Author: Christos Chapeshis
Date: July 1, 2026
Abstract
Pressure ulcers/injuries have resisted decades of prevention science, clinical guidelines, and quality-improvement work, and they remain a global problem. Recent bibliometric studies offer a useful vantage point on where the field is actually moving. Basli’s 2024 analysis of nursing research on pressure injury prevention traced a body of literature that grew steadily between 2018 and 2023, with the most-cited work clustering around prevalence, incidence, systematic reviews, and meta-analyses, and with specialist journals such as the Journal of Tissue Viability and Advances in Skin & Wound Care acting as the field’s main outlets (Basli, 2024). A companion bibliometric analysis covering prevention and measurement tools from 1997 to 2023 confirms the same sustained appetite for work on risk assessment, prevention technologies and quality of care (Azizoğlu and Terzi, 2024).
This review reads those trends against recent literature updates and the current International Pressure Injury Guideline. Taken together, the evidence backs a multidimensional model of prevention: structured risk assessment, skin and tissue assessment, individualized repositioning, nutritional screening, pressure redistribution, heel offloading, microclimate management, device vigilance, and system-level implementation. What it does not provide is certainty: many of the relevant recommendations are conditional or framed as good practice rather than high-certainty mandates. The direction of travel is toward individualized prevention, biomechanical monitoring, sensor-assisted repositioning, better support-surface evaluation, and pragmatic real-world studies. Innovation, on this reading, should be judged not by product claims but by how well it aligns with validated mechanisms, guideline-based prevention bundles, and clinically meaningful outcomes.
Introduction
Pressure ulcers/injuries are localized damage to skin and underlying tissue caused by pressure, or by pressure combined with shear, and they tend to appear over bony prominences or beneath medical devices. Calling them nursing-sensitive adverse events undersells them. They sit at the intersection of tissue tolerance, perfusion, mobility, nutrition, microclimate, systemic illness, device loading, and the reliability of care delivery.
The research has widened accordingly. Where the older literature fixated on turning schedules and mattress choice, the contemporary work reads as a broader prevention science. Basli’s 2024 bibliometric analysis is valuable precisely because it maps that landscape rather than testing one intervention; drawing on Web of Science data and Biblioshiny/RStudio, it identified prevalence and incidence studies, systematic reviews and meta-analyses as the most influential publication types between 2018 and 2023 (Basli, 2024). A field that consolidates its evidence this way is maturing, even as it continues to struggle with implementation, measurement, and translating findings into reliable bedside practice.
Berlowitz and colleagues, reviewing the 2023 literature, make a related point: the evidence base is expanding so quickly that clinicians now need synthesis simply to distinguish practice-changing findings from preliminary observations (Berlowitz et al., 2024). Azizoğlu and Terzi add a longer view, showing that risk-measurement tools and prevention strategies have stayed at the center of the research conversation for more than two decades (Azizoğlu and Terzi, 2024).
Why Pressure Ulcers/Injuries Remain a Global Challenge
Prevention is hard because the condition is genuinely multifactorial. Immobility usually sits at the center of it, but rarely alone. Poor perfusion, diabetes, malnutrition, edema, vasopressor exposure, moisture, sensory loss, medical devices, critical illness, and frailty all erode tissue tolerance. At the heel and lower limb in particular, peripheral arterial disease, diabetes, shock states, vasopressors, friction, and shear are recognized drivers of injury.
Prevention is also time-dependent in a way that defeats casual observation. Tissue deformation, ischemia-reperfusion injury, and microclimate stress can begin well before anything shows on the skin. That is the reasoning behind the current guideline’s good-practice position that risk should be screened as soon as possible after admission and reassessed whenever the patient’s condition changes.
And pressure ulcers/injuries are system failures as often as they are patient-level events. Clinicians can understand the principles perfectly and still watch prevention break down on the realities of staffing, surface availability, inconsistent documentation, delayed equipment, thin nutrition pathways or weak device surveillance. For that reason, the latest guideline frames prevention as a risk-based plan rather than any single intervention.
Current Research Trends
The bibliometric work points in a few clear directions. The most visible shift is toward evidence synthesis. Basli found the highly cited literature dominated by prevalence and incidence studies, systematic reviews, and meta-analyses (Basli, 2024), a sign that the field is no longer defined by scattered single-site trials but by the harder work of aggregating and interpreting them.
