Running head EXERCISE PROGRAMS TO PREVENT FALLS .docx

Running head: EXERCISE PROGRAMS TO PREVENT FALLS
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EXERCISE PROGRAMS TO PREVENT FALLS
5
Exercise Programs to Prevent
Fall Related Injuries in Older Adults
Student
Student
Gwynedd Mercy University
Abstract
The implementation of exercise programs was evaluated to

identify best-practice in fall-related injury prevention. This
paper incorporates information from four different studies to
identify the evidence that suggests best-practice protocol.
Evidence of these studies suggests that implementing exercise
programs helps to prevent fall-related injuries in long-term care
facilities for older adults. Incorporating exercise programs
increases patient safety, prevents further injury, and promotes
communication between patients and staff. By implementing
these programs, patients’ overall health improves and they’re
more satisfied by their ability to perform activities of daily
living on a more independent level.
Exercise Programs to Prevent Fall Related Injuries in Older
Adults
As individuals age through life, the risk for falls increase
immensely. This is due to the lack of strength as well as a lack
of balance in the human body. It is important for nurses to take
l precautions to help stop patient falls because in many
instances, falls are preventable (Ambutas, Lamb, & Quigley,
2017). Fall prevention includes important interventions that
stop subsequent injuries from happening to patients. Everyday,
nurses take precautions to prevent falls but additional actions

could be taken in order to make these interventions more
effective. Every patient is at risk of falling, especially older
adults because they lose muscle mass and balance as they age
(Taylor, Lillis, & Lynn, 2015, p. 142). After performing fall-
risk assessments on each patient, nurses implement suggested
best practice protocols for low-risk, moderate-risk, and high-
risk patients. Best practice includes educating patients and
families on fall risk, using bed or chair alarms, lowering the
beds, encouraging regular toileting and other precautions
(Taylor, et al., p. 145). Exercise programs act as another
important measure that nurses could implement, in order to help
patients improve their balance, strength and mobility while
performing activities of daily living, and reduce risk for falls
(Ambutas, Lamb & Quigley).
The following clinical question will be used to identify best
practice related to exercise programs in order to prevent falls in
older adults:
P: Older adults living in long-term care facilities
I: Exercise programs
C: (none)
O: Prevent fall-related injuries
T: (None)
In long-term care facilities for older adults, how do exercise
programs help prevent fall-related injuries?
Review of Literature
Dal Bello-Haas, Thorpe, Lix, Scudds, and Hadjistavropoulos
(2012) completed a quantitative research study that focused on
the implementation of a walking program in long-term care
facilities, in order to prevent falls. Risk for falling increases
with advancing age. The research question that these authors
asked was a to assess the effectiveness of an individualized,
progressive, walking program compared to usual care in
individuals residing in long-term care facilities. The study
participants were over the age of 60, resided in a long-term care
facility, and participated in several different walking programs.
The results of this study suggested increased activity and

participation in exercise contribute to prevention of falls in the
long-term. The researchers stated nurses and health care
providers working in long-term care environments should
implement exercise programs for residents to prevent falls.
Kato, Izumi, Hiramatsu, and Shogenji (2006) also investigated
the use of exercise to prevent falls in the older adult population,
who are at increased risk for falls. The participants in this
quantitative study completed stretching, muscle strengthening,
and toe exercises three times per week. Results of this study
showed older adults who participated in the exercise program
experienced less falls. The researchers suggested exercise
programs were effective in reducing falls in residents of long-
term care facilities and should be considered for use with this
patient population.
In addition to focusing on strength and balance, a quantitative
study by Gschwind, Kressig, Lacroix, Muehlbauer, Pfenninger,
and Granacher (2013) also investigated the effects of exercise
on improvement of psychosocial well-being. Preventing falls in
the older adult may require interventions to address more than
one focus area. The researchers designed a rehabilitation
program for older adults living at home in which patients
worked to improve everyday balance, strength, and psychosocial
well-being. The objective for this program is to prevent the risk
of falls in the older adult population. Older adults in the study
were taught balance and strength training exercises. Participants
were contacted by phone to encourage use of the exercises. The
results of this experiment showed improvement in strength,
balance, and an increase in daily living activities. The
researchers state that patient education is important for older
adults living in community settings to incorporate exercise into
daily activities.
Sherrington, Tiedemann, Fairhall, Close, and Lord (2011)
also investigated the use of exercise to prevent the risk of falls.
In addition to focusing on older adults, the researchers included
participants from other age groups in this quantitative study.
Study participants completed balance exercises and participated

in progressive walking activities. The results suggested exercise
can help lower the risk of falls in the older adult. In addition,
the researchers stated fall prevention exercise training should
not be confined to just the aging adult, but also offered and
implemented in the general population. In doing so, everyone
can increase their balance ability, which ultimately decreases
the risk of falls. The type of training should vary with each
individual. If the patient is healthy, the balance exercise along
with strength training and brisk walking is appropriate. On the
other hand, if the patient is at high risk for falls, balance
exercises should be the area of focus.
Summary
Results from the reviewed studies suggest that the
implementation of exercise programs is effective in preventing
fall-related injuries in older adults and can be effective for use
in long-term care environments. Exercise allows for the
strengthening of muscles in the lower extremities, which in turn
helps to prevent loss of balance and mobility. Ultimately, falls
are reduced when patients gain strength and ambulate regularly.
According to these authors, patient safety is increased with the
implementation of exercise programs that include walking,
muscle strengthening and balance routines. The findings
presented by these authors suggest that implementing exercise
programs for older adults in long-term care facilities would be
beneficial for safety and satisfaction of patients.
Barriers and Suggested Strategies
There are potential barriers to the implementation of the
recommendations in the reviewed studies. Patients with
decreased mobility or complete immobility would not be able to
complete these exercise programs. It would also be difficult to
implement the exercise protocol for patients with physical,
cognitive, or psychosocial impairments. Nurses should consider
variations in exercise regimens appropriatge for patients with
decrased mobility or other impariments. Nurse could provide
passive exercise activities for patients who are completely
immobile.

Implementation of the suggested interventions may be difficulty
for patients experiencing pain. Adequate and appropriate use of
pharmacological and nonpharmacological interventions for pain
management should be implemented before use of the suggested
exercise interventions. Nurses should assess patients’ pain and
collaborate with other health care providers to provide pain
relief.
It could be very costly to implement the recommended exercise
programs, as many of them would have to be individualized to
the patient which would require trained personnel. This could
be a potential barrier to implementation of the suggested
strategies. Nurses may have to work with managers and
administrators to find solutions for financial resources.
Lastly, patient interest is a potential barrier to the
recommendations because patients have to be willing to
exercise. Nurses should involve patients in exercise decisions
and provide patient education to support the patient’s treatment
decisions. Nurses should also be flexible and creative in
determining exercise regimens for patients, allowing the patient
input into desired activities and activities based on patient
interests.
Conclusion
Patient safety has always been a main concern in nursing
practice but further precautions to fall-related injuries can be
taken. Exercise is proven to have many positive outcomes on
the mind and body. Therefore, incorporating exercise programs
in long-term care facilities, nurses can increase patient safety
measures and promote improved overall quality of life.

References
Ambutas, S., Lamb, K.V., & Quigley, P. (2017). Fall reduction
and injury prevention toolkit: Implementation on two medical-
surgical units. MEDSURG Nursing, 26(3), 175-179.
Bello-Haas, V PM., Thorpe, L., Lix, L., Scudds, R., and
Hadjistavropoulos, T. (2012). The
effects of a long-term care walking program on balance, falls
and well-being. BMC
Geriatrics, 12(76), N.PAG. doi: 10.1186/1471-2318-12-76
Kato, M., Izumi, K., Hiramatsu, T., & Shogenji, M. (2006).
Development of an exercise
program for fall prevention for elderly persons in a long-term
care facility. Japan Journal
of Nursing Science, 3(2), 107–117. doi:10.1111/j.1742-
7924.2006.00057.x
Gschwind, Y. J., Kressig, R. W., Lacroix, A., Muehlbauer, T.,
Pfenninger, B., & Granacher, U.
(2013). A best practice fall prevention exercise program to
improve balance, strength / power, and psychosocial health in
older adults: Study protocol for a randomized controlled trial.
BMC Geriatrics, 1 (105), N.PAG. doi: 10.1186/1471-2318-13-
105
Sherrington, C., Tiedemann, A., Fairhall, N., Close, J., & Lord,
S. (2011), Exercise to prevent
falls in older adults: An updated meta-analysis and best practice
recommendations. New
South Wales Public Health Bulletin, 22(3-4), N.PAG. doi:
10.1071/NB10056
Taylor, C., Lillis, C., & Lynn, P. (2015). Fundamentals of
nursing: The art and science of
nursing care. (8th ed.). Philadelphia: Wolters Kluwer

Health/Lippincott Williams &
Wilkins.
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
mailto:[email protected]
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
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
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.
Healing Society 13
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)
Among patients at lower risk of pressure ulcers (Braden scale
score �14)
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.
Healing Society14
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.
Healing Society 15
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
Healing Society16
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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203
JRRDJRRD Volume 48, Number 3, 2011Pages 203–214
Journal of Rehabilitation Research & Development
Assessing evidence supporting redistribution of pressure for
pressure
ulcer prevention: A review
Stephen Sprigle, PhD, PT;* Sharon Sonenblum, PhD
Rehabilitation Engineering and Applied Research Lab, Georgia
Institute of Technology, Atlanta, GA
Abstract—The formation and underlying causes of p ressure
ulcers (PUs) are qu ite complex, with multiple influencing fac-
tors. However, by definition pressure ulcers cannot form with-
out loading, or pressure, on tissue. Clinical interventions
typically target the magnitude and/or duration of loading. Pres-
sure magnitude is managed by the selection of support surfaces
and postural supports as well as body posture on supporting
surfaces. Duration is addressed via turning and weight shifting
frequency as well as with th e use of dynamic s urfaces that
actively redistribute pressure on the body surfaces. This article
shows that preventative interventions must be targeted to both
magnitude and duration and addresses the rationale behind sev-
eral common clinical interventions—some with more scientific
evidence than others.
Key words: body posture, clinical interventions, postural sup-
ports, pressure magnitude, pressure ulcers, prevention inter-
ventions, support surface, tissue loading, turning frequency,
weight shifting frequency, wheelchair.
INTRODUCTION

The formation a nd underlying c auses of pressure
ulcers (PUs) are quite complex, with multiple influencing
factors. However, by definition PUs cannot form without
forces, or press ure, on tissue. Because tissue loading is
the defining characteristic of PU formation, i t naturally
garners significant attention in research in PU prevention
strategies.
Research has clearly demonstrated that the damaging
effects of pressure are related to both its magnitude and
duration. Simply stated, tissues can withstand higher
loads for shorter periods of time. Kosiak first demon -
strated this characteristic 50 years ago by applying vary-
ing loads to the trochanters and ischial tuberosities of
dogs for varying periods of time [1]. High loads for short
durations and low loads for long durations induced
ulcers, with the time-at-pre ssure curve following an
inverse parabola. Reswick and Rogers tried to extend this
animal research into clinica lly relevant i nformation, and
using combinations of interviews and interface pressure
measurements (IPMs), de termined a pressure-time rela -
tionship that was similar to that of Kosiak [2].
Using the premise that both the ma gnitude and dura-
tion of loading are important, we c an diagram a simple
model of PU development (Figure 1) that illustrates the
reasoning behind certain clin ical interventions. Pressure
magnitude is managed by the selection of support sur-
faces and postural supports as well as body posture upon
supporting surfaces. Duration is a ddressed via turning
and weight shifting frequency as well as with the use of
dynamic surfaces that a ctively redistribute pressure on
the body surfaces.

Abbreviations: IPM = interface pressure measurement, Mobil-
ity RERC = Rehabili tation Engineering Research Center on
Wheeled Mobility, PU = pressure ulcer, SCI = spinal cord
injury.
*Address all correspondence to Stephen Sprigle, PhD, PT;
Georgia Tech–Applied Physiology, 490 Tenth St NW,
Atlanta, GA 30032-0156; 404-385-4302; fax: 404-894-9320.
DOI:10.1682/JRRD.2010.05.0102
204
JRRD, Volume 48, Number 3, 2011
This article reviews the evidence supporting clinical
interventions that address the magnitude of pressure and
the duration of that pressure. Within this article, “support
surfaces” will refer to devices designed for horizont al
(mattresses, overlays) and s eated (wheelchair cushions)
postures. The ter m “pressure” will refer to the force or
load exerted over an area of the body or on a lo calized
area of the body surface.
LOADING
A fairly extensive amount of re search has applied
loads to tissues and monitored physiological outcomes.
For obvious re asons, research with animal models uses
controlled loading to create PUs or tissue necrosis,
whereas human studies are limited to indirect measures,
such as the effect of loading on blood flow.

