What is the best strategy for preventing pressure ulcers, in addition to frequent repositioning?

Best Strategy for Preventing Pressure Ulcers Beyond Repositioning

Use advanced static mattresses or overlays as the primary additional intervention for all at-risk patients, combined with prophylactic multilayer foam dressings over high-risk areas like the sacrum and heels. 1, 2

Primary Support Surface Selection

The American College of Physicians strongly recommends advanced static mattresses or overlays over standard hospital mattresses for all patients at increased risk of pressure ulcers. 1 This recommendation is based on moderate-quality evidence showing significantly lower ulcer rates compared to standard mattresses, and these surfaces cost substantially less than dynamic alternatives while providing equivalent or superior outcomes. 1, 3

• Avoid alternating-air mattresses or overlays — the American College of Physicians explicitly recommends against these systems because they provide no clear benefit over advanced static surfaces and cost significantly more without improving outcomes. 1, 3

Prophylactic Dressing Application

Apply multilayer foam dressings over the sacrum and heels as a key component of bundled prevention protocols. 2 This intervention is explicitly recommended for high-risk patients and represents one of the most practical additions to repositioning schedules. 2

• Silicone-based prophylactic dressings reduce shear forces and protect vulnerable skin areas. 4
• Dressings should be applied to bony prominences including sacrum, heels, ischium, and occiput in high-risk patients. 2

Nutritional Supplementation

Provide high-protein oral nutritional supplements to reduce pressure ulcer risk. 2, 3 The European Society for Clinical Nutrition and Metabolism found significant reduction in ulcer development with protein supplementation (odds ratio 0.75; 95% CI 0.62-0.89). 2, 3

• Protein or amino acid supplementation also reduces wound size in patients who develop ulcers despite prevention efforts. 2
• Do not prioritize vitamin C supplementation — it shows no benefit for pressure ulcer prevention. 2

Multicomponent Prevention Bundle

The American College of Physicians recommends implementing bundled care practices with moderate-quality evidence showing improved outcomes in both acute and long-term care settings. 1, 3 Key components include:

• Standardized protocols and documentation to ensure consistent application of preventive measures. 1, 3
• Multidisciplinary team involvement with designated skin champions who coordinate prevention efforts. 1, 3
• Ongoing staff education with sustained audit and feedback mechanisms. 1, 3
• One hospital system reported $11.5 million annual savings from implementing comprehensive multicomponent programs. 3

Risk Assessment

Perform systematic risk assessment using validated tools or clinical judgment to identify at-risk patients. 1, 3 The American College of Physicians notes that clinical judgment alone is equally effective for experienced clinicians, though tools may be especially useful for those without expert gestalt. 1

• The Braden, Norton, Cubbin and Jackson, and Waterlow scales all predict pressure ulcer risk with moderate-quality evidence, though all have low sensitivity and specificity. 1
• Risk factors include immobility, sensory impairment, incontinence, diabetes, edema, impaired microcirculation, hypoalbuminemia, and malnutrition. 1, 3

Skin Care and Moisture Management

Keep skin clean and dry, addressing incontinence promptly. 2 Daily skin assessment should include visual and tactile examination of sacrum, heels, ischium, and occiput at least once daily. 2

• Low-quality evidence shows that skin cream containing fatty acid and cleansers other than soap decrease pressure ulcer risk. 1
• Wash skin daily with careful drying and apply emollients to dry skin. 3

Critical Positioning Considerations

Use a 30-degree tilt position for repositioning every 2-4 hours to reduce pressure on bony prominences. 2 This specific angle is important because:

• Head elevation ≥30 degrees can increase pressure ulcer risk in dependent areas, particularly the sacrum. 2
• 45-degree elevation increases decubitus ulcer risk compared with 30-degree elevation according to 2024 Intensive Care Medicine guidelines. 2
• Keep the head of bed at the lowest safe angle (15-20 degrees) for hemodynamically unstable patients until stabilization occurs. 2

Interventions to Avoid

Never use donut cushions — they are explicitly contraindicated because they concentrate pressure around the perimeter of the opening, creating a tourniquet effect that impairs circulation to central tissue. 2 There is no quality evidence supporting their use. 2

Cost-Effectiveness Considerations

Advanced static surfaces represent high-value care because they are significantly less expensive than alternating-air systems while providing equivalent or superior outcomes. 1, 3 The American College of Physicians emphasizes that using expensive alternating-air and low-air-loss systems adds unnecessary burden on the healthcare system without demonstrated benefit. 1