In a study conducted by Smith et al., In the article XYZ, the authors discussed strategies to ? o In a metanalysis that included 3 hospitals over a 5-year pe

Effect of Varying Repositioning Frequency on Pressure Injury Prevention in Nursing Home Residents: TEAM-UP Trial Results Tracey L. Yap, PhD, RN, CNE, WCC, FGSA, FAAN; Susan D. Horn, PhD; Phoebe D. Sharkey, PhD; Tianyu Zheng, MS; Nancy Bergstrom, PhD, RN, FAAN; Cathleen Colon-Emeric, MD; Valerie K. Sabol, PhD, MBA, ACNP, GNP, FAANP, FAAN; Jenny Alderden, PhD, APRN; Winston Yap, MD; and Susan M. Kennerly, PhD, RN, CNE, WCC, FAAN

Original Investigation

ABSTRACT 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. KEYWORDS: compliance, cueing, geriatrics, nursing home, pressure injury, pressure ulcer, prevention, repositioning

ADV SKIN WOUND CARE 2022;35:315–25.

DOI: 10.1097/01.ASW.0000817840.68588.04

Tracey L. Yap, PhD, RN, CNE, WCC, FGSA, FAAN, is Associate Professor, Duke University School of Nu of Utah School of Medicine, Salt Lake City. Phoebe D. Sharkey, PhD, is Professor Emeritus, Loyola Univ Department of Population Health Sciences. Nancy Bergstrom, PhD, RN, FAAN, is Professor Emeritus, Un is Professor, Duke University School of Medicine. Valerie K. Sabol, PhD, MBA, ACNP, GNP, FAANP, FA Professor, Boise State University School of Nursing, Idaho. Winston Yap, MD, Carroll County Memorial East Carolina University College of Nursing, Greenville, North Carolina. Copyright © 2022 the Author(s). P the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where i changed in any way or used commercially without permission from the journal. Acknowledgments: The was funded by the National Institutes of Health, National Institute of Nursing Research (R01NR016001 necessarily represent the official views of the National Institutes of Health. The authors have disclosed December 23, 2021; published online ahead of print January 19, 2022.

WWW.ASWCJOURNAL.COM 315

INTRODUCTION Pressure injuries (PrIs; localized damage to skin and/or underlying tissues over bony prominences from pres- sure or shear forces) are common, yet seemingly intrac- table geriatric conditions that are mostly preventable complications in nursing home (NH) residents,1 who are typically older, withmultiple comorbidities, mobility challenges, and severely compromised health.2–4 Annual PrI prevalence of 7.3% in long-stay and 2.3% in short- stay residents5 and incidence up to 59% have been re- ported,1 hence the emphasis on PrI prevention. Pressure injuries have severe negative impacts on patients (eg, pain, infection, death), healthcare settings, and insurers,1,6 poten- tially exceeding $26 billion in costs annually.7

Assessment of PrI risk is standard practice in NHs,8–10

but prevention has proved elusive.11 There is limited evi- dence for PrI prevention,12with support surfaces andman- ual repositioning having been the focus.High-specification foamalternatives to standard hospital foammattresses sig- nificantly reduce PrI incidence.2,13,14 Repositioning (“turn- ing people to change body position”11) reduces pressure duration and tissue hypoxia and has theoretical appeal as a preventive approach; however, it also increases nursing workload and disrupts sleep.1,11 No conclusive evidence for either an optimal repositioning frequency13,14

or angle/positionhas emerged,11 relegatingpractice settings to use status quo 2-hour intervals based on 60-year-old findings.15 Staff compliance with 2-hour repositioning is challenging to achieve; the impact of cueing staff to re- position on time is not established.

rsing, Durham, North Carolina, United States. Susan D. Horn, PhD, is Adjunct Professor, University ersity Maryland, Baltimore. Tianyu Zheng, MS, is Research Assistant, University of Utah iversity of Texas Health Science Center at Houston School of Nursing. Cathleen Colon-Emeric, MD, AN, is Professor, Duke University School of Nursing. Jenny Alderden, PhD, APRN, is Associate Hospital, Carrollton, Kentucky. Susan M. Kennerly, PhD, RN, CNE, WCC, FAAN, is Professor, ublished by Wolters Kluwer Health, Inc. This is an open-access article distributed under the terms of t is permissible to download and share the work provided it is properly cited. The work cannot be authors thank Judith Hayes, PhD, RN, and Elizabeth Flint, PhD, for editorial assistance. This project ; Yap, principal investigator). The content is solely the responsibility of the authors and does not no other financial relationships related to this article. Submitted December 5, 2021; accepted

