Repositioning is a time-honored intervention for preventing pressure ulcers. Indeed, after comparing recommendations from the Hartford Institute for Geriatric Nursing and the Registered Nurses' Association of Ontario, the National Guideline Clearinghouse (NGC) found that "recommendations concerning positioning and pressure-relieving devices are similar between guidelines."1 The NGC noted that both organizations stated "the need for frequent repositioning of bed-bound and chair-bound patients and the need to use pressure-reducing mattresses and positioning devices such as wedges and pillows." In addition, both recommended positioning patients in a 30[degrees] side-lying position, maintaining the head of the bed at or below 30[degrees], and repositioning patients every two hours (or more often if they're at high risk).

Figure. A nurse places a patient in a 30[degrees] side-lying position and uses pillows to maintain the position and prevent skin breakdown, as recommended by current guidelines. But there may be insufficient evidence to support this practice.

Although the reviewed guidelines are clear and in agreement, in a recent systematic review of the literature, Krapfl and Gray found limited evidence to support current pressure ulcer prevention practice.2 Specifically, they found insufficient evidence to support placing patients in a 30[degrees] rather than a 90[degrees] lateral position. They also found new, though limited, evidence that "repositioning every four hours, when combined with an appropriate pressure redistribution surface, is just as effective for the prevention of facility-acquired pressure ulcers as a more frequent (every two hour) regimen."2 This makes sense given that the two-hour turning schedule was established by expert opinion based on observational studies conducted decades ago when pressure redistribution surfaces were less advanced and available. Although less frequent repositioning is good news for busy clinicians, the authors caution that clinical findings based on daily skin inspections, not rigid turning schedules, should guide repositioning frequency and that gaps in pressure ulcer knowledge remain.2

Well-designed and rigorously conducted clinical studies are needed to develop evidence-based protocols that preserve both the patients' skin and the nurses' sanity. This is where the American Recovery and Reinvestment Act of 2009 can come to the rescue; it will offer funding for research that may ultimately "provide patients, clinicians, and others evidence-based information to make informed decisions about health care."3 Health care professionals are encouraged to sign up for updates on research opportunities at http://effectivehealthcare.ahrq.gov.

Pressure ulcer prevention efforts consume vast resources, yet they're based on limited research. Let's support efforts to develop new evidence-based protocols and put our time-honored nursing traditions to the test!!

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