Effectiveness of Repositioning on the Incidence of Pressure Ulcers - Literature review Example

LITERATURE REVIEW INSITUTION LITERATURE REVIEW FINDINGS The purpose of this study is to find out the effectiveness of repositioning on theincidence of pressure ulcers. Various studies have so far been conducted to determine this fact and they have all yielded different results pertaining to this fact. This study looks at the various studies from different medical sites so as to gain further understanding of this treatment. Most of the studies conducted all concluded that using a 30 degree tilt to reposition persons at risk of pressure ulcers will reduce the risk they are already exposed to. The 1st study on the effectiveness of repositioning was conducted in 16 Belgian nursing homes. The reason behind the choice of nursing homes was that people who stay in them for too long tend to develop pressure ulcer lesions; hence the need to determine prevention measures for the same. The patients selected for the study were averagely 84 years, free of pressure ulcers and who would stay for 3 days continuously at the nursing homes. The patients were carefully placed into two groups; control group and the experimental group. A control group means that the conditions of the experiment remain the same for the participants throughout the study (Vanderwee et. Al, 2007; 12). Patients in the experimental group were repositioned at a 30 degree angle between unequal time intervals while those in the control group were repositioned at the same angle but at a constant interval of 4 hours. At the end of the study, 20 out of the 122 patients in the experimental group developed pressure ulcer while 24 out of the 113 in the control group developed the pressure ulcer. A10% sacral pressure ulcer development was recorded in the experimental group while those who developed the condition on the knees or ankles were around 6%. In the control group, sacral pressure ulcers were recorded at 18% and 3.5 % for the knees and ankles. It was also noted that incidences of pressure ulcers began from day 3 of the study. This is when the nurses in charge began noticing mild changes in the patients’ skins as asked by those conducting the study. Any pressure ulcer that developed before day 4 was regarded a pre-condition to the study. The study aimed at identifying whether or not repositioning of a patient is an effective way of reducing incidences of pressure ulcers. From the findings, it is clear that repositioning plays a role, however small in prevention of pressure ulcers (Vanderwee, et. Al, 2007; 36). There were fewer incidences of pressure ulcers in the experimental group mainly because of more frequent turning that was not liable to any frequency. On the other hand, more incidences were recorded from the control group mainly due to the extensive repositioning period (4 hours). Some patients also complained that the frequent turnings were quite disturbing though they were for their own benefit. Suggestions on other methods of reducing pressure ulcer incidences were also brought forth. For one, it was recommended that the patients would be better off using low-air-loss mattresses and air-fluidized systems. The 2nd study was conducted at the republic of Ireland across 12 long term care institutions of older persons. The people chosen for the study were those who were identified as been in risk of pressure ulcer development and whose medical conditions allowed for the use of repositioning in the course of the study. In total, 213 participants were selected for the study; with 114 of them been enrolled as the control arm while the rest were taken as the experimental arm. Some of the participants were placed on beds while others had the study conducted while they were seated. For those who were seated, 99% of them had a pressure distribution device (86% for control arm and 96% for experimental arm). It is reported that 6 patients died; 3 from the control group and 3 from the experimental group. The chi-squared analysis was used to determine any statistical data used during the course of the study. It was identified that a total of 16 patients developed pressure ulcers; 3 from the experimental group and 13 from the control group. Some of these patients developed pressure ulcers despite the fact that they had pressure redistribution devices throughout the course of the study. According to the chi-square analysis, the pressure redistribution devices do not have any effect as to whether or not one will develop pressure ulcers; all other factors held constant. The study indicates that mobility and activity of a patient are the most probable factors that contribute to the development or lack of pressure ulcers (Moore et. Al, 2011; 8). Notably, most pressure ulcers were developed on the sacrum while the rest were located on the knee. None of the participants recorded a pressure ulcer on the heel. Out of the 16 pressure ulcers developed, 7 were classified as grade 1 while 9 were classified as grade 2. Grades 1 & 2 have so far been recorded as the most severe grade of pressure ulcers. The Irish study was conducted using a demographic profile of people aged 80 years and above; most of whom were women. In the study, mobility and activity were recorded as the highest predictors of pressure ulcer development. Most of the pressure ulcers developed were located in the sacrum, as was earlier recorded in the International Literature for Medicine in 2001. However, it still remains a fact that repositioning plays a huge role in the incidence of pressure ulcer development. The main challenge, in accordance to the study remains finding out how a patient is to be positioned to avoid development of the same. The results of the study are coherent with the recommendations of