What are the ways to reduce pressure ulcers in an Intensive Care Unit (ICU) patient?

Pressure Ulcer Prevention in ICU Patients

Use advanced static mattresses or overlays as your first-line support surface, implement systematic repositioning every 2-4 hours using a 30-degree tilt position, and bundle this with daily skin assessment, moisture management, nutritional support, and heel elevation—while avoiding alternating-air mattresses due to lack of benefit and higher cost. 1, 2

Risk Assessment

• Perform systematic risk assessment using the Braden Scale upon ICU admission, recognizing it has low sensitivity and specificity but serves as a useful screening tool rather than definitive predictor 1, 2
• The Cubbin and Jackson scale was specifically developed for ICU patients but shows similar diagnostic accuracy to the Braden and Waterlow scales in this setting 1
• Conduct daily visual and tactile skin assessments of all pressure-prone areas (sacrum, heels, ischium, occiput) with documentation 2, 3
• Reassess risk with any clinical condition changes, as static scores don't capture evolving patient status 2

Support Surface Selection

Select advanced static mattresses or advanced static overlays immediately for all at-risk ICU patients—this is the only support surface with moderate-quality evidence showing reduced pressure ulcer incidence compared to standard hospital mattresses. 1, 2, 3

• Do not use alternating-air mattresses or alternating-air overlays despite their widespread use in U.S. hospitals, as current evidence shows no clear benefit over static surfaces and they cost significantly more without improving outcomes 1, 3
• Advanced static surfaces are less expensive than alternating-air or low-air-loss systems and should be the preferred approach to high-value care 1

Repositioning Protocol

Implement systematic repositioning every 2 hours around the clock for all ICU patients, regardless of Braden score, with pressure zone checks at each turn. 2, 4

• Use the 30-degree tilt position rather than standard 90-degree lateral rotation, which reduces pressure on bony prominences (relative risk 0.62 in low-quality evidence) 2
• Avoid the flat supine position entirely as it concentrates pressure on vulnerable areas 2, 3
• A dedicated "turn team" in one SICU study dramatically reduced pressure ulcers from 15.1% to 5.2% (p<0.0001) by ensuring consistent 2-hour repositioning 4
• Evidence comparing 2-hour versus 4-hour repositioning intervals on alternating pressure mattresses showed no difference in ulcer incidence (10.3% vs 13.4%, p=0.73), but the 2-hour protocol increased device-related adverse events (47.9% vs 36.6%, p=0.02) 5

Critical Positioning Considerations for Hemodynamically Unstable Patients

• Keep head of bed at the lowest safe angle (15-20 degrees) until hemodynamics stabilize, as head elevation ≥30 degrees can reduce venous return and worsen hypotension 3
• Head elevation ≥30 degrees increases pressure ulcer risk in dependent areas, particularly the sacrum 3
• Vasopressor use is not a contraindication to repositioning—monitor blood pressure and heart rate during turns 3
• Gradually increase head elevation if tolerated once hemodynamics stabilize 3

Skin Care and Moisture Management

• Keep skin clean and dry at all times, addressing urinary or fecal incontinence promptly as moisture increases skin maceration and ulcer risk 2, 3
• Use skin cleansers other than soap, which showed decreased pressure ulcer risk in low-quality evidence 1, 2
• Apply fatty acid-containing creams, which demonstrated reduced ulcer risk in low-quality evidence 1, 2
• Apply barrier sprays and lubricants judiciously to protect skin from friction during repositioning 2

Prophylactic Dressings

Place multilayer foam dressings over the sacrum and heels as an additional preventive strategy beyond frequent repositioning for high-risk ICU patients. 3

• Prophylactic dressings in high-risk areas are explicitly recommended for patients with high-risk profiles 3
• This is a key component of bundled interventions recommended by the American College of Physicians 3

Heel Protection

• Elevate heels off the bed surface using specialized devices or pillows to avoid interosseous contact 2, 3
• Heel protection with pressure-relieving devices is essential for high-risk ICU patients 3
• Low-quality evidence showed mixed results for specific heel supports or boots, but the principle of offloading remains important 1

Nutritional Support

Provide high-protein oral nutritional supplementation for ICU patients at risk, as this reduces pressure ulcer development (odds ratio 0.75,95% CI 0.62-0.89). 3

• Protein or amino acid supplementation also reduces wound size in patients who develop ulcers despite prevention efforts 3
• Vitamin C supplementation shows no benefit and should not be prioritized 3
• Address malnutrition as it significantly impairs wound healing and increases ulcer risk 2, 3

Early Mobilization

• Begin mobilization as soon as medically stable, starting with passive range-of-motion exercises for at least 20 minutes per zone 2
• Progress to active mobilization using a structured protocol aiming for the highest achievable mobility level at each session 2
• Combine early mobilization with other preventive measures 6

Multicomponent Implementation Strategy

Establish a bundled prevention program that includes simplification and standardization of interventions, multidisciplinary team involvement with designated "skin champions," ongoing staff education, and sustained audit and feedback. 1, 2, 3

• Moderate-quality evidence from 26 implementation studies showed multicomponent interventions can improve skin care and reduce pressure ulcer rates in both acute and long-term care settings 1
• Key components include weekly prevalence reports, formal and informal feedback, all-facility meetings, and team meetings with motivational campaigns 1
• One 2-hospital system (548 beds) estimated annual cost savings of approximately $11.5 million from statistically significant reductions in pressure ulcer prevalence 1, 6
• Form multidisciplinary teams with designated leaders, implement regular audits, address staffing overload, and ensure adequate availability of advanced support surfaces 2

Common Pitfalls to Avoid

• Do not use donut cushions—they are explicitly contraindicated as they concentrate pressure around the perimeter, creating a tourniquet effect that impairs circulation to central tissue 3
• Do not rely solely on risk assessment scores—the Braden Scale has low sensitivity and specificity and should be combined with clinical judgment 1, 6
• Do not assume repositioning alone is sufficient—evidence shows standard care that included repositioning still resulted in ulcers without the full bundle of interventions 1
• Do not use alternating-air systems thinking they are superior—they provide no additional benefit over advanced static surfaces and waste resources 1, 3