Turning and Repositioning Frequency to Prevent Hospital-Acquired Pressure Injuries Among Adult Patients: Systematic Review

Abstract

Turning and repositioning is considered one of the strategies to reduce the incidence of pressure injuries (PIs) among hospitalized patients, as it helps to redistribute and minimize direct pressure on the targeted skin and enhance blood perfusion in the affected areas. The frequency of turning and repositioning is generally uniform across clinical settings, with most clinical guidelines recommending a substantial change in a patient’s position according to their health status. Notably, the optimal time interval between the position changes has not yet been established. Therefore, this study aimed to review the current literature in relation to the frequency of turning and repositioning adult patients to prevent PIs. The author used a systematic review following Whittemore and Knafl’s review strategy. The author used the following databases: CINAHL, Scopus, PubMed, ProQuest, Ovid, MedLine, Web of Science, and Google Scholar. During the search, Boolean logic operators, MeSH terms, and keywords were utilized. The researcher followed the Johns Hopkins Nursing Evidence-based Practice Grading Scale to evaluate the quality of selected studies. The search yielded 723 articles, of which 10 were included in this review. These 10 articles revealed several frequency intervals for comparison purposes: 2-hourly, 3-hourly, 4-hourly, and 6-hourly depending on the healthcare setting, with a combination of supine, 30° tilt, or 90° tilt. This review shows that the optimal frequency of turning and repositioning to prevent PIs remains unclear and further investigation is necessary. Considering the varying nature of clinical settings, there is a lack of clarity regarding a golden standard for the same. Therefore, patients’ health conditions should be considered when choosing the proper frequency to prevent PIs.

• What do we know so far about the topic?

• PIs are adverse events that require serious attention from healthcare providers, particularly nurses. Nurses play a crucial role in preventing PIs by using different prevention measures such as repositioning patients.

• What contribution does this research make to the field?

• This review provides an overview of the ideal frequency of turning and repositioning in different healthcare settings. This could help policymakers update their policies related to the same.

• What are the implications of the research for theory, practice, or policy?

• Identifying the optimal frequency of turning/repositioning is fundamental for preventing PI in healthcare settings. Additionally, nursing researchers should be encouraged to undertake further research to investigate the factors that influence the effectiveness of turning frequencies on the development of PIs.

Introduction

In 2017, the National Pressure Ulcer Advisory Panel (NPUAP) attempted to phase out the term pressure ulcer, recommending that pressure injury (PI) be used in its place. In contrast to the term pressure ulcer, PI encompasses both intact and ulcerated skin. ¹ A PI is defined as any destruction of the skin layers in certain areas due to malnutrition or the application of physical pressure for prolonged periods, especially continuous pressure on bony prominences or areas beneath medical devices, such as ventilators and nasogastric tubes. ¹ This process of skin destruction undergoes 6 stages (1, 2, 3, 4, unstageable, deep tissue, and mucosal membrane pressure injury stages), depending upon the severity of the destruction. ¹ PIs are a serious health issue that affect patients’ overall prognosis. PIs are often used as a quality care indicator.^2,3 PIs can lead to a number of complications and have been a factor in increasing the risk of death, specifically among the elderly. ³ Globally, the PI prevalence rate was 12.8% and the incidence rate was 8.4% among hospitalized patients. ⁴ In addition, PIs increase patients’ experience of pain, result in extended hospitalization, and increase the risk of secondary infections.^5,6 Therefore, PIs increase the total treatment cost and are a burden on the health care system budget. In the US, PIs usually cost approximately $11 billion annually. ⁷

Pressure injuries are typically considered avoidable and may develop when the healthcare provider neglects to adequately evaluate the patient’s illness and PI risk factors. ² Failing such timely evaluation, the health care provider is unlikely to plan and implement appropriate interventions, oversee and evaluate the effectiveness of interventions, or change interventions as appropriate. ⁹ Nonetheless, PIs may develop despite the best efforts of the healthcare provider. ⁹ In these cases, accurate evaluation and monitoring of the patient, from the moment of their admission, may help to predict the patient’s risk of developing a PI, thus allowing appropriate care to be implemented early on.^2,8,9

Several strategies can be used to prevent or reduce PIs in patients with immobility or movement difficulties. One of the more popular strategies involves frequent turning and repositioning of patients. This helps to reduce and redistribute direct pressure on the targeted skin and enhance blood perfusion in the affected area. ¹⁰ The frequency of turning and repositioning is generally uniform across clinical settings, with most clinical guidelines recommending a substantial change in the patient’s position every 2 h. ¹⁰ However, questions have been raised regarding the effectiveness of 2-hourly turning in terms of reducing or preventing the occurrence of PIs. Consequently, the literature has explored the efficacy of alternate turning and repositioning schedules, including 3-hourly, 4-hourly, and 6-hourly schedules. Much of the research on turning and repositioning has explored the effects of using different positioning angles.

