Preventing Sacral Pressure Injuries

Turning and repositioning protocols—combined with implementation of pressure-reducing and pressure-relieving devices—are crucial to addressing the risk of sacral pressure injuries.

When implementing protocols, it is important to take into consideration the four main risk factors for sacral pressure injuries: pressure, friction, shear, and moisture.1 The European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP) guidelines recommend that repositioning should be undertaken to reduce the duration and magnitude over vulnerable areas of the body while avoiding subjecting the skin to pressure and shear forces and using an alternating 30-degree tilted side-lying position.2 The Wound Ostomy and Continence Nurses Society (WOCN) recommends addressing moisture with underpads that are absorbent to wick incontinence moisture away from the skin.3

Another important factor to consider when developing a turning and repositioning protocol is staff safety. Turning and repositioning puts staff at risk for musculoskeletal disorders (MSDs).4 In fact, one survey found that 89% of clinicians said that they or a co-worker have experienced a back, shoulder, or wrist injury due to turning or boosting a patient.5

REFERENCES: 1. Clinical Practice Guidelines: the use of pressure-relieving devices (beds, mattresses and overlays) for the prevention of pressure ulcers in primary and secondary care. Royal College of Nursing, Oct 2003. 2. 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, pp16-18. 3. Wound Ostomy Continence Nurses Society, Guideline for prevention and management of pressure ulcers, 2010, pp14-15, 21. 4. Occupational Safety and Health Administration (OSHA), Guidelines for nursing homes: ergonomics for the prevention of musculoskeletal disorders, 2009. 5. Survey conducted by Sage Products LLC, data on file.

New Turning and Positioning System Facilitates Patient Repositioning to Aid in Pressure Ulcer Healing
Caryn Baldwin, RN; Wound Care Coordinator
Kindred Healthcare, October 2010
Download case study (PDF)

Intervention With a New Turning and Positioning System Promotes Recommended Pressure Ulcer Care
Diane Zeek, MS, APN, NP-C, CWOCN and Renee Malandrino, APN, CWOCN
Northwest Community Hospital, Arlington Heights, IL
Download case study (PDF)

Pressure Injury (PI) Reduction Initiative in Hemodynamically Unstable Patients
Roxy Lupien MSN, RN, CNL, CWOCN, CFCN and Rados Stoddard BSN, RN, CWON, CFCN
Poster presented at the 2017 Biennial NPUAP Conference; New Orleans, LA March 9-10
Download poster (PDF)
Protecting Skin While Saving Butts, Backs and Bucks
Susie Lee BSN, RN, WCC
Poster presented at the 2017 Biennial NPUAP Conference; New Orleans, LA March 9-10
Download poster (PDF)
Quality Improvement Intervention with Patient Repositioning Device Results in HAPU Prevention and Cost Savings
Melinda Edger, RN, BSN, CWOCN (clinical nurse 4); Sheryl Bailey, RN, BSN, CWOCN
Presented at the 27th Annual Symposium on Advanced Wound Care Spring/Wound Healing Society, April 23-27, 2014 in Orlando, FL
Download poster (PDF)
A Comparative Study of Two Methods for Turning and Positioning and the Effect on Pressure Ulcer Development
Powers J
Presented at the 27th Annual Symposium on Advances in Skin and Wound Care: October 20-23 2012
Download poster (PDF)
Safe Patient Handling Initiative Results in Reduction in Injuries and Improved Patient Outcomes for Pressure Ulcer Prevention
Heather Way RN, BSN, MSN, Critical Care Clinical Specialist
Presented at the 2014 Safe Patient Handling East Conference on March 27, 2014
Download poster (PDF)
Use of a Repositioning System in Postoperative Cardiovascular ICU Patients Results in a 63% Reduction in Facility-Acquired Sacral Pressure Ulcers
Flockhart L, Fielding C
Presented as the 17th Annual Wound Care Conference November 3-6, 2011
Download poster (PDF)
A Successful Quality Improvement Initiative Results in Reduction of Hospital Acquired Heel and Sacral Pressure Ulcers
Kathryn Bell, MS, RN, CCRN, CCNS; Clinical Nurse Specialist, CCU/ICU
Presented at the 27th Annual Symposium on Advanced Wound Care Spring/Wound Healing Society, April 23-27, 2014 in Orlando, FL
Download poster (PDF)
Evaluating the Effectiveness of a Patient Repositioning System for Preventing Workplace Injury
Debbie Burris, RN BSc.N, Director of Clinical Practice & Transformation
Presented at the 19th Annual CAWC Conference; November 7-10, 2013, Vancouver, Canada
Download poster (PDF)
Combination of Safe Patient Handling and Use of Ergonomic Repositioning Device Reduces Hospital Acquired Pressure Ulcers and Employee Injury Claims
Molly Persby, RN, C, MHSA, Divisional Vice President, Clinical and Quality Services, Select Medical
Poster presented at the ALTHA’s 2012 National Clinical Conference, Dallas TX, May 16-18, 2012
Download poster (PDF)
Save the Butts: Preventing Sacral Pressure Ulcers by Utilizing an Assistive Device to Turn and Reposition Critically Ill Patients
Hall K, DNP, RN, GCNS-BC, CWCN-AP, Clinical Nurse Specialist
Poster presented at the Poster presented at the 25th Annual Symposium on Advanced Wound Care (SAWC); April 19-22, 2012
Download poster (PDF)
Reduction In Unit-Acquired Pressure Ulcers
Leonida Lacdao, RN, Nurse Manager and the 6E Nursing Staff
Poster presented at the Association for Professionals in Infection Control & Epidemiology (APIC), San Antonio, TX, June 2012
Download poster (PDF)
In vitro Measurement of the Impact of Transfer and Positioning Devices on Microclimate when Left in Place Following Use
Justin Pedersen MS; Brian Bill; and Evan Call MS RSM (NRM)
Poster presented at the 26th Annual Symposium on Advanced Wound Care (SAWC); May 1-5, 2013
Download poster (PDF)
Two Independent Case Studies Using a New Turn and Position Device
Zeek D., Malandrino R., Baldwin C
Poster presented at the 24th Annual Symposium on Advanced Wound Care and Wound Healing Society (SAWC/WHS); April 14-17, 2011
Download poster (PDF)
Download handout (PDF)

