Preventing Heel Pressure Injuries

The heel and anklebone are the second and fifth most common sites for pressure injury development.1 Incorporating a heel pressure injury prevention protocol—along with early, aggressive implementation of pressure-reducing and pressure-relieving devices—has been proven to reduce the rate of heel pressure injuries.2

The National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP) guidelines recommend ensuring “that the heels are free of the surface of the bed… Heel-protection devices should elevate the heel completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon.”3

Implementing a protocol that keeps the heel offloaded in patients at risk for heel pressure injuries is crucial. Heel pressure injuries often take time to become visible—the NPUAP/EPUAP states that “the time between development of a pressure ulcer and the point when the ulcer becomes visible at the skin varies between several hours to three to five days.”3 This means that it is important to incorporate heel pressure-relieving devices before an ulcer is present, as it may have latent symptoms.

REFERENCE: 1. Amlung SR, Miller WL, Bosley LM, Adv Sking Wound Care. Nov/Dec 2001; 14(6):297-301. 2. Walsh J, et al., Keeping Heels Intact: Evaluation of a Protocol for Prevention of Facility-Acquired Heel Pressure Ulcers. Presented at the Symposium on Advanced Wound Care, San Antonio, TX. Apr. 2006. 3. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington DC National Pressure Ulcer Advisory Panel; 2009.

Preventing Heel Pressure Ulcers and Plantar Flexion Contractures in High Risk Sedated Patients
Meyers T
J Wound Ostomy Continence Nurs. 2010 Jul-Aug;37(4):372-8.
View abstract – PubMed 

Practice Recommendations for Preventing Heel Pressure Ulcers
Evonne Fowler, Suzy Scott-Williams and James B. McGuire
Ostomy Wound Management
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Saving heels in critically ill patients
Cuddigan J, Ayello E, Black J
World Council of Enterostomal Therapists Journal
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Evaluation of a protocol for prevention of facility-acquired heel pressure ulcers
Walsh JS, Plonczynski DJ
Journal of Wound, Ostomy & Continence Nursing. March/April 2007; 34(2):178-183.
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Keeping heels intact: using a nursing professional practice model can improve outcomes
Walsh JS
Advance for Nurses. 2006 Nov 6;8(24):25.
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Risk factors associated with having a pressure ulcer: a secondary data analysis
Maklebust J, Magnan MA
Advances in Wound Care. Nov 1994;7(6):25,27-8,31-4 passim.
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Four Years of Heel Pressure Ulcer Prevention
Hanna-Bull D, RN, BScN, MN; Stephen Martin MD FRCS(c); Maclean J, OT Reg(Ont)
Poster presented at the 19th Annual CAWC Conference; November 7-10, 2013, Vancouver, Canada
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A Successful Quality Improvement Initiative Results in Reduction of Hospital Acquired Heel and Sacral Pressure Ulcers
Bell K, MS, RN, CCRN, CCNS; Clinical Nurse Specialist, CCU/ICU
Poster presented at the 27th Annual Symposium on Advanced Wound Care Spring/Wound Healing Society, April 23-27, 2014 in Orlando, FL
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Evidence-Based Quality Improvement Initiative and Nursing/Physical Therapy Collaboration Results in Decreased Hospital-Acquired Heel Pressure Ulcers
Dyckman F, MSN, BSN, PHN, APRN-CNS, CWOCN; Love C, PT, DPT
Presented at The Symposium on Advanced Wound Care, October 16–18, 2014; Las Vegas, NV
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Limited Mobility and the Foot: Plantar Flexion Contractures, Heel and Malleoli Pressure Ulcers, Peroneal Nerve Damage  How Can We Prevent Them? What Happens If We Dont?
Loehne H, PT, DPT, CWS, FACCWS
Poster presented at the 26th Annual Symposium on Advanced Wound Care (SAWC); May 1-5, 2013
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Never Events: Can The Congressional Mandate Be Met?
Lyder C
Poster Presented at the Institute for Health Care Improvement (IHI), Orlando, FL December 6-8, 2010
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Pressure Ulcer Prevention Protocols and Evidence-Based Interventions Reduce Pressure Ulcers at Sacrum and Heel
Heighton R, BScOT Reg NS; Interim Director of Rehabilitation Services, Guysborough Antigonish Strait Health Authority
Poster presented at the CAWC and CAET 20th Annual Conference, Toronto, Ontario, Canada; October 30, 2014-November 2, 2014
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Evidence-Based Heel Pressure Ulcer Prevention Guideline Development for Saskatoon Region
Flahr D, RN, BSN, MSc (WHTR) CMSN(C), Davis D, BSc. O.T. Reg. (Sask.), Sheppard S, PhD, BScPT
Posted presented at the 18th Annual Conference of the Canadian Association of Wound Care, November 8-11, 2012, London, Ontario
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Successful Quality Improvement Initiative Results in 95% Decrease of Facility-Acquired Heel Pressure Ulcers
Witkowski K, Reg.N., BScN, ET – Nurse Clinician Enterostomal Therapy – Skin/Wound & Ostomy
Poster presented at the 18th Annual Conference of the Canadian Association of Wound Care, November 8-11, 2012, London, Ontario
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Human Cadaver Testing to Determine the Reliability of Heel Boot Positioning or Grip of Eight Commercially Available Pressure Relieving Heel Protector Boots
Bill B, Pedersen J, and Call E, MS RSM (NRM)
Poster presented at the Poster presented at the 25th Annual Symposium on Advanced Wound Care (SAWC); April 19-22, 2012
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Heel Pressure Ulcer Prevention: A Comparative Effective Evaluation
McGovern J, DiPerri J
Poster presented at the 25th Annual SAWC Conference April 19-22 2012
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Heel Pressure Ulcer Prevention – The Continued Journey within an Acute Care Facility
Hanna-Bull D, RN, BScN, MN
Poster presented at the WOCN conference, New Orleans, LA, June 2011
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Zero Tolerance: Reduction of Nosocomial Heel Pressure Ulcers
Morgan C, McNamara M
Poster presented at the NPUAP Biennial Conference, Las Vegas, NV, February 2011
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Taking on the Challenge: Developing a Mulitdisciplinary Decision Tree for Heel Protection in the ICU
Van Houten C, BSN, RN, CWON, Freeland N, MS, RN, CCRN, Sacco T, MS, RN, CCRN, Odden H, PT, DPT, Brown R, MS, CPO, FAAOP
Poster presented at the NPUAP Biennial Conference, Las Vegas, NV, February 2011
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Compliance is Key: Successes in Reducing Wound Size in Complex, Chronic Heel Pressure Ulcers by Offloading Heels with an Engineered Heel Protector
Liden B, DPM, Berger Hospital Wound Care Clinic, Circleville, OH
Poster presented at the NPUAP Biennial Conference, Las Vegas, NV, February 2011
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Successes in Reducing Heel Pressure Ulcer Wound Size by Offloading Heels with an Engineered Off-loading Heel Protector
Liden B, DPM, Berger Hospital Wound Care Clinic, Circleville, OH
Poster presented at APMA the Conference, July 15-18 2010
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Heel Pressure Reduction through use of Assistive Boots
Leitkam S, Bush TR, Linden B, Friederichs K, Deland T
Poster presented at APMA the Conference, July 15-18 2010
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Under Pressure: Offloading and Protecting Heels
Lucky D, RN, MSN, WCC
Poster presented at the 2010 NADONA/LTC National Conference, June 12 -16, 2010
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Pressure Ulcers in Adults: Prediction and prevention
AHRQ (formerly AHCPR) Clinical Practice Guideline Number 3, AHCPR Pub. No. 92-0047: May 1992.
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Pressure Ulcer Prevention and Treatment
National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009.
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Pressure Ulcer Prevention
Association of Perioperative Registered Nurses (AORN) Standards Recommended Practices and Guidelines
“Use devices that eliminate or redistribute pressure” to prevent perioperative* heel ulcers.
*Perioperative defined as a pressure-related deep tissue injury under intact skin that presents within the first 5 days following surgical procedures.
View AORN website

