Dr. Levine is a nationally recognized expert in wound care and pressure ulceration. and has published and spoken widely on this topic. He is a Board Member of the National Pressure Ulcer Advisory Panel (NPUAP). Dr. Levine's Pocket Guide to Pressure Ulcers co-authored by Elizabeth Ayello RN and published by the New Jersey Hospital Association is in its 4th printing and has sold over 30,000 copies.

The industry standard for turning and repositioning a patient at risk for pressure ulcers is every two hours. There is, however, limited research to support this standard. As the costliest elements of pressure ulcer prevention are support surfaces and repositioning, a change in this standard would have major economic impact. A research study published in the October 2013 issue of the Journal of the American Geriatrics Society (JAGS) could potentially alter the standard for turning frequency for nursing home residents at risk for pressure ulcers.

Jeff Levine, Jeffrey Levine MD geriatrician physician artist photographerBergstrom et al. tested whether there was a difference in pressure ulcer incidence in persons at moderate (Braden score 13-14) or high risk (Braden score 10-12) who were turned at 2, 3, or 4 hour intervals when a high density foam mattress was in use. Persons at very high risk (Braden score 6-9) were excluded. They studied 942 nursing home residents in 20 facilities in the US and Canada. Subjects were age 65 and older with the most common diagnoses of cardiovascular disease and dementia. All were newly admitted short-stay or long-stay residents of nursing homes, and were followed for three weeks. The researchers found no difference in pressure ulcer incidence between those repositioned at 2, 3, or 4 hour intervals.

The surface used was a high density foam mattress as opposed to a spring type mattress. Powered surfaces such as alternating pressure air mattresses (APAMs) or low air-loss mattresses (LAL) were not studied. High density foam is commonly used for sofa cushions, benches, chairs and mattresses, and density reflects how much weight polyurethane foam can handle per cubic foot.

There are several considerations for interpretation of these results before they can be applied to the larger population of persons at risk for pressure ulcers. Only 3 of the 20 (17%) nursing facilities included in the study were for-profit, while for-profit facilities are actually 69% of all nursing homes in America. Data from CMS demonstrates higher prevalence of survey deficiencies and poorer staffing ratios in for-profit homes than non-profit or government run facilities. The data may therefore be skewed to represent higher quality sites with better staffing levels and less staff turnover.

Prior data has demonstrated that education alone can decrease the prevalence of pressure ulcers. It may be that higher scrutiny and required documentation inherent in a research protocol may have raised awareness of skin issues resulting in better outcomes independent of variation in turning schedules. The authors acknowledge that vigilant assessment and documentation required by their study may have cued staff and helped reduce pressure ulcer incidence.

A key element of this study was accurate scoring on the Braden risk-assessment tool.  The study protocol included extra training in 3 hour sessions for the licensed nurses who performed the scoring – training that may not be available in most nursing facilities.  The authors justify why residents at very high risk (Braden < 9) were excluded,  stating that they “are often cared for on powered mattresses or alternating-pressure relief overlays.” This statement was not referenced by supportive data and may not be true in many facilities. Finally, this study did not include hospitalized patients who have acute illness or surgery, with concomitant physiologic changes that add to pressure ulcer risk.

Whether results from this research paper will alter the “Q2H” standard of care for pressure ulcer prevention remains to be seen, but it certainly opens it up for challenge. The temptation to save money in today’s healthcare climate is great, but these data may not be generalizable to all nursing home residents and certainly not to patients in hospitals. I would urge caution when considering changes in policy that may adversely impact large numbers of persons at risk for the devastating complications of pressure ulceration.

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Citation for this research is: Bergstrom et al. Turning for Ulcer ReductioN: A Multisite Randomized Clinical Trial in Nursing Homes. JAGS 61: 1705-1713, 2013.   This paper may be downloadable here.

Download CMS data on nursing home characteristics in America in 2012.

Related posts:

CMS recognizes the Kennedy Terminal Ulcer in Long-Term Care Hospitals
Determining the Avoidability of Pressure Ulcers
New Pocket Guide to Pressure Ulcers
Historical Roots of the “Avoidable-Unavoidable” Pressure Ulcer Controversy
New Research Sheds Light on Hospital Acquired Pressure Ulcers



  • A Concerned Nurse
    10/31/2013, 3:09 pm  Reply

    You know I can’t sit quiet when an article such as Bergstrom’s recent publication comes out. This article, in my opinion is dangerous to stand behind. While I also feel that the study is flawed in many aspects, the suggestion of the authors to leave patients without turning at frequent time periods strikes fear in my heart.

    While their focus is solely on pressure ulcer prevention from a turning perspective, they failed to discuss other significant preventable problems associated with immobility. Nurses are taught that turning every two hours is for many reasons. These are a few that these authors have totally neglected to discuss:

    Comfort and prevention of contractures and loss of joint mobility, pain and discomfort, relief of joint fatigue, pulmonary toilet, urinary stasis, and bowel management? what about socialization???

    As you know “high density” foam mattresses are not all alike. Nursing homes may choose lower cost options that have more limited life spans and surface material that will break down easily. Without a program for replacement, inspection, and infection control, a foam mattress in 6 months may do more harm than good if the management is not diligent in product integrity. In my experience, one older maintenance man for a 120 bed facility will not have the resources to ensure mattress integrity, and I can almost guarantee that these homes will not budget for best quality mattress replacement every 18 months or more frequently.

    This is just my two cents and you are a great voice for the elderly. Choosing to leave patients in one position for longer than 2, 3 and 4 hours will promote a host of issues for our elders.

    In the higher risk patient those with malnutrition, dehydration, renal disease, diabetes, cancer will develop pressure ulcers. Care providers may cherry pick information in this article and ignore the fact that the subjects studied had lower risks than the normal nursing home demographic. Urinary tract infections will be on the rise, we will see more contractures, bowel impactions, and patients who are more depressed.

  • 10/29/2013, 3:36 pm  Reply

    I think situations like this give caregivers an “out” to be less involved in patient care. From what I see, healthcare providers have become too reliant on modern technology in managing patient positioning and mobility. For example, using chair features for a hospital bed rather than actually getting the patient out of bed. Relying on the turn feature on a low air loss bed is not the same as turning the patient and stabilizing them in that position using pillows or wedges. If you can picture a mattress shifting side to side while the patient remains static, wouldn’t that cause the same shearing forces as leaving the patient in a sitting position with the bed >30 degrees. If the patient has a compromised nutritional status or immunological system then I don’t think it will matter whether they are turned or not. Not unless those risk factors are controlled. It’s an interesting notion to consider because couldn’t the powers-that-be use this type of research to justify rationing services to our elderly population?

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Dr. Jeffrey M. Levine has authored numerous articles on topics related to healthcare of the elderly. These include medical history, prevention and treatment of chronic wounds such as pressure ulcers, elder neglect and abuse, and physical restraints. He has also edited a book on legal and regulatory aspects of nursing homes.