A study on pressure ulcers shows that patients may not need to be turned every two hours as a preventive measure, which has been common practice for decades.
For decades it's been standard practice to turn nursing home patients every two hours to prevent pressure ulcers. But new research could turn that standard on its head.
Pressure ulcers, long acknowledged as a common, normal complication among hospital patients with limited mobility, are coming under renewed scrutiny. Anticipating poor quality ratings and financial penalties, and armed with better data, providers are starting to reduce instances of this hospital-acquired condition.
A study, led by Nancy Bergstrom, Ph.D., RN, FAAN, associate dean at The University of Texas Health Science Center at Houston (UTHealth) School of Nursing, has found that nursing homes that use high-density foam mattresses may not need to turn residents multiple times per day.
At a time when safe-patient handling is at the forefront of policy discussions and nurses are "positively deviating" from the norm to provide better care, these study results could be a game-changer in the world of nursing.
See Also: Pressure is On to Reduce Pressure Ulcers
"For 50 years we've been turning people every two hours," Bergstrom tells me. "This is really changing practice."
Not only has Bergstrom's research focused on pressure ulcers, but she says her own mother was in a nursing home, so she knows firsthand how serious pressure ulcers can be. And she knows that turning patients every two hours comes with its own problems, such as disrupting the sleep of patients who often can't get back to sleep after they've been awakened. Turning also takes a lot of time and physical labor from the staff.
"This isn't really a benign thing," Bergstrom says. So she started with the basic premise that pressure ulcers are caused by the amount and duration of pressure on the body.
"The high-density foam mattresses do a very good job of distributing pressure more evenly," she says. After conducting six pilot studies to be sure that her study participants would be safe, Bergstrom led a randomized controlled trial of 942 nursing home residents at-risk for pressure ulcers.
[Disclaimer: Bergstrom is co-owner of a website dedicated to dissemination, education, and training related to the Braden Scale for Predicting Pressure Sore Risk and pressure ulcer prevention and receives royalties.]
"The people that we studied were residents that were moderate or high risk, but not very high risk," Bergstrom says.
The patients were randomly assigned to being turned every two, three, or four hours, and an independent nurse who didn't know which patients were assigned to which turning frequency assessed the patients.
The study showed that that there was no difference in the incidence of pressure ulcers for residents turned at different intervals. Moreover, only 2% of patients developed pressure ulcers at all, and ones who did developed only stage one or two pressure ulcers.
"That's an extremely low rate," Bergstrom says.
Bergstrom says the cost of buying new, high-density foam mattresses is absolutely worth it.
"Not having as many pressure ulcers is worth the money invested in the mattresses," she says. "Facilities have to invest in new mattresses from time to time anyway."
In addition to reducing the incidents of pressure ulcers and improving patient's quality of life by letting them sleep, Bergstrom says less-frequent patient turning could benefit nurses and CNAs, too. Firstly, they'll have the physical burden of turning patients only half as often if they do it every four hours instead of every two. Secondly, a less-frequent turning schedule will free up some of their time.
"Time for CNAs is precious," Bergstrom says. "They could spend that time feeding residents; they could spend time helping them to walk, and toilet."
Bergstrom says that if a facility wants to change its protocols, nurse leaders need to be prepared for staff members' reluctance to change; it's tough to break a 50-year-old habit. And in making the change, facilities need to do it carefully. (See her steps for doing so, below).
"When you do it, you need to pay attention and make sure it's working for you," Bergstrom says.
Considerations for less-frequent patient turning:
1. Residents "need to have a high density foam mattress on the bed," Bergstrom says, not an overlay or pad on top of another type of mattress.
2. Use a safety checklist. Bergstrom's team developed a safety checklist, "which was almost an unintended consequence" of the study, she says.
The checklist took one minute for nurses to complete; they did it every time they turned a patient. It asked: What time was the patient was turned, and what position was he/she put in?; Were the patient's heels up (yes or no)?; Was the skin normal, red, bruised, or open?; Were the patient's briefs dry, wet, or soiled?; What was the brief care: washed, barrier cream, clean briefs? (check all that apply).
"It goes back to one of the first things I know; if you're going to turn people it's wise to look at the skin at every turn," Bergstrom says. "Everybody was rated on this checklist every time, and we believe this became a major safety factor in the study."
3. Be systematic. Facilities "need to teach the nurses to do these observations; they need to monitor."
Alexandra Wilson Pecci is an editor for HealthLeaders.