ADVANCES IN SKIN & WOUND CARE • JUNE 2022

Table 1. INCLUSION CRITERIA FOR NURSING HOMES AND RESIDENTS Nursing Home Inclusion Criteria Resident Inclusion Criteria

>100 beds Aged ≥18 y

Standard use of high-density foam mattresses No pressure injury on admission or within 72 h

Adequate internet bandwidth capacity to support real-time data collection and storage

Braden Scale score ≥ 10

Full electronic health record capability No adhesive allergy or other clinical contraindications

The repositioning intervention of the clinical trial pro- tocol for the Turn Everyone And Move for Ulcer Preven- tion (TEAM-UP) trial16 was derived from the International Pressure Injury Prevention Guidelines1 every 2-hour stan- dard for repositioning residents that allows individuali- zation of repositioning intervals of up to 4 hours; the pro- tocol was used by all participating NHs. The TEAM-UP trial examines 2-, 3-, and 4-hour repositioning intervals (prompted by wearable patient position sensors) and the 28-day PrI incidence among NH residents using viable 7-inch high-density foam mattresses and having PrI risk scores of low, mild, moderate, or high (not severe) as mea- sured by the Braden Scale (≥10). The final study results were intended to provide evidence of overall repositioning effectiveness among the three repositioning intervals.

METHODS This study aimed to determine whether the reposition- ing interval can be extended from 2 to 3 or 4 hours for NH residents without compromising PrI incidence. An embedded pragmatic cluster randomized controlled trial designwas selected because these studies are designed to inform decision-makers regarding the comparative bal- ance of benefits, burdens, and risks of using biomedical or behavioral health interventions.17 The study was de- signed with input from healthcare stakeholders18 and was intended to represent the real-world NH environ- ment that included (1) a diverse representative study population, (2) an intervention that could be incorporated easily into routine clinical workflow as standard of care, (3) outcomes important to decision-makers (in this case, PrI and compliance), and (4) comprehensive data col- lected through standard documentation in an electronic health record (EHR) within the healthcare setting. Prior to NH selection, three arms (arm 1 = 2-hour,

arm 2 = 3-hour, arm 3 = 4-hour) were determined, with planned assignment of three NHs to each arm by applying a randomized sequencing of the arm assign- ments according to the chronologic order identified for NHs. The repositioning intervals were implemented in chronologic sequence after completing one round of arm 1, arm 2, and arm 3 to ensure all three intervals could be safely implemented; then, a predetermined se- quence was followed, resulting in NHs 1, 6, and 8 in arm 1; NHs 2, 4, and 9 in arm 2; and NHs 3, 5, and 7 in arm 3. Nine NHs from a large proprietary system in 34 states

met the eligibility requirements, accepted the invitation to participate, and were assigned to one of the three NH-wide repositioning interval arms as described pre- viously. The magnitude of within-cluster (arm) depen- dence was quantified by the intraclass correlation coeffi- cient (ICC), and the precision of this measure was quan- tified by its confidence interval (CI).

ADVANCES IN SKIN & WOUND CARE • JUNE 2022 316

During the intervention, a patient monitoring system cued staff to reposition residents and tracked events. Four-week incidence of new PrI was compared among the three arms, controlling for resident characteristics and staffing levels. Details of the trial design were published previously.16

Study Setting, Residents, and Procedures All Medicare-certified NHs providing intermediate and skilled nursing care within the proprietary company (n = 473) were eligible for randomization. Inclusion criteria for NHswere: over 100 beds; standard use of high-density foam mattresses determined to be viable or replaced within 2 months of study implementation; adequate in- ternet bandwidth capacity to support real-time data col- lection and storage; and full EHR capability including activities of daily living, laboratory, and radiology re- sults (Table 1). The requirement for NHs to have full elec- tronic record capabilitieswas essential to facilitate data col- lection and ensured that the study would have robust data sets. Investigators invited 83 eligible NHs meeting eligibil-

ity to participate in the trial, which required mandatory staff in-service training to explain the study and patient monitoring system implementation. The sample size power requirement (95%) was satisfied by the first nine NHs that agreed to participate based on total residents to be recruited. The nine study NHs (1) had the same standard care delivery policies, (2) were of typical size and characteristics of the other eligible sites, (3) signed implementation agreements, (4) received a nominal sti- pend to support project implementation, and (5) were randomized via a predetermined random sequencing procedure16 to one of three repositioning intervals (arms). Eligible study participants met the following criteria:

18 years or older, without PrIs (on admission or within 72 hours), Braden Scale score ≥ 10 (assessed weekly), and without adhesive allergy or other clinical contrain- dications (paranoia, dermatitis, personal defibrillator garment andmonitor, or “do-not-turn” order). Residents

WWW.ASWCJOURNAL.COM

at severe PrI risk (Braden Scale score < 10)were excluded because of unique repositioning and surface needs. Available electronic historic data for study residents

were retrieved for the 12-month baseline period prior to the intervention start at eachNH. Residents with both intervention and baseline EHR, Minimum Data Set, and NH Risk Management System data formed the effective sample for pre-post analyses.

Intervention Each arm included three NHs assigned a NH-wide repo- sitioning interval (2, 3, or 4 hours) during the 4-week intervention. A wireless patient monitoring system using a wearable, resident-specific sensor worn on the upper chest tracked position/movement and cued staff com- pliance with the prescribed NH-wide repositioning in- terval.19 Health Insurance Portability and Accountabil- ity Act-compliant visual cues displayed each resident’s time-stamped repositioning history and status on unit desk and hallway monitors. Patient monitoring system fidelity checks (6 per week) ensured accuracy. Standard PrI prevention care other than repositioning

intervals was provided in all three arms in accordance with International Pressure Injury Prevention Guidelines1

(head-of-bed elevation, position angle, and duration and use of pillows/wedges tomaintain position, turning sheets, and lift devices as appropriate).1 Staff assisted non-bedfast residents to stand/move/reposition and used preventive seating cushions as needed. All residents/families received information about the study, repositioning protocol, and their right to refuse care and/or receive a more fre- quent repositioning interval.

Outcomes The primary outcome was PrI incidence during the in- tervention. Daily and weekly NH staff skin assessments were recorded using NH system policies.1 Certified nurs- ing assistants observed skin daily over bony prominences, between skin folds, in genitalia/buttocks areas, and at sensor sites. Change in skin appearance was reported to licensed staff with oversight for repositioning, safety, weekly skin care checks, and EHR documentation re- lated to PrI status (stage and manifestations). Safety al- gorithms were published previously.16

The secondary outcome was fidelity of staff reposi- tioning compliance tracked by wearable patient sensors, enhanced by NH-mandated in-service training for full- and part-time RNs, LPNs, and Certified Nursing Assis- tants (79% participation). The required education focused on PrI etiology, Braden Scale risk assessment, evidence- based prevention practices, repositioning benefits, roles and responsibilities, staff workflow, trial protocol, and pa- tient monitoring system information. A researcher visited the NH each shift duringweek 1 and at least daily during

WWW.ASWCJOURNAL.COM 317

the second through fourth weeks to ensure the patient monitoring system was functioning, answer staff ques- tions, and stock supplies.

Assessments All NHs and eligible residents were assessed retrospec- tively for the baseline period (maximum 365 days) be- fore the intervention start date and prospectively for the 4-week intervention period. The NH parent com- pany provided all EHR, Minimum Data Set, and Risk Management System data for the full 28-day interven- tion period regardless of the number of days reposition- ing was monitored. Assessments of all eligible residents were extracted from the EHR, Minimum Data Set, or NH Risk Management System. The EHR provided de- mographic characteristics, medical diagnoses as Interna- tional Classification of Diseases version 9 (baseline period data) and/or International Classification of Diseases ver- sion 10 codes (most frequently occurring codes were grouped into the most common diagnosis categories), height/weight, vital signs, and laboratory data. The EHR data were supplemented by the Minimum

