Long-Term Care. The use of an individualized repositioning schedule is a recommended strategy for prevention and management of pressure ulcers. The literature suggests that using a visual cue or diagram with body positions may be a helpful reminder of Resident positioning schedules. Prior to the implementation of the Turning Clocks, communication of at-the-bedside information relating to individualized Resident repositioning schedules was limited.
Therefore, to promote a person-centred care approach in pressure ulcer prevention and management, the Turning Clock by Safe Moves Injury Prevention Solutions was trialed and evaluated in one Manitoba Revera Home in Based on the positive outcomes of the evaluation, the Turning Clock was implemented in the 7 other Manitoba Revera Homes in and extended to Revera Homes across Canada.
When care is provided at the bedside, the caregiver can tell by looking at the Clock when and how the Resident is to be positioned next. The Turning Clocks are primarily used for Residents who are at high-risk of skin breakdown with impaired bed mobility or have an existing pressure ulcer, and in end-of-life care.
Step around to the other side of the bed and lower the side rail. Ask the patient to look towards you. This will be the direction in which the person is turning. The patient's bottom arm should be stretched towards you. Place the person's top arm across the chest. Cross the patient's upper ankle over the bottom ankle. Turning a Patient. The following steps should be followed when turning a patient: If you can, raise the bed to a level that reduces back strain for you.
Make the bed flat. Get as close to the person as you can. You may need to put a knee on the bed to get close enough to the patient. Place one of your hands on the patient's shoulder and your other hand on the hip. Standing with one foot ahead of the other, shift your weight to your front foot or knee if you put your knee on the bed as you gently pull the patient's shoulder toward you. Then shift your weight to your back foot as you gently pull the person's hip toward you.
You may need to repeat steps 4 and 5 until the patient is in the right position. All subjects will receive a wearable patient sensor Leaf Healthcare, Inc. This information is relayed through a proprietary mesh network to a central server for display on a user-interface to assist with nursing care.
This information is used to guide preventative care practices for those within the treatment group. Patients will be monitored throughout their admission in the intensive care unit. We plan to conduct a randomized control trial, which to our knowledge is the first of its kind to use a wearable patient sensor to quantify and establish optimal preventative care practices, in an attempt to determine whether this is effective in reducing hospital-acquired pressure ulcers.
Peer Review reports. Acutely ill patients are at risk for the development of pressure ulcers due to immobility, reduced perfusion, and prolonged duration of mechanical ventilation [ 2 ]. Pressure ulcers form when there is sustained pressure, predominately over bony prominences such as the sacrum, heels, occiput, and shoulders.
Unrelieved pressure causes compression of cellular tissue, impaired blood flow, and can lead to localized tissue damage and cellular death. Pressure ulcers initially appear as areas of reddened skin but can quickly develop into large open wounds if the pressure is not relieved.
To prevent pressure ulcers, the currently accepted standard of care is to turn patients at least every 2 h, day and night. However, there are no published research studies that support the every 2-h turning schedule in critically ill patients.
To improve adherence to turning as a preventative practice, Leaf Healthcare Inc. Pleasanton, CA, USA has developed a patient-monitoring system designed to optimize patient-turning practices.
Data for all patients are displayed on a User-Dashboard, allowing staff to easily identify patients who are in need of turning. Two single-center clinical studies have been completed using the monitoring equipment. A small first-in-human Institutional Review Board IRB -approved study was performed to test the feasibility of the patient sensor, mesh network, and monitoring system, and to collect baseline data regarding turning protocol compliance.
After this, a second single-center IRB-approved clinical study tested the efficacy, usability, and safety of the monitoring system ClinicalTrials. To date, the study team are unaware of any study that has used a wearable patient sensor to quantify patient movement and positioning, in an effort to assess whether adherence to optimal patient turning results in a reduction in pressure ulcer occurrence.
As such, the following protocol describes the study to be conducted to evaluate whether optimal patient turning, defined as regular turning every 2 h with at least 15 min of tissue decompression, reduces HAPUs in acutely ill patients.