the International Pressure Ulcer Prevention Guidelines (IPUPG) that a 30 degree tilt and a 3-hour repositioning duration are the most likely prevention angles. The 3rd study was conducted across various nursing homes at the United States of America. Most of these nursing homes have identified that high density mattresses are better repositioning objects as compared to spring foam mattresses. The latter are therefore in a process of been replaced throughout the country. The study, turning for Ulcer Reduction (TURN), aimed at identifying the frequency of repositioning for patients in nursing homes who had been identified as highly susceptible to pressure ulcer development (Bergstrom, 2013; 7). The nursing homes selected for the study were chosen based on the level of services they offered to the residents. Participants were required to be below the age of 65, free of pressure ulcers but still at risk of developing the condition. The recruitment procedures for the study were conducted by highly qualified nurses who followed the procedures as required of them. The study required the residents to continue with their daily routines while still under observation. This meant that they could continue with their therapies, bath and take meals as usual. For those in beds, repositioning was done after every 30 minutes, 2 hours, 3 hours and 4 hours; with a nurse documenting observations after every repositioning schedule. The schedules were different for the chosen participants so as to determine a good repositioning interval. The schedules were also arranged in accordance to the risk group that a participant was placed in; low, middle or high level risk. The results of the study indicated that most pressure ulcers developed on the sacrum as was the case in Ireland. The pressure ulcers developed were also graded to be highest in grade 1 and 2. However, there was no big difference in the development of pressure ulcers based on the previously determined risk groups. The study recorded relatively lower incidences of pressure ulcers, mainly due to the use of high density foam mattresses and frequent turning of the patients under observation. The findings of this study have played a major role in improving the quality of services offered in nursing homes as prevention measures for pressure ulcer development are offered. Like the Irish and Belgian studies, most of the participants in the TURN study were also women. Incidences of pressure ulcers development were reported to be low (2%) for both middle and high risk participants. It was noted that the levels of the condition were lower than expected. This was attributed to the use of high density foam mattresses to reduce pressure on the participants, frequent repositioning and proper documentation to capture their results (Bergstrom, 2013; 10). Documentation served to remind the nurses in charge of the repositioning program to report any observable changes on the patients. The data presented from this study suggests that longer repositioning periods are a very high cause of pressure ulcer development. The next study was conducted across a total of 9 hospitals that are members of the Baltimore Hip Studies Network in the US. Seven of these hospitals were in Maryland while the other 2 were in Pennsylvania. The main aim of the study was to establish whether or not the previously suggested repositioning period of 2 hour was adequate enough to reduce incidences of pressure ulcers. Participants were required to be 65 years and above and to also have undergone hip surgery in any of the selected hospitals. All the patients selected were required to be bed-bound as per the National Clinical Guidelines. The mental and general health status of the patients was assessed before beginning the study so as to determine whether or not they were viable for the numerous turnings they would have to endure. At the end of the study, findings indicted that the patients who developed pressure ulcers developed the grade 2 ulcers. Patients who were frequently repositioned recorded 10% incidences of pressure incidence were those who were repositioned on an interval basis recorded higher incidences of the condition (approximately 13%). The frequency of repositioning was also found to relate highly with the level of risk that a patient had to pressure ulcers. The Braden Scale used during the study indicated that a high risk patient who underwent frequent repositioning had lower chances than one who did not undergo the prevention measure of the condition. In low risk patients, the incidence of pressure ulcer was higher for those who were repositioned frequently than for those who were not. Generally, the results of this study indicate that a 2 hour repositioning of patients with hip fractures is not directly linked to lower incidences of pressure ulcer incidences (Rich, 2010;15). It was noted during the study that there was no significant difference in the number of pressure incidences for patients who were repositioned on a 2 hour interval and those who were turned on a 4 hour interval. Further studies suggest that 2 hours is actually enough to cause simple damage to a person’s muscle tissues. The study also revealed that the patients who were turned on a more frequent basis, with less than 2 hours interval were less likely to develop pressure ulcers. The results of the study suggest that it is important to bear other factors in mind while determining the repositioning period of a patients. Such factors include the general health of the patient and his risk level in relation to pressure ulcers. Any costs related to the repositioning should also be considered as not all people can afford the approximately $15000 associated with this treatment procedure. Studies were also conducted on patients with Caucasian