A randomised controlled clinical trial of repositioning, using the 30° tilt, for the prevention of pressure ulcers

Abstract

Background. Pressure ulcers are common, costly and impact negatively on individuals. Pressure is the prime cause, and immobility is the factor that exposes individuals to pressure. International guidelines advocate repositioning; however, there is confusion surrounding the best method and frequency required. Design. A pragmatic, multi-centre, open label, prospective, cluster-randomised controlled trial was conducted to compare the incidence of pressure ulcers among older persons nursed using two different repositioning regimens. Method. Ethical approval was received. Study sites (n = 12) were allocated to study arm using cluster randomisation. The experimental group (n = 99) were repositioned three hourly at night, using the 30°tilt; the control group (n = 114) received routine prevention (six-hourly repositioning, using 90°lateral rotation). Data analysis was by intention to treat; follow-up was for four weeks. Results. All participants (n = 213) were Irish and white, among them 77% were women and 65% aged 80 years or older. Three patients (3%) in the experimental group and 13 patients (11%) in the control group developed a pressure ulcer (p = 0AE035; 95% CI 0AE031-0AE038; ICC = 0AE001). All pressure ulcers were grade 1 (44%) or grade 2 (56%). Mobility and activity were the highest predictors of pressure ulcer development (b = À0AE246, 95% CI = À0AE319 to À0AE066; p = 0AE003); (b = 0AE227, 95% CI = 0AE041-0AE246; p = 0AE006). Conclusion. Repositioning older persons at risk of pressure ulcers every three hours at night, using the 30°tilt, reduces the incidence of pressure ulcers compared with usual care. The study supports the recommendations of the 2009 international pressure ulcer prevention guidelines. Relevance to clinical practice. An effective method of pressure ulcer prevention has been identified; in the light of the problem of pressures ulcers, current prevention strategies should be reviewed. It is important to implement appropriate prevention strategies, of which repositioning is one.

Consistent pressure ulcer prevention practice: The effect on PU prevalence and PU stages, and impact on PU prevention—A quasi‐experimental intervention study

“…The results are in line with a previous study of 28 LOPD residents 33 where after the PU prevention bundle in four areas—heel protection/skin assessment, repositioning, incontinence, and nutrition—only stage I PUs existed. The results of this study are opposite to those reported in earlier studies conducted in LOPC facilities of PU prevention interventions consisting of repositioning, 29 mattresses, overlays or cushions, 31 , 32 and PU prevention programmes, 34 where stage II PUs still existed. This shows the effectiveness of the conducted intervention and also recommends the use of bundles in PU prevention.…”

“…However, unlike in previous studies, in this study, PUs were also found in other areas of the feet, which can be explained by the higher number of walking residents who were in better condition. In contrast to previous studies, 18 , 25 , 29 after the intervention, there were no PUs in the heels and only two stage I PUs in the sacrum, buttock, and hip areas. This indicates the effectiveness of the conducted intervention in decreasing PUs in the most common PU areas.…”

“…condition. In contrast to previous studies, 18,25,29 after the intervention, there were no PUs in the heels and only two stage I PUs in the sacrum, buttock, and hip areas. This indicates the effectiveness of the conducted intervention in decreasing PUs in the most common PU areas.…”

Consistent pressure ulcer prevention practice: The effect on PU prevalence and PU stages, and impact on PU prevention—A quasi‐experimental intervention study

“…The results are in line with a previous study of 28 LOPD residents 33 where after the PU prevention bundle in four areas—heel protection/skin assessment, repositioning, incontinence, and nutrition—only stage I PUs existed. The results of this study are opposite to those reported in earlier studies conducted in LOPC facilities of PU prevention interventions consisting of repositioning, 29 mattresses, overlays or cushions, 31 , 32 and PU prevention programmes, 34 where stage II PUs still existed. This shows the effectiveness of the conducted intervention and also recommends the use of bundles in PU prevention.…”

“…However, unlike in previous studies, in this study, PUs were also found in other areas of the feet, which can be explained by the higher number of walking residents who were in better condition. In contrast to previous studies, 18 , 25 , 29 after the intervention, there were no PUs in the heels and only two stage I PUs in the sacrum, buttock, and hip areas. This indicates the effectiveness of the conducted intervention in decreasing PUs in the most common PU areas.…”

“…condition. In contrast to previous studies, 18,25,29 after the intervention, there were no PUs in the heels and only two stage I PUs in the sacrum, buttock, and hip areas. This indicates the effectiveness of the conducted intervention in decreasing PUs in the most common PU areas.…”

Turning for Ulcer ReductioN: A Multisite Randomized Clinical Trial in Nursing Homes

“…Considering only 2‐, 3‐, 4‐, or 6‐hour repositioning intervals in previous randomized studies of repositioning (Table ), the low incidence of PrUs in the TURN Study is similar to the 3% (2 ulcers/66 participants) incidence reported previously for a 4‐hour repositioning group on viscoelastic mattresses (the only group equivalent to the current study) and similar to that of another study that reported a 3% (3 ulcers/99 participants) incidence for those on powered mattresses repositioned every 3 hours. Incidence of PrU Stages 2 to 4 reported previously ranged from 14.3% to 24.1% without high‐density foam mattresses …”

Turning frequency in adult bedridden patients to prevent hospital‐acquired pressure ulcer: A scoping review

“…This was not surprising because a shorter interval reduces the period of uninterrupted pressure. Furthermore, in terms of enhancing the effectiveness of repositioning, a 30° lateral tilt is found to be more effective than supine and 90° lateral positioning as a 30° lateral tilt minimises interface pressure, especially to the sacrum, enhancing blood flow and transcutaneous oxygen levels to the tissues . This coincides with the results from a previous study that repositioning every 3 hours at a 30° tilt (right tilt, back, left tilt, back) was found to be significantly more effective in decreasing PU incidences than 6‐hourly at a 90° lateral rotation .…”

