Repositioning for pressure injury prevention in adults.

BACKGROUND: A pressure injury (PI), also referred to as a 'pressure ulcer', or 'bedsore', is an area of localised tissue damage caused by unrelieved pressure, friction, or shearing on any part of the body. Immobility is a major risk factor and manual repositioning a common prevention strategy. This is an update of a review first published in 2014. OBJECTIVES: To assess the clinical and cost effectiveness of repositioning regimens(i.e. repositioning schedules and patient positions) on the prevention of PI in adults regardless of risk in any setting. SEARCH METHODS: We searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase, and EBSCO CINAHL Plus on 12 February 2019. We also searched clinical trials registries for ongoing and unpublished studies, and scanned the reference lists of included studies as well as reviews, meta-analyses, and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication, or study setting. SELECTION CRITERIA: Randomised controlled trials (RCTs), including cluster-randomised trials (c-RCTs), published or unpublished, that assessed the effects of any repositioning schedule or different patient positions and measured PI incidence in adults in any setting. DATA COLLECTION AND ANALYSIS: Three review authors independently performed study selection, 'Risk of bias' assessment, and data extraction. We assessed the certainty of the evidence using GRADE. MAIN RESULTS: We identified five additional trials and one economic substudy in this update, resulting in the inclusion of a total of eight trials involving 3941 participants from acute and long-term care settings and two economic substudies in the review. Six studies reported the proportion of participants developing PI of any stage. Two of the eight trials reported within-trial cost evaluations. Follow-up periods were short (24 hours to 21 days). All studies were at high risk of bias. Funding sources were reported in five trials. Primary outcomes: proportion of new PI of any stage Repositioning frequencies: three trials compared different repositioning frequencies We pooled data from three trials (1074 participants) comparing 2-hourly with 4-hourly repositioning frequencies (fixed-effect; I² = 45%; pooled risk ratio (RR) 1.06, 95% confidence interval (CI) 0.80 to 1.41). It is uncertain whether 2-hourly repositioning compared with 4-hourly repositioning used in conjunction with any support surface increases or decreases the incidence of PI. The certainty of the evidence is very low due to high risk of bias, downgraded twice for risk of bias, and once for imprecision. One of these trials had three arms (967 participants) comparing 2-hourly, 3-hourly, and 4-hourly repositioning regimens on high-density mattresses; data for one comparison was included in the pooled analysis. Another comparison was based on 2-hourly versus 3-hourly repositioning. The RR for PI incidence was 4.06 (95% CI 0.87 to 18.98). The third study comparison was based on 3-hourly versus 4-hourly repositioning (RR 0.20, 95% CI 0.04 to 0.92). The certainty of the evidence is low due to risk of bias and imprecision. In one c-RCT, 262 participants in 32 ward clusters were randomised between 2-hourly and 3-hourly repositioning on standard mattresses and 4-hourly and 6-hourly repositioning on viscoelastic mattresses. The RR for PI with 2-hourly repositioning compared with 3-hourly repositioning on standard mattress is imprecise (RR 0.90, 95% CI 0.69 to 1.16; very low-certainty evidence). The CI for PI include both a large reduction and no difference for the comparison of 4-hourly and 6-hourly repositioning on viscoelastic foam (RR 0.73, 95% CI 0.53 to 1.02). The certainty of the evidence is very low, downgraded twice due to high risk of bias, and once for imprecision. Positioning regimens: four trials compared different tilt positions We pooled data from two trials (252 participants) that compared a 30° tilt with a 90° tilt (random-effects; I² = 69%). There was no clear difference in the incidence of stage 1 or 2 PI. The effect of tilt is uncertain because the certainty of evidence is very low (pooled RR 0.62, 95% CI 0.10 to 3.97), downgraded due to serious design limitations and very serious imprecision. One trial involving 120 participants compared 30° tilt and 45° tilt with 'usual care' and reported no occurrence of PI events (low certainty evidence). Another trial involving 116 ICU patients compared prone with the usual supine positioning for PI. Reporting was incomplete and this is low certainty evidence. Secondary outcomes No studies reported health-related quality of life utility scores, procedural pain, or patient satisfaction. Cost analysis Two included trials also performed economic analyses. A cost-minimisation analysis compared the costs of 3-hourly and 4-hourly repositioning with 2-hourly repositioning schedule amongst nursing home residents. The cost of repositioning was estimated at CAD 11.05 and CAD 16.74 less per resident per day for the 3-hourly or 4-hourly regimen, respectively, compared with the 2-hourly regimen. The estimates of economic benefit were driven mostly by the value of freed nursing time. The analysis assumed that 2-, 3-, or 4-hourly repositioning is associated with a similar incidence of PI, as no difference in incidence was observed. A second study compared the nursing time cost of 3-hourly repositioning using a 30° tilt with standard care (6-hourly repositioning with a 90° lateral rotation) amongst nursing home residents. The intervention was reported to be cost-saving compared with standard care (nursing time cost per patient EUR 206.60 versus EUR 253.10, incremental difference EUR -46.50, 95% CI EUR -1.25 to EUR -74.60). AUTHORS' CONCLUSIONS: Despite the addition of five trials, the results of this update are consistent with our earlier review, with the evidence judged to be of low or very low certainty. There remains a lack of robust evaluations of repositioning frequency and positioning for PI prevention and uncertainty about their effectiveness. Since all comparisons were underpowered, there is a high level of uncertainty in the evidence base. Given the limited data from economic evaluations, it remains unclear whether repositioning every three hours using the 30° tilt versus "usual care" (90° tilt) or repositioning 3-to-4-hourly versus 2-hourly is less costly relative to nursing time.