The preferred position for distributing pressure equally underneath patients is the flat position, which helps to minimize shearing and prevent sacrum/coccyx PI. ¹¹ However, patients cannot be placed in a flat position if they are on mechanical ventilation or a nasogastric tube. As a result, elevating the head of the bed in certain conditions helps to prevent ventilator-associated pneumonia or aspiration with enteral feeding. ¹¹ In such a condition, one recommendation is to elevate the head of the bed by 30° or less, which may play an important role in decreasing the risk of developing a PI. ¹¹ This degree of elevation is also considered good for preventing aspiration, especially among critically ill patients. While a combination of turning, repositioning, and bed head elevation is widely used for the prevention of PIs, a debate rages about what constitutes the best turning and repositioning frequency, especially in the presence of pressure-relieving devices.^8,12 Therefore, this study aimed to review the current literature in relation to the frequency of turning and repositioning adult patients to prevent PIs in different healthcare settings.

Method

A systematic review was undertaken to evaluate the existing literature on the optimal frequency of repositioning in relation to preventing pressure injuries among adult patients. The researcher followed Whittemore and Knafl’s ¹³ review strategy, which is divided into 5 stages: formulating the problem, searching the literature, evaluating the data, analyzing the data, and presenting the data. ¹³

Source of Information

From December 2022 to February 2023, the researcher searched the following databases: CINAHL, Scopus, PubMed, ProQuest, Ovid, MedLine, Web of Science, and Google Scholar. The Boolean logic operators (AND, OR, NOT) were employed for this search. In addition, the researcher specified MeSH terms and keywords as the following: pressure ulcer, pressure injury, turning, repositioning, frequency, and nursing.

Inclusion and Exclusion Criteria

All studies included in this review were published in English, with no date limit. These included randomized controlled studies, cohort studies, retrospective studies, observational studies, and pilot studies. In addition, the selected studies target adult patients older than 18 years at any risk level of PI. The excluded studies were reports, qualitative, opinions, written in non-English language, and systematic reviews and meta-analyses.

Process of Data Selection and Extraction

The PRISMA flow chart presented in Figure 1 shows the selection process. This chart reveals the number of studies included or excluded. After identifying the initial revealed studies, the researcher skimmed and scanned them to remove the unrelated/non-illegible studies. Then, the researcher checked for duplications for the remaining studies by using the Zotaro software. The remaining studies were checked by reading the titles and abstracts. Afterward, the researcher read the full texts, which led to the exclusion of illegible studies. Then, the researcher re-read the full texts of the final remaining studies. The researcher used Microsoft Word to create a table displaying the studies’ characteristics such as author, year, title, aim, design, population, setting, country, intervention, and results (Table 1).

Figure 1.

PRISMA flow chart of studies that are eligible for meta-analysis.

Table 1.

Characteristics of the Nine Studies Involved in the Meta-Analysis.

