A New Frontier for Battling Pressure Ulcers

By Brandi Redding

New technology may suggest the need for a change in guidelines regarding the interval between repositionings for bed-ridden patients.

Research published in the October 2013 issue of the Journal of the American Geriatrics Society could potentially change guidelines for the amount of time between repositioning bed-ridden patients to prevent pressure ulcers. The current standard, based on research from the 1960s, requires turning intervals of every two hours. But the Turning for Ulcer ReductioN (TURN) study, predicated on the use of high-density foam mattresses, investigated extending rotations to between three and four hours. The randomized, controlled trial of at-risk residents showed no difference in the incidence of pressure ulcers for residents turned at the standard vs. extended times.

The study assigned participants at moderate and high risk, but not very high risk, of developing pressure ulcers to repositioning intervals of two, three, or four hours for three weeks, during which nurse assistants turned residents according to the schedule for that patient. A nurse, unaware of the turning frequency of each patient, documented skin conditions every week. A checklist was used at each turning to track the type of reposition, heel position, brief condition, and skin care at each turn. No serious pressure ulcers developed during the study.

“High-density foam mattresses do a better job of reducing pressure than older spring-type mattresses. For that reason, it is likely that people can lie in one position for longer periods of time without developing skin problems,” says Nancy Bergstrom, PhD, RN, the Theodore J. and Mary E. Trumble Professor of Aging Research and associate dean for research at the University of Texas Health Science Center at Houston and lead study investigator. “This does not mean that repositioning is not necessary; rather, turning can occur less frequently.”

Patient and Staff Benefits
Reducing the number of rotations for each patient has several added advantages: Residents have longer periods of uninterrupted sleep; staff have reduced exposure to back injury; and staff time can be directed to other more meaningful activities, such as feeding residents and helping them with mobility, while pressure ulcer prevention is not compromised.

“Two other studies considered turning residents at four- or six-hour intervals,” Bergstrom says. “There was a greater incidence of pressure ulcers and more severe pressure ulcers with six-hour turning. For now, facilities [that use high-density foam mattresses] can more safely consider turning at three- or four-hour intervals.”

The increased time between repositioning means that the patient’s skin over bony prominences should be carefully evaluated at each encounter, Bergstrom recommends.

In the study, “Nursing assistants monitored the skin when they did the turning, using a checklist to document what was done,” says Susan D. Horn, PhD, senior scientist at the Institute for Clinical Outcomes Research. “Whatever they did at that repositioning episode—whether it was two hours, three hours, or four hours—they all observed the same protocols in terms of checking.”

According to Bergstrom, the safety checklist documented the time of the turn (to track frequency); whether the heels were elevated; skin condition (red, bruised, open, or normal); the condition of the briefs (wet, dry, soiled); and brief care (washed, barrier cream, brief change). This degree of watchfulness helps keep patients safe.

Different Patients, Different Considerations
Jeanine Maguire, MPT, CWS, director of skin integrity & wound management at Genesis HealthCare, agrees that many patients may prefer the less frequent interruptions to sleep, and that diligent routine skin assessment is vital. “I think a logical algorithm that serves as a starting guide and directs very high-risk residents and/or those with actual pressure ulcers to a two-hour schedule would be key. The guide would need to acknowledge and support that some residents will need different surfaces based upon their individual needs.”

She adds that extending intervals necessitates continuously educating staff on inspecting for tissue tolerance while auditing compliance with both turning requirements and skin checks. Conditions to monitor, she says, include “any visible changes in the skin color especially over boney prominences, any changes in palpable skin temperature over the boney prominences, and any complaints of discomfort.”

While the expense of the mattress may be a concern, Bergstrom says, “The facility has to approach this in a practical manner and realize that any additional cost may be offset by the protection the mattress provides to the resident in terms of comfort and reduction in pressure ulcer risk.” In addition, she points out that all mattresses wear out over time and, as they do, new high-density mattresses can be purchased to replace the old spring types.

Other potential concerns come from the mattresses themselves. For consumers living at home, the average mattress surface depth ranges between 8 and 12 inches and with average widths ranging from double to king. In nursing homes, the standard surface available to fit the hospital bed frame typically is a 6-inch depth and a twin width. “Not only does the narrow width cause concern with safe turning and care, but based on overall surface utilization and patient factors like immobility, weight, and moisture/incontinence, these foam surfaces could bottom out in as little as four or five years,” Maguire says.

However, Bergstrom advises that engineers consider a 6-inch thick mattress to be adequate for nursing homes. In addition, researchers examined all mattresses used in the study because they can wear out within five years, so it is an equipment concern of which staffers need to be aware.

“The movement toward high-density foam surfaces as a standard in nursing homes is an excellent step in improving outcomes. Additionally, when tissue tolerance permits, decreasing the frequency of turning regimens for moderate- to high-risk individuals may be more realistic for caregivers and more preferable to the patient,” Maguire says. “However, serious thought in the specs of these surfaces and the length of time they are expected to provide a therapeutic effect is needed. Additionally, centers that are moving in this direction need to routinely check these surfaces for viability. Also, a surface replacement plan must be a key piece of the plan.”

Another concern could be that the increased immersion of a foam surface, as opposed to older spring-type mattresses, may challenge independent mobility by making it more difficult for users to turn and/or transfer out of bed. This often is addressed by manufacturers with the use of denser foam around the edges of the surface and softer foam for ingress/egress areas. Although this factor does not prevent selection of foam mattresses, it should be a clinical consideration when introducing this surface to a new patient.

Even considering these potential complications, the study calls into question a guideline that has been in place for more than 50 years. “People just assumed that it was handed down from on high, and they never really thought about relooking at it,” Horn says.

“The newer technology high-density foam mattresses really reduce the intensity of pressure to which the person is exposed,” Bergstrom says. “It was time to consider whether they could safely be turned less often.”

“This is an example showing why we really need to examine and test all of our assumptions,” Horn says. “Because we’re now at a point in health care where we have the ability to look at multiple variables in the actual practice of care and assess which things are really associated with better outcomes.”

As advancements change how care is offered, tracked, and applied, the standards and guidelines need to be monitored and evaluated. The importance of evidence-based medicine should extend to proving that evidence is still valid when the environment surrounding the circumstances changes.

“Here is a sterling example of what can be learned in a field where I think most people would have thought there’s not much else you can do for frail elderly people,” Horn says.

— Brandi Redding is the assistant editor for Today’s Geriatric Medicine.