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

Jeanine Maguire, MPT, CWS, Vice President, Skin Integrity & Wound Management, Genesis Healthcare, Kennett Square, PA; Annemari Cooley, MBA, MA, Senior Director, Clinical Development, Clinical Affairs, Smith + Nephew; and Denine Hastings, RN, BSN, MBA, Senior Director, Clinical Product-IT, Nursing, Genesis Healthcare

The 2-hour turning schedule has been the standard of pressure injury (PrI) prevention since the 1850s¹ despite lacking robust scientific evidence in long-term care. Recent studies² have compared outcomes using 2-hour, 3-hour, and 4-hour turning protocols in the nursing home setting, showing that extending repositioning periods to 4 hours is safe.³ While new guidelines⁴ recommend individualizing patient repositioning schedule, operationalizing them can be challenging.

A 6-month quality improvement pilot was initiated at 2 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 admissions⁵ residents with pre-existing PrI or significant decline were considered eligible. Wireless sensors were used to cue staff about repositioning needs of individual residents. 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.

A total of 155 residents, mean age 71 years (SD 14.5) and mostly male, qualified for the program and were monitored for a mean of 16.2 days (SD 19.9, range 0.3-145 days). Mean turn protocol adherence was 83% and 95% for nursing homes A and B, respectively. Thirty-six percent (36%) 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 the Q3 or Q4 turning schedules.

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.

References

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2. Yap TL, Kennerly SM, Horn SD, Bergstrom N, Datta S, Colon-Emeric C: TEAM-UP for quality: a cluster randomized controlled trial protocol focused on preventing pressure ulcers through repositioning frequency and precipitating factors. BMC Geriatr. 2018;18(1):54. doi:10.1186/s12877-018-0744-0

3. Bergstrom N, Horn SD, Rapp MP, Stern A, Barrett R, Watkiss M. Turning for Ulcer Reduction: a multisite randomized clinical trial in nursing homes. J Am Geriatr Soc. 2013;61(10):1705–1713. doi: 10.1111/jgs.12440

4. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. 3rd ed. EPUAP/NPIAP/PPPIA; 2019.

5. Lyder CH, Ayello EA. Pressure ulcers: a patient safety issue. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality; 2008.