origin and were admitted at a local hospital in the UK. The patients selected were elderly, had no existing pressure ulcers cases but they were at risking of developing the condition if preventive measures were not taken. The study was undertaken to prove the efficiency of a 30 degree tilt compared to a 90 degree tilt in reducing incidences of pressure ulcer among the selected patients. Both degrees of repositioning were applied to patients in the experimental group while those in the control group were subjected only to standard repositioning. It was also estimated that a 30 degree tilt would reduce incidences of pressure ulcers development by around 35 degrees as would be the same percentage decrease with a 90 degree tilt. In the course of the study, the researcher made frequent observations on the patients’ skins to assess if there had been in any changes in the color or any noticeable sores. Whenever he noticed a reddened patch on a patient’s skin, he would gently apply finger pressure on the area to determine whether or not it was tissue damage. At the end of the study, it was recorded that 13% of the patients in the experimental group had incidences of pressure ulcers while only 9% of the control group developed the condition. Out of the 13%, 4% had sacral pressure ulcers while the remaining percentage developed the condition on the knees and the heel. In the control group, the entire 9% developed pressure ulcers on the sacrum. In both groups, it was noted that the patients would frequently move themselves out of the positions that the nurses would place them in. Consequently, repositioning was found to be effective when a patients is also self-mobile and relevant pressure systems are used to aid relief of pressure from areas such as the sacrum, the knee, ankles and the heels. The frequency of repositioning during the study was conducted on a 2-3 hour interval; with varying degrees for the experimental group. The study attributes the high degree of pressure ulcer incidences in the experimental group to lower mobility level among the group members as compared to those in the control group who were more flexible. Discussion At the end of the study, only a small number of the selected sample developed minor signs of pressure ulcers. A larger sample size would therefore be required to rule out the assumption that a 30 degree tilt in repositioning could decrease incidences of pressure ulcers. Consequently, the study found no evidence that repositioning of elderly patients at a certain degree will reduce their chances of developing pressure ulcers in the long run (Young, 2004; 14). Following the results, no patient developed pressure that resulted in epidemical damage. These results could be attributed to the fact that patients were under constant supervision as every night nurses were required to make their observations as the repositioning procedure went on. The use of pressure redistributing mattresses in the hospital also contributed to the decreased reports of pressure ulcers. The study was conducted in a hospital setting, with the nurses helping out in the observations and repositioning of patients. Clinically, it is recommended that a patient ought to be turned every 2 hours and every clinical officer has to obey this rule. Therefore, there was no way the study could have been conducted to prove that even longer repositioning hours are effective. The nurses also ensured that patients who were termed as high to pressure ulcers were placed on high density foam mattresses to help in the redistribution of pressure. Whilst the study aimed at keeping some of this factors constant in all patients, nurses constantly interfered as it was their role to ensure a patient’s comfort in the hospital (Young, 2004; 6). At the end of the study, it was noted that the patients were in frequent movements given that they were elderly and got tired of one position quickly. It was therefore suggested that further studies be conducted to determine viability of mobility in other patients in relation to pressure ulcers incidences. The final study on this issue was conducted at Geriatric Nursing Home where the patients underwent a 4 weeks experimental period. The patients were selected on a Braden score basis where it was supposed to be above 17 for any willing participant. On top of this, written consent either from the patient, his friends, relatives or head nurse of the nursing home was required (Defloor, 2005; 2). The participating patients were grouped and turned according to 4 experimental designs: * turning every 2 h on a standard institutional mattress * turning every 3 h on a standard institutional mattress * turning every 4 h on a viscoelastic polyurethane foam mattress * turning every 6 h on a viscoelastic polyurethane foam mattress. The pressure ulcers to be identified in this study were defined as: 1. Non-blanchable erythema where the skin gained some sort of redness which lasted for more than 1 day and it could not be pressed away by a thumb. This is named as grade 3 and above of pressure ulcers. 