• Improve Respositioning

    Repositioningis one of the main pressure ulcer preventive measures. It is a current practice
    in the intensive care units to turn the patient every 2h, however, this
    frequency was reduced to 4h schedule as a standard protocol. A single-site open
    label, parallel group randomised control trial involving 330 patients assessed
    efficacy of each turning regime (2-h against 4-h) for the prevention of
    pressure ulcer incidence (at least grade 2) in critical patients under invasive
    mechanical ventilation.

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    Active mattresses were used as a concomitant intervention in both groups

    All repositioning was performed manually by the nursing stuff. The pressure ulcerincidence was 10.3% in the 3-h group and 13.4% in the 4-h group (P=0.73). Therewere no differences in the ICU mortality, hospital mortality, median mechanicalventilation duration or length of ICU. Significantly different was found adaily nursing workload, 21min/patient in the 2-h group versus 11min/ patient inthe 4-h group (P<0.001)

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    Assessmentof safety endpoints in the same study indicated that there was a significant
    difference between 2 regimes with 47.9% for 2-h vs 36.6% for 4-h, P=0.02,

    For the composite end point of device-related adverseevents (all adverse events combined). Out of all adverse events assessed, only
    endotracheal tube obstruction was different between the groups, 36.4% vs 30.5%
    for 2-h and 4-h regimes respectively, P=0.065. All other adverse events
    (unplanned extubation, loss of medical device, reintubation, cardiac arrest of
    any cause, atelectasis, respiratory instability, clinical ventilator-associated
    pneumonia) did not differ significantly between the groups.

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    Asystematic comparative effectiveness review of Chou et al describes 6 trials
    investigating the effect of repositioning on pressure ulcer incidence

    .One fair-quality cluster randomised trial with 213 participants found that
    repositioning at a 30-degree tilt every 3 hours was associated with lower risk
    for pressure ulcer incidence after 28 days compared to the standard of care (3%
    vs 11%; RR 0.27, 95% CI 0.08 to 0.93). Another fair quality trial with 235
    patients found no difference in risk of pressure ulcer development between
    different repositioning intervals. Four other trials either found no effect of
    repositioning on the pressure ulcer incidence or were susceptible to
    confounding due to differential use of support surfaces .

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    Aclinical trial involving 838 geriatric patients in nursing homes investigating
    four different repositioning schemes in combination with pressure reducing
    mattresses (viscoelastic foam) or standard institutional mattress followed up
    for 28 days found no difference in the incidence of stage 1 pressure ulcers at
    34.8 to 38.1% (all NS).

    The following repositioning regimes and mattresscombinations were evaluated: turning every 2h in combination with standard
    institutional mattress, turning every 3h in combination with standard
    institutional mattress, turning every 4h in combination with viscoelastic foam
    mattress and turning every 6h in combination with viscoelastic foam mattresses.

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    Whilethe difference in the incidence of stage 1 pressure ulcers was not significant,
    development of the stage 2 and higher pressure ulcers was significantly reduced
    in the group of 4h repositioning + viscoelastic foam mattress (3.0% vs 14.3% -
    24.1% for other groups).

  • References:

     

    EPUAP. (2019). Prevention and treatment of pressure ulcers/injuries: Clinical practice guideline. Available at: https://www.epuap.org/guidelines/ [Accessed 19 June 2024].
    Baker G, Bloxham S, Laden J, Gush R. Vascular endothelial function is improved after active mattress use. J Wound Care. 2019 Oct 2;28(10):676-682. doi: 10.12968/jowc.2019.28.10.676. PMID: 31600104.
    Manzano, F. et al. (2014). Repositioning every 2 hours vs. every 4 hours. Journal of Critical Care, 29(4), pp.657.e1-657.e6. Available at: https://doi.org/10.1016/j.jcrc.2014.03.006 [Accessed 19 June 2024].
    NICE. (2020). Pressure ulcers: Prevention and management. NICE guideline [NG179]. Available at: https://www.nice.org.uk/guidance/ng179 [Accessed 19 June 2024].
    EPUAP. (2019). Prevention and treatment of pressure ulcers/injuries: Clinical practice guideline. Available at: https://www.epuap.org/guidelines/ [Accessed 19 June 2024].
    NHS England. (2020). Pressure ulcer prevention guidance. Available at: https://www.nationalwoundcarestrategy.net/wp-content/uploads/2021/06/Pressure-ulcer-prevention-guidance[Accessed 19 June 2024].