Author, Year, Title	Aim	Design	Population/Setting	Intervention	Finding	Comment	Level of evidence/Quality
Bergstrom et al. 12 (2013). “Turning for Ulcer Reduction: A Multisite Randomized Clinical Trial in Nursing Homes.”	To investigate optimum frequency of turning among nursing home (NH) tenants who at risk of pressure ulcer and use high-density foam mattresses.	Multisite RCT	(942) NH residents aged 65 years or older. With no PUs. (20) NH in the USA, and (7) in Canada.	Using 3 different turning intervals: 2 h (n = 321), 3 h (n = 326), and 4 h (n = 295). Turning should be within ± 30 min. CNAs are responsible for patients turning. Documentation process. High-density foam mattresses were used.	• 21 PUs (stages I[n = 2] & II[n = 19]) were developed on 19 participants during the study period. • 18 in the sacrum area, 1 in the trochanter, and 2 in the heels. • There was no sig. difference between three groups (2, 3, & 4 h) in term of PU incidence. • 8 participants developed PUs among 2 h group. 2 participants developed PUs among 3 h group. 9 participants developed PUs among 4 h group. • There was no sig difference between at risk level. Also, there was no sig difference between length of stay (≤7 days or ≤90 days).	Braden Scale was used. Participants at moderate (13-14) or at high (10-12) risk. PU incidence rate was 2%. Most of the participants were female (77.6%) Recommendation: using the combination of turning (3 & 4 h), foam mattress, and documentation are the best way to prevent PUs in moderate and high at risk patients. The study period from 2008 to 2011. The measure obtained in the base of 3-week.	Level I & high quality A Level 1/High Quality—A
Vanderwee et al. 18 (2007). “Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions.”	To examine PUs incidence rate of turning pts interchangeably 2 h on lateral 30° and 4 h semi-Fowler 30° positions compared with 4 h turning only.	RCT	(235) NH patients with stage one of PU, spent more than 3 days in NH, and aged 82 and older. NHs in Belgium.	Intervention group (n = 122) had interchangeably 2 h on lateral 30° and 4 h semi-Fowler 30° positions. Control group (n = 113) had 4 h turning only with the same positions in the intervention group. Both groups had foam mattresses. Pts should stand up every 2 h.	• 20 PUs were developed among intervention group. 13 (sacrum area) and 7 heels. Also, 17 with stage II and 3 with stage III or IV. • 24 PUs were developed among control group. 20 (sacrum area) and 4 heels. 22 with stage II and 2 with stage III or IV. • There was no sig difference btw two groups. • Age, sex, BMI, Braden score, nursing home, maximum duration of sitting and mobility were not statistically sig to PUs incidence.	Using pillows to support back and cushion to release pressure from heels. Nurses received training about Pressure Ulcer Classification (PUCLAS). Small sample size. Braden scale was used for the assessment. Most of the participants were female (n = 196). Recommendation: using foam mattresses and 4 h repositioning help to reduce PUs incidence rate. The study period was from 2003 to 2005.	Level I & good quality B Level I/Good Quality—B
Rich et al. 16 (2011). “Frequent manual repositioning and incidence of pressure ulcers among bed-bound elderly hip fracture patients.”	To identify the association between frequent manual 2 h turning and PUs incidence rate.	Prospective Cohort	(269) bedbound patients aged 65 years or older and with hip fracture surgery. (7) hospitals in Maryland and (2) in Pennsylvania.	Turning patients’ information were gathered from nursing flow sheet by a RN expert on EMR. A trained research nurse assessed skin as soon as possible after the admission as a baseline. Patients had 11 assessments during 21 days.	• There was no association between 2 h repositioning and reducing or preventing PUs. • Patients developed Stage II and higher.	Braden Scale was used. Observational design. Focused on patients with hip fracture, and mainly at high risk of developing PUs. The period of the study was from 2004 to 2007.	Level III & good quality B
Manzano et al. 21 (2014). “Comparison of two repositioning schedules for the prevention of pressure ulcersin patients on mechanical ventilation with alternating pressure air mattresses.”	To establish a comparison between 2 h and 4 h turning intervals in preventing PUs incidence.	RCT	(329) ICU patients on mechanical ventilator (MV) and alternating pressure air mattress. With no PUs. Two mixed ICUs at one hospital in Spain.	Intervention group (n = 165) had 2 h repositioning interval. Control group (n = 164) had 4 h repositioning interval. Positions applied for both groups: [left side with 30° tilt, supine with 30° elevation of the head end and the foot end of the bed, and right side with 30° tilt].	• 17 (10.3%) of the intervention group develop stage II of PU and higher. • 22 (13.4%) of the control group develop stage II of PU and higher. • 47.9% (79 patients) of the intervention group had a device related adverse event. • 36.6% (60 patients) of the control group had a device related adverse event.	RN to patient ratio 1:2. APACHE II was used. Inability to blind nursing staff. The period of the study was from 2009 to 2011. The measure obtained in the base of 28-day.	Level I & good quality B
Moore et al. 15 (2011). “A randomized controlled clinical trial of repositioning, using the 30° tilt, for the prevention of pressure ulcers.”	To compare three hourly 30° repositioning with routine practice to prevent PUs among elderly patients.	Cluster RCT	(213) elderly patients aged from 65 and above. With no PUs. (12) hospitals in Ireland.	Intervention group (n = 99) distributed in 10 different hospitals; [turning patients every 3 h at night with using 30° tilt]. Control group (n = 114) distributed in 2 hospitals; [(routine care) turning patients every 6 h at night with using 90° tilt].	• Intervention group had 3 (3%) patients with PUs, in 3 of 10 hospitals (one patient in each hospital). [One of three PU at stage I, and two of three PUs at stage II]. • Control group had 13 (11%) patients with PUs, in both hospitals (3 & 10 patients). [6 PUs of 13 at stage I, and 7 of 13 at stage II].	Braden scale was used. 12 hospitals have the same level of care. These findings support international guidelines (EPUAP & NPUAP). Recommendation: every 3 h turning with 30° tilt shown benefits to prevent PU better than the other technique. The period of the study was 28 days. The measure obtained in the base of 4-week.	Level I & high quality A
