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Rotating Beds

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Research question: What are the benefits of a rotating/powered turning bed compared to manual night-time repositioning for people who are unable to reposition themselves overnight? Date: 23/12/2021 Requestor: Brigid [[s47F - personal privacy](/foi-library/releases/759e22e37354-foi-24-25-0593-decision-document/release-materials/material-001__s47f-personal-privacy/)](/foi-library/releases/759e22e37354-foi-24-25-0593-decision-document/release-materials/material-001__s47f-personal-privacy/) Endorsed by (EL1 or above): Sandi s47F - personal privacy Cleared by: Megan s47F - personal privacy

  1. Contents

Rotating Beds ……………………………………………………………………………………………………………. 1

  1. Contents ……………………………………………………………………………………………………….. 1

  2. Summary ………………………………………………………………………………………………………. 2

  3. Patient Repositioning ………………………………………………………………………………………. 2

  4. Continuous Lateral Rotation Therapy ………………………………………………………………… 2

4.1 Prevention of Pressure Ulcers ……………………………………………………………………….. 2

4.2 Prevention of Respiratory Complications …………………………………………………………. 3

  1. Conclusion …………………………………………………………………………………………………….. 4

  2. References ……………………………………………………………………………………………………. 5

  3. Version control ……………………………………………………………………………………………….. 6

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  1. Summary

For people who are unable to reposition themselves at night, a carer may assist to help them to adjust their positioning. There is limited research on the benefits of night-time repositioning for people with disabilities, except in the acute stages of an injury such as Spinal Cord Injury where the person is generally unable to leave their bed and is likely in hospital. Continuous Lateral Rotation Therapy (CLRT) is the use of a bed which automatically moves a person from side to side and is most commonly used in hospitals for critically ill patients in intensive care. CLRT is only likely to be beneficial for participants who are unable to be safely repositioned by a carer due to a safety risk to the carer or participant. Manual repositioning is more beneficial as the carer can move the participant into a greater variety of positions (supine, side and prone). Many participants who are unable to reposition themselves at night may not be required to adjust their position, with other supports such as wheelchair tilt/recline systems, standing systems and recliner chairs enabling them to change positions throughout the day and therefore reduce the chance of developing pressure ulcers. Guidelines recommend that regular repositioning at two hour intervals is only required when the person is in the acute or rehabilitation stages.

  1. Patient Repositioning

People who are unable to transfer from their bed due to their disability or because they are critically ill in hospital benefit from being regularly repositioned to prevent pressure ulcers forming and to reduce the risk of respiratory complications such as pneumonia [1]. Continuous lateral rotation therapy (CLRT) is the use of a moving bed which automatically shifts a person from side to side. It is most often used in hospitals for critically ill, immobile patients in the intensive care unit [1].

  1. Continuous Lateral Rotation Therapy

Research on the benefits of CLRT primarily focuses on critically ill patients in hospital intensive care units [1]. Although no research specifically on CLRT for people with disability was found, in this section we discuss how the benefits of CLRT to critically ill patients may relate to people with disability. The primary benefits of CLRT for critically ill hospital patients are prevention of pressure ulcers and prevention of respiratory complications [1].

4.1 Prevention of Pressure Ulcers

For people with disability, regular repositioning can reduce the chance of developing pressure ulcers, with people with disability who have limited mobility benefiting from regular standing, adjusting the tilt/recline position of their wheelchair, and regular repositioning at night [2,3,4]. Although there are no studies investigating the benefits of CLTR for people with disability, the effects of CLTR on the risk of pressure ulcers has been investigated in the context of a critically ill hospital patient [5]. In people who are healthy and do not have a disability, CLTR

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has been found to reduce pressure on the ischial tuberosities (part of the pelvis), therefore possibly reducing the risk of pressure ulcers developing around the buttocks or sacrum [6]. However, the results are less clear in studies on critically ill hospital patients. A literature review investigating the impact of regular repositioning and pressure ulcers found that there is no clear evidence that regular repositioning reduces the risk of developing pressure ulcers [7]. There is also limited evidence that for people over 60, CLTR may speed up the healing time of pressure ulcers [8]. It is possible that the results from these studies could differ for people with disability who are at increased risk of developing pressure ulcers such as people with Spinal Cord Injury (SCI) [9].

There is evidence that regular repositioning in bed is beneficial for people with disability who have limited mobility, particularly people with SCI, to prevent pressure ulcers [4]. The Clinical Practice Guideline for Pressure Ulcer Prevention from the Journal of Spinal Cord Medicine recommend that in the acute and rehabilitation phases of SCI, patients should be turned every two hours to prevent pressure ulcers forming [4]. The technique used to reposition the patient is important to prevent friction on the bed causing skin breakdown. Using lifting devices such as hoists can prevent skin breakdown due to friction. Poor turning and transfers can also be ineffective at reducing the risk of pressure ulcers if done incorrectly [4]. As these guidelines recommend that skin is inspected between turns to ensure that skin breakdown is minimised, pillows or wedges should be used and the patient should be positioned in all body positions if tolerated (supine, side, and prone). CLRT may not be suitable for these patients. CLTR can only rotate the patient laterally and cannot adjust their position from supine to side and prone positions.

