Harnessing the power of intervention in pressure injury/ulcer prevention and management

Due to the multifactorial nature of pressure injuries, prevention remains a critical priority in minimising both their incidence and severity. Effective prevention strategies require a comprehensive, patient-centred approach that includes thorough risk assessment, individual repositioning regimen, evidence-based skincare protocols, appropriate support surface selection based on care goals, and ongoing staff education. Key interventions focus on alleviating pressure, redistributing load, preserving tissue perfusion, and optimising nutritional status. Additionally, enhancing patient and caregiver awareness, fostering interdisciplinary collaboration, and adhering to evidence-based guidelines are essential to strengthening prevention efforts and improving clinical outcomes.

As an industry supporter of STOP Pressure Injury/Ulcer Day, we are committed to empowering clinicians to improve outcomes in pressure injury prevention with a range of options to enable effective intervention, from support surfaces and repositioning systems to pressure injury prevention programs.

It goes without saying that all interventions to prevent pressure injuries must be led by the latest evidence-based guidance and coordinated by the multidisciplinary team. The International Guideline - Prevention and Treatment of Pressure Ulcers/Injuries, has been produced since 2009 by the European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Injury Advisory Panel (NPIAP), and Pan Pacific Pressure Injury Alliance (PPPIA), in conjunction with Associate Organisations. Over the last couple of years, we have observed the ongoing development of the 2025 Guideline, which will be the fourth edition and is planned for completion by the end of the year. For the first time, they are released as a ‘living guideline’ and available at The International Guideline website. At the time of writing this blog, the online guideline is in Beta mode, and the guideline governance group request our patience as they continue to update and finalise the content.

The new International Guideline offers greater clarity over and above the good practice statements, as they are supported, where necessary, by new clarifiers, more detailed implementation considerations, and comprehensive supporting information. This article focuses on providing a summary of the good practice statements as they apply to individual repositioning as part of the pressure injury prevention and management care pathway.

The intervention of repositioning as part of the pressure injury prevention and management care pathway

Beginning with Good Practice Statement (GPS) R1, which states that:

R1: ‘It is good practice to reposition individuals at risk of pressure injuries regardless of the type of pressure redistribution full body support surface being used. The interval between repositioning might be adjusted depending on the pressure redistribution capabilities of the support surface and the individual’s response. However, no support surface can entirely replace repositioning’^¹.

For those who have existing tissue damage, this is further clarified, with a proposal of similar advice in GPS R4:

R4: ‘It is good practice to reposition all individuals with or at risk of pressure injuries using an individualised regimen’^¹.

Some key takeaways from these evidence-based GPS:

• If an individual is at risk or has existing skin tissue damage, they need to reposition (independently or with assistance) regardless of the support surface or mattress they are on. No support surface can entirely replace repositioning.
• There is no pre-determined repositioning interval, and whilst the support surface may allow for the interval to be adjusted, we must monitor and observe the individual’s response for effectiveness and adjust the interval accordingly.

What is meant by the ‘individual’s response for effectiveness’?

This can be determined through multiple activities including visual skin tissue assessment, goals of care, comfort level and sleep pattern. Whether the individual is at risk and/or has existing skin tissue damage, GPS R6 provides further recommendation on this:

R6: ‘It is good practice to assess for signs of early skin and tissue injury that may mean the individual requires more frequent repositioning or preferential positioning off damaged areas’^¹.

As a reminder of what a full comprehensive assessment includes, GPS R5 cover this in detail:

R5: ‘It is good practice to determine appropriate and individualised repositioning intervals based on a comprehensive assessment of the individuals:

• level of activity and mobility
• ability to independently reposition
• skin and tissue tolerance
• clinical condition
• comfort
• sleep patterns
• goals of care, and
• the full body support surface in use’^¹

Goals of care are the specific clinical and personal outcomes that a patient wants to achieve during an episode of care. These are determined through a shared decision-making process with their healthcare team.

Factors for consideration when planning the individuals repositioning frequency

When we consider a repositioning regime, this includes how to reposition the individual when they are at risk or have existing skin tissue damage. GPS R2 suggests:

R2: ‘It is good practice to reposition the individual in such a way that optimal offloading of pressure points and maximum redistribution of pressure are achieved’^¹.

Additionally, as clarified in GPS R3:

R3: ‘It is good practice to use specialised equipment designed to reduce friction and shear when repositioning individuals. If manual handling is necessary, techniques that minimise friction and shear should be applied’^¹.

This may include the use of friction reducing slide sheets or slide sheets in combination with patient lifts and slings. The facility’s patient handling equipment can play an important part in the overall pressure injury prevention strategy, in addition to improving comfort and dignity during repositioning practices.

Learn more about Arjo’s patient handling systems here 

When we consider combining interventions of repositioning with a full body support surface, thinking back to GPS R1, it stated ‘no support surface can entirely replace repositioning’, GPS R7 provides additional repositioning regimen information:

R7: ‘We suggest that either repositioning at two hourly or three hourly intervals could be implemented for most individuals at risk of pressure injuries, if they are also on an appropriate pressure redistribution full body support surface’^¹.

Additionally, the clarifiers for R7, suggest:

• ‘Individualise frequency of repositioning based on a clinical assessment, as specified in the good practice statements.
• Critically ill individuals or others with systemic hypoperfusion or shock states may require more frequent, incremental repositioning and supplementation of full body repositioning with assisted small shifts in body position.
• Individuals receiving palliative or end of life care should be given the option of repositioning frequency intervals that are best suited to their goals of care and comfort needs, and with full knowledge of pressure injury risk incurred with less frequent repositioning’^¹.

