Can the time between turning patients be increased?

Turning Frequency for Pressure Ulcer Prevention in Immobile Patients

The time between turning patients can be increased beyond the traditional 2-hour interval in certain circumstances, particularly when patients are on pressure-reducing surfaces and when individualized risk assessment supports it.

Current Evidence on Turning Intervals

The traditional practice of turning patients every 2 hours to prevent pressure ulcers has been challenged by recent evidence:

• The 2023 International Journal of Nursing Studies guideline acknowledges that while turning patients is important for pressure injury prevention, the optimal turning frequency remains unclear 1
• Competing clinical priorities often make strict adherence to 2-hour turning schedules challenging in real-world settings 1
• A 2007 randomized controlled trial found that repositioning patients on pressure-reducing mattresses alternately for 2 hours in lateral position and 4 hours in supine position did not result in statistically significant differences in pressure ulcer incidence compared to repositioning every 4 hours 2

Factors That Allow for Extended Turning Intervals

Extended turning intervals may be appropriate when:

1. Pressure-redistributing surfaces are in use:

   • Specialized support surfaces can reduce pressure and allow for longer intervals between manual repositioning
   • Evidence suggests that pressure-reducing mattresses can mitigate the need for frequent turning 2

2. Patient-specific risk factors are considered:

   • Braden Scale scores and other validated risk assessment tools should guide turning frequency
   • Higher-risk patients may still require more frequent repositioning

3. Proper positioning technique is used:

   • The 2016 study showed that using a patient positioning system (PPS) achieved better turning angles (31.03° vs 22.39° with standard of care) and maintained position better over time 3
   • Proper positioning with appropriate support to relieve pressure on bony prominences is essential 4

Implementation Recommendations

To safely implement extended turning intervals:

1. Conduct thorough risk assessment:

   • Use validated tools like the Braden Scale to stratify patient risk 4
   • Consider patient-specific factors such as mobility, nutrition, and comorbidities

2. Document and monitor:

   • Record each position change and skin condition 4
   • Regularly inspect skin, especially over bony prominences

3. Use appropriate support surfaces:

   • Ensure patients at risk are on appropriate pressure-redistributing surfaces
   • Consider specialized positioning devices that maintain proper positioning 3

4. Adjust frequency based on individual needs:

   • A 2023 systematic review confirms that the optimal turning frequency varies depending on healthcare setting and patient condition 5
   • Patients with emergency ICU/HCU admissions may require more frequent turning as they are at higher risk 6

Important Caveats

• Very high-risk patients may still require more frequent repositioning
• Regular skin assessment is crucial regardless of turning frequency
• The 2024 expert panel guidelines emphasize that mobilization should be protocol-based with both active and passive components 1
• If signs of skin breakdown appear, revert to more frequent repositioning

Conclusion

While the traditional 2-hour turning schedule remains a reasonable baseline, evidence supports that turning intervals can be safely extended to 3-4 hours for patients on pressure-redistributing surfaces who demonstrate stable skin integrity. The decision should be based on comprehensive risk assessment, proper positioning technique, and ongoing skin monitoring.