The TURN Study: Is there a difference in pressure ulcer incidence with 2, 3, or 4 hour turning of nursing facility residents? Nancy Bergstrom, Susan D.

The TURN Study: Is there a difference in pressure ulcer incidence with 2, 3, or 4 hour turning of nursing facility

residents?

Nancy Bergstrom, Susan D. Horn,Mary Pat Rapp, Anita Stern,

Ryan Barrett, Michael D. Watkiss

Purpose of Study

Is there a significant difference in the incidence of pressure ulcers among moderate and high risk nursing facility residents cared for on a high density foam mattress when repositioning occurs every 2, compared to every 3 or 4 hours?

Hypothesis• It is hypothesized that there is no difference in

pressure ulcer incidence among moderate or high risk residents randomly assigned to repositioning every 2-, compared with every 3- or 4 hours.

Randomized Controlled Trial

• Random allocation– High risk ( 2, compared with 3 or 4 hour turn)– Moderate risk (2, compared with 3 or 4 hour turn)

• 3 week follow up• Weekly and final skin assessment (blinded)• Outcome PrU on coccyx, sacrum, heels• Stage 1 must be present on 2 days

The Intervention

• Random assignment to turning schedule• Turning clock kept in bedside folder• Documentation (24- hr safety checklist: skin

observation, position in bed, position of heels in bed, time spent in chair, bathing, meal intake, continence care)

• Fidelity measures (% on time turning, % position agreement between CNA and Supervisor)

• Shift handoff

Outcome Assessors

• Trained in risk assessment using the Braden Scale

• Trained using video, vignettes, observation• Prior to study to determine selection and risk• Weekly throughout study

• Trained in skin assessment• Blinded to turning frequency• Assessed for PUs weekly

Facility Criteria

• Provide basic good care• Use high density foam mattresses (mattress

provided to all participants in Canada due to variability in existing surfaces)

• Willingness to provide staff time to participate• Initial screening of residents verify number of

eligible, at risk subjects

Resident Criteria

• Newly admitted (within 7 days), or• Long term (> 90 days)• Age > 65 years• At risk for PrUs

• Moderate risk (Braden scores 13, 14)• High risk (Braden scores 10-12)

• No PrUs at outset• High density foam mattress

Sample Size

• Assuming a change from 4% incidence to 8% would be considered significant, a one-tailed test, and an alpha of .05, the power to detect such a difference is 0.82 for 900 participants.

Lost to follow-up: (n=26)

Hospitalized: (n=8), Died: (n=1), Discharged: (n=2), Withdrew: (n=10), Other: (n=5)

Enrollment

Analyzed (n=295) Did not receive allocated intervention: (n=4)

Assessed for eligibility (n= 6240) Excluded (n=5273) Not meeting inclusion criteria (n= 4840) Declined to participate (n= 204) Other reasons (n= 229)



Hospitalized: (n=8), Died: (n=6), Discharged: (n=2), Withdrew: (n=14), Other: (n=5)


Hospitalized: (n=13), Died: (n=2), Discharged: (n=8), Withdrew: (n=5)


Analyzed

Randomized (n=967)

Allocation

Follow-up

Allocated to intervention (n=335)

Received allocated intervention (n=321)Did not receive allocated intervention: (n=14) Death:(n=2), Hospitalized(n=1),Other(n=3),Participant Choice:(n=8)


Received allocated intervention (n=326)Did not receive allocated intervention: (n=7) Hospitalized:(n=1), Participant Choice: (n=6)


Received allocated intervention (n=295)Did not receive allocated intervention: (n=4) Hospitalization: (n=2), Participant Choice: (n=1), Other: (n=1)

2 Hour Turn Group

3 Hour Turn Group

4 Hour Turn Group

CharacteristicsVariable All (N=942) Mod Risk

(N=617)High Risk(N=325)

P=(T-test)

Age (years)(M + SD)

85 (7.7) 85 (7.7) 85 (7.7) 0.36

Braden (M + SD)

12.8 (1.1) 13.6 (0.5) 11.4 (0.7) <.001

Canada

US

505 (53.6)437 (46.4)

336 (54.4)281 (45.5)

169 (52.0)156 (48.0)

0.49



P=(T-test)

Female # (%)

731 (77.6) 464 (75.2) 267 (82.2) 0.017

Race # (%)