Consistent pressure ulcer prevention practice: The effect on PU prevalence and PU stages, and impact on PU prevention—A quasi‐experimental intervention study

“…The results are in line with a previous study of 28 LOPD residents 33 where after the PU prevention bundle in four areas—heel protection/skin assessment, repositioning, incontinence, and nutrition—only stage I PUs existed. The results of this study are opposite to those reported in earlier studies conducted in LOPC facilities of PU prevention interventions consisting of repositioning, 29 mattresses, overlays or cushions, 31 , 32 and PU prevention programmes, 34 where stage II PUs still existed. This shows the effectiveness of the conducted intervention and also recommends the use of bundles in PU prevention.…”

“…However, unlike in previous studies, in this study, PUs were also found in other areas of the feet, which can be explained by the higher number of walking residents who were in better condition. In contrast to previous studies, 18 , 25 , 29 after the intervention, there were no PUs in the heels and only two stage I PUs in the sacrum, buttock, and hip areas. This indicates the effectiveness of the conducted intervention in decreasing PUs in the most common PU areas.…”

“…condition. In contrast to previous studies, 18,25,29 after the intervention, there were no PUs in the heels and only two stage I PUs in the sacrum, buttock, and hip areas. This indicates the effectiveness of the conducted intervention in decreasing PUs in the most common PU areas.…”

Turning for Ulcer ReductioN: A Multisite Randomized Clinical Trial in Nursing Homes

“…Considering only 2‐, 3‐, 4‐, or 6‐hour repositioning intervals in previous randomized studies of repositioning (Table ), the low incidence of PrUs in the TURN Study is similar to the 3% (2 ulcers/66 participants) incidence reported previously for a 4‐hour repositioning group on viscoelastic mattresses (the only group equivalent to the current study) and similar to that of another study that reported a 3% (3 ulcers/99 participants) incidence for those on powered mattresses repositioned every 3 hours. Incidence of PrU Stages 2 to 4 reported previously ranged from 14.3% to 24.1% without high‐density foam mattresses …”

Turning frequency in adult bedridden patients to prevent hospital‐acquired pressure ulcer: A scoping review

“…This was not surprising because a shorter interval reduces the period of uninterrupted pressure. Furthermore, in terms of enhancing the effectiveness of repositioning, a 30° lateral tilt is found to be more effective than supine and 90° lateral positioning as a 30° lateral tilt minimises interface pressure, especially to the sacrum, enhancing blood flow and transcutaneous oxygen levels to the tissues . This coincides with the results from a previous study that repositioning every 3 hours at a 30° tilt (right tilt, back, left tilt, back) was found to be significantly more effective in decreasing PU incidences than 6‐hourly at a 90° lateral rotation .…”

Consistent pressure ulcer prevention practice: The effect on PU prevalence and PU stages, and impact on PU prevention—A quasi‐experimental intervention study

“…The results are in line with a previous study of 28 LOPD residents 33 where after the PU prevention bundle in four areas—heel protection/skin assessment, repositioning, incontinence, and nutrition—only stage I PUs existed. The results of this study are opposite to those reported in earlier studies conducted in LOPC facilities of PU prevention interventions consisting of repositioning, 29 mattresses, overlays or cushions, 31 , 32 and PU prevention programmes, 34 where stage II PUs still existed. This shows the effectiveness of the conducted intervention and also recommends the use of bundles in PU prevention.…”

“…However, unlike in previous studies, in this study, PUs were also found in other areas of the feet, which can be explained by the higher number of walking residents who were in better condition. In contrast to previous studies, 18 , 25 , 29 after the intervention, there were no PUs in the heels and only two stage I PUs in the sacrum, buttock, and hip areas. This indicates the effectiveness of the conducted intervention in decreasing PUs in the most common PU areas.…”

“…condition. In contrast to previous studies, 18,25,29 after the intervention, there were no PUs in the heels and only two stage I PUs in the sacrum, buttock, and hip areas. This indicates the effectiveness of the conducted intervention in decreasing PUs in the most common PU areas.…”

Turning for Ulcer ReductioN: A Multisite Randomized Clinical Trial in Nursing Homes

“…Considering only 2‐, 3‐, 4‐, or 6‐hour repositioning intervals in previous randomized studies of repositioning (Table ), the low incidence of PrUs in the TURN Study is similar to the 3% (2 ulcers/66 participants) incidence reported previously for a 4‐hour repositioning group on viscoelastic mattresses (the only group equivalent to the current study) and similar to that of another study that reported a 3% (3 ulcers/99 participants) incidence for those on powered mattresses repositioned every 3 hours. Incidence of PrU Stages 2 to 4 reported previously ranged from 14.3% to 24.1% without high‐density foam mattresses …”

Turning frequency in adult bedridden patients to prevent hospital‐acquired pressure ulcer: A scoping review

“…This was not surprising because a shorter interval reduces the period of uninterrupted pressure. Furthermore, in terms of enhancing the effectiveness of repositioning, a 30° lateral tilt is found to be more effective than supine and 90° lateral positioning as a 30° lateral tilt minimises interface pressure, especially to the sacrum, enhancing blood flow and transcutaneous oxygen levels to the tissues . This coincides with the results from a previous study that repositioning every 3 hours at a 30° tilt (right tilt, back, left tilt, back) was found to be significantly more effective in decreasing PU incidences than 6‐hourly at a 90° lateral rotation .…”