The TURN Study for Pressure Ulcer Prevention: A Symposium

1. The TURN Study for Pressure Ulcer Prevention: A Symposium Presented at the State of the Science Congress September,15, 2012

2. TurningforUlcerReductioN Nancy Bergstrom, UTH Susan Horn, ISIS, ICOR Mary Pat Rapp UTH Anita Stern, UT, THETA

3.  4 year, multi-site, multidisciplinary RCT $2,533,654 [NINR & NIA]  $507,520 Ontario Ministry of Health 20 study sites in the US and 7 in Canada 8 Disciplines: Nursing; Medicine; Bioengineering; Physics; Health Services Researchers; Health Economists; Wound Care Specialists; & Health Department Regulators Turning for UlcerReductioN

4. Principal Investigators Nancy Bergstrom PhD, RN, FAAN1 Susan Horn PhD2 Murray Krahn PhD3 Project Director: Mary Pat Rapp PhD, RN1 Data Analysts2 Randall Smout MS Ryan Barrett BS Michael Watkiss BFA Research Co-ordinator: Anita Stern PhD, RN3 Study Co-ordinator: Gina Trubiani PhD3 Study Sites United States N = 20 Canada N = 7 1University of Texas Health Science Center on Aging 2International Severity Information Systems, Inc. and the Institute for Clinical Outcomes Research 3University of Toronto, Toronto Health Economic Technology Assessment Collaborative, Ontario Ministry of Health and Long Term Care

5. Study design, settings, and demographic characteristics of participants Nancy Bergstrom, Susan D. Horn, Mary Pat Rapp, Anita Stern, Michael D. Watkiss, & Ryan Barrett

6. Purpose of Paper • Describe the background and design of the TURN Study • Identify demographic characteristics of enrolled participants • Differentiate between high and low risk participants

7. Background • Turning Q 2 H is a worldwide practice • Net result • Turn 12 X a day X 365 days = 4380 times/year • 4380 turns X 5 minutes = 21,900 minutes or 365 hours or 15.2 days/year/resident of turning • Awaken residents, deprive of sleep • Decrease quality of life • Impossible standard

8. In the beginning…….(1960s) • Norton (nurse) and Exton-Smith (doctor) in UK found: • Residents in an old folks home who were turned every 2 – 3 hours had fewer pressure ulcers than those turned less often • Mattresses were made of heavy metal coils or springs covered with heavy plastic • Mattresses were hard and made people sweat

9. That was then, this is now 2012 • Mattresses are made from high density foam • Distribute pressure more evenly • Covering is microfiber, breathable material • Less sweating • Is every 2 hour turning necessary? • Need evidence that turning less often is safe

10. Purpose of TURN Study • Is there a significant difference in the number of moderate and high risk nursing facility residents cared for on high density foam mattresses who develop pressure ulcers when repositioning occurs every 2, compared to every 3 or 4 hours?

11. Randomized Controlled Trial • Random allocation (blocks of 6) • 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 (masked) • Outcome is number of participants with PrU on coccyx, sacrum, heels, trochanter • Stage 1 must be present on 2 days

12. Participants • Newly admitted (within 7 days), or • Long term (> 90 days) • Age > 65 years • At risk for pressure ulcers • Moderate risk (Braden Scale scores 13 - 14) • High risk (Braden Scale scores 10-12) • Mobility subscale score (1-3) • No pressure ulcers at outset • High density foam mattress

13. Characteristics

14. Characteristics

15. Characteristics

16. Characteristics

17. Conclusions

18. Background • Evidence supporting 2-hour turning is old, but tradition keeps the recommendation in place • Newer technology opens the door for consideration of different turning schedules

19. Differences in at risk participants • Participants at moderate and high risk studied since both may require repositioning, but interval may be different • Participants at two Braden Scale risk levels are different in important ways previously associated with risk • High risk are older, lower BMI, ate less, more brief changes, more females