White Black Asian Hispanic

758 (80.5) 55 ( 5.8)101 (10.7) 22 ( 2.3)

506 (82.0) 37 ( 6.0) 59 ( 9.6) 14 ( 2.3)

252 (77.5) 18 ( 5.5) 42 (12.9) 8 ( 2.5)

0.056



P=(T-test)

Diagnosis # (%) Dementia Cerebro Diabetes Cardio Musculo Thyroid Nutrition

672 (72.5)341 (36.8)252 (27.2)713 (76.9)506 (54.6)167 (18.0) 18 ( 1.9)

421 (69.0)216 (35.4)173 (28.4)491 (80.5)333 (54.6)111 (18.2) 5 (0.82)

251 (79.2)125 (39.4) 79 (24.9)222 (70.0)173 (54.6) 56 (17.7) 13 ( 4.1)

0.0010.2510.2770.0010.9990.8580.001

LOS # (%)

0.231

Long Short

814 (86.4)128 (13.6)

527 (85.4) 90 (14.6)

287 (88.3) 38 (11.7)

Analysis• 942 participants, power 80%, and 1-tailed

type I error of p<0.05, to detect a difference of about 4% between turning schedules

• Moderate risk, 3 hour turn group was significantly different

• Chi square/Fisher’s exact test• ANOVA• Original prediction 4% incidence/group

Incidence of PrU by Risk and Turning Group

Group Ulcers/Group% Ulcers

Ulcers2-hour% Ulcers

Ulcers3-hour% Ulcers

Ulcers 4-hour% ulcers

Group (p=)

All participants

19/942(2.02%)

8/321(2.49)

2/326(0.61%)

9/295(3.05%)

(0.07)

Moderate Risk

13/617(2.11%)

6/210(2.86%)

0/209 (0%)

7/198(3.54%)

(0.03)

High Risk 6/325(1.85%)

2/111(1.80%)

2/117(1.71%)

2/97(2.06%)

(0.98)

Moderate vs. High

(0.73)

Discussion

EVIDENCE FOR TURNING

Study Braden Scale Score

Support Surface

2-hour 3-hour 4-hour 6-hour

Defloor et. al. 2005Belgium

Mean 13.0 + 2

Standard Visco elastic mattress

9/63 (14%) 14/58 (24%)2/66 (3%) stage 2

10/63 (15.9%)Stage 2

Vanderwee et. al., 2007 Belgium

Mean 15.0 + 3

Visco elastic foam overlay (7 cm), 2-4-2 turns

17/122 stage 2 (13.9%) stage 3 or 4(2.5%)

22/113 Stage 2 (19.5%)Stage 3 or 4 (1.8%)

Moore et al., 2011Scotland

Braden Activity and Mobility Subscales

99% had powered redistribution device

2/99 (2%) 7/114 (6%)

TURN StudyUS & Canada

BradenModerate Risk (13-14)High Risk(10-12)

Visco elastic, high density foam mattresses

Moderate:6/210 (2.86%)High:2/111 (1.8%)

Moderate:0/209 (0.00%)High:2/117 (1.71%)

Moderate:7/198 (3.54%)High:2/97 (2.06%)

Study Braden Scale Score

Support Surface

2-hour 3-hour 4-hour

Defloor et. al. 2005

Mean 13.0 + 2 Visco elastic

mattress2/66 (3%) stage 2

TURN Study BradenModerate Risk (13-14)High Risk(10-12)

Visco elastic, high density foam mattresses

Moderate:6/210 (2.86%)High:2/111 (1.8%)

Moderate:0/209 (0.00%)High:2/117 (1.71%)

Moderate:7/198 (3.54%)High:2/97 (2.06%)

Conclusions

Implementation

Turn Q 3 or 4 hours, IF…1. High density foam mattress 2. Braden risk scores 10 – 143. Using guideline based care:

(chair cushions, nutrition, briefs, careful vigilant staff)

Implementation

3. Use Checklist to ensure safety and consistency of care

4. Use Checklist to monitor care and change care plan if needed

5. Monitor outcomes on a pilot basis

The TURN Study: Is there a difference in pressure ulcer incidence with 2, 3, or 4 hour turning of nursing facility residents? Nancy Bergstrom, Susan D.

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