What the Experts Say – Preventing Pressure Ulcers: Turning & Positioning (PDF)
What the Experts Say – Turning & Repositioning: Potential for Staff Injury (PDF)

European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP)1
1.1 Repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body.
1.2 The use of repositioning as a prevention strategy must take into consideration the condition of the patient and the support surface in use.
3.2 Avoid subjecting the skin to pressure and shear forces.
3.6 Repositioning should be undertaken using the 30-degree tilted side-lying position (alternately, right side, back, left side)…
Wound Ostomy and Continence nurses Society (WOCN)2
III. Interventions: Prevention
    A. Reducing Risk of Developing Pressure Ulcers
  • Minimize friction and shear.
  • Use 30-degree side lying position (alternating from the right side, the back and left side) to prevent pressure, sliding and shear-related injury.
  • Minimize Pressure.
  • Schedule regular repositioning and turning for bed and chair bound individuals.
    B. Managing Incontinence
  • Select underpads…that are absorbent to wick incontinence
    moisture away from the skin.
    I. Education
  • Educate patients, caregivers, and health care providers involved in the continuum of care about prevention, treatment and factors contributing to recurrence of pressure ulcers. Areas to be addressed should include: … positioning and use of support surfaces.

 

Hartford Institute for Geriatric Nursing (HIGN)3

  • Use a 30-degree lateral side lying position; do not place client directly on their trochanter.
  • Protect high-risk areas such as elbows, heels, sacrum, back of head from friction injury.

 

Registered Nurses Association of Ontario (RNAO)4

    For individuals restricted to bed:
  • Reposition at least every 2 hours or sooner if at high risk.
  • A 30-degree turn to either side is recommended to avoid positioning directly on the trochanter.

Patient Turning and Repositioning: Current Methods & Challenges, a WOCN Perspective
72% of Wound Care Nurses Report Patients Frequently Move Out of Position After a Turn
Download (PDF)

Patient Turning and Repositioning: Current Methods & Challenges, a Critical Care Nurse Perspective
93% of Nurses Report Staff Injury Due to Turning or Boosting a Patient
Download (PDF)

Who Is Turning the Patients? A Survey Study
Voz, Anita BSN, CWCN; Williams, Carol BSN; Wilson, Marian MPH, RN-BC
Journal of Wound, Ostomy & Continence Nursing
View abstract