Support surfaces and repositioning

Clinical question: What prevention and interventions are required to reduce pressure injury incidence in the adult ICU?

SectionRecommendationGrade of recommendation
11. As a minimum use a high specification reactive (constant low pressure) support foam mattress on beds and trolleys for patients at risk of pressure injuries. No one specific high specification reactive (constant low pressure) support foam mattress is better than another. (1) A
12. Those patients classified as high risk or very high risk of pressure injury should be placed on an active (alternating pressure) support mattress. (1) A
13. Any device used to prevent heel pressure injuries should be selected and fitted appropriately to ensure pressure is adequately offloaded and hyperextension of the Achilles tendon is avoided. Consensus
14. When seated in a chair or wheelchair patients at risk of pressure injury should be placed on the appropriate reactive or active cushion.(1) C
The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that changes these recommendations.

Support Surfaces

Ideally, all intensive care unit beds should have alternating pressure support mattresses however, all patients who are classified as high risk or who have an existing or greater than grade two pressure injury must have an active alternating pressure mattress. Unless contraindicated, at risk patients should be repositioned at least every two hours. The use of available pressure redistribution surface should be escalated in accordance with the Braden Pressure Scale.

Practice point 1 - Protect and promote skin integrity

Protect and promote skin integrity by:

  • not vigorously rubbing the patient’s skin
  • developing and implementing an individualised continence management plan
  • protecting the skin from moisture by using pH balanced skin cleanser and drying thoroughly
  • using water-based skin emollients to maintain skin hydration.


Repositioning has long been thought of as the mainstay practice for pressure injury prevention in critically ill patients in combination with the use of pressure redistribution surfaces (2). Repositioning regimes often vary according to staff availability, unit protocols, staff skill mix and the patient’s severity of illness (3). Frequent repositioning is thought to have a positive impact on reducing pressure injury incidence and/or severity; however consensus about the frequency of repositioning has not been clearly described in relation to intensive care unit settings (3). Having reviewed the current literature the group consensus was that all patients within the ICU should be repositioned at a minimum of second hourly unless contraindicated by their medical condition (1, 4). The frequency of repositioning is considered independent of the type of pressure redistribution surface the patient is on (5).

Repositioning of the patient is classified as a change in the patient’s position that changes the area/s of increased interface pressure. It is described as a minimum change in position of 30o lateral incline, supported with pillows behind the back and knees (5). It is also recommended that patients remain with a head-up position of 30o and knees bent (6). The 30o head-up position is chosen as opposed to 45o due to the increased risk of shearing forces placed on the body at a 45o angle. An angle of not less than 30o is preferred as it is inline with the ventilator-associated pneumonia prevention bundle (2008) (6).

SectionRecommendationGrade of recommendation
15. Unless contraindicated at-risk patients should be repositioned at least every two hours (1, 2, 4, 6-8) even if on an active or reactive support surface. (2) C

When deciding on the frequency of repositioning and choice of patient position, the clinician should consider:

  • risk or presence of pressure injury
  • skin response
  • comfort/pain
  • cognition
  • ability to move
  • medical condition
  • support surface used. (1, 5, 6, 9)
17. Reposition patients to reduce duration and magnitude of pressure over vulnerable areas, including under medical devices, bony prominences and heels. (1, 5, 6) A
18. As a minimum, position patients using 30° lateral inclination alternating from side to side or a 30° inclined recumbent position. (1, 5, 6) C
19. Patients in seated positions should ideally have pressure relief every 30-60 minutes. For specific patient groups (for example patients with spinal cord injuries) this may need to be more frequent. (1, 10)  
The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that change these recommendations.

The patient position should be chosen and alternated at a minimum of two hours according to several factors including, but not limited to, the patient’s underlying presentation/illness, patient comfort, position of invasive/non-invasive devices, and haemodynamic stability. This could include the use, where appropriate, of prone positioning (9). During repositioning staff should always check the positioning of heels, bony prominences, and the location of medical devices. Pressure injuries secondary to medical devices accounted for 29% of injuries reported on Incident Information Management System in NSWICUs between 2009-2011.

Patients in the seated position are shown to have an increased risk for pressure injury (7). For patients in the seated position it is recommended that, for those patients who are not able to reposition themselves at regular intervals, a minimum of hourly repositioning is attended to (6). Alternatively, complete removal of the interface pressure should be achieved through standing or elevation from the seated position. If patients are scored ‘at risk’ according to the Braden scale, a pressure redistribution surface should also be used in the chair (6).

Practice point 2 -  Repositioning patients

When repositioning a critically ill adult, staff should ensure that:

  • all medical devices, especially tracheal tubes and central lines, are being monitored to ensure accidental dislodgment does not occur and the tubing and lines are not left where they can lead to pressure or mucosal injury.
  • an experienced clinician is holding the tracheal tube to ensure it remains within the trachea. This is especially important for patients where re-intubation is difficult, such as those with tracheostomy tubes in situ for less than 72 hours and/or obese patients with adjustable flange tubes.
  • bedding is not folded underneath the patient.

Grading of recommendations

Grade of recommendation Description
A Body of evidence can be trusted to guide evidence
B Body of evidence can be trusted to guide practice in most situations
C Body of evidence provides some support for recommendation/s but care should be taken in its application
D Body of evidence is weak and recommendation must be applied with caution
Consensus Consensus was set as a median of ≥ 7
Grades A–D are based on NHMRC grades (2)


  1. Australian Wound Management Association. Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. Australian Wound Management Association. 2011.
  2. Theaker C, Kuper M, Soni N. Pressure ulcer prevention in intensive care - a randomised control trial of two pressure-relieving devices. Anaesthesia. 2005;60(4):395-9.
  3. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. Jama. 2006;296(8):974-84.
  4. Bours GJ, De Laat E, Halfens RJ, Lubbers M. Prevalence, risk factors and prevention of pressure ulcers in Dutch intensive care units. Results of a cross-sectional survey. Intensive Care Med. 2001;27(10):1599-605.
  5. Gray-Siracusa K, Schrier L. Use of an intervention bundle to eliminate pressure ulcers in critical care. J Nurs Care Qual. 2011;26(3):216-25.
  6. Baldelli P, Paciella M. Creation and implementation of a pressure ulcer prevention bundle improves patient outcomes. Am J Med Qual. 2008;23(2):136-42.
  7. Nijs N, Toppets A, Defloor T, Bernaerts K, Milisen K, Van Den Berghe G. Incidence and risk factors for pressure ulcers in the intensive care unit. J Clin Nurs. 2009;18(9):1258-66.
  8. Kaitani T, Tokunaga K, Matsui N, Sanada H. Risk factors related to the development of pressure ulcers in the critical care setting. J Clin Nurs. 2010;19(3-4):414-21.
  9. Malbrain M, Hendriks B, Wijnands P, Denie D, Jans A, Vanpellicom J, et al. A pilot randomised controlled trial comparing reactive air and active alternating pressure mattresses in the prevention and treatment of pressure ulcers among medical ICU patients. J Tissue Viability. 2010;19(1):7-15.
  10. Bours GJJW, De Latt E, Halfens RJG, Lubbers M. Prevalence, risk factors and prevention of pressure ulcers in Dutch intensive care units. Intensive Care Medicine. 2001;27:1599-605.


The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one. ICNSW attests to the accuracy of the information contained here but takes no responsibility for how it may apply to an individual patient. Please refer to the full disclaimer.