New research from the University of New South Wales has raised questions about the correct way to care for those requiring pressure area care.

The common practice of repositioning every two hours those at risk of developing bedsores may be interrupting their natural sleep rhythms, causing them to become more agitated and distressed, according to the new study.

The practice of repositioning also fails to prevent bedsores from developing, the researchers say.

The fact that the practice continues is a form of “unintentional institutional elder abuse”, they say.

However, experts we have spoken to say repositioning (and other factors) are required for those assessed as being at risk of developing bedsores. The frequency of repositioning will depend on a number of factors, including the patient’s risk of a pressure injury developing, their comfort, and medical condition.

The study: Two-hourly repositioning does not prevent bedsores

Researchers from the University of New South Wales examined the records of 80 aged care residents who had died. The residents had been living in eight different aged care facilities across Australia.

The researchers looked at whether the residents had been assessed as being at risk of developing bedsores, how two-hourly repositioning impacted them, and whether the residents had bedsores in the final week of their life.

The study found that 91 per cent of the residents considered at risk of developing bedsores were repositioned every two hours, even through the night.

However, more than one-third of them still had one or more of the “excruciating” skin conditions when they died.

In their paper, recently published in Bioethical Enquiry, the researchers Catherine Sharp, Jennifer Schulz Moore and Mary-Louise McLaws wrote, “For decades, aged care facility residents at risk of pressure ulcers have been repositioned at two-hour intervals, twenty-four-hours-a-day, seven-days-a-week. Yet, pressure ulcers still develop.”

What is a bedsore?

Bedsores are also known as pressure ulcers, decubitus ulcers or pressure injuries.

They are injuries to skin caused by ongoing pressure, friction or shear, and particularly effect bony prominence in the body.

Bedsores are common among aged care residents, and occur in one-third of frail people at the end of their lives. They can be extremely painful.

Alternating Pressure Air Mattresses

Rather than two-hourly repositioning, the researchers recommend that those assessed as being at risk of developing bedsores be given alternating pressure air mattresses.

They say APAMs have been shown to prevent bedsores. However, we note that this research dates back to 1967.

“Pressure relief should be provided in the form of an APAM, not waking residents up for the purpose of repositioning,” the researchers say.

“An APAM provides pressure relief to all parts of the body every few minutes throughout the twenty-four hours without waking residents, whereas repositioning for pressure relief is usually only carried out two-hourly.

“It is unacceptable that this prevalence of PUs be allowed to continue.”

Two-hour repositioning is “abuse”

“We believe the practice of 24/7 two-hourly repositioning may be unintentional institutional abuse of elders,” the researchers say.

The practice is not effective in that it fails to prevent bedsores from developing.

It interrupts natural sleep patterns, causing constant tiredness, which the research say can “trigger” the person to acting out their feelings of frustration.

In addition, patients with dementia are often not able to give their consent to the practice, the researchers say.

Sometimes getting access to pressure-relieving equipment can take days, or sometimes it’s not ever provided, the researchers say.

What do the Australian Wound Management Association’s official guidelines say?

Professor Geoff Sussman, Chairman of Wounds Australia, told HelloCare that the Australian Wound Management Association’s ‘Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury’ give the evidence based and the most widely accepted guidelines in the region for preventing pressure sores.

The key recommendations for prevention of pressure injuries for those who have been assessed as being at risk of developing them include:

  • Add high protein oral nutritional supplements to a regular diet.
  • Use a high specification reactive (constant low pressure) support foam mattress on beds, or active (alternating pressure) support mattresses as an alternative.
  • Reposition patients to reduce the duration and magnitude of pressure over vulnerable areas, including bony prominences and heels.
    • Frequency of repositioning will depend on the patient’s risk of pressure injury development, skin response, comfort, functional level, medical condition, and the support surface used.
  • Position patients using 30° lateral inclination alternating from side to side or a 30° inclined recumbent position. Use the prone position if the patient’s medical condition precludes other options.
  • When repositioning the patient in any position always check the positioning of heels and other bony prominences.
  • Use a support cushion for patients at risk of pressure injury when seated in a chair or wheelchair.  Limit the time a patient spends in seated positions without pressure relief.
  • Select and fit devices for heel pressure injuries.

Repositioning is required and has benefits: expert says

Jan Rice, would specialist and Director of WoundCare Services, told HelloCare she believes mattresses can not be the only method used to prevent bedsores as there is no evidence to suggest it is effective.

Mattresses require that the same parts of the body remain in contact with the bed, and therefore the risk of developing bedsores will remain, she said.

Ms Rice said she trains people to reposition residents every two hours during the day, but to cut it back to every three of four hours at night, so as not to disturb sleep excessively.

She gave the example of repositioning at around 10pm, 2am and 6am during the night.

However, she acknowledged that repositioning people living with dementia can be more complex.

Ms Rice said repositioning also has significant other benefits for older people:

  • It provides human contact and comfort.
  • It allows airflow to the skin, for example if the skin has become sweaty, repositioning will allow that area to dry.
  • Repositioning provides an opportunity for the person to have some fluids. It staff come in and the resident is awake, they should be offering them the opportunity to have a sip of water.

Ms Rice said she also often sees mattresses used incorrectly by staff, which could reduce their effectiveness and make matters even more uncomfortable for residents.

Please note: The image used to illustrate this article does not refer to actual events or people. Image: iStock.

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