Key messages
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There is no clear evidence showing that any particular frequency of changing a person's position (repositioning) or any particular position (e.g. tilting the bed to a 30-degree angle) works better than any other to prevent bedsores (pressure injuries) in adults in hospital or care homes.
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Some repositioning frequencies and positions may reduce the costs of care, but this evidence is limited and uncertain.
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This is the second update of a review published in 2014. Research is still limited. Most studies are small and not well designed.
What are bedsores?
Bedsores (also called pressure injuries, pressure ulcers, pressure sores, decubitus ulcers) happen when people are not able to move much, or spend a lot of time sitting or lying down, such as elderly people or those who are very ill. When a body part presses against a mattress or chair for a long time, the skin rubs over bony parts of the body, like the heels, tailbone, hips, back, and the back of the head. Blood flow is reduced and skin and tissue break down.
How are bedsores prevented?
Changing a person's position can improve blood flow to areas that press against the bed or other surfaces, and it can have other benefits, such as increased comfort and mental well-being. The approaches used to prevent bedsores include:
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repositioning: moving or turning someone regularly, for example, every 2, 3, or 4 hours;
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position: placing someone in different positions, for example, raising the head of the bed or tilting the body;
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micromovement: frequent, small position changes made for people who cannot move (e.g. during surgery); and
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specially adapted mattresses and dressings.
What did we want to find out?
We wanted to know:
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which repositioning approaches (e.g. frequencies (how regularly someone is moved) and positions) are best for preventing bedsores;
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their effects on healthcare costs; and
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their effects on health-related quality of life, pain, and patient satisfaction.
What did we do?
We searched for studies that involved adults without bedsores who were receiving care in any hospital, long-term, or aged healthcare facility. The studies investigated which approaches to repositioning were most effective for preventing bedsores.
We summarised the findings and assessed our confidence in the results, based on how the studies were designed and conducted.
What did we find?
We found three new studies published since the 2020 version of the review. This 2026 updated review includes 11 studies and two cost evaluations.
The studies took place in China, Belgium, North America, Iran, and the UK. Most studies were in hospitals (intensive care units, operating theatres, wards); three were in nursing homes. The studies involved 4462 adults aged 18 to 90 years.
Repositioning
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We combined results from four studies comparing different repositioning frequencies. It is unclear whether changing a patient’s position every 2 versus 4 hours, every 2 versus 3 hours, every 3 versus 4 hours, or every 4 versus 6 hours makes any difference to the chance of developing bedsores (4 studies, 2175 people).
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One study tested a device worn by patients that electronically tracks their position and feeds that information back to nurses. Nurses in one group got visual reminders from the sensor to turn the patient every two hours, while nurses in the other group did not get reminders and turned patients based on their own judgement. The visual warnings provided by the device probably reduce the chance of getting bedsores (1 study, 1312 people).
Position
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The effect of 30° tilt, 3-hourly repositioning overnight compared to 90° tilt, 6-hourly repositioning overnight on developing bedsores is unclear (2 studies, 252 people).
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Raising the head of the bed by 30° compared to 45° may have no effect on bedsores (1 study, 80 people), but the evidence is unclear.
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Lying face down (prone) with 'lung recruitment manoeuvres' (a procedure to help open up the lungs) may result in more bedsores than lying face up (1 study, 116 people).
Micromovement
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Micromovement may reduce bedsores (2 studies, 477 people).
Cost-effectiveness
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One study estimated that repositioning costs are lower per resident per day with 4-hourly compared to 2-hourly repositioning, mostly due to reduced nursing time.
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Another study estimated that repositioning every 3 hours with a 30-degree tilt costs less than standard care (repositioning every 6 hours with a 90-degree tilt).
Other measures
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No studies reported the other measures we were interested in.
What are the limitations of the evidence?
Our confidence in the evidence is low or very low. Most studies were small or poorly designed. Information about cost-effectiveness was very limited. Health-related quality of life, pain, and patient satisfaction were not reported at all.
As the evidence does not show the best way to prevent pressure injuries, how often to change someone's position should be based on the person's medical condition, personal preferences, comfort, and how much they can move themselves.
How up to date is this review?
This is an update of a review published in 2014 and updated in 2020. The evidence is current to 7 August 2025.
Read the full abstract
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 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.
Search strategy
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.
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
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.
Funding
None
Registration
Protocol (2012) DOI: 10.1002/14651858.CD009958
