Patient Safety

Pressure Injury Prevention

Turning schedules, smart surfaces, and the return of a very old problem.

9 min readUpdated February 8, 20262 topics

State of practice

Prevention combines risk assessment on admission, scheduled repositioning, appropriate support surfaces, and skin inspection at handoff. Sensor-equipped mattresses that prompt repositioning are increasingly common; the evidence supports them as a nudge, not a replacement for the schedule.

NPIAP staging

The National Pressure Injury Advisory Panel (NPIAP, formerly NPUAP) stages injuries:

StageDescription
Stage 1Non-blanchable erythema of intact skin
Stage 2Partial-thickness skin loss with exposed dermis
Stage 3Full-thickness skin loss; subcutaneous tissue visible
Stage 4Full-thickness loss with exposed muscle, tendon, bone
UnstageableBase obscured by slough or eschar
Deep tissue injuryPersistent non-blanchable deep red / maroon discoloration

The prevention bundle

  1. Braden Scale on admission and at defined intervals.
  2. Repositioning schedule (commonly Q2H, tailored to surface and patient).
  3. Support-surface matched to risk (foam → alternating pressure → low-air-loss).
  4. Skin inspection at each handoff, documented.
  5. Nutrition and hydration review; protein supplementation as indicated.
  6. Moisture management — incontinence care and skin barriers.

References

  • NPIAP/EPUAP/PPPIA Clinical Practice Guideline (2019).
  • CMS Hospital-Acquired Conditions — Stage 3 and 4 pressure injuries are non-payable HACs.
  • AHRQ Preventing Pressure Ulcers in Hospitals toolkit.

References & further reading

  1. 1NPIAP/EPUAP/PPPIA — Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline (2019)
  2. 2AHRQ — Preventing Pressure Ulcers in Hospitals
  3. 3CMS Hospital-Acquired Conditions list

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