The Use of Turning and Repositioning Versus Pressure Redistributing Support Surfaces in the

Prevention of Pressure Ulcers

Rachel M Collins, Ayana A Kleckner, and Brianna P Sparks

Cedarville University School of Nursing

 Abstract

Currently, 1,300 new adults are been reported each and every month (Source NHS

Digital) and in 2017/2018 about 200,000 people were been reported with new ulcer (Guest et al

2017). Treating pressure ulcer in United Kingdom can cost from £1,214 to £14,108 depending on

the category. The overall cost for treating pressure ulcer every day for the NHS is more than £1.4

million (Guest et al 2017). In this review the PICO question is “The patients that are critically ill

in the hospital, how much of the occurrence of pressure ulcers can be prevent by T&R (q2h to

q4h) as compared to PRSS?” To conduct this review, many different articles were been found and

each of them are rated as (n=7) for excellent, (n=2) for good, and (n=1) for fair. The Appendix A

will show all the relevant articles that are used for the review along with their critical appraisal.

The articles that were found suggest that there are some considerable statistically evidence about

the use of one intervention over the other has more effectiveness (PRSS Vs T&R (q2h to q4h))

(Bergstrom, 2013; Chou, 2013; Huang, 2013; Manzano, 2013; Manzano, 2014; Rich, 2011b;

Smith, 2013). There are some articles that suggest that, the chance of preventing PU is increased

when both the preventing measures are used together (Chou, 2013; Rich, 2011a; Smith, 2013).

Key words: Turning and repositioning, preventing PU, PU, mattresses that alternate pressure
 The Use of T&R Vs PRSS in Preventing PU

Pressure ulcers (PU) affect about 1,300 new adults every month in the United Kingdom

alone (Source NHS Digital). PU can be described as the area were decentralized damage to the

skin as well as to the tissues that are underlying over the prominence of the bone, shear and

pressure are combined (Chou, 2013, p. 28). Currently, in the United Kingdom, the everyday

treatment cost for PU is more than £1.4 million and the range of treatment per PU is about £1,214

to £14,108 (Guest et al 2017). For the patients having pressure ulcer acquiring stage 3 or 4,

Medicare reimbursements while they are staying inpatient are no longer been received the

hospitals since October of 2008 (Zaratkiewica et al., 2010). These kinds of restrictions regarding

to Medicare reimbursements are also been adopted by the private insurers (Mattie & Webster,

2008). There are different kinds of methods for preventing the occurrence of PU in the light of

recent researches. The PICO question for this review is “The patients that are critically ill in the

hospital, how much of the occurrence of pressure ulcers can be prevent by T&R (q2h to q4h) as

compared to PRSS?”

P: Patients those are seriously ill

I: T&R (q 2-4 hours)

C: PRSS

O: Preventing PU

This review aims to assess about which of these interventions are the best to prevent PU in

patients that are critically ill.

Methods
Search Strategy

The process of searching the research studies was conducted using the following

databases which include UpToDate, OneSearch by Cedarville Library, PubMed and EBSCOhost

by Cedarville Library. The terms which were included for conducting the search are mattresses

that alternate pressure, PU, repositioning and turning, preventing PU.

Inclusion and Exclusion

The research studies that were selected were 20, because they had relevance with our topic

which is PU. Cedarville library database was used to find all these articles. Here the process of

narrowing down the list starts, the list of research studies was narrowed up to 10 research studies

that were more specifically relevant with the topic of PRSS and T&R. Out of them, 7 research

studies were excellent (LOE 1-3), 2 of the research studies were good (LOE 4-5), and 1 research

study was fair (LOE 6-7). Out of those 10 articles, only two of them were used for explaining and

defining the concept, rest of them were excluded from the process. Those 8 articles were excluded

from the research process due to the sample size which was small (n=1), they had zero relevance

with the topic (n=6), and from the current date they were over 5 years date (n=1).

Interview

An interview was conducted for this review, from an RN, who works in the

cardiovascular unit, at St John & St Elizabeth Hospital. She stated that PRSSs were used for the

patient’s care as a standard, specifically a mattress that alters air pressure. For the usage of

PRSSs, T&R two hours were employed. For the patients, who had higher risk of breaking down

their skin, turning and repositioning was preponderantly used according to Braden (RN at St

John & St Elizabeth Hospital, personal communication, Oct. 20, 2014).

