Does Regular Repositioning Prevent Pressure Ulcers?

Lee Ann Krapfl  Mikel Gray  

Journal of Wound, Ostomy and Continence NursingNovember/December 2008 Volume 35 Number 6Pages 571 - 577

Abstract

BACKGROUND: Prolonged exposure to pressure is the primary etiologic factor of a pressure ulcer (PU) and effective preventive interventions must avoid or minimize this exposure. Therefore, frequent repositioning of the patient has long been recommended as a means of preventing PU.

OBJECTIVES: To review the evidence on the efficacy of repositioning as a PU prevention intervention.

SEARCH STRATEGY: A systematic review of electronic databases MEDLINE and CINAHL, from January 1960 to July 2008, was undertaken. Studies were limited to prospective randomized clinical trials or quasi-experimental studies that compared repositioning to any other preventive interventions or any study that compared various techniques of repositioning such as turning frequency. Only those studies that measured the primary outcome of interest, PU incidence, were included in our review.

RESULTS: Limited evidence suggests that repositioning every 4 hours, when combined with an appropriate pressure redistribution surface, is just as effective for the prevention of facility- acquired PUs as a more frequent (every 2 hour) regimen. There is insufficient evidence to determine whether a 30° lateral position is superior to a 90° lateral position or a semi-Fowler's position.

IMPLICATIONS FOR PRACTICE: The current regulatory and legal environment has focused increased attention on PU prevention. Pressure redistribution methods and the frequency of application are among the first factors scrutinized when a PU develops. Our clinical experience validates that regular movement of the immobilized patient is important, but evidence defining the optimal frequency of repositioning or optimal positioning is lacking.

Questions1. Does regular repositioning reduce the incidence of pressure ulcers?Introduction

The National Pressure Ulcer Advisory Panel 1 defines a pressure ulcer (PU) as localized injury to the skin or the underlying tissue that usually occurs over a bony prominence. They further state that a PU occurs as a result of pressure or pressure in combination with shear or friction. The European Pressure Ulcer Advisory Panel 2 similarly defines PU as an area of localized damage to the skin and underlying tissue caused by pressure or shear or a combination of these factors. The US Agency for Health Care Policy and Research (now called the Agency for Health Quality Research) Panel for Prevention and Prediction for Pressure Ulcers in Adults 3 and the Wound Continence Society 4 have defined PU as areas of necrosis when tissue is compressed between a bony prominence and an extracorporeal surface for a prolonged time period. Clearly, all of these definitions (as well as the term we use to name these wounds) concur that prolonged exposure to pressure is the primary etiologic factor of a PU, resulting in tissue damage from ischemia and necrosis.

It logically follows that, since a PU is caused by pressure, effective preventive interventions must avoid or minimize exposure to prolonged pressure.5 Healthy individuals, whether awake or asleep, rely on a variety of sensory cues that prompt them to reposition their bodies in order to avoid ischemia and tissue damage. However, those with paralyzing neurological disorders, acutely or chronically ill persons, or otherwise healthy individuals exposed to prolonged periods of immobility during elective surgical or related circumstances are at high risk for pressure ulceration unless actions are taken to prevent their development. Multiple interventions are recommended for PU prevention 4; they can generally be classified as (1) assessment (including PU risk assessment); (2) pressure redistribution; (3) interventions to reduce or prevent exposure to friction and shear; (4) interventions to alleviate contributing factors including moisture and impaired nutrition; and (5) education of patients, families, and care providers.

Frequent repositioning of the patient has long been recommended as a means of preventing PU (Table 1).6–8 Trumble 6recommended repositioning patients as a means of PU prevention and treatment as early as 1930. Kosiak 7,8 is credited for recommending turning the patient every 2 hours based on studies of measurement of tissue interface pressures in healthy volunteers. However, a careful critique of his work reveals that he refers to a clinical tradition of 2-hour turning rather than a novel conclusion based on data from his research.

