-46.5; 95%CI: EURO-1.25 to EURO-74.60).

Authors’ conclusions

Repositioning is an integral component of pressure ulcer prevention and treatment; it has a sound theoretical rationale, and is widely

recommended and used in practice. The lack of robust evaluations of repositioning frequency and position for pressure ulcer prevention

mean that great uncertainty remains but it does not mean these interventions are ineffective since all comparisons are grossly under-

powered. Current evidence is small in volume and at risk of bias and there is currently no strong evidence of a reduction in pressure

ulcers with the 30° tilt compared with the standard 90º position or good evidence of an effect of repositioning frequency. There is a

clear need for high-quality, adequately-powered trials to assess the effects of position and optimal frequency of repositioning on pressure

ulcer incidence.

The limited data derived from one economic evaluation means it remains unclear whether repositioning every 3 hours using the 30º

tilt is less costly in terms of nursing time and more effective than standard care involving repositioning every 6 hours using a 90º tilt.

P L A I N L A N G U A G E S U M M A R Y

Repositioning to prevent pressure ulcers

Pressure ulcers, also called pressure injury, pressure sores, decubitus ulcers and bed sores are caused by pressure, rubbing or friction at

the weight-bearing bony points of the body (such as hips, heels and elbows). A pressure ulcer is characterised by an area of localised

injury to the skin or underlying tissue over a bony prominence that results from pressure or shearing, or a combination of both. Pressure

ulcers most commonly occur in the elderly, or those who are immobile, either when in bed or sitting. Repositioning (i.e. turning) is one

strategy used alongside other preventative strategies to relieve pressure, and so prevent development of pressure ulcers. Repositioning

involves moving the person into a different position to remove or redistribute pressure from a particular part of the body.

We identified three studies which recruited 502 people. Evidence to support the use of repositioning to prevent pressure ulcers is low in

volume and quality and we still do not know if particular positions or frequencies of repositioning reduce pressure ulcer development.

None of the trials reported on pain or quality of life. There is a need for further research to measure the effects of repositioning on pressure

ulcer development and to find the best repositioning regimen in terms of frequency and position. It is important to emphasise that this

2Repositioning for pressure ulcer prevention in adults (Review)

lack of evidence showing that repositioning is effective or which repositioning regimen is the best does not mean that repositioning is

ineffective.

B A C K G R O U N D

Description of the condition

A pressure ulcer (PU) (also known as pressure sore, pressure in-

jury, or bedsore) is “a localised injury to skin or underlying tissue

usually over a bony prominence as a result of pressure or pressure

in combination with shear” (European Pressure Ulcer Advisory

Panel 2009; NPUAP 2009). PUs occur when the soft tissue is

compressed between a bony prominence and an external surface

for a prolonged period of time.

PU classification systems provide an accurate and consistent means

by which the severity and level of tissue injury of a PU can

be described and documented (Australian Wound Management

Association 2011).The words ’stage’ (European Pressure Ulcer

Advisory Panel 2009), ’grade’, and ’category’ are used interchange-

ably to describe the levels of soft-tissue injury. The original stag-

ing system includes Stages 1 to 4. Stage 1 reflects persistent

non-blanching erythema (redness) of the skin (Australian Wound

Management Association 2011; European Pressure Ulcer Advisory

Panel 2009). Stage 2 involves partial-thickness skin loss (epi-

dermis and dermis). Stage 3 reflects full-thickness skin loss in-

volving damage, or necrosis, of subcutaneous tissue, whereas in

Stage 4 the damage extends to the underlying bone, tendon or

joint capsule. However, more recently, two additional classifica-

tions have been identified, namely: ’unclassified/unstageable’ and

’deep tissue injury’ (Australian Wound Management Association

2011; European Pressure Ulcer Advisory Panel 2009; National

Pressure Ulcer Advisory Panel 2007). PUs are associated with pain,

an increased risk of infection and sepsis, longer hospital stays,

higher hospitalisation costs and mortality (Institute for Healthcare

Improvement 2008; Thomas 1996).

Despite a general consensus that PUs are preventable (Brandeis

2001), hospital-acquired PUs are among the top five adverse events

reported. Estimates of PU incidence in hospitalised patients have

ranged from less than 3% to over 30% (Nixon 2006;Queensland

Health 2008 Mulligan 2011,Schuurman 2009). Costs of treating

PUs vary globally, but represent a considerable financial burden

on hospital budgets wherever they occur. Costs to the Australian

healthcare system have been estimated at AUD 285 million per

annum (Mulligan 2011). The total cost for treatment of PUs in

the UK was GBP 1.4 billion to GBP 2.1 billion annually (4%

of total National Health Service’s expenditure) (Bennett 2004),

whilst the total cost in the US was estimated at USD 11 billion

per year (Institute for Healthcare Improvement 2008). Much of

this cost is allocated to nursing time (Bennett 2004).

