Positioning immobile critically ill patients who are at risk of pressure injuries using a purpose‐designed positioning device and usual care equipment: An observational feasibility study

Abstract

The prevalence of pressure injuries in the intensive care unit (ICU) setting is high with rates ranging from 13.1% to 45.5%. Evaluation of interventions to prevent pressure injuries should be informed by preliminary research to identify factors that should be considered during the design of future trials. The study objectives were to evaluate the process of participant recruitment and monitoring in the ICU; measure the maintenance of body angle (in the side‐lying lateral tilt position) and head and neck alignment angle (in the supine position) among immobile critically ill patients when using a purpose‐designed positioning device and usual care equipment, and; ascertain the time required to position patients with the purpose‐designed positioning device and the usual care equipment. A prospective, observational, feasibility study was conducted in an ICU in Victoria, Australia. The sample was immobile critically ill adults at high‐risk of developing pressure injuries. The usual care interventions were pillows, foam wedges, and rolled towels, and the intervention device was the Z‐Flo Fluidized Positioner. The body angle and head and neck alignment were measured on six occasions (at baseline, 1 hour, and 2 hours). The time required for positioning was also measured. The sample was predominately male (n = 5, 62%) with a mean age of 59 years. The majority of patients (n = 106, 92.2%) were not immobile and therefore were ineligible to participate. A total of 48 turning and positioning interventions were observed. For the side‐lying lateral tilt position, the degree of difference from baseline to 2 hours was no more than three degrees for all the devices (the Fluidized Positioner 25°‐26°, the foam wedge 29°‐27°, and the pillow 23°‐21°). For the head and neck position, the degree of difference from baseline to 2 hours was the greatest for the pillow and rolled towel (78°‐71°, a difference of 7°) and the pillow alone (79°‐74°, a difference of 5°). The degree of difference was the lowest for the Fluidized Positioner (84°‐86°, a difference of 2°). Future research to evaluate positioning equipment in the ICU should consider patient eligibility characteristics, particularly immobility. The conduct of preliminary studies to inform the design of larger pressure injury prevention trials is recommended.

1. INTRODUCTION

The prevalence of pressure injuries in the intensive care unit (ICU) setting is high with rates varying worldwide from 13.1% to 45.5%. ¹ Pressure injuries cause unnecessary pain and suffering and increase the risk of sepsis and premature death. ¹ Pressure injuries prolong hospital length of stay and lead to significant and often preventable hospital costs.2, 3

Positioning the body is an important pressure injury prevention strategy. Positioning refers to the movement and placement of the patient's body, for example, to rest in the side‐lying lateral tilt position or the supine position. ⁴ Body positioning has the potential to redistribute pressure and shear forces, and subsequently prevent the internal tissue deformation, tissue ischaemia, and irreversible tissue damage that causes pressure injuries. ⁵ Lateral tilt positioning and correct alignment and positioning of the head and neck is considered a beneficial intervention for preventing sacral and occipital pressure injuries,6, 7, 8 and for the ICU patient who is intubated, this intervention may also have other benefits, for example, prevention of endotracheal tube dislodgement.9, 10

Maintenance of the position of the body is usually undertaken with equipment such as pillows, foam wedges, and rolled towels. ¹¹ Pillows and foam wedges are typically placed along the patient's back to support the side‐lying lateral tilt position ¹² and towels are typically rolled and applied on the sides of the neck to maintain the head and neck in a neutral alignment when lying in the supine position. ⁶ It is recognised that equipment typically used for turning and positioning has not been designed for this purpose, and there is evidence to suggest that usual care equipment is associated with poor maintenance of body position and, potentially, pressure injury development.12, 13

It has been suggested that purpose‐designed positioning devices may be helpful for positioning and may assist to prevent pressure injuries. ¹⁴ The Z‐Flo Fluidized Positioner (Mölnlycke Healthcare AB, Gothenburg, Sweden) is one such positioning device. The Fluidized Positioner is composed of a polyurethane bag containing a viscous fluid mix that can be moulded by hand to adjust to the body of each patient. The device maintains the shape that it is moulded into and has no shape memory so can subsequently be moulded into any shape required. The device can be remoulded at any time, for example, at the next position change.6, 12

Computational modelling has identified that the Fluidized Positioner envelops the surface of the body that is in contact with and enables immersion of the body into the surface of the device, which are qualities that assist with redistribution of pressure and reduction of shear stresses. ⁷ Research conducted by Kapp et al ¹² in the residential aged care setting provided preliminary evidence that maintenance of the side‐lying tilt position is better maintained with the Fluidized Positioner when compared with pillows among elderly, immobile patients at high‐risk of pressure injury development. Research has sought to establish the effect of the Fluidized Positioner on the rate of sacral and occiput pressure injuries in the ICU setting and has suggested positive outcomes,6, 15, 16 however, randomised controlled trials have not yet been reported.

