Effect of Varying Repositioning Frequency on Prevention of Pressure Injuries in Nursing Home Residents: TEAM‐UP Cluster‐Randomized Clinical Trial Results

Abstract

Background: Pressure injuries (PrIs) cause pain and infection, lengthen institutional care, raise healthcare costs, and hasten death in nursing home (NH) residents. Repositioning residents to offload pressure on tissues is the most common prevention strategy, yetthe optimal interval remains uncertain.Objective: Investigate clinical effectiveness of three nursing-home-wide repositioning intervals (2-,3-, or 4-hours) without compromising PrI incidence in four weeks in adult nursing home residents.Design, Setting, and Participants: Anembedded pragmatic cluster randomized controlled trial was conducted in 9 NHs from a large proprietary system located in 34 states. Each NH was randomly assigned to one of three NH-wide repositioning interval Arms (every 2, 3, or 4 hours). Data were provided for 12-month Baseline and 4-week Intervention during the Turn Everyone And Move for Ulcer Prevention (TEAM-UP) study. Intervention residents were without current PrIs, had PrIrisk (Braden Score) ≥10 (low, mild, moderate, or high risk; not severe risk), and used viable 7” high-density foam mattresses.Methods: Each Arm included three NHs with assigned single repositioning interval as standard care during the 4-week Intervention. Mandatory staff education sessions were provided.A wireless patient monitoring system, using wearable single-use patient sensors, cued staff by displaying resident repositioning need on conveniently placed monitors.Primary outcome was PrI incidence; secondary outcome was staff repositioning compliance fidelity.Results: Eleven hundred residents from 9 NHs were fitted with sensors; 108 of these were ineligible for some analyses due to missing Baseline data. Effective sample size included 992 residents (mean age 78 years [SD13]; 63% female). Pressure injury incidence during the Intervention was 0.0% compared to 5.24% in Baseline, even though Intervention resident clinical risk scores were significantlyhigher (p<0.001). Repositioning compliance for 4-hour repositioning interval (95%) was significantly better than 2- (80%) or 3- (90%) hours (p<.001).Conclusions: This study contributes to understanding alternativerepositioning intervalssuggestingcurrent 2-hour protocolscan be relaxed for many without compromising PrI development. Causal link was not established between three repositioning interval treatments and primary outcome—PrIs; however, no new PrIs developed. Cueing staff may benefit repositioningimplementation; compliance improved as repositioning interval lengthened.Trial Registration: (ClinicalTrials.gov Identifier: NCT02996331).Date: 16/05/2017

Characteristics of Nursing Home Resident Movement Patterns: Results from the TEAM-UP Trial

“…Generalizability of secondary data analysis findings may be limited by the absence of PrI development during the TEAM-UP trial. 19,20 The TEAM-UP findings extended evidence about repositioning residents using high-density foam mattresses at 2-, 3-, and 4-hour intervals to a 4-week study period (which was longer than prior studies) with no PrI development. These findings advanced PrI prevention knowledge by demonstrating that most residents could be repositioned at a 3-or 4hour interval and still prevent PrIs.…”

“…Residents’ movements were collected during a 4-week intervention period; the number of days of movement data varied based on resident length of stay. The target sample of the TEAM-UP study was powered at 95% with a one-tailed significance level of .05 to detect an effect size of .38 to test an increase in PrI incidence from standard 2-hour repositioning to 3 or 4 hours 19,20 …”

“…The sample of residents from all nine NH sites (N = 913) included residents with dementia and/or obesity as part of the population examined in the secondary data analyses. The TEAM-UP trial enrollment, allocation, and follow-up are reported elsewhere 19,20 . All residents participating in the TEAM-UP study’s intervention were eligible for inclusion without regard to diagnoses or demographic characteristics, which were subsequently analyzed.…”

“…This descriptive exploratory study was conducted using secondary data collected in nine NHs in the 1R01NR016001 Turn Everyone And Move for Ulcer Prevention (TEAM-UP) cluster randomized controlled trial. 19 , 20 The TEAM-UP trial examined the effects of repositioning frequency on PrI incidence using an NH-wide protocol with repositioning intervals of 2, 3, or 4 hours on residents at low, mild, moderate, or high risk of developing PrIs over a 4-week intervention period. Each NH was randomly assigned to one of three study arms (2, 3, or 4 hours) while continuing to provide standard PrI prevention and other nursing care.…”

“…Weekly/ monthly observations are even more accurate, increasing to 81% sensitivity and 73% specificity. 24,25 Risk categories are based on Braden Scale total scores: low (19)(20)(21)(22)(23), mild (15)(16)(17)(18), moderate (13)(14), and high (10)(11)(12) risk.…”