Cost-effective minimally invasive gynecologic surgery: emphasizing surgical efficiency.

PURPOSE OF REVIEW: The United States has the highest healthcare costs among developed countries. This review evaluates surgical practices and equipment choices during endoscopic hysterectomy, highlighting opportunities for the gynecologic surgeon to reduce costs and maximize surgical efficiency. RECENT FINDINGS: There are opportunities to economize at every step of the endoscopic hysterectomy. When surgeons are provided education about instrumentation costs, the cost of hysterectomy has been shown to decrease. Colpotomy has been found to be the rate-limiting step in laparoscopic hysterectomy; use of a uterine manipulator likely saves time and money. When evaluating the economic impact of route of surgery, the cost differential between laparoscopic and robotic-assisted hysterectomy has decreased. Robotic-assisted hysterectomy may be more cost-effective in some cases, such as for larger uteri. From a systems-level perspective, dedicating a specific operating room team to the gynecology service can decrease operative time. SUMMARY: The gynecologic surgeon is best equipped to control surgery-related costs by making choices that improve surgical efficiency and decrease operating room time. If a costlier piece of equipment leads to a more efficient case, the choice may be more cost-effective. There are multiple systems-level changes that can be implemented to decrease surgery-related costs.

The Cost-Effectiveness of Interventions to Increase Utilization of Prone Positioning for Severe Acute Respiratory Distress Syndrome.

OBJECTIVES: Despite strong evidence supporting proning in acute respiratory distress syndrome, few eligible patients receive it. This study determines the cost-effectiveness of interventions to increase utilization of proning for severe acute respiratory distress syndrome. DESIGN: We created decision trees to model severe acute respiratory distress syndrome from ICU admission through death (societal perspective) and hospital discharge (hospital perspective). We assumed patients received low tidal volume ventilation. We used short-term outcome estimates from the PROSEVA trial and longitudinal cost and benefit data from cohort studies. In probabilistic sensitivity analyses, we used distributions for each input that included the fifth to 95th percentile of its CI. SETTING: ICUs that care for patients with acute respiratory distress syndrome. SUBJECTS: Patients with moderate to severe acute respiratory distress syndrome. INTERVENTIONS: The implementation of a hypothetical intervention to increase the appropriate utilization of prone positioning. MEASUREMENTS AND MAIN RESULTS: In the societal perspective model, an intervention that increased proning utilization from 16% to 65% yielded an additional 0.779 (95% CI, 0.088-1.714) quality-adjusted life years at an additional long-term cost of $31,156 (95% CI, -$158 to $92,179) (incremental cost-effectiveness ratio = $38,648 per quality-adjusted life year [95% CI, $1,695-$98,522]). If society was willing to pay $100,000 per quality-adjusted life year, any intervention costing less than $51,328 per patient with moderate to severe acute respiratory distress syndrome would represent good value. From a hospital perspective, the intervention yielded 0.072 (95% CI, 0.008-0.147) more survivals-to-discharge at a cost of $5,242 (95% CI, -$19,035 to $41,019) (incremental cost-effectiveness ratio = $44,615 per extra survival [95% CI, -$250,912 to $558,222]). If hospitals were willing to pay $100,000 per survival-to-discharge, any intervention costing less than $5,140 per patient would represent good value. CONCLUSIONS: Interventions that increase utilization of proning would be cost-effective from both societal and hospital perspectives under many plausible cost and benefit assumptions.