Immobility and physical inactivity are considered to be major risk

factors for PU development in hospitalised patients (Allman 1995;

Institute for Healthcare Improvement 2008; Lindgren 2004),

however, the aged and individuals who have severely compromised

states of health are particularly at risk (Institute for Healthcare

Improvement 2008). For example, of the 3.55 million hospital

admissions in Australia each year (excluding day cases), 50% of pa-

tients will be at risk of PUs and 10% or more will develop an ulcer

(Queensland Health 2009). Screening tools based on individuals’

levels of activity and mobility scores have been widely used for

the assessment of PU risk (Braden 2005; Jalali 2005; Thompson

2005). Various interventions are in use and believed to reduce

the incidence of PUs with varying levels of supporting evidence

including different mattresses and overlays (Nixon 2006; Reddy

2006; Vanderwee 2005) and regular position changes (Buss 2002;

Krapfl 2008; Reddy 2006).

Description of the intervention

Repositioning (i.e. turning people to change their body position to

relieve or redistribute pressure) has long been a fundamental com-

ponent of pressure ulcer prevention (PUP). Manual repositioning

regimens are used in PU risk-prevention programs to re-distribute

pressure between the body and the support surface (Manorama

2010).The 90o lateral position has been shown in laboratory stud-

ies to decrease blood flow and transcutaneous oxygen tension close

to anoxic levels (extremely low levels of oxygen) and to increase

interface pressure. Conversely, this appears not to be the case when

the patient is placed in a 30o lateral inclined tilt position. Repo-

sitioning is regarded as also important for the prevention of other

complications associated with prolonged immobility such as pneu-

monia, joint contractures, and urinary tract infections.

Best practice guidelines developed in Europe, USA and Aus-

tralia advocate routine repositioning of people at risk of PUs.

These guidelines commonly advocate two-hourly repositioning

(Australian Wound Management Association 2011; Defloor 2000;

European Pressure UlcerAdvisory Panel 1998; Queensland Health

2009). These recommendations appear to be based on small stud-

ies (not RCTs) conducted 20 or more years ago, that either com-

pared different repositioning schedules or repositioning schedules

3Repositioning for pressure ulcer prevention in adults (Review)

with no manual repositioning (spontaneous body movements)

(Exton-Smith 1961; Norton 1962; Palmen 1987; Smith 1990).

The usefulness of these studies for today’s decision making is fur-

ther compromised since the standard of hospital mattresses has

greatly improved since then.

How the intervention might work

Pressure, from lying or sitting on a particular part of the body

results in oxygen deprivation to the particular area (Defloor 2000).

Normally, this results in pain and discomfort, which stimulates

the person to change position. However, if the person is unable

to reposition themselves, or has impaired sensation and therefore

does not experience the discomfort, assistance will be required.

Repositioning reduces the duration of pressure experienced by

the tissues and so decreases tissue hypoxia (Catania 2007) and

consequently the theoretical risk of pressure ulceration (Braden

1987).

Negative aspects of frequent repositioning

Whilst frequent repositioning underpins current practice guide-

lines, it may also be associated with negative consequences for pa-

tients, nursing staff and health care (Australian Institute of Health

and Welfare 2009; Bureau of Labor Statistics 2002; Carskadon

2005; Dawson 2007; Humphries 2008; Raymond 2004; Vieira

2009). Repositioning can lead to disruption of sleep, particularly

sleep fragmentation (Humphries 2008). In acutely ill people, dis-

ruption of sleep can lengthen recovery, suppress immune function

and predispose people to infection (Carskadon 2005; Raymond

2004). A sleep cycle, which has light and deep stages of sleep, oc-

curs about every 90 minutes. Consequently if repositioning is un-

dertaken every two hours, it may result in fragmentation of sleep

at a detrimental stage of the sleep cycle (Dawson 2007).

Other negative effects of repositioning include possible increases

in patients’ pain perception. Although regular movement is impor-

tant, unnecessary repositioning may cause increased discomfort

for people with wounds, stiff joints, bony pain or contractures.

In addition to people experiencing the negative effects of reposi-

tioning, nurses experience musculoskeletal disorders at a rate ex-

ceeding that of workers in construction, mining, and manufactur-

ing (Bureau of Labor Statistics 2002). These injuries are attributed

partly to repeated manual patient-handling activities, often asso-

ciated with repositioning patients and working in extremely awk-

ward positions (Bureau of Labor Statistics 2002; Vieira 2009).

Back pain and injury have a major impact on the efficiency of the

nursing workforce (Trinkoff 2001). Registered nurses rank seventh

across all occupations for back injuries involving days away from

work in private industry (Bureau of Labor Statistics 2002). Back

injuries and the resultant workers’ compensation claims for nurses

are expensive (Dawson 2007). For example, injuries in the health-

care sector cost Australia over AUD 4.3 billion in 2005 to 2006

(Australian Safety and Compensation Council 2009). Reducing

the amount of manual handling undertaken by nurses when repo-

sitioning patients could have major nursing and hospital benefits.