It is important that feasibility research is conducted to inform the design and conduct of trials that aim to test the effectiveness of health care interventions such as purpose‐designed positioning devices. Although other positioning devices are available, the previous studies utilising the Fluidized Positioner6, 7, 12, 15, 16 provide the strongest suggestion to date that a worthwhile effect may be expected with this particular device. These studies report that the Fluidized Positioner is effective from a computational modelling perspective and that the device may better maintain the body position required to prevent sacral pressure injuries when compared with usual care equipment. The research has also reported that the Fluidized Positioner is acceptable, reliable, and safe in clinical practice. For these reasons, the fluidised positioner was selected as the device to be evaluated in our study.

1.1. Study objectives

The objectives of the study were to:

1. Evaluate the process of participant recruitment and monitoring in the ICU.

2. Measure the maintenance of the body angle in the side‐lying lateral tilt position and the head and neck alignment angle in the supine position among immobile critically ill patients when using a purpose‐designed positioning device and the usual care equipment.

3. Ascertain the time required to position immobile critically ill patients with the purpose‐designed positioning device and the usual care equipment.

2. METHODS

2.1. Design

A prospective, observational, feasibility study was conducted. A feasibility study is a small‐scale study used to examine important parameters of research design and implementation to inform the design of a larger study. ¹⁷ Feasibility studies may be particularly useful to understand factors that have the potential to negatively affect clinical research, such as participant recruitment rate, feasibility of measurements, and acceptability of interventions.17, 18

2.2. Population and setting

The study population was critically ill adults. Members of this population are typically intubated and immobile for a period of time. The study setting was an 18 bed medical and surgical ICU in a hospital located in Victoria, Australia. The ICU is a level 2 facility (capable of providing complex and multisystem life‐support treatments such as mechanical ventilation, extracorporeal continuous renal replacement therapy, and invasive cardiovascular monitoring) with approximately 1400 patient admissions per annum and 116 admissions per month. The ICU employs approximately 90 registered nurses, and the staff ratio is one nurse to one critically ill patient and one nurse to two high acuity patients.

2.3. Site preparation

A training session of 1 hour duration was conducted 8 weeks and 4 weeks prior to the study commencing by a device company representative and two members of the research team. The sessions were conducted in the ICU (with a vacant bed) and focused on the function, application, and cleaning of the Fluidized Positioner. Thirty nurses, one physiotherapist, three personal care assistants, and three doctors attended one of the training sessions. One‐to‐one training was also provided by the author IS at the bedside and this was delivered to any nurse providing care to study participants. Follow‐up instructions and support were offered as needed.

2.4. Eligibility

Patients were eligible to participate if they met the following criteria: admitted to the ICU; aged ≥18 years of age; expected to stay in ICU for a minimum period of 24 hours; were completely immobile (unable to independently move in any way or at any time); required assistance of the nursing staff and personal care assistants for positioning; and were assessed as at high‐risk of pressure injury development (Braden scale score ≤ 12 on admission).

2.5. Sample

A nonprobability, convenient sample (n = 8) of ICU patients was selected on account of pragmatic factors, including available funding for purchase of the devices and time constraints for completion of the project.

2.6. Screening and recruitment

The author IS undertook the screening of potentially eligible patients over a 28‐day period during January, February, and March 2019. This involved reviewing a list of the patients admitted to the ICU each day and assessing patients according to the eligibility criteria. Written consent was obtained prior to recruitment of the participants to the study.

2.7. Interventions

The usual care intervention was the equipment typically used in the participating ICU (pillows, foam wedges, and rolled towels). The selection of the usual care equipment (pillow or foam wedge for side‐lying and the rolled towel or pillow for head and neck alignment) was decided by the treating nurse. The interventional device was the Z‐Flo Fluidized Positioner (Mölnlycke Healthcare AB, Gothenburg, Sweden) (https://www.molnlycke.us/products-solutions/molnlycke-z-flo-fluidized-positioner/).