Risk assessment remains a heavyweight theme. Azizoğlu and Terzi’s analysis of work from 1997 to 2023 focused specifically on prevention and measurement tools, underscoring how much effort still goes into accurately identifying risk before injury occurs (Azizoğlu and Terzi, 2024). The guideline tempers this, though: standardized risk tools, when used, should be supplemented with additional risk factors and read through clinical judgment. The distinction is not pedantic. A scale can structure a clinician’s thinking; it cannot stand in for expert assessment.
The agenda is also growing more biomechanical. Support surfaces, heel offloading, prophylactic dressings, microclimate management, friction and shear reduction, and sensor systems all reflect rising attention to tissue loading rather than to visible skin inspection alone. The 2026 quick reference guideline allows that sensor systems may help evaluate repositioning needs where resources permit, but it keeps this as a conditional recommendation resting on very low-certainty evidence.
Medical device-related pressure injury has meanwhile separated out as its own prevention domain. The guideline acknowledges that device-related injuries carry overlapping but distinct risk profiles compared with immobility-related ones, and that a patient should be treated as at risk the moment a device is applied, a point with obvious weight in intensive care, perioperative medicine, rehabilitation, respiratory care and long-term care.
Major Advances Since 2023
The most consequential development since 2023 is not a device or a single intervention. It is the refinement of prevention into a stratified, individualized, evidence-graded model. By separating strong recommendations, conditional recommendations, and good-practice statements, the current international guideline gives clinicians a way to avoid overstating what the evidence can actually bear.
On support surfaces, the guideline strongly recommends a full-body pressure-redistribution foam surface for at-risk individuals, while acknowledging that the certainty behind that recommendation is low. It conditionally offers alternatives, including active alternating pressure air surfaces, reactive air surfaces, and low-air-loss reactive surfaces, again at low or very low certainty. The honest reading is not that every surface performs alike, but that the comparative clinical evidence to rank them simply is not there yet.
On repositioning, the good-practice position is blunt: repositioning stays necessary whatever surface is in use, and no surface fully replaces it. Conditional recommendations include 30-degree lateral positioning and keeping head-of-bed elevation at or below 30 degrees where clinically appropriate, sensible defaults that still need tailoring to the individual.
Nutrition has been clarified too. Screening and comprehensive assessment are endorsed as good practice, and supplementation is conditionally suggested for at-risk individuals who are malnourished, or at risk of malnutrition, when ordinary intake falls short. Notably, the guideline strongly recommends against tube feeding solely to prevent pressure injury in those with or at risk of malnutrition, while making clear that this does not address tube feeding that is clinically indicated on other grounds.
Clinical Implications for Healthcare Providers
In practice, prevention starts with structured risk screening and moves to a comprehensive assessment whenever screening flags concern. Minimum screening should at least capture mobility and activity limitation, the presence of medical devices, and any existing pressure injuries. Full assessment widens that to skin assessment, the relevant risk factors, standardized tools where they add value, clinical judgment, and proper documentation.
From there the plan has to follow the risk. A low-mobility patient with adequate perfusion and nutrition needs something quite different from a vasopressor-dependent ICU patient carrying edema and several devices. Someone with diabetes and peripheral arterial disease has a particular heel vulnerability. A wheelchair user with a spinal cord injury needs seated redistribution, posture management, transfer assessment, and education in self-repositioning.
Equipment, finally, should never be mistaken for a solution. A high-specification surface reduces mechanical loading, but it does not eliminate the need for repositioning, skin inspection, continence care, nutrition optimization, heel offloading, and device management. The surface buys time; it does not buy the care.
The Role of Support Surfaces in Evidence-Based Prevention
Support surfaces matter because they reshape the mechanical environment at the body-support interface, chiefly through pressure redistribution, immersion, envelopment, shear reduction and sometimes microclimate management.
The current guideline strongly recommends pressure redistribution foam full-body surfaces for at-risk individuals while rating the underlying certainty as low and conditionally suggests alternating pressure air or reactive foam surfaces, reactive air or foam surfaces, and low-air-loss surfaces in selected patients, particularly where heat and moisture at the skin interface are in play. That graded language is the point: surfaces should be chosen against patient risk, body size, mobility, posture, skin response, microclimate needs, care goals, and clinical context, not against a generic “premium” label. For seated patients, seating surfaces with redistribution properties carry a stronger, moderate-certainty recommendation.