Turning High-Risk Individuals: An Economic Evaluation of Repositioning Frequency in Long-Term Care.

Recent evidence suggests that less frequent repositioning of long-term care residents at moderate to high risk of developing pressure ulcers (PrUs) is noninferior to current repositioning standards in preventing PrUs, but the long-term health and economic consequences of less frequent repositioning have not been adequately estimated. Our objective was to estimate the cost-effectiveness of different repositioning strategies (2-, 3-, 4-hour intervals). We conducted a cost-utility analysis using a lifetime horizon based on data from a randomized clinical trial and the literature. We updated a published PrU decision model with resource usage, unit costs, and epidemiological estimates from the literature and from a small observational study. The Ontario Ministry of Health and Long-Term Care perspective was taken. We estimated lifetime costs to be CAN$5,425 (95% credible interval (CrI)=$922-12,166) less per resident with 3-hour repositioning than with 2-hour repositioning and CAN$3,296 (95% CrI=$483-9,738) less than with 4-hour repositioning. The gain in expected quality-adjusted life years from a 3- to a 2-hour repositioning strategy was 0.008, (95% CrI=0.005-0.016) and from a 3- to a 4-hour repositioning strategy was 0.009 (95% CrI=0.007-0.018). Repositioning at 3-hour intervals was the dominant strategy with respect to the incremental cost-effectiveness ratio against the 2- and 4-hour strategies. Sensitivity analysis showed a 99% probability that 3-hour repositioning was a dominant strategy. We concluded that repositioning at 3-hour intervals for residents at moderate or high risk of PrUs and who were cared for on high-density foam mattresses appeared to be the most cost-effective strategy.

PROTECT - trial: a multicentre prospective pragmatic RCT and health economic analysis of the effect of tailored repositioning to prevent pressure ulcers - study protocol.

AIM: The aims of this trial were as follows: (1) to compare the (cost-) effectiveness of a turning and repositioning system and an algorithm for a tailored repositioning vs. usual care to improve reposition frequency in patients at risk; and (2) to compare the (cost-) effectiveness of standardized incontinence care vs. usual care. BACKGROUND: Pressure ulcers are a serious and common problem for hospitalized patients. In many countries, pressure ulcers are recognized as a national health issue and governments designate pressure ulcers as one of the most important sentinel events for health care. International guidelines recommend the use of pressure redistributing support surfaces, systematic patient repositioning and preventive skin care to prevent pressure ulcers. Interventions should be patient-tailored and based on a thorough assessment of both the patient and contextual risk factors. There is a lack of rigorous research addressing the effectiveness of a turning and repositioning system and it is unclear how to tailor the frequency and posture to specific patient needs. DESIGN: Multicentre, cluster, three-arm, randomized, controlled pragmatic trial and a cost-effectiveness analysis. The ward is the unit of randomization. METHODS: Tailored repositioning, the use of a device to facilitate patient repositioning and an optimal procedure for incontinence care will be combined. Participating wards will be intensive care units, geriatric and rehabilitation wards. A sample size calculation was performed (80% power, α = 0·05). This study is approved by the Ethics Committee (February 2016). DISCUSSION: Data collection is currently ongoing. The results are expected to be obtained in March 2017.

Strategies for Providing Low-Cost Water Immersion Therapy With Limited Resources.