Defloor et al. 14 (2005). “The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers.”	To investigate the effectiveness of turning patients every 2 h or 3 h with using standard mattresses, and turning patients every 4 h or 6 h with using foam mattresses.	RCT	(838) nursing home patients. (11) nursing homes in Belgium.	Intervention groups (n=262): 1. (65) patients had 2 h turning with using standard mattresses. 2. (65) patients had 3 h turning with using standard mattresses. 3. (67) patients had 4 h turning with using foam mattresses. 4. (65) patients had 6 h turning with using foam mattresses. 5. Control group (n = 576) patients received usual care.	Intervention Groups (n = 250 remaining): • Group One (n = 63 remaining): PUs developed, Stage I = 30, Stage II = 7, Stage III = 0, Stage IV = 2. • Group Two (n = 58 remaining): PUs developed, Stage I = 26, Stage II = 12, Stage III = 1, Stage IV = 1. • Group Three (n = 66 remaining): PUs developed, Stage I = 28, Stage II = 2, Stage III = 0, Stage IV = 0. • Group Four (n = 63 remaining): PUs developed, Stage I = 29, Stage II = 8, Stage III = 0, Stage IV = 2. • Control group (n = 511 remaining): PUs developed, Stage I = 220, Stage II = 73, Stage III = 25, Stage IV = 4. Generally: There was no difference to reduce stage I (NBE) in all intervention groups compared with the control group. However, the lesion stages were significantly reduced by combining turning and use foam mattresses compared with the turning only.	Braden and Norton were used. The semi- Fowler and lateral position was used with elevating bed head and foot end with 30°. Recommendation: turning patients every 4 h with using foam mattresses and cushions significantly reduce stages II to IV. The measure obtained in the base of 4-week.	Level I & high quality A
Wong 19 (2011). “Skin Blood Flow Response to 2-Hour Repositioning in Long-term Care Residents.”	To examine the variations of transcutaneous oxygen (tcO2), skin temperature, and hyperemic response during turning patients every 2 h.	Pilot Study	(9) elderly participants aged from 68 to 100 years. One nursing home. United States	Oxygen and temperature were used to be attached on sacrum, heels, and trochanters. Patients turning procedure: • (preload) 30 min laterally. • Then, (load) supine position with 30° bed head elevated for 2 h. • Then, (unload) turning patients laterally (right or left with 30°) for 2 h.	There was no sig result in changing the tcO2 and skin temperature during three turning procedure on the three areas (sacrum, heels, and trochanters). The 2 h turning need more investigation specially the supine positioning because oxygen level decreased to <40 mm Hg on the sacrum area.	Braden Scale was used. The period of the data collection 5 h.	Level III & good quality B
Still et al. 17 (2013). “The turn team: A novel strategy for reducing pressure ulcers in the surgical intensive care unit.”	To determine if a devoted team specialized to turn stable surgical ICU patients could reduce PUs incidence.	Hospital-based study	(507) stable SICU patients with mean age 57 years.	Pre-intervention (n = 278 patients); nurses were encouraged to turn and reposition patients frequently without specific frequency. Then, 15 official inspections for PU prevalence rate between DEC. 2008 to MAR. 2010. Post-intervention (n = 229 patients); RNs and PCAs received online training on how to reposition and use Braden scale. Two PCAs (turning tem) were responsible to the patients every 2 h. this intervention was btw APR. 2010 to SEP. 2010.	Pre-intervention period:(n = 42 of 278 patients) developed PUs detected. (Stage I = 7, Stage II = 27, and stage III and above = 8). Post-intervention period:(n = 12 of 229 patients) developed PUs. (Stage I = 2, Stage II = 5, Stage III and above = 5). The most frequent location was “Sacrum” area in both groups.	Braden scale was used. EP Pre-intervention used “point prevalence approach.” Patients have to be hemodynamically stable.	Level II & high quality A
Young 20 (2004). “The 30° tilt position vs the 90° lateral and supine positions in reducing the incidence of non- blanching erythema in a hospital inpatient population: a randomized controlled trial.” Yap et al. 23 (2022) “Effect of Varying Repositioning Frequency on Pressure Injury Prevention in Nursing Home Residents: TEAM-UP Trial Results.”	To compare 30° tilt position with 90° tilt and supine positions in to reduce stage I PUs. This study aims to investigate the clinical effectiveness of three nursing-home-wide repositioning intervals (2-, 3-, or 4-h) without compromising pressure injury (PrI) incidence in 4 weeks.	RCT RCT	(46) elderly patients in medical ward. Participation period was 1 night. Wales 992 residents from nine NHs were fitted with sensors. United States	Intervention group (23): 30° tilt position with 2 to 3 h frequency range. Control group (23): 90° tilt and supine positions with 2 to 3 h frequency range. Baseline (12 months) and 4-week intervention data were provided during the TEAM-UP (Turn Everyone And Move for Ulcer Prevention) study Nursing Homes assigned randomly in one of the three intervals (2, 3, or 4 h).	Intervention group (n = 3 of 23 patients) developed stage I PUs. Control group (n = 2 of 23 patients) developed stage I PUs. There was no statistical differences found in the both groups. The PrI incidence during the intervention was 0.0% compared with 5.24% at baseline, even though intervention resident clinical risk scores were significantly higher (P < .001). Repositioning compliance for the 4-hour repositioning interval (95%) was significantly better than for the 2-h (80%) or 3-h (90%) intervals (P < .001).	Waterlaw risk assessment was used. Most of the participant repositioned their selves independently. Differences in first Braden Scale scores and mean total Braden Scale scores across arms within the intervention period were compared separately using either analysis of variance or χ2 analyses. Paired t tests evaluated differences in mean total Braden Scale scores between baseline and intervention cohorts by arm. Two-sided tests (P < .05)	Level I & good quality B Level I & Good Quality B