Tissue Response to Loading in Animal Models
As mentioned previously, Kosiak u ndertook seminal
research by applying load s to the trochan ters and isch ial
tuberosities of dogs [1]. Load s ranged from 100 to
500 mmHg, and durations ranged from 1 to 1 2 hours.
Kosiak monitored animals for 14 days postischemia to
determine the occurrence of PUs. Dinsdale applied pres-
sures between 45 and 1,500 mmHg for 3 hours to swine
with and without paraplegia [3]. Normal pressure was com-
bined with friction in half the specimens. The results indi-
cated that no necrosis occurred with normal pressures
below 150 mmHg, but in combination with friction, tissue
changes could be seen after loading with 45 mmHg. Daniel
et al. also studied swine with and without paraplegia [4].
Using an indenter to apply load at the greater troch anter,
they found that application of 200 mmHg for 15 hours did
not induce a PU. Ulcers were obtained by applyin g
500 mmHg for 4 hours and 800 mmHg for 8 hours.
Linder-Ganz and Gefen exposed rat hind limbs to
pressure magnitudes of 86, 262, and 525 mmHg for 2, 4,
and 6 hours, respectively [5]. They used finite ele ment
modeling to calculate internal stresses and concluded that
tissue damage occurred with 13 kPa o f internal stress
applied for 6 hours and 40 kPa of interna l stress applied
for 2 ho urs. Both conditions represent an approximate
stress application rate of 80 kPa/h.
While this is not a comprehensive list of animal PU
etiology research, collectiv ely the studies illustrat e
results obtained by applying different loads over different
durations (Table). The use of different sizes and shapes
of indenters, dif ferent loading parameters , and different
animal models explains why a range of mag nitudes and

durations are linked to PU development. Despite these
differences, the evidence suggests that both magnitude
and duration of loa ds must be considered in PU preven -
tion and validates the simple intervention model in
Figure 1.
Blood Flow Response to Loading in Humans
While research has clearly shown a rela tionship
between pressure magnitude and duration and tissue
damage, these studies have not de fined a critical ma gni-
tude above whic h ischemia occurs. Many studies have
used controlled experimental approaches for determining
the pressure at whic h blood flow to tissue cea ses with
significantly varying results. Lassen and Holste in found
that the pressure required for vascular occlusion approxi-
mated diastolic pressures when the measured skin
approached heart level [6]. Holloway et al. loaded the
forearm and found that blood flow decreased as external
pressure approached mean arterial pressure and that
occlusion was reached at ~120 mmHg [7]. Ek et al. found
“weak positive correlations” between blood flow during
Figure 1.
Rationale for redistribution of pressure.
205
SPRIGLE and SONENBLUM. Redistributing pressure to
prevent pressure ulcers
loading at the heel and systolic blood pressure [8]. Load-
ing at the sac rum did not resu lt in the same relationship
with blood pressure. Sangeorzan et al. de termined that

71 mmHg was need ed to occl ude flow over the tibialis
anterior (a “soft” site) but only 42 mmHg occluded flow
over the tibia (a “hard” site ) [9]. Bennett et al. measured
occlusion pressure at the thenar eminences of nondis -
abled subjects and found that 100 to 120 mmHg was nec-
essary to occlude v essels in “low shear” conditions and
60 to 80 mmHg was needed in the pre sence of “high
shear” conditions [10]. Bar re viewed the literature and
concluded that a critical pressure is necessary to occlude
blood flow and that while this threshold is related to ves-
sel pressure, it appears to vary widely [11].
The animal and human studies contribute important
information to the field of PU research by identifying tis-
sue’s response to external loads. However, the results are
very hard to apply clinically. Controlled loading at specific
anatomical sites simply doe s not generalize to the person
lying in bed or sitting in a wheelchair. For exa mple, the
magnitudes and durations of loading used to induce dam -
age in animals greatly exceed those deemed a cceptable in
clinical environments. This apparent discrepancy does not
invalidate either the research or the clinical interpretation
of the findings. Rather, these animal tests inform us about
the mechanism of injury and the complex relationships
between the variables involved when supporting the
human body in sitting or lying positions.
To date, research has not identified a specific thresh-
old at which loads can be d eemed harmful across people
or sites on the body. Tissue’s tolerance to load varies
according to the condition of the tissue and its location,
age, hydration, and metabolism. All the factors common
to PU risk assessment tools tend to influence how the tis-
sue distributes the loading and its ability to wi thstand
load.

INTERVENTIONS
Support Surfaces
Support surfaces attempt to redistribute forces away
from bony prominences, thereby reducing the magnitude
of loading at these at-risk sites. In general, creating suc -
cessful support surfaces is challenging because of the dif-
ferences in ind ividual risk factors, as well as the
complicated nature by which force is distributed through-
out tissue. For example, when a person sits on a cushion,
normal loading works in combination with shear and fric-
tional forces to induce complex tissue distortion. Conse-
quently, myriad support surface designs ex ist that have
benefit for some p eople, but for the most part, no single
surface is optimal for all persons. Two very general cate -
gories of support surfaces can be defined: reactive sur-
faces that respond to the load placed upon them and active
surfaces that dynamically a lter the body–support-surface
interface. Although active surfaces serve as a duration
intervention, their primary role as a supp ort surface (thus
affecting magnitude of loading) makes it natural to
present them together with reactive support surfaces.
Table.
Examples of animal pressure ulcer models highlighting different
loading parameters.
Author Animal Model Loading Conditions Outcome
ischial tuberosity
100–500 mmHg over 1–12 h Proposed inverse magnitude-
duration

relationship.
Dinsdale [2] Swine with and w
spinal injury
45–
and without friction
Loading at 45 mmHg in the presence
of friction-induced damage.
spinal injury
200 mmHg for 15 h, 500 mmHg
for 4 h, 800 mmHg for 8 h
No damage at 200 mmHg for 15 h,
but damage under other conditions.
Linder-Ganz & Gefen [4] Rat hind limbs 86, 262, and 525
mmHg for 2, 4,
and 6 h, respectively
Tissue damage occurred with loading
rate of 80 kPa/h.
1. Kosiak M. Etiology and pathology of ischemic ulcers. Arch
Phys Med Rehabil. 1959;40(2):62–69. [PMID: 13618101]
2. Dinsdale SM. Decubitus ulcers in swine: Light and electron
microscopy study of pathogenesis. Arch Phys Med Rehabil.
1973;54(2):51–56. [PMID: 4692634]
3. Daniel RK, Wheatley D, Priest D. Pressure sores and
paraplegia: An experimental model. Ann Plast Surg.
1985;15(1):41–

DOI:10.1097/00000637-198507000-00005
4. Linder-Ganz E, Gefen A. Mechanical compression-induced
pressure sores in rat hindlimb: Muscle stiffness, histology, and
computational models. J Appl Phys-
iol. 2004;96(6):2034–
DOI:10.1152/japplphysiol.00888.2003
http://www.ncbi.nlm.nih.gov/pubmed/13618101
http://dx.doi.org/10.1097/00000637-198507000-00005
http://dx.doi.org/10.1152/japplphysiol.00888.2003
206
Judging the effectiveness of support surfaces is done
with both direct and indirect methods. Indirect methods
use physiological means such as blood flow , tissue oxy-
genation, and interface pressure to judge performance.
Direct methods follow a group of patients over time to
determine PU occurrence. Direct methods are more valu-
able but are harder to adminis ter and are limited in the
number of interventions that can be inve stigated (i.e.,
types of surfaces).
In their systematic review focused on randomiz ed
controlled trials with PU development as an outcome,
Cullum et al. used the term “constant low-pressure sup-
port surfaces” to describe the myriad foam, air , water,

and elastomeric mattresses, overlays, and cushions [12].
Their review of the literature concluded that these sur-
faces outperform standard hospital mattresses in prevent-
ing PU formation. Comparisons between dif ferent
constant low-pressure surfaces did not result in definitive
outcomes. In othe r words, differences across the more
common reactive surfaces have not been demonstrated in
terms of PU outcomes.
Studies on wheelchair cushions are not as common as
those on mattresses, but informative evidence is still
available. Indirect measures, specifically interface pres-
sures, comprise the bulk of studies on cushions [13–16].
Researchers have shown tha t high s eated interface pres-
sures were associated with PU occurrence [17–19].
Therefore, despite the limita tions in IPM as a less accu-
rate representation of localized loading [5,20–22], it can
be useful in selecting cushions.
Because active surfaces vary loading of pa rticular
regions of the body, they intend to alter both the magni-
tude and duration of loading. Active surfa ces are avail-
able for both mattresses and wheelchair cushions, with
mattresses being use d and studie d more freque ntly. In
part, this is the result of a funding decision in the United
States by the Ce nters for Me dicare and Medic aid Ser-
vices to not pay for powered wheelchair cushions for PU
prevention. Evidence on commercially available a ctive
cushions is limited to seco ndary outcomes [16,23].
Because the secondary measurements vary throughout
the cycle of ac tive cushions, the results of such studies
are hard to apply clinically.
Studies of active mattresses and overlays a re more
common than those of cushions and have used both direct
and indirect outcomes. Two recent systematic reviews do

a very thorough job of covering the literature on alternat-
ing pressure mattresses so the details will not be repeated
here [12,24]. Cullum et al. focused exclusively on direct
outcomes (PU development), while Vanderwee et al.
extended their review to include studies with indirect out-
come measurements and a lternative study designs. But
both groups reached the same conclusions: alternating
pressure air mattres ses are better than standard hospital
mattresses but their bene fit over constant low -pressure
mattresses is unclear. Furthermore, differences across
types of alternating pressure air mattresses were not dem-
onstrated. Active surfaces also provide inc reased poten-
tial for mechanical problems and user error compared
with some alternatives. One major limitation of most of
the reviewed studies, as pointed out by Cullum et al., was
that turning schedules were not controlled. Therefore, it
is possible that nurses made a point to turn patients on the
standard mattresses more frequently than those on the
active surfaces because of a perceived need for increased
intervention. If true, than comparable outcomes could
come with the benefit of re duced clinical intervention
time for the active surfa ce, but research to evaluate this
possibility is needed.
Interventions for Reducing Duration of Loading
The body’s motor and sensory systems are responsi-
ble for ensuring that we move periodically to change our
posture. This may be in the form of discomfort eliciting
movement or subconscious postural shifts or fidgeting.
Many studies over the years have monitored movements
in chairs a s metrics of co mfort and function [25–28],
thereby establishing a base of knowledge about sitting as
a dynamic activity. Many people at risk of dev eloping
PUs are either unable to effectively reposition themselves

or are not provided with the sensory feedback that elicits
movements. Therefore, that loss of mobility and sensa-
tion are identified as risk fa ctors within every PU risk
assessment scale is not surprising.
We use this information to tar get movement as a
means of redistributing pressure and altering the duration
of loading on tissues. Cli nically, this includes turning
schedules for patients who are in bed and weight shifting
strategies for those who are seated.
Turning Frequency
In a st udy on PU prev ention interventions, Richard -
son et al. found that manual repositioning was the most
commonly used intervention and that it was also the most
expensive [29]. The idea of necessary repositioning has
appeared throughout literature and textbooks since the
207
1800s [30]. Evidence that some repositioning is neces-
sary can be found across decades of literature.
In the United S tates, common practice requires that
at-risk patients be repositioned at least every 2 hours if
consistent with overall patient goals [31]. Despite efforts
by a number of researchers to identify the origins of this
practice, or at the very least identify evidence supporting
the 2-hour turning practice, no strong scientific support
exists [30,32–33]. In fact, earlier texts often included

suggestions that the turning schedule depend on the mag-
nitude of loading and condition of the patient.
Therefore, the s tandard practice of using the sa me
turning schedules independent of support surface is not
reflective of earlier work. Re cent evidence demonstrates
the need to account for the support surface in determining
the optimal turning schedule. Defloor et a l. showed that
2- and 3-hour turning schedules resulted in the develop-
ment of PUs in 14 to 24 percent of patients lying on
standard mattresses. A 6-hour turning sc hedule for
patients lying on a viscoelastic mattress resulted in simi -
lar outcomes, but a 4-hour turning schedule for patie nts
lying on a visc oelastic mattress signific antly reduced
stage II PUs . Other research suggests that turning ma y
need to occur more frequently than every 2 hours and that
sufficient pressure reduction surfaces are needed in addi -
tion to turning [32,34–36]. Recently, Vanderwee et al.,
using a pressu re-reducing mattress, found no difference
between repositioning patient s every 4 hours and alter -
nating between 2 hours in late ral and 4 h ours in supine
[36]. In both interventions, more than 16 percent of parti-
cipants developed a PU. Additionally, two studies of sec-
ondary outcomes demonstrated that redness and ox ygen
reduction while lying in bed occurred in less than 2 hours
[37]. Furthermore, in studies on turning, patients who are
able will change posture between scheduled reposition-
ings. As a result, these subjects are exposed to more posi-
tion changes than offered by the intervention, which may
mask a need for more frequent repositioning in those
unable to reposition themselves [36]. The necessary repo-
sitioning frequency may be so high that implementation
is impractical for immobile patients [32].
Positioning Devices and Posture
The entire premise behind turning is obviously to

reduce the amount of time di fferent body surfaces are
exposed to loading. Operati onally, many facilities
sequence between supine and two side-lying postures.
The loading at specific body surfaces is highly dependent
on the resulting postures an d any positioning devices
used. For example, side lyin g may expose a malleolus to
damaging loading but proper positioning of the lower
limbs and judicious use of positioning devices can effec-
tively reduce loa ds from this bony prominence ( Figure
2(a)). Adopting a supine posture with the head of the bed
elevated alters loading on the buttocks, which is why it is
a controversial posture. Elevating only the head of the
bed increases both the normal and frictional forces on the
sacrum [38–39]. Mechanics suggests that as the head ele-
vates, more of the upper-body weight will be transmitted
through the buttocks to the supporting surface. In addi-
tion, the tendency to slide is increased as the trunk sup -
port is inclined. The complication is that it is a functional
posture, adopted so people can converse with others ,
read, and eat, to name a fe w activities. Some of the fric -
tional forces can be counteracted by raising the foot of
Figure 2.
(a) Use of positioning devices to redistribute pressure and (b)
raising
foot of bed counteracts sliding tendency.
208
the bed, but this will not reduce the normal forces on the

buttocks [38] (Figure 2(b)).
The seated posture also affects how loads are re distrib-
uted. Sitting on a sling seat with a pelvic obliquity induces
asymmetric loading on the isch ial tuberosities, not to men-
tion contributing to postural instability (Figure 3(a)). A
slouched, kyphotic posture is typ ified by p osterior pelvic
tilt, a posture that loads the sacrum and coccyx while seated
(Figure 3(b)) [40–41].
In summary, body posture and positioning have a
direct relationship to loads on specific body sites, which
is why posture must be co nsidered when devising PU
prevention strategies.
Weight Shifting
Wheelchair users are often at high risk of developing
sitting-acquired PUs. Persons with absent or diminished
sensation and/or mobility are always at high risk of PUs
[42–43]. A variety of maneuvers to shift body weight off
the buttocks are taught to wheelchair users at risk of PUs.
They can push down on the seat or armrests to lift the
buttocks off the cushion s urface (Figure 4(a)), lean for -
ward to rest t heir trunk upon the lower limbs (Figure
4(b)), or lean to one side and then lean to the opposite
side (Figure 4(c)). Persons who use power wheelchairs
and cannot independently perform these maneuvers are
sometimes prescribed variable position wheelchairs that
incorporate powered tilt and/or recline to redistribute
weight off the buttock area (Figure 5).
Most guidelines that suggest weight shift or pressure
relief frequency have been developed for p ersons with
spinal cord injury (SCI) because of the effect of SCI on
sensation and mobility. For the SCI po pulation, recom-

mendations for weight shift frequency have typically
ranged from 15 to 30 seconds every 15 to 30 minutes to
60 seconds every hour [44–47]. Based on the wide range
of these guidelines, one can infer that they were based on
a combination of clinical experience, clinical insight, and
research findings.
In addition to weight shift frequency, one must also
consider the duration for which a weight shift is held . In
other words, not only do wheelchair users have to perform
weight shifts regularly, they must attend to the duration of
these maneuvers. The ability to sustain a weight shift is
dependent on myriad factors, including functional ability,
strength, flexibility, and postural control [46]. A 2003 study
measured tissue perfusion to investigate the length of time
required for tissue to rep erfuse in an SCI cohort ( n = 46)
[48]. The mean duration of weight shift required to return
transcutaneous partial pressure of oxygen to unloaded lev-
els following upright sitting was 1 minu te 51 seconds
(range = 42– 210 seconds). This fin ding suggests that the
Figure 3.
(a) Pelvic obliquity from sitting on sling seat and (b) posterior
pelvic
tilt loads sacrum and coccyx.
209
duration of weight shifts currently recommended (i.e., 15–
30 seconds) is inadequ ate. Further, this suggests that th e

