Characteristics of Nursing Home Resident Movement Patterns: Results from the TEAM-UP Trial.

OBJECTIVE: To determine movement patterns of nursing home residents, specifically those with dementia or obesity, to improve repositioning approaches to pressure injury (PrI) prevention. METHODS: A descriptive exploratory study was conducted using secondary data from the Turn Everyone And Move for Ulcer Prevention (TEAM-UP) clinical trial examining PrI prevention repositioning intervals. K-means cluster analysis used the average of each resident's multiple days' observations of four summary mean daily variables to create homogeneous movement pattern clusters. Growth mixture models examined movement pattern changes over time. Logistic regression analyses predicted resident and nursing home cluster group membership. RESULTS: Three optimal clusters partitioned 913 residents into mutually exclusive groups with significantly different upright and lying patterns. The models indicated stable movement pattern trajectories across the 28-day intervention period. Cluster profiles were not differentiated by residents with dementia (n = 450) or obesity (n = 285) diagnosis; significant cluster differences were associated with age and Braden Scale total scores or risk categories. Within clusters 2 and 3, residents with dementia were older (P < .0001) and, in cluster 2, were also at greater PrI risk (P < .0001) compared with residents with obesity; neither group differed in cluster 1. CONCLUSIONS: Study results determined three movement pattern clusters and advanced understanding of the effects of dementia and obesity on movement with the potential to improve repositioning protocols for more effective PrI prevention. Lying and upright position frequencies and durations provide foundational knowledge to support tailoring of PrI prevention interventions despite few significant differences in repositioning patterns for residents with dementia or obesity.

Movement Patterns of Transient and Prolonged Positioning Events in Nursing Home Residents: Results from the TEAM-UP Trial.

OBJECTIVE: To characterize transient and prolonged body position patterns in a large sample of nursing home (NH) residents and describe the variability in movement patterns based on time of occurrence. METHODS: This study is a descriptive, exploratory analysis of up to 28 days of longitudinal accelerometer data for 1,100 NH residents from the TEAM-UP (Turn Everyone and Move for Ulcer Prevention) clinical trial. Investigators analyzed rates of transient events (TEs; less than 60 seconds) and prolonged events (PEs; 60 seconds or longer) and their interrelationships by nursing shift. RESULTS: Residents' positions changed for at least 1 minute (PEs) nearly three times per hour. Shorter-duration movements (TEs) occurred almost eight times per hour. Residents' PE rates were highest in shift 2 (3 pm to 11 pm ), when the median duration and maximum lengths of PEs were lowest; the least active time of day was shift 3 (11 pm to 7 am ). Three-quarters of all PEs lasted less than 15 minutes. The rate of TEs within PEs decreased significantly as the duration of PEs increased. CONCLUSIONS: The NH residents demonstrate complex patterns of movements of both short and prolonged duration while lying and sitting. Findings represent how NH residents naturally move in real-world conditions and provide a new set of metrics to study tissue offloading and its role in pressure injury prevention.

Effect of Varying Repositioning Frequency on Pressure Injury Prevention in Nursing Home Residents: TEAM-UP Trial Results.

OBJECTIVE: To investigate the clinical effectiveness of three nursing-home-wide repositioning intervals (2-, 3-, or 4-hour) without compromising pressure injury (PrI) incidence in 4 weeks. METHODS: An embedded pragmatic cluster randomized controlled trial was conducted in nine nursing homes (NHs) that were randomly assigned to one of three repositioning intervals. Baseline (12 months) and 4-week intervention data were provided during the TEAM-UP (Turn Everyone And Move for Ulcer Prevention) study. Intervention residents were without current PrIs, had PrI risk (Braden Scale score) ≥10 (not severe risk), and used viable 7-inch high-density foam mattresses. Each arm includes three NHs with an assigned single repositioning interval (2-, 3-, or 4-hour) as standard care during the intervention. A wireless patient monitoring system, using wearable single-use patient sensors, cued nursing staff by displaying resident repositioning needs on conveniently placed monitors. The primary outcome was PrI incidence; the secondary outcome was staff repositioning compliance fidelity. RESULTS: From May 2017 to October 2019, 1,100 residents from nine NHs were fitted with sensors; 108 of these were ineligible for some analyses because of missing baseline data. The effective sample size included 992 residents (mean age, 78 ± 13 years; 63% women). The PrI incidence during the intervention was 0.0% compared with 5.24% at baseline, even though intervention resident clinical risk scores were significantly higher (P < .001). Repositioning compliance for the 4-hour repositioning interval (95%) was significantly better than for the 2-hour (80%) or 3-hour (90%) intervals (P < .001). CONCLUSIONS: Findings suggest that current 2-hour protocols can be relaxed for many NH residents without compromising PrI prevention. A causal link was not established between repositioning interval treatments and PrI outcome; however, no new PrIs developed. Compliance improved as repositioning interval lengthened.

