New research is changing the way we treat pressure ulcers in the elderly
Mary’s* mother had just fallen asleep when a nursing home staff member woke her in the process of turning her in bed. Like many patients with dementia, her mother spent the rest of the night calling out, “Help! Help me!” — depriving both her mother and her mother’s roommate of a night’s sleep — and distressing the staff.
Turning a bedridden patient like Mary’s mother to prevent pressure ulcers is a tradition in health care. Without specific evidence to support the practice, nursing personnel reposition patients and nursing home residents every two hours around the clock. Turning can lead to sleeplessness for patients and physical strain and back injuries among nursing professionals.
Some relief may be in sight thanks to recent results of a major research study led by Nancy Bergstrom, PhD, the Theodore J. and Mary E. Trumble Professor of Aging Research and director of the Center on Aging at The University of Texas Health Science Center at Houston (UTHealth) School of Nursing.
Bergstrom’s clinical trial, reported in the October 2013 issue of the Journal of the American Geriatrics Society, studied the frequency of turning nursing home residents when high-density foam mattresses are used. After studying more than 960 patients at moderate or high risk for pressure ulcers in 27 nursing homes in the United States and Canada, Bergstrom and her colleagues found no statistically significant difference in the rate of pressure ulcers when turning patients at two-, three- or four-hour intervals. Especially important, no serious ulcers occurred during this study.
“It has to do with providing the best care,” Bergstrom says. “If we could reduce turning unnecessarily, and if we didn’t cause more pressure ulcers, we might meet care needs with less disruption to sleep and quality of life.”
A common, serious problem
Pressure ulcers are a common problem with nursing home residents and other bedridden patients. A pressure ulcer is a wound resulting from prolonged pressure on a particular point on the body. Painful and potentially life-threatening, pressure ulcers most commonly occur on the buttocks, elbows, hips, heels, ankles, shoulders, back and back of the head.
“One of the things we have been told since the early ‘60s is that you need to turn people every two hours in order to prevent pressure ulcers,” Bergstrom says. “Of course, at that time mattresses were very different.”
The goal is to either relieve the pressure entirely, usually by turning the person, or to reduce the amount of pressure. To reduce the amount of pressure, Bergstrom says, “We used to add overlays to mattresses. I remember ‘egg crates’ [a soft foam pad with bumps and dips that look like a large egg carton], which are largely ineffective.”
Instead, several studies from the early 2000s consistently showed that high-density foam mattresses outperformed other surfaces. “They help to reduce pressure enough so that it’s making an enormous difference in the care we’re giving,” Bergstrom says, adding that most nursing homes are moving toward high-density foam mattresses now.
Assessing the risks
Bergstrom’s recent large, multi-site study showed that for patients at moderate or high risk, on high-density foam mattresses, turning may be performed every three or four hours. The research was funded by the National Institute of Nursing Research, the National Institute on Aging Research and the Ontario Ministry of Health and Long Term Care, and conducted in cooperation with the Toronto Health Economic Technology Assessment collaborative.
Nursing home residents were first assessed by the Braden Scale for Predicting Pressure Sore Risk, considered the gold standard of risk assessment, to identify those at moderate and high risk of developing pressure ulcers. There is no point in turning people who are not at risk, and previous pilot studies had shown that people at mild risk were usually moving themselves in bed enough to relieve pressure.
The Braden Scale determines a person’s risk for pressure ulcers by assessing the person’s levels of:
- Moisture – such as from incontinence or perspiration
- Friction – such as from sliding down in bed or being pulled across the sheets
- Cognitive or sensory awareness – individuals with neurological impairments may not be able to feel pressure or may not realize, “I ought to be turning.”
Bergstrom is known for her groundbreaking work on developing and testing the scale, along with originator Barbara Braden, PhD, dean emerita, University College and Graduate School at Creighton University.
Study participants were randomized in separate moderate- and high-risk groups to a turning schedule of two, three or four hours, and turned according to that schedule for three weeks.
Certified Nursing Assistants in all the facilities were trained to make and document simple safety observations at the time of each turn. Documentation on a checklist required only one minute and included time of repositioning, new position (right, left, back, chair), heel position (up or not), skin condition (normal, red, bruised, open), briefs condition (wet, dry, soiled), and skin care (washed, barrier cream, briefs change).
In addition, weekly assessments were performed by licensed nurses who did not know the turning frequency for each patient in order to assure there was no bias to research outcomes.
Lower than expected
For all turning schedules, pressure ulcer incidence was lower than expected. Incidence did not differ significantly among two-, three- and four-hour turning schedules.
In addition to the high-density foam mattresses, Bergstrom says, “The safety checklist that we developed is also really important.” Not only did the checklist monitor care during the study, but it also reminded the staff to practice conscious observation and preventive care.
Under those conditions, “I think we could say for most moderate and many high risk people, we could turn them every three or four hours,” Bergstrom says. “In a nursing home, this would be ideal.”
If a nurse’s clinical judgment detected some special circumstance, or if the patient were at higher risk, the staff would need to determine appropriate turning frequency.
Turning nursing home residents less frequently than every two hours would benefit the residents and would also benefit the nursing homes by allowing staff to attend to other needed care, such as feeding and bathing, and by reducing the incidence of back injuries to staff members.
Making the change
Yet, nursing homes may be hesitant to change long-established practices because of concerns about potential liability if a resident does develop a pressure ulcer. Residents of nursing homes and their families may elect less frequent turning even if that is not the nursing home’s general practice.
“According to regulations, nursing homes are supposed to do whatever is necessary for the resident’s mental, physical and psychosocial well-being, so if a resident feels that this [turning every two hours] is annoying them or causing them anxiety and discomfort, they may make a conscious decision to change it,” says Greg Shelley, volunteer coordinator for the Harris County (Texas) Long-Term Care Ombudsman Program at the UTHealth School of Nursing.
The resident, or the resident’s family if the resident is not able to communicate, should discuss concerns with the nursing home’s director of nursing or administrator. In that way, a new turning schedule can be incorporated into the resident’s care plan.
If concerns are not met to the resident’s or family’s satisfaction, they may find help by contacting the ombudsman program. An ombudsman staff member or volunteer can advise them or can serve as a go-between with the nursing home staff and an advocate for the resident.
“It’s almost always going to be about getting something into the care plan to get it established and coming back on a regular basis, every week or every other week, to reinforce it to make sure that it’s getting done,” Shelley says. “Patience and persistence are the most important tools we have, and it would be the same for any family advocate.”
The family’s role in prevention
For family members, the most useful thing they can do to prevent pressure ulcers is to look at the patient’s skin every day, Bergstrom advises. If the patient is in a nursing home, family members can be partners in care and work with nurses to address care concerns.
If the patient is at home:
- Get a good high-density foam mattress.
- Use high-quality incontinence briefs that wick away moisture to keep the patient’s skin dry.
- Maintain good nutrition.
- Always look at the patient’s skin every day.
“If you’re starting to see some red skin, reduce pressure and call for help,” Bergstrom says. Perhaps the family can enlist a friend to help reposition the patient more often. Or perhaps hiring a home health care worker would be appropriate. Information on home health care agencies is available in Texas through the Department of Aging and Disability Services (DADS).
Whether at home or in a nursing home, Shelley reminds families, it is important to establish a care plan or service plan with the care provider to address individual needs. “The people providing the care in general want the same thing that you do. They want to do a good job; they want to provide good care.”
*The name has been changed to protect her privacy.