common practice of sitting push-ups is not sustainable for
many to achieve reperfusio n. Consequently, the authors
supported the use o f alternate, sustainab le methods of
weight shift, namely fo rward lean, lateral lean, and rear -
ward tilt. Partial weight shifts may also allow for better sus-
tainability by persons with SCI.
Figure 4.
(a) Push-up weight shift, (b) forward-lean weight shift, and (c)
side-
lean weight shift.
Figure 5.
(a) Manual Tilt-in-Space wheelchair and (b) Power T ilt-in-
Space
wheelchair. Images used with permission. ©Invacare
Corporation.
210
Three recent studies inve stigating PU prevalence in
an SCI cohort considered weight shift behavior as a
potential risk factor [49–51]. None of the st udies found
weight shift behavior or frequency of weight shifts to be
associated with PU occ urrence. However, each of the
studies used self-report to measure weight shift practices.
Further objective analyses ar e needed to determine the
role of weight shifts in PU prevention.
CONCLUSIONS
The review of res earch corroborated the clinical

interventions commonly used for load redistribution but
also identified areas of uncertainty. As with all means of
prevention, some interventions are better supported than
others and some interventions have a legacy quality to
them and little el se. Nonetheless, several clinically ori-
ented suggestions can be made.
Support Surface Assessment
Selections of mattre sses, overlays, and cushions
should be based upon as sessment. Research is cle ar that
individual factors can contribute to PU susceptibility, and
all the PU risk assessment scales are based upon indi -
vidualized evaluation. Research has also shown that indi-
vidualized evaluation improves the selection of mattress
[52] and wheelchair cus hions [53]. Long-standing evi-
dence supports the use of seating clinics to select and pre-
scribe wheelchair cushions [54]. One of the benefits of
this type of individuali zed evaluation is its educational
aspect in informing patients and clients about skin health
and proper equipment use.
Interface Pressure
Interface pressure can be used to identify a reas of
unacceptably high pressures and to ensure a s ite is a de-
quately off-loaded during posture changes or a weight
shift. We advocate for use of pressure mapping to rule out
products rather than as a sole means to presc ribe a par-
ticular product [21]. For exa mple, if the interface pres-
sure under the ischial tuberosity is deemed too high for a
particular person by a clinician, then the clinician should
deem that p roduct unacceptable. That said, one cannot
infer that published IPM va lues will generalize to other
clients or patients. Another useful role for IPM is as sess-
ing how posture or position changes influence loading on

tissue. Repositioning in bed or while seated is necessary
to unweight different parts of the body. IPM can offer
visual feedback to clinicians, patients, and clients as they
sequence through different postures.
Weight Shift and Turning Frequency
Periodic repositioning is an important preventative
measure. Patients and clients who can independently
redistribute pressure should be educated to do so and
taught strategies to ensure compliance. Persons who can-
not reposition must rely on others to set and follow a rou-
tine. Evidence on how often a weight shi ft should be
performed and evidence behind turning schedules is lim-
ited. The odds are that repositioning frequency is not the
same for all people and surfaces. This can be inferred by
the wealth of evidence in dicating the individualized
nature of PU ris k and supports the approach that reposi-
tioning frequency should reflect the person, his or her
equipment, and the environment of use.
• Standard hospital beds are poor support surfaces.
Ample evidence has show n that standard ma ttresses
are inadequate to prevent PU s. Even relati vely “low
tech” mattresses and overlays offer better prevention
[12].
• Increasing activity has many health benefits, includ-
ing tissue health. In a study of more than 600 persons
with SCI with and without a history of recurrent PUs,
Krause and Broderick identif ied behaviors that were
shown to be protective [50]. These behaviors included
a healthy lifestyle, fitness, and exercise. Putting peo-
ple into equipment and postures that permit functional
activity addresses the key PU risk fac tor of immobil-

ity. We should promote reaching, leaning, and moving
as a means of promoting functional independence and
maintaining skin integrity.
• The European and U.S. National Pressure Ulcer Advi-
sory panels have recently released their joi nt Interna-
tional Pressure Ulcer Guidelines for Prevention and
Treatment. The document addresses both PU preven-
tion and PU trea tment by assessing many clinical
interventions.
• When reviewing conflicting literature, pay close atten-
tion to external validity. Literature regarding pressure
redistribution and support surfaces is o ften equivocal
and may be contradictory. This can oc cur because of
differences in methods, measurements, and subjects.
When reviewing literature, pay attention to how the
studies reflect your clinical situation. P erhaps some
studies better reflect your patient mix or techniques.
211
ACKNOWLEDGMENTS
Study concept and design: S. Sprigle, S. Sonenblum.
Analysis and interpretation of data: S. Sprigle, S. Sonenblum.
Drafting of manuscript: S. Sprigle, S. Sonenblum.
Critical revision of manuscript for important intellectual
S. Sprigle, S. Sonenblum.

Administrative, technical, or materia
S. Sonenblum.
Financial Disclosures: The authors have declared that no
competing
interests exist.
Funding/Support: This material was based on work supported by
the
Rehabilitation Engineering Research Center on Wheeled
Mobility
(Mobility RERC) and the Georgia Institute of Technology. The
Mobil-
ity RERC is funded by the National Institute on Disability and
Reha-
bilitation Research of the U.S. Department of Education (grant
H133E080003).
Additional Contributions: We thank Dr. Kath Bogie for her
guid-
ance in outlining the manuscript and offering important
feedback.
Disclaimer: The opinions contained in this article are those of
the
authors and do not necessarily reflect those of the U.S.
Department of
Education or the Georgia Institute of Technology.
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477
JRRDJRRD Volume 50, Number 4, 2013Pages 477–488

Patient repositioning and pressure ulcer risk—Monitoring
interface
pressures of at-risk patients
Matthew J. Peterson, PhD;1* Nikolaus Gravenstein, MD;2
Wilhelm K. Schwab, PhD;2 Johannes H. van
Oostrom, PhD;1 Lawrence J. Caruso, MD2
1J. Crayton Pruitt Family Department of Biomedical
Engineering, University of Florida College of Engineering,
Gainesville, FL; 2Department of Anesthesiology, University of
Florida College of Medicine, Gainesville, FL
Abstract—Repositioning patients regularly to prevent pres-
sure ulcers and reduce interface pressures is the standard of
care, yet prior work has found that standard repositioning does
not relieve all areas of at-risk tissue in nondisabled subjects. To
determine whether this holds true for high-risk patients, we
assessed the effectiveness of routine repositioning in relieving
at-risk tissue of the perisacral area using interface pressure
mapping. Bedridden patients at risk for pressure ulcer forma-
tion (n = 23, Braden score <18) had their perisacral skin-bed
interface pressures recorded every 30 s while they received
routine repositioning care for 4–6 h. All participants had spe-
cific skin areas (206 +/– 182 cm2) that exceeded elevated pres-
sure thresholds for >95% of the observation period. Thirteen
participants were observed in three distinct positions (supine,
turned left, turned right), and all had specific skin areas (166
+/–
184 cm2) that exceeded pressure thresholds for >95% of the
observation period. At-risk patients have skin areas that are
likely always at risk throughout their hospital stay despite
repositioning. Healthcare providers are unaware of the actual
tissue-relieving effectiveness (or lack thereof) of their reposi-
tioning interventions, which may partially explain why pressure
ulcer mitigation strategies are not always successful. Relieving

at-risk tissue is a necessary part of pressure ulcer prevention,
but the repositioning practice itself needs improvement.
Key words: decubitus ulcer, interface pressure, patient reposi-
tioning, pressure, pressure sore, pressure ulcer, pressure ulcer
risk, prevention, standard of care, triple-jeopardy area.
INTRODUCTION
Pressure ulcers are a high-risk, high-volume, and
high-cost problem for hospitalized and bedridden
patients. Overall pressure ulcer prevalence rates have
been reported at 12.3 percent across all facilities, with
prevalence being highest in long-term acute care facili-
ties (22%), and facility-acquired prevalence being high-
est in adult intensive care units (8.8%–10.3%) [1].
Preventing pressure ulcers and reducing their incidence is
an ongoing challenge because they are associated with
increased cost, length of stay, morbidity, and mortality.
Managing one full-thickness ulcer can cost up to $70,000
[2], and over $17 billion is spent on pressure ulcer treat-
ments annually in the United States [3].
Note: The authors would like to dedicate this article
to the memory of their colleague Dr. Schwab.
Abbreviations: BMI = body mass index, HOB = head of bed,
NPUAP = National Pressure Ulcer Advisory Panel, q2h =
every 2 h, SLR = supine-left-right.
*Address all correspondence to Matthew J. Peterson, PhD;
James A. Haley Department of Veterans Affairs Medical
Center (151R), HSR&D/RR&D Center of Excellence, 8900
Grand Oak Circle, Tampa, FL 33637; 813-558-3979; fax:
813-558-3990. Email: [email protected]

478
A pressure ulcer, as defined by the National Pressure
Ulcer Advisory Panel (NPUAP), is a “localized injury to the
skin and/or underlying tissue usually over a bony promi-
nence, as a result of pressure, or pressure in combination
with shear and/or friction” [4]. It is widely accepted that
this mechanical loading is the main cause of pressure
ulcer formation; however, the pathophysiological
responses to this loading are less agreed upon [5]. Theo-
ries include localized ischemia [6], reperfusion injury [7],
impaired interstitial fluid flow [8], and sustained cell
deformation [9]. Tissue-loading models have been devel-
oped to study pressure ulcer formation, and results have
shown that acute stresses and strains in the deep tissue
(fat, muscle), which is more susceptible to damage than
the skin, present themselves before they are apparent in
the superficial tissue [5,10–11]. However, tissue pres-
sures greater than capillary pressure can be endured for
some time before ischemia results [12].
Pressure ulcers result when increased pressure on the
skin and subcutaneous tissues exceeds the local capillary
pressure, which compromises blood flow and results in
ischemia and decreased oxygen delivery [13]. Healthy
capillary pressures typically range from 10 to 30 mm Hg
[14]; however, capillary pressures may be lower for indi-
viduals in poor health [15–16]. Studies on blood flow in
response to loading vary in the amount of pressure
required to stop or reduce blood flow and oxygen deliv-
ery as well as by anatomical location or tissue type [17–

21]. Therefore, no widely accepted value exists that will
ultimately lead to pressure ulceration [5,22]. When pres-
sures exceed capillary pressure, tissue hypoperfusion,
accumulation of metabolites, and impairment of tissue
reperfusion may occur, all of which can damage the tis-
sue [23–25]. It is well established in animal and human
studies that not only is the magnitude of pressure a factor
for tissue damage but the duration is important as well—
the greater the pressure, the less time it takes until dam-
age occurs [6,22,26–29]. Over time, prolonged high pres-
sure applied to a tissue area will inevitably cause damage.
Interface pressure is the perpendicular force per unit area
between the support surface and the body. Interface pres-
sures are greatest around the sacrum, coccyx, and ischial
tuberosities, so it is not surprising that the majority of
pressure ulcers develop near these locations [30–31]. How-
ever, note that tissue interface pressures do not directly
measure internal tissue and capillary pressures [22].
The Centers for Medicare and Medicaid Services
recently designated pressure ulcers as a quality measure,
and consequently, they will not reimburse additional
patient expenses resulting from a reasonably preventable
condition that occurs while providing care [32–33]. Thus,
pressure ulcers have become a liability for hospitals,
long-term care facilities, and other healthcare providers
[34–35]. However, disagreement persists about the pre-
sumed inherent preventability of all pressure ulcers [36–
37]. To address this issue, the NPUAP hosted a multidis-
ciplinary consensus conference in 2010 and redefined
what is generally considered avoidable and unavoidable.
The group unanimously agreed that most, but not all,
pressure ulcers are avoidable [37]. Consensus was
reached that “unavoidable pressure ulcers may develop in
patients who are hemodynamically unstable, terminally

ill, have certain medical devices in place, and are nonad-
herent with artificial nutrition or repositioning” [37].
PATIENT REPOSITIONING
Repositioning patients regularly—every 2 h (q2h)—
to prevent sustained high pressures on any particular tis-
sue area is the standard of care [2,16,37–40]. However,
several recent studies in which repositioning was used as
the primary intervention strategy failed to reduce the
incidence of pressure ulcer formation [39–41]. Addition-
ally, the NPUAP conference could not reach a consensus
that q2h repositioning should be the standard of care.
However, they did agree that q2h repositioning should be
the “guideline for care” when clinically appropriate [37].
It was also unanimously agreed that pressure-redistributing
surfaces cannot replace patient repositioning care [37].
Our prior work found that standard, lateral turning by
experienced nurses does not reliably relieve all areas of
high skin-bed interface pressures in the perisacral region
of nondisabled adult subjects [42], i.e., the collective tis-
sue area around the sacrum, coccyx, and ischial tuberosi-
ties. Even though subjects are repositioned and the
perisacral area is no longer touching the mattress, this
perisacral skin area remains exposed to significant levels
of interface pressure between the pillow or wedge that is
supporting the laterally turned position. Furthermore,
specific skin areas remain at risk even after being placed
in all three positions: supine, turned left, and turned right.
These specific skin regions are termed “triple-jeopardy
areas” because the same tissue remains at risk while in any
of the three different positions [42]. This may help explain
why pressure ulcers still develop despite implementation of

479
PETERSON et al. Patient repositioning and pressure ulcer risk
standard preventive measures, including scheduled
patient repositioning. To determine whether this is the
case for at-risk patients, this study examined the effect of
routine repositioning over an extended time period on the
interface pressures of the perisacral skin area of bedrid-
den patients at risk for pressure ulcer formation using
interface pressure mapping.
METHODS
Study Design
We performed a descriptive, observational study, col-
lecting data at a tertiary care, university-affiliated hospi-
tal with 170 intensive and intermediate care beds from
2007 to 2009. Subjects were invited to enroll in the study
during regular care by their physician. We hypothesized
that bedridden patients undergoing q2h repositioning
would demonstrate a triple-jeopardy area (i.e., triple-
jeopardy area is not zero). To achieve a power of 80 per-
cent, a one-tailed test with an effect size of 0.8, and an
error probability of 5 percent required a minimum sample
size of 12. The effect size, though seemingly large, is
conservative based on results from our previous study
with nondisabled subjects [42] and, since a negative area
does not exist, a one-tailed test is appropriate. We enrolled
participants in the study until we monitored at least 12 in
all three distinct positions: supine, turned left, and turned
right. To compute the power, we used G*Power 3.0
(Institut für Experimentelle Psychologie, Heinrich Heine
Universität Düsseldorf; Düsseldorf, Germany).

