Preventing Pressure Ulcers in Elderly Patients: Turning Protocols

The elderly often contend with various health challenges throughout their lives, from chronic pain and disease to harsh medications and demanding treatments. Elderly patients are frequently placed in nursing homes or hospitals to prevent accidental harm and to receive assistance with daily activities such as eating and personal hygiene. In these settings, many elderly individuals become bed-bound. One common and serious problem that bed-bound elderly patients face is the development of pressure ulcers (PrUs). Research indicates that turning a patient every two to four hours can reduce the rate of pressure ulcer occurrence. Recent studies demonstrate not only the efficacy of turning but also identify supplemental supportive measures, such as mattress substitution, and establish the longest effective turning interval that still results in a meaningful reduction of PrU incidence.

Pressure ulcers are a recurrent and difficult problem in hospitals and nursing homes. Nursing home residents and elderly patients frequently report pain and discomfort from ulcers that develop during prolonged bed rest. Among elderly populations at high risk, PrU prevalence at the start of studies typically ranges from 15% to nearly 25% on standard mattresses or foam overlays. While support surfaces combined with positional shifting were recognized as more costly components of PrU prevention, repositioning through bed turning has attracted significant attention due to positive study outcomes. Turning decreases pressure not only on the skin but also at the interface between bony prominences and protruding surfaces, which otherwise obstruct or diminish blood flow to surrounding tissue — a mechanism widely believed to cause PrUs.

PrUs must be considered alongside other injuries that elderly patients and nursing home residents acquire in care settings, because reducing such injuries leads to higher quality care and greater patient and resident satisfaction. As Miles, Nowicki, and Fulbrook (2014, p. 32) note, "The prevention of hospital-acquired pressure injuries (PIs) is an indicator of care quality, according to the Australian Commission on Safety and Quality in Health Care." Repositioning and redistribution of the body to reduce prolonged contact with pressure-sensitive areas effectively prevents PrUs. Beyond regular turning, evidence suggests that high-density foam mattresses distribute pressure more evenly than standard spring mattresses. Evidence also indicates that repositioning is, in practice, performed less consistently than the recommended every two hours, and additional research suggests that every two to four hours may be a more appropriate interval. Because research on quarter-turn repositioning specifically in elderly patients to minimize PrUs remains limited, no conclusive interval shorter than two to four hours has been formally recommended.

In a study by Bergstrom et al. (2013), the authors evaluated both the two-hour turning interval and the substitution of standard mattresses with high-density foam alternatives. Their findings showed that "there was no difference in PrU incidence over 3 weeks of observation between those turned at 2-, 3-, or 4-hour intervals in this population of residents using high-density foam mattresses at moderate and high risk of developing PrUs when they were repositioned consistently and skin was monitored" (Bergstrom et al., 2013, p. 1706). These results demonstrate that, as long as patients were repositioned within the recommended two-to-four-hour window, the specific interval did not produce a statistically significant difference in outcomes. Mattress substitution may have contributed to reducing PrU risk to some degree, but because the study's primary focus was on turning frequency, this variable was not fully analyzed.

The substitution of standard spring mattresses for high-density foam mattresses is an idea supported by both clinical evidence and common-sense reasoning. Spring mattresses have long been associated with insufficient support for the body's pressure points, which is why many individuals have already chosen foam alternatives in everyday settings. Even high-end retail markets now prominently feature foam mattresses based on strong consumer feedback: customers report better sleep quality and reduced pain compared to standard spring mattresses.

Although the primary focus of this paper is quarterly turning to prevent pressure ulcers, facilities that can afford the somewhat higher cost of foam mattresses will benefit from reduced reliance on frequent manual repositioning. Foam mattresses are therefore best understood as a supplement to regular turning rather than a replacement for it. Turning remains, as the evidence consistently suggests, the most effective method for reducing pressure ulcer occurrence.

In a study by Still et al. (2013), the authors demonstrated that a systematic turning program improved outcomes and reduced ulcer incidence. "At baseline, when frequent turning was encouraged but not required, a total of 42 pressure ulcers were identified in 278 patients. After implementation of the turn team, a total of 12 pressure ulcers were identified in 229 patients" (Still et al., 2013, p. 373). Importantly, the study did not require turning as frequently as every hour; rather, the results suggest that turning frequency can be reduced to as little as every four hours while still achieving meaningful reductions in pressure ulcer incidence.