2. Pressure ulcer lesion where there would be blistering, deep or superficial pressure on areas such as the sacrum, knees, ankles and heel. In terms of grading, this is the grade 1 or 2 of pressure ulcers. The nursing home nurses were educated on how to identify the above listed symptoms and also on proper documentation of the same. The staff nurse and the researcher were also authorized to make abrupt visits and observations on the patients. A total of 838 patients were subjected to the study. In the course of the study, 23 patients died while 30 were admitted to the hospital due to other medical conditions. At the end of the study, the various findings were made based on the turning schemes earlier identified. The reported incidences of non-blanchable erythema were 47.7% for the 2 hour turning, 44.8% for the 3 hour turning, 42.4% for the 4 hour turning and 46% for the 6 hour turning group. The incidences of pressure ulcer lesions were reported as 14.3% in the 2 hour turning group, 24.1% for the 3 hour turning group, 3% for the 4 hour turning group and 15.9% for the 6 hour turning group. It was noted that the various turning schemes did not have much effect on incidences of non-blanchable erythema. However, the turning intervals had a significant impact on the incidents of pressure ulcer lesions. As indicated above, there are significant differences in the percentages of developing pressure ulcers. The research did not however indicate the duration of time it takes for a pressure ulcer lesion or a non-blanchable erythema to be noticeable (Defloor, 2005; 6). Prior to the study, 43% of the patients had been identified to be at risk of developing pressure ulcers. Research indicates that the cost of prevention for a single patient on a daily basis is around $43.11. However, the high percentage of patients at risk of the condition raises the need to have effective prevention measures. In the course of study, repositioning was identified to play a vital role as a preventive measure for pressure ulcers incidences. As noted, none of the turning schemes led to a reduction of non-blanchable erythema which leads to the conclusion that it cannot be prevented by turning. It is also important to note that this condition disappears as quickly as it appears. When it comes to pressure ulcer lesions, turning plays a vital role in its prevention both for low risk and high risk patients. Conclusion Pressure ulcers are common, costly and impact negatively on health-related quality of life. Immobility is the key risk factor that predisposes an individual to the development of pressure ulcers, thus interventions to combat this risk need to be focused initially on mobility. This is more so for patients who are confined to hospital beds or those who have been discharged but are required to be under bed rest for a considerable amount of time. The patients need to be moved and not allowed to sit in just a single position for lengthy periods of time. Pressure ulcers remain a significant problem; therefore, it is vied that it is now time to reconsider our prevention practices to reduce the commonness and occurrence of what is reflected to be essentially an avoidable problem. This has led to the carrying out of various studies so as to determine the efficiency of repositioning as a way of reducing pressure ulcer incidences. The studies also aim ate establishing proper interval repositioning schedules for patients, either those who are low risk, moderate, high or no risk at all. The studies discussed have studied the effect of different turning intervals on the occurrence of pressure ulcers. In the case of the last study, the use of turning in blend with pressure-reducing positions and materials did not lessen the occurrence of non-bleachable erythema (pressure ulcer grade I). This indicates that turning, however much applied does not save a patient form developing non-blanchable erythema. However, changing position every 4 h on a pressure-reducing mattress in combination with pressure-reducing positions and cushions resulted in a substantial decrease in the number of pressure ulcer lesions (pressure ulcer grades II–IV). This makes turning a feasible preventive method in terms of effort and cost. Similarly, adopting the 30_ tilt and three-hourly transposition has revealed to make a statistically significant alteration to pressure ulcer incidence equated with standard care and would avoid roughly three-quarters of pressure ulcers Another study has provided evidence that shifting interchangeably 2 hours in a sideways position and 4 hours in a horizontal position on a pressure-reducing mattress do not lead to fewer pressure ulcers in contrast with moving every 4 hours. Subsequently, turning more regularly cannot be considered by explanation as a more effective preventive measure of pressure ulcer incidences. In both groups that participated in the study, none of the patients developed a pressure ulcer lesion at the hips. A considerable number of patients changed from sideways to a horizontal position between the turning intervals and were lying in a flat on ones back position for a longer period. A 30 degree position cushion may be a solution to achieve a more stable and comfortable sideways position. Work cited BERGSTROM N, HORN SD, RAPP MP, STERN A, BARRETT R, WATKISS M. (2013). Turning for Ulcer Reduction: a multisite randomized clinical trial in nursing homes. J Am Geriatr Soc The Journal of American Geriatrics Society 61(10), 1705-13. MOORE Z, COWMAN S, CONROY RM. (2011) A randomised controlled clinical trial of repositioning, using the 30° tilt, for the prevention of pressure ulcers. Journal of Clincial Nursing 20, 2633 – 44. K VANDERWEE, M H F GRYPDONCK, D DE BACQUER, TOM DEFLOOR (2007). Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions. Journal of Advanced Nursing 57(1), 59-68. DEFLOOR T, DE BACQUER D, GRYPDONCK MH. (2005). The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers. International Journal of Nursing Studies 42(1), 37-46. YOUNG T. (2004). The 30 degree tilt position vs. the 90 degree lateral and supine positions in reducing the incidence of non-blanching erythema in a hospital inpatient population: a randomised controlled trial. Journal of Tissue Viability 14(3), 88-96. RICH SE, MARGOLIS D, SHARDELL M, HAWKES WG, MILLER RR, AMR S, BAUMGARTEN M. (2010). Frequent manual repositioning and incidence of pressure ulcers among bed-bound elderly hip fracture patients. Wound Repair and Regeneratioin 19(1), 10-18. Read More