1. The TURN Study: Ensuring Treatment and Outcome Fidelity Nancy Bergstrom, Mary Pat Rapp, Susan D. Horn, Anita Stern, Michael D. Watkiss, & Ryan Barrett

2. The intervention Random assignment Bedside folder with clock hands for turning frequency Large clock Documentation forms (24 hour) CNA told when to start protocol CNA told when participant is wearing actigraphs Turn on time schedule and check briefs when in bed

3. How will we know……. (Treatment fidelity) If participants are being turned? 1.CNA documentation (on time turning, time in position) 2.Supervisor Repositioning Checklist (% agreement with CNA)

4. Treatment Fidelity On-Time Turning CNA –PSW repositioning – % time CNA repositioned participant on time schedule + 30 minutes – Reported by am, pm, and turning schedule – Calculated and reported monthly with goal of 80% on time turning – Sent bar graphs to share with staff for staff feedback and training

5. Fidelity (On time turning)

6. Fidelity (Time in position)

7. Treatment fidelity (continued) Supervisor/CNA-PSW Agreement – CNA-PSW documented position/time – Supervisor observed position at next 1-3 hours – % agreement between observations – Reviewed with each facility monthly

8. Agreement (CNA-PSW/Supervisor)

9. Nursing Facility Team Site Coordinator Site Supervisor or Unit Manager Recruiter Assessor Charge Nurses Certified Nurses Aides Data Collector

10. CNA Repositioning Expectations Certified Nursing Assistants will – Turn participant on the assigned schedule – Continue all other pressure ulcer prevention care – Document care procedures Turning Skin observations Continence care Bathing Meal intake Actigraph care

11. Patient Safety CNA/PSW observes skin at every turn and documents (normal, red, open, bruised) Nurse assessor does weekly skin assessment Red areas reported to nurse by CNA/PSW Assessed, dressed, and reported Adverse event reporting upon discovery Data and Safety Monitoring Board

12. CNA Shift Documentation

13. Charge Nurse Expectations Document using Supervisor Repositioning Checklist Assist CNA in completing the CNA Shift Documentation Record Initiate treatment for Stage 1 or 2 pressure ulcer (Pre-approved protocol) Report Adverse Events to Nurse Managers and/or Supervisors and COA

15. Assessors Braden Scale – Trained using video, vignettes, observation – Prior to study to determine selection and risk – Weekly throughout study Skin Assessment – Trained using video, observation – Prior to study to determine eligibility – Weekly throughout study – Quarterly interrater reliability

16. Assessors Masked to turning frequency – Documentation in a folder at participants bedside – No visible cues in room – Assessor is licensed nurse from one unit who goes to another just to assess skin or – Is designated to assess skin on all residents – Asked monthly, “Can you guess the turning schedule of any participants?”

17. Conceptual Schema for the Study of the Etiology of Pressure Sores Mobility Activity Sensory Perception Extrinsic Factors Pressure Sore Development Tissue Tolerance Intensity & Duration of Pressure Moisture Friction & Shear Nutrition Aging Low arteriolar pressure Low oxygen tension Intrinsic Factors

19. Brief changes with turning Evaluate the effect of every 2, 3, or 4 hourly incontinence care on the skin health of residents at risk for pressure ulcers. Incontinence care at time of repositioning Check brief, skin cleansing, barrier cream, brief change as necessary Soiled briefs changed at time of soiling CNA Documentation of brief changes Skin assessment

20. Discussion

21. Implementation Turn Q 3 or 4 hours, IF… 1. High density foam mattress 2. Braden risk scores 10 – 14 3. Using guideline based care: (chair cushions, nutrition, careful vigilant staff)

22. Implementation 3. Implement observation and reporting 4. Use documentation to prompt and verify care 5. Monitor outcomes on a pilot basis

23. Conclusions

24. Intervention resulted in 2.02% PrU (2% less than 4% expected) No significant difference between turning groups Implement turning only with known Braden Scale risk levels of Moderate or High Must use high density foam mattresses Change briefs with turning unless soiled Elevate heels Document and report skin condition