2.7.1. Usual care

The pillows used during the study were the Wipeclean Stitched Seams Pillow (Haines Medical Australia). The pillows were 66 cm × 45 cm in size, composed of polyfill material with a sewn waterproof polyvinyl chloride cover, and were covered with a pillowcase. These pillows are used for all pillow‐related purposes in the ICU, including its application against the patient's body to support the side‐lying lateral tilt position and under the head for comfort and to maintain the patient's head and neck alignment. The foam wedges used in the study were the Positioning Wedge Triangle Pillow (DEARJANE MEDICAL), size 20 cm × 20 cm × 40 cm, and were also covered in a pillowcase. These foam wedges are also commonly used in ICU to support the side‐lying lateral tilt position. The towels used in the study were made of 100% cotton of size 70 cm × 140 cm. Towels are often rolled and placed against the intubated patients to support head and neck alignment at 90° (to prevent patients from flexing, hyperextending, or rotating the head to the side).

2.7.2. Devices

The Z‐Flo Fluidized Positioner is composed of a polyurethane bag containing polydimethylsiloxane, which is a viscous fluid mix. ¹² The 41 cm × 76 cm device was used for lateral positioning, and the 30 cm × 51 cm device was used for head and neck positioning. The Fluidized Positioner is registered with the Australian Therapeutic Goods Administration (ARTG 282967) for the purpose of patient positioning and was used as recommended, for single‐patient use, in the study. The device was covered in a pillowcase during the study and was cleaned in between each position change with Clinell universal sanitising wipes.

2.8. Data collection

Baseline data were collected by the author IS from the patient's health record and included age, gender, height, weight, current medical diagnosis, body mass index (BMI), Acute Physiology Chronic Health Evaluation (APACHE) III score, and the Braden Scale for Predicting Pressure Sore Risk. ¹⁹

Participants (n = 8) were observed while using the purpose‐designed device (the Fluidized Positioner) and while using the usual care equipment (the pillow, foam wedge, and/or rolled towel). This occurred on six occasions over 2 consecutive days for each participant. This monitoring period and the decision to monitor the intervention device before the usual care equipment was determined on the basis of an expected short length of stay (48 hours is the average length of stay in this ICU) and agreement in this ICU that high‐risk patients should be positioned every 2 to 4 hours.

The researcher liaised with nursing staff to attend during positioning events to undertake the observations required. Turning and positioning was undertaken by the nurses and personal care assistants. The primary responsibility of personal care assistants is to provide general patient care, including assisting nursing staff in positioning patients in bed. All participants were using a Hill‐Rom TotalCare P500 intensive care bed. Observations (and measurements of body angle) were taken when the participant was in (a) the side‐lying lateral tilt position and (b) when laying supine. Each of the six occasions involved data collection at three time points: immediately after the patient had been positioned (baseline), and then 1 hour and 2 hours from baseline.

2.9. Measures

The side‐lying lateral tilt position angle was measured by placing an iPhone with clinometer application on the participant's suprasternal notch. The head and neck alignment angle (when laying supine) was measured by placing the iPhone on the right contralateral side of the head with the clinometer level aligned with the eyes. The same iPhone was used with all participants to ensure consistency. The iPhone was enclosed in a bag and the bag was changed in between participants.

The method of body angle measurements used in the study was informed by previous research,12, 13, 20 and the clinometer iPhone application (Peter Breitling, version 4.6, http://www.plaincode.com/products) was chosen due to good level of intrarater reliability and a moderate to good validity level when compared with usual measurement devices used for related purposes in health care with the added advantage of providing simple and fast measurements through a readily available device.20, 21 The measurement process was piloted and refined by the research team in testing with four healthy volunteers in a nursing laboratory at the University of Melbourne before the study commenced. This included confirming the process for identifying the anatomical landmarks of the body required for correct placement of the iPhone.

