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Hill-Rom® Clinical Resource Center

Helping you implement evidence-based programs with connected technologies

Hill-Rom® Clinical Resource Center

Pressure Injury Management


  • Pressure Ulcer Risk in the Incontinent Patient
    Lachenbruch C | Journal of Wound, Ostomy & Continence Nursing | 2016

    This article is an analysis of incontinence and pressure ulcers from the International Pressure Ulcer Prevalence™ Survey. It concludes that incontinent patients had higher Braden Scale scores and higher overall and facility-acquired pressure ulcer prevalence. Incontinence was associated with an increased risk for all pressure ulcers, but especially full-thickness injuries.

  • Pressure Ulcer Risk Assessment and Prevention: Comparative Effectiveness
    Chou R, et al. | Agency for Healthcare Research and Quality | 2013

    Pressure ulcers are a relatively common occurrence across all care settings, resulting in significant health burdens. However, risk-assement scales and preventive interventions can decrease the incidence or severity of pressure ulcers. 

  • Comparison of Air-Fluidized Therapy With Other Support Surfaces Used to Treat Pressure Ulcers in Nursing Home Residents
    Ochs RF, et al. | Ostomy Wound Management | 2005

    This retrospective pressure ulcer prevention and treatment study compared healing rates for different support surfaces in nursing home residents. Support surface types were categorized into 3 groups: static overlays and replacement mattresses (1); low-air-loss beds, alternating pressure, and powered/non-powered overlays/mattresses (2); and air-fluidized beds (3). Mean healing rates were as follows: 5.2 cm2/wk (Group 3); 1.8 cm2/wk (Group 2); 1.5 cm2/wk (Group 1) (P=0.007 comparing Group 3 to 1 and 2). Mean healing rates were also significantly greater for stage III/IV ulcers on Group 3 surfaces. Groups 1 and 3 had fewer hospitalizations and ER visits compared to Group 2 (P=0.01).

  • Air-Fluidized Therapy: Physical Properties and Clinical Uses
    Annals of Plastic Surgery | 2010

    This review describes the benefits and drawbacks of air-fluidized therapy compared to other support types in terms of factors known to impact skin breakdown: interface pressure, shear, friction, heat, and moisture. The clinical benefits of air-fluidized therapy include faster pressure ulcer healing, decreased rate of hospitalization and ER visits for long-term care pressure ulcer patients, and decreased mortality and increased comfort for patients with burns and inhalation injury.

  • The Effect of Using a Low-Air-Loss Surface on the Skin Integrity of Obese Patients: Results of a Pilot Study
    Pemberton V, et al. | Ostomy Wound Management | 2009

    This study assesses the impact of a new low-air-loss, continuous lateral rotation therapy bed in 21 obese, bariatric acute care patients. During this pilot study, pressure ulcers decreased in size from an average 5.2 cm2 to 2.6 cm2, and no new pressure ulcers developed.

  • Microclimate Management: So Much More Than Just Airflow
    Lachenbruch C | 2017

    This whitepaper discusses factors impacting the skin microclimate and describes the ideal combination of airflow, temperature, and surface material for preventing skin breakdown.

  • Pressure Ulcer Incidence and Progression in Critically Ill Subjects: Influence of Low Air Loss Mattress Versus a Powered Air Pressure Redistribution Mattress
    Black J, et al. | Journal of Wound, Ostomy & Continence Nursing | 2012

    This study evaluated the change in existing pressure ulcers and incidence of new pressure ulcers in surgical ICU patients using a new low-air-loss, weight-based, microclimate management (LAL-MCM) system compared to the standard SICU bed with an integrated, powered air pressure redistribution (IP-AR) surface. Incidence of supine pressure ulcers was 0% in the LAL-MCM group and 18% in the IP-AR group (P=0.046), despite more comorbidities in the patients in the LAL-MCM group.

