A Prospective, Descriptive, Quality Improvement Study to Investigate the Impact of a Turn-and-Position Device on the Incidence of Hospital-acquired Sacral Pressure Ulcers and Nursing Staff Time Needed for Repositioning Patients

Patients in critical care areas are at risk for developing hospital-acquired pressure ulcers (HAPUs) due to their physical conditions and limited ability to reposition themselves. A prospective, 2-phase quality improvement study was conducted from September to November 2011 and from February to April 2012 in 1 medical and 1 surgical ICU to investigate the impact of a turn-and-assist device on the incidence of HAPUs and the time and personnel required to reposition patients reported as person/minutes (staff x minutes).A consecutive, convenience sample of patients was selected from newly admitted ICU patients who were at least 18 years old, nonambulatory, and required 2 or more people to assist with turning and repositioning. Sociodemographic data (patient age, gender, height, weight, body mass index, incontinence status); total Braden score and subscores for Activity, Mobility, and Moisture on admission; length of ICU stay and ventilator days; and sacral pressure ulcer incidence and stage and turn-and-assist data were collected. Fifty (50) patients participated in each phase. In phase 1, standard care for positioning included pillows, underpads, standard low-air-loss beds and additional staff as required for turning. In phase 2, the study product replaced standard care repositioning products including pillows; and a larger disposable moisture-wicking underpad (included as part of the turn study project kit) was substituted for the smaller, standard moisture-wicking disposable underpad. Turning procedures were timed with a stopwatch. Data were collected for a total of 32 hours during the observation periods; all patients were followed from admission until discharge from the ICU for a maximum of 14 days. T-tests were used to compare patient characteristics and person-minutes needed for repositioning differences, and Fisher’s exact test was used to compare the incidence of sacral HAPUs during phase 1 and phase 2 of the study. No statistically significant sociodemographic or clinical differences were noted between the 2 groups. During phase 1, 14 patients (28%) developed a Stage 2 sacral HAPU. During phase 2, no patients developed a sacral HAPU (P <0.0001). The average time spent for repositioning was 16.34 person/minutes (range 4–60, SD 10.08) during phase 1 and 3.58 minutes (range 1.12–8.48, SD 2.31) during phase 2. The mean difference between person/minutes for the 2 phases was 12.76 minutes (P = 0.0006). In this population of ICU patients, the rate of sacral HAPUs and person/time needed for repositioning were significantly lower following implementation of a turn-and-assist product. Future research is indicated on the effect of this type of product on improving outcomes for patients and making the work of patient care safer and more efficient.

Patients in critical care areas are at risk for developing hospital-acquired pressure ulcers (HAPUs) due to their physical conditions and often limited ability to reposition themselves.¹ HAPU data estimate prevalence to range from 10% to 41% in adult ICUs.^1–5 The International Pressure Prevalence Survey⁶ (2008–2009) reported a HAPU prevalence in the medical ICU of 20.7% (N = 1940) and in the surgical ICU of 16.6% (N = 1842). 

Repositioning has been shown in randomized, controlled trials^7,8 to help prevent the development of pressure ulcers. However, additional randomized, controlled trials and observational studies^9-11 have demonstrated that implementing best practices in preventing pressure ulcers in the intensive care unit (ICU) is fraught with numerous obstacles, including nurse perception of the patient’s medical readiness for repositioning and mobility and the physical challenges associated with repositioning patients, which can be complicated by the work environment, including high patient acuity and limited staffing resources. According to a retrospective review,¹¹ patients receiving hemodynamic or oxygen support, multiple vasopressors, continuous renal replacement therapy, extracorporeal membrane oxygenation, or high-flow oscillator ventilation are often physically unstable and may not be able to tolerate turning and repositioning. In other situations (eg, patients with a high body mass index [BMI], critical illness, or isolation), staff may be required to utilize personal protection equipment (PPE) or multiple staff members to safely turn the patient. When staff is limited in number to assist with turning and repositioning due to high patient acuity and care needs, it can be a challenge to meet the recommendations for frequent turning.⁷ 

Although repositioning these patients is essential to their care, it can be challenging for staff to accomplish this safely and efficiently. Safe patient handling is defined by the American Nurses Association¹² (ANA) as “policies and programs that enable nurses to move patients in a way that does not cause musculoskeletal strain or injury to the clinical staff.” Safe patient handling is a concept that is in direct alignment with recommendations in the Occupational Safety and Health Administration¹³ (OSHA) manual stating: “Manual lifting of patients should be minimized in all cases and eliminated when feasible. Employers should put an effective ergonomics process in place that provides management, involves employees, identifies problems, implements solutions, addresses injury reports, provides training, and evaluates ergonomic efforts.”