TABLE 1. Repositioning for the Prevention of Pressure Ulcersa

Despite consistent clinical recommendations that repositioning is an effective intervention for PU prevention and treatment, the optimal technique for repositioning has not been completely elucidated.9 Repositioning is often conceptualized as turning the patient from side to side when lying in the bed or similar surface.5,9 Within this context, the patient tends to be placed in a side-lying position and the pelvis rotated approximately 30° from supine. Placing the patient in a true lateral position is typically discouraged 5 because it is believed to cause higher tissue interface pressures over the affected trochanter when compared to the 30° tilt. A prone position has also been shown to reduce tissue interface pressures in the sacral area, but this position is rarely used because of patient preference, comfort, and physiologic considerations following certain surgical procedures.

Repositioning the patient lying in a bed also encompasses the position of the head and the knees. However, mixed evidence about optimal positioning of the head and the knees illustrates gaps in our knowledge of ideal positioning for PU prevention. Defloor 10 evaluated tissue interface pressures in 62 healthy volunteers and found that pressures in the sacral area were higher when the head was elevated to 90° as compared to subjects placed in a supine position with the head of the bed elevated to 60°. He also found that the lowest tissue interface pressures were achieved when the subject was placed in a semi-Fowler's position with the head of the bed elevated to 30° and the knees elevated 30° as well. In contrast to these findings, Sideranko and coinvestigators 11 evaluated sacral tissue interface pressures in 57 patients in a surgical intensive care unit. They found that subjects placed in a semi-Fowler's position had higher sacral tissue interface pressures when compared to other positions, regardless of the type pressure redistribution surface selected.

As these seemingly conflicting results illustrate, multiple factors influence the tissue interface pressures achieved when patients are placed in a certain position. In addition to the use of a pressure redistribution surface, physiologic factors, such as hemodynamic stability, also influence repositioning.5,12 For example, compromised pulmonary and cardiovascular function may contraindicate placing patients in a semi-Fowler's

position with the head and the knees elevated to 30°. In these patients, minimal position changes, such as placement of a pillow or small folded towel, may be used in an attempt to reduce tissue interface pressures and prevent PU formation. However, the efficacy of these repositioning techniques is unclear and sparse evidence reveals that traditional thinking about optimal positioning may not produce intended results.5For example, Turpin and Pemberton 12 found that routine placement of pillows in a group of 6 critically ill patients placed on a continuous lateral rotation therapy device paradoxically elevated rather than reduced sacral tissue interface pressures, potentially increasing rather than ameliorating the risk of hospital-acquired PUs.

The optimal technique for repositioning is also impacted by the body surface area under consideration. The heels have a comparatively small surface area, large underlying bony surface, and thin layer of tissue between bone and epidermis. Heel perfusion is also affected by a variety of intrinsic factors affecting tissue oxygenation. As a result, they are at particular risk for ischemia and pressure ulceration and the incidence of facility-acquired PUs on the heels can be significant.13 Based on an integrative review of the literature, Wong and Stotts 14 note that even when placed on a pressure redistribution surface, tissue interface pressures at the heels tend to be higher than sacral pressures. Therefore, they recommend elevating the heels off the support surface altogether, especially if the patient has diabetes mellitus and peripheral vasculopathy.

Despite gaps in our knowledge of optimal positions for specific patient groups, the ideal frequency of repositioning and the complex relationships among support surfaces, repositioning practices, and tissue interface pressures, contemporary clinicians and scholars continue to assert that repositioning is an essential component of a PU prevention program. Repositioning is perceived as essential because it temporarily reduces interface pressures, allowing compressed tissues to reperfuse before necrosis occurs.2–5 However, a growing body of research reveals that even though reperfusion is necessary to limit the irreversible damage caused by unrelieved pressure, it may paradoxically result in further compromise of ischemic tissues in certain instances, potentially raising the risk of pressure ulceration.15

