1. Under Pressure
Christopher Boroanka, BSN, RN; Chamir N. Chouloute, BSN, RN;
Meagan Groneman, BSN, RN; Iris Robles, BSN, RN
Problem Identification
Background
• Hospital-Acquired Pressure Ulcers
(HAPUs) are a known problem in acute
care facilities in the United States.
HAPUs reduce the patient quality of life,
are associated with higher in-hospital
mortality and ”contributed $1.99 billion
in excess health care costs for
Medicare patients between 2007 and
2009” (Bergquist-Beringer, Dong, He,
Dunton, 2013).
• Optimal turning frequencies must take
into account negative consequences of
frequent repositioning for patients, staff,
and healthcare (Gillespie BM, Chaboyer
WP, McInnes E, Kent B, Whitty JA,
Thalib L., 2014).
Clinical Question
Among elderly patients in an acute
care medical-surgical setting, is
repositioning every two hours more
effective than longer periods of time
when attempting to decrease the
incidence of pressure ulcers (PU)
during a patients stay?
Current NYP Practice
• NewYork-Presbyterian Hospital
(10/2015) states the RN “will implement
turning schedule, at least every 2 hours
while in bed/stretcher for all patients
found at risk. Patients will be
repositioned every 1 hour while in
chair, if unable to shift weight
independently.”
Evidence Review
• Although, there is no clear evidence
that supports the impact of
repositioning to reduce or prevent
pressure ulcers it does not mean that
repositioning is ineffective (Gillespie
et al.,2014).
• Bergquist-Beringer et al. (2013)
Gathered data from 1,419 NDNQI
participating hospitals and used a
hierarchical logistic regression
analysis to identify variables
associated with hospital acquired
pressure ulcer.
• Moore et al. (2012) conducted a
review to clarify the role of
repositioning in the management of
patients with pressure ulcers. RCTs
and CCTs that compared
repositioning with no repositioning,
different repositioning techniques and
frequencies were considered in the
review. The study found that there is
a lack of well-designed controlled
trials examining the effects of
repositioning.
Appraise Evidence
• Gillespie et al.(2014):
• Strengths: Authors found that all
three studies reported the proportion
of patients developing PU of any
grade, stage or category.
• Limitations of the studies were that
none the trials reported on pain, or
quality of life, and only one reported
on cost. All three trials were at high
risk of bias.
• Bergquist-Beringer et al. (2013):
• Strengths: The study used
information collected over a full year
which allowed for a complete
database. Meta analysis allows for
variable aspects to be taken into
consideration simultaneously.
• Limitations: Only NDNQI
participating hospitals were used in
this sample. Also there was a
disproportionate amount of Magnet
hospitals represented in this sample
in comparative to the national
average. Future studies could
include a wider variety of hospital
types.
• Moore et al. (2012):
• Strengths: The article that was
reviewed is a systematic review. The
review had a thorough plan to
extract and summarize the studies
and included multiple assessment
tools, expert advice, and explored
unpublished studies.
• Limitations: The authors declare that
every attempt was made to identify
all relevant studies but acknowledge
that it was possible to miss eligible
studies though highly unlikely.
Recommendations
• Moore et al. (2012) suggests that a
cluster-randomized study should be
conducted to validate the role of
repositioning in the healing of pressure
ulcers. Cluster-randomized focuses on
units rather than individual patients.
• Berquist-Beringer et al. (2013)
suggests that each variable they
studied should be looked at in more
detail to determine the impact on
pressure ulcer prevention.
Next Steps
• Consult with Nursing Research & EBP
Committee to conduct Randomized
Controlled Trials (RCTs) with clustered
randomization of units across all NYP
campuses to examine relationship
between repositioning interval and
HAPUs (2, 3 and 4 hour turning or
combination of).
• Increase frequency of Skin Care
Resource Nurse Program seminar and
make attendance mandatory for all new
nurses and aides on Med-Surg units.
References
NewYork-Presbyterian Hospital. (10/2015). Pressure Ulcer
Management, PROT 1860. Unpublished internal document.
Bergquist-Beringer, S. Dong, Dunton, N. He, J. (2013) Pressure
Ulcers and Prevention Among Acute Care Hospitals in the
United States. The Joint Commission Journal on Quality and
Patient Safety. Volume 39 Number 9.
Gillespie BM, Chaboyer WP, McInnes E, Kent B, Whitty JA,
Thalib L. Repositioning for pressure ulcer prevention in adults.
Cochrane Database of Systematic Reviews 2014, Issue 4. Art.
No.:CD009958. DOI: 10.1002/14651858.CD009958.pub2.
Moore, Z.E. & Cowman, S. (2012). Repositioning for treating
pressure ulcers. Cochrane Database of Systematic Reviews, 9.
doi:10.1002/14651858. CD006898.pub3.
For more information, please contact: Christopher Boroanka (chb9157@nyp.org), Chamir N. Chouloute (cnc9017@nyp.org), Meagan Groneman (meg9072@nyp.org), Iris Robles (irr9016@nyp.org).

