The Conundrum of Turning/Repositioning Frequency, Sleep... : Advances in Skin & Wound Care

The Conundrum of Turning/Repositioning Frequency, Sleep... : Advances in Skin & Wound Care

A pressure injury (PI), formerly known as a pressure ulcer, is “localized damage to the skin and underlying soft tissue usually over a bony prominence or related to medical or other devices.” Pressure injuries are traditionally staged, and the stages are often correlated with the degree of injury and related treatment plans. The primary risk factors for PI development are classified into two categories. The first category is mechanical boundary condition, which includes magnitude and time duration of the mechanical load, as well as the type of mechanical load (shear, compression, or friction). The second category is susceptibility and tolerance of the individual, which is related to bony prominences, tissue morphology and mechanical tissue properties, capacity of tissue for repair, thermal properties of tissue, and transport ability (Figure).

Although PIs result from a variety of factors, the mechanical load between the forces of an individual’s body weight and a solid surface (ie, mattress, chair cushion) is important in each instance. Tissue damage results from intense and/or prolonged pressure leading to tissue deformation, obstruction of capillary blood flow, and/or tissue damage from shear. Skin and deeper tissue deformations precipitated by the body’s weight occur when the deformation is sustained for a long period, resulting in a PI. Sustained loading refers to a duration of minutes to hours or days during which the body is in contact with a surface. Tissue deformation and damage depend on both the magnitude of the load and the duration of time. The higher the load, the shorter the time period in which damage can occur; lighter loads can still cause damage over a longer period. Different types of tissue respond differently to sustained deformations from pressure; muscle tissue, for example, is particularly sensitive to pressure. Tissues can also be affected by age, health status, comorbidities, perfusion, condition of the soft tissue, and microclimate.

Pressure injuries are common, painful, and costly. Worldwide, PI prevalence across healthcare settings ranges from 0% to 72.5%, and the mean incidence is 6.3%. A 2018 systematic review reported a 14.8% prevalence in acute care and 3% to 30% prevalence in long-term care. Costs for preventing and treating PIs are high, with the yearly US cost for PI care estimated to be $11.6 billion between 2000 and 2012. A 2019 study on the costs of hospital-acquired PIs estimated the annual US cost to be $26.8 billion; with inflation, this could approach $30 billion. Common costs include additional days of hospitalization, dressings and ointments, staff time for prevention and treatment, and support surfaces.

To meet the goal of preventing and/or minimizing skin breakdown, individuals who are immobile or have limited mobility need to be repositioned periodically, particularly throughout the night. Unfortunately, the required frequent night awakenings interrupt sleep cycles and can have other undesirable consequences. Less frequent turning on a specialty mattress, such as a high-density foam mattress, might increase sleep and improve quality of life for residents/patients. In a literature review, Marklew found no difference in PI incidence when patients were turned at 3- or 4-hour intervals versus every 2 hours. One intervention to potentially limit the frequency of waking individuals for repositioning is a support surface that minimizes and redistributes pressure.

In this article, the authors focus on periodic turning and repositioning (T&R) to prevent and treat skin breakdown and how this care intervention impacts individuals’ sleep and well-being. In addition, the impacts that specialized support surfaces/mattresses may have on PI development, sleep, and repositioning are also discussed.

In April 2020, the authors searched PubMed and CINAHL using the search strategies detailed in Table 1. Five authors assessed the articles for relevance and further scanned the reference lists of the located studies to identify additional studies. Included articles were quantitative and qualitative clinical trials, systematic reviews, and meta-analyses written in English published between 2005 and 2020 that included inpatient hospital patients and patients in long-term care. Certainty of the evidence was assessed, and articles studying mechanically ventilated patients, COVID-related positioning, positioning for apnea, and positioning of children were excluded. The search was updated in August 2021, including articles from 2020 to 2021. Because this was a scoping review conducted to determine the coverage of this topic in the literature of medicine and allied health, levels of evidence for the individual studies were not ascertained.

Considered a basic care intervention, T&R consists of moving or changing the position of an individual to relieve or redistribute pressure and enhance comfort. The goal is to minimize the duration and magnitude of pressure in vulnerable body areas, particularly over bony prominences, to reduce tissue deformation, enhance tissue oxygenation, improve circulation, and prevent tissue breakdown. Regardless of patient setting, current recommendations for those with limited mobility are for individualized, frequent repositioning.