Ischemia-reperfusion injury is the culmination of multiple biochemical events leading to cellular damage or destruction, leukocyte and complement activation, microvascular dysfunction, and oxidative stress reactions.15 The process begins when unrelieved pressure leads to local ischemia and a reduction in ATP production. This reduction alters the transmembrane potentials of local cell walls, resulting in influx of various ions and subsequent swelling of the cell. The elevated calcium ion levels in the affected cells activate enzymes that lead to cell wall disruption. Ischemia also provokes release of endothelial adhesion molecules and cytokines, resulting in a proinflammatory state. Reperfusion activates leukocytes that adhere to the endothelium, and may migrate in the interstitial space. This results in activation of an inflammatory cascade leading to local tissue damage. Reperfusion also may impair local perfusion by inducing an oxidative stress response, characterized by the release of reactive oxygen species. This reaction may overwhelm endogenous defenses and extend the scope of tissue damage. Nitric oxide production also may be impaired during reperfusion, resulting in microvascular dysfunction. When combined with the leukocyte trapping described earlier, the patient may experience a “no-reflow phenomenon,” characterized by failure to reestablish restorative local perfusion despite pressure relief and accompanying reperfusion. Animal model research demonstrates that repetitive episodes or ischemia and reperfusion exert a cumulatively negative effect, suggesting that this process may play a clinically relevant role in the pathophysiology of pressure ulceration.

Based on these considerations and the recent Centers for Medicare & Medicaid Services policy changes concerning reimbursement for hospital-acquired PUs in particular,16 a review of the evidence focusing on the efficacy of repositioning as a PU prevention intervention is indicated. This Evidence Based Report Card systematically reviewed the literature in order to identify and review studies that evaluated the effectiveness of any type of repositioning intervention on PU incidence in all care settings.

Methods

A systematic review of electronic databases MEDLINE and CINAHL, from January 1960 to July 2008, was undertaken using key words: (1) repositioning, (2) positioning, and (3) turning. Each of these key words was combined with the terms “pressure ulcer” or “decubitus ulcer.” Studies were limited to prospective randomized clinical trials or quasi-experimental studies that compared repositioning to any other preventive interventions or any study that compared various techniques of repositioning such as turning frequency. Only those studies that measured the primary outcome of interest, PU incidence, were included in our review. All studies were

independently reviewed for the presence of inclusion criteria and methodologic quality by both authors. Nevertheless, all studies that met inclusion criteria and were published in English or had an English language abstract were included in this review even if the methodologic quality was judged less than optimal. The Cochrane Database for Systematic Reviews was also searched using the key term repositioning. The ancestry of review articles and research reports were searched for additional studies. Finally, Web-based engines, Google and Google Scholar, were searched using the key terms repositioning and pressure ulcer.

Question 1: Does repositioning reduce the incidence of pressure ulcers?

Our search of the electronic databases MEDLINE and CINAHL identified 194 references. Elimination of duplicate references and references that did not contain original data or systematically review evidence reduced the number of references to 23. An ancestry search, primarily focusing on the 2 systematic reviews, revealed an additional 3 studies not identified when electronic databases were reviewed. A search of the Cochrane Database identified a protocol (review in process) for a systematic review of repositioning as a preventive intervention for PU. Among these 26 references, 20 reported primary data. However, only 5 are included in our review.17–21 Of the 15 references excluded, 8 studies did not measure the primary outcome measure of interest (PU incidence), 4 studies did not meet the design criteria specified for this review, 1 study did not use human subjects, and 2 studies did not employ repositioning as an intervention. One study by Norton and coworkers 21 was published in 1962 in a book and was not available for review. Both authors independently reviewed all references containing primary data, including systematic reviews, to ensure consensus based on inclusion criteria.

Two systematic reviews were identified that evaluated the efficacy of repositioning as an intervention for PU prevention. Reddie and coworkers 17 identified 2 randomized clinical trials with a combined total of 884 subjects that compared the frequency of turning 18 or 3 positions (head elevated to 30° vs 90° lateral vs supine) for PU prevention.19 Based on the results of these trials, they concluded that repositioning, along with use of support surfaces, optimizing nutritional status, and moisturizing the sacral skin are appropriate for PU prevention. Clark 20 completed a systematic review of the literature and identified 8 studies that explored repositioning for PU prevention, 7 of which were available for review.21–27None of the studies cited by Clark were included in the review of Reddie and coworkers.

