Every month, the leadership team at the Gerontological Advanced Practice Nurses Association (GAPNA) highlights the most important published literature that impacts geriatric practice. This month, Valerie K. Sabol, PhD, MBA, ACNP, GNP, ANEF, FAANP, FAAN, past president of GAPNA, explores the theme of pressure injury prevention in nursing home patients. She comments on 3 recent studies on prevention of pressure injuries including optimizing the frequency of repositioning, examining the effectiveness of the Braden Scale in predicting risk for pressure injury, and addressing special needs of the growing obese nursing home population.
Effect of Varying Repositioning Frequency on Pressure Injury Prevention in Nursing Home Resident: TEAM-Up Trial Results
Adv Skin Wound Care. 2022;35(6):315-325.
Summary: The study investigated the clinical effectiveness of 3 different repositioning intervals (every 2, 3, or 4 hours) to see if the current 2-hour protocols can be relaxed in nursing home residents without increasing the incidence of pressure injury (PrI). Over a 5-month period, 992 nursing home residents were fitted with sensors that cued their need for repositioning and high-density foam mattresses. The PrI incidence during the study was 0% compared with 5.24% at baseline, suggesting that the interval between repositioning may be relaxed for many residents.1
Commentary by Dr Sabol: The current practice recommendation to reposition patients every 2 hours is so deeply ingrained in our health care culture that it is considered common knowledge even among other disciplines. However, what is rarely understood is that ‘turn q2h’ (turn/reposition every 2 hours) is a recommendation from a retrospective study of 100 women, of whom only 32 were ‘turned as many as 12 times in 24 hours.2 Appreciating conventional wisdom of the time, much has changed and traditional standard of care approaches have been challenged by this randomized control trial.
The TEAM-UP (Turn Everyone and Move for Ulcer Prevention) study was a pragmatic cluster trial conducted in 9 nursing homes that were randomly assigned to 1 of 3 repositioning intervals (ie, every 2, 3, or 4 hours) over a 4-week period. Intervention nursing home residents were without current PrI, had a PrI risk (Braden Score) ≥10 (not severe risk), and used a 7-inch high-density foam mattress. A wireless patient monitoring system using single-use wearable sensors cued nursing staff on when to reposition residents by displaying individual repositioning needs on conveniently located display monitors.
The primary outcome of this study was PrI incidence during the 4-week trial and the secondary outcome was repositioning compliance to the 3 repositioning time intervals. From May 2017 to October 2019, a total of 992 eligible residents participated in the intervention (mean age 78 ±13 years, 63% women). Most notably, although PrI risk scores were significantly higher during the intervention than at baseline (12 months prior, P <0.001), incidence of PrI development during the intervention was 0% for each of the 3 repositioning time intervals (compared with 5.24% at baseline). Additionally, repositioning compliance for 4-hour intervals (95%) was significantly better than 2-hour (80%) and 3-hour (90%) repositioning compliance (P <0.001).
Evidence from this randomized control trial suggests the current practice of repositioning every 2 hours can be safely extended through use of standardized high-density foam mattresses and on-time (cued) repositioning compliance. Implementation of these evidenced-based findings would be a significant departure from current practice, reducing the frequency of an often labor- and time-intensive nursing task. Moreover, extending repositioning times may allow the opportunity for nurses to engage with nursing home residents in other meaningful ways that were previously limited because of the demands of regular repositioning. For nursing home residents, extending repositioning time may improve their quality of life by allowing for longer periods of uninterrupted sleep.
Advanced practice nurses (APNs) are well-positioned to lead and build strong, high-functioning care delivery teams that can advocate for standardized equipment and supplies necessary for PrI prevention (ie, high-density foam mattresses, pillows, and clean linens that support repositioning). Additionally, APNs can communicate these evidenced-based practices to health care team members, nursing home residents, and their families so that they have an educated, shared understanding of ways to safely achieve goals of care and quality of life. Such leadership may also facilitate team building and improve communication (ie, team or family report changes in appetite that have altered nutrition intake, a known PrI risk factor).
Pressure Injury Risk Assessment and Prevention in Patients with COVID-19 in the Intensive Care Unit.
AACN Adv Crit Care. 2022;33(2):173-185
Summary: Researchers studied critically ill patients and evaluated the validity of the Braden Scale in predicting device-related PrI for patients with and without COVID-19. A total of 1920 patients were included in the study sample, including 407 with COVID-19. Among the latter group, at least 1 hospital-acquired pressure injury developed in each of 120 patients (29%); of those, device-related pressure injury developed in 55 patients (46%). The Braden Scale score area under the receiver operating characteristic curve was 0.72 in patients without COVID-19 and 0.71 in patients with COVID-19, indicating fair to poor discrimination.3
Commentary by Dr Sabol: Critically ill patients in an ICU setting are at higher risk of developing a hospital-acquired pressure injury (HAPrI), especially those caused by medical devices (hereafter device-related PI, or DRPrI) used for monitoring or supporting care delivery (ie, telemetry wires, oxygen tubing, and endotracheal tubing). COVID-19 infection impairs oxygenation and perfusion, which increases illness severity and often necessitates use of monitoring and supportive medical devices. In fact, patients with COVID-19 often require prone positioning during mechanical ventilator support, which makes repositioning, a fundamental PrI prevention strategy, more challenging.
