Repositioning for Pressure Injury Prevention
Selecting a Prone Position in Critical Care
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Good Practice Statement
R12: It is good practice to select a prone position when required by the individual’s medical condition, and to cease prone positioning as soon as clinically appropriate.
Clinical question: What are the general considerations regarding when to place an individual in prone position and how should an individual be protected a while in prone position?
Implementation considerations
Implement an interdisciplinary proning team with specialized training in safely proning the individual in clinical areas where prone positioning is required for medical care (97, 101). Interdisciplinary proning teams collaboratively ensure the individual’s airway is maintained, clinical needs are addressed and harms are minimized.
Include a certified/ specialty-trained wound and skin care professional on a prone positioning team (102).
The full body support surface should be flat (no head-of-bed elevation) when positioning the individual in a prone
Repositioning
Limit the amount of time spent in the prone position. Develop a clear protocol with indications for proning and a safety checklist for positioning in prone (e.g., airway management, line management and positioning management (97).
Continue to reposition as the individual’s medical condition allows. Consider using the swimming/freestyle position and supplementing repositioning with frequent, small movements of the extremities and head (35). Alternate the arms and the head every two hours (99).
Assessment
Assess the skin at the face, thorax, clavicles, breast region, iliac crest, symphysis pubis, genitalia, knees, tibial plateau and toes before and after using the prone position (103, 104, 105), and at each repositioning..
Full body support surfaces and pillows
Use pillows (e.g., viscoelastic foam or gel) under the chest and pelvis to avoid pressure on the abdomen. Use pillows under the shins to avoid stretching knee and ankle joints.(97, 100) Consider using a preventive dressing for pressure points (35).
Use a facial pillow under the face/head to avoid direct pressure on eyes, ears and endotracheal (ET) tube (35, 74, 106). When selecting the pillow, consider the likely duration of proning,(3) angle of face and ET tube, and pillow height (35).
Consider using headrests to avoid direct pressure on the orbits. Consider reverse Trendelenburg positioning of the full body support surface if optical pressure and edema are observed. A mirror can be used to assess the eyes (99).
Skin and face care
Regularly reposition the head as much as possible (107).
Consider using preventive dressings over pressure points in contact with the full body support surface (e.g. forehead, chin, clavicle, elbow, iliac crest, knee and dorsum of foot) (99).
Keep the skin clean and dry from excess moisture (103).
Care for the eyes: use ophthalmic lubricant and tape the eyes shut horizontally (35, 107).
Care for the mouth: ensure the tongue is inside the mouth and regularly assess for injury. Consider using a bite block (35). Be aware of the risk for mucosal PIs and regularly assess inside the mouth.
Manage moisture with frequent suctioning and use of topical skin protectants (35).
Medical devices
Remove any lines or devices that are no longer required.
Avoid positioning the individual on medical devices, where possible (100).
Relocate medical devices away from pressure loading surfaces if possible. For example, place electrocardiogram (EKG/ECG) leads on the individual’s back (35) and rotate clamps/locks on tubing so they are not underneath the individual.
Use medical devices according to manufacturer’s instructions. For example, some ET fixation devices are not approved for use in the prone position.
ET tube securement devices may create additional pressure in prone position. Consider taping ET tube in place rather than using a securement device designed for safety in supine position (107).
Consider repositioning the ET tube from side-side. Validate the insertion depth is maintained when repositioning the ET tube (103, 107).
Secure tubes and devices away from the skin, regularly evaluate and manage tubes and other medical devices and consider using preventive dressings under devices (35, 99, 103).
Supporting Information
Prone positioning is most often used in critical care settings for management of medical conditions, (e.g., severe acute respiratory distress syndrome (97)). Prone position promotes gas exchange and improves lung function, reducing the requirement for ventilator support (98, 99). In these situations, the ability to implement major repositioning may be limited and there is an increased risk of PI occurrence on the anterior surface of the body (100). The use of medical devices due to the individual’s clinical condition also contributes to PI risk in the prone position. Small, incremental shifts (micromovements) may be the only opportunity to slightly offload areas at risk.
Resources
Prone position pressure points
Swimming/freestyle position
Strategies to Optimize Repositioning Implementation
Strategies to optimize implementation of repositioning may include:
Providing education and instruction to individuals and their informal carers to promote optimal self-repositioning frequency and techniques
Mechanisms to prompt awareness and performance of repositioning
Technology to indicate if repositioning is required based on the individual’s bed mobility, activity or increasing interface pressure
Technology to evaluate the effectiveness of repositioning in achieving off loading of pressure
These interventions are frequently used as a part of a bundled implementation strategy that uses multiple interventions to reduce PI occurrence.