Why it is important to do this review

PUs may be painful, distressing and life-threatening (causing in-

fection, sepsis and even death), yet many are preventable (Allman

1997; Schuurman 2009). Manual repositioning regimens are used

in PU risk-prevention programs to alternate areas of pressure dis-

tribution between the body and the support surface, including

when sitting or lying in a chair (Manorama 2010). These strate-

gies have major implications for repositioning hospitalised patients

and warrant investigation.

Whilst the potential negative aspects of repositioning have been

described, the magnitude of any benefits are also uncertain, as is

the optimum frequency of repositioning and the best position.

It is noteworthy that, more recently, the National Pressure Ulcer

Advisory Panel 2007 and the European Pressure Ulcer Advisory

Panel 2009 Guidelines did not advocate 2-hourly repositioning

as best practice due to a lack of empirical evidence. A rigorous

systematic review is required to summarise current evidence for

the effects of repositioning of adults, the optimal repositioning

schedules, and to ensure that future trials are based on the best

available evidence.

O B J E C T I V E S

The objectives of this review were to:

1. assess the effects of repositioning on the prevention of PUs

in adults, regardless of risk or in-patient setting;

2. ascertain the most effective repositioning schedules for

preventing PUs in adults; and

3. ascertain the incremental resource consequences and costs

associated with implementing different repositioning regimens

compared with alternate schedules or standard practice.

M E T H O D S

Criteria for considering studies for this review

Types of studies

Any RCT that used a method of random allocation of adult pa-

tients (without an existing PU at baseline) between two or more

4Repositioning for pressure ulcer prevention in adults (Review)

alternative repositioning interventions for PU prevention was el-

igible. We also included cluster-RCTs, irrespective of the cluster

group (i.e. patient, nurse, hospital). We excluded cross-over trials

(even if randomised) and quasi-randomised studies, i.e. studies

where treatment allocation was, for example, alternate or by date

of birth.

The review of health economic evidence included comparative

full and partial economic evaluations conducted within the frame-

work of eligible RCTs (i.e. cost-effectiveness analyses, cost-utility

analyses, cost-benefit analyses and cost-analyses of a repositioning

intervention and a relevant comparator), as well as RCTs report-

ing more limited information, such as estimates of resource use or

costs associated with repositioning and a comparator. The review

considered only health economics studies conducted alongside ef-

fectiveness studies included in the effectiveness component of the

review.

Types of participants

Any adult, without an existing PU, admitted to any healthcare or

long-term care setting.

Types of interventions

We anticipated that likely comparisons would include reposition-

ing regimens compared with other standard practices or with al-

ternative repositioning regimens. We included studies evaluating

the following comparisons:

1. Comparisons between the frequencies of repositioning, for

example 2-hourly turning, 3-hourly turning, 4-hourly turning

etc. where the only systematic difference between groups was the

frequency of repositioning.

2. Comparisons between different positions for repositioning,

for example chair positioning, 30o recumbent tilt versus 90o

lateral rotation, where the only systematic difference between

groups was the positioning.

3. Comparisons of the repositioning regimen with standard

practice (as defined by the author(s)).

Types of outcome measures

Primary outcomes

The proportion of participants with a new PU of any stage,

grade,or category using previously defined criteria (European

Pressure Ulcer Advisory Panel 1998; European Pressure Ulcer

Advisory Panel 2009; National Pressure Ulcer Advisory Panel

2007), or however defined by the trial authors, anywhere on the

body following recruitment into the study. We excluded trials

where the unit of analysis was the PU and not the person or group.

Secondary outcomes

1. Health-related quality of life (HRQoL) including utility

scores (however reported by the author(s)).

2. Procedural pain (however reported by the author(s)).

3. Patient satisfaction (however reported by the author(s)).

4. Cost including: costs of PU prevention; costs of related

health practitioner time or visits; costs avoided by PU prevention

(e.g. treatment costs per patient per PU wound; costs to treat

adverse events, infections or complications of PU; duration or

costs of hospital stay for PU wound healing, adverse events and

complications; indirect costs to society associated with PU such

as lost productivity).

5. Incremental cost per event avoided, such as per additional

PU prevented; incremental cost per life year gained; incremental

cost per quality adjusted life year (QALY) gained, and cost-

benefit ratio.