Subjects
We enrolled 23 participants in the study from a con-
venience sampling of intensive care (n = 20) and interme-
diate care (n = 3) unit patients. We obtained written
informed consent from the patient or his or her proxy.
The patient inclusion criteria were bedridden, residing in
intensive care or intermediate care unit, at risk for pres-
sure ulcer formation determined by a Braden score of
-
ing as part of routine care. Not all patients were intubated
or sedated, but none was able to reposition themselves in
bed. Table 1 shows the demographics of the study cohort
(sex, age, height, weight, and body mass index [BMI])
and Braden scores (on date of data collection). The
subgroup of patients that we observed in all three posi-
tions will be referred to as the supine-left-right (SLR)
group (n = 13).
Instrumentation
We obtained interface pressure measurements using a
pressure mapping system (XSENSOR Technology Cor-
poration; Calgary, Canada). The pressure sensor is a flexi-
ble, thin pad with 48 × 48 half-inch sensors forming a 24 ×
24 in.2 array. The 2,304 independent sensors use proprie-
tary capacitive technology to discretely measure the pres-
sures applied to the sensor array. The interface box relays
individual pressure information from each sensor to a
computer for real-time visualization and recording. We
calibrated the sensor array according to the manufac-
turer’s recommendations to measure pressures from 10 to
200 mm Hg, with a reported accuracy of ±10 percent,
placing the sensor array between two air bladders held

together in a metal frame and inflated to specific pres-
sures. During calibration, sensor readings were all within
±10 percent of the measured value across the calibrated
range. We used the same calibration file for all subjects.
Before use in the clinical environment, we wrapped the
sensor array in very thin (0.0254 mm) plastic sheeting to
protect it from contamination and placed it beneath the
patient’s underpads (thin, towel-like incontinence pads).
We disinfected the sensor array after each use. We used a
modern hospital bed with low air-loss technology for all
measurements (Total Care or Total Care SpO2RT, Hill-
Rom; Batesville, Indiana). The bed’s built-in ball-bearing
indicator located in the side rail of the bed indicated the
head of bed (HOB) elevation.
Protocol
We placed the sensor array beneath the patient, span-
ning from the lower back to mid-thigh to ensure data col-
lection of the perisacral area. Placing the sensor array
required the nurses to roll the patient to one side and then
the other so that the array could be positioned, without
wrinkles, beneath the patient.
We recorded interface pressure measurements every
30 s as the patient lay in bed and received routine care,
which included lateral turning by his or her nurse. The
lateral turning methods included the use of pillows and/or
wedges placed behind the back and thighs. The reposi-
tioning technique was not prescribed by the study, and
the nursing technique was unconstrained so that the
results would reflect current clinical practice. Any pil-
lows or wedges that were used to maintain a laterally

Patient Sex Age (yr) Height (m) Weight (kg) BMI Braden Score
SLR Group
1 M 65 1.78 111 35.0 13 —
2 F 73 1.65 75 27.5 — —
3 M 69 1.83 80 23.9 16 —
5 M 70 1.78 86 27.3 15 —
8 F 53 1.68 70 24.9 12 —
9 M 58 1.73 120 40.1 15 —
10 M 71 1.80 65 20.1 16 —
14 M 76 1.75 79 25.7 11 —
15 F 74 1.60 71 27.7 15 —
16 F 67 1.40 55 28.2 12 —
Total 14 M, 9 F 63.3 ± 12.7 1.70 ± 0.11 85.9 ± 21.9 29.3 ± 5.6
13.3 ± 2.8 —
SLR Group 8 M, 5 F 60.1 ± 15.2 1.71 ± 0.09 89.6 ± 23.2 30.3 ±
480

turned position were placed beneath the sensor array to
allow continuous measurement of interface pressures
between the patient and the supporting device. The sensor
array was inspected after each turn to confirm that the
patient’s perisacral area was recorded. If the sensor array
got bunched up or if the patient’s perisacral area moved
off the array, adjustments were made only when the
patient was already in the process of being repositioned
to avoid interfering with patient care.
We monitored patients for 4 to 6 h. We chose this
time frame to allow for observation of the three distinct
positions (supine, turned left, and turned right) during the
q2h repositioning protocol. The same investigator (M.P.)
recorded the general positioning of the patient (direction
of turn and HOB elevation) for all of the data collection
periods for all patients. We obtained demographic infor-
mation from the patients’ charts.
Data Variables
Definitions of four data variables of interest and how
we calculated them include—
• At-risk areas (centimeters squared) for pressure ulcer
formation are the skin areas exposed to various inter-
face pressure thresholds (32 mm Hg—a historical and
contested value [5,16,20,22]—used for statistical
analyses, 40 mm Hg, and 50 mm Hg). We calculated
at-risk areas for every position experienced by each
patient, as well as for how long these particular skin
Table 1.
Patient demographics and Braden score data. These data
represent mean ± standard deviation for demographic and

Braden score data for study
cohort and for supine-left-right (SLR) group.
female, M = male.
481
areas were at risk. At-risk areas could be located over
any load-bearing tissue, such as the greater trochanter
while laterally turned.
• Always-at-risk areas (centimeters squared) are the
skin areas at risk for >95 percent of the total observa-
tion period, regardless of the number of positions
experienced. We used >95 percent of the patient’s
monitoring time rather than 100 percent to provide a
more realistic representation of what the patients actu-
ally experienced. For example, if a patient momen-
tarily rolled to one side and then back during a
recording, the pressure profile could indicate that spe-
cific tissue areas were relieved, though just briefly.
• Triple-jeopardy areas (centimeters squared) refer to
the same always-at-risk areas of skin that coincide in
all three positions. This term only applies to the
patients observed in all three distinct positions and to
areas in the perisacral region.
• Peak pressure over time (millimeters of mercury) was
calculated by averaging the peak interface pressure
measurement of each pressure profile obtained over

the duration of each position (supine, turned left, or
turned right). This value demonstrates the constancy
of the maximal pressures experienced, rather than just
a one-time value experienced for 30 s of a 2 h time
period.
Data Analysis
We used MATLAB (MathWorks; Natick, Massachu-
setts) and Excel (Microsoft; Redmond, Washington) to
image, align, analyze, compile, plot, and compare the
interface pressure data. Each pressure profile provided
the interface pressure (millimeters of mercury) at each of
the 2,304 discrete sensors. We determined peak interface
pressures and confined them to the tissues surrounding the
perisacral area, buttocks, and greater trochanters. We also
calculated the skin areas that were subjected to various
pressure thresholds over time. In addition to the 32 mm Hg
threshold, we also analyzed the data using more strin-
gent at-risk area interface pressure thresholds of 40 and
50 mm Hg, an increase of 25 and 56 percent, respectively.
We used the pressure profiles of the various positions
obtained for each patient to determine how repositioning
affected the patients’ interface pressures. We anatomi-
cally aligned the pressure profile images by maximizing
normalized two-dimensional cross-correlation, as con-
ducted in previous work [42], and then adjusted them fur-
ther, if necessary, by visual inspection to ensure that skin
areas from one position were compared with the same
skin areas of another position. We used a one-sample
Wilcoxon signed rank test to test the hypothesis that the
triple-jeopardy area was not zero. Wilcoxon rank sum
and signed rank tests were used, as appropriate, to com-
pare interface pressures, at-risk areas, and triple-jeopardy

areas between positions. We also compared these at-risk
patients with the nondisabled subject findings from
Peterson et al. [42] using similar statistical techniques;
we considered p < 0.05 significant.
RESULTS
Pressure Profiles and Patient Positioning
We recorded a total of 15,784 pressure profiles from
more than 131 h of patient monitoring; each patient was
monitored an average of 5.7 ± 1.0 h. We could not ana-
lyze some of the pressure profiles (<8%) because data
were recorded during patient repositioning or because the
perisacral area had moved off the sensor array. After
removing these profiles, we analyzed 14,527 pressure
profiles from 121 h of monitoring. The SLR group con-
sisted of 8,028 profiles from 66.9 h of monitoring time.
Table 2 shows the specific positions observed for
each patient. We recorded the HOB elevations for each of
the positions periodically throughout the study. For the
supine position, the average HOB elevation was 30°
–65°); for the turned-left position, the average
–40°); and for the
turned-right position, the average HOB elevation was
–45°).
Interface Pressures and At-Risk Areas
The peak interface pressures, peak pressures over
time, and at-risk areas did not differ significantly by posi-
tion (Table 3). However, on an individual basis, the peak
interface pressures and specific areas of at-risk skin were
susceptible to significant changes upon patient reposi-
tioning. For example, the peak interface pressures for one

patient upon being turned to the left from a supine posi-
tion increased nearly threefold due to shifting of the
patient’s body weight directly over the greater trochanter
(Figure 1).
Always-at-Risk and Triple-Jeopardy Areas
All 23 patients demonstrated always-at-risk areas,
with a mean always-at-risk area of 206 ± 182 cm2 (Table 2).
Patient Positions No. of Positions Always-at-Risk Area (cm2)
Triple-Jeopardy Area
(cm2)
1 R, L, R, L 4 297 —
2 R, L 2 5 —
3 S, L 2 469 —
4 S, L, R, L 4 8 8
5 S, L, S 3 73 —
6 S, R, S, L 4 108 108
7 S, L, R 3 119 119
8 S, L 2 169 —
9 S 1 261 —
10 R 1 247 —
11 S, R, L, R 4 110 110
12 R, S, L 3 456 456
13 S, R, L 3 613 613
14 S, Sit, S, R 4 516 —
15 S, L 2 427 —
16 R, L, R, L 4 105 —
17 S, L, S, R 4 76 76
18 R, S, L 3 15 15
19 R, L, R, S 4 195 195

20 S, L, R 3 248 248
21 S, R, L 3 2 2
22 S, L, R 3 15 15
23 S, L, R 3 194 194
Mean ± SD — 3.00 ± 0.95 206 ± 182 166 ± 184
482
Accordingly, all 13 patients in the SLR group demon-
strated triple-jeopardy areas as well and had a mean tri-
ple-jeopardy area of 166 ± 184 cm2 (Table 2). These
unambiguous results support our hypothesis that bedrid-
den, at-risk patients do demonstrate a triple-jeopardy area
(SLR group, p < 0.001) or always-at-risk area (all
patients, p < 0.001). To view the areas of skin that were
always-at-risk and for how long, we compiled the at-risk
areas from every pressure profile from each patient’s
entire monitoring period. Figure 2 illustrates the typical
interface pressure profiles for the three different positions
and how the at-risk skin areas were affected over time.
We also analyzed the data with more stringent inter-
face pressure thresholds. At 40 mm Hg, 18 of 23 patients
(9 of 13 in SLR group) had always-at-risk areas, and at
50 mm Hg, 10 of 23 patients (3 of 13 in SLR group) still
had always-at-risk areas. Since the at-risk patients dif-
fered in age, Braden score, and body type, we also ana-
lyzed the data to see whether any of these factors affected
the results. However, no trend emerged upon analyzing
always-at-risk or triple-jeopardy areas with respect to
age, height, weight, BMI, or Braden score.
DISCUSSION

Regular q2h repositioning of patients is the standard
of care that is routinely implemented to reduce the risk of
pressure ulcer formation. Our results clearly demonstrate
that bedridden, at-risk patients have substantial areas of
Table 2.
At-risk patient positions observed and corresponding always-at-
risk and/or triple-jeopardy areas.
Note: In “Sit” position, head of bed was 65°.
L = left, R = right, S = supine, SD = standard deviation.
Peak Interface Pressures (mm Hg) PositionSupine Left Right
At-Risk Patients with HOB Elevation
Peak Pressures*† 122.5 ± 45.1 134.2 ± 43.7 119.8 ± 33.8
Peak Pressures Over Time* 99.1 ± 34.3 99.5 ± 30.0 88.9 ±
17.1
Nondisabled Subjects — 69.2 ± 12.8 64.8 ± 9.1
Left Side
68.6 ± 19.5 — —
Right Side
65.8 ± 11.7 — —
— 84.5 ± 17.5 80.4 ± 11.4
At-Risk Areas (cm2) PositionSupine Left Right
At-Risk Patients with HOB Elevation‡ 716 ± 290 742 ± 304 744
± 287

Nondisabled Subjects — 468 ± 151 434 ± 147
Left Side
470 ± 170 — —
Right Side
480 ± 170 — —
— 569 ± 192 558 ± 159
Triple-Jeopardy and Always-at-Risk
Areas (cm2) Triple-Jeopardy Area Always-at-Risk Area
At-Risk Patients 166 ± 184 206 ± 182§
Nondisabled Subjects 60 ± 54 —
483
skin that do not get relieved and remain at risk despite
repositioning by experienced nurses. This observation
was not isolated to only a few patients—all 23 patients
monitored in this study demonstrated always-at-risk
areas. We monitored patients for approximately 6 h con-
secutively, and they had specific skin areas that remained
at risk during the entire observation period. Based on
these results, we can reasonably assume that these skin
areas are at risk for the majority of time a patient is bed-
ridden. These results mirror those of the nondisabled sub-
ject study that first described the triple-jeopardy area
phenomenon [42] and confirm that at-risk patients also
have substantial always-at-risk skin areas despite routine

repositioning.
Since there is no widely accepted value for an inter-
face pressure threshold for tissue risk or damage, we also
used more stringent interface pressure thresholds. Upon
evaluation with greater interface pressure thresholds, the
results revealed that always-at-risk areas and triple-jeopardy
areas still continued to exist in a significant subset of at-
risk patients, which suggests that the current standard of
care is not sufficient. However, of the patients that dem-
onstrated an always-at-risk area, the fraction of those
patients that were from the SLR group decreased as the
interface pressure thresholds increased. Furthermore, the
mean always-at-risk area was less for the SLR group (tri-
ple-jeopardy area) than for the overall study population
as a whole. These results provide objective support that
routine patient repositioning, when done properly,
reduces always-at-risk areas, which should, in turn,
reduce pressure ulcer risk. Accordingly, future studies are
needed to assess whether patients with always-at-risk
Table 3.
Comparison of interface pressure (mm Hg), at-risk areas (cm2),
triple-jeopardy areas (cm2), and always at-risk areas (cm2)
between patients at
risk for pressure ulcer formation and nondisabled subjects. Data
were taken on
same brand of modern hospital bed. Nondisabled subject data
from Peterson et al. [42].
*At-risk patient values were significantly larger than
nondisabled subjects for corresponding supine and laterally
turned positions (p < 0.001).
†At-risk patient values were significantly larger than