The time required for positioning was measured with the modified Work‐Sampling Method by Activity Timing (WOMBAT) tool. ²² This tool has been used successfully in the ICU setting for observation of nursing tasks ²³ and in pressure injury prevention research specifically. ²⁴ The timing of the positioning event commenced when the nursing staff member started organising the equipment and staff to assist with the intervention and concluded when the turning and positioning was completed, specifically when the patient was lying in the desired position and the bed rails were pulled up. If unexpected hygiene and toileting care was necessary, prior to the positioning being completed this time was included. The nurses were not advised that the intervention was being timed to minimise the risk of this influencing their behaviour. The iPhone stopwatch (lap‐time function) was used to measure the time required for positioning. The person‐minutes required for positioning was determined by the number of minutes for preparation and positioning the patient multiplied by the number of staff members performing the task.

2.10. Analysis

Baseline and position data were entered into a Microsoft Excel (Microsoft Office 365, Australia) (version 16.23, 2019) spreadsheet for analysis. Descriptive statistics included frequency, mean, and range to describe the sample, and mean and range were used to analyse the position data (side‐lying lateral tilt angle and the head and neck alignment angle) and the time required to turn and position the participants.

2.11. Ethics and funding

The study was approved by the Austin Health Human Research Ethics Committee (HREC), Victoria, Australia, in September 2018. The study was conducted independent of the device manufacturer. The governing University paid for the devices and the study received no other funding support.

3. RESULTS

During the 28‐day recruitment period, a total of 115 ICU patients were admitted and all were screened for eligibility. The majority of patients (n = 106, 92.2%) were ineligible to participate. Most ineligible patients were not completely immobile (n = 80). Other reasons for exclusion included the intention to extubate and mobilise in less than 24 hours (n = 16) and being younger than 18 years of age (n = 7). This resulted in 12 eligible patients being approached to participate in the study. The requirement of 24 hours to consider participation in the study resulted in three patients becoming not eligible to participate, as by the time consent could be obtained the patient was scheduled for discharge. The remaining nine patients were recruited to the study.

The nine participants represented 7.8% of the patients admitted to the ICU during the time the researcher screened for eligible participants, and 75% of the patients that were initially identified as eligible. None of the participants were able to consent for themselves (cognitive impairment, n = 1, and decreased level of consciousness, n = 8), therefore consent was obtained from the person responsible. No participants withdrew from the study; however, one participant deteriorated after data collection had commenced and then passed away before completing the study. This deterioration was not unexpected and not related to the study. Data from this participant were incomplete, therefore was excluded from the analysis.

3.1. Sample characteristics

The sample included in the analysis (n = 8) was predominately male (n = 5, 62%) and 59 years of age on average (minimum 24 years, maximum 87 years). A total of 31 different comorbidities affected the sample, and the mean number of comorbidities was 3.9 per patient (minimum 1, maximum 6). Comorbidities included cardiovascular disease (n = 5, 63%), obesity (n = 5, 63%), diabetes (n = 4, 50%), mental health concern (n = 3, 38%), arthritis/musculoskeletal condition (n = 1, 13%), and asthma (n = 1, 13%). The APACHE III score was on average 79 (minimum 48, maximum 111), which predicted a mean risk of death of 39% (minimum 1.6%, maximum 77%) during the patients' ICU admission. All participants were sedated at recruitment and during the monitoring period, and the majority (n = 7, 88%) were receiving vasopressors. All participants were completely immobile and required full assistance with positioning in bed at the time of recruitment.

A total of 48 turning and positioning interventions (6 per participant) were observed. This included 32 side‐lying lateral tilt positionings (4 per participant) and 16 supine positionings (2 per participant). The three measures (at baseline, 1 hour, and 2 hours) were achieved for each observation, and there were no missing data. None of the participants developed a pressure injury during the study. The baseline characteristics of the sample are presented in Table 1.

TABLE 1.

Baseline characteristics of the sample

Age (years) (mean and range)	59 (24‐87)
Gender (%)
Male	62
Female	38
Comorbidities (%)
Cardiovascular disease	63
Obesity	63
Diabetes	50
Mental health	38
Asthma	13
Arthritis and musculoskeletal	13
Cancer	0
Injury prevention and control	0
Dementia	0
APACHE III Score (mean and range)	79 (48‐111)
APACHE III Risk of Death (%) (mean and range)	39 (1.6‐77)
Braden scale score (mean and range)	9 (9‐10)
Continence management (%)
Indwelling catheter	100
Faecal management device	25
Continence pad	25
Medication (%)
Sedatives	100
Vasopressors	88
Medical device (%)
Arterial line	100
Central venous catheter	100
Peripheral intravenous cannula	38
Vascular catheter	13
Endotracheal tube	100
Nasogastric tube	100
Temperature management device	25

3.2. The side‐lying lateral tilt position

The degree of difference from baseline to 2 hours was no more than three degrees for all the devices (the Fluidized Positioner 25°‐26°, the foam wedge 29°‐27°, and the pillow 23°‐21°). The degree of difference was the lowest for the Fluidized Positioner (1°) (refer to Table 2).