More information
Good Practice Statement
R13: It is good practice to provide education to the individual and their informal carers on:
the rationale for repositioning,
its significance in preventing pressure injuries, and
strategies to safely and regularly implement repositioning.
Clinical question: What are general considerations for promoting implementation of repositioning for individuals at risk of pressure injuries?
Implementation considerations
Provide education to the individual and their informal carers on the rationale for repositioning and its significance in preventing PIs. This understanding can encourage active self-management and participation in the care process (18, 30, 48), foster a collaborative approach to care and safety (16, 48), and may increase adherence to repositioning schedules.
Provide carers with individualized education and skills in repositioning and regularly evaluate their manual handling capabilities (48).
For individuals who are non-adherent to repositioning, explore and address potential reasons (48) (e.g., cognition, competence, pain, post traumatic stress disorder, etc.). Facilitate access to education, resources, equipment and referral to appropriate health professionals (e.g., occupational therapist, physiotherapist, physical therapist, psychology services, etc.).
Additional implementation considerations for special populations
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Educate individuals with spinal cord injury (SCI) on repositioning during their initial rehabilitation period and regularly thereafter to reinforce self-management and adherence to repositioning over time.(18, 48, 109, 111).
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Pressure injury prevention is an opportunity for informal carers to be involved in end-of-life care. Provide carers with individualized education and skills in repositioning, particularly if the individual is receiving home-based care.
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Consider referral to allied health services (e.g., physiotherapy, physical therapy, and occupational therapy) for advice and education on repositioning, and assistance in accessing and selecting repositioning equipment.
Supporting Information
The Guideline Governance Group have identified consumer education interventions, including components of PI education interventions that are effective in achieving increased knowledge and behavior change, as a topic for future exploration as a clinical question. However, until a full exploration is undertaken, the Guideline Governance Group have made a Good Practice Statement to reinforce best practice because education and consumer engagement is such a significant component of addressing repositioning needs. Preliminary evidence indicates that education for all individuals at risk of PI is a significant component in successful implementation of PI prevention (108). Education is particularly important for individuals with conditions that place them at lifetime increased risk of PIs (e.g., SCI and other neurological conditions) as it facilitates self-management (109) .However, education is also important for people at short-term PI risk (e.g., following surgery) as it enables individuals to actively engage in their own care and work with clinical staff to prevent PIs (110).
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R14: Good Practice Statement
It is good practice to implement repositioning reminder strategies to promote adherence to repositioning regimens.
Clinical question: Are repositioning reminder strategies effective in promoting adherence to repositioning regimens?
Implementation considerations
Remind individuals who are independent in mobility to mobilize regularly (118). Consider engaging the assistance of non-clinical staff and informal carers to remind more independent individuals to self-reposition.
Consider using verbal cues, visual reminders (e.g. posters or turn clocks) (116, 117) or facility-wide audio cues (113, 114, 115) to remind the care team that repositioning is required. These systems can also be used to prompt self-mobile individuals and informal carers (33, 113, 119).
At the organizational level, electronic medical record systems can be used to integrate reminders for repositioning and other PI preventive care (30).
Additional implementation considerations for special populations
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Educate individuals in the community to implement reminder strategies to promote regular repositioning (e.g., alarm clocks, wearable technology and smart apps) (120).
Encourage self-repositioning by integrating repositioning into the individual’s daily routine where possible, for example encouraging incidental movement or natural breaks in activities (18).
Supporting Information
Repositioning regimens have been shown to have low rates of staff adherence (62, 112). Various types of reminder systems to prompt self-repositioning individuals, informal carers and health professionals to perform repositioning have been used to improve adherence. Reminder systems reported in the literature, including audio cues (113, 114, 115) and visual cues at the bedside (116, 117), have been associated with reduced PI occurrence (113) and improved adherence to repositioning (114, 115, 117).
Some technologies are also used to provide a visual and/or sound alert to prompt repositioning. These technologies are addressed in additional clinical questions. The use of movement sensors is addressed below, and clinical questions regarding the use of interface mapping systems are currently being investigated by the Guideline Governance Group.
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R15: Recommendation
We suggest that a sensor system that monitors the individual’s movement could be used to assist in evaluating repositioning needs for individuals at risk of pressure injuries when resources permit.
