The Signature Prevention Move: In the healthcare and Quality Improvement fields, I advocate for the use of "micro-repositioning with floating heels". The coccyx (tailbone) is a high-risk area, but also the heel or calcaneus (heel bone) is considerably at risk of injury when patients are unable to move their legs due to illness or technology/equipment surrounding the patient's legs, etc. To help prevent heel injury, we use foam boots and floating techniques using offloading pillows. That way the calcaneus bone (which has very little fatty padding) will not come in contact with the mattress surface, thus preventing localized pressure to this area. The Evidence in Action: During a quality audit at a long-term care unit we had a patient with a high acuity level who is on a ventilator most of the time. Many times the mechanical burden of the equipment restricts the ability to turn the patient 90 degrees; therefore, we implemented "micro-turns," which are small weight shifts of 15 to 30 degrees using wedges. This allowed for a reduction of localized pressure to the skin's capillary bloodstream, sufficient enough to maintain tissue oxygenation, without disturbing the life-support equipment. Averted Stage 2 Example: We had a patient with an extremely low Braden Scale score that indicated that he was at an extremely high risk. We observed the start of a Stage 1 "bruised" appearance on his left heel. We implemented our heel floating protocol and used foam prophylactically to prevent the skin from blistering. Had we not provided this intervention, the localized pressure would have progressed to a Stage 2 "partial-thickness" injury within one shift. As of 2026, the prevention of these types of injuries is critical to the overall safety rating of the hospital.
The Signature Prevention Move: I am an advocate of early support by emergency departments (ED). As the "ED Transition Protocol" was developed as a primary prevention intervention strategy, many patients (particularly elderly ones) are admitted to hospitals after waiting for long periods of time on uncomfortable ED stretchers in transit, thus increasing their risk of developing pressure injuries. I support the use of prophylactically applied sacral foam dressings on all immobilized patients at the moment of admission to the ED or at least in the first hour of arriving in hospital. Prevention should begin during the trauma bay phase rather than waiting to transfer to the medical-surgical (med-surg) unit an average of 24 hours later for additional treatment and care. Evidence in Action: An example of the ED Transition Protocol's use was an elderly trauma patient who had been immobilized on a backboard to protect her spine. Due to her length of immobilization, combined with the stiffness of the backboard, her risk of developing a skin breakdown or injury in the sacral area was significantly increased. Following our ED Transition Protocol, we placed a silicone foam dressing under her sacrum before she was ever transferred out of the trauma bay to await imaging and clearance for surgery. Reducing Iatrogenic Risk: By the time this patient was transferred to the ICU, her skin remained intact. By using prophylactic dressings and anticipating iatrogenic risk in the ED phase—before physical injury can occur—we reduce the likelihood for skin breakdown and iatrogenic injury. By taking a proactive approach to treatment, we can close the "window of vulnerability" that often exists in high-risk patients not receiving timely skin protection that leads to Stage 2 skin tears and pressure wound development.
The Signature Prevention Move: As a clinical leader, I always have my team perform a "visual skin inspection huddle" at each shift change. Our preferred signature move is called a "two-person micro turn with moisture barrier application." In addition, we use both a high quality barrier cream and a prophylactic foam dressing for the patient with incontinence because moisture is the leading cause of skin maceration or breakdown. When skin is moist or soggy, it takes less pressure for a Stage II injury to occur. The Evidence in Action: We managed a patient with severe mobility problems and frequent episodes of incontinence in a collaborative care setting who was at extreme risk for developing a Stage II injury. We created a policy that had two team members micro turning every two hours to ensure that the patient had a moisture barrier reapplied and that the sacral foam dressing did not bottom out. This ensured the patient's skin was never in contact with moisture or a single pressure point for any length of time. Averted Stage II Example: During one of our huddles, we noticed a hot spot, which is a bright red area that did not change appearance with pressure. We increased the frequency of micro turns and ensured that the prophylactic foam was properly centered to prevent the skin from breaking down. One week later, the area returned to normal healthy pink. This prevented a Stage II injury that would have led to the need for specialized wound care, additional nursing hours, and an increase in the patient's pain and suffering.