Lifting is not the only aspect of moving patients that presents physical demands for nursing staff. National labor statistic reporting^14,15 shows lateral transfers (repositioning the patient in the bed, turning the patient in the bed, moving the patient to the head of the bed, and transferring the patient from bed to bed) are the most frequent type of patient transfers; they are reported to require the most exertion for dependent patients. More than half of the injuries attributed to personnel working in health care are due to overexertion and most frequently result from lifting, further emphasizing the need for adhering to Safe Patient Handling best practices.²

The average HAPU rates in 2 of the ICUs in the authors’ hospital were higher than the benchmarks provided by the National Database for Nursing Quality Improvement¹⁶ (NDNQI) and rates for similar units. This was of concern to administration and frontline nurses, and a quality improvement project was designed to reduce the incidence of HAPUs. A study team comprised of the Clinical Nurse Specialist, the nurse researcher, and registered nurses from the ICUs developed a study to enhance turning and repositioning of patients while incorporating concerns for staff safety during this process. 

The study device (Prevalon Turn and Positioning Systems® 2.0 [TAP], Sage Products, Cary, IL) is designed to assist staff with turning and repositioning patients and to help reduce the incidence of pressure ulcers by offloading the sacrum. This is achieved by helping patients maintain a 30˚ side-lying position. The system has 3 components: 1) a low-friction, microclimate glide sheet with integrated handles placed under the patient to help prevent skin injury from shearing and friction forces; 2) a disposable moisture-wicking incontinence underpad to assist with incontinent effluent containment; and 3) 2 foam wedges designed to help bolster the patient’s sacral offloading position. The microclimate glide sheet stays with the patient throughout the duration of the admission, and the disposable moisture-wicking incontinence underpad is replaced every 12 hours or as needed if it becomes soiled. Although data to support that this device reduces the incidence of HAPUs are limited to case study series and anecdotal reports, the device addresses multiple clinical issues commonly correlated to the development of sacral pressure ulcers.

The purpose of this study was to evaluate the impact of this patient repositioning system on 1) the incidence of sacral pressure ulcers and 2) the amount of time required to turn and reposition stable, but immobile ICU patients pre- and post-implementation of the device.

Setting. This study was conducted in 2 12-bed ICUs (1 medical, 1 surgical) at a Magnet-designated, 703-bed Level I trauma center in western Virginia. These units were selected because of their consistently high HAPU rates and high level of patient acuity, which made their patient population well-suited to the study purposes. The hospital Institutional Review Board deemed this project a quality improvement study, and patient consent was not required.

Sample. A consecutive, convenience sample of patients was selected from newly admitted ICU patients who were at least 18 years old, nonambulatory, and required 2 or more people to assist with turning and repositioning determined by nursing assessment of a Braden Scale mobility subscore <2. Patients who were able to assist with turning or unable to tolerate repositioning (systolic blood pressure decreased ≥10 mm Hg when attempting to turn) were excluded from the study. Patients also were excluded from the study if they had been admitted to the units before initiation of the project or if they had a pressure ulcer on the sacrum/coccyx/buttocks that was present on admission to the ICU. The charge nurse of the units reviewed each admission and determined if the patient met the inclusion criteria. At that time, the nurse caring for the patient was informed the patient was to be included in the study and the appropriate documentation and protocol were implemented. The primary investigator (PI), a doctoral-prepared, wound care Clinical Nurse Specialist, reviewed patient admissions each day to confirm appropriate inclusion and exclusion. 

Outcome measures. The primary outcome measures for the study were the incidence of sacral HAPUs in the ICUs and the time required for turning and repositioning patients following implementation of the TAP. For the purpose of this study, HAPUs were defined as the occurrence of new pressure ulcers during the study period, staged according to the National Pressure Ulcer Advisory Panel Guidelines for Pressure Ulcer Staging.¹⁷ The amount of time required to turn and reposition patients was recorded as person-minutes (ie, the number of minutes to prepare for and reposition the patient, multiplied by the number of staff members performing the task¹⁸). 