Conditional recommendation; Very low certainty of evidence
Clinical question: Should a sensor system that measures the individual’s movement be used to inform the frequency of repositioning versus not using a movement sensor system to prevent PI occurrence in individuals at risk?
Implementation considerations
Sensor devices (i.e., movement sensors) should complement rather than replace clinical judgement and existing protocols and preventive strategies (e.g. risk and skin assessment, pressure redistribution full body support surfaces and regular repositioning).
Regularly inspect the individual’s extremities, including the head/ears, elbows and heels when using movement sensors. These technologies may not adequately indicate whether pressure has been offloaded at these vulnerable areas (24, 123).
Consider using movement sensors to evaluate the individual’s self-positioning capabilities to inform the development of an individualized repositioning regimen (46, 124, 125). However, be aware that the movement sensor may not accurately detect the individual’s episodic and/or small changes in position, nor evaluate the technique used to self-repositioning (e.g., whether it increases shear forces).
Consider engaging local champions to educate staff on using the cues provided by movement sensors and to encourage implementation of repositioning regimens (121, 122).
Locate monitors at appropriate places within the facility to maximize staff engagement with visual feedback data (122).
Ensure adequate staff are available to respond to sensor cues for repositioning.
Evidence Summary
The meta-analysis included three studies (112, 121, 122) comparing the use of a sensor placed on the individual’s body to measure the frequency of movement* versus no system. The meta-analysis showed that using a movement sensor was associated with a non-significant lower rate of PI occurrence (0.7% versus 6.9%, RR 0.15, 95% CI 0.02 to 1.08, p = 0.06, relative effect of 58 fewer PIs per 1,000 individuals treated [from 67 fewer to 5 more]). There is very little confidence that this effect estimate represents a true effect. The evidence was downgraded due to risk of bias, inconsistency, indirectness and imprecision. The studies were conducted in critical care (112) and aged care (121, 122) settings. Using a decision analytic model to simulate expected costs and outcomes, the patient wearable sensor was found to be cost-saving. Modelling from critical care settings in the US assumed better clinical outcomes (77% reduction in HAPIs) compared to standard care and an expected cost savings of USD 6,621 per patient over a one-year period. A 77% reduction in HAPIs may not be realistic in all settings. Regardless of simulated cost savings, this might not be economically feasible to implement in some clinical (121) and geographic settings. The Guideline Governance Group considered the feasibility of implementing movement sensors was variable based on issues reported in the evidence (e.g., individuals with cognitive impairment removing the sensor, having sufficient monitors in the health service for staff to view the sensor data (122), etc.). Access is likely to be limited in many clinical and geographic settings.
* All studies investigated the same frequency of movement sensor system, as detailed in the data extraction tables. In all the studies, the sensor was programmed with a scheduled repositioning frequency, based on which a visual cue was delivered to a monitor indicating to care staff whether the person was due to be repositioned. If the sensor detected sufficient self-repositioning had occurred, the duration before the visual cue was displayed was extended accordingly by the system.
Data tables (Downloads)
Process document (includes meta-analysis)
Data extraction tables (coming soon)
Full evidence discussion (coming soon)
Certainty of Evidence
| Certainty assessment | No of patients | Effect | Certainty |
Importance |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
No of studies |
Study design |
Risk of bias |
Inconsistency |
Indirectness |
Imprecision |
Other considerations |
Movement sensor |
No movement sensor |
Relative (95% CI) |
Absolute (95% CI) |
||
| 3 | randomized and non-randomized trials | Very Serious [a] |
Very serious [b] |
Not serious |
Very serious [c] | none | 6/857 (0.7%) |
87/1268 (6.9%) |
RR 0.15 (0.02 to 1.08) |
58 fewer per 1,000 (from 67 fewer to 5 more) |
Very Low |
CRITICAL |
[a] Moderate risk of bias in all studies
[b] I2 = 70%
[c] CI crosses the threshold for no effect
Evidence to Decision Framework
Problem:
Desirable Effects:
Undesirable Effects:
Certainty of Evidence:
Values:
Balance of Effects:
Resources Required:
Certainty of Evidence of Required Resources:
Summary of Judgements
Cost Effectiveness:
Inequity:
Acceptability:
Feasibility:
Yes
Large
Trivial
Very low
No important uncertainty or variability
Probably favors the intervention
Moderate costs
No included studies
Varies
Probably increased
Varies
Probably yes
Mobilization
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R16: Recommendation
We suggest that an early mobilization program be implemented in individuals at risk for pressure injuries based on the individual’s activity tolerance.