  • Role of Bed Design and Head-of-Bed Articulation on Patient Migration
    Davis K, et al | Journal of Nursing Care Quality | 2015

    Repositioning patients in bed puts both patients and caregivers at risk.  Patients experience shear and friction which are risk factors for pressure ulcers, while caregivers who are repositioning patients are at risk for lower back injuries.  This study examined the influence of hospital bed design on patient migration. Over 180 trials, Bed A (Hill-Rom® Progressa® bed system) showed 85-86% (p< 0.001) less patient migration and 34% less torso compression compared to current alternatives.  Three in four subjects preferred the Hill-Rom® Progressa® bed system. The author concludes that optimal bed design should reduce patient migration which may lead to clinically significant reductions in health risks to patients and caregivers.

  • The Demographics of Suspected Deep Tissue Injury in the United States: An Analysis of the International Pressure Ulcer Prevalence™ Survey 2006-2009
    VanGilder C, et al. | Advances in Skin & Wound Care | 2010

    This article reports data from the International Pressure Ulcer Prevalence™ survey 2006-2009 in patients with suspected deep tissue injury (sDTI). Overall and facility-acquired pressure ulcer prevalence was constant in 2006-2008 and decreased by about 1% in 2009 (P<0.001). The prevalence of pressure ulcers identified as sDTI increased to 9% of all observed ulcers in 2009, a 3-fold increase, while the proportion of stage I and II ulcers has decreased and stage III and IV ulcers remained constant. This increase may be due in part to education of staging definitions.

  • A Pilot Study of Pressure Ulcer Incidence and Healing of Pressure Ulcers Comparing Subjects Placed on the LAL-MCM Mattress Versus a Standard Bed SICU Mattress
    Black J, et al. | 2010

    This study evaluated the change in existing pressure ulcers and incidence of new pressure ulcers in surgical ICU patients using a new low-air-loss, weight-based, microclimate management (LAL-MCM) system compared to the standard SICU bed with an integrated, powered air pressure redistribution (IP-AR) surface. Incidence of supine pressure ulcers was 0% in the LAL-MCM group and 18% in the IP-AR group (P=0.046), despite more comorbidities in the patients in the LAL-MCM group.

  • The national cost of hospital-acquired pressure injuries in the United States
    Padula WV, Delarmente BA. | International Wound Journal


    Our objective was to estimate the US national cost burden of hospital‐acquired pressure injury (HAPI) using economic simulation methods. We created a Markov simulation to estimate costs for staged pressure injuries acquired during hospitalisation from the hospital perspective. The model analysed outcomes of hospitalised adults with acute illness in 1‐day cycles until all patients were terminated at the point of discharge or death. Simulations that developed a staged pressure injury after 4 days could advance from Stages 1 to 4 and accrue additional costs for Stages 3 and 4. We measured costs in 2016 US dollars representing the total cost of acute care attributable to HAPI incidence at the patient level and for the entire United States based on the previously reported epidemiology of pressure injury. US HAPI costs could exceed $26.8 billion. About 59% of these costs are disproportionately attributable to a small rate of Stages 3 and 4 full‐thickness wounds, which occupy clinician time and hospital resources. HAPIs remain a concern with regard to hospital quality in addition to being a major source of economic burden on the US health care system. Hospitals should invest more in quality improvement of early detection and care for pressure injury to avoid higher costs.

  • Relative contributions of interface pressure, shear stress, and temperature on ischemic-induced, skin-reactive hyperemia in healthy volunteers: a repeated measures laboratory study
    Lachenbruch C, Tzen YT, Brienza D, Karg PE, Lachenbruch PA | Ostomy Wound Manage | 2015