Search methods for identification of studies

Electronic searches

We searched the following electronic databases to identify reports

of relevant RCTs:

1. The Cochrane Wounds Group Specialised Register

(searched 06 September 2013);

2. The Cochrane Central Register of Controlled Trials

(CENTRAL) (2013, Issue 8);

3. Ovid MEDLINE (1948 to August, Week 4, 2013);

4. Ovid MEDLINE (In-Process & Other Non-Indexed

Citations September 04, 2013);

5. Ovid EMBASE (1974 to 2013 Week 35);

6. EBSCO CINAHL (1982 to 30 August 2013).

We searched the Cochrane Central Register of Controlled Trials

(CENTRAL) using the following exploded MeSH headings and

keywords:

#1 MeSH descriptor Pressure Ulcer explode all trees

#2 pressure NEXT (ulcer* or sore*):ti,ab,kw

#3 decubitus NEXT (ulcer* or sore*):ti,ab,kw

#4 (bed NEXT sore*) or bedsore*:ti,ab,kw

#5 (#1 OR #2 OR #3 OR #4)

#6 MeSH descriptor Posture explode all trees

#7 (reposition* or re-position*):ti,ab,kw

#8 position*:ti,ab,kw

#9 (turn* NEAR/5 patient*):ti,ab,kw

#10 (turn* NEAR/5 interval*):ti,ab,kw

#11 (turn* NEAR/5 frequen*):ti,ab,kw

#12 (body NEAR/5 postur*):ti,ab,kw

#13 turning:ti,ab,kw

#14 (pressure NEXT relie*):ti,ab,kw

#15 (mobilis* or mobiliz*):ti,ab,kw

5Repositioning for pressure ulcer prevention in adults (Review)

#16 (#6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12

OR #13 OR #14 OR #15)

#17 (#5 AND #16).

We adapted this strategy to search Ovid MEDLINE, Ovid EM-

BASE and EBSCO CINAHL (See Appendix 1). We combined

the Ovid MEDLINE search with the Cochrane Highly Sensi-

tive Search Strategy for identifying randomised trials in MED-

LINE: sensitivity- and precision-maximising version (2008 revi-

sion) (Lefebvre 2011). We combined the EMBASE and CINAHL

searches with the trial filters developed by the Scottish Intercolle-

giate Guidelines Network (SIGN 2011).

We conducted separate searches to identify economic studies in

the following databases:

1. NHS Economic Evaluation Database (2013, Issue 8);

2. Ovid MEDLINE (In-Process & Other Non-Indexed

Citations August, week 4, 2013);

3. Ovid EMBASE (1948 to 2013 week 35);

4. EBSCO CINAHL (1982 to 30 August 2013);

5. EURONHEED (http://infodoc.inserm.fr/euronheed/);

6. Health Economics Evaluations Database HEED (http://

onhttp://onlinelibrary.wiley.com/book/).

We used the economics search strategy shown in Appendix 2 to

search Ovid MEDLINE and adapt this strategy to search other

databases.

We also searched the following clinical trials registries for details

of relevant protocols and contacted the relevant research teams in

November 2012:

1. Clinical trials.gov;

2. International Clinical Trials Registry Platform search Portal;

3. Australian and New Zealand Clinical Trials Registry;

4. Current Controlled Trials.

We did not restrict searches by language, study setting, date of

publication or publication status. We made every effort to obtain

translations of papers that were not published in English.

Searching other resources

We searched the reference lists of included studies and any sys-

tematic reviews identified by the search process and contacted cor-

responding authors of identified studies. Where appropriate, we

contacted experts in the field (e.g. council members of the Euro-

pean Wound Management Association, the National Pressure Ul-

cer Advisory Panel, the World Union of Wound Healing Societies,

and the Australian Wound Management Association) to ask for

information about any unpublished studies. We included confer-

ence proceedings or programme abstracts in our search. Where we

were unable to obtain details of the full study, we contacted the

author(s).

Data collection and analysis

Selection of studies

Two review authors (BG, EM) independently assessed all titles

and abstracts of studies retrieved from searching. Full reports of all

potentially relevant trials were retrieved for further assessment of

eligibility based on the inclusion criteria. Differences of opinion

were resolved by consensus or referral to a third review author

(WC). We recorded reasons for exclusion and were not blind study

authorship.

Data extraction and management

For eligible studies, two review authors (BG, EM) independently

extracted data using a pre-designed data collection tool while a

third author (WC) adjudicated where there were differences of

opinion. For studies where there was an economic component

included, JW (Health Economist) and BG extracted the relevant

data. We included studies published in duplicate, but extracted

data to ensure that information was not missed and identified

the primary reference for the purpose of this review. If data were

missing from reports, we attempted to contact the trial authors to

obtain the missing information. One review author (BG) entered

the data into Review Manager 5 software (RevMan) and data were

checked for accuracy by EM. Abstracted data included the follow-

ing information.

1. Author, title, journal title, year of publication, country.

2. Healthcare setting.

3. Inclusion/exclusion criteria.

4. Sample size.

5. Patient characteristics by treatment group.

6. Methods (number eligible and randomised, adequacy of

randomisation, allocation concealment, blinding, completeness

of follow-up).

7. Treatment of missing values (e.g. use of intention-to-treat,

per protocol or other imputation method).

8. Intervention details.

9. Types of outcome measures in relation to primary

(percentage of new PU) and secondary outcomes.