Critical Appraisal

For each and every article, a critical appraisal was completed (See Appendix A). For

these ten articles, the appraisal contains four emerged recurrent themes. These themes revolve

around the usage of PRSS as a single intervention, the usage of T&R alone, or implementing

both of the intervention to prevent PU better, and the presence of a gap.

Results

Turning and Repositioning

 First finding of this review states that there was some considerable evidence that for (q2h

to q4h) of T&R is effective in preventing PU. When the frequency of T&R is increased (q2h vs.

q4h) no significant signs of reduction in PU were found (Manzano et al, 2014). According to

another article, which stated that no considerable differences in the reduction of PU was been

noted by the different intervals of T&R (q2, 3, & 4h) (Bergstrom, 2013).

Repositioning frequently was not found useful in reducing PU (Rich et al. 2011). However, the

need of frequent manual repositioning is not over. For determining the best schedule for

repositioning (i.e. q 2 to 4 h) requires additional studies. Since the question arises “How effective

is T&R in the prevention of PU?” To validate the findings requires further more researches, in

order to tell about the importance of repositioning the patients that have a higher chance in

developing risk.

Pressure Redistributing Support Surfaces

According to the second finding of this review which states that there were considerable

evidence related to the use of PRSS in preventing pressure ulcers. With the use of PRSS, the rate

of PU was lowered (Rich et al. 2011b). Even though PRSS is effective in decreasing PU, but still

there are no considerable evidence related to the implementation of PRSS on regular basis for

reducing the PU at a higher rate (Huang et al., 2013). The measures for prevention were very

conflicting, although PRSS can be used as a protective factor against PU (Manzano, 2012).

Hence this finding is not acceptable as a considerable one. Still are little evidence regarding to

PRSS’s effectiveness along with some other interventions such as heel bots, wheelchair cushions

and nutritional supplements (Chou et al, 2013). However, some considerable evidence exist that

shows moderate amount of healing in adults having PU by using PRSS (Smith et al, 2103).

Continuous Bedside Pressure Mattresses (CBPM)

CBPM can never directly relate to the decrease in rate of hospitals that acquire PU

(Behrendt et al, 2014). For validating the finding, more confirmable evidences are been required,
even though CBPM is suggested as an effective tool in preventing PU. For determining the best

schedule for repositioning, more studies are been needed for patients who have a higher risk of

developing PU.

Compare and Contrast T&R and PRSS

Gap: To prove that one intervention is better than the other, more evidences and proves

are been required to fulfil those gaps that still exist. Since there is an absences of heel PU,

however, these finding are not been generalized due to the short evaluation period and small

sample size (Masterson & Younger, 2014). For proving its efficacy, more data is been required.

Evidence to support the routine of PRSS is been required for the postoperative setting (Huang et

al, 2013). Besides the finding which states about the effectiveness of PRSS in decreasing the PU

that are related to surgery, but still more relevant data is been required. More Robust studies are

required for testing the hypothesis further regarding to the mattresses that alternate air pressure as

compared to overlays that alternate air pressure are more effective (Manzano et al, 2012). There

is still a gap in the evidence, because of smaller sample of participants observed related to bed

bound (Rich et al, 2011b). No distinction was found in PU’s rate related to different use of PRSS,

within these participants. For showing the effectiveness of using the standard care as compared

with use of PRSS, still more researches are required (Chou et al & Smith et al, 2013).

Effective together: The last finding of this review was that the T&R is coupled with

PRSS for preventing PU more effectively. For the personnel that are related to medical, the PRSS

serves as a cue in turning the patients by reposting them with increased frequency (Rich et al,

2011a). According to these findings the main reason behind the usage of both the preventive

measures combined together. When T&R and PRSS are combined together can produce more

effective results rather than using PRSS alone (Chou et al, 2013). There are some moderate

evidence that show that complete healing of PU in adults can be improved by using PRSS and

T&R are combined with other preventive measures such as electrical stimulation, protein
 supplementation and radiant heat dressing (Smith et al, 2013).

Discussion

The selection of this review was made on the basis of highlighting the importance of the

community’s health and care and for promoting the quality of care guide by the help of the

practices that are based on evidences using the Iowa Model. For providing support to this review

sufficient amount of data was been gathered while adopting the settings of healthcare regarding

to the intervention (Titler et al, 2001).