    Although the primary risk factors for pressure ulcer development - pressure, shear, skin temperature, moisture, and friction - have been identified for decades, the relative contribution of each to this risk remains unclear. To confirm the results of and expand upon earlier research into the relative contributions of interface pressures, shear stress, and skin temperature among 4 healthy volunteers, a study involving 6 additional healthy 40- to 75-year-old volunteers was conducted and results of the 2 studies were pooled. All 3 variables (interface pressures, shear stress, and skin temperature) were systematically and randomly varied. In the prone position, volunteers each underwent 18 test conditions representing different combinations of temperature (28˚ C, 32˚ C, 36˚ C), pressure (8.0 and 13.3 kPa), and shear (0, 6.7, and 14.0 kPa) using a computer-controlled indenter applied to the sacrum for 20 minutes exerting weights of 100 g and 200 g to induce 0.98 N and 1.96 N of shear force, respectively. Each condition was tested twice, resulting in a total of 360 trials. Magnitude of postload reactive hyperemia as an index of ischemia was measured by laser Doppler flowmetry. Fixed effects regression models were used to predict 3 different indices of reactive hyperemic magnitude. Friedman tests were performed to compare the reactive hyperemia among 3 different skin temperatures or shear stresses under the same amount of localized pressure. In all regression models, pressure and temperature were highly significant predictors of the extent of reactive hyperemia (P <0.0001 and P <0.0001, respectively); the contributions of shear stress were not statistically significant (P = 0.149). With higher temperature, reactive hyperemia increased significantly, especially at greater localized pressure and shear stress, and the difference was more profound between 32˚ C and 36˚ C than between 28˚ C and 32˚ C. These results confirm that, in laboratory settings, temperature is an important factor in tissue ischemia. Additional studies examining the relative importance of pressure, shear, and temperature and potential effects of lowering temperature on tissue ischemia in healthy volunteers and patients at risk for pressure ulcer development are warranted. Because deformation at weight-bearing areas often results in blood flow occlusion, actively lowering the temperature may reduce the severity of ischemia and lower pressure ulcer risk. In this study, shear did not appear to contribute to ischemia in the dermal tissues when assessed using laser Doppler; further work is needed to examine its effect on deeper layers, particularly with regard to nonischemic mechanisms.

  • Predictors of superficial and severe hospital-acquired pressure injuries: A cross-sectional study using the International Pressure Ulcer Prevalence™ survey.
    Kayser SA, VanGilder CA, Lachenbruch C | International Journal of Nursing Studies. | 2019



    Prevalence of hospital-acquired pressure injuries has declined over time. However, it is unknown if this decline is consistent for different stages of pressure injuries. It is also unknown if risk factors differ between superficial (stage 1 and 2) and severe (stage 3, 4, deep tissue, and unstageable) pressure injuries.


    To examine changes in prevalence of superficial and severe hospital-acquired pressure injuries from 2011 to 2016. To evaluate differences between risk factors associated with superficial versus severe hospital-acquired pressure injuries.

  • A Laboratory Study Comparing Skin Temperature and Fluid Loss on Air-Fluidized Therapy, Low-Air-Loss, and Foam Support Surfaces
    Lachenbruch, Charles | Ostomy/Wound Management | 2010


    To ensure appropriate fluid replacement, caregivers need to understand the effect of support surfaces on the rate of moisture loss from the body. A prospective study was conducted to 1) measure the rate of weight (fluid) loss on an air-fluidized therapy (AFT) surface; 2) determine the effect of bath temperature on weight loss; 3) compare weight loss and skin temperatures between foam and low-air loss (LAL) surfaces; 4) compare characteristics of individuals with high and low weight loss rates; and 5) compare weight loss rates to previously measured rates of support surface evaporative capacity. Eight healthy adult volunteers (three men, five women, average age 33 years, average body mass index 31.0 kg/m²) participated in eight 180-minute trials (one trial per day) on a foam, an LAL, and an AFT surface at five different bath temperatures (range: ~99.0 °F [hot] to ~88.0 °F [low]). Weight (± 10 g) was obtained before and after each trial and skin temperature (across the back) was recorded continuously. Using linear regression, weight loss rate on AFT was found to be strongly dependent upon bath temperatures: weight loss/day (g/m²-24 hours) = 53.9 x T (F) - 4030, where T is the mean skin temperature on the patient's back (also equal to bath temperature) in (F) Fahrenheit. Using this regression equation at mid-range (94 °F), fluid loss in an average woman (145 lb/64.5 inches/1.72 m² body surface area [BSA]) on AFT would be estimated to be 850 g/day higher than on foam. Compared with LAL, weight loss on AFT was estimated to be 700 g/day and 800 g/day higher for the typical woman and man, respectively (P < 0.05 at a mid-range bath temperature of 94 °F). Weight loss rates varied from 480 g/m²-24 hours to 3,470 g/m²-24 hours. Weight loss and mattress evaporative rates also suggest that moisture accumulation may occur on a foam but not on an LAL or AFT surface. However, fluid intake should be increased on AFT, particularly when bath temperature settings are high.