Discussions related to the role of T&R have occurred in the literature since at least 1848. Frequent repositioning to prevent skin breakdown has been recommended for nearly a century, yet timing or frequency of this care intervention remains debatable (Table 2). Nearly 70 years ago, Kosiak reported on the inverse relationship between intensity of “pressure” and “duration” as two key variables in tissue viability. He modified the repositioning recommendation to advocate for repositioning every 2 hours to prevent skin breakdown. However, his recommendation was based on studies of tissue interface pressure measurements in animals and healthy volunteers and thus had limited generalizability. Reswick and Rogers advanced this research with human participants but only assessed superficial skin damage. Thus, the practice of routine T&R was based on primarily observational studies (rather than randomized controlled trials [RCTs]) of animals and healthy participants who were not necessarily at risk for PI, as well as clinicians’ expert opinion.

Up until the International Pressure Ulcer Guidelines of 2014, common practice was to reposition individuals at risk for PI development at 2-hour intervals, 24 hours per day, 7 days per week. This practice remains debatable, with limited and mixed evidence as PIs continue to develop across healthcare settings. This care intervention is largely based on tradition rather than research. In addition, this “one size fits all” practice is “no longer considered appropriate.” Two reports noted that although clinical recommendations have been quite consistent in recommending a 2-hour T&R schedule for PI prevention and treatment, “the optimal technique for repositioning has not been completely elucidated.” In fact, the 2019 International Guidelines stated “reposition all individuals with or at risk of PIs on an individualized schedule, unless contraindicated,” or base the T&R frequency on the patient’s level of activity and individual ability to independently reposition. No time schedule was recommended. Having no specific T&R frequency in the recommendation does assume that nursing staff understand how to evaluate and individualize T&R frequency for an individual in relation to risk, support surface, and so on.

Clark examined the evidence on repositioning for PI prevention and concluded that little evidence exists in support of 2-hour repositioning for all. Two Belgian studies examined repositioning schedules for older adults on viscoelastic foam (VEF) surfaces who were repositioned every 2 to 6 hours. Defloor et al examined four different repositioning regimens over 28 days in 11 Belgian nursing homes, studying 838 older adults: 2- and 3-hourly on a standard institutional mattress and 4- and 6-hourly on VEF mattresses. The researchers found the incidence of PIs stage 2 and greater was 3% in the 4-hourly group, compared with 14.3% in the 2-hourly group, 24.1% in the 3-hourly group, and 15.9% in the 6-hourly group. Although 4-hour turning on a VEF mattress resulted in a significant reduction in PIs, a later Cochrane systematic review (2020) concluded that “it is uncertain whether 2-hourly repositioning compared with 4-hourly repositioning used in conjunction with any support surface increases or decreases the incidence of pressure injuries.” The Cochrane Review for PI prevention in adults isolated eight trials, involving 3,941 participants. Authors concluded that there remains a lack of clear evidence to guide repositioning frequency and positioning for PI prevention.

Vanderwee et al conducted a multisite study comparing two repositioning schemas: (1) every 2 hours in the lateral position and every 4 hours in the supine position and (2) a control group of 4 hours alternating between the supine and lateral positions. After excluding stage 1 PIs, the researchers reported no significant difference between the two groups in developing a stage 2 to 4 PI (P = .40). Interestingly, the researchers noted that 34% to 61% of participants changed position spontaneously.

Moore et al reported on a multicenter, prospective, cluster-randomized trial in 12 aged-care facilities comparing two different nighttime (8 pm to 8 am) repositioning regimens. Experimental group participants (n = 99) were repositioned at 3-hour intervals in the 30° lateral tilt and supine positions during the night, whereas the control group (n = 114) was repositioned according to usual practice, which consisted of repositioning every 6 hours at night using the 90° lateral rotation. Whereas 13 patients (11%) in the control group developed a PI, only 3 patients (3%) developed a PI in the every 3-hour experimental group (P = .035, 95% confidence interval [CI]). All PIs were stage 1 (44%) or stage 2 (56%). For this sample of patients, the intervention resulted in fewer PIs.