Data Set, a federally mandated, comprehensive, stan- dardized assessment of NH residents’ functional and health needs conducted quarterly and/or at condition change. The NH assessments (location, specialty units, Medicare-certified beds, census, occupancy, staff hours, and payor type) for intervention and baseline were ex- tracted as reported to the CMS. Braden Scale assessments produced the only data for which the data extraction/ collection schedule varied between baseline and interven- tion periods. During baseline, Braden Scale risk scores (10–12, high; 13–14, moderate; 15–18, mild; 19–23, low) were assessed on admission, four times weekly, quarterly, and upon condition change. During the intervention, Braden Scale scores were assessed weekly; no residents were withdrawn because of a Braden Scale score of 9 or less. The PrI incidence for eligible residents during the

12-month baseline period was extracted retrospectively from the NH Risk Management System and supple- mented by the Minimum Data Set and EHR, as previ- ously described.16 The PrI incidence was determined through standard weekly licensed nursing staff skin as- sessments for the 4-week intervention, directly reported to researchers, and documented as an adverse event through the NH company’s Risk Management System. Researchers ensured study fidelity by randomly verify- ing assessments and receipt in real time of secure email notification triggered by the reported event. The patient monitoring system served as a reposition-

ing fidelitymeasure and assessed several factors for each resident: days with active sensors worn, number of Turn Alert cues, Turn Alert overdue hours, and degree angle of repositioning with ±2.5% accuracy. Turn Alert cues

ADVANCES IN SKIN & WOUND CARE • JUNE 2022

appeared on screens to notify staff that a resident had not had a position change andwas due for repositioning within the allocated interval. Turn Alert overdue hours counted time beyond prescribed repositioning interval that a resident remained in the same position. The 24-hour on-time repositioning compliance was calculated as (1 − [# Turn Alert overdue hours for period of interest]/ [total hours monitored for period of interest]) and indi- cated the degree to which the expected repositioning in- terval was being achieved.

Statistical Analysis Primary analyses of PrI outcomes were performed ac- cording to the intention-to-treat principle. Analyses were conducted using Statistical Analysis Software (SAS version 9.4, Cary, North Carolina). Analysis of InterventionOutcomes. The initial analy-

sis plan to test whether the PrI rate during intervention was higher for 3- or 4-hour repositioning compared with 2-hour is reported elsewhere.16 Overlap between the 95% CIs of rates of PrI and the 2-hour repositioning would confirm the hypothesis for no group difference. However, given that no PrIs developed during the inter- vention, the trial’s original analysis plan was modified to report the trial’s characteristics and pre-post comparative analyses by testing baseline (pretest, 2-hour repositioning) versus intervention (posttest, 3-hour, and 4-hour protocols) PrI rates. Analysis ofDifferences in Baseline and Intervention

Risk. Propensity score logistic regression analysis based on baseline datawas used to account for an imbalance in PrI risk associated with significant differences in NH and resident characteristics across arms. The adequacy of the fi- nal model fit was ensured by generating a 70% random sample to train/build themodel anda 30%randomsample to validate themodel. Regression coefficients from the fitted training data set model provided unbiased risk predictions of developing a PrI during the intervention.Contribution of each variable to likelihood of developing a PrI was deter- mined by odds ratios (ORs) generated from the model. C statistics were used to assess goodness of fit. Differences in first Braden Scale scores and mean total

Braden Scale scores across arms within the intervention period were compared separately using either analysis of variance orχ2 analyses. Paired t tests evaluated differ- ences inmean total Braden Scale scores between baseline and intervention cohorts by arm. Two-sided tests (P < .05) were used for all analyses. Power Analyses. Statistical power and sample size

analyses are published elsewhere.16 The expected PrI inci- dence for this study’s 4-week intervention was 3.5% based on the TURN study’s13 highest rate (for moderate-risk patients) during that 3-week intervention. Target sample size was 951 residents (≥317 per arm) to detect minimum

ADVANCES IN SKIN & WOUND CARE • JUNE 2022 318

detectable effect size of 0.38 difference between study arms with a power of 0.95 based on a one-sided rather than a two-sided test to determine if PrI incidence with 3- or 4-hour repositioning frequency was greater than with 2-hour repositioning; detection of a decrease in PrI was not of concern. Stopping boundaries were main- tained during the trial as described in the Data Safety Monitoring Plan; no safety concerns were identified, and the trial was completed. Powerwas adjusted postin- tervention after taking into consideration the ICC of the NHs in the three treatment arms. Intraclass correlation coefficient and its CI were calculated.