Four separate findings were discovered in result of this review’s critical appraisals.

According to the first finding that shows the considerable evidences about the effectiveness of

using T&R (q2h to q4h) for preventing PU (Bergstrom, 2013; Manzano, 2014; Rich, 2011b).

According to the second finding which states about the considerable evidences regarding to the

usage of PRSS for preventing PU was effective (Chou, 2013; Huang, 2013; Manzano, 2013;

Rich, 2011b; Smith, 2013). According to other finding that was related to the gaps that are still

exist in between the evidences and researches for proving that one preventing measure is better

than the other (Behrendt, 2014; Chou, 2013; Huang, 2013; Manzano, 2013; Manzano, 2014;

Masterson & Younger, 2014; Rich, 2011b; Smith, 2013). The last finding is all about using both

the preventing measures together for increasing the effectiveness rather than using them

separately such as T&R coupled with PRSS (Chou, 2013; Rich, 2011a; Smith, 2013).

Recommendation Based on Evidences

According to the recommendations given by the researchers, that are based on gathered

facts and information that are used for this process, are stated as T&R for every 2 hour is when

combined with PRSS produces the most effective results in preventing PU (Chou, 2013; Rich,

2011a; Smith, 2013).

After all these studies, still gaps in between exists, to fill the gaps, more studies are been

required for proving the efficacy regarding to these recommendations, along with the usage of all
other alternatives to the preventing measures (Behrendt, 2014; Chou, 2013; Huang, 2013;

Manzano, 2013; Manzano, 2014; Masterson & Younger, 2014; Rich, 2011b;Smith, 2013).

Limitations

During the review was conducted, different intervention could not been discovered,

which is the one of the limitations of this review. Other comparative measures are not focused

in this review, even though researchers have identified them. Use of hygiene in prevention,

nutritional and protein supplements, electrical stimulation, radiating heat dressing and last the

surgery; these are the few of the other interventions that need further investigation (Smith

2013).

The last limitation that this review has is the lack of generalisation of the population of

patient. Finding of this review were non-generalised, because the population of the elder those

who were ill along with fractured hips very limited, errors were been committed while this study

was being conducted, and the nature of the review was based on observations (Rich et al. 2011b).

Since in this review only the patients those who were critically ill were been focused only, so the

result of this review cannot be generalised due to the failure of not focusing on the patients those

who were at PU’s risk.

Conclusion

Conclusion of this review is that, to find out which intervention is more superior than the

other requires further researches, in order to give evidence that are considerable. According to the

researches, greater impact in preventing PU occurs when both the intervention are been coupled

together (T&R and PRSS) as compared to any intervention used alone (Chou, 2013; Rich, 2011a;

Smith, 2013). The review’s limitation is, just focusing on PRSS as a comparison. Remember that

this comparative intervention is not just the only one.

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 Appendix 1
Critical Appraisal of Literature

Author(s)&Year Purpose Sample Treatment Results LOE

Behrendt… To test the About 422 pts were For turning pts q2h to CBPM group: 2 of 213 pts 3
Siddiqui (2014) effectiveness of admitted in the MICU at match q2h protocol, (0.9%) had HAPUs--stage 2
using CBPM in Henry Ford Hospital. CBPM developed a PUs
order to reduce PU Which were base on the programme to notify the Control group: 10 of 209
in the associated availability of beds, On staff for the control group (4.8%) had HAPUs--stage 2
hospitals For Barden scale of PUs
treating the medical assessment, 18 or less
ICU (MICU) very score for the risk of
PU
Horn et al., (2013) For determining the There were 942 willing While the pts were in bed In the PU, no considerable 2
efficacy schedule for residents who had no they were repositioned. difference related to
three repositioning PU having ages around According to the repositioning group (2, 3, or 4
of PU prevention in 65 and older, but they stratification of risk the h), was found. Even there was
the residents of still were at a risk that pts were randomly no considerable difference in
nursing home (NH) ranges from moderate assigned for being between the PU groups of high
(13-14) to high (10-12) repositioned for 3 wks and and moderate risk. When
related to the developing q2, 3, or 4h. Skin was mattresses of foam’s that are of
PUs on Braden Scale. assessed weekly by high-density can redistribute
Pts also had limited blinded assessors. Within pressure effectively, then the
mobility and were using 30 mins of the scheduled frequency of repositioning can
mattresses of high- time repositioning was be reduced which might help
density foam. completed. Each episode in without increasing PU..
has documentation.