nondisabled subjects for corresponding turned with HOB
elevation positions (p < 0.001).
‡At-risk patient values were significantly larger than
nondisabled subjects for corresponding supine and laterally
turned positions (p < 0.003).
§At-risk patient values were significantly larger than
nondisabled subjects (p < 0.006).
HOB = head of bed.
484
areas are more likely to develop (1) pressure ulcers,
(2) more severe pressure ulcers, and/or (3) pressure
ulcers at these specific
Figure 1.
Interface pressure changes by position. Peak interface pressures
over time are displayed for two different patients. Peak
pressures
were located around perisacral area and greater trochanters.
Repositioning at times resulted in large sustained changes in
peak pressures (bottom graph) but not always (top graph).
(a) Peak interface pressures for patient 6 initially in supine
posi-
tion, turned right at minute 7, supine at minute 210, and turned
left at minute 325. (b) Peak interface pressure for patient 18
initially
turned right, supine at minute 147, and turned left at minute
268.
tissue locations.
Despite the standard of care (q2h), repositioning

intervals varied between patients (Table 2, “Positions”)
and none was effective in relieving all at-risk tissue areas.
For example, two patients were not repositioned during
the entire monitoring period. It was not clear why the
repositioning procedures were different, but we believe
our observations mirror typical interoperator reposition-
ing technique differences. All the same, it may not matter
exactly how repositioning is accomplished, but rather
that the at-risk tissue gets relieved regularly from pres-
sure. To put our observations in perspective, the average
always-at-risk area was over 200 cm2; therefore, an area
one-third the size of an 8.5 × 11 in. sheet of paper is not
getting relieved and remains at risk for pressure ulcer for-
mation. Hence, future research is needed to establish how
pressure mapping, implemented as a patient monitoring
device or as a means to educate caregivers to improve
their repositioning techniques, can further reduce or elim-
inate high skin-bed interface pressures, at-risk areas, and
always-at-risk areas (including triple-jeopardy areas) in
at-risk patients to reduce pressure ulcer risk.
We are not aware of any prior work examining the
interface pressures of a cohort of patients during an inter-
val of care that covers the spectrum of positions experi-
enced by patients who typically have the highest
prevalence of pressure ulcer formation. Comparing the
at-risk patients of this study with nondisabled subjects
[42] (for values and statistical significance, see Table 3),
we found the peak interface pressures were 49 to 59 per-
cent and 85 to 94 percent higher for the at-risk patients
than for nondisabled subjects, with and without HOB ele-
vation, respectively. The peak pressures over time of at-
risk patients were 11 to 18 percent and 37 to 51 percent
greater than the peak pressures of nondisabled subjects,

with and without HOB elevation, respectively. The at-risk
areas were 30 to 33 percent and 52 to 71 percent larger
for the at-risk patients than nondisabled subjects in the
supine and laterally turned positions, with and without
HOB elevation, respectively. The triple-jeopardy and
always-at-risk areas were also considerably larger for the
at-risk patients than for nondisabled subjects, 277 and
343 percent, respectively. Perhaps due to pain, frailty,
medical condition, or the reservation of nurses to not dis-
turb the patient too much, bedridden at-risk patients
experience higher interface pressures and larger at-risk
and always-at-risk areas (including triple-jeopardy areas)
than nondisabled subjects. These results that demonstrate
at-risk patients have higher interface pressures than non-
disabled subjects are consistent with data reported by
Berjian et al. [43].
Our study had a few limitations. First, tissue interface
pressures do not directly measure internal tissue and cap-
illary pressures. We are not implying that an at-risk area
485
is ischemic, but we feel these areas are at-risk due to ele-
vated interface pressures. Moreover, interface pressure
mapping is currently the best noninvasive method to
measure pressures applied to the skin. The use of peak
interface pressures has been reported to be unreliable for
test-retest scenarios [44], but this did not affect our
always-at-risk and triple-jeopardy results. Second,
patient shifting and/or raising the HOB could result in a
patient moving off the sensor array, generating unusable

pressure profiles
Figure 2.
Interface pressure profiles by position and triple-jeopardy areas.
(a) Typical perisacral interface pressure profiles from one
intensive
care unit patient; color bar is in millimeters of mercury with
color denoting at-risk areas. (b) Total amount of triple-jeopardy
(always-at-
risk) area. (c) Schematic of patient lying in bed on pressure
sensor. Pressure profiles should be viewed as if you are facing
patient.
(d) Amounts of time specific areas of skin were at risk across
all positions experienced by patient. Color bar indicates time (in
hours)
that specific skin areas were at risk. Areas at risk for maximal
amount of time (dark red) were always at risk and never
relieved.
(<8% of total data collected). However,
active movements (absent shear) are likely beneficial
because they redistribute the patient’s weight similar to
nondisabled people, for example, when shifting weight
while sitting in a chair. Third, we anatomically aligned
patient interface pressure profiles when necessary to
ascertain that specific areas of skin were correctly
tracked over time. We needed alignment for half of the
patients we observed. This adjustment, or any patient
movement, could have led to minor errors in tracking
specific skin areas, but we found no significant difference
in triple-jeopardy or always-at-risk areas between patients
who had their pressure profiles aligned compared with
those who did not. Last, we placed the sensor array beneath
the patient’s underpads to protect it from the patient and
additional contaminants and so that it would not be used

in place of the underpads to help lift and reposition the
486
patient. The underpads may aid in slight pressure relief,
thus resulting in lower measured pressures.
CONCLUSIONS
Bedridden patients at risk for pressure ulcer forma-
tion exhibit high skin-bed interface pressures and specific
skin areas that are likely always at risk (i.e., triple-jeopardy
and always-at-risk areas) for the vast majority of the time
patients are in bed despite routine repositioning care.
Healthcare providers are unaware of the actual tissue-
relieving effectiveness (or lack thereof) of their reposi-
tioning interventions, which may partially explain why
pressure ulcer mitigation strategies are not always suc-
cessful. Relieving at-risk tissue is a necessary part of
pressure ulcer prevention, but the repositioning practice
itself needs improvement. Further research is needed to
determine how pressure mapping can be used to develop
better patient repositioning techniques and improve at-
risk tissue pressure relief to help prevent pressure ulcer
formation.
ACKNOWLEDGMENTS
Author Contributions:
Study concept and design: M. J. Peterson, N. Graven
W. K. Schwab, J. H. van Oostrom, L. J. Caruso.
Data collection: M. J. Peterson, W. K. Schwab, L. J. Caruso.

Data analysis: M. J. Peterson.
Data interpretation: M. J. Peterson, N. Gravenstein, W. K.
J. H. van Oostrom, L. J. Caruso.
Drafting of manuscript: M. J. Peterson.
Critical revision of manuscript for important intellectual
M. J. Peterson, N. Gravenstein, W. K. Schwab, J. H. van
L. J. Caruso.
Financial Disclosures: The authors have declared that no
competing
interests exist.
Funding/Support: This material was based on work supported by
the
Department of Anesthesiology, University of Florida College of
Engineering, University of Florida College of Engineering;
Shands
Hospital, University of Florida College of Medicine; and Health
Development Center of Excellence, James A. Haley Department
of
Veterans Affairs Medical Center.
Additional Contributions: This work was presented in part at the
2010 National Patient Safety Foundation Patient Safety
Congress,
Orlando, Florida (May 17–19, 2010), and the NPUAP Biennial
Con-
ference, Las Vegas, Nevada (February 25–26, 2011). Dr.
Peterson is
now with the Health Services Research &
Development/Rehabilita-

tion Research & Development Center of Excellence, James A.
Haley
Department of Veterans Affairs Medical Center, Tampa,
Florida.
Institutional Review: This study received institutional review
board
approval and all patients or their proxies provided informed
consent.
Participant Follow-up: The authors have no plans to inform the
par-
ticipants of the publication of this study.
Disclaimer: The contents of this manuscript are those of the
authors
alone and do not represent the views of the Department of
Veterans
Affairs, the University of Florida, or the U.S. Government.
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Submitted for publication March 5, 2012. Accepted in
revised form September 10, 2012.
This article and any supplementary material should be
Peterson MJ, Gravenstein N, Schwab WK, van Oostrom
JH, Caruso LJ. Patient repositioning and pressure ulcer
risk—Monitoring interface pressures of at-risk patients. J
Rehabil Res Dev. 2013;50(4):477–
ResearcherID/ORCID: Johannes H. van Oostrom, PhD:
B-1407-2008
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b=PubMed&list_uids=15582638&dopt=Abstract]

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Repositioning for pressure ulcer prevention in adults.
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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
standard hospital mattresses, Outcome 2 Pressure ulcer risk
(category 2 to 4). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
34
viscoelastic foam mattresses, Outcome 1 Pressure ulcer risk

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

Copyright © 2014 The Cochrane Collaboration. Published by
John Wiley & Sons, Ltd.
[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. [email protected]
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)
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

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 Ulcer Advisory 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
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
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
#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.
http://infodoc.inserm.fr/euronheed/
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
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;

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.
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.
(Review)
Figure 2. Study flow diagram for economic studies
(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.
(Review)
Figure 3. Risk of bias summary: review authors’ judgements
about each risk of bias item for each included
study
(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
(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
category
In the Defloor 2005 trial, various repositioning regimens of dif-
ferent frequencies (2-, 3-, 4- and 6-hourly), positions (i.e. semi-
Fowlers and lateral), and support surfaces (i.e. viscoelastic and
standard mattresses) were compared.
For the purposes of this review we compared the outcomes for
repositioning frequency where the support surface was the same
for both groups i.e., 2-hourly vs. 3-hourly repositioning (all on
the

standard hospital mattress) and 4-hourly vs. 6-hourly
reposition-
ing (all on the viscoelastic foam mattress). On the standard
hospi-
tal mattress, 39/63 (62%) participants receiving 2 hourly reposi-
tioning developed a pressure ulcer of any severity compared
with
40/58 (69%) receiving 4-hourly repositioning (RR 0.90, 95% CI
0.69 to 1.16) (Analysis 1.1).
For participants nursed on viscoelastic foam mattresses, 30/66
(46%) of participants receiving 4-hourly repositioning
developed
a pressure ulcer of any severity compared with 39/63 (62%) of
those receiving 6-hourly repositioning (RR 0.73, 95% CI 0.53 to
1.02) (Analysis 2.1).
The proportion of new pressure ulcers category 2 to 4
We also examined whether there was a treatment effect when
only
breaks in the skin (category 2 to 4 ulcers) were analysed
however
we did not pre-specify this analysis in our protocol and the
results

are merely exploratory.
On the standard hospital mattress, 9/63 (14%) of participants re-
ceiving 2 hourly repositioning developed an ulcer of Category 2
and above compared with 14/58 participants (24%) receiving 3-
hourly repositioning (RR 0.59, 95% CI 0.28 to 1.26) (Analysis
1.2). On the viscoelastic foam mattress, 2/66 (3%) participants
receiving 4-hourly repositioning developed an ulcer of Category
2 or above compared with 10/63 (16%) receiving 6-hourly repo-
sitioning (RR 0.19, 95% CI 0.04 to 0.84) (Analysis 2.2).
Comparison 2: different positions for repositioning
Primary outcomes
The proportion of new pressure ulcers of any grade, stage or
category (two trials)
Both trials reported this outcome (Moore 2011; Young 2004).
Moore 2011 examined the use of 30° 3-hourly tilt (overnight)
compared with repositioning 6-hourly 90° tilt (overnight) in a
study involving 259 randomised (252 analysed) participants.
The

(Review)
incidence of pressure ulcers (Categories 1 and 2) was
significantly
lower in the 30° tilt group (RR 0.27, 95% CI 0.08, 0.91)
compared
with the 90° tilt group (Analysis 3.1). This study was at high
risk
of bias due to unblinded outcome assessment.
In the small trial by Young 2004 (46 randomised, 39 analysed
par-
ticipants), the main outcome was Category/Stage 1 non-blanch-
able erythema, and the follow-up period was 24 hours. A 3-
hourly
30o tilt compared with a 3-hourly 90o lateral (overnight) and
supine position (overnight) was used. There was no statistically
significant difference in risk of pressure ulceration (RR 1.37,
95%
CI 0.25 to 7.41) (Analysis 3.1) however this comparison is
grossly

underpowered with only 5 events.The trials of Moore 2011 and
Young 2004 compared the same tilts (30º vs 90º) using simi-
lar repositioning frequencies; 3-hourly for the 30º tilt; 6-hourly
overnight for the 90º tilt in Moore 2011; and 2- to 3-hourly
overnight in the Young 2004 trial therefore we pooled them us-
ing a random effects model (moderate to high heterogeneity, I2
= 69%). Overall there was no difference in the risk of Category/
Stage 1 or 2 pressure injury (persistent erythema) between 30º
and
90º tilts however this comparison is at risk of a Type II error
due
to the lack of statistical power (pooled RR 0.62, 95% CI 0.10 to
3.97) (Analysis 3.1).
Secondary outcomes
Health-related quality of life (HRQoL)
No trial reported health-related quality of life (HRQoL).
Procedural pain
No trial reported procedural pain.
Patient satisfaction

No trial reported patient satisfaction.
Cost
One within-trial cost evaluation by Moore 2013 is included in
this review. Moore 2013 performed a cost-effectiveness analysis
based on data derived from their cluster randomised controlled
trial (Moore 2011) comparing 3-hourly repositioning using the
30° tilt overnight (n=99, unadjusted for clustering) with
standard
care consisting of 6-hourly repositioning using the 90° lateral
rota-
tion overnight (n=114, unadjusted for clustering), in
participants
recruited from 12 long term aged-care facilities in Ireland.
Moore 2013 compared the nursing time costs and incidence of
PU development over the four week trial period. Nurse time was
calculated from information recorded in the clinical study
indicat-
ing number of turns per patient, nurses per turn, and nurse time
per turn. A unit cost of EURO23.94 per nurse hour was then ap-
plied, based on the rate for a staff nurse scale point 8 in mid-