Unlike Reddie and coworkers, Clark included studies that reported intermediate outcomes such as tissue interface pressures, transcutaneous oxygen, and transcutaneous carbon dioxide levels. Based on this review, Clark 20 concludes that while national guidelines tend to advocate repositioning for PU prevention, little evidence exists that supports this practice. Specifically, he questions the efficacy of a 2-hour turning schedule despite evidence of PU development following regular repositioning in 2 studies. He further speculates that while more frequent repositioning might be more effective, such a schedule may be impractical in routine practice since it might require repositioning multiple times each hour. Instead, he argues that pressure redistribution surfaces may replace regular repositioning efforts. Clark also asserts that research into positioning may be a more beneficial line of inquiry than protocols comparing turning frequency, and he especially advocated further investigation of the 30° tilt.

Three trials were identified that met inclusion criteria for this systematic review. Vanderwee and coinvestigators 28completed a randomized clinical trial comparing a 2-hour repositioning protocol to a 4-hour regimen. Subjects randomized to the 2-hour regimen were repositioned alternatively every 2 hours in a lateral position with the hips elevated 30° from supine and 2 hours in a semi-Fowler's position with both head end and foot end of the bed elevated 30° from supine. When placed in the lateral position, the back was supported with an ordinary pillow. Comparison group subjects were placed in the same positions as those in the intervention group, but repositioning was completed every 4 hours. All subjects were placed on a viscoelastic foam overlay mattress (Tempur, Tempur-World, Inc, Lexington, Kentucky). The heels of all subjects were elevated using a wedge-shaped cushion to render the heels pressure free. Two hundred thirty-five residents from 16 Belgian long-term care facilities participated in the study; the median age of subjects was 87 years and median follow-up was 15 days. Their mean Braden score was 15 ± 3.09 (mean ± SD). Subjects randomized by the 2-hour turning protocol experienced a 16.4% incidence of grade 2 to 4 PU as compared to 21.2% of control group subjects. This difference was not statistically significant. No statistically significant differences were detected when results were analyzed for severity of PU. They concluded that more frequent repositioning on a pressure-reducing surface did not result in fewer PUs. Of note, the researchers observed that 34% of subjects in both groups spontaneously moved themselves from a 30° lateral position to a supine position between formal

repositionings.

Defloor and colleagues 18 compared 4 repositioning regimens to standard care in a randomized clinical trial. Patients in the intervention group were turned every 2, 3, 4, or 6 hours. They were positioned in the 30° lateral or 30° semi-Fowler's position that was described in the trial of Vanderwee and coinvestigators 28 and the 2000 study of healthy volunteers of Defloor.10 Subjects who were turned every 2 and 3 hours were placed on standard hospital mattresses. Those randomized to every 4- and 6-hour repositioning regimens were placed on a viscoelastic foam mattress (Tempur-Pedic, Fagerdala, Sweden). Complementary PU prevention interventions in the standard care group were based on providers' clinical judgment. These interventions did not include PU risk assessment using a validated instrument or a protocol-driven repositioning regimen. Pressure redistribution devices included water mattresses, alternating pressure mattresses, gel cushions, and sheepskins. The number of patients who spontaneously moved into a new position between assisted repositionings via the study protocol was not recorded. The sample population comprised 838 long-term care facility residents with a mean age of 84.4 ± 8.33 years. Their mean Braden Scale score was 13.2 ± 2.36. Seventy-four of 838 subjects (9.1%) did not complete the study; the most common reasons for dropping out were admission to hospital (n = 30), death (n = 23), and incomplete data collection (n = 24). The incidence of stage I PU (presence of nonblanchable erythema) was not different when the 4 groups were compared. However, the incidence of grade 2 and higher PU were significantly lower among subjects repositioned every 4 hours and placed on a viscoelastic foam mattress (3% vs 14.3%–24.1%, P = .002).