Quality of Evidence

Measuring the quality of evidence is important to examine the match between studies’ methodology and inferences. ²² For this systematic review, the researcher utilized the Johns Hopkins Nursing Evidence-based Practice Grading Scale to evaluate the quality of selected studies. This scale has 5 main domains: sufficiency of the sample size, reliability and validity of the used tools, generalizability of the findings; and constancy between literature reviews, methods, results, recommendations, and conclusions. ²² In this scale, the quality level is divided into 3 levels: level A studies were indicated as high-quality studies; level B studies were indicated as good-quality studies; and level C studies were indicated as low-quality studies (Table 1).

Findings

A preliminary search yielded 723 articles. The exclusion criteria were as follows: 629 articles did not meet the inclusion criteria, 77 were duplications, 4 were systematic reviews, 2 were not empirical studies, and one targeted a healthy adult. As a result, 10 articles that met the purpose of this systematic review were identified (See Figure 1).

After conducting a comprehensive search, the 10 selected articles were investigated and summarized, as shown in the literature matrix (Table 1). The 10 articles employed a combined or pooled sample of 4489 patients, and were published between 2004 and 2022. The 10 studies discussed in this review were conducted over a range of settings, including 6 nursing homes (NHs), 2 intensive care units (ICUs), and 2 medical-surgical units. In addition, the selected studies were conducted in 6 countries: the US,^12,16,17,19 Canada, ¹² Belgium,^14,18 Spain, ²¹ Ireland, ¹⁵ and Wales. ²⁰ The 10 articles differed somewhat in terms of research design. Seven were randomized controlled trials (RCTs), and 3 were observational studies (2 prospective designs, one before and one after design). The Braden Scale for Predicting Pressure Sore Risk was the most frequently used PI risk assessment instrument among the 10 studies.^{12,14 -19} Other assessment tools used in the reviewed studies included the Water-Law Risk Assessment Scale, ²⁰ APACHE II, ²¹ Norton Pressure Sore Risk-Assessment Scale, ¹⁴ and an unspecified risk assessment. ²²

The turning and repositioning of patients is essential for alleviating localized pressure on certain skin areas and for increasing blood flow to those areas.^{12,14 -21,23} Guidelines from the Wound, Ostomy & Continence Nurses Society indicate that the frequency of repositioning should be determined by the individual’s tissue tolerance, level of activity and mobility, skin condition, overall medical condition, treatment goals, type of pressure redistribution surface in use, and comfort of the patient. ²⁴ Despite these recommendations, the incidence of PI remains exceptionally high across most healthcare organizations. Therefore, the authors of the 10 selected studies investigated one or more of the 4 main turning and repositioning frequencies: 2-hourly, 3-hourly, 4-hourly, or 6-hourly. These frequencies were combined with one or more of the 3 positions: supine, 30° tilt, or 90° tilt.^{12,14 -21,23} Each of these studies attempted to draw a clear conclusion about what constitutes the best frequency for the prevention of PIs in 3 healthcare settings: nursing homes (NHs), intensive care units (ICUs), and medical and surgical units.

The 3 healthcare settings were extracted as 3 themes. The reason behind identifying themes according to healthcare settings is that severity of illnesses and quantity of administered medications are different among settings. Those 2 conditions may play an important role in influencing patients’ skin integrity and tolerance. As a result, nurses should select appropriate PI prevention measures such as frequency of turning and repositioning. In addition, the technology used in each healthcare setting varies, such as the availability of standard and foam mattresses. ¹⁴ Furthermore, the diversity of nursing workload in each healthcare setting should be considered when deciding the frequency of turning and repositioning.

