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TURN Study Overview

The purpose of this multi-site, randomized, controlled trial is to determine the optimal frequency of repositioning nursing facility residents with mobility limitations who are at moderate and high risk for pressure ulcer development who are cared for on high density foam mattresses for the purpose of preventing pressure ulcers. One of the most basic nursing care acts is repositioning patients. This practice was derived from a simple observational study and a small experimental study (Norton, McLaren, & Exton-Smith, 1962) and is the primary source of recommendations for turning every two hours. This practice is observed world wide and failure to carry out this maneuver may result in penalties and legal judgments against nursing facilities. It is likely that new technology has made this nursing care less necessary, yet this premise has not been tested. If the frequency of treatment could be safely tailored to risk level, if residents could sleep for longer intervals without getting pressure ulcers, if staff could be exposed to less risk of injury and have time for other important care, an innovation in care could be claimed. This knowledge could transform fundamental aspects of care.

Pressure ulcers are defined as any skin lesion over a bony prominence that results from prolonged exposure to pressure. There are two major factors that determine the exposure of the tissue to pressure sufficient to lead to tissue damage: a) exposure to pressure due to the inability to change position, and b) properties of the support surface that deflect and reduce pressure. The accepted standard of care among nurses has been to reposition patients every two hours. Initially, the support surface industry produced mattress overlays to reduce pressure at the interface between the patient and the support surface to less than the capillary closing pressure, 32 mmHg. Despite the best efforts of industry, few of the original foam overlay products could achieve this objective and, among the best, there remained problems.

More recently, manufacturers are producing high-density foam core mattresses that replace the springform plastic coated mattresses. In most studies comparing foam or other mattress overlays with high-density foam replacement mattresses, the incidence of pressure ulcers was lower with replacement mattresses (Whittemore, 1998) . The premise of this study is based on the belief that the decreased exposure to pressure from the new support surfaces has opened the door for less frequent repositioning. This may be true particularly if nursing facility residents are somewhat mobile in bed and are able to make small or large shifts in body position that result in tissue reperfusion. Two advantages of less frequent repositioning are the potential improvement in quality of life for residents who are allowed to sleep for more than two hours without being awakened and the obvious saving of nursing time that could be devoted to other therapeutic activities, such as walking, toileting or feeding residents. At night, more time can be devoted to answering resident call lights.

Schnelle and colleagues (Schnelle, Ouslander, Simmons, Alessi, & Gravel, 1993) called for studies that individualize resident care to allow repositioning and other care while promoting sleep, suggesting awakening residents only every 3 hours. It is important to note that according to current practice, for every nursing facility resident requiring repositioning every two hours, 12 repositioning episodes should occur per day, 365 days a year, or 4380 times per year. At 5 minutes of Certified Nursing Assistant (CNA) time per repositioning episode a total of 21,900 minutes or 365 hours or 9.15 weeks per year are required for this one intervention. When repositioning is done, it often requires two CNAs, which means that 8,780 times per year per resident, or 730 hours or 18.3 weeks per year is required per resident. Repositioning exposes a CNA to risk of injury and a resident at risk for decreased quality of life when they are not permitted to sleep enough to feel rested. Clearly identifying those residents at risk for pressure ulcers, estimating the degree of mobility, controlling pressure exposure from the support surface and determining the optimal frequency of repositioning would revolutionize care and permit more time for activities that enhance quality of life (eg. ambulating, feeding, toileting, and more). Determining the appropriate frequency of repositioning is important to keep residents safe, improve quality of life and make judicious use of staffing time in the health care industry.

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The purpose of this multi-site, randomized, controlled trial is to determine the optimal frequency of repositioning nursing facility residents with mobility limitations who are at moderate and high risk for pressure ulcer development who are cared for on high density foam mattresses for the purpose of preventing pressure ulcers. The specific aims of this study are to determine if:

1. there is a significant difference in the incidence of pressure ulcers among:

a. moderate risk (Braden Scale Score, 13-14) residents randomly assigned to be repositioned every 2-, compared with every 3- or 4- hours; or

b. high risk (Braden Scale Score, 10-12) residents who are turned every 2- compared with every 3- or 4 hours.

c. residents at different levels of mobility defined by the Braden Scale Mobility Subscale Scores 1, 2, or 3.

2. mobility is a significant covariate with repositioning in the incidence of pressure ulcers.

3. resident characteristics and resident influencing factors (shown in Figure 1) are significant covariates of 2-, 3- or 4- hour repositioning schedules on pressure ulcer incidence

Hypotheses . It is hypothesized that:

•  there is no difference in pressure ulcer incidence among a) moderate risk residents randomly assigned to repositioning every 2-, compared with every 3- or 4 hours; or b) high risk residents who are turned every 2- compared with every 3-hours.

•  mobility is significantly less among residents who develop pressure ulcers than those who do not.

•  resident characteristics are co variates with repositioning schedules of pressure ulcer development. Specifically a higher incidence of pressure ulcers will occur in residents characterized by a) older age, b) male sex, c) Black race, d) lower body weight, e) more medical diagnoses, f) higher Severity of Illness and g) a past history of pressure ulcer.

•  influencing factors are co variates with repositioning schedules of pressure ulcer development. Specifically a higher incidence of pressure ulcers will occur in residents with lower Braden Scale Subscale Scores for a) mobility, b) nutritional status c) moisture exposure, d) friction and shear, e) sensory perception, and f) who receive processes of care including assistance with eating and other activities of daily living, and lower incidence of pressure ulcers when moisture barriers, disposable briefs, toileting, dietary supplements, fluid orders, and seat cushions are utilized.

Norton, D., McLaren, R., & Exton-Smith, A. N. (1962). An investigation of geriatric nursing problems in hospital (Resubmitted in 1975 ed.). Edinburgh: Churchill Livingston.

Schnelle, J. F., Ouslander, J. G., Simmons, S. F., Alessi, C. A., & Gravel, M. D. (1993). Nighttime sleep and bed mobility among incontinent nursing home residents. J Am Geriatr Soc, 41 (9), 903-909.

Whittemore, R. (1998). Pressure-reduction support surfaces: a review of the literature. J Wound Ostomy Continence Nurs, 25 (1), 6-25.

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Conceptual Framework

In the study conceptual framework, participants who are at moderate or high risk for pressure ulcers (Braden Scale score 13-14, 10-12, respectively) and who are cared for on a high density foam replacement mattress will be randomly assigned to the intervention (see Figure). The intervention alters the primary risk factor (pressure exposure) through a 3 week repositioning schedule based on level of risk. Mobility may be a significant and unappreciated covariate with repositioning frequency and this variable will be studied via actigraphy to determine if there is a relationship with pressure ulcer development. Factors that influence exposure to risk or that decrease tissue tolerance will be measured. These influencing factors are reflected in resident demographic factors (age, sex, race, height/weight, diagnoses, severity of illness and prior history of pressure ulcer), resident influencing factors (Braden Scale subscale concepts of mobility & activity, sensory perception, moisture, nutrition, and friction and shear) including processes of care (assistance with eating and other activities of daily living, dietary supplements and fluid orders, toileting, moisture barriers, disposable briefs, and chair seat cushions). The primary outcome is the incidence and severity of pressure ulcers.

 

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