2. Under Pressure
Christopher Boroanka, BSN, RN; Chamir N. Chouloute, BSN, RN;
Meagan Groneman, BSN, RN; Iris Robles, BSN, RN
Research Article/
Author(s)/Year
Methods Results
Level of
Evidence
Gillespie BM, Chaboyer WP,
McInnes E, Kent B, Whitty JA,
Thalib L. Repositioning for
pressure ulcer prevention in
adults. Cochrane Database of
Systematic Reviews 2014, Issue
4. Art. No.: CD00995
The method used for this systemic review were databases to identify
reports of the relevant controlled trials: the Cochrane Wounds Group
Specialized Register ( searched 06 September 2013), the Cochrane
Central Register of Controlled Trials (Central )(2013, issue 8); Ovid
Medline (1948 to August, Week 4, 2013), OVIDE EMBASE(1974 to
2013,Week 35.); EBESCO CINAHL (1982 to August 30,2013; and
reference sections of studies that were included in the review. The
selection criteria used were Randomized Control Trials(RCT's),
Published or unpublished, that assessed the effects of any positioning
schedule or different patient positions and measured PU incidence in
adults in any setting.
This systemic review looked at three RCTs and one economic
study representing 502 randomized participants from acute and
long term care settings. Two of the trials compared the 30
degree and 90 degree tilt using similar
repositioning frequencies. The third RCT trial compared
alternative repositioning between 2-hourly and 3-hourly
repositioning on standard hospital mattress versus the 4-hourly
and 6-hourly repositioning on viscoelastic foam
mattresses. The economic study was looking at cost effective
analysis using data from one of the included parallel RCTs
compared 3-hourlyrepositioning using the 30 degree tilt
overnight with standard care consisting of 6 hour repositioning
using the 90 degree lateral rotation overnight. After analyzing
all three studies the conclusion was that there was not enough
evidence to support the use of repositioning to prevent pressure
ulcers. It is also unknown if particular positions or
frequencies of repositioning reduce pressure ulcer
development.
Level I: Systematic
Reviews and Meta-
Analysis
Bergquist-Beringer, S. Dong,
Dunton, N. He, J. (2013) Pressure
Ulcers and Prevention Among
Acute Care Hospitals in the
United States. The Joint
Commission Journal on Quality
and Patient Safety. Volume 39
Number 9.
This systemic review looked at three RCTs and one economic study
representing 502 randomized participants from acute and long term
care settings. Two of the trials compared the 30 degree and 90 degree
tilt using similar repositioning frequencies. The third RCT trial
compared alternative repositioning between 2-hourly and 3-hourly
repositioning on standard hospital mattress versus the 4-hourly and 6-
hourly repositioning on viscoelastic foam mattresses. The economic
study was looking at cost effective analysis using data from one of the
included parallel RCTs compared 3-hourlyrepositioning using the 30
degree tilt overnight with standard care consisting of 6 hour
repositioning using the 90 degree lateral rotation overnight. After
analyzing all three studies the conclusion was that there was not
enough evidence to support the use of repositioning to prevent
pressure ulcers. It is also unknown if particular positions or
frequencies of repositioning reduce pressure ulcer development.
The study of 710,626, 40%(282,500) of patients were
considered high-risk for pressure ulcers which was determined
by their last Braden score. Within this group 75% of the patients
were repositioned routinely within the last 24 hours. The
surveyors found that a failure to routinely reposition a patient
resulted in a 14% greater likelihood of acquiring a pressure
ulcer in a hospital setting. Level I: Systematic
Reviews and Meta-
Analysis
Moore, Z.E. & Cowman, S.
(2012). Repositioning for treating
pressure ulcers. Cochrane
Database of Systematic Reviews,
9. doi:10.1002/14651858.
CD006898.pub3
A collection of Randomized Controlled Trials and Controlled clinical
trials comparing repositioning with no repositioning, repositioning
techniques and repositioning frequencies were considered for the
systematic review. The participates of the review involved people of
any age, in any healthcare setting with existing pressure ulcers. The
following databases where searched: Cochrane Wounds Group
Specialized Register; The Cochrane Central Register of Controlled
Trials; Ovid MEDLINE, Ovid EMBASE, and EBSCO CINAHL from the
years 2012-2014 and data was collected and analyzed by two review
authors independently.
The searches identified 362 citations. Following independent
review of the titles and abstracts of the citations by two review
authors, no papers met the inclusion criteria. No eligible studies
randomized controlled or controlled clinical trials were
identified. The use of repositioning is an integral part of
pressure ulcer prevention and management however little
evidence exists to base clinical decisions. There is no RCT
evidence that addresses the question of whether repositioning
patients improves the healing rates of pressure ulcers.
Level I: Systematic
Reviews and Meta-
Analysis
For more information, please contact: Christopher Boroanka (chb9157@nyp.org), Chamir N. Chouloute (cnc9017@nyp.org), Meagan Groneman (meg9072@nyp.org), Iris Robles (irr9016@nyp.org).