Young 29 completed a randomized clinical trial comparing a 30° tilt versus a 90° tilt in a group of 46 patients in an acute care facility. The mean age of subjects in the 2 groups was similar (70.1 ± 11.1 vs 70.5 ± 14.7 years), as was their mean Waterlow scores (20 ± 3.6 vs 20 ± 3.1). Intervention group subjects were repositioned using a 30° pelvic tilt position, and comparison group subjects were repositioned in a 90° side-lying position. Pillows were used to achieve the 30° tilt. The frequency of repositioning was not specified in the study protocol; instead, subjects were repositioned based on a number of clinical considerations including PU prevention (87%–91% of episodes), administration of medications or to aid breathing (0%–4% of episodes), or at the participant's request (4% of episodes). The median and mode for frequency of repositioning (every 2–3 hours) did not differ between groups. In addition, 61% of subjects in the 30° tilt group and 58% of the 90° side-lying group spontaneously repositioned themselves on at least 1 occasion throughout the night. Subjects were placed on 1 of 3 pressure redistribution surfaces: (1) alternating pressure mattress (67%), (2) low air loss bed (26%), and (3) static foam or fiber mattress (6%). Data collection occurred over a 1-night period and PU incidence was limited to occurrence of stage 1 PU, assessed by the researcher, who applied light finger pressure to any reddened area. Areas that demonstrated nonblanching erythema were judged to have pressure damage (stage 1 PU). Despite the comparatively brief data collection period (1 night), 7 subjects (31%) did not complete the study, including 5 subjects randomized to the 30° tilt position and 2 subjects randomized to the 90° side-lying position group. Analysis revealed no statistically significant differences in stage 1 PU incidence (4% vs 9%), and so subjects developed a higher stage PU. The author also noted that neither positions consistently provided pressure relief on the sacrum and the heels even when evaluated immediately after repositioning.

The systematic reviews identified in this Evidence Based Report Card reach different conclusions. Reddie and coworkers17 analyzed results of 2 randomized clinicalm trials and concluded that existing evidence supports repositioning as one component of a PU prevention strategy. In contrast, Clark 20 questioned the effectiveness of routine repositioning. Specifically, he concluded that repositioning may exemplify an intervention that is advocated in clinical practice guidelines but not routinely carried out in daily clinical practice because the clinical experiences of most nurses fail to reflect the efficacy of this intervention. These systematic reviews are also remarkable because they contain no overlapping references. The review of Clark 20 was published in 1998, whereas that of Reddie and coworkers 17 was published in 2006. Therefore, it might be anticipated that Reddie, Gill and Rochon may have drawn upon of the references cited by Clark. Instead, Reddie and coworkers based their conclusions on 2 randomized clinical trials published in 2004 and 2005, respectively. While the authors of these respective reviews disagree about the strength of evidence supporting the need for repositioning, they agree that further research is urgently needed to more completely define optimal techniques for repositioning including turning frequency and the role of the 30° tilt.

Our review identified 3 randomized clinical trials that compared different repositioning regimens to standard care. Two of the studies 18,28 compared repositioning frequencies that vary from every 2 to 6 hours. Similar positions were used in each of the studies, based on results obtained when Defloor 10 evaluated tissue interface pressures using healthy volunteers. Neither study found that frequent repositionings (every 2 hours) were more

effective than every 4-hour regimens for PU prevention. This lack of difference persisted whether a pressure redistribution surface was used for both groups or when the use of a pressure redistribution surface was limited to subjects repositioned every 4 to 6 hours. These results suggest that repositioning every 2 hours is no more effective than repositioning every 4 hours. It is also important to note that 34% of subjects in Venderwee and coinvestigators'28 study were found to have spontaneously changed their position between formal episodes of repositioning. Similarly, Young 29 reported that 58% to 61% of subjects spontaneously repositioned themselves between episodes of formal repositioning. The magnitude of this effect on study results in the 3 studies included in our review is not known.

Methodologic limitations observed in Young's 29 study limit its impact on evidence-based conclusions about the efficacy of repositioning. Specifically, the significant dropout rate (26%) despite a very brief data collection time (<24 hours), variability in turning frequency, and the observation that more than half spontaneously repositioned themselves preclude the ability to easily compare these findings with those of Vanderwee and coworkers 28 or Defloor and coworkers 18 or to reach firm conclusions about clinically relevant differences in PU incidence based on the repositioning strategies described in this trial.