Study phases.
Phase 1: assessment. In Phase 1, study nurses reviewed all new admissions to the study ICUs from September to November 2011 to identify patients who met inclusion criteria. Patients included in the study had skin assessments and turning interventions documented within 6 hours of admission. All patients were assessed daily and repositioned at least every 2 hours per facility policy. No study product was provided during this phase of the study; nursing staff provided standard care for turning and repositioning tasks using pillows, underpads, and standard low-air loss ICU beds as well as additional staff for repositioning as required. At the beginning of this phase, the PIs (a Wound Care Clinical Nurse Specialist and the Nurse Researcher) educated staff regarding pressure ulcer staging, wound differentiation, study protocol, and documentation. 

Phase 2: intervention. This phase of the study occurred from February 2012 to April 2012. Before implementing phase 2, the PI educated the staff about proper use of the TAP and ensured the product was available in the ICUs supply rooms. Signs were placed outside the rooms of the patients enrolled in the study to provide visual reminders to the staff to use the TAP. During this phase of the study, patients were placed on standard low-air-loss ICU beds, and the TAP system was used for turning and repositioning in lieu of pillows and standard-size, moisture-wicking disposable underpads. 

Data collection and analysis. All staff members, consisting of Bachelor and Associate Degree Registered Nurses, were trained by the PI on skin assessments, pressure ulcer staging, and study protocol at the beginning of each phase of the study. Turnover on these units during the study period was limited. Only registered nurses provide patient care in these units; assistive personnel did not complete assessments or provide patient care. Nurses completed skin assessments twice daily and recorded data on the paper assessment sheet developed by the PI, who transferred the data to a spreadsheet. Study nurses recorded if patients developed a sacral HAPU and staged the ulcer per NPUAP guidelines.¹⁷ 

The PI conducted daily rounds during both phases of the study to ensure enrolled patients met inclusion criteria and that data collection and patient assessment, including pressure ulcer staging, were accurate. All patients enrolled in the study were followed daily from admission for 14 days or until discharge from the ICU. None of the patients in phase 1 were included in phase 2 of the study. 

Patient characteristics. Patient characteristics recorded included age, gender, height, weight, BMI, incontinence status, total Braden score and subscores (Activity, Mobility, and Moisture) on admission, length of ICU stay, and ventilator days. Data were collected for 100 patients who met inclusion criteria (50 in each phase). 

The PIs observed unit nurses to determine the time required for turning and repositioning patients before and during the implementation of the TAP. The observation period used a modified Work-Sampling Method by Activity Timing (WOMBAT) technique that used manual calculations rather than electronic data input.^19,20 Data were collected for a total of 32 hours (4 4-hour periods during day and evening shifts in each of the phases). Time was measured with a stopwatch and included the physical time and the number of clinicians required to perform a turn and repositioning maneuver, average time per task, and time spent with patients. Timing of the work was stopped during interruptions to this process. 

The time elapsed and the number of clinicians required were recorded on a paper graph form and transferred to a spreadsheet. The PIs collaborated to develop a consistent observation method during a 1-hour time period on 1 of the ICUs to be sure the observations of the work flows were consistent between them. 

Descriptive statistics including range, frequencies (percentages), and means were reported for patient characteristics. T-tests were conducted to determine if the groups were statistically similar on specific characteristics (see Table 1). Fisher’s exact test was performed to determine statistical significance between the incidence of HAPUs in each phase of the study. Person-minutes for the 2 phases were reported as the difference in total time. The t-test was used to calculate significance between means in the 2 phases of the study. 

Patient characteristics. A total of 100 patients were included; 50 in phase 1 for baseline comparison purposes and 50 in Phase 2 for the intervention group. In phase 1, 30 patients (60%) were male, 20 patients (40%) female; in phase 2, 28 patients (56%) were male, 22 (44%) female. In phase 1, 47 (94%) patients had indwelling catheters and 1 (2%) was incontinent of urine. Forty-eight (48) patients (96%) in phase 2 had indwelling catheters and 1 (2%) was incontinent. Patients in both phases had fecal management devices: 27 (54%) patients in phase 1 and 26 (52%) in phase 2. No statistically significant differences (P = 0.05) were noted between the patient populations of phases 1 and 2 in terms of age, weight, Braden scale scores, length of stay in the ICU, and days on the ventilator (see Table 1). 

HAPU rates. During phase 1 of the study, 14 patients (28%) receiving standard care developed a sacral area HAPU, all of which were Stage 2. During phase 2 of the study, following the implementation of the TAP, no patients developed a sacral HAPU. Fisher’s exact test indicated a significant difference (P <0.0001) in the incidence of HAPUs of the sacrum between phase 1 and 2 following implementation of the TAP product for turning patients.