Conditional recommendation; Very low certainty of evidence
Clinical question: Should an early mobilization intervention versus delayed mobilization or standard care be used to prevent PI occurrence in individuals at risk?
Implementation considerations
Evaluate the safety of individuals as they commence and increase mobilization.
Progress individuals on bedrest to sitting and ambulation as rapidly as they can tolerate to offset the clinical deterioration associated with prolonged bedrest.
Provide adequate supervision. This might require an increase in staffing (118, 129, 135).
Use appropriate mobilization techniques to avoid increased shear forces.
Facilitate access to appropriate mobility aids and footwear.
Evidence summary
The meta-analysis included six RCTs (126, 127, 128) and six non-randomized comparative studies (129, 130, 131, 132, 133, 134) that compared early mobilization versus delayed mobilization for individuals at risk of PIs. The meta-analysis showed that an early mobilization protocol was associated with a significantly lower rate of PI occurrence (5.2% versus 6.9%, RR 0.75, 95% CI 0.61 to 0.92, p=0.009, relative effect of 17 fewer PIs per 1,000 individuals treated [from 27 fewer to 5 fewer]. There is very little confidence that this effect estimate represents a true effect.
The evidence was downgraded due to a high risk of bias (127, 134), indirectness and inconsistency. Several other desirable effects have been reported, including prevention of intensive care-related weakness (RR 0.49, 95% CI 0.32 to 0.74), prevention of deep vein thrombosis (RR 0.16, 95% CI 0.06 to 0.47) and prevention of pneumonia (RR 0.39, 95% CI 0.16 to 0.98) (127, 134). The overall number of adverse events, including falls, injuries, cardiac or respiratory events, self-extubation, or line disconnections were not different between early mobilization programs and usual care (134). However, there was an increase in the number of falls associated with early mobilization (3.3% versus 1.9%, odds ratio [OR] 1.74, 95% CI 0.38 to 8.08) (134).
No formal cost effectiveness analyses were reported. A meta-analysis (127) reported that early mobilization is associated with a reduced hospital length of stay (cost saving) and a second study (134) reported that early mobilization requires an increase in care staff time (cost). The literature (134) and the Panel Group provided expert advice that early mobilization may not be appropriate in the context of hemodynamic or pulmonary instability.
Data tables (Downloads)
Process document (includes meta-analysis)
Data extraction tables (coming soon)
Full evidence discussion (coming soon)
Certainty of Evidence
| Certainty assessment | No of patients | Effect | Certainty |
Importance |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
No of studies |
Study design |
Risk of bias |
Inconsistency |
Indirectness |
Imprecision |
Other considerations |
early mobilization intervention |
delayed mobilization intervention |
Relative (95% CI) |
Absolute (95% CI) |
||
| 12 | RCTs and randomized trials | Serious [a] | Serious [b] | Serious[c] | Not serious |
none | 144/2764 (5.2%) |
191/2788 (6.9%) |
RR 0.75 (0.61 to 0.92) |
17 fewer per 1,000 (from 27 fewer to 5 fewer) |
Very Low |
CRITICAL |
[a] Downgraded for almost all the studies were at high risk of bias in at least one category
[b] Downgraded for I2=60%
[c] Downgraded for wide variation in “mobilization” interventions including ambulating, wheelchair use, or sitting out of bed exercises. exercises. In many studies the intervention is not described.
Evidence to Decision Framework
Problem:
Desirable Effects:
Undesirable Effects:
Certainty of Evidence:
Values:
Balance of Effects:
Resources Required:
Certainty of Evidence of Required Resources:
Summary of Judgements
Cost Effectiveness:
Inequity:
Acceptability:
Feasibility:
Yes
Moderate
Trivial
Very low
No important uncertainty or variability
Probably favors the intervention
Moderate costs
Very low
Favors the intervention
Probably no impact
Done know
Varies
Resources
Typical early mobilization protocol (132, 134, 135)
Individualize exercise based on capability
Perform each stage 2-3 times/day as tolerated
Progress to next stage as tolerated and safe
Staged early mobilization:
Passive range of movement exercises
Dangling limbs over the side of the bed
Sitting out of bed
Standing with or without support/aids
Walking with or without support/aids
Tools to support early mobilization protocol development and implementation are available at:
Repositioning in the Operating Room
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The repositioning recommendations and good practice statements presented above generally apply to individuals in the operating room, where they are possible to implement in that context.