Key Points[check mark] Limited evidence suggests that repositioning every 4 hours, when combined with an appropriate pressure redistribution surface, is just as effective for the prevention of facility-acquired PUs as a more frequent (every 2 hour) regimen. (Level of evidence: 3)[check mark] There is insufficient evidence to determine whether a 308 lateral position is superior to a 908 lateral position or a semi-Fowler's position. (Level of evidence: 3)Clinical Implications

The current regulatory and legal environments are focusing increased attention on PU prevention. Pressure redistribution methods and the frequency of application are typically the first things scrutinized when a PU develops, including regular turning and repositioning efforts. Our clinical experience validates that regular movement of the immobilized patient is important, but evidence documenting efficacy is clearly lacking.

Current PU repositioning recommendations reflect historical and well-established practices but often give little guidance to practitioners when clinical circumstances demand deviation or modification. The limited evidence base reviewed here does not address the multiple medical and clinical conditions where turning and repositioning are contraindicated or must be strictly curtailed. Patient repositioning is also one of the more labor-intensive preventive interventions. We are approaching a perfect storm, where our population is becoming older, sicker, and heavier, resulting in a growing group of patients who need PU prevention at a time when nursing workforces are older and in short supply in many healthcare facilities. Therefore, our repositioning efforts must be efficient as well as therapeutic.

This review of the existing scientific literature validates the need for further research addressing the ideal frequency of repositioning as well as the effectiveness of the 30° lateral recumbent bed position. This position is advocated as best practice for side-lying positioning because it minimizes the interface pressures on the trochanter, shoulder, and lateral malleolus. But this is not a typical position that most healthy subjects assume when moving into a side-lying position, and we have found that some patients find this position to be awkward or uncomfortable. The spontaneous repositioning rates observed in the studies of Vanderwee and coworkers 28 and Young 29 validate this common clinical observation. Patients benefit most from repositioning efforts if the position can be maintained. Therefore, the efficacy of the 30° lateral recumbent position must be questioned if patients have difficulty maintaining this position. Given the current and anticipated workforce issues, we must also determine whether it is necessary to reposition all at-risk patients or only those with certain clinical and intrinsic risk factors rendering routine repositioning truly essential. While the spontaneous repositioning of some of the participants in these studies may have reduced apparent differences when positioning frequencies were compared, we believe that it also offers insight into the role of small weight shifts as a potentially effective method of pressure redistribution.

Although the evidence is sparse, clinical recommendations for best practice support a turning/repositioning schedule frequency of every 2 hours if the patient is on a standard mattress. Clinical evidence supports reducing this frequency to every 4 hours if the patient is on a pressure redistribution surface. Heels should be suspended with appropriate positioning methods or devices in at-risk patients regardless of the type of support surface. The

process of improving consistency in repositioning schedules continues to be a challenge in all settings. Facilities have tried a wide variety of cues and reminders to staff, such as playing music over the intercom when patients are to be turned or posting signs on doors alerting staff of patients' PU risk, and these may have some effect on improving consistency in the short term.30,31 The reality is that rigid turning schedules are difficult to maintain, especially in acute care, where they are interrupted by tests, procedures, treatments, therapies, and a wide variety of nursing activities. Ultimately, clinical findings of a daily skin inspection should guide repositioning frequency, and educational efforts must emphasize this responsibility. Early evidence of skin changes indicative of stage I PU development is an important warning sign to act on and would support increasing repositioning frequency. While a regular turning schedule might not be practical or appropriate in certain settings, small weight shifts are considered to be of value in these populations. Studies investigating the efficacy of small weight shifts are urgently needed.

Many wound experts believe that some PUs are unavoidable, especially in very high-risk patients.32,33 An unavoidable PU has been defined as an ulcer that occurred despite an evaluation of risk, implementation of preventive interventions consistent with the patient's needs and recognized standards of practice, evaluation of the interventions, and revisions in the approaches as appropriate.34 The Centers for Medicare & Medicaid Services has listed a PU as a clinical complication that can be reasonably prevented with the application of clinical practice guidelines.35 Nevertheless, a workable definition of “reasonable” describing medical conditions and clinical circumstances that would contribute to an unavoidable PU has eluded both regulators and clinicians alike. Additional research addressing the efficacy of interventions, including repositioning on PU prevention, as well as scrutiny on the factors leading to PU occurrence in some patients despite a PU prevention program, is needed to answer this ongoing and clinically relevant question.

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