A Closer Look at Recent Research on Pressure Injuries

The frequency of repositioning for nursing home patients and the relationship of pressure injuries (PI) to angiosomes are the focus of recent research into pressure injuries.

The Turn Everyone And Move for Ulcer Prevention (TEAM-UP) randomized controlled trial protocol, as first reported in 2018, is studying repositioning frequency and precipitating factors to prevent PIs.¹ As the authors note, the current pressure injury prevention protocols recommend repositioning residents every 2 hours if they are at moderate, high, or severe risk. As the study says, visco-elastic (VE) high-density foam support-surfaces may now make it possible to extend the repositioning interval to every 3 or 4 hours without a higher risk of PI development.

As study author Tracey Yap, PhD, RN, WCC, CNE, FGSA, FAAN, notes, she and her coauthors recently submitted her findings for the TEAM-UP study. She notes repositioning helps with blood flow and reduces injury, but notes a lack of evidence as far as the ideal interval for repositioning.

“Could we safely extend repositioning out every 4 hours, rather than doing this every 2 hours?” asks Dr. Yap. She says the longer time between repositioning may help residents sleep better, noting they already face the disruptions inherent to nursing homes, such as floors and halls bustling with staff activity. In looking at repositioning every 3 and every 4 hours in 9 nursing homes during a 4-week intervention, Dr. Yap notes they “did not have one pressure injury.”

“So it looks like for most people if you use a viable mattress and you are compliant with the repositioning interval, it seems reasonable to think that we could extend repositioning out every 4 hours,” says Dr. Yap.

As Dr. Yap says, sometimes repositioning can fall by the wayside as nursing staff become busy with urgent duties such as patients wandering off or patients with low blood sugar. To alert the staff to the need for repositioning, the study used an individual sensor on each of the residents that transmitted information to a monitor, with monitors conveniently placed throughout the facility.

“It’s a better quality of care, better quality sleep and it frees nurses up to do other tasks,” says Dr. Yap.

As part of recent research into pressure injuries, a recent case study in Advances in Skin and Wound Care focused on a 46-year-old man who developed a deep tissue pressure injury, which evolved into a stage 4 pressure injury, following elective surgery for a coronary artery bypass graft.² The study investigates whether these more severe PIs may result from ischemic insults of a named vessel within specific vascular territories (labeled as angiosomes).

Study author Jenny Alderden, PhD, APRN, CCRN, CCNS, notes the patient’s PI started out as a deep tissue pressure injury and then evolved into a stage 4 on a place that was not exposed to very much external pressure at all. However, she says the pressure injury mapped almost perfectly onto an angiosome, a three-dimensional block of tissue.

Dr. Alderden says the study suggests some serious pressure injuries—such as deep tissue injuries or stages 3 and 4—actually occur because of vascular occlusion due to inadequate blood flow of oxygen-rich blood to an angiosome.

“Our main thrust is preventing pressure, injuries and yet we always think of pressure injuries only in terms of external pressure,” according to Dr. Alderden. “The study suggests more research is needed and that it may be necessary to really look at what's happening inside the body in terms of the perfusion clinicians might need to optimize the delivery of oxygen rich blood.”

Click here to listen to a Speaking of Wounds podcast on this topic.

1. Yap TL, Kennerly SM, Horn SD, Bergstrom N, Datta S, Colon-Emeric C. TEAM-UP for quality: a cluster randomized controlled trial protocol focused on preventing pressure ulcers through repositioning frequency and precipitating factors. BMC Geriatrics. 2018; 18(54).
2. Yap TL, Alderden J, Lewis M, Taylor K, Fife CE. Angiosomal vascular occlusions, deep-tissue pressure injuries, and competing theories: a case report. Adv Skin Wound Care. 2021; 34(3):157–64.