Heels warrant separate attention. Heel elevation is treated as good practice, with heel offloading devices conditionally suggested according to mobility and activity level. Preventive soft silicone multilayer foam dressings may serve as adjuncts to elevation and repositioning, though here, too, the certainty ranges from low to very low.
Research Gaps and Future Directions
The open question is not whether pressure redistribution matters. It plainly does. It is about matching a specific technology to a specific patient phenotype and setting. The field would gain more from studies that move beyond blunt “standard versus special mattress” comparisons and instead interrogate mechanisms such as immersion, envelopment, shear, heat, humidity, durability, edge effects, heel loading, transfer safety, and real-world adherence.
Pragmatic trials with outcomes clinicians actually care about are equally overdue: incidence of category/stage 2 or greater injuries, heel injuries, device-related injuries, time to injury, patient comfort, nursing workload, cost-effectiveness and implementation fidelity, rather than surrogate endpoints alone.
Measurement science is a third priority. Sensor-assisted repositioning, subepidermal moisture assessment, thermography, AI-based risk prediction, and digital wound imaging all look promising, but most still need stronger validation across skin tones, care settings, and patient populations before they can be trusted at scale.
That last point shades into equity, which prevention research has to take more seriously. Pressure ulcers/injuries are harder to detect in darker skin tones, and classification reliability remains a live concern. The current guideline acknowledges as much, noting that classification updates and education should support reliability and validity across the full continuum of skin tones.
Practical Takeaways
Prevention is best run as a structured clinical pathway rather than a checklist. Screen early, repeat after any clinical change, and combine repositioning, skin assessment, nutrition, support surfaces, heel offloading, device surveillance, moisture control, and patient-centered goals into a single coherent plan.
Support surfaces are essential, but not sufficient. They reduce loading; they do not replace care, and repositioning stays necessary even on redistribution surfaces. Nutritional supplementation is for the malnourished or at-risk, not for everyone. And the moment a medical device is applied, it should trigger immediate awareness of the risk of pressure injury.
Procurement, by extension, should weigh evidence grading, the patient population, surface performance, maintenance, staff usability, compatibility with repositioning and monitoring requirements, not headline specifications in isolation.
Conclusion
Pressure injury prevention is becoming a more mature, multidisciplinary science, one that draws together nursing surveillance, biomechanics, nutrition, support-surface engineering, device safety, digital monitoring, and implementation research. The bibliometric record shows a field tilting toward evidence synthesis, measurement tools, risk assessment, and the refinement of prevention strategies. Yet the uncertainty is real and substantial: a great many recommendations remain conditional or rest on good practice rather than high-certainty trial evidence.
ABeWER’s role belongs inside that frame. Device innovation should follow evidence-based design principles, track the evolving international guidance, and support guideline-based prevention, without claiming more certainty than the evidence can currently sustain.
References
Azizoğlu, F. and Terzi, B. (2024) ‘Research topics on pressure injury prevention and measurement tools from 1997 to 2023: a bibliometric analysis using VOSviewer’, Intensive and Critical Care Nursing, 80, 103557. doi:10.1016/j.iccn.2023.103557.
Basli, A.A. (2024) ‘Nursing research on pressure injury prevention: bibliometric analysis’, Advances in Skin & Wound Care, 37(9), pp. 1–7. doi:10.1097/ASW.0000000000000203.
Berlowitz, D., Konchinski, B., Chen, L. and DeCastro, S.S. (2024) ‘The 2023 update on pressure injuries: a review of the literature’, Advances in Skin & Wound Care, 37(11–12), pp. 571–578. doi:10.1097/ASW.0000000000000218.
Brienza, D. et al. (2022) ‘The vision and scope of the prophylactic dressing standard initiative of the European Pressure Ulcer Advisory Panel and National Pressure Injury Advisory Panel’, International Wound Journal, 19(5), pp. 963–964. doi:10.1111/iwj.13859.
National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance (2026) Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide. The International Guideline: Fourth Edition. Emily Haesler (ed.). Available at: internationalguideline.com.
European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance (2019) Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. Emily Haesler (ed.). EPUAP/NPIAP/PPPIA.