Nursing Homes

Six studies were conducted in different NHs.^{12,14,15,18,19,23} NHs are a logical choice of setting for PI studies because residents stay longer in these facilities than they do in hospitals.^{12,14,18,19,24} A multi-site RCT was conducted with a sample of 942 residents across 20 NHs in the US and 7 in Canada. ¹² Residents identified as moderate or high risk for PI development based on Braden scores were distributed across 3 turning interval groups (ie, 2-hourly, 3-hourly, and 4-hourly). All residents were placed on foam mattresses, and residents with a history of PI were excluded. ¹² This RCT failed to produce any statistically significant results between the 3 intervals with respect to the incidence of PIs, regardless of risk level or length of stay. ¹² Twenty-one PIs were found in 19 residents, with PIs varying from Stage I to Stage II. ¹² Of 19 residents, 8 were turned every 2 h, 2 were turned every 3 h, and 9 were turned every 4 h. ¹²

Defloor et al. ¹⁴ conducted an RCT trial of 761 NH residents (intervention group, n = 250; control group, n = 511) over 11 NHs. The intervention groups were divided into 4 cohorts: the first cohort used standard mattresses with 2-hourly turning; the second cohort used standard mattresses with 3-hourly turning; the third cohort used pressure-reducing viscoelastic foam mattresses with 4-hourly turning; and the fourth cohort used pressure-reducing viscoelastic foam mattresses with 6-hourly turning. All of those cohorts were compared with the control group, which received standard preventative care. Forty-one (65.1%) of 63 residents who were placed in the first cohort developed Stages 1 (30), 2 (7), and 2 (2) PIs. ¹⁴ Forty (67%) of 58 residents who were assigned to the second cohort developed Stages 1 (26), 2 (12), 3 (1), and 4 (1) PIs. ¹⁴ Interestingly, 30 (54.5%) of 66 residents placed in the third cohort developed Stages 1 (28) and 2 (2) PIs only. ¹⁴ Among the 63 residents assigned to the fourth cohort, 39 (62%) developed Stages 1 (29), 2 (8), and 4 (2) PIs. ¹⁴ However, among the control group, 220 (43.1%) residents developed Stage 1 PIs; 73 (14.3%) residents developed Stage 2 PIs; 25 (4.9%) residents developed Stage 3 PIs; and 4 (0.8%) residents developed Stage 4 PIs. ¹⁴ This RCT did not detect any significant differences in the development of Stage I PIs across the intervention and control groups. ¹⁴

An RCT involving a sample of 213 elderly patients in a long-care unit compared the efficacy of 3-hourly and 6-hourly turning to prevent PI. ¹⁵ The intervention group (n = 99) was turned every 3 h at night using a 30° tilt, and the control group (n = 114) was turned every 6 h at night with a 90° tilt. ¹⁵ In total, 16 patients developed Grade 1 or 2 PIs with a statistically significant difference between the groups, with only 3 patients in the intervention group and 13 in the control group. ¹⁵

Another RCT was conducted on 235 NH patients with Stage I PI. All residents in this study were already using a foam mattress. ¹⁸ The intervention group was turned using unequal intervals according to the following schedule: 2 h on lateral 30°, and 4 h on semi-Fowler at 30°. ¹⁸ The control group was simply turned using equal intervals on a 4-hourly basis using the same positions as the intervention group. ¹⁸ It was found that 20 (16.4%) of 122 patients in the intervention group developed Stage 2 (17) PIs, and 3 developed Stage 3 or 4. Among 113 patients in the control group, 24 (21.2%) developed Stages 2 (22) and 3 and 4 (2) PIs. ¹⁸ The incidence, severity, location, and time for developing PIs were not statistically significant between the intervention and control groups.

A pilot study of 9 NH residents was conducted to examine variations in transcutaneous oxygen (tcO₂), skin temperature, and hyperemic response while turning patients. Turning the patients was achieved in the following steps: lateral pre-load position for 30 min, turning supine with the head of the bed elevated 30°, and sacrum and heels on the bed for 2 h, followed by positioning lateral again for 2 h. ¹⁹ The results of this study reflected that 6 out of 9 people had a hyperemic reaction when the position was moved from supine to a lateral position. Only a third of the people had sacral tcO₂ of 40 mmHg or higher at the end of 2 h of lateral positioning. The tcO₂ for both heels went down in the first 30 min after loading. ¹⁹ Prolonged supine position for 2 h decreased sacral oxygenation (tcO₂) to below 40 mmHg in some subjects, irrespective of preload tcO₂. Lateral repositioning after 2 h of supine placement did not result in tcO₂ returning to preload levels. ¹⁹

A recent RCT ²³ was conducted on 992 nursing home residents from 9 NHs in 34 states. In this study, 3 intervals (2, 3, and 4) were used for repositioning. The 9 NHs were randomly assigned to one of these intervals. ²³ In each NH, the residents were attached to sensors that provided signals for the nurses regarding residents’ repositioning. ²³ Yap et al. ²³ found that after implementing the TEAM-UP intervention, the PI incidence rate was 0% compared to the baseline, which was 5.24%.