10. Analysis; results and conclusions relevant to review.

11. Funding sources.

For economic studies, we planned to extract additional data extract

in relation to the following.

1. Estimates of specific items of resource use per person.

2. Estimates of unit costs (extracted separately to resource use).

3. Price year and currency.

4. Decision-making jurisdiction.

5. Analytic perspective.

6. A point estimate and a measure of uncertainty (e.g.

standard error or confidence interval) for measures of

incremental resource use, costs and cost-effectiveness, if reported.

7. Details of any sensitivity analyses undertaken, and any

information regarding the impact of varying assumptions on the

magnitude and direction of results.

6Repositioning for pressure ulcer prevention in adults (Review)

http://infodoc.inserm.fr/euronheed/
http://infodoc.inserm.fr/euronheed/
http://infodoc.inserm.fr/euronheed/
http://infodoc.inserm.fr/euronheed/
http://onhttp:/onlinelibrary.wiley.com/book/
http://onhttp:/onlinelibrary.wiley.com/book/
http://onhttp:/onlinelibrary.wiley.com/book/
http://onhttp:/onlinelibrary.wiley.com/book/
http://onhttp:/onlinelibrary.wiley.com/book/
http://onhttp:/onlinelibrary.wiley.com/book/
Assessment of risk of bias in included studies

Two review authors independently assessed the risk of bias of el-

igible trials (BG, EM) using The Cochrane Collaboration tool

for assessing risk of bias (Higgins 2011c).This tool addresses six

specific domains; namely sequence generation, allocation conceal-

ment, blinding, incomplete outcome data, selective outcome re-

porting and other issues that may potentially bias the study (see

Appendix 3 for details of the criteria on which the judgments were

based). Items were rated as low risk of bias, high risk of bias or

unclear (unknown) risk of bias. In assessing bias, the review au-

thors were not blinded to the names of trial authors, institutions,

or journals.

In assessing the risk of bias, we distinguished between primary

outcome (proportion of participants with a new PU), secondary

subjective outcomes (HRQoL, procedural pain, patient satisfac-

tion), and the objective economic outcome. As the primary out-

come for this review, regardless of how it was measured, was sub-

ject to potential observer bias, blinding of outcome assessment was

particularly important. We planned to make separate judgements

for secondary outcomes for the domain of incomplete outcome

data. We classified trials as being at overall high risk of bias if they

were rated as ’high’ for any one of three key domains (allocation

concealment, blinding of outcome assessors and completeness of

outcome data).

Disagreements between review authors were resolved by consensus

or referral to another review author (WC). Where there was a

high risk of bias in any of the key domains, we endeavoured to

contact the trial authors, and asked open-ended questions about

the design and conduct of the study. We reported bias, and within

economic evaluations, planned to use the Drummond checklist,

as recommended by The Cochrane Collaboration (Shemilt 2011),

to assess the methodological quality of full and partial economic

evaluations.

We presented an assessment of risk of bias using ’Risk of bias’ sum-

mary figures, which detail all the judgments in a cross-tabulation

of study by entry. This display of internal validity indicates the

weight the reader may give the results of each study. We classified

studies as being at high risk of bias overall if any one of the criteria

was judged to be at high risk of bias. We recorded trials as being

at unclear risk of bias if authors did not report validity criteria.

Measures of treatment effect

We have reported effect estimates for dichotomous outcomes (e.g.

relative proportions of people developing PU during follow up)

as risk ratios (RR) with 95% confidence intervals. RR is the pro-

portion of participants developing PUs in the experimental group

divided by proportion in the control group and indicates the like-

lihood of PU development on the experimental regimen (turning

frequency or position) compared with a standard treatment. We

have used the RR rather than odds ratio (OR), since ORs may be

misinterpreted as RR, and can give an inflated impression of the

effect size when event rates are greater than 20% (Deeks 2002).

We planned to use MD as a summary statistic in meta-analysis

when outcome measurements in all studies were made on the same

scale.

Review of economic evaluations

We planned to present a tabled analysis of economic data in accor-

dance with current guidance on the use of economics methods in

the preparation of Cochrane reviews (Shemilt 2011). We planned

to classify economic evaluations according to the framework in

Drummond 2005, and to assess the methodology using the check-

list published by Drummond and colleagues. We planned to tabu-

late the main characteristics and results of the identified economic

evaluation studies, and to expand these with a narrative descrip-

tion.

For any included studies, given the likely lack of direct compa-

rability in resource use and cost data between different health-

care contexts and settings, we did not intend to pool economic

outcomes. Rather, we planned to incorporate a discussion of key

drivers and impact of assumptions on the available economic eval-

uations, scenarios that are likely to lead to the most and least cost-

effective use of repositioning for PUP, as well as guidance on future

research that might be required to assess the economic value of

repositioning as an intervention for PUP.