Once the person with SCI is beyond the acute and rehabilitation phases, regular repositioning during the night is no longer required [4]. Many other supports such as standing frames, power wheelchair standing systems, and wheelchair tilt/recline systems can reduce the risk of developing pressure ulcers [2, 3]. These supports also offer additional benefits for people with disability such as increased independence and social and community participation [2, 3].

4.2 Prevention of Respiratory Complications

For critically ill hospital patients, prolonged immobilisation increases the risk of respiratory complications such as pneumonia, particularly in patients who are mechanically ventilated [1]. A recent systematic review and meta-analysis found that CLRT is an effective method of preventing pneumonia in critically ill patients [1]. This is likely to be because continuous rotation reduces the amount of fluid in the lungs, improves the ventilation-perfusion relationship [10] and reduces the chance of lung collapse [11].

For some people their disability puts them at higher risk of respiratory complications. For example, pneumonia is one of the most common causes of death in children with Cerebral Palsy (CP) as some people with CP have reduced cough reflexes and aspirate more frequently due to impaired swallowing mechanisms and gastro-oesophageal reflux [12]. For people with CP, respiratory symptoms are managed through use of a Continuous Positive

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Airway Pressure (CPAP) machine and/or a feeding tube [12, 13]. Similarly, people with cervical SCI are prone to respiratory infections such as pneumonia due to dysphagia which can lead to aspiration [14]. Additionally, for people with SCI in the early stage of their injury, repositioning can assist to reduce the risk of pneumonia [15]. For people with cervical spinal cord injury with dysphagia, early implementation of a PEG feeding tube can reduce the risk of pneumonia [14]. Risk of respiratory infections is also higher for people with other disabilities such as stroke and muscular dystrophy due to dysphagia [16, 17].

Many people with disability who are at higher risk of respiratory complications such as pneumonia are at greater risk due to frequent aspiration [12, 14, 16-17]. This is a different mechanism to critically ill hospitalised patients who are at risk of respiratory complications due to factors such as prolonged immobilisation, mechanical ventilation, and because they are critically ill [1]. It appears that regular bed repositioning only has respiratory benefits for patients in the acute stage of their injury and are unable to leave their bed and likely in hospital [15]. It is therefore unlikely that CLTR would be beneficial to prevent respiratory complications for people with disability unless they are in the acute stages.

  1. Conclusion

As the majority of research on CLTR focuses on critically ill hospital patients, it is challenging to determine the benefits for people with disability. The respiratory benefits of CLTR in intensive care units is unlikely to be relevant to many people with disability unless they are in the acute stages of an injury (such as SCI, stroke, acquired brain injury) and are unable to reposition or transfer from a bed.

Both critically ill hospital patients and some people with disability, particularly people with SCI, are at increased risk of pressure ulcers due to prolonged immobilisation [1, 9]. It is important to note that critically ill hospital patients do not mobilise during the day and without CLRT or conventional patient repositioning are in a supine position 24 hours a day. In contrast, many people with disability who have limited mobility are able to mobilise when they are not sleeping by using Assistive Technology such as manual and power wheelchairs, or with assistance from carers. They are also able to reposition by using supports such as standing frames, standing systems, wheelchair tilt/recline systems, wheelchair elevating leg rests, or recliner chairs. These supports can reduce the risk of pressure ulcers [2,3]. Supports such as carers and hoists can assist with transfers to and from the bed if the person is unable to transfer independently. The Clinical Practice Guidelines from the Journal of Spinal Cord Medicine outline that repositioning should be used during the acute and rehabilitation stages of an injury, but do not mention bed repositioning during sleep being used after this point for people with SCI [4].

If a participant is unable to leave their bed, such as if they are in the acute or rehabilitation phases of a disability such as a stroke, SCI, or acquired brain injury, they will need to be repositioned regularly to reduce the risk of pressure ulcers forming [4]. The Clinical Practice Guidelines from the Journal of Spinal Cord Medicine specify that repositioning should include

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inspection of the skin for signs of damage, the use of pillows or foam wedges, and all body positions should be used if the patient is able to tolerate all positions [4]. It is therefore unlikely that CLRT would be as beneficial as manual repositioning as the participant is unable to be positioned on their side or in a prone position using CLRT. However, risk of injury to the carer(s) repositioning the participant must be taken into account. Factors such as the patient’s weight may make it unsafe for a carer to reposition the participant [18]. Assistive Technology such as hoists can assist in making repositioning safer for the participant and carer [4]. If the participant unable to be safely repositioned in bed even with the aid of Assistive Technology such as hoists, a CLRT would possibly be appropriate to reduce the risk of pressure ulcers due to evidence that CLRT significantly reduces pressure on the pelvis [6]. However it may not be as effective as manual repositioning [4]. It is important to note that CLRT also increases the pressure in the heels, so heel-protection devices (for example heel pressure relief boots or heel elevation cushions) may be required to prevent pressure ulcers developing on the feet if CLRT is regularly used [6].