At our university-affiliated medical center, a major renovation of the women's health and birthing unit resulted in the temporary loss of the permanent tub used for water immersion therapy during labor. Because 40 percent of the women in the nurse-midwifery practice utilize hydrotherapy, we undertook a rigorous search for an interim solution. We developed a safe and cost-effective strategy that can be easily replicated and utilized by others to provide hydrotherapy for laboring women.

Repositioning for pressure ulcer prevention in adults.

BACKGROUND: A pressure ulcer (PU), also referred to as a 'pressure injury', 'pressure sore', or 'bedsore' is defined as an area of localised tissue damage that is caused by unrelieved pressure, friction or shearing forces on any part of the body. PUs commonly occur in patients who are elderly and less mobile, and carry significant human and economic impacts. Immobility and physical inactivity are considered to be major risk factors for PU development and the manual repositioning of patients in hospital or long-term care is a common pressure ulcer prevention strategy. OBJECTIVES: The objectives of this review were to:1) assess the effects of repositioning on the prevention of PUs in adults, regardless of risk or in-patient setting;2) ascertain the most effective repositioning schedules for preventing PUs in adults; and3) ascertain the incremental resource consequences and costs associated with implementing different repositioning regimens compared with alternate schedules or standard practice. SEARCH METHODS: We searched the following electronic databases to identify reports of the relevant randomised controlled trials: the Cochrane Wounds Group Specialised Register (searched 06 September 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 8); Ovid MEDLINE (1948 to August, Week 4, 2013); Ovid EMBASE (1974 to 2013, Week 35); EBESCO CINAHL (1982 to 30 August 2013); and the reference sections of studies that were included in the review. SELECTION CRITERIA: Randomised controlled trials (RCTs), published or unpublished, that assessed the effects of any repositioning schedule or different patient positions and measured PU incidence in adults in any setting. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS: We included three RCTs and one economic study representing a total of 502 randomised participants from acute and long-term care settings. Two trials compared the 30º and 90º tilt positions using similar repositioning frequencies (there was a small difference in frequency of overnight repositioning in the 90º tilt groups between the trials). The third RCT compared alternative repositioning frequencies.All three studies reported the proportion of patients developing PU of any grade, stage or category. None of the trials reported on pain, or quality of life, and only one reported on cost. All three trials were at high risk of bias.The two trials of 30º tilt vs. 90º were pooled using a random effects model (I² = 69%) (252 participants). The risk ratio for developing a PU in the 30º tilt and the standard 90º position was very imprecise (pooled RR 0.62, 95% CI 0.10 to 3.97, P=0.62, very low quality evidence). This comparison is underpowered and at risk of a Type 2 error (only 21 events).In the third study, a cluster randomised trial, participants were randomised between 2-hourly and 3-hourly repositioning on standard hospital mattresses and 4 hourly and 6 hourly repositioning on viscoelastic foam mattresses. This study was also underpowered and at high risk of bias. The risk ratio for pressure ulcers (any category) with 2-hourly repositioning compared with 3-hourly repositioning on a standard mattress was imprecise (RR 0.90, 95% CI 0.69 to 1.16, very low quality evidence). The risk ratio for pressure ulcers (any category) was compatible with a large reduction and no difference between 4-hourly repositioning and 6-hourly repositioning on viscoelastic foam (RR 0.73, 95% CI 0.53 to 1.02, very low quality evidence).A cost-effectiveness analysis based on data derived from one of the included parallel RCTs compared 3-hourly repositioning using the 30º tilt overnight with standard care consisting of 6-hourly repositioning using the 90º lateral rotation overnight. In this evaluation the only included cost was nursing time. The intervention was reported to be cost saving compared with standard care (nurse time cost per patient €206.6 vs €253.1, incremental difference €-46.5; 95%CI: €-1.25 to €-74.60). AUTHORS' CONCLUSIONS: Repositioning is an integral component of pressure ulcer prevention and treatment; it has a sound theoretical rationale, and is widely recommended and used in practice. The lack of robust evaluations of repositioning frequency and position for pressure ulcer prevention mean that great uncertainty remains but it does not mean these interventions are ineffective since all comparisons are grossly underpowered. Current evidence is small in volume and at risk of bias and there is currently no strong evidence of a reduction in pressure ulcers with the 30° tilt compared with the standard 90º position or good evidence of an effect of repositioning frequency. There is a clear need for high-quality, adequately-powered trials to assess the effects of position and optimal frequency of repositioning on pressure ulcer incidence.The limited data derived from one economic evaluation means it remains unclear whether repositioning every 3 hours using the 30º tilt is less costly in terms of nursing time and more effective than standard care involving repositioning every 6 hours using a 90º tilt.