Costs

If we found any economic studies, all substantial costs that were

observed to differ between people repositioned for PUP and peo-

ple administered the comparator treatment were intended to be

captured and reported as part of the review of economic evalua-

tions.

We planned to report resource utilisation and unit costs separately,

along with the currency and price year in each original study. These

costs would then be converted to 2012 values by employing a web-

based conversion tool that applies implicit price deflators for gross

domestic product (GDP) of that currency and then converted

into the currency most frequently observed in the articles reviewed

using Purchasing Power Parities (PPP) (Shemilt 2010).

The main costs were likely to be those associated with the devel-

opment of PUs, specialist and other practitioner costs as measured

by time or number of visits, potential cost-savings from a change

in the number of bed days in hospital, and costs stemming from

differing rates of adverse events and complications (including pro-

cedures initiated due to the failure of wounds to heal, such as am-

putation). We planned to identify key cost drivers that would en-

able users of the review to gain a clear understanding of the nature

of resource use associated with repositioning for PUP.

Health state utility weights

7Repositioning for pressure ulcer prevention in adults (Review)

We planned to examine information on the change in HRQoL re-

ported by included trials via utilities measured by a multi-attribute

utility instrument (MAUI) or other approaches (such as the time

trade-off, standard gamble). We planned to assess the utility data

for comparability and representativeness considering issues such

as the stages of PU, the patient populations, timing of the baseline

point and follow-up collection, the MAUI used and the algorithm

for scoring the MAUI. We planned to present a discussion of the

potential impact on HRQoL attributable to the intervention as

part of the review.

Unit of analysis issues

In all trials included in our review, we treated the person as the

unit of analysis and we took into account the level at which ran-

domisation occurred. For a parallel group design, we collected and

analysed a single measurement for each outcome for each person.

In these types of studies, it was possible that the unit of analysis

was the PU rather than the individual person. We considered in-

stances where there were multiple observations per person for the

same outcome. Where this occurred we first used the PU that was

the most advanced in relation to its staging. If this could not be

determined, then we contacted the trial author(s).

For cluster-randomised trials that had not taken clustering into

account in the study analysis, we considered adjusted sample sizes

using the methods described in Chapter 16 of the Cochrane Hand- book for Systematic Reviews of Interventions (Higgins 2011a). How- ever the best estimate of a relevant intraclass correlation coefficient

(ICC) for estimating the design effect was so small (0.001) that

we used the original reported study data without adjustment. This

ICC (0.001) was estimated from a relevant cluster trial (Moore

2011) and identical to that estimated from a falls study (similar

patient group, similar context of care) (Cumming 2008) so we felt

justified in this approach.

Dealing with missing data

If some outcome data remained missing despite our attempts to

obtain complete outcome data from authors, we planned to per-

form an available-case analysis, based on the numbers of people

for whom outcome data were known since this is a more con-

servative approach in this context than using numbers originally

randomised and assuming that losses to follow up did not incur

pressure injury. We also planned to conduct best-case and worst-

case analysis where we needed to test the robustness of findings

to different assumptions about the outcomes of people who did

not contribute endpoint data. If standard deviations (SD) were

missing, we planned to impute them from other studies or, where

possible, computed them from standard errors (SE) using the for-

mula SD = SE x √

N, where these values were available (Higgins

2011a).

Assessment of heterogeneity

We considered clinical and statistical heterogeneity in relation to

the primary outcomes, PU incidence, and secondary outcomes

such as HRQoL patient satisfaction, and procedural pain. For

cluster-trials, we assessed the outcome at the same level as the

group allocation (Deeks 2011).

We assessed clinical heterogeneity by examining the types of par-

ticipants, and/or groups, interventions and their duration, and the

outcomes of each study. If appropriate, we pooled data using meta-

analysis (using RevMan 5). We did not plan to pool studies for

economic outcomes as the variability in, and generalisability of,

these outcomes were considered problematic.

Statistical heterogeneity was assessed visually and by using the Chi 2 statistic with significance being set at P value less than 0.10. In

addition we investigated the degree of heterogeneity by calculating

the I2 statistic (Deeks 2002). The I2 test examines the percentage

of total variation across studies due to heterogeneity rather than

chance. Values over 50% indicate a substantial level of heterogene-

ity. Where appropriate, in the absence of clinical heterogeneity and

in the presence of statistical heterogeneity (I2 greater than 60%),

we used a random effects model, Where studies were sufficiently

similar to consider pooling, we planned to use a fixed effect model

for low to moderate levels of heterogeneity (I2 values between 0%

and under 60%). We did not plan to pool studies where hetero-

geneity exceeded 75% (Higgins 2011b).

Assessment of reporting biases

We planned to assess potential publication bias using funnel plots

and to assess funnel plot asymmetry visually (Sterne 2011).

Subgroup analysis and investigation of heterogeneity

We planned a subgroup analysis, if possible, to examine the effect

of potentially influential factors on outcome, e.g. care setting and

patient characteristics.