The guideline does address the question of potentially increasing the repositioning intervals beyond 3 hours for individuals at risk of pressure injuries in GPS R8:

R8: ‘We suggest not routinely extending repositioning intervals to four, five or six hourly for individuals at risk of pressure injuries’^¹.

The clarifier for this GPS is important as it does go on to state:

‘Progressive extension of repositioning intervals may be appropriate for some individuals based on decreasing pressure injury risk, increased capacity for effective self-repositioning and maintenance of normal skin and tissue status’^¹.

Again, the individualised approach to appropriate intervention along with the goals of care are key factors as part of the shared decision-making process.

Often discussed is what happens when the individual is too unstable to achieve full repositioning at the intervals agreed as part of their care pathway. Typically, this is seen in the critical care environment, and GPS R9 does address this:

R9: ‘It is good practice to initiate frequent, small and incremental shifts (micromovements) in body position for critically ill individuals who are too unstable to maintain a regular repositioning regimen, and to supplement regular repositioning’^¹.

Lateral repositioning angles and sitting the individual up in bed

Always a topic of discussion is how far do I need to turn the individual when placing them into a side lying position to redistribute pressure. In addition to this question, is the consideration of how high we should sit them up in bed for pressure injury prevention. A couple of key GPS’s are covered in R10 & R11:  

R10: ‘We suggest using 30-degree lateral positioning to prevent pressure injury occurrence in individuals at risk for pressure injuries’^¹.

The clarifiers do help with additional information as it applies to maximum offloading, specifically on those with a higher BMI and pre-adolescents:

• Individualise turning angles to ensure maximum offloading of both the sacrum and the trochanter. 30-degree lateral positioning may not be maintainable or adequately offload the sacrum in individuals with higher body mass index. Modifying to a 40-degree lateral position might be necessary.
• In pre-adolescent children, a 30-degree turn is equivalent to a full body turn due to their smaller body width.

R11: ‘We suggest that the head-of-bed elevation be maintained at 30-degrees or lower to prevent pressure injury occurrence; however, higher head-of-bed elevation may be required in some clinical situations (e.g., individuals at higher risk for aspiration)’^¹.

This good practice statement is key for clinicians who recognise that competing clinical priorities may take priority and keeping to angles lower than 30-degrees is not advocated. As a reminder this is where reviewing the implementation considerations may really help as they suggest additional tips. In this case, amongst other things, suggestions of re-evaluating the support surface and/or elevating the thigh area to minimise sliding or migration down the bed that is associated with an increase in shear forces which contribute to skin tissue damage.

Throughout the repositioning chapter of the International Guidelines¹, evaluating and re-evaluating the support surface in use is referenced many times. It is equally as important to review the next chapter of the guidelines, ‘Support Surfaces’², as it discusses full body support surfaces for pressure injury prevention.

Register here for the upcoming ARJO webinar, in conjunction with STOP pressure injury day 2025, where we will be walking through the good practice statements as they apply to support surfaces, in addition to some of the implementation consideration to support clinicians with support surface selection:

 REGISTER NOW

To learn more about Arjo’s support surfaces and microclimate management products here 

Empowering clinicians with the ability to strengthen intervention strategies

Arjo Mobility Outcome Value Engagement (MOVE) programs are designed to arm clinical staff with the tools and knowledge to drive improvement towards both clinical and operational goals.

The MOVE Pressure Injury Prevention Programme is driven by facility data, combined with education and our expertise, to work in partnership to embed cultural change to achieve reduction in hospital acquired pressure injuries (HAI’s). 

Learn more about Arjo’s MOVE programs Here 

STOP Pressure Injury Day 2025

The awareness day in November each year aims to educate the public, professionals and politicians about pressure injures and how to prevent them.

This year’s theme ‘What matters to me’, drives focus on the patient voice. As discussed earlier, the goals of care is a shared decision-making process and combines not only clinical outcomes, but the personal outcomes that a patient wants to achieve during an episode of care.

Download

To aid understanding of support surface selection Arjo have two reference documents to help educate and inform clinical decision making.

The Science Behind the Support Surface: Download

This clinical summary offers an introduction to the principal pathology underlying pressure injury development. It considers the role of the support surface in pressure injury prevention and management strategies, and examines how surface design characteristics can affect overall product performance, highlighting the importance of measuring critical performance characteristics to help support and inform clinical decision making at the bedside.

Considerations for Support Surface Selection: Download

Support surfaces are a crucial element of an individualised comprehensive management plan for pressure injury prevention. With the shared understanding that ‘one product does not fit all’, this summary provides an introduction to commonly discussed topics to consider when selecting an appropriate support surface based on an individual’s pressure redistribution needs. Additionally, it explains performance characteristic testing and how this can be used to support decision-making.

Watch the Pressure Injury Prevention educational webinar series

Part One: The Pressure Injury/Pressure Ulcer (PI/PU) Prevention Maze: Navigating the Role of Support Surface Technology, led by Sharon Maris, Director Global Medical Affairs for Pressure Injury Prevention at Arjo

In this webinar we provide an overview of pressure injury/ulcer development, including insight related to the pressure injury damage cascade. Explain the basics of support surface technologies and discusses support surface testing and its clinical relevance.

Watch the webinar

 

Part Two: An Individualised Approach to Support Surface Selection, led by Sharon Maris, Director Global Medical Affairs for Pressure Injury Prevention at Arjo

This webinar explores support surface selection, including features that may play an additional role in pressure injury prevention and factors that may influence performance while the product is in use.

Watch the webinar

 

Part Three: Register here for the upcoming ARJO webinar, in conjunction with STOP pressure injury day 2025, where we will be walking through the International Guidelines good practice statements as they apply to support surfaces, in addition to some of the implementation consideration to support clinicians with support surface selection: 

 REGISTER NOW

 

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