  1. References

[1] Schieren M, Piekarski F, Dusse F, Marcus H, Poels M, Wappler F, Defosse J. Continuous lateral rotational therapy in trauma—A systematic review and meta-analysis. Journal of Trauma and Acute Care Surgery. 2017 Nov 1;83(5):926-33.

[2] Dicianno BE, Arva J, Lieberman JM, Schmeler MR, Souza A, Phillips K, Lange M, Cooper R, Davis K, Betz KL. RESNA position on the application of tilt, recline, and elevating legrests for wheelchairs. Assistive Technology. 2009 Jun 12;21(1):13-22.

[3] Arva J, Paleg G, Lange M, Lieberman J, Schmeler M, Dicianno B, Babinec M, Rosen L. RESNA position on the application of wheelchair standing devices. Assistive Technology. 2009 Sep 18;21(3):161-8.

[4] The Consortium for Spinal Cord Medicine. Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. The Journal of Spinal Cord Medicine. 2001; 24:sup1, S40-S101.

[5] Gillespie BM, Walker RM, Latimer SL, Thalib L, Whitty JA, McInnes E, Chaboyer WP. Repositioning for pressure injury prevention in adults. Cochrane Database of Systematic Reviews. 2020(6).

[6] Anderson R, Kleiber C, Greiner J, Comried L, Zimmerman M. Interface pressure redistribution on skin during continuous lateral rotation therapy: A feasibility study. Heart & Lung. 2016 May 1;45(3):237-43.

[7] Anderson C, Rappl L. Lateral rotation mattresses for wound healing. Wound Management & Prevention. 2004 Apr;50(4):50-4.

[8] Anderson C, Rappl L. LATERAL ROTATION MATTRESSES FOR WOUND HEALING. Journal of Wound Ostomy & Continence Nursing. 2003 May 1;30(3):S23-4.

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[9] Kruger EA, Pires M, Ngann Y, Sterling M, Rubayi S. Comprehensive management of pressure ulcers in spinal cord injury: current concepts and future trends. The journal of spinal cord medicine. 2013 Nov 1;36(6):572-85.

[10] Bein T, Reber A, Metz C, Jauch KW, Hedenstierna G. Acute effects of continuous rotational therapy on ventilation-perfusion inequality in lung injury. Intensive care medicine. 1998 Feb;24(2):132-7.

[11] Raoof S, Chowdhrey N, Raoof S, Feuerman M, King A, Sriraman R, Khan FA. Effect of combined kinetic therapy and percussion therapy on the resolution of atelectasis in critically ill patients. Chest. 1999 Jun 1;115(6):1658-66.

[12] Reddihough DS, Baikie G, Walstab JE. Cerebral palsy in Victoria, Australia: mortality and causes of death. Journal of paediatrics and child health. 2001 Apr 10;37(2):183-6.

[13] Hayward H, Louis M, Edwards L, Jacob R. Sleep Disordered Breathing in Adults with Cerebral Palsy: What Do We Know So Far?. Southern Medical Journal. 2021 Jun 1;114(6):339-42.

[14] Ramczykowski, T., Grüning, S., Gurr, A. et al. Aspiration pneumonia after cervical spine injury. Trauma surgeon. 2012;115, 427–432.

[15] Consortium for Spinal Cord Medicine. Respiratory management following spinal cord injury: a clinical practice guideline for health-care professionals. The Journal of Spinal Cord Medicine. 2005;28(3):259.

[16] Westendorp WF, Vermeij JD, Hilkens NA, Brouwer MC, Algra A, van der Worp HB, Dippel DW, van de Beek D, Nederkoorn PJ. Development and internal validation of a prediction rule for post-stroke infection and post-stroke pneumonia in acute stroke patients. European stroke journal. 2018 Jun;3(2):136-44.

[17] Pane M, Vasta I, Messina S, Sorleti D, Aloysius A, Sciarra F, Mangiola F, Kinali M, Ricci E, Mercuri E. Feeding problems and weight gain in Duchenne muscular dystrophy. European journal of paediatric neurology. 2006 Sep 1;10(5-6):231-6.

[18] Skotte J, Fallentin N. Low back injury risk during repositioning of patients in bed: the influence of handling technique, patient weight and disability. Ergonomics. 2008 Jul 1;51(7):1042-52.

  1. Version control

Version Amended Brief Description of Change Status Date by

1.0 MBK223 Research paper investigating the benefits of Approved 23/12/2021 rotating beds.

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