TABLE 2.

The side‐lying lateral tilt position angle over time

	Baseline	1 hour from baseline	2 hours from baseline
Fluidized Positioner (n = 8) (mean and range)	25° (15‐36)	25° (15‐36)	26° (15‐38)
Foam wedge (n = 5) (mean and range)	29° (20‐51)	28° (11‐66)	27° (14‐39)
Pillow (n = 3) (mean and range)	23° (15‐31)	20° (12‐27)	21° (12‐30)

3.3. The head and neck position

The degree of difference from baseline to 2 hours was the greatest for the pillow and rolled towel (78°‐71°, a difference of 7°) and the pillow alone (79°‐74°, a difference of 5°). The degree of difference was the lowest for the Fluidized Positioner (84°‐86°, a difference of 2°) (refer to Table 3).

TABLE 3.

The head and neck alignment angle over time

	Baseline	1 hour from baseline	2 hours from baseline
Fluidized Positioner (n = 8) (mean and range)	84° (82‐86)	85° (82‐88)	86° (83‐87)
Pillow (n = 6) (mean and range)	79° (73‐86)	77° (64‐88)	74° (62‐89)
Pillow and rolled towel (n = 2) (mean and range)	78° (66‐90)	62° (61‐88)	71° (56‐85)

3.4. Time required to position in the side‐lying lateral tilt position

The time required to position in the side‐lying lateral tilt position was similar when using the Fluidized Positioner and usual care equipment, an average of 7 minutes. The average number of staff required was also similar (3 staff). The resulting person‐minutes was similar to the usual care equipment (24 minutes) compared with the Fluidized Positioner (23 minutes) (refer to Table 4).

TABLE 4.

Time and staff required to turn and position in the side‐lying lateral tilt position

	Purpose‐designed positioning device	Usual care equipment
Staff members required for turning and positioning (mean and range)	3.13 (2‐4)	3.18 (2‐4)
Time required to turn and position (minutes and seconds) (mean and range)	7.14 (5.45‐10.30)	7.52 (2.26‐12.30)
Person‐minutes (mean) (minutes and seconds)	22.8	24.01

3.5. Time required to position the head and neck

The average time required to position the head and neck was higher for the Fluidized Positioner (6.5 minutes) compared with the usual care equipment (3 minutes). The average number of staff required was similar (2 staff). The resulting person‐minutes was higher for the Fluidized Positioner (16 minutes) than that for the usual care equipment (7 minutes) (refer to Table 5).

TABLE 5.

Time and staff required to turn and position in the supine position (head and neck alignment)

	Purpose‐designed positioning device	Usual care equipment
Staff members required for turning and positioning (mean and range)	2.25 (1‐4)	2.25 (1‐4)
Time required to turn and position (minutes and seconds) (mean and range)	6.33 (3.45‐12.42)	2.56 (1.22‐4.52)
Person‐minutes (mean) (minutes and seconds)	15.59	6.95

4. DISCUSSION

The objectives of the study were to evaluate the process of participant recruitment and monitoring in the ICU; measure the maintenance of the body angle in the side‐lying lateral tilt position and the head and neck alignment angle in the supine position among immobile critically ill patients when using a purpose‐designed positioning device and the usual care equipment and; ascertain the time required to position immobile critically ill patients with the purpose‐designed positioning device and the usual care equipment. A prospective observational feasibility study was conducted with critically ill adults receiving care in an ICU.

Participants (n = 8) were monitored on three occasions while using the purpose‐designed positioning device (a Fluidized Positioner) and three occasions while using the usual care equipment (the pillow, foam wedge, and/or rolled towel). Each occasion involved measurement of the body angle with a clinometer application on an iPhone to determine the side‐lying angle or the head and neck alignment at baseline, 1 hour, and 2 hours. Data to ascertain the time spent positioning the patient were also collected. The following discussion considers each of objective of the study.