Still et al. (2013) assessed turning patients every two hours and found that frequency could be modified with continued positive outcomes. Forty-two ulcers — concentrated especially in high-risk patients — were reduced to twelve. The authors concluded that "a team dedicated to turning SICU patients every 2 hours dramatically decreased the incidence of pressure ulcers. The majority of stage I and stage II ulcers appear to be preventable with an aggressive intervention aimed at pressure ulcer prevention" (Still et al., 2012, p. 373). Additionally, Moore, Cowman, and Posnett (2013, p. 2354) found that "repositioning every 3 hours, using 30° tilt, has been shown to be more effective and less costly in terms of nurse time compared with standard care." If comparable positive results can be achieved at three-hour intervals, it is reasonable to infer that a four-hour interval may also yield acceptable outcomes.

Turning patients every four hours means that patients can be repositioned a minimum of six times per day — for example, once before sleep, once during the night, once upon waking, and three additional times throughout the day. This schedule is not only manageable for staff but also conserves time and resources that might otherwise be spent managing pressure ulcer complications. In order to promote consistent quarterly turning, hospitals and nursing homes should implement a formal turning protocol that all staff members are required to follow. This would represent the most cost-effective preventive strategy, particularly given that positive results have been documented at four-hour intervals.

Elderly patients often develop pressure ulcers because staff are too busy or fatigued to reposition them every one to two hours. Requiring twelve turns per day is difficult to sustain; reducing that to six — as the evidence suggests is effective — makes it more likely that staff will consistently follow through. Unfortunately, some cases have been reported in which elderly patients were left in the same position for extended periods, resulting in multiple pressure ulcers and muscular weakness. While this is not representative of all facilities, it underscores the need for structured, enforceable turning protocols.

As previously noted, foam mattresses serve as a valuable adjunct to turning protocols. Despite the higher upfront cost, their benefits in distributing pressure more evenly are well supported. Irrespective of any limitations in the literature, the overall evidence strongly supports repositioning and turning as effective means of reducing pressure ulcers. Reducing PrU occurrence not only improves patient comfort but also gives staff more capacity to deliver higher-quality care overall. Nursing homes, hospitals, and the staff within these facilities must implement effective training strategies to ensure consistent and proper repositioning of patients at risk.

In an article by Ayello (2011), the author explains the use of the Braden Scale for predicting pressure sore risk. "Assessing risk in six areas (sensory perception, skin moisture, activity, mobility, nutrition, and friction/shear), the Braden Scale assigns an item score ranging from one (highly impaired) to three/four (no impairment)." The Braden Scale is a useful clinical tool for documenting and assessing pressure sore risk. Staff need a standardized method to evaluate whether the current turning frequency is effectively reducing PrU incidence. Observation and ongoing evaluation are essential components of any evidence-based intervention strategy, and the Braden Scale serves precisely this function — enabling proper implementation and reassessment of quarterly turning protocols.

Turning patients can be difficult to manage consistently, particularly for busy and fatigued care personnel. Using tools like the Braden Scale allows for structured evaluation of current practices and their effectiveness in reducing pressure ulcers. Staff can use the scale's findings to determine whether the current turning frequency is sufficient, whether the interval can be safely extended in patients who are responding well, or whether it should be increased for patients who are beginning to show signs of skin breakdown.

Preventing pressure ulcers is important not only for improving patient care quality but also for reducing healthcare costs for both facilities and patients. Estimates suggest that pressure ulcer management can cost upwards of $11 billion annually in the United States, with expenses related to life-threatening infections and prolonged hospital stays. Before implementing any preventive protocol, it is also important to identify which individuals are at greatest risk. As Hughes (2008, p. 1) notes in Patient Safety and Quality: An Evidence-Based Handbook for Nurses, "Some physiological (intrinsic) and non-physiological (extrinsic) risk factors that may place adults at risk for pressure ulcer development include diabetes mellitus, peripheral vascular disease, cerebral vascular accident, sepsis, and hypotension." Understanding which populations are most vulnerable and how to assess their needs helps guide the selection and prioritization of preventive strategies.