1. 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

2. 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?

3. 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.

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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.

10. Lost to follow-up: (n=26) Hospitalized: (n=8), Died: (n=1), Discharged: (n=2), Withdrew: (n=10), Other: (n=5) 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) Analyzed (n=321) Did not receive allocated intervention: (n=14) Lost to follow-up: (n=35) Hospitalized: (n=8), Died: (n=6), Discharged: (n=2), Withdrew: (n=14), Other: (n=5) Lost to follow-up: (n=28) Hospitalized: (n=13), Died: (n=2), Discharged: (n=8), Withdrew: (n=5) Analyzed (n=326) Did not receive allocated intervention: (n=7) 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) Allocated to intervention (n=333)  Received allocated intervention (n=326) Did not receive allocated intervention: (n=7) Hospitalized:(n=1), Participant Choice: (n=6) Allocated to intervention (n=299)  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

11. Characteristics VariableAll (N=942)Mod Risk (N=617) High Risk (N=325) P= (T-test) Age (years) (M + SD) 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

12. Characteristics VariableAll (N=942)Mod Risk (N=617) High Risk (N=325) 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

13. Characteristics VariableAll (N=942)Mod Risk (N=617) High Risk (N=325) 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) 0.001 0.251 0.277 0.001 0.999 0.858 0.001 LOS # (%) 0.231 Long Short 814 (86.4) 128 (13.6) 527 (85.4) 90 (14.6) 287 (88.3) 38 (11.7)

14. 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

15. Incidence of PrU by Risk and Turning Group GroupUlcers/ Group % Ulcers Ulcers 2-hour % Ulcers Ulcers 3-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 Risk6/325 (1.85%) 2/111 (1.80%) 2/117 (1.71%) 2/97 (2.06%) (0.98) Moderate vs. High (0.73)

16. Discussion

17. EVIDENCE FOR TURNING

18. Study Braden Scale Score Support Surface 2-hour3-hour4-hour6-hour Defloor et. al. 2005 Belgium 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., 2011 Scotland Braden Activity and Mobility Subscales 99% had powered redistribution device 2/99 (2%)7/114 (6%) TURN Study US & Canada Braden Moderate 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%)

19. Study Braden Scale Score Support Surface 2-hour3-hour4-hour Defloor et. al. 2005 Mean 13.0 + 2 Visco elastic mattress 2/66 (3%) stage 2 TURN StudyBraden Moderate 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%)

20. Conclusions

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, briefs, careful vigilant staff)

22. 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