4.1. Objective 1. Evaluate the process of participant recruitment and monitoring in an intensive care unit setting

The study has provided valuable insights regarding the process of participant recruitment and monitoring for pressure injury prevention research in an ICU setting. The screening process was effective with all patients admitted during the 28‐day screening period (n = 115, 100%) being checked for eligibility. The rate of conversion to recruitment was however low with the majority (n = 106, 92.2%) not eligible on account of most often not being fully immobile. Although the missed opportunities for recruitment were low in number (n = 3 of the n = 12 eligible patients), this should be considered in the context of what was a low sample size study.

Recruitment of ICU patients to research can be challenging on account of research team workload, limited availability, narrow time windows for inclusion, difficulties in contacting families, non‐existent person responsible, lack of physician support, and protocols prohibiting co‐enrolment. ²⁵ As our study was a student project, the research team workload was not a barrier, and the study was well supported by physicians. The greatest barrier to recruitment identified in our study was a population that included only one in 10 patients who were fully immobile. Although not an issue for our study (which did not seek or require a large sample), this is an important consideration for future research in the ICU setting. The local and international trend has been towards shorter periods of immobility among ICU patients on account of more effective health care interventions, ²⁶ and in particular, alternative respiratory support options and earlier extubation. ²⁷ This trend will continue to have an impact on the feasibility of participant recruitment and monitoring when immobility is a necessary inclusion criteria.

Testing measures and outcomes that require fully immobile patients (such as the maintenance of body angle using devices for positioning) may therefore be better suited to other settings where immobility lasts longer and repeated measures over a longer period of time are feasible. Kapp et al, ¹² for example, reported that 48% of screened patients were immobile in a residential aged care setting, this patient group less likely to experience transient immobility on account of chronic factors that may permanently affect their mobility and sleep patterns. For research in the ICU setting, multisite studies could be considered to address the barrier of relatively mobile populations. When the study outcomes are broader, for example, rate of pressure injury development, the immobility factor will not be such a concern, as immobility is not the only risk factor for developing pressure injuries.

4.2. Objective 2. Measure the maintenance of the turning angle in the side‐lying lateral tilt position and the head and neck alignment angle in the supine position when using purpose‐designed devices and usual care equipment

The study provided an opportunity to measure the maintenance of the turning angle in the side‐lying lateral tilt position and the head and neck alignment angle in the supine position when using purpose‐designed devices and usual care equipment. Measuring these body positions was feasible and successful in the study. There were no implementation performance issues experienced with the iPhone or clinometer application and the schedule of measurements was achieved.

Frequent turning and positioning can be a challenge to implement in the ICU setting due to limited staff resources and high patient acuity and care needs ²⁴ ; however, this was not identified as an issue in the present study. This may be on account of the presence of the researcher during the study and the interest of the staff in the alternative to usual care equipment. The use of inclinometer applications for measurement of body angle has, to our knowledge, only been reported in three other related studies.12, 13, 28 Although we appraised the literature to decide which inclinometer application to use and the process for measurement, this is a scantily explored topic. Effort to better understand the ways to measure such outcomes would be a welcomed refinement in this area of research.

Although the results of the body angle and head and neck alignment are not suitable for informing practice, the findings are worthy of discussion. Of note, the average and minimum‐maximum measures of the head and neck when lying supine with the Fluidized Positioner demonstrated the closest results of all reported in the study (baseline 84°, 82‐86°, 1 hour 85°, 82‐88°, and 2 hours 86°, 83‐87°). Head and neck alignment when lying supine is particularly important in the ICU patient who is intubated, and the results are encouraging given that the usual care equipment (rolled towels and pillows) is considered to be inadequate for this purpose,6, 7 and the Fluidized Positioner has been reported as useful to support the critically ill patient's head by preventing rotation to the side. ⁶ These findings align with the computational modelling conducted by Katzengold and Gefen ⁷ who reported that the Fluidized Positioner is effective in reducing shear and minimising tissue distortion and pressure in the occipital area. Future research should therefore involve highly controlled studies to determine the clinical effectiveness of the Fluidized Positioner for prevention of occipital pressure injuries in settings where these injuries are a highly prevalent concern.