A 2014 study by Manzano et al compared a 2-hour versus a 4-hour repositioning schedule on ICU patients undergoing mechanical ventilation while positioned on an alternating pressure air mattress (APAM) with head-of-bed elevation of 30°. Researchers found that increasing the repositioning frequency to 2 hours versus 4 hours did not reduce the incidence of stage 2 to 4 PIs (10.3% vs 13.4%).

Another 2013 study, the TURN (Turning for Ulcer ReductioN) study, a multisite RCT of 20 US and 7 Canadian nursing homes, studied the optimal frequency of turning long-term care residents who had mobility limitations and were at moderate or high risk of PI development. All residents were on a high-density foam mattress. Researchers compared 3- and 4-hour T&R schedules with a 2-hour schedule. The study included 942 residents with a mean age of 85.1 years. No full-thickness PIs developed, and 20 superficial PIs developed (stage 1 = 1, stage 2 = 19). Researchers found no significant difference in PI incidence (P = .68) among turning schedules. There were 6 PIs among high-risk patients (1.85%) compared with 13 among moderate-risk patients (2.11%;P = .79). The researchers concluded that turning at 3- and 4-hour intervals was “no worse than the current practice of turning every 2 hours” on a high-density foam replacement mattress. They noted that it could increase sleep time, enhance quality of life, result in fewer staff injuries, and save overall time for other care.

In a study by Rich et al, older adults with hip fractures were repositioned at least every 2 hours on 53% of the days assessed. Researchers studied the average turning rate per 24 hours based on chart review methodology and defined “frequent” as 12 or more turns per day. When compared with less frequent repositioning, the incidence of PI per patient day did not differ (incidence ratio, 1.1; 95% CI, 0.5–2.4). The authors noted that this result calls into question resource allocation to support manual frequent repositioning for those not at high risk.

A 2011 publication reviewed evidence supporting clinical interventions to decrease the magnitude and duration of pressure in PI formation. They concluded that the evidence on the efficacy of turning is limited. Sharp et al, in a retrospective study of 80 older adults in their last week of life, reported that repositioning them every 2 hours did not prevent PI development. In fact, one-third of the at-risk residents had one or more PIs at the time of death. They concluded that routinely repositioning at-risk residents every 2 hours “could be unintentional institutional abuse rather than a preventive safety practice.” Several authors have questioned 2-hourly repositioning as an effective tool for the prevention of PIs and recommend that T&R be individualized (Table 2). The guidelines noted that existing evidence is conflicting as to differences in turning frequencies. Five studies found different frequencies (2, 3, or 4 hours) to be somewhat effective.

The ideal frequency of and benefits related to frequent turning remain unclear. Gammon et al reported that residents who can reposition independently within a 4-hour duration do not develop PIs. Whether it be 2-, 3-, or 4-hourly repositioning, all have been shown to be effective to a degree. The mattresses used in several of the earlier studies were perhaps less effective in preventing PI development than the contemporary ones. Given that the pressure-redistribution properties of mattresses and overlays have improved greatly over time and that some individuals may actually incur more tissue damage with frequent repositioning, less rather than more frequent repositioning schedules may be realistic.

Support surfaces are specialized devices for pressure redistribution designed to manage tissue loads, microclimate, and/or other therapeutic functions (eg, mattresses, overlays, or seat cushions). Two main types of support surfaces exist: reactive and active. A reactive support surface can be powered or nonpowered and modifies the load distribution when a load is applied. An active surface is powered and can modify its load distribution properties with or without a load. A wide variety of types of support surfaces exist, including air-, foam-, gel-, and fluid-filled varieties; overlays of medical sheepskin; and pressure-relieving overlays on operating tables.

Support surfaces have been extensively studied for the role that they play in the prevention and minimization of PIs and may have an impact on how frequently a person is repositioned. An extensive review of the literature about the different types of surfaces and overlays can be found in a meta-analysis by Reddy et al. The meta-analysis examined studies that juxtaposed repositioning and support surfaces, concluding that it is not known whether any specific repositioning schedule is more effective than standard care alone for preventing PIs (low-quality evidence).