It is usually not possible to significantly reduce the length of time that the skin and tissues are subjected to pressure during a surgical procedure. Positioning options can be limited given the need to ensure a stable, visible and accessible operative field for the surgical procedure. The ability to reposition the individual is also limited, because the overall surgical position must usually be maintained to ensure procedural access, and movement may not be possible while the surgical procedure is being performed. Additionally, other adverse events from positioning in the operating room (e.g., peripheral nerve injury, musculoskeletal injury and eye injury) also require management (136).
Implementation considerations
Follow local policies and standard safety practices when positioning an individual for surgery (137).
The initial position the individual is placed in should distribute pressure over the largest body surface area possible, reducing pressure on pressure points as much as possible. Be familiar with pressure points that are unique to the intraoperative position, which will require attention (see Table 1).
Be aware of the intended surgical position, the equipment that will be used and the likely points of contact with the individual. Having knowledge of the intended procedures and equipment allows the selection of appropriate full body support surfaces and protective strategies in place.
Position the individual preoperatively and postoperatively in a different position than that used during surgery (138). When possible, wait until the individual has been anaesthetized before positioning them in the surgical position, then reposition immediately following the surgical procedure. This will minimize the duration of pressure exposure from the surgical position.
Interface pressure mapping might be used in the operating room to guide effectiveness of initial positioning (139, 140).
Offload the heels (See the Heel Pressure Injuries section of this guideline).
Consider using preventive dressings (See the Preventive Skin Care section of this guideline).
Use repositioning devices with pressure redistribution properties (i.e., ability to immerse and envelop) to assist in positioning.
Evaluate individuals who enter the perioperative setting with medical devices in situ to determine how positioning and instrumentation may impact their pressure injury risk. Do not position the individual directly on a medical device unless it cannot be avoided.
Plan to reposition the individual during surgery where possible, especially for longer procedures (i.e. longer than 2 hours). Repositioning can be determined by the type of surgery, the surgical position, the duration of the surgery and the individual’s clinical condition. IP mapping is another option to identify the need to reposition.(139, 140) At commencement of the surgery, determine when during the procedure the individual could be repositioned so the team is prepared to take a short procedural break. This may be done using small shifts of body weight (micromovements) (71, 72) and/or repositioning the extremities if the surgery is of longer duration.
Document the position in which the individual was placed during surgery, including any straps or securements.
Key points for positioning in the operating room
Select an initial position based on surgical requirements
Use pressure redistribution full body support surfaces and positioning devices
Know and protect the vulnerable pressure points for the selected position
Distribute pressure over the largest body area possible
Offload the heels
Pay attention to medical devices
Use a different position prior to and following surgery
Table: Pressure points of concern in different surgical positions
Position and pressure points of specific concern
Supine
Occiput
Shoulder blade (scapula)
Elbows
Sacrum
Coccyx
Buttocks
Heels
Trendelenburg
As per supine position
PLUS:
Shoulders and scapula
Reverse Trendelenburg
As per supine position
PLUS:
Soles of the feet
Shoulders and scapula
Sitting/modified sitting
As per supine position BUT ESPECIALLY:
Buttocks
Ischium
Coccyx
Sacrum
Back of knees
Heels
Lithotomy
As per supine position BUT ESPECIALLY:
Sacrum
Coccyx
Back of knees
Prone
Forehead
Chin
Cheeks
Shoulder (anterior)
Elbow
Chest (breasts)
Genitalia
Anterior pelvic bones (iliac crests & ischium)
Knees (patella)
Dorsal feet and toes
Nose (if positioned incorrectly)
Lateral
Lateral face and ear
Elbow
Shoulder
Axilla
Superior and dependent arms
Ribs
Hips (trochanter)
Malleoli
Bent lower leg
Knees
Ankles
Kneeling position (knee/chest position)
As per prone position BUT ESPECIALLY:
Face and ear
Anterior chest
Elbows
Anterior pelvic bones (iliac crests and ischium)
Knees
Anterior tibia
Anterior ankle
Freestyle/swimming position
(Note: “Hidden” pressure points on the individual’s underside are illustrated with dotted outlines)
As per prone position BUT ESPECIALLY:
Lateral face and ear
Illustrative position noting pressure points
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