How can decubital ulcers be prevented?

Decubital Ulcer Prevention

Use advanced static mattresses or overlays as your primary prevention strategy in at-risk patients, combined with a multicomponent approach that includes risk assessment, repositioning, skin care, and nutritional support. 1

Risk Assessment and Identification

• Perform systematic risk assessment using validated tools (Braden, Norton, Waterlow, or Cubbin-Jackson scales) to identify patients at increased risk, though clinical judgment alone is equally effective for experienced clinicians. 1
• Risk factors include: immobility, sensory impairment, physical impairments, urinary/fecal incontinence, diabetes, edema, impaired microcirculation, hypoalbuminemia, and malnutrition. 1
• Repeat screening every 6-12 months for low-risk patients, every 3-6 months for moderate-risk, and every 1-3 months for high-risk patients. 1

Support Surface Selection (Primary Intervention)

• Choose advanced static mattresses or advanced static overlays for all patients at increased risk—this is a strong recommendation with moderate-quality evidence showing lower ulcer rates compared to standard hospital mattresses. 1
• Avoid alternating-air mattresses or alternating-air overlays as they provide no clear benefit over static surfaces and cost significantly more without improving outcomes. 1
• No specific brand of advanced static surface has proven superior to others. 1

Skin Care and Hygiene

• Educate patients to wash feet/skin daily with careful drying (particularly between toes), apply emollients to dry skin, and cut toenails straight across. 1
• Instruct patients to examine their skin daily and immediately contact healthcare professionals if pre-ulcerative lesions or skin changes appear. 1
• Treat pre-ulcerative lesions promptly, including excess callus, ingrown toenails, and fungal infections. 1

Repositioning Strategies

• Implement regular repositioning as part of standard care, though optimal frequency remains unclear from evidence—the traditional 2-hour interval is standard practice despite limited evidence. 1, 2
• Evidence suggests repositioning every 4 hours combined with appropriate pressure redistribution surfaces may be as effective as 2-hourly repositioning. 2
• Be aware that standard repositioning may not relieve all at-risk tissue areas even when performed correctly, particularly in the perisacral region. 3

Footwear and Mobility Protection

• Instruct at-risk patients never to walk barefoot, in socks only, or in thin-soled slippers, whether indoors or outdoors. 1
• Prescribe properly fitting footwear that accommodates foot shape; consider therapeutic shoes, custom-made insoles, or toe orthoses for patients with foot deformities or pre-ulcerative lesions. 1

Nutritional Support

• Provide high-protein oral nutritional supplements (30 energy percent protein) to reduce pressure ulcer risk—meta-analysis shows significant reduction in ulcer development (OR 0.75; 95% CI 0.62-0.89). 1
• Nutritional supplementation is particularly important for malnourished patients or those with existing ulcers. 1

Multicomponent Interventions (Highest Impact Strategy)

Implement bundled care practices as moderate-quality evidence shows multicomponent interventions improve outcomes in both acute and long-term care settings. 1

Key components of successful programs include:

• Standardization of interventions and documentation 1
• Multidisciplinary team involvement with designated "skin champions" 1
• Ongoing staff education through team meetings and motivational campaigns 1
• Sustained audit and feedback with weekly prevalence reports and facility-wide meetings 1
• Integration of evidence-based guidelines into daily practice 1

Cost-Effectiveness Considerations

• Advanced static surfaces are significantly less expensive than alternating-air systems while providing equivalent or superior outcomes. 1
• Multicomponent prevention programs demonstrate substantial cost savings—one 2-hospital system reported $11.5 million annual savings from reduced ulcer prevalence. 1

Common Pitfalls to Avoid

• Do not rely solely on expensive alternating-air or low-air-loss systems—they add unnecessary healthcare costs without proven benefit over static surfaces. 1
• Do not assume standard repositioning alone is sufficient—it must be combined with appropriate support surfaces and other preventive measures. 1
• Do not neglect patient education—structured education about foot/skin self-care is essential for at-risk patients. 1
• Avoid harsh antiseptics for routine skin care as they can damage tissue. 4