Sensitivity analysis

We planned to perform sensitivity analyses where necessary to

test whether findings were robust to the method used to obtain

them, and compared the results of two or more meta-analyses

using different assumptions (Higgins 2011c).

Presentation of results

We planned to include the following primary and secondary out-

comes (both desirable and undesirable) in the summary of find-

ings tables:

1. development of a new PU;

2. HRQoL;

3. pain;

8Repositioning for pressure ulcer prevention in adults (Review)

4. patient satisfaction;

5. costs;

6. incremental cost.

R E S U L T S

Description of studies

See Characteristics of included studies; Characteristics of excluded

studies; and, Characteristics of studies awaiting classification. With

the exception of the TURN trial (Bergstrom), we are not aware of

any relevant ongoing trials (ISRCTN register checked September,

2013).

Results of the search

Interventions search

Electronic searches yielded 258 results of which we excluded 254

because they did not meet one or more of our inclusion criteria.

We retrieved full text versions of the remaining four papers for

inspection, and included three trials in the review (Defloor 2005;

Moore 2011; Young 2004). See Figure 1 study flow diagram. All

the included trials had been published in the last 10 years. One

ongoing study was identified (Bergstrom) which will be considered

for inclusion in the next update of this review.

9Repositioning for pressure ulcer prevention in adults (Review)

Figure 1. Study flow diagram for clinical studies

10Repositioning for pressure ulcer prevention in adults (Review)

Economic analysis search

Electronic searches yielded 238 references, of which 237 were ex-

cluded because they did not meet our inclusion criteria. One eco-

nomic substudy by Moore 2013 was identified. See Figure 2 study

flow diagram.

11Repositioning for pressure ulcer prevention in adults (Review)

Figure 2. Study flow diagram for economic studies

12Repositioning for pressure ulcer prevention in adults (Review)

Included studies

Types of participants

We did not adjust sample sizes for clustering in the two cluster

RCTs (see above) (Defloor 2005; Moore 2011). A total of 1097

participants were enrolled in the three trials included in this re-

view (Defloor 2005; Moore 2011; Young 2004). Total numbers

randomised in the included studies were 838 (Defloor 2005), 213

(Moore 2011), and 46 (Young 2004). However, in Defloor 2005

only 262 participants were randomised to arms relevant to this re-

view meaning a total of 521 randomised participants were poten-

tially considered here. Ultimately 502 participants were included

in the analyses reported here as 19 people were lost to follow up

and we conducted a complete case analysis. Within these trials the

majority of participants were residents of long-term care settings

(Defloor 2005; Moore 2011), whilst one small study recruited 46

participants from a single acute care facility (Young 2004). Partic-

ipants in all three trials were aged over 65 years and all trials were

conducted in Europe (Belgium (Defloor 2005), Ireland (Moore

2011), and Wales (Young 2004)).

Types of interventions

In two of the three trials (Moore 2011; Young 2004), a 30º tilt

position was compared with a standard 90º supine/lateral position.

Participants in both the intervention and control groups were tilted

left side, back, right side, and back. Essentially, the Moore 2011

and Young 2004 trials compared the same tilts (30º vs 90º) and

the same repositioning frequency for the 30º tilt. However, there

was a difference in the frequency of repositioning overnight for

the 90º tilt groups. In the Moore 2011 trial, patients in the 90º tilt

group were repositioned 6-hourly overnight compared with two

to 3-hourly overnight in the Young 2004 trial.

The third trial (Defloor 2005) evaluated different repositioning

frequencies (2-, 3-, 4- and 6-hourly) using a semi-Fowler or lat-

eral position, in combination with standard or viscoelastic mat-

tresses. The participants receiving the 2 hourly and 3 hourly repo-

sitioning all received the standard hospital mattress whilst those

receiving the 4 and 6 hourly repositioning received viscoelastic

foam mattresses. In this study there was also a large “standard care”

arm comprising 576 people allocated care based on nurses’ clinical

judgement (a range of support surfaces but no repositioning). We

disregarded this treatment arm for the purposes of this review as it

systematically differed from the other 4 arms in both the allocation

of support surface and repositioning. In the other 4 groups, co-

interventions such as the use of nutritional supplements, skin care

and allocation of pressure relieving cushions during chair sitting

were also used.

Types of outcomes

The primary outcome in each of the included trials was the propor-

tion of participants developing a new PU (Defloor 2005; Moore

2011; Young 2004). Two trials reported the incidence of PU and

included Stages 1 to 4 over a 28-day period (Defloor 2005; Moore

2011), while the third trial reported a much briefer follow-up pe-

riod of 24 hours and reported only Stage 1 PU (i.e. non-blanch-

able erythema) (Young 2004).

Excluded studies

One trial was excluded after the full text had been screened

(Vanderwee 2007). In this trial, participants who had pre-existing

Stage 1 non-blanchable erythema at baseline were included, and

those who did not have non-blanchable erythema were excluded.