Time for turning and repositioning. During phase 1, 23 turning/repositioning maneuvers were observed and recorded by either the PI or the Nurse Researcher. An average of 2.26 staff members (range 2–5) required an average of 5.89 minutes to reposition a patient (range 2–12 minutes). In terms of person-minutes, the mean time spent on the maneuver was 14.14 minutes (range 4–60, SD 11.55). During phase 2, it took an average of 1.48 staff members (range 1–4) an average of 2.38 minutes (range 1.12–4.06) to reposition a patient. Mean person-minutes for phase 2 was 3.28 minutes (range 1.12–8.48, SD 1.93). The mean difference between person/minutes for phase 1 and 2 was 10.86 minutes. The t-test analysis indicated a statistically significant difference (P = 0.0006) between the means for person/minutes for phases 1 and 2 for turning and repositioning.

This 2-phase study investigated the impact of using a turning and repositioning system on the incidence of sacral pressure ulcers in 2 ICUs and the time and number of staff required to accomplish the task. In this study population, the incidence of sacral HAPUs decreased from 28% to 0% following implementation of the TAP system. The time for turning and repositioning patients decreased significantly, requiring fewer staff and less time overall. 

Regardless of the common, prevalent use of turning and repositioning as a factor in treating and preventing pressure ulcers, no randomized trials have been conducted that correlate the effects of turning and repositioning patients on the incidence or healing rates of pressure ulcers. Consequently, a direct conclusion cannot be made as to whether turning and repositioning patients directly impacts the incidence and healing of pressure ulcers. ² The results of this study indicate the use of a turn-and-assist device may have the potential to reduce sacral HAPUs and decrease the amount of time and personnel required to reposition patients. Although other risk factors for pressure ulcer development for critically ill patients were not studied or correlated to the data collected in this study, general patient characteristics were similar in the pre- and post-intervention groups. 

Anecdotal information from staff participants was not collected as a part of the study, but during phase 1 nursing staff repeatedly reported the difficulty in turning/repositioning critically ill patients based on a variety of factors including patient conditions (patient size, immobility, intubated/sedated, isolation with the need for PPE) and the work environment (lack of resources, not enough nursing/nursing assistant staff). In phase 2, the nurses reported the TAP allowed them to reposition patients easier, with fewer personnel. Nursing staff also noted use of the TAP device may have prevented patients from sliding down in the bed and maintained them in positions with the sacral area offloaded for longer periods of time than with standard care. The nursing staff on the 2 study units was enthusiastic about this product and insisted it be added to the available unit resources; the Chief Nursing Operator was encouraged to round on the units to see this product in use. 

Because study findings are based on a small sample of patients in the ICU setting, this study is limited in terms of generalizability. The turn-and-assist device was implemented as part of a quality improvement project in a clinical environment served by many different caregivers, a factor that could influence consistency of care. Although the PIs worked to standardize data collection regarding the time and number of staff members required to turn and reposition patients, they were able to capture only a small portion of the work over the time of the study. The staff also may have modified their behaviors in the presence of the observers. In addition, the time frame and sample size may have limited the ability to determine the full effect of the product for nurses. Future stringent randomized controlled trials are indicated to study the effect of this type of product on improving outcomes for patients and making the work of patient care safer and more efficient. 

Prevention of HAPUs in the critical care patient population remains a challenge for nursing staff due to the high acuity and complex care requirements of these patients. To the authors’ knowledge, this is the first study documenting that a turn-and-assist device may reduce nursing staff time to reposition patients as well as the incidence of sacral HAPUs. 

Further research into comprehensive approaches for HAPU prevention in the critical care patient population is warranted. Although no data were collected on workman’s compensation injuries related to moving/repositioning patients, this would be a valuable topic for future investigation. 

Financial support was provided by Sage Products (Cary, IL), who provided products for use during this study.

Dr. Hall is a Wound Care Clinical Nurse Specialist; and Dr. Clark is Senior Director for Nursing Research and Evidence Based Practice, Carilion Clinic, Roanoke, VA.

Please address correspondence to: Kimberly D. Hall, DNP, RN, GCNS-BC, CWCN-AP, Carilion Clinic, 1906 Belleview Avenue, Roanoke, VA 24014; email: kdhall2@carilionclinic.org.