In this retrospective review, the predictive validity of the Braden Scale for those with and without COVID-19 infection was evaluated. Of those infected with COVID-19 (n=407), risk of developing HAPrI was higher than that among those who were not infected. Nearly half (46%) of patients with HAPrIs in this study were device-related; common DRPrI sites identified included the face (nare, mouth, lip, and cheek), ear, and extremities (wrist, hand, finger, arm, toe). Fragile skin, common among older adults, was also identified as a risk factor for developing DRPrI.
This study also highlights that the Braden Scale lacks predictive validity (ability to predict which patients will develop HAPrI) in the ICU population because of low specificity (percentage of all patients remaining PrI-free that the scale accurately rated as ‘not high risk’). Accordingly, nurses are well-advised to consider intrinsic/extrinsic and static/dynamic factors not included in the Braden Scale during routine HAPrI/DRPrI risk assessment. Awareness of the risk for DRPrI is critical for targeted prevention strategies (ie, selecting and fitting devices, targeting skin assessment under and around devices, and reducing and redistributing pressure at the device and skin interface whenever feasible and not medically contraindicated), which may not only contribute to decreased incidence of HAPrI/DRPrI development but also improved patient care outcomes and significant cost savings.
Nursing Home Directors of Nursing Experiences Regarding Safety Among Residents With Obesity
Geriatr Nurs. 2022;47:254-264
Summary: Obesity rates are rising among nursing home residents. Obesity (body mass index [BMI] ≥30) exacerbates age-related decline in physical function and mobility, which can lead to difficulty participating in common activities of daily living (ADL) that require movement as well as increased reliance on nursing/caregiver assistance using specialized equipment. To find out how nursing homes are handling these challenges, Sefcik et al interviewed 15 directors of nursing. The authors learned that admission decisions for nursing home referrals of patients with obesity are complex because of reimbursement issues, available space and resources, and resident characteristics. Directors described the need to coach and mentor certified nursing assistants to provide safe quality care and the need for more staff education.4
Commentary Dr Sabol: A relatively new phenomenon in nursing homes is that nearly 1 in 4 residents is living with obesity. Using a qualitative descriptive design with semistructured individual interviews with directors of nursing and adapting a structure-process-outcomes model, this study looked at the increasing prevalence of obesity among nursing home residents and associated care-related challenges (ie, specialized equipment for safe patient handling, space to maneuver, and ongoing staff recruitment, training, and retention). Antecedents, or the environmental context and individual characteristics that could affect structure, process, and outcomes, were also explored. Fifteen geographically diverse directors were interviewed with an average 14.3 years of experience (range, 2.5-30 years).
Multiple antecedent, structure, process, and outcome experiences regarding care and safety for nursing home residents living with obesity were identified. An important outcome of this study was the challenges associated with skin integrity. Increased body weight and physical size can complicate even the simplest ADL, and equipment typically used in nursing homes include standard-sized beds, wheelchairs, and recliners, any of which can restrict movement and inhibit successful turning in bed or shifting weight in a chair. Regular repositioning, the cornerstone for PrI prevention, often requires bariatric-proportioned beds and chairs and special bariatric lift devices that can safely accommodate increased size and weight. Nurses are well-positioned to influence environmental antecedents, structures, and processes identified in this study.
A negative outcome highlighted by the study findings is the unanticipated dangers of state mandates that require bed side rails to be down. While well-intended to allow nursing home residents to safely move/transfer in and out of bed, for those who are living with obesity, independent/voluntary side-to-side repositioning with side rails down can result in injury from rolling out of bed onto the floor. There is not enough surface/space to allow for safe repositioning movement, particularly if momentum is required to reposition, and side rails are not up to prevent a fall out of the bed. Awareness of this potential risk for injury allows the opportunity for nurses to revisit and advocate for policies that suggest a one-size-fits-all approach may not be appropriate for those nursing home residents who are living with obesity.
1. Yap TL, Horn SD, Sharkey PD, et al. Effect of varying repositioning frequency on pressure injury prevention in nursing home residents: TEAM-UP trial results. Adv Skin Wound Care. 2022;35(6):315-325. doi:10.1097/01.ASW.0000817840.68588.04
2. Norton D, McLaren R, Exton-Smith AN, eds. An Investigation of Geriatric Nursing Problems in Hospital. Churchill Livingstone; 1962.
3. Alderden J, Kennerly SM, Cox J, Yap TL. Pressure injury risk assessment and prevention in patients with covid-19 in the intensive care unit. AACN Adv Crit Care. 2022;33(2):173-185. doi:10.4037/aacnacc2022335
4. Sefcik JS, Felix HC, Narcisse MR, et al. Nursing home directors of nursing experiences regarding safety among residents with obesity. Geriatr Nurs. 2022;47:254-264. doi:10.1016/j.gerinurse.2022.08.002