2009.
Efficacy was measured as PU incidence (the primary outcome of
the clinical trial), which would appear to be represented as the
number of patients developing a new PU during the four week
trial period. Moore 2013 also reported some data for the total
cost
of dressings for treating PUs that developed during the trial, but
did not report a unit cost and did not include dressing costs in
the
incremental analysis.
Incremental cost per event avoided
The 30° 3-hourly tilt positioning intervention was reported to be
cost saving in nurse time compared with standard care (mean
nurse
time cost per patient EURO206.6 vs EURO253.1, incremental
difference EURO-46.5; 95%CI: EURO-1.25 to EURO-74.60)
(Moore 2013). The intervention dominated the control in terms
of cost-effectiveness, since the trial also found the intervention
to
be more effective than the control. The lower nurse time cost
for

the intervention group despite the greater turning frequency was
due to the lower time and reduced number of nurses required for
each turn.
Given the intervention dominated the control, it was
unnecessary
for Moore 2013 to estimate an incremental cost-effectiveness
ra-
tio although they did. There is some inconsistency in the report-
ing and interpretation of the incremental analysis made by
Moore
2013, leading to a lack of clarity in the paper around the
estimated
cost-effectiveness. Moore 2013 suggest their efficacy outcome
in
the incremental analysis as both “patient free of PU” and “PU
avoided”. The rationale for changing between outcome measures
of “patient free of PU” and “PU avoided” is unclear. Neverthe-
less, in this instance these outcome measures would appear to
be
equivalent since the number of patients developing an ulcer and
the number of PUs developing during the trial was the same (n=

16) (Moore 2011). Moore 2013 reported the incremental cost
per
patient free of PU (-EURO73.40) and per pressure ulcer avoided
(-EURO547.00). Although not explicitly stated, the estimated
in-
cremental cost effectiveness ratios appear to be intended to rep-
resent an incremental cost per additional incremental outcome.
However, these values are inconsistent with each other, given
the
incidence of PUs developing was the same in the trial (Moore
2011) regardless of whether defined as number of patients
devel-
oping PU or number of PUs developing during the trial. Further,
neither of these values could be confirmed from the data
provided
in the main body of the Moore 2013 paper. The former value (-
EURO73.40 per patient free of PU) appears to have been incor-
rectly estimated from the data presented in the paper. The lat-
ter value of -EURO547 per (additional) PU avoided is
consistent
with the efficacy data presented in the abstract, but the efficacy

data presented in the abstract is inconsistent with efficacy data
presented in the main body of the report, and does not precisely
match the efficacy data provided in the original clinical trial
report
(Moore 2011).
Despite this limitation in interpretation, the reported findings
(Review)
suggest that for every 100 patients treated with the 3-hourly
repositioning intervention rather than standard care,
EURO4,650
would be saved in nurse time costs and an additional 8 patients
would avoid a PU. Moore 2013 concluded that repositioning ev-
ery 3 hours using the 30° tilt is less costly in terms of nursing
time
and more effective than standard care involving repositioning
ev-
ery 6 hours using 90° tilt.

D I S C U S S I O N
Summary of main results
The proportion of new pressure ulcers of any grade,
stage or category
The main aim of this systematic review was to present and ap-
praise all existing evidence regarding the relative effectiveness
of
repositioning on the prevention of PUs in adults. There is
limited
evidence, with only three small trials and data from a total of
502
participants contributing to this analysis. Moreover the three
trials
were at high risk of bias.
The results of the review are that we have insufficient evidence
to
draw a reliable conclusion of whether more frequent
repositioning
(in this review we report 2-hourly vs. 3-hourly, and 4-hourly vs.
6-
hourly) or different positions (the 30° tilt compared with the
90°

lateral position) are more effective in reducing pressure
damage.
The lack of statistical power means we cannot say there is no
bene-
fit associated with more frequent repositioning since in each
com-
parison the proportion of people developing pressure ulcers was
lower in the groups receiving more frequent changes of position
but the differenced did not reach conventional levels of
statistical
significance and so may be chance rather than “real”
differences.
There was a statistically significant reduction in pressure ulcers
of Category 2 and above with 4-hourly repositioning compared
with 6-hourly (Defloor 2005) however we did not prespecify
this
outcome and this finding is exploratory.
It is noteworthy that in Defloor 2005, 46% of participants
receiv-
ing 4-hourly repositioning and 62% of those receiving 6-hourly
developed pressure damage, despite being nursed on
viscoelastic

foam mattresses. This suggests that although another Cochrane
re-
view (McInnes 2011) found that more advanced foam mattresses
reduce pressure damage relative to the standard hospital
mattress,
high rates of pressure damage are still observed and careful
moni-
toring of skin condition is required.
Repositioning regimens are widely used and recommended in
best
practice guidelines (European Pressure Ulcer Advisory Panel
1998;
Australian Wound Management Association 2011), however
there
is limited empirical evidence of their effect on the prevention
of pressure ulcers. That said, the theoretical rationale for
reposi-
tioning (to reduce isolated tissue ischaemia by relieving
pressure)
makes physiological sense. However current evidence does not
en-
able conclusions to be drawn regarding the optimum position or
frequency of re-positioning. The lack of experimental evidence

for repositioning per se, or for specific positions and
frequencies,
should not be interpreted as evidence of ineffectiveness.
Overall completeness and applicability of
evidence
There was limited evidence available to assess the benefits of
dif-
ferent regimens for the prevention of pressure ulcers. Overall
the
three studies in this review had sample sizes resulting in a lack
of
statistical power to detect a treatment effect if it exists. Small
sam-
ple sizes increase the risk of Type 2 errors and reduce the
precision
of the estimates.
There was wide variation in sample sizes among the trials. Only
one
of the trials was conducted in an acute care setting and included
only hospital patients over the age of 65 years (Young 2004).
The
primary study outcome reported in all three trials was the inci-
dence of pressure ulcers. None of the included trials examined

out-
comes such as pain, quality of life or participant satisfaction.
Only
one trial author performed a parallel economic substudy (Moore
2013).
The focus of the interventions of the three trials that met our in-
clusion criteria varied, with two trials using tilts and three-
hourly
overnight repositioning (Moore 2011; Young 2004), while the
third used various repositioning frequencies and positions in
com-
bination with different types of mattresses (Defloor 2005). An-
other limitation was the inconsistency in follow-up periods,
which
ranged between 24 hours (Young 2004) to 28 days (Defloor
2005
and Moore 2011). All three trials were conducted in Europe
which
may limit the generalisability of the findings. Furthermore,
tech-
nological developments in mattress composition and materials,
as

well as bed design, has occurred since the two earliest studies
were
conducted, which also limits the external validity of these
results,
as it is likely that other support surfaces are now in use.
Quality of the evidence
The quality of the body of evidence has been appraised using
the
GRADE approach in relation to study limitations, inconsistency
of results,indirectness, imprecision and risk of bias,as specified
in
the Handbook (Schünemann 2011) and a Summary of Findings
Table will be included in the next update. There is very low
quality
of evidence from the three trials that assessed the use of
different
repositioning regimens. The evidence was downgraded because
of the low number of participants with consequent imprecision
together with high risk of bias. The primary outcome, pressure
ulcer development, requires a subjective judgement of whether
(Review)

tissue damage has occurred (at least for Grade 1 pressure ulcer)
and
only one study (Young 2004) used blinded outcome assessment.
Potential biases in the review process
We followed clearly defined, pre-specified procedures to
prevent
potential bias in the review process. A comprehensive and
system-
atic literature search was conducted, that was both transparent
and
reproducible. That notwithstanding, it is possible that we
missed
trials published in journals that were outside our search
strategy.
Whilst we had intended to conduct a sensitivity analysis to test
the robustness of the results to different assumptions about the
outcomes of people who were lost to follow up, we felt that this
was not necessary due to the poor volume and quality of the
evi-

dence and our consequent inability to draw any conclusions (no
sensitivity analysis would help in this regard).
None of the review authors has any conflict of interest.
Agreements and disagreements with other
studies or reviews
Our results are consistent with others’ assessment of the
evidence
for repositioning. The systematic review by Reddy 2006, was
pub-
lished before one of our included trials, Moore 2011, was
under-
taken. The results of the review by Reddy 2006 suggested that
the evidence around repositioning remains somewhat inconclu-
sive, and the methodology for PUP trials sub optimal.
A U T H O R S ’ C O N C L U S I O N S
Implications for practice
There is currently insufficient evidence that the 30° tilt is more
effective than the 90° tilt (two trials, only 21 events in total).
Repositioning in some form is recommended in all clinical
guide-
lines though implementation is probably variable and highly de-

pendent on the available resources (particularly staffing levels).
It
is noteworthy that more recent clinical guidelines no longer ad-
vocate repositioning patients every two hours (European
Pressure
Ulcer Advisory Panel 2009; National Pressure Ulcer Advisory
Panel 2007).
It is surprising that, to date, there is little evidence available
from
RCTs that addresses the question of whether repositioning pa-
tients does decrease the risk of acquiring pressure ulcers. The
lack
of evidence is a cause for concern considering that estimates of
incidence of hospital-acquired pressure ulcers range from less
than
3% to over 30% of patients (Mulligan 2011; Queensland Health
2008; Schuurman 2009; Nixon 2006).
The aetiology of pressure ulcer development is linked to
localised
vascular obstruction that reduces capillary blood flow to the
skin

surface area (European Pressure Ulcer Advisory Panel 2009).
Thus,
there are reasonable grounds to expect that repositioning hospi-
talised patients will minimise the risk of oxygen deprivation and
nutrients that are required for tissue repair. However, the opti-
mal frequency with which this should occur must consider the
other negative effects of turning such as the potential for sleep
disruption,heightened increases in patients’ pain perception and,
for nurses, musculoskeletal injuries
Implications for research
There is an urgent need for appropriately-powered, high-quality,
multicentre trials to evaluate the clinical and cost effectiveness
of
repositioning regimens on the prevention of pressure ulcers. The
modest sample sizes in the trials reviewed is a major limitation.
Thus in future trials, larger numbers of participants are needed,
particularly if cluster trials are conducted. Two of the thee trials
reviewed here were conducted in long-term care settings,
therefore,
there is a need to use acute care settings to address the rise in

prevalence of hospital acquired pressure ulcers (Mulligan
2011).
Consistency in the measures used to classify pressure ulcers of
any severity is essential. Given the high costs associated with
the
prevention and treatment of pressure ulcers, priority should be
given to robust RCTs with economic evaluations. Trialists
should
consider comparisons of:
1. the repositioning frequencies and optimal positioning;
2. the effects of repositioning in patients with limited mobility
(e.g. paraplegia);
3. the economic costs (including incremental costs) of PUs;
and,
4. the economic and social impacts of PUs on patients’
HRQoL using valid and reliable HRQoL measures.
Good quality trials also need to address the methodological
limi-
tations identified in the trials of this review. Trialists must
ensure

transparency of research process and adhere to the CONSORT
statement for reporting RCTs (The CONSORT Statement 2010).
To minimise the sources of bias, trialists need to pay careful at-
tention to elements of research design and execution with regard
to allocation concealment, randomisation, blinding, and partici-
pant attrition (Polit 2010). For instance, having an observer who
is blinded to the outcome perform the outcome assessment. If
cluster-RCTs are used, trialists need also to consider the
potential
for bias in terms of selection bias, baseline comparability,
analysis,
and loss of clusters (Higgins 2011a).
A C K N O W L E D G E M E N T S
(Review)
The authors would like to thank the following referees: Wounds
Group Editors Nicky Cullum and Andrea Nelson; Trials

Search Co-odinator Ruth Foxlee; Statistical Consultant
Giovanni
Casazza; and, Expert Referees Zena Moore and Carol
Dealey.The
authors also thank Ms Jodie Vickery from Griffith University
for
assistance with selection of the economic studies and Elizabeth
Royle for copy editing.
R E F E R E N C E S
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Nursing 2011;20(17-18):2633–44.
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C H A R A C T E R I S T I C S O F S T U D I E S
Characteristics of included studies [ordered by study ID]
Defloor 2005
Methods Study design: 5-armed cluster RCT with a 4-week (28-
day) follow-up period (only 4
arms analysed in this review - see below)
Quote: “Each ward applied the prevention scheme selected for a
period of 4 weeks. The
randomisation procedure was repeated for a second period of 4
weeks. During the second
period each ward used a different prevention scheme than used
in the first period” (pp
39)
Ethics and informed consent: ethics approval and consent
obtained.

Sample size calculation: yes.
ITT analysis: participants analysed in the groups to which they
were assigned, but data
were incomplete for 24 participants, and they were not included
in the analysis
Quote: “The observations were incomplete in the case of 24
patients.”
Participants Location: 32 wards across 11 nursing homes in
Flanders, Belgium
Baseline data reported in relation to group comparisons for age,
gender and Braden scale
scores
Mean ages:
Group A: 85.2 years (± 7.2)
Group B: 85.2 years (± 6.2)
Group C: 84.7 years (± 7.7)
Group D: 85.4 years (± 7.3)
Inclusion criteria: 838 people fulfilled inclusion criteria. This
review excludes partici-
pants from the usual care group who received care that was
different in terms of both
support surface AND repositioning

1. Geriatric residents with a Braden score of < 17 or a Norton
score of < 12
2. Informed consent of the patient/family.
3. No PU at time of recruitment to study.
Exclusion criteria: none stated, but total of 1114 people
excluded.
Interventions Aim(s): to investigate the effect of 4 different
preventative regimes involving either fre-
quent turning (2- to 3-hourly) or the use of a pressure-reducing
mattress in combination
with less frequent turning (4- to 6-hourly)
Group A: 2-hourly turning regimen on standard mattress (65
randomised, 63 analysed)
Group B: 3-hourly turning regimen on standard mattress (65
randomised, 58 analysed)
Group C: 4-hourly turning regimen on viscoelastic polyurethane
(pressure-relieving)
mattress (67 randomised, 66 analysed)
Group D: 6-hourly turning regimen on viscoelastic polyurethane
(pressure-relieving)
mattress (65 randomised, 63 analysed)
Alternating turning positions: semi-Fowlers with feet elevated

30o alternating with 30
o lateral rotation, pillow placement under back from shoulder
on standard mattress
Specified sitting position: experimental group sitting periods
were recorded but not
standardised; they sat on thick air cushions. Backrest tilt on
chair, legs on footrest but
heels not supported. Cushion for back
Group 2 Control: n = 576 patients.
Care given according to patients’ level of risk; water
mattresses, alternating mattresses,
(Review)
Defloor 2005 (Continued)
sheepskins and gel cushions; based on nurses’ clinical
judgement. No PU risk assessment
tool used. For the purposes of this review we have disregarded
this group since their
care was highly heterogeneous and differed systematically from
the others in terms

of BOTH the support surface provision policy AND the
(absence of a) repositioning
policy.
Study date(s): not stated.
Outcomes Primary outcome: incidence of a PU (any category)
during a 28-day period.
Seondary outcomes: risk assessment using Braden and Norton
scores.
Time points: twice weekly for 4 weeks
Notes Not reported whether water mattresses, alternating
mattresses, sheepskins and gel cush-
ions were used singly or in combination with each other
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote:“Using computerised randomisa-
tion tables, the prevention schemes were
randomly allocated to 32 wards (table 1)
Randomisation also occurred over a sec-

ond 4-week period. During this second pe-
riod, each ward used a different prevention
scheme than used in the first 4-week period
(pp. 39)
Diagram of randomisation schedule in-
cluded in the paper as a table pp 39
Allocation concealment (selection bias) Unclear risk Quote: “a
sealed envelope containing all
the room numbers in a random order was
opened. The first 5 patients who satisfied
the inclusion criteria were included.”
Quote: “labour intensive nature of some
of the prevention schemes, the number of
patients participating in the experimental
groups was limited to 5 per ward.”
Comment: concern that allocation not
fully concealed
(performance bias)

All outcomes
High risk Quote: “’It was impossible to blind the
nurses for preventative care.”
Comment: Not blinded
Blinding of outcome assessment (detection
bias)
All outcomes
High risk Quote: “The nurses were blinded for the
Braden and Norton scores of their individ-
ual patients.”
Comment: impossible for nursing staff to
be blinded due to the differences in the
(Review)
Defloor 2005 (Continued)
types and varieties of turning regimens

Incomplete outcome data (attrition bias)
All outcomes
High risk Flow chart (fig 1, pp 41) showed patient
attrition across each of the 5 groups
Quotes:
“Of the 838 included patients, 761 patients
completed the 4-week study period.”
“The data on three patients were incom-
plete and it could not be guaranteed that
the protocol was strictly followed. Those
patients were excluded.”
Comment: ITT analysis not implemented
Selective reporting (reporting bias) Unclear risk Comment:
clinical outcomes were pre-
sented in Tables 2 and 3 of the paper. A
published protocol was not available. Mea-
sures used reflect aims of the intervention
and outcomes

Other bias Low risk None identified.
Moore 2011
Methods Study design: 2-armed cluster RCT with a 4-week (28-
day) follow-up period
obtained.
Sample size calculation: yes.
ITT analysis: yes, all participants randomised were analysed.
Participants Location: 12 hospital sites with long-term residents
in Ireland.
Mean age: not reported
gender and Braden scale
scores
Inclusion criteria:
1. In-patient in a long term geriatric facility.
2. Over 65 years of age.
3. At risk of PU development using the activity and mobility
components of Braden
scale
4. No PU at time of recruitment to study.