Turning for Ulcer Reduction (TURN) Study: An Economic Analysis.

BACKGROUND: The Turning for Ulcer Reduction (TURN) study was a multisite, randomized controlled trial that aimed to determine the optimal frequency of turning nursing facility residents with mobility limitations who are at moderate and high risk for pressure ulcer (PrU) development. Here we present data from the economic analysis. OBJECTIVES: This economic analysis aims to estimate the economic consequences for Ontario of switching from a repositioning schedule of 2-hour intervals to a schedule of 3-hour or 4-hour intervals. DATA SOURCES: Costs considered in the analysis included those associated with nursing staff time spent repositioning residents and with incontinent care supplies, which included briefs, barrier cream, and washcloths. RESULTS: The total economic benefit of switching to 3-hour or 4-hour repositioning is estimated to be $11.05 or $16.74 per day, respectively, for every resident at moderate or high risk of developing PrUs. For a typical facility with 123 residents, 41 (33%) of whom are at moderate or high risk of developing PrUs, the total economic benefit is estimated to be $453 daily for 3-hour or $686 daily for 4-hour repositioning. For Ontario as a whole, assuming that there are 77,933 residents at 634 LTC facilities, 25,927 (33%) of whom are at moderate or high risk of developing PrUs, the total economic benefits of switching to 3-hour or 4-hour repositioning are estimated to be $286,420 or $433,913 daily, respectively, equivalent to $104.5 million or $158.4 million per year. LIMITATIONS: We did not consider the savings the Ontario Ministry of Health and Long-Term Care might incur should less frequent repositioning reduce the incidence of work-related injury among nursing staff, so our findings are potentially conservative. CONCLUSIONS: A switch to 3-hour or 4-hour repositioning appears likely to yield substantial economic benefits to Ontario without placing residents at greater risk of developing PrUs.

Percutaneous nephrostolithotomy: an assessment of costs for prone and Galdakao-modified supine Valdivia positioning.

OBJECTIVE: To examine the relative costs of prone percutaneous nephrostolithotomy (PCNL) versus PCNL performed with the patient in the Galdakao-modified supine Valdivia (GMSV) position to determine whether a cost differential exists. METHODS: We compared prone PCNL with PCNL using GMSV positioning. Cost data were obtained from the urology departmental and hospital billing offices at our institution and from the 2011 local Medicare reimbursement scales. The costs were divided into 5 major categories: surgeon fees, anesthesia fees, surgical supplies, hospital-related fees, and lost revenue. RESULTS: The overall cost of prone PCNL ranged from $23 423 to $24 463, and the cost for PCNL performed with GMSV positioning ranged from $24 725 to $25 830. The difference between the 2 positions ranged from approximately $1302 for stones ≤ 2 cm to $1367 for stones >2 cm. The lost office revenue because of the requirement for a second surgeon was estimated at $1987. CONCLUSION: Our assessment of the cost for prone versus GMSV PCNL technique found GMSV positioning to be more costly. The presence of 2 surgeons was the main driver of the cost differential, because it resulted in more equipment use, with greater instrument repair costs and higher surgeon fees. It also brings into consideration the opportunity cost of having a second surgeon in the operating room and not in the office.

Patient positioning in the proton radiotherapy era.

The main hindrance to the diffusion of proton therapy facilities is the high cost for gantry installations. An alternative technical option is provided by fixed-beam treatment rooms, where the patient is rotated and translated in space with a robotic arm solution to enable beam incidence from various angles. The technological efforts based on robotic applications made up to now for patient positioning in proton beam facilities are described here, highlighting their limitations and perspectives.