4.3. Objective 3. Ascertain the time required to position patients with the purpose‐designed positioning device and the usual care equipment

The modified WOMBAT tool ²² was a feasible tool for measuring the time required to position the study participants, this aligning with reports by others.23, 24 The time required to turn and position in the side‐lying lateral tilt position was short, just 7 minutes on average with either the usual care equipment or purpose‐designed positioning device. The difference however was notable for positioning the head and neck, 3 minutes on average for the usual care equipment, and 6.5 minutes on average for the Fluidized Positioner. Although this result arises from a small data set, possible explanations for this may be that the staff required time to develop confidence with the Fluidized Positioner and that applying the usual care equipment (rolling and then situating a towel) required less technique than preparing the Fluidized Positioner (for which the nurses had to mould the device to the participant's head and then form divots around the ears and devices such as monitoring cables and invasive lines).

As with all new healthcare interventions, confidence with use may build over time, ¹⁵ therefore we perceive this result as a baseline, which likely would have improved. The researcher did not intervene to educate during the positioning event so as to not affect the time taken to do so. In usual practice, this would not have occurred, and support would have been provided immediately. This would have improved the skill of the staff in a timelier manner. It should be noted that even if an intervention takes longer to use, this may be more cost effective in the long term if the intervention is effective at preventing pressure injuries. ²⁹ Research conducted in other settings, for example, residential aged care, has suggested that the contribution of positioning to the cost of pressure injury prevention is significant and that can be difficult to determine the time spent positioning patients as documentation of this activity may not be a standardised practice. ³⁰ Observational research to build the evidence base of this topic is required and should use well tested and accepted approaches to measurement of positioning and the time taken to complete this intervention.

4.4. Strengths and limitations

The study evaluated the feasibility of conducting real‐world research involving the use of a purpose‐designed positioning device and usual care equipment for maintenance of the side‐lying lateral tilt position and head and neck alignment in the supine position, among critically ill patients at high‐risk of developing pressure injuries. The study is the first identified in the literature to evaluate the feasibility aspects of this type of research; therefore, the strength of the study is how the outcomes can inform future research on pressure injury prevention in the ICU setting. The limitations of the study include a short recruitment and monitoring period and a small number of study participants.

4.5. Recommendations

Positioning of the body is an important strategy for pressure injury prevention and particularly so in the intensive care setting. In our study, an alternative to the usual care pillows, wedges, and rolled towels was successfully used in the ICU setting. The effectiveness of positioning is paramount and the time required to position patients must be feasible. Importantly, the time healthcare providers spend positioning patients must be used wisely, and for this to be optimised, the devices that they use must function in the desired manner.

Future research to evaluate maintenance of the body angle and the head and neck alignment when using purpose‐designed positioning devices and usual care equipment in the ICU will require consideration of patient eligibility characteristics, particularly immobility. This will help to ensure an adequate sample is achieved so as to draw meaningful conclusions that may be attributed with confidence to the interventions being studied. The time required to position patients is an integral component of a cost‐effectiveness evaluation and utilising a well‐tested tool to inform measurement of time for positioning is highly recommended. Preliminary studies (feasibility or pilot) should be conducted to inform the design of larger pressure injury prevention trials. Such studies may be particularly suited to research students who are committed to the topic under study, who are eager to share the results of such research, and who can take the associated knowledge with them as their research career progresses.

4.6. Conclusion

Well‐designed pressure injury prevention research is dependent on preliminary studies to evaluate the feasibility of interventions and measurement of outcomes in real‐world settings. Participant recruitment in the ICU may be challenging if the required participant characteristics are not present and particularly if immobility is sought. This potential barrier is likely not transient given the trend over recent years to extubate and discharge patients earlier in the ICU setting. Monitoring of ICU study participants and measurement of the maintenance of the body angle (in the side‐lying lateral tilt position and the head and neck alignment angle in the supine position) when using a purpose‐designed positioning device and the usual care equipment is feasible although short length of stay will impact on the time available to monitor outcomes. Ascertaining the time required to position immobile critically ill patients is essential to develop a more accurate understanding of the significance of the contribution of this activity to the cost of pressure injury prevention.

Sousa I, Kapp S, Santamaria N. Positioning immobile critically ill patients who are at risk of pressure injuries using a purpose‐designed positioning device and usual care equipment: An observational feasibility study. Int Wound J. 2020;17:1028–1038. 10.1111/iwj.13365