The Nursing Home Severity Index and Application to Pressure Injury Risk: Measure Development and Validation Study.

BACKGROUND: An assessment tool is needed to measure the clinical severity of nursing home residents to improve the prediction of outcomes and provide guidance in treatment planning. OBJECTIVE: This study aims to describe the development of the Nursing Home Severity Index, a clinical severity measure targeted for nursing home residents with the potential to be individually tailored to different outcomes, such as pressure injury. METHODS: A retrospective nonexperimental design was used to develop and validate the Nursing Home Severity Index using secondary data from 9 nursing homes participating in the 12-month preintervention period of the Turn Everyone and Move for Ulcer Prevention (TEAM-UP) pragmatic clinical trial. Expert opinion and clinical literature were used to identify indicators, which were grouped into severity dimensions. Index performance and validation to predict risk of pressure injury were accomplished using secondary data from nursing home electronic health records, Minimum Data Sets, and Risk Management Systems. Logistic regression models including a resident's Worst-Braden score with/without severity dimensions generated propensity scores. Goodness of fit for overall models was assessed using C statistic; the significance of improvement of fit after adding severity components to the model was determined using the likelihood ratio chi-square test. The significance of each component was assessed with odds ratios. Validation based on randomly selected 65% training and 35% validation data sets was used to confirm the reliability of the severity measure. Finally, the discriminating ability of models was evaluated using propensity stratification to evaluate which model best discriminated between residents with/without pressure injury. RESULTS: Data from 1015 residents without pressure injuries on admission were used for the Nursing Home Severity Index-Pressure Injury and included laboratory, weights/vitals/pain, underweight, and locomotion severity dimensions. Logistic regression C statistic measuring predictive accuracy increased by 19.3% (from 0.627 to 0.748; P<.001) when adding four severity dimensions to Worst-Braden scores. Significantly higher odds of developing pressure injuries were associated with increasing dimension scores. The use of the three highest propensity deciles predicting the greatest risk of pressure injury improved predictive accuracy by detecting 21 more residents who developed pressure injury (n=58, 65.2% vs n=37, 42.0%) when both severity dimensions and Worst-Braden score were included in prediction modeling. CONCLUSIONS: The clinical Nursing Home Severity Index-Pressure Injury was successfully developed and tested using the outcome of pressure injury. Overall predictive capacity was enhanced when using severity dimensions in combination with Worst-Braden scores. This index has the potential to significantly impact the quality of care decisions aimed at improving individual pressure injury prevention plans. TRIAL REGISTRATION: ClinicalTrials.gov NCT02996331; http://clinicaltrials.gov/ct2/show/NCT02996331.

Nursing Assessment of Pressure Injury Risk with the Braden Scale Validated against Sensor-Based Measurement of Movement.

Nursing staff assessment to accurately identify pressure injury (PrI) risk is a hallmark in PrI prevention care. Risk scores from the Braden Scale for Predicting Pressure Sore Risk© (hereafter Braden), a commonly used tool for assessing PrI risk, signal the need for preventative care. Braden Mobility, Activity, and Sensory Perception subscale subgroups associated with repositioning movement features help identify preventative strategies that minimize pressure intensity and duration. Evidence confirming subscale rating accuracy is needed. This study compared assessment score accuracy with movement data collected via accelerometer sensor. Sample included 913 nursing home residents from the Turn Everyone and Move for Pressure Ulcer Prevention (TEAM-UP) cluster randomized trial. Movements and Braden Mobility and Activity subscale scores were evaluated for significant differences and associations. Mobility subgroups explained a small-medium amount of variance in mean lying and upright movement features (0.002 ≤ R2 ≤ 0.195). Activity subgroups explained a small-medium amount of variance in mean lying, upright, and ambulating movements (0.016 ≤ R2 ≤ 0.248). Significant associations occurred among subscale subgroups and most movements. Nursing assessment ratings using Braden scale's Mobility and Activity subscale scores are accurate indicators of actual repositioning movements and can be relied upon for PrI prevention care planning for older adults.