We had pre-specified that only studies where patients had no ex-

isting PU skin damage were eligible for inclusion.

Risk of bias in included studies

We present an assessment of the risk of bias using ’Risk of bias’

summary figures (Figure 3 and Figure 4), which detail all of the

judgements in cross-tabulations of study by entry. All three trials

were at unclear or at high risk of bias.

13Repositioning for pressure ulcer prevention in adults (Review)

Figure 3. Risk of bias summary: review authors’ judgements about each risk of bias item for each included

study

14Repositioning for pressure ulcer prevention in adults (Review)

Figure 4. Risk of bias graph: review authors’ judgements about each risk of bias item presented as

percentages across all included studies

Allocation

Random sequence generation

All three trials described a process to generate the random allo-

cation list (Defloor 2005; Moore 2011; Young 2004). Two tri-

als used a computer-based random number generator (Defloor

2005; Moore 2011), while the Young 2004 trial used sequentially-

numbered envelopes that contained a randomisation code. In the

Defloor 2005 trial, randomisation also occurred over a second 4-

week period. During this second period, each ward used a differ-

ent prevention scheme than used in the first 4-week period.

Allocation concealment

Assessment of allocation concealment in the three included trials

involved examination of whether trial authors described how the

assignment sequence was protected before and until allocation. We could not adequately assess the extent of allocation concealment

for the Defloor 2005 trial since the randomisation was influenced

during the trial by resources and we therefore rated this “unclear”.

In the Young 2004 trial, the allocation was concealed from the

researcher and the nurses in a sealed and sequentially numbered

envelope (low risk of bias). In the Moore 2011 study, allocation

concealment was achieved using remote randomisation (also low

risk of bias).

Blinding

Blinding of participants and personnel

It is hard to envisage how blinding of participants and personnel

to the frequency and nature of repositioning could be possible and

therefore all three trials are likely to be at risk of performance bias.

Two out of three trial reports did not state whether participants

and nursing staff were blinded (Defloor 2005; Young 2004). The

Moore 2011 trial was described as “open label”, usually meaning

that the participants, care givers and researchers were aware of

group allocation. The Defloor 2005 and Moore 2011 trials were

classified as at high risk of performance bias while the Young 2004

trial was classified as unclear risk of bias.

Blinding of outcome assessors

There was considerable variability in assessment of all grades of

PU among the three trials (Defloor 2005; Moore 2011; Young

2004). Such variability is problematic, as the use of a subjective

primary outcome measure is open to ascertainment bias.

Outcome measurement was not blinded in two trials (Defloor

2005; Moore 2011) and these were rated as high risk. In the

Young 2004 trial, the outcome assessor was “unaware” of group

allocation, as the positioning aids (pillows) were removed from

under the patient prior to outcome measurement (low risk). Only

15Repositioning for pressure ulcer prevention in adults (Review)

Moore 2011 considered the reliability of outcome using several

outcome assessors to minimise this form of bias. However, inter-

rater reliability data were not presented.

Incomplete outcome data

Assessment of whether incomplete outcome data had been ade-

quately addressed in each trial involved examining whether reasons

for attrition or exclusion were reported, whether there was re-in-

clusion of participants, and whether completeness of data for each

main outcome was described. In two of the three trials (Defloor

2005; Young 2004), participants were excluded from the analysis

in sufficient numbers to threaten bias. Defloor 2005 excluded 77

(9.2%) of 838 randomised participants from the analysis, and in

the Young 2004 trial, seven (15.2%) of the 46 randomised partici-

pants were excluded; two due to death (both in the control group)

and five in the experimental group, who were unable to tolerate the

intervention and for whom outcome data collection then ceased.

For both the Young 2004 and Defloor 2005 trials, we conducted

a complete case analysis (which makes no assumption about the

outcomes for patients lost to follow up as this was felt more con-

servative than analysing losses as if they had not sustained pressure

injury). Attrition bias and lack of intention-to-treat analysis were

contributing factors to incomplete outcome data. In Moore 2011,

all randomised participants were included in the analysis.

Selective reporting

Each study reported all pre-specified outcomes – as defined in the

papers – in the results. No published protocol was available for any

of these trials.

Other potential sources of bias

We planned to assess potential publication bias using funnel plots

and to assess funnel plot asymmetry visually, however, as only

three studies were included in this review, this was not appropriate

(Sterne 2011).

Effects of interventions

Comparison 1: frequencies of repositioning (one trial)

One cluster randomised trial (Defloor 2005) was included in this

comparison however we did not adjust the data for clustering as

the ICC of 0.001 (from Moore 2011 and Cumming 2008) was so

small as to make no difference.

Primary outcomes

The proportion of new pressure ulcers of any grade, stage or

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Turning And Repositioning To Reduce Pressure Injuries

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