IHI 5 Million Lives Campaign targets pressure ulcer prevention 
The 5 Million Lives Campaign is an initiative to protect patients from five million incidents of medical harm over the next two years (December 2006 – December 2008).
View campaign highlights
View campaign materials for pressure ulcer prevention

Preventing Heel Pressure Ulcers and Plantar Flexion Contractures in High Risk Sedated Patients
Meyers T
J Wound Ostomy Continence Nurs. 2010 Jul-Aug;37(4):372-8.
View abstract – PubMed 

Evaluation of a protocol for prevention of facility-acquired heel pressure ulcers
Walsh JS, Plonczynski DJ
Journal of Wound, Ostomy & Continence Nursing. March/April 2007; 34(2):178-183.
View abstract 
View full text (Login required) 
Download article (.pdf*) (Login required) 

Successful Heel Pressure Ulcer Prevention Program in a Long-term Care Setting
Lyman V
Journal of Wound, Ostomy and Continence Nursing: November/December 2009 – Volume 36 – Issue 6 – p 616-621
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A comparison of two pressure-relieving devices on the prevention of heel pressure ulcers
Tymec AC, Pieper B, Vollman K.
Adv Wound Care. 1997 Mar-Apr;10(2):9.
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National prevalence and incidence study: 6-year sequential acute care data
Whittington KT, Briones R
Advances in Skin & Wound Care. Nov/Dec 2004;17(9):490-4
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The 1999 national pressure ulcer prevalence survey: a benchmarking approach
Amlung SR, Miller WL, Bosley LM
Advances in Skin & Wound Care. Nov/Dec 2001;14(6):297-301.
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Physiology and prevention of heel ulcers: the state of science
Wong VK, Stotts, NA
Journal of Wound, Ostomy, & Continence Nursing. Jul 2003;30(4):191-8.
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Pressure-reducing effects of heel protectors
De Keyser G, Dejaeger E, De Meyst H, Eders GC
Advances in Wound Care. Jul 1994;7(4):30-2,34.
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Risk factors for pressure ulcers 
Wounds1.com, WOUND NEWS: Wound Technology, Jan 22, 2002.
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Research comparing three heel ulcer-prevention devices 
Gilcreast DM, Warren JB, Yoder LH, Clark JJ, Wilson JA, Mays MZ
Journal of Wound, Ostomy, and Continence Nursing. Mar/Apr 2005;32(2):112-20.
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Preventing heel breakdown
Graff MK, Bryant J, Beinlich N
Orthopaedic Nursing. Sep/Oct 2000;19(5):63-9.
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Use of support surfaces in the ICU
Coats-Bennett U
Critical Care Nursing Quarterly. May 2002;25(1):22-32.
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Diabetic foot wounds: pathogenesis and management
Levin M
Advances in Wound Care. Mar/Apr 1997;10(2):24-30.
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Intervention with a new heel protection device and silver alginate dressing to prevent amputation of the leg due to stage IV ulcer of the heel and malleolus
Garrett D
Salem Village Nursing and Rehabilitation Center, Joliet, IL
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Pressure mapping Comparison of unprotected heels on a hospital bed vs. heels positioned in the Prevalon® Pressure Relieving Heel Protector.
Bush T, Ph.D.
Michigan State University Biomechanical Design and Research Laboratory, September 2009
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