The results of the 6 studies showed variations in the PI incidence rates regardless of the frequency used. Several studies found that 2-hourly turning with a combination of standard or foam mattresses did not prevent PIs.^12,14,15,18 During 2-hourly turning intervals, patients developed PIs staged between 1, 2, and 4.^12,14,15,18 These results confirmed that 2-hourly turning is not enough to allow blood flow to nourish the affected area. ¹⁹ In addition, 2 studies found that the 3-hourly turning interval did not prevent the development of PIs among nursing home residents.^12,14 However, the 4-hourly turning interval with a combination of foam mattresses showed a significant reduction in the incidence of PIs staged between 3 and 4, compared with more frequent turning on the standard mattress or less frequent turning on the foam mattress.^14,18,23

Intensive Care Units

Two studies were conducted in ICU settings to determine appropriate turning intervals.^17,21 Still et al. evaluated the effectiveness of a turn team in preventing PIs. ¹⁷ Using data from point prevalence surveys, the authors compared hospital-acquired pressure injury rates before and after the implementation of designated turn teams. The intervention involved turning patients using 2-h intervals with a combination of pressure relief mattresses. ¹⁷ Baseline data showed 42 (15.11%) PIs among 278 patients, including 34 Stage 1-2 cases and eight higher stages cases. Following the implementation of the turn team, 12 (5.24%) PIs were identified in 229 patients (P < .0001), with seven Stage 1-2 and five higher stages cases.

Manzano et al. ²¹ conducted an RCT of 329 ventilated patients in 2 ICUs where alternative pressure air mattresses were used as support surfaces. These patients were randomly assigned to either the intervention group (n = 165) with 2-hourly repositioning, or the control group (n = 164) with 4-hourly repositioning. ²¹ In both groups, repositioning followed by the following sequence: left side with a 30°-tilt, supine with a 30°-elevation of the bed head and the foot end of the bed, and right side with a 30°-tilt. ²¹ Eventually, both intervention and control groups in the RCT developed Stage 2 and higher PIs. ²⁰ PIs developed in 17 (10.3%) patients in the intervention group, ²¹ 22 (13.4%) patients in the control group; however, the results showed no statistically significant difference between both groups. Measurements of daily nursing workload between the groups were statistically significant, with median minutes per day devoted to turning 21 min/patient in the intervention group compared to 11 min/patient in the control group. ²¹

Those 2 studies used 2-hourly turning frequency combined with support surfaces such as air mattresses as PI preventive measures.^17,21 Also, they found that using unspecified frequency ¹⁷ and 4-hourly frequency ²¹ did not help to prevent or reduce the incidence of PIs among ICU patients.

Medical and Surgical Units

Three studies investigated the turning intervals among patients in medical and surgical units. These studies included one RCT ²⁰ and prospective studies. ¹⁶ Young ²⁰ conducted an RCT in 46 medical patients to compare a 30°-tilt position with a 90°-tilt and a supine position to reduce the incidence of PIs. In this RCT, the intervention group (n = 23) was placed in a 30° tilt and supine position within 2 to 3 h. The control group (n = 23) was placed in a 90° tilt and supine position within 2 to 3 h. ²⁰ However, 7 of the 46 patients could not adhere to the study guidelines for the whole night, leaving only 39 participants. ²⁰ Five of the 39 patients who completed the study developed non-blanchable erythema (3 from the experimental group and 2 from the control group). There was no significant difference between the 2 groups. ²⁰ An evaluation of the feasibility of the 30° side-lying position revealed that 78% of the participants had difficulty achieving or maintaining their position. ²⁰

A prospective study was conducted to examine the association between the incidence of PI and 2-hourly turning. ¹⁶ The findings of this study are based on data collected from 269 elderly bed-bound patients (aged > 65 years) following hip surgery. ¹⁶ Of 269, 134 patients were repositioned after at least every 2 h, and 130 patients were repositioned less frequently. ¹⁶ Among the 134 patients repositioned every 2 h, 10 (7.46%) developed PIs greater than Stage 1. ¹⁶ However, 12 of the remaining 130 patients developed PIs greater than Stage 1. ¹⁶

Discussion

The purpose of this systematic review was to review the current literature in relation to the frequency of turning and repositioning adult patients to prevent PIs in different healthcare settings. After reviewing the findings of the 10 studies, it is clear that PIs, especially Stages I and II, were detected in all 10 studies.^{12,14 -21,23} This implies that no intervention is capable of completely preventing PIs. However, there are discrepancies in the findings of these studies with respect to the frequency of turning and repositioning. These discrepancies make it difficult to identify the optimal frequency of turning and repositioning to prevent PIs.