Ethics The trial was approved by Duke University Institutional Review Board (#Pro00069413). The Board approved a waiver of informed consent per the US Department of Health and Human Services guidelines 21 CFR 46 be- cause (1) an NH-wide repositioning schedule was pro- vided to the entire cluster of low-, mild-, moderate-, and high-risk residents; (2) the intervention-assigned re- positioning interval was adopted as part of NH-wide practice that standardized the repositioning workflow; (3) minimal risk was involved in the arm-level interven- tion, and (4) a coded data set was created with assigned study identification (ID) number for resident data ex- tracted from the patient monitoring system database, Minimum Data Set, and EHR, and the coded data set was placed directly into a secured network folder. Also, fliers summarizing the project notingNHMedical Direc- tor approval were mailed to residents and their family member/responsible party informing them of the op- tion to choose not to participate; the principal investiga- tor’s mobile phone number was included for concerns and questions. The principal investigator guided on- site data collection with the project director, who was re- sponsible for implementation fidelity. The research team was responsible for data quality control/analyses. A busi- ness associates’ agreement was signed between the NH corporation and patient monitoring system company. All methods were performed in accordance with the rele- vant guidelines and regulations (Declaration of Helsinki). Data Sharing Statement. The data used in this publica-

tion include protected health information and therefore cannot be freely shared. Data sharing will be possible with case-by-case approval from the authors’ institutional review board; requests may be directed to the principal investigator.

RESULTS Repositioning intervals were implemented in the ran- domly ordered sequence as planned to ascertain whether repositioning interval could be extended from 2 to 3 or 4 hours forNH residents.No PrIs developed among par- ticipating residents, even though the preintervention PrI

WWW.ASWCJOURNAL.COM

incidence at the nine NHs ranged from 2.3% to 18.3%. Intervention results are described related to NH and res- ident characteristics and primary and secondary out- comes. Additional analyses were performed to examine PrI risk and repositioning compliance.

Nursing Homes Characteristics of the three NHs in each arm during baseline are presented in Table 2; the ICC and its CI are 0.056 (CI, −0.78 to 0.89). The NHs were primarily subur- ban, with 126 to 238 Medicare-certified beds; some NHs had dementia and/or transitional resident specialty units. The average census ranged from approximately 143 to 162 residents, with Medicare-certified bed occu- pancy between 79% and 90%. Certified Nursing Assis- tants provided most care hours to residents, who were primarily Medicaid supported.

Residents FromMay2017 toOctober 2019, 1,100 residentswere fitted with sensors; 108 of thesewere ineligible for some analyses because of missing baseline data or other disqualifying conditions. The effective sample size included 992 resi- dents. The NH enrollment and randomization, resident assessment and allocation, follow-up, and analysis are shown in the Figure and were developed according to

Table 2. NURSING HOME (N = 9) CHARACTERISTICS AT BAS

Characteristics Arm 1 2 ha (n =

Location S, S, S

Specialty units None, D/

No. of Medicare-certified beds per facility, mean (range) 181.0 (18

Patient census,b mean (SD) 143.2 (37

% Occupancyb (census-certified beds), mean (SD) 79.2 (17.6

No. of staff hours per resident, db meanc (SD)

RN 1.6 (0.20)

LPN 2.9 (0.70)

Certified nursing assistant 6.5 (1.40)

Resident payor type, mean (% coverage by payor type)

Managed care 3.8 (2.6)

Medicaid 112.7 (78

Medicare A 17.9 (12.5

Private pay 4.5 (3.2)

Other payor 4.3 (3.0)

Abbreviations: D, dementia unit; NH, nursing home; S, suburban; T, transitional care unit; U, urban. Note: Percentages may not sum to 100 because of rounding. aRepositioning interval for each intervention arm. bBaseline values are for the 6-month period prior to the intervention. cNo. of monthly hours/NH monthly census, by staff category.