Bougatsos et al., For reviewing the The observational and N/A The static of surface support were 1
(2013) comparative utility of trails were more advanced and also are more
clinic for instruments randomized on the effective than the standard
for risk assessment of effects of usage of mattresses of the hospital for
PU and the harms and clinical risk preventing PU that is prevailing in
the benefits of these assessment outcomes the pts of higher-risk. The
preventing measures. and trials that are evidence was limited regarding to
randomized on the the competitiveness and
clinical outcomes of effectiveness of surfaces that are
preventing measures. dynamic and evidence were
limited on other preventing
 measures.
Chen and Xu-Juan For the assessment of For meta-analysis, 10 N/A The incidence of the surgery can 1
(2013) preventing impact that studies provided be decreased effectively by using
are relative to PRSS sufficient amount of PRS, while still there is no
Vs the standard data for the inclusion considerable evidence for the
mattresses of the criteria. routine of intra-operation of these
hospitals on the surfaces.
incidence of PU
surgery.
Colmenero et al., To know about the Only 221pts were the Two groups were been In 18.67 cases, PU of Stage 2 or 3
(2013) effectiveness of ventilated made in which the pts greater was occurred per 1000
mattresses that alter air mechanically for 24 were been divided. days of the stay in the ICU for the
pressure vs. The hours on non-invasive APAM was been used overlay group and for the group
overlays that prevent or invasive vent. by one of the group, that used APAM, the cases per
pts of PU who are while overlay was 1000 days were 12.41during the
ventilated been used by the other. stay in the ICU.
mechanically. Standard protocol was
been used by both the
groups for T&R q4h.

Manzano… For comparing Adults who were On the APAM, pts were At the least PU of stage 2 was 2
Fernández- repositioning effects on seriously ill are 329 been placed and then developed in 10.3% of the pts
Mondéjar (2014) preventing PU q2 or 4h who had no PU at the they were divided into who turned q2h vs the pts who
development in pts time of admission in two groups. One group turned q4h were 13.4%. No
who are mechanically the ICU. They were was turned q2h while considerable difference between
ventilated in the ICU. invasively ventilated the other was turned the two groups was found.
mechanically for at q4h
least 24h
Masterson and For determining either There were 82 pts for Using Nimbus 4 vs During the evaluation period no 7
Younger (2014) the Wound value a period of 10 wk. other measures pts was cared of using mattress
technology along with Out which 24 were at including offloading the Nimbus 4 for developing ulcer
Nimbus 4for the heel level 3and the heel of heel.
section would provide remaining were at
effective relief in heel level 2.
by offloading pressure.

Margolis et al., Ascertaining whether 269 patients with 65 Often manual Pts often repositioned (12xper 4
(2011a) there is link of manual or above age with hip repositioning day or q 2 h) almost certainly
repositioning q 2 h fracture surgery compared with those
with lower PUs in fracture between repositioned less often to
elderly hip fracture pts 2004-2007 in any develop PUs at baseline
 bounded to bed; nine healthcare (p=0.006), along with more
Ascertaining obedience organisations probable to have high level of
with recommendations associated with nutrition-associated complicates
about manual Baltimore Hip risk (p=0.06), and lower score
repositioning Studies network, who (p=0.07) on the Braden scale
were adjudged bed-
bound by the Braden
scale

Shardell et al., Evaluating the 650 older people were Pts get standard of care Whether Stage II or higher, I
(2011b) relationship between recruited aged 65 and as per their Braden scale the research nurse noted Pus
using PRSS and above experiencing score. There were some on study visits at 4.5%, 3.6%
incident PUs in aged hip fracture surgery pts positioned on a and 4.2% of visits with
patients having hip powered PRSS, non- powered PRSS, non-powered
fracture powered PRSS, and on and with no PRSS
no PRSS. respectively.
Hickam et al., Examine the Randomized trials N/A Moderate-strength evidence 1
(2013) comparative and comparative shows that healing of PU in
effectiveness and observational studies adults is improved with the
harms of therapies and of treatment for PU in use of air-fluidized beds,
approaches to treating adults and protein supplementation,
PU. noncomparative radiant heat dressing, and
intervention series for electrical stimulation.
surgical interventions
and evaluation of
harms. n=174