ICU care bundles and infection prevention

Pressure injury prevention and early mobilisation

Reviewed Nov 2026·3 references
New· views rounded down, updated weekly

Risk assessment, repositioning, support surfaces, device-related injuries, staging, and how hard to mobilise after TEAM.

Definition
Pressure injury: localised damage to skin and underlying tissue, usually over a bony prominence or under a medical device, from pressure or pressure with shear. ICU patients are at high risk because of immobility, sedation, vasopressors, oedema and devices.

At the bedside

Timed steps
  1. 1

    Assess risk

    Admission + daily

    On admission and daily with a structured tool (Braden ≤ 18 indicates risk) plus clinical judgement; inspect skin including under devices.

  2. 2

    Reposition

    Individualised repositioning schedule (commonly 2-4 hourly), 30° lateral tilt; avoid positioning on existing injury or erythema.

  3. 3

    Support surface

    High-specification reactive foam or active (alternating pressure) mattress for at-risk patients.

  4. 4

    Heels and sacrum

    Offload heels (heel elevation devices or pillows under calves); consider prophylactic multilayer silicone foam dressings on sacrum and heels.

  5. 5

    Devices

    Check and pad under NG/ET tubes, NIV masks, oxygen tubing, collars and catheters; reposition devices regularly.

  6. 6

    Prone patients

    Protect face, chest, knees and other pressure points; reposition head every 2 h.

  7. 7

    Skin and nutrition

    Manage moisture and incontinence; optimise nutrition and protein.

  8. 8

    Mobilise

    Daily assessment for rehabilitation: in-bed exercises progressing to sitting, standing and walking when stable. Avoid aggressive maximal early mobilisation in the first days of ventilation (TEAM).

Pressure injury staging (NPIAP/EPUAP)

StageDescription
1Intact skin with non-blanchable erythema
2Partial-thickness skin loss with exposed dermis
3Full-thickness skin loss; fat visible; no bone, tendon or muscle
4Full-thickness skin and tissue loss with exposed bone, tendon, muscle or cartilage
UnstageableObscured by slough or eschar
Deep tissue injuryPersistent non-blanchable deep red, maroon or purple discoloration
Red flag · call your senior now
Deep tissue injury (purple, boggy skin) over the sacrum or heels in a patient on vasopressors - it may evolve to stage 3-4 within days; offload immediately.
Pitfall
Massaging reddened skin over bony prominences - not recommended.
Pitfall
Forgetting device-related injuries from ET tube ties and NIV masks.
Pearl
TEAM showed that maximising early active mobilisation did not increase days alive out of hospital and caused more adverse events - mobilise steadily as part of usual care rather than maximally.

References

  1. 1

    European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers/injuries: clinical practice guideline. The international guideline, 3rd ed. 2019.

  2. 2

    Devlin JW, Skrobik Y, Gelinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS). Crit Care Med 2018;46:e825-73.

  3. 3

    TEAM Study Investigators and the ANZICS Clinical Trials Group. Early active mobilization during mechanical ventilation in the ICU. N Engl J Med 2022;387:1747-58.

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