Implementation of Individualized Turn Protocol for Pressure Injury Prevention in Post-Acute Care: A Quality Improvement Program

BACKGROUND AND SIGNIFICANCE: Two-hour turning schedule has been the standard of pressure ulcer (PrI) prevention since the 1850’s [1] despite lacking robust scientific evidence in long-term care.  Recent studies[2] have compared outcomes using 2-hour, 3-hour and 4-hour turning protocols in the nursing home setting, showing [3] that extending repositioning periods to 4 hours are safe. While new guidelines[4] recommend individualizing patient repositioning schedule, operationalizing them can be challenging.

INTERVENTION: A six-month quality improvement pilot was initiated at two Northeast nursing homes to individualize turning schedules (Q1, Q2, Q3 and Q4) based on resident risk factors and PrI history. A turn protocol selection tool was developed based on expert opinion and existing science. Staff were trained on the protocol tool, and its validity was tested on 20 staff volunteers. New admissions[5], residents with pre-existing PrI or with significant decline were considered eligible. Wireless sensors were used to cue staff on repositioning needs per individual resident frequency. Sensors automatically ‘credited’ any resident self-turns and reset the turn timer. Daily and weekly skin checks were used to assess the appropriateness of the selected turn protocol.

RESULTS: A total of 155 residents, mean age 71 (SD 14.5) and mostly male, qualified for the program and were monitored for mean 16.2 days (SD 19.9, Range 0.3-145 days). Mean turn protocol adherence was 83% and 95% for NH A and B respectively. Thirty-six percent had pre-existing PrI. More than half the residents (57%) received a turn period greater than 2 hours, saving an estimated 156 unnecessary turns per each resident during their monitoring period.  There were no new in-house acquired PrI on residents’ turning surfaces while in the program. Residents on Q1 and Q2 turn periods were more likely to refuse staff repositioning than residents on Q3 or Q4 turning schedule.

CONCLUSIONS: Individualized turn protocol is feasible to implement and can be operationalized with the aid of technology. Longer turn periods were safe, well tolerated by residents and saved caregiver time to focus on other resident care activities. Challenges to enterprise-wide expansion included cost and adhesive sensor wear-time.