Turning for Ulcer ReductioN: A Multisite Randomized Clinical Trial in Nursing Homes
Nancy Bergstrom, PhD, RN,* Susan D. Horn, PhD,†‡ Mary Pat Rapp, PhD, RN,* Anita Stern, PhD, RN,§ Ryan Barrett, BS,†‡ and Michael Watkiss, BFA†‡
OBJECTIVES: To determine optimal repositioning
frequency of nursing home (NH) residents at risk for pressure ulcers (PrUs) when cared for on high-density foam mattresses.
DESIGN: Multisite, randomized, clinical trial, known as
Turning for Ulcer ReductioN (TURN Study).
SETTINGS: NHs in the United States (n = 20) and
Canada (n = 7) using high-density foam mattresses.
PARTICIPANTS: Consenting residents (N = 942) aged 65
and older without PrUs at moderate (scores 13–14) or high
(scores 10–12) risk of PrUs according to the Braden Scale. INTERVENTION: Participants were randomly allocated
using risk stratiﬁcation (moderate vs high) to a repositioning schedule (2, 3, or 4 hour) for 3 weeks. Blinded assessors assessed skin weekly.
MEASUREMENTS: PrU incidence (coccyx or sacrum,
RESULTS: Participants were mostly female (77.6%) and
Caucasian (80.5%) and had a mean age of 85.1 Æ 7.7.
The most common diagnoses were cardiovascular (76.9%)
and dementia (72.5%). Nineteen (2.0%) participants
developed superﬁcial PrUs. There was no signiﬁcant
difference (Wilcoxon test for ordered categories) in PrU
incidence (P = .68) according to repositioning group
(2 hour, 8/321, 2.5%; 3 hour, 2/326, 0.6%; 4 hour, 9/
295, 3.1%), nor was there a statistically signiﬁcant
difference in the incidence of PrU between the high and
moderate-risk groups (P = .79). Also, PrU incidence was
not statistically signiﬁcantly different between high-risk participants based on repositioning schedule (6/325, 1.8%,
P = .90) or between moderate-risk participants based on
repositioning schedule (13/617, 2.1%, P = .68).
From the *School of Nursing, University of Texas Health Science Center at, Houston, Houston, Texas; †International Severity Information Systems, Inc., Salt Lake City; ‡Institute for Clinical Outcomes Research, Salt Lake City, Utah; and §Toronto Health Economics and Technology Assessment Collaborative, University of Toronto, Toronto, Ontario, Canada. Address correspondence to Nancy Bergstrom, School of Nursing, University of Texas Health Science Center at Houston, 6901 Bertner Blvd. 5th Floor, Houston, TX 77030. E-mail: email@example.com DOI: 10.1111/jgs.12440
JAGS 61:1705–1713, 2013
© 2013, Copyright the Authors
Journal compilation © 2013, The American Geriatrics Society
CONCLUSION: There was no difference in PrU incidence
over 3 weeks of observation between those turned at
2-, 3-, or 4-hour intervals in this population of residents
using high-density foam mattresses at moderate and high
risk of developing PrUs when they were repositioned
consistently and skin was monitored. This ﬁnding has
major implications for use of nursing staff and cost of NH
care. J Am Geriatr Soc 61:1705–1713, 2013.
Key words: pressure ulcer prevention; nursing home;
repositioning; Turning for Ulcer ReductioN Study
ressure ulcers (PrUs) are a common problem in nursing
home (NH) residents; the prevalence of PrUs in residents at high risk of developing PrUs at the outset of the study was 11.6% according to Nursing Home Compare;1
other studies have reported a 14% to 24% PrU incidence
on standard mattresses or foam overlays.2,3 Economic
evaluation of the cost of prevention is emerging and
variable, with support surfaces and repositioning identiﬁed as more costly elements of prevention.4–6 Pressure at the
interface between bony prominences and support surfaces
sufﬁcient to occlude or reduce blood ﬂow to tissues is
thought to cause PrUs.7,8 Redistributing (through properties of support surfaces) and relieving (through repositioning) pressure to reduce length of exposure to pressure prevents PrUs. High-density foam mattresses distribute
pressure more evenly and are replacing...
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