WWW.ASWCJOURNAL.COM 319

the cluster trial’s extension of the CONSORT (Consoli- dated Standards of Reporting Trials) Statement. Table 3 presents characteristics of the 1,100 residents

allocated to the three intervention arms; 108 residents were excluded from the pre-post analyses, and the re- maining 992 residents were analyzed by arms. The 108 excluded residents did not form a PrI; they were signifi- cantly younger (P < .001), were primarily men (P = .002) and had less cerebrovascular disease (P = .004), gastro- esophageal reflux disease (P = .026), Alzheimer disease and related dementias (P < .001), and difficulty swallow- ing (P < .001), but had more hypertension (P < .001) and diabetes (P = .003) than the 992 residents analyzed in the intervention population. Differences in age, race, ethnicity, diagnosis categories,

and intervention length of stay (LOS) were statistically significant across arms (Table 3); this imbalance was ad- dressed using propensity analyses (Table 4). Black resi- dents comprised 53% of arm 2 compared with less than 18% in arms 1 and 3. Fifty-two residents (27% of whom were Black) had one or more incident baseline PrIs that healed prior to intervention start (untabled). Total LOS reflects the time from admission that could have oc- curred during or before baseline period until the inter- vention end date or resident discharge from NH. The LOS for only the intervention period (intervention-only LOS) was 1 day shorter in arm 3, which was statistically

ELINE BY ARM

319) Arm 2 3 ha (n = 323)

Arm 3 4 ha (n = 350)

S, U, S S, U, S

T, D T, D, T D/T, T, T

0–183) 178.7 (176–180) 180.3 (126–238)

.9) 161.5 (4.3) 159.1 (47.7)

) 90.3 (2.3) 88.5 (3.0)

2.1 (0.53) 2.4 (0.53)

2.6 (0.49) 2.7 (0.93)

7.5 (0.36) 7.6 (0.57)

7.9 (4.9) 11.2 (7.0)

.7) 131.9 (81.7) 115.4 (72.5)

) 10.1 (6.2) 18.4 (11.6)

5.4 (3.4) 3.3 (2.1)

6.2 (3.8) 10.8 (6.8)

ADVANCES IN SKIN & WOUND CARE • JUNE 2022

Figure. NURSING HOME ENROLLMENT AND RANDOMIZATION, RESIDENT ASSESSMENT AND ALLOCATION, FOLLOW-UP, AND ANALYSIS

Abbreviation: NH, nursing home.

significant, but a single-day difference is not considered clinically relevant to the outcome.

PrI Risk Across and Within Arms Baseline. Table 4 presents clinical risk (Braden Scale) comparisons, predicted propensity, and observed PrI inci- dence among residents at baseline and during the inter- vention. At baseline, neither first nor mean total Braden Scale scores differed significantly by arm, although risk dif- fered slightly acrossmean Braden categories (P = .03). Pro- pensity for a resident to develop a PrI at baseline (Table 4) was significantly higher in arm 2 (P< .001) than either arm 1 or 3 (Tukey honestly significant difference, P≤ .05); arms 1 and 3 did not differ significantly. The ORs for PrI devel- opment during baseline (propensity model C statistic, 0.76) included: Black race (OR, 2.24; CI, 1.04–4.80); mild Braden risk category (OR, 3.96; CI, 1.57–9.94); and mod- erate Braden risk category (OR, 4.69; CI, 1.48–14.91). No other resident characteristics (age, sex, diagnoses) orNH or staffing characteristics were significant predictors for developing a PrI. Observed annual PrI incidence across all NHs during baseline was 5.24% (52/992; range, 2.3%– 18.3% across NHs); the overall monthly expected number of PrIs was 4.33. Intervention.No new PrIs developed during the inter-

vention regardless of NH allocation to 2-, 3-, or 4-hour

ADVANCES IN SKIN & WOUND CARE • JUNE 2022 320

repositioning interval. Despite significant differences in propensity to develop PrIs, the incidence was 0.0% across all arms, which included 52 residents with a prior baseline PrI that had healed before the start of the inter- vention. Propensity to develop a PrI during the interven- tion was s

Collepals.com Plagiarism Free Papers

Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.

Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS

Why Hire Collepals.com writers to do your paper?

Quality- We are experienced and have access to ample research materials.

We write plagiarism Free Content

Confidential- We never share or sell your personal information to third parties.

Support-Chat with us today! We are always waiting to answer all your questions.