  • Pressure ulcer incidence and progression in critically ill subjects: influence of low air loss mattress versus a powered air pressure redistribution mattress
    Black, Joyce; Berke, Christine; Urzendowski, Gail | ournal of Wound, Ostomy and Continence Nursing | 2012



    The primary objective of this study was to compare facility-acquired pressure ulcer incidence and progression of pressure ulcers present on admission in critically ill patients, using 2 different support surfaces.

  • Factors associated with safe patient handling practice in acute care and its relationship with patient mobilization: A cross-sectional study
    Kayser S, Wiggermann N, Kumpar D | International Journal of Nursing Studies | 2019


    Mobilizing hospital patients is associated with improved outcomes and shorter length of stay. Safe patient handling and mobility programs that include mechanical lift use facilitate mobilizing patients and reduce the likelihood of musculoskeletal disorders in staff. However, there is little information on the prevalence of lift use or why some patients are more likely to have a lift used than others. Such information is needed to inform public policy, benchmark lift use over time, and contextualize barriers for lift use.

  • Incontinence-Associated Dermatitis and Immobility as Pressure Injury Risk Factors: A Multisite Epidemiologic Analysis
    Gray M, Giuliano KK. | J Wound Ostomy Continence Nurs. | 2017



    The purpose of this study was to measure the prevalence of incontinence-associated dermatitis (IAD) among incontinent persons in the acute care setting, characteristics of IAD in this group, and associations among IAD, urinary, fecal, and dual incontinence, immobility, and pressure injury in the sacral area.

  • The Standardized Pressure Injury Prevention Protocol for improving nursing compliance with best practice guidelines.
    Padula WV, Black JM | Journal of Clinical Nursing. | 2018


    Compliance with international best practice guidelines can effec-tively prevent most hospital-acquired pressure injuries (HAPIs) (Black et al., 2011; Padula et al., 2016) These guidelines include sev-eral nursing interventions that first were introduced in 1992 by the U.S. Agency for Healthcare Research & Quality (AHRQ), and have since been updated by the National Pressure Ulcer Advisory Panel (NPUAP) every 3–5 years (NPUAP, 2014; Panel on the Prediction and Prevention of Pressure Ulcers in Adults, 1992. AHCPR Publication No. 91-0047). Following admission, nurses should perform a daily skin check and risk assessment using a validated risk tool (Bergstrom, Braden, Laguzza, & Holman, 1987; Braden & Bergstrom, 1994). Patients determined to be high-risk receive additional measures: (a) repositioning every 2–4 hr; (b) managing skin care and incontinence; (c) improving nutrition; (d) using pressure-relieving support surfaces; and (e) reducing friction and shear (Agency for Healthcare Research and Quality, 2011; NPUAP, 2014). Many hospitals struggle to incor-porate these guidelines into a daily routine given the intense amount of nursing time, costliness to implement, uncertain clinical effective-ness, and competing patient demands and hospital priorities.

  • Time of Onset to Changes in Skin Condition During Exposure to Synthetic Urine: A Prospective Study.
    Phipps L, Gray M, Call E. | J Wound Ostomy Continence Nurs



    The purpose of this study was to evaluate the impact of incontinence on epithelial-moisture barrier function and the subsequent risk for incontinence-associated dermatitis by exposing healthy volunteers to a premium incontinence pad wet with synthetic urine.


    Prospective, single-group study.

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