5. No medical condition that would preclude the use of
repositioning
6. Consent.
Exclusion criteria: patients with existing PU. Total of 57
patients excluded.
Interventions Aim(s): to examine whether repositioning using
30° tilt and 3-h repositioning reduces
the incidence of PU compared with usual care
Group 1: 30° tilt (n = 99 participants randomised, 99 analysed)
Repositioning by clinical staff using 30° tilt at night (left side,
back, right side, back) 3-
h overnight (8 pm-8 am). During the day, position changes
occurred 2-3h
Group 2: Usual care (n = 114 participants randomised, 99
analysed)
Usual care consisted of repositioning by clinical staff every 6-h
using the 90° tilt (left
(Review)

Moore 2011 (Continued)
side, back, right side, back) overnight, (8 pm-8 am). During the
day, position changes
occurred 2- to 3-h
Co-interventions : participants in both groups nursed as per
planned care regarding
nutritional regimens, toileting, changing of incontinence pads,
preparation for feeding,
and pressure redistribution devices on chairs. Repositioned
every 2- to 3-h during the
day.
Outcomes Primary outcome: incidence of all PUs during a 28-
day period
Quote: “The EPUAP pressure ulcer (PU) classification system,
ranging from non-blanch-
ing erythema of intact skin to full scale tissue destruction”
(Grades I to IV)
Quote: “A pressure ulcer was defined as localised areas of
tissue damage caused to skin
and underlying soft tissue caused by sustained mechanical
loading and shearing forces.”
Secondary outcomes:
• Risk assessment using Braden scale components to predict PU

development:
• Activity scores
• Mobility
• Economic outcomes: 1) mean daily nurse time for
repositioning, 2) nurse time
cost per patient, 3) cost of patient free of PU; and, 4) projected
annual cost
Validity of measures: inter-rater reliability not reported, but
quote: “The skin was then
assessed by the assigned key staff member, the clinical
manager, and the researcher. Agree-
ment between assessors was reached by comparing patients’
skin condition to images of
the EPUAP grading system.”
Time points: weekly follow-up over 4 weeks.
Notes PU risk status on study entry not stated by group.
Imbalances in cluster size.
ICC used in analysis and reported in text, Kish design effect
reported (pp 2639)
Risk of bias

bias)
Low risk Quote: “The clusters were the specific study
sites (n=12) and these were randomly al-
located to either the intervention group or
the control group.”
Quote: “The allocation was generated by
a statistician not directly involved with the
study and was determined using comput-
erised randomisation.”
Allocation concealment (selection bias) Low risk Quote: “The
allocation was generated by
a statistician not directly involved with the
study and was determined using comput-
erised randomisation.”
Quote: “ . . . allocation concealment was
achieved through use of distance randomi-
sation, meaning that the statistician, not
the researcher, controlled the randomisa-

(Review)
Moore 2011 (Continued)
tion sequence.”
(performance bias)
All outcomes
High risk Quote: ’The research design employed was
. . . open label, pragmatic“ (pp 2635)
Comment: Impossible for participants and
nurses to be blinded.
bias)
All outcomes
High risk Quote: “The skin was then assessed by
the assigned key staff member, the clinical

nurse manager and the researcher. Agree-
ment between assessors was achieved by
comparing the participant’s skin condition
to the images on the EPUAP grading sys-
tem.”
Comment: not stated, but most likely im-
possible. In an effort to minimise this form
of bias, several assessors were used, although
inter-rater reliability data were not pre-
sented
All outcomes
Low risk Quote: ”Data were analysed using SPPS
version 13 on an intention to treat (ITT)
basis.”
Flow chart (fig 3, pp 2639) showed pa-
tient attrition across the 2 groups, but same
number of patients who were randomised

were also analysed
Selective reporting (reporting bias) Low risk Comment: clinical
outcome, development
of PU was reported. A published protocol
was not available. Measures used reflect
aims of the intervention and outcome
Other bias Unclear risk 1. No table/data to show baseline
comparisons for each group and whether
PU risk was equivalent at study entry.
2. Economic data: The rationale for
changing between outcome measures of
“patient free of ulcer” and “pressure ulcer
avoided” is unclear. In this instance these
outcome measures would appear to be
equivalent since the number of patients
developing an ulcer and the number of
PU developing during the trial was the
same (n=16).

(Review)
Young 2004
Methods Study design: RCT (groupings for allocation not
reported) with a 24-h follow-up period
obtained
Sample size calculation: yes
ITT analysis: reported as ITT
Participants Location: medical ward of an acute general hospital
in Wales, UK
Mean age:
Group 1: 70.1 years (± 11.1)
Group 2: 70.5 years (± 14.7)
gender, weight, height
and Waterlow scale scores
Inclusion criteria:

1. Elderly patients
2. At risk of developing a pressure ulcer using Waterlow
3. Able to lie in 30° tilt position
4. Given informed consent
5. No existing pressure damage
6. Caucasian
Exclusion criteria: not stated
Interventions Aim(s): to examine the effects of the 30° tilt in
reducing non-blanchable erythema
Group 1 Intervention: n = 23 patients randomised, 18 analysed
Repositioning using 30° tilt (left side, back, right side, back) 2-
3-hourly overnight, 2-3-
hourly during the day
Sacrum and heels free from contact with support surface
Support mattress: alternating pressure mattress or low air loss
mattress
Group 2 Control: n = 23 patients randomised, 21 analysed.
90° lateral and supine positions 2-3-hourly overnight, 2-3-
hourly during the day
Support mattress: low air loss mattress.

Study date(s): April-July 1999
Outcomes Primary outcome: incidence of non-blanchable
erythema during a 24-h period
Quote: “NBE was used as a definition for pressure damage.”
Validity of measures: not reported
Time points: one
Notes
Risk of bias
bias)
Unclear risk Quote:“The randomisation was based on
block allocation“
Comment: No mention of how the blocks
were generated (i.e., computer or random
number table) or allocation ratio to each
block. Thus the process for electing the
blocks is unclear

(Review)
Young 2004 (Continued)
Allocation concealment (selection bias) Unclear risk Quote:
“specific intervention being se-
lected by sequential opening of sealed
opaque envelopes.”
Quote: “The ward staff were then handed
the sequentially numbered envelopes con-
taining randomisation code and the re-
searcher left the clinical area.”
Comment: This trial used blocked ran-
domization with group assignments being
revealed after recruitment, therefore there
is the potential to be able to predict future
assignments
Potential for interference with envelopes,

which are more susceptible to manipula-
tion than are other approaches.
(performance bias)
All outcomes
High risk Comment: not stated. Impossible for nurs-
ing staff to be blinded due the differences
in the intervention and usual care. Difficult
to conceal from participants and nursing
staff once patients were randomised
bias)
All outcomes
Low risk Quote: ”The next morning the researcher
was unaware of which method of reposi-
tioning had been used, therefore masking
the researcher to treatment allocation.”
Comment: researcher blinded totreatment

group
All outcomes
High risk Quote: “A total of 7 patients had no post
intervention data collected.”
Quote: “Statistical comparisons were made
on an intention-to-treat basis.”
“No post-intervention assessment of pres-
sure damage was performed on any of these
seven subjects.”
Comment: use of ITT stated, however,
participants were excluded from the analy-
sis if they discontinued the intervention or
were nursed on a foam mattress (pp 92)
Selective reporting (reporting bias) Low risk Comment: clinical
outcome, development
of PU was reported. A published protocol
was not available. Measures used reflect
aims of the intervention and outcome

Other bias Low risk Comments: None identified.
(Review)
Abbreviations
COI = conflict of interest
fig = figure
h = hour(s)
ICC = intra-cluster correlation coefficient
ITT = intention to treat analysis
NBE = non-blanchable erythema
pp = page(s)
PU = pressure ulcer
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Vanderwee 2007 Inclusion/Exclusion criteria: patients who had
a pre-existing grade 1 PU (i.e. non-blanchable erythema) were

included, and those who did not have non-blanchable erythema
(n = 1944) were excluded (fig 1, pp 63)
Abbreviations
fig = figure
PU = pressure ulcer
Characteristics of ongoing studies [ordered by study ID]
Bergstrom
Trial name or title TURN Study
Methods Cluster RCT
Participants 66 nursing short stay (< 7 days) and long stay (> 90
days) aged care residents 65 years and over
Interventions In-bed repositioning every 2 h compared to 3 h or
4 h and associated continence care
Outcomes Incidence of PU
Starting date Started in 2008 and completed in June 2011
Contact information Nancy Bergstrom
Theodore J and Mary E Trumble Professor of Aging Research
Associate Dean for Research (Interim)
School of Nursing
University of Texas Health Science Center-Houston

6901 Bertner Ave, 6.625
Houston 77030
(Review)
Bergstrom (Continued)
Notes Correspondence with N Bergstrom. Study has been
submitted for publication and is under review at the time
of writing this review
(Review)
D A T A A N D A N A L Y S E S
Comparison 1. 2h versus 3h repositioning on standard hospital
mattresses
Outcome or subgroup title
No. of

studies
No. of
participants Statistical method Effect size
1 Pressure ulcer risk (category 1 to
4)
1 121 Risk Ratio (M-H, Fixed, 95% CI) 0.90 [0.69, 1.16]
4)
Comparison 2. 4h versus 6h repositioning on viscoelastic foam
mattresses
No. of
studies
No. of
4)

4)
Comparison 3. 30o tilt 3-hourly overnight versus 90o tilt
overnight
No. of
studies
No. of
4)
2 252 Risk Ratio (M-H, Random, 95% CI) 0.62 [0.10, 3.97]
(Review)
standard hospital mattresses, Outcome 1

Pressure ulcer risk (category 1 to 4).
Review: Repositioning for pressure ulcer prevention in adults
Comparison: 1 2h versus 3h repositioning on standard hospital
mattresses
Outcome: 1 Pressure ulcer risk (category 1 to 4)
Study or subgroup 2h repositioning 3h repositioning Risk Ratio
Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Defloor 2005 39/63 40/58 100.0 % 0.90 [ 0.69, 1.16 ]
Total (95% CI) 63 58 100.0 % 0.90 [ 0.69, 1.16 ]
Total events: 39 (2h repositioning), 40 (3h repositioning)
Heterogeneity: not applicable
Test for overall effect: Z = 0.82 (P = 0.41)
Test for subgroup differences: Not applicable
0.01 0.1 1 10 100
Favours 2h repositioning Favours 3h repositioning
standard hospital mattresses, Outcome 2

Comparison: 1 2h versus 3h repositioning on standard hospital
mattresses
Weight Risk Ratio
Defloor 2005 9/63 14/58 100.0 % 0.59 [ 0.28, 1.26 ]
Total (95% CI) 63 58 100.0 % 0.59 [ 0.28, 1.26 ]
0.01 0.1 1 10 100
Favours 2h Favours 3h
(Review)

viscoelastic foam mattresses, Outcome 1
Comparison: 2 4h versus 6h repositioning on viscoelastic foam
mattresses
Weight Risk Ratio
Defloor 2005 30/66 39/63 100.0 % 0.73 [ 0.53, 1.02 ]
Total (95% CI) 66 63 100.0 % 0.73 [ 0.53, 1.02 ]
0.01 0.1 1 10 100
Favours 4h repositioning Favours 6h repositioning
viscoelastic foam mattresses, Outcome 2

Comparison: 2 4h versus 6h repositioning on viscoelastic foam
mattresses
Weight Risk Ratio
Defloor 2005 2/66 10/63 100.0 % 0.19 [ 0.04, 0.84 ]
Total (95% CI) 66 63 100.0 % 0.19 [ 0.04, 0.84 ]
0.01 0.1 1 10 100
Favours 4h Favours 6h
(Review)

Analysis 3.1. Comparison 3 30o tilt 3-hourly overnight versus
90o tilt overnight, Outcome 1 Pressure ulcer
risk (category 1 to 4).
Comparison: 3 30
o
tilt 3-hourly overnight versus 90
o
tilt overnight
Study or subgroup
30
o
tilt
3-hourly
overnight 90
o
tilt overnight Risk Ratio Weight Risk Ratio
n/N n/N
M-
H,Random,95%

CI
M-
H,Random,95%
CI
Moore 2011 3/99 13/114 54.7 % 0.27 [ 0.08, 0.91 ]
Young 2004 3/18 2/21 45.3 % 1.75 [ 0.33, 9.34 ]
Total (95% CI) 117 135 100.0 % 0.62 [ 0.10, 3.97 ]
Total events: 6 (30
o
tilt 3-hourly overnight), 15 (90
o
tilt overnight)
Heterogeneity: Tau2 = 1.24; Chi2 = 3.21, df = 1 (P = 0.07); I2
=69%
0.001 0.01 0.1 1 10 100 1000
Favours 30 tilt Favours 90 tilt
A P P E N D I C E S
Appendix 1. Ovid MEDLINE, Ovid EMBASE and EBSCO
CINAHL effectiveness search strategies