This study is a single-site, open-label, two-arm, randomized controlled trial. As this is an open-label trial, a short observation pilot study will be undertaken during installation and testing of the patient-monitoring system to account for potential observer bias the Hawthorne effect. The true intent of the technology will be obfuscated to patients and clinical staff in an effort to record baseline data that more accurately represent current turning practices within these units.
A convenient sample of 25 subjects will be enrolled from each participating unit. All subjects will be randomly assigned, with the aid of a computer-generated schedule, to receive either standard care control group or optimal pressure ulcer preventative care treatment group. To minimize the risk of predicting the treatment assignment, randomization is performed in permuted blocks of two, four, and six, with random variation of block sizes.
To minimize bias at the patient level, randomization is further stratified by unit of admission and admitting service, either medicine or surgery Fig. Once randomized, each subject will receive a nominal study identification number based on the unit of admission and admitting service.
The lowest available number will be provided to each subject in sequential order. This study will enroll all patients admitted to two ICUs.
These patients are critically ill with exacerbations of acute and chronic medical conditions, or are receiving aggressive post-surgical care for neurological, cardiac, or trauma-related conditions.
They typically have altered levels of consciousness and are dependent on clinical staff for activities of daily living. Due to immobility and other clinical factors these patients are at high risk for developing pressure ulcers. Therefore, all patients over the age of 18 years admitted to one of the two ICUs will be enrolled in the study. Patients under 18 years of age, those with a known allergy to skin adhesive, or who possess a physical barrier preventing the application of the monitoring sensor, are not eligible for inclusion.
This is performed by two registered nurses RNs. Any pre-existing pressure ulcer that is detected during this assessment is documented in the electronic medical record EMR. If an exclusion condition is present, this will be documented and the patient will not be enrolled in the study and will not receive a patient sensor.
At this time the unit secretary will open an envelope, pre-filled with the computer-generated randomized group allocation. A patient sticker will be affixed to the back of the randomization card and stored in a secure location for later retrieval and verification of correct randomization and enrollment.
The patient will then be enrolled in either a treatment or control group. The clinical team will review this information and be guided by visual displays to provide pressure ulcer-prevention turning practices. With the use of the User-Dashboard, nurses will be prompted to perform pressure ulcer preventative care, namely patient turning with satisfactory tissue decompression for 15 min, at least every 2 h optimal.
If a patient does not receive the full time of tissue decompression, the Leaf Patient Monitoring System automatically adjusts, proportionally reducing the time-to-next-turn.
For example, if the patient was on their back and moved to their right side, but returned to their back within 7—8 min, the time-to-next-turn will be adjusted reciprocally from 2 h to 1 h. This ensures that patients receive at least 15 min of tissue decompression every 2 h. This will turn the sensor information off and therefore not display any information to the User-Dashboard. Patients in the control group will continue to receive standard care practices, that is, pressure ulcer-prevention activities initiated by nurses using their usual care routines.
The patient sensor will continue to collect these data for the purposes of research analysis only. Upon leaving the unit, the patient sensor will be removed and the patient will be discharged automatically from the Leaf Patient Monitoring System. The Leaf Patient Monitoring System is a wireless monitoring system that enables personalized turning protocols.
This allows for simplified and accurate patient enrollment and seamless tracking of patient movement throughout the study units. Proprietary turning data will be acquired from the Leaf Patient Monitoring System. Compliance to preventative turning care will be defined by two measures. The first will sum the overall time the patient is overdue for turning care, divided by the total monitoring time, and will be reported as a percentile of time.
Although we believe that the time in compliance is more appropriate than the proportion of turns within 2 h blocks, we will test and report on both measures as the latter reflects current clinical care practices. Adjudication will occur with the study team for any wounds that are difficult to stage. Stage I, non-blanchable erythema : intact skin with non-blanchable redness of a localized area usually over a bony prominence.
Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.
Category I may be difficult to detect in individuals with dark skin tones. Stage II, partial thickness skin loss : partial-thickness loss of dermis presenting as a shallow, open ulcer with a red-pink wound bed, without slough. This category should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration or excoriation. Stage III, full-thickness skin loss : full-thickness tissue loss.
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