Three of the NH studies tested turning/repositioning at 2-hourly, 3-hourly, 4-hourly, and 6-hourly intervals. There was consensus with respect to 4-hourly turning and repositioning with the use of foam mattresses.^12,14,18,23 This combined approach appears important in the prevention of PI Stages II and IV, which are considered adverse events.^12,14,18,23 However, Stage I and II PIs were present in participants who received 2-hourly turning/repositioning.^{12,14,15,18,23} Therefore, one study indicated that 2-hourly turning and repositioning is not an optimal practice because the area is subjected to high pressure,^15,19 thus resulting in insufficient blood perfusion, and tcO₂. ¹⁹ The controversy between studies supports the Wound, Ostomy & Continence Nurses Society guidelines, which recommend turning patients according to their needs and situations as standard care. ²³ These conclusions might be influenced by several factors; firstly, the NHs in these studies were located in the US,^12,19 Canada, ¹² Belgium, and Ireland.^14,15,18 Therefore, the nature of NHs services in each country may vary. The second factor is that NH residents are typically aged ≥ 65 years. Moreover, NH residents typically experience several health issues simultaneously, making PIs more difficult to prevent. Third, in most NHs, turning and repositioning are activities primarily performed by nursing assistants. These nurse staff often have limited knowledge with respect to the pathology of PIs, nor do they necessarily appreciate the importance of turning and repositioning; therefore, nursing assistants should be provided with additional training sessions to ensure that they have a more comprehensive understanding of the importance of turning and repositioning.^12,14,18 These differences between registered nurses and nursing assistants also mean there may be some discrepancies in terms of reporting or documenting the status of PIs.

The ICU setting is also a critical location where patients are seldom well enough to move independently given the seriousness of their illness. Two studies in this review investigated 2-hourly turning and repositioning in ICU patients.^17,21 In both studies, the patients still developed PIs despite this 2-hourly intervention.^17,21 However, Manzano et al. ²¹ neglected to identify the stage of PIs in relation to frequency; Still et al., ¹⁷ on the other hand, did report the PI stages. From these outcomes, it seems that the special circumstances of ICU patients may lead to PIs. Neither of these studies recommended an optimal turning/repositioning schedule for patients in the ICU. Nevertheless, both studies^17,21 suggested the benefit of 2-hourly repositioning. Although through designated turn teams to ensure more consistent repositioning, Manzano demonstrated a slight decrease with 2-hourly turning versus 4-hourly turning, the effect was not statistically significant; this study may be performed on a larger sample.

Patients in medical and surgical units may develop PIs if they are required to remain hospitalized and have limited mobility for long periods. In the prospective cohort study, ¹⁶ the authors had no control over the confounding variables because they relied on data extracted from the electronic medical record. One RCT studies ²⁰ were also conducted with patients in medical units. This RCT confirmed that 3-hourly turning/repositioning with a 30° tilt could be effective in reducing the incidence of PIs. ²⁰ However, this RCT observed participants for only a single day in a single hospital unit. ²⁰ As such, the results of these studies do little to shed light upon the ideal frequency for turning/repositioning patients to prevent PI.

In summation, 2-hourly turning/repositioning does not seem to be the optimal frequency. At this frequency level, the demand for nurses’ workload increases, and the outcome in terms of the incidence of PI remains largely unchanged. Therefore, considering patients’ health status and then determining the frequency of turning and repositioning them is the best way to prevent PIs. ¹ In addition, this review did not find any discernible differences between care settings. This suggests that several factors should be considered when determining the ideal frequency.

Nursing Implications

PI is a sentinel event in a patient’s healthcare journey, thus healthcare providers expend considerable resources to prevent PIs. Several strategies have been proposed to prevent the occurrence of PI, including frequent turning and repositioning of the patients. This review synthesized the literature to identify the optimal frequency of turning/repositioning to prevent PI; however, it failed to do so. Nonetheless, healthcare providers may benefit from this review by thinking about what constitutes the best turning frequency to help their patients avoid PIs. Additionally, nursing researchers should be encouraged to undertake further research to investigate the factors that influence the effectiveness of turning frequencies on the development of PIs. Moreover, these factors could be related to patients’ or health practitioners’ ability to appropriately use the proper turning frequency.

Limitations

This review had 2 main limitations. First, there was limited literary evidence, thus limiting this review to only 3 healthcare settings. It should involve the operating rooms, palliative care units, and emergency departments. Second, this review included just a single pilot study that had a sample size too small to be reliable. However, most of the studies in this review were RCTs, and the search was comprehensive. Third, most of the studies were published before 2015, although one study published in 2022 was added. Fourth, this review focused on studies written in English only. Fifth, only one author wrote this review, albeit the author put significant effort into minimizing bias.

Conclusion

Turning and repositioning immobile patients is an essential nursing practice that is irreplaceable, even with the introduction of support surfaces. However, there is no gold standard for the frequency of turning and repositioning followed by healthcare providers. Therefore, based on a review of published studies, this systematic literature review concluded that it is difficult to determine the optimal frequency of turning and repositioning to prevent the onset of PIs. In particular, more RCT studies are needed in ICU settings to provide a clearer set of recommendations and guidelines to inform nurses of the optimal turning and repositioning frequency for this high-risk group. Moreover, efforts should be made to recruit a sufficiently large sample to ensure the validity and generalizability of any results concerning the effectiveness of turning/repositioning scheduled to prevent PIs.