Vanderwee and colleagues’ study of 235 residents in aged-care facilities in Belgium examined turning frequency specific to residents on VEF mattresses. The experimental group (n = 122) was repositioned alternately 2 hours in a 30° lateral position and 4 hours in a supine position. The control group (n = 113) was repositioned alternately 4 hours in a 30° lateral position and 4 hours in a supine position. Researchers reported no statistically significant difference between groups in the development of category/stage 2 to 4 PIs (16.4% vs 21.2%, P = .40). Researchers concluded that more frequent repositioning on a pressure-reducing mattress “does not necessarily lead to fewer pressure ulcers and consequently cannot be considered a more effective preventive measure.”

Sharp et al conducted a retrospective study of records of 80 residents in their last week of life from 8 Australian aged-care facilities. Investigators determined 91% were at risk for PI development, and 96% were repositioned at 2-hour intervals around the clock. Of these, 34% (25/73) died with one or more PIs. Researchers found that only 5% (n = 4; CI, 1-10) of the 80 patients were on an APAM, and they recommended that all residents be provided with an APAM. Two-hourly repositioning is the primary PI prevention intervention globally and in Australia, yet the authors concluded that this intervention did not significantly impact PI prevalence in this sample. Marsden et al studied alternating 2- and 4-hour repositioning compared with 4-hour repositioning. They found that although marginally more clinically effective, alternating repositioning strategies was not cost-effective.

Ten articles were included in a 2018 scoping research study on turning frequency in adult patients who were bedridden. Researchers concluded that a pressure-redistributing device and repositioning schedules could potentially reduce PI incidence. The team noted that the topic requires further research to improve and guide what may be outdated guidelines regarding repositioning and PI prevention.

Some studies have indicated that the type of support surface used may be associated with the turning interval schedule. Bergstrom et al found that when using a high-density foam or VEF mattress support surface, patients could be turned at 4-hour intervals without increasing the risk of developing a PI.

Nixon et al reported on a high-level UK multicenter RCT that compared APAMs and high-specification VEF mattresses in nearly 3,000 acute care patients. Results showed no differences between APAMs and overlays in PI prevention.

From these studies, it is clear that providers should individualize T&R frequency to possibly lengthen the turning interval when a VEF mattress is used. Further study is needed about different support surfaces and their relationship to turning frequency.

Sleep is essential for human survival as it promotes optimum physiologic and psychological functioning. It is critical for patients to obtain two uninterrupted sleep cycles of 2.5 to 4 hours for physical and psychological well-being and healing.

Although the amount of sleep needed by an individual varies, the average adult needs 7 to 9 hours of sleep per 24 hours to feel rested and alert. Sleep deprivation affects all body systems. It also leads to memory issues, mood changes, decreased ability to think and concentrate, weakened immunity, muscular complications, accidents, hypertension, weight gain, risk of heart disease, depression, and poor balance. Sleep deprivation is common in hospitalized individuals, resulting from noise, lights, patient care interventions, alarms, pain, and so on. Sleep deprivation can also result frequent repositioning. When an individual is hospitalized, sleep patterns need to be assessed, followed by implementation of sleep promotion strategies.

The customary practice for decades for individuals who have some degree of immobility has been to reposition them every 2 hours. Although this can be important to prevent PI development, it can result in difficulty returning to a state of sleep. When this occurs more than once per night, it can contribute to loss of sleep time. A multitude of other patient interventions interrupt sleep as well (eg, medication administration). Ultimately, loss of sleep time has been associated with a declining functional status, daytime sleepiness, and sleep deprivation. Although the 2-hour repositioning practice is common, Van Leen and Shols noted that often, caregivers are not willing to “disturb the privacy and sleep of residents.”

The provocative question becomes whether repositioning individuals, particularly older adults, at 2-hour intervals around the clock has positive results on balance when it results in loss of quality sleep. The 2-hourly repositioning custom is not without controversy, and PIs still occur in many patients at end of life. Several authors have posited that 2-hourly repositioning is a poor preventive practice.

