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

2. Turning for Ulcer ReductioN 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 Ulcer ReductioN

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

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 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

14. Characteristics VariableAll (N=942)Mod Risk (N=617) High Risk (N=325) P = (Chi-square test) Female # (%) 731 (77.6)464 (75.2)267 (82.2)0.017 Fisher’s exact 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

15. Characteristics VariableAll (N=942)Mod Risk (N=617) High Risk (N=325) P= (Fisher’s exact test) Diagnosis # (%) Dementia Cerebro Diabetes Cardio Musculo Thyroid Nutrition 672 (73.5) 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 Group # (%) 0.231 Long Short 814 (86.4) 128 (13.6) 527 (85.4) 90 (14.6) 287 (88.3) 38 (11.7)

16. Characteristics VariableAll (N=942)Mod Risk (N=617) High Risk (N=325) P= (t-test) Mod vs High BMI (Kg/m2) (M + SD) 25.1 (6.0)25.7 (5.9)24.0 (6.1)<.001 % Eaten (M + SD) 75.1 (21.6)76.5 (20.9)72.3 (22.7)<.004 Wet Times/Day 4.17 (1.6)4.04 (1.6)4.43 (1.6)<.001

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