The Conundrum of Turning/Repositioning Frequency, Sleep Surface Selection, and Sleep Disruption in Preventing Pressure Injury in Healthcare Settings

)) OR “pressure reduc*” OR “pressure releas*”) AND (“moving and lifting patients” [MeSH] OR (“patient” AND (“move” OR “moving” OR “reposition*”))) AND (2005:2021 [pdat]) 2005–2021 English PubMed 130 Written in English, adults, inpatient and long-term care settings, research study, Cochrane review, or meta-analysis Pediatric population, mechanically ventilated patients, COVID-19 positioning, staff injuries from lifting, moving patients Sleep, pressure ulcers, sleep disruptions (frequen* AND (beds [MeSH terms] OR bed OR beds OR mattress* OR (“surface” [Title/Abstract] AND (sleep [Title/Abstract] OR support [Title/(“patient” AND (“move” OR “moving” OR “reposition”)) ) AND MH (“moving and lifting patients”) “sleep deprivation” OR “sleep fragment” OR “insufficient sleep” 2005–2021 English PubMed, CINAHL, and Google Scholar 6 Written in English, inpatient studies, long-term care studies, Cochrane review, or meta-analysis Sleep medications, noise interruptions Abbreviation: MeSH, Medical Subject Headings. WWW.ASWCJOURNAL. COM 253 ADVANCES IN SKIN & WOUND CARE • MAY 2022 Practice Reflections Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved. Practice Reflections clinical trials, systematic reviews, andmeta-analyseswritten in English published between 2005 and 2020 that included inpatient hospital patients and patients in longterm care. Certainty of the evidence was assessed, and articles studying mechanically ventilated patients, COVIDrelated 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. RESULTS 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 thosewith limitedmobility 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 Table 2. TURNING AND REPOSITIONING FREQUENCY Author (Year) Setting Turning Frequency and Type of Sleep Surface Defloor et al (2005) Long-term care 4and 6-h repositioning on VEF or 2 and 3 h on foam vs control group without standard repositi Vanderwee et al (2006) Long-term care 2-h lateral tilt and 4-h supine repositioning on V control group of 4-h lateral and supine Moore et al (2011) Long-term care 3-h 30° lateral tilt repositioning vs routine 6-h 9 tilt repositioning; both groups only 8 PM to 8 AM Manzano et al (2013) Intensive care 2vs 4-h repositioning in mechanically ventilate (left and right 30° tilt and supine with head of b on an alternating pressure air mattress) Rich et al (2011) Acute care 2-h vs less frequent repositioning in patients with Sharp et al, 2019 Long-term care Positioning at end of life (cross-sectional survey residents in Australian nursing homes, 2-h repos Bergstrom et al (2013) Long-term care 2-, 3-, and 4-h turning of nursing home patients Krapfl and Grey (2008) Systematic review Review of three randomized controlled trials and systematic reviews Abbreviations: PI, pressure injury; VEF, viscoelastic foam. ADVANCES IN SKIN & WOUND CARE • MAY 2022 254 Copyright © 2022 Wolters Kluwer H recommendationtoadvocate for repositioningevery2hours 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