Humphries and Pilkington noted that not only did the 2-hourly repositioning fail to prevent PI development in one-third of at-risk residents, but it also led to sleep fragmentation and longer recovery times. Some have postulated that this routine may breach the rights of residents: Sharp et al maintain that it is possible a resident could view this repositioning practice as torture. Conversely, the lack of frequent turning could be viewed as neglect and lead to legal action should a PI develop. Indeed, a fine balance is needed to maintain care needs while minimizing risks and honoring patient preferences when considering repositioning strategies.

A 2011 study in 24 nursing homes in Minnesota implemented 4-hour turning intervals and found no increase in PI development when using pressure redistribution mattresses and appropriate overnight incontinence products. The researchers also used technology to monitor residents’ independent movements. Interestingly, several residents who were not thought to move independently made subtle movements while they slept. This finding suggests that monitoring movement could perhaps impact turning frequency.

As previously noted, support surfaces are important for pressure redistribution and are also relevant to an individual’s sleep comfort and sleep quality. Pressure always exists to some area of the body in a recumbent position regardless of the surface the individual is lying on because no support surface completely eliminates pressure. Turning frequency can vary by the type of support surface and may also depend on the individual’s risk level and tissue tolerance. In addition, individual preferences for type of support surface may influence turning frequency, which may also have an impact on sleep.

A study of 191 at-risk residents in 12 Belgian nursing homes assessed PI incidence (4.7%) and perceptions of comfort with static air support surfaces. The support surface was found to be comfortable for daily use, and the researchers reported that comfort and sleep quality were essential considerations in the selection of a support surface. Given that some surfaces are associated with higher levels of patient satisfaction and self-reported sleep quality, it seems wise to consider the patient’s individual needs and preferences when selecting a mattress/support surface as well as a repositioning routine. If preferences cannot be determined because of cognitive disability, consider how the surface is affecting the patient, which surface is appropriate, and the patient’s individualized turning schedule. If a patient is at high risk and the mattress is not redistributing pressure adequately, more frequent repositioning and/or a different support surface might need to be considered.

At times, a patient might need sleep more than PI prevention interventions allow. If sleep is the higher priority and disrupting the patient less often will lead to better sleep, then a mattress that is less affected by frequency of turning should be selected for the patient. There might be short periods when health and/or recovery needs, affected by sleep, are prioritized higher than PI development.

Studies to date are heterogeneous in terms of participant comorbidities, age, sex, sleep preferences, support surfaces, environmental temperature and noise, care settings, medications, care interruptions, subjective assessments, sample size, and blinding. In addition, there is often missing outcome data, an undefined standard of care, varying repositioning frequencies, Hawthorne effect, and a low number of events (ie, PI). As a result, it is difficult, if not impossible, to pool data, limiting advancements in this area.

Further, since the recommendation of 2-hourly T&R was first made nearly a century ago, support surfaces have significantly improved in pressure redistribution ability and comfort. Nixon et al recommend that support surfaces should be individualized to the patient’s needs. The TURN study noted the conceptual relationship between turning frequency and support surface.

Because 2-hour repositioning has been in practice for several decades, changes may not be easy to implement, and further research should be encouraged. Few studies have evaluated 24 hours per day/7 days per week T&R schedules and their impact on the occurrence of sleep deprivation in long-term care residents.

No clear evidence exists as to which position(s) and repositioning schedule is best. However, the optimal frequency of repositioning would mitigate negative effects such as sleep deprivation, pain, and (for nurses) musculoskeletal injuries. Overall, study quality is limited. Although repositioning is needed to prevent PI, less rather than more frequent turning may be realistic, given the properties of newer mattresses and lack of agreement in the evidence over whether 2-, 3-, or 4-hour repositioning is best. Frequency of T&R requires further study.

Very few articles were located that dealt with sleep interruptions related to PI prevention and treatment, so further research is needed. Priority in research would be well directed toward the frequency of turning for PI prevention and treatment, with consideration given to how it affects sleep. The authors recommend the use of technology to monitor sleep cycles of individuals being routinely turned and repositioned. Individualizing the turning regimen to the patient, their comorbidities, current condition, and mobility is recommended. When support surface decisions are made, patient preferences, mobility, nutrition status, and current skin condition should be considered. The authors recommend that criteria be developed for each category of support surface used, particularly for PI prevention. It is hoped that this article spurs new research in this field.

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