Ovid MEDLINE
1 exp Pressure Ulcer/ (5231)
2 (pressure adj (ulcer* or sore*)).tw. (4365)
3 (decubitus adj (ulcer* or sore*)).tw. (579)
4 (bedsore* or (bed adj sore*)).tw. (245)
5 or/1-4 (6546)
6 exp Posture/ (27564)
7 (reposition* or re-position*).tw. (6619)
8 position*.tw. (235791)
9 (turn* adj5 patient*).tw. (3591)
10 (turn* adj5 interval*).tw. (126)
11 (turn* adj5 frequen*).tw. (777)
12 turning.tw. (7625)
13 (body adj5 posture*).tw. (1092)
14 pressure relie*.tw. (417)
15 (mobilis* or mobiliz*).tw. (34978)
16 or/6-15 (301537)

(Review)
17 5 and 16 (834)
18 randomized controlled trial.pt. (240548)
19 controlled clinical trial.pt. (39492)
20 randomized.ab. (195665)
21 placebo.ab. (91366)
22 clinical trials as topic.sh. (79465)
23 randomly.ab. (134439)
24 trial.ti. (72586)
25 or/18-24 (543387)
26 (animals not (humans and animals)).sh. (1612439)
27 25 not 26 (494803)
28 17 and 27 (107)
Ovid EMBASE
1 exp Decubitus/ (9094)
2 (pressure adj (ulcer$ or sore$)).tw. (5623)

3 (decubitus adj (ulcer$ or sore$)).tw. (773)
4 (bedsore$ or (bed adj sore$)).tw. (415)
5 or/1-4 (10271)
6 exp patient positioning/ (10577)
7 (reposition$ or re-position$).tw. (9126)
8 position$.tw. (316430)
9 (turn$ adj5 patient$).tw. (5673)
10 (turn$ adj5 interval$).tw. (168)
11 (turn$ adj5 frequen$).tw. (1215)
12 turning.tw. (10505)
13 (body adj5 posture$).tw. (1519)
14 or/6-13 (344598)
15 5 and 14 (1057)
16 Randomized controlled trials/ (24734)
17 Single-Blind Method/ (15386)
18 Double-Blind Method/ (85329)
19 Crossover Procedure/ (31526)
20 (random$ or factorial$ or crossover$ or cross over$ or cross-

over$ or placebo$ or assign$ or allocat$ or volunteer$).ti,ab.
(930632)
21 (doubl$ adj blind$).ti,ab. (89452)
22 (singl$ adj blind$).ti,ab. (9568)
23 or/16-22 (964333)
24 animal/ (717007)
25 human/ (8542238)
26 24 not 25 (478486)
27 23 not 26 (932575)
28 15 and 27 (175)
EBSCO CINAHL
S16 S5 and S15
S15 S6 or S7 or S8 or S9 or S10 or S11 or S12 or S13 or S14
S14 TI body N5 posture* or AB body N5 posture*
S13 TI turning or AB turning
S12 TI turn* N5 frequen* or AB turn* N5 frequen*
S11 TI turn* N5 interval* or AB turn* N5 interval*
S10 TI turn* N5 patient* or AB turn* N5 patient*
S9 TI position* or AB position*

S8 TI ( reposition* or re-position* ) or AB ( reposition* or re-
position* )
S7 (MH “Patient Positioning+”)
S6 (MH “Posture+”)
(Review)
S5 S1 or S2 or S3 or S4
S4 TI ( bedsore or bed sore ) or AB ( bedsore or bed sore )
S3 TI ( pressure ulcer* or pressure sore* ) or AB ( pressure
ulcer* or pressure sore* )
S2 TI decubitus or AB decubitus
S1 (MH “Pressure Ulcer”)
Appendix 2. Ovid MEDLINE economics search strategy
1 exp Pressure Ulcer/
2 (pressure adj (ulcer* or sore*)).tw.
3 (decubitus adj (ulcer* or sore*)).tw.
4 (bedsore* or (bed adj sore*)).tw.

5 or/1-4
6 exp Posture/
7 (reposition* or re-position*).tw.
8 position*.tw.
9 (turn* adj5 patient*).tw.
10 (turn* adj5 interval*).tw.
11 (turn* adj5 frequen*).tw.
12 turning.tw.
13 (body adj5 posture*).tw.
14 pressure relie*.tw.
15 (mobilis* or mobiliz*).tw.
16 or/6-15
17 5 and 16
18 economics/
19 exp “costs and cost analysis”/
20 economics, dental/
21 exp “economics, hospital”/
22 economics, medical/

23 economics, nursing/
24 economics, pharmaceutical/
25 (economic* or cost or costs or costly or costing or price or
prices or pricing or pharmacoeconomic*).ti,ab.
26 (expenditure* not energy).ti,ab.
27 value for money.ti,ab.
28 budget*.ti,ab.
29 or/18-28
30 ((energy or oxygen) adj cost).ti,ab.
31 (metabolic adj cost).ti,ab.
32 ((energy or oxygen) adj expenditure).ti,ab.
33 or/30-32
34 29 not 33
35 letter.pt.
36 editorial.pt.
37 historical article.pt.
38 or/35-37
39 34 not 38

40 Animals/
41 Humans/
42 40 not (40 and 41)
43 39 not 42
44 17 and 43
(Review)
Appendix 3. Risk of bias criteria
1. Was the allocation sequence adequately generated?
Low risk of bias
The investigators describe a random component in the sequence
generation process such as: referring to a random number table;
using
a computer random number generator; coin tossing; shuffling
cards or envelopes; throwing dice; drawing of lots.
High risk of bias
The investigators describe a non-random component in the
sequence generation process. Usually, the description would
involve some

systematic, non-random approach, for example: sequence
generated by odd or even date of birth; sequence generated by
some rule
based on date (or day) of admission; sequence generated by
some rule based on hospital or clinic record number.
Unclear
Insufficient information about the sequence generation process
to permit judgment of low or high risk of bias.
2. Was the treatment allocation adequately concealed?
Low risk of bias
Participants and investigators enrolling participants could not
foresee assignment because one of the following, or an
equivalent
method, was used to conceal allocation: central allocation
(including telephone, web-based and pharmacy-controlled
randomisation);
sequentially-numbered drug containers of identical appearance;
sequentially-numbered, opaque, sealed envelopes.
High risk of bias
Participants or investigators enrolling participants could
possibly foresee assignments and thus introduce selection bias,
such as allocation
based on: using an open random allocation schedule (e.g. a list
of random numbers); assignment envelopes were used without

appropriate
safeguards (e.g. if envelopes were unsealed or non-opaque or
not sequentially numbered); alternation or rotation; date of
birth; case
record number; any other explicitly unconcealed procedure.
Unclear
Insufficient information to permit judgment of low or high risk
of bias. This is usually the case if the method of concealment is
not
described or not described in sufficient detail to allow a definite
judgment, for example if the use of assignment envelopes is
described,
but it remains unclear whether envelopes were sequentially
numbered, opaque and sealed.
3. Blinding - was knowledge of the allocated interventions
adequately prevented during the study?
Low risk of bias
Any one of the following.
• No blinding, but the review authors judge that the outcome
and the outcome measurement were not likely to be influenced
by
lack of blinding.
• Blinding of participants and key study personnel ensured, and
unlikely that the blinding could have been broken.

• Either participants or some key study personnel were not
blinded, but outcome assessment was blinded and the non-
blinding of
others unlikely to introduce bias.
(Review)
High risk of bias
• No blinding or incomplete blinding, and the outcome or
outcome measurement is likely to be influenced by lack of
blinding.
• Blinding of key study participants and personnel attempted,
but likely that the blinding could have been broken.
• Either participants or some key study personnel were not
blinded, and the non-blinding of others likely to introduce bias.
Unclear
Either of the following.
• Insufficient information to permit judgement of low or high
risk of bias.

• The study did not address this outcome.
4. Were incomplete outcome data adequately addressed?
Low risk of bias
• No missing outcome data.
• Reasons for missing outcome data unlikely to be related to
true outcome (for survival data, censoring unlikely to be
introducing
bias).
• Missing outcome data balanced in numbers across intervention
groups, with similar reasons for missing data across groups.
• For dichotomous outcome data, the proportion of missing
outcomes compared with observed event risk not enough to have
a
clinically relevant impact on the intervention effect estimate.
• For continuous outcome data, plausible effect size (difference
in means or standardised difference in means) among missing
outcomes not enough to have a clinically relevant impact on
observed effect size.
• Missing data have been imputed using appropriate methods.
High risk of bias

• Reason for missing outcome data likely to be related to true
outcome, with either imbalance in numbers or reasons for
missing
data across intervention groups.
• For dichotomous outcome data, the proportion of missing
outcomes compared with observed event risk enough to induce
clinically relevant bias in intervention effect estimate.
• For continuous outcome data, plausible effect size (difference
in means or standardised difference in means) among missing
outcomes enough to induce clinically relevant bias in observed
effect size.
• ‘As-treated’ analysis done with substantial departure of the
intervention received from that assigned at randomisation.
• Potentially inappropriate application of simple imputation.
Unclear
• Insufficient reporting of attrition/exclusions to permit
judgement of low or high risk of bias (e.g. number randomised
not stated,
no reasons for missing data provided).
• The study did not address this outcome.
5. Are reports of the study free of suggestion of selective

outcome reporting?
Low risk of bias
(Review)
• The study protocol is available and all of the study’s pre-
specified (primary and secondary) outcomes that are of interest
in the
review have been reported in the pre-specified way.
• The study protocol is not available, but it is clear that the
published reports include all expected outcomes, including
those that
were pre-specified (convincing text of this nature may be
uncommon).
High risk of bias
• Not all of the study’s pre-specified primary outcomes have
been reported.
• One or more primary outcomes are reported using
measurements, analysis methods or subsets of the data (e.g.

subscales) that
were not pre-specified.
• One or more reported primary outcomes were not pre-specified
(unless clear justification for their reporting is provided, such
as
an unexpected adverse effect).
• One or more outcomes of interest in the review are reported
incompletely so that they cannot be entered in a meta-analysis.
• The study report fails to include results for a key outcome that
would be expected to have been reported for such a study.
Unclear
Insufficient information to permit judgment of low or high risk
of bias. It is likely that the majority of studies will fall into this
category.
6. Other sources of potential bias
Low risk of bias
The study appears to be free of other sources of bias.
High risk of bias
There is at least one important risk of bias. For example, the
study:
• had a potential source of bias related to the specific study
design used; or

• has been claimed to have been fraudulent; or
• had some other problem.
Unclear
There may be a risk of bias, but there is either:
• insufficient information to assess whether an important risk of
bias exists; or
• insufficient rationale or evidence that an identified problem
will introduce bias.
W H A T ’ S N E W
Last assessed as up-to-date: 6 September 2013.
(Review)
Date Event Description
24 February 2015 Amended Contact details updated.
C O N T R I B U T I O N S O F A U T H O R S
Wendy Chaboyer: conceived and designed the review, checked
the quality of data extraction, analysed or interpreted data,
performed

part of data analysis or interpretation, performed part of the
writing or editing, made an intellectual contribution to, secured
funding
for and approved the final version of the review prior to
submission.
Brigid Gillespie: conceived, designed and co-ordinated the
review. Extracted data, undertook quality assessment, analysed
or interpreted
data, performed part of data analysis or interpretation,
performed statistical analysis and completed the first draft of
the review. Performed
part of writing or editing, made an intellectual contribution to
and approved final review prior to submission. Wrote to study
authors,
experts, and companies and acted as guarantor of the review.
Elizabeth McInnes: designed the review, extracted data,
undertook quality assessment, analysed or interpreted data,
performed part
of data analysis or interpretation, performed part of writing or
editing and made an intellectual contribution to the review.
Wrote to
study authors, experts, and companies, performed previous work
that was the foundation of the current review and approved the
final
review prior to submission.
Bridie Kent: analysed or interpreted data, performed part of

data analysis or interpretation, performed part of writing or
editing, made
an intellectual contribution and approved the final review prior
to submission.
Jenny Whitty: analysed or interpreted data, performed part of
editing,
made an intellectual contribution, performed economic analysis
and approved the final review prior to submission.
Lukman Thalib: analysed or interpreted data, performed part of
editing,
made an intellectual contribution and approved the final review
prior to submission.
Contributions of editorial base
Nicky Cullum: advised on methodology, interpretation and
protocol content, edited and re-wrote sections of the final
review including
re-entering and analysing data, approved the final review prior
to publication.
Sally Bell-Syer: co-ordinated the editorial process, advised on
methodology, interpretation and content, edited the protocol.
Jo Dumville: checked the re-analysis of the data and checked
the final version for publication after NC.
Ruth Foxlee: designed the search strategy and edited the search

methods section.
D E C L A R A T I O N S O F I N T E R E S T
Dr Brigid Gillespie; Dr Wendy Chaboyer; Dr Elizabeth
McInnes; Dr Bridie Kent; Dr Jennifer Whitty and Dr Lukman
Thalib have
no conflicts of interest to declare.
(Review)
S O U R C E S O F S U P P O R T
Internal sources
• NHMRC, Australia.
The NHMRC provided funding for this review from its Centre
of Research Excellence Scheme, which funds one or more of the
authors
• Jennifer Whitty received a Research Fellowship funded by the
Queensland Government Department of Employment, Economic
Development and Innovation, Queensland Health and Griffith
University, Australia.
External sources

• The National Institute from Health Research (NIHR) is the
sole funder of the Cochrane Wounds Group, UK.
D I F F E R E N C E S B E T W E E N P R O T O C O L A N D
R E V I E W
We had originally planned to undertake subgroup analyses
based on type of setting (long-term and acute care) and the type
of patient.
Although one study was conducted in an acute care setting, the
others were set in long-term care facilities, and all with
geriatric patients.
We have instead, undertaken a subgroup analysis with regard to
tilt regimes (i.e. 30o versus 90o tilt) in relation to participants
who
developed a grade 1 pressure ulcer.
I N D E X T E R M S
Medical Subject Headings (MeSH)
Beds; Cost-Benefit Analysis; Patient Positioning [economics;
∗ methods]; Pressure Ulcer [∗ prevention & control];
Randomized Con-
trolled Trials as Topic; Time Factors
MeSH check words
Adult; Aged; Humans; Middle Aged

(Review)
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.

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