Repositioning for pressure injury prevention in adults

Pressure injuries (or pressure ulcers) are localised damage to skin or tissue (or both) occurring over bony prominences, resulting from prolonged pressure or shear forces (or both). Adults receiving care in any healthcare setting can develop pressure injuries. Immobility, malnutrition, and reduced sensation are some known risk factors. Regular repositioning is a theoretically sound prevention strategy that is part of standard patient care. This is the second update of a review published in 2014 and updated in 2020.

To evaluate the benefits and harms, and cost-effectiveness, of repositioning regimens (i.e. repositioning frequencies, position, micromovement) for pressure injury prevention in adults in acute, long-term, or aged healthcare settings, compared to standard care or another repositioning regimen.

To identify studies for inclusion in the review, we searched the Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Embase, EBSCO CINAHL Plus, and trial registries on 7 May 2025. We also scanned the reference lists of included studies, reviews, meta-analyses, and health technology reports.

We included randomised controlled trials that assessed the effects of any repositioning regimen and measured pressure injury incidence in adults (at least 18 years of age) without an existing pressure injury, in any acute, long-term, or aged healthcare setting.

The primary outcome was the cumulative incidence of pressure injuries (any category/stage). Secondary outcomes were health-related quality of life, procedural pain, patient satisfaction, pressure injury prevention and treatment costs, and incremental costs per pressure injury avoided.

We assessed the risk of bias in the evidence using the Cochrane RoB 2 tool. We evaluated the certainty of the evidence using GRADE methodology and GRADEpro software.

Seven review authors were involved in independently undertaking study selection, data extraction, and RoB and GRADE assessment. All outcomes were binary and reported as risk ratios (RR) with 95% confidence intervals (CI). We pooled data using the fixed-effect or random-effects model, depending on clinical and methodology heterogeneity.

We found three new trials. This 2026 update of the review therefore includes 11 trials, which were conducted in acute and aged healthcare settings, and involved 4462 participants aged 18 to 90 years. No new economic substudies were identified, so our cost analysis is based on the two economic evaluations that were included in the previous version of the review.

Primary outcome: incidence of new pressure injury (any category/stage) Repositioning frequencies Five trials evaluated different repositioning frequencies in intensive care unit (ICU) and nursing home settings. We pooled the results of four trials that compared 2- versus 4-hourly repositioning (RR 1.05, 95% CI 0.79 to 1.39; 4 trials, 1104 participants), but we judged the certainty of the evidence as very low. There were three other comparisons of repositioning frequencies: 2-hourly versus 3-hourly (RR 1.10, 95% CI 0.30 to 4.08; 3 trials, 795 participants); 3-hourly versus 4-hourly (RR 0.99, 95% CI 0.22 to 4.43; 3 trials, 776 participants); and 4-hourly versus 6-hourly (RR 0.73, 95% CI 0.53 to 1.02; 1 trial, 129 participants). We judged the certainty of the evidence for these results as very low. Therefore, for comparisons of different repositioning frequencies, the evidence is very uncertain. One trial evaluated real-time wearable patient sensor data with visual reminders for 2-hourly repositioning compared to standard care (real-time patient sensor data without visual reminders and with nurse-initiated repositioning) in 1226 ICU patients. The study reported a significant reduction in pressure injuries with the visual warnings from the sensors (RR 0.28, 95% CI 0.10 to 0.75). We judged the certainty of this evidence as moderate. Position Four trials evaluated patient position. Two of the trials compared 30° tilt (and 3-hourly repositioning overnight) versus 90° tilt (and 6-hourly repositioning overnight) in acute and nursing home patients. We pooled their data and found an RR of 0.62 (95% CI 0.10 to 3.97; 2 trials, 252 participants), but we judged the certainty of this evidence as very low. One trial (120 participants) compared 30° and 45° tilts with 'usual care' in three ICUs and reported no pressure injuries in either trial arm, but we judged the certainty of this evidence as very low. One trial (116 participants) compared prone versus supine positioning in ICU patients, and found there may be higher pressure injury incidence in the prone group (RR 4.55, 95% CI 2.31 to 8.98). We judged the certainty of this evidence as low. Micromovement We pooled two trials comparing micromovement with standard care (silicone foam dressing) in operating rooms. The results suggested a reduction in pressure injuries with micromovement (RR 0.28, 95% CI 0.11 to 0.67; 2 trials, 477 participants), but the number of events was low. We judged the certainty of the evidence as low. Secondary outcomes No trials reported health-related quality of life, procedural pain, or patient satisfaction. Cost analysis Two trials, both conducted in nursing homes, included parallel economic evaluations. One compared costs of 2-hourly repositioning (321 participants) versus 3-hourly (326 participants) and 4-hourly (295 participants) schedules, with costs being $11.05 and $16.74 (Canadian dollars) less per resident per day for the 3- and 4-hourly regimens, respectively. The other compared 3-hourly repositioning using a 30° tilt versus standard care (6-hourly with a 90° lateral rotation) in 213 participants. It found that the intervention was cost-effective (EUR 206.60 versus 253.10, incremental difference EUR 46.50, 95% CI 1.25 to 74.60), with a projected annual saving of EUR 512,800 (equating to 21,462 nursing-care hours).

Repositioning is a frequently used strategy for pressure injury prevention in adult patients in acute, long-term, and aged healthcare settings. This updated review includes three new trials, but the findings and conclusions align with our earlier reviews. Most of the evidence is of low or very low certainty. There is a lack of robust evaluation of repositioning regimens for pressure injury prevention, and studies are small, resulting in uncertainty about the review findings. There are limited economic evaluation data, making it difficult to reach reliable conclusions about the relative costs of different repositioning regimens.

None REGISTRATION: Protocol (2012) DOI: 10.1002/14651858.CD009958.