Note: The following content abbreviates Pressure Injury (Pressure Injury) as PI.
On June 22, 2023, the National Pressure Injury Advisory Panel in the United States released the Standardized Pressure Injury Prevention Protocol version 2.0 (SPIPP 2.0) and welcomes industry peers to reference it! The following content provides an overview and main checklist of the protocol:
In the context of clinical guidelines, creating a simple, operational version that is easy for clinical use has become increasingly necessary. Therefore, on June 22, 2023, the National Pressure Injury Advisory Panel in Massachusetts released the second edition of the Standardized Pressure Injury Prevention Protocol, abbreviated as “SPIPP” (pronounced S – PIP). SPIPP is a streamlined bedside prevention checklist, with the main content adapted from the 2019 Clinical Practice Guidelines for Pressure Injury Prevention and Management.
SPIPP 2.0 targets populations with limited mobility and more severe conditions. The SPIPP 2.0 checklist considers the patient’s current or anticipated mobility as a significant risk factor, which is also of considerable importance for perioperative patients. Additionally, because mild pressure injuries in patients with darker skin tones may not be easily detected under insufficient lighting, SPIPP 2.0 highlights darker skin as an important item to raise awareness and promote implementation in practice, enhancing protective measures.
SPIPP 2.0 provides clear and concise items for managing skin cleanliness, moisture, and other aspects. The protocol specifically states that staff should actively explain the risks of pressure injuries (PI) and the prevention plan to patients and their families, which helps achieve timely and adequate preventive effects through their cooperation.
Expert panels from across the United States have assessed that the content validity index of SPIPP 2.0 is 0.93. Below are the main items of the Standardized Pressure Injury Prevention Protocol version 2.0 (SPIPP 2.0: Standardized Pressure Injury Prevention Protocol):
Standardized Pressure Injury Prevention Protocol Version 2.0 (SPIPP 2.0:Standardized Pressure Injury Prevention Protocol)
Assessment Items
Completion Status
Evaluation
Assess risk factors for pressure injuries (PI) to guide prevention
Current or anticipated significant mobility issues
Use structured risk assessment methods upon admission (such as Braden or other validated risk assessment tools)
Reassess risk factors during each shift and when there are significant changes in the patient’s condition
Explain the risks of pressure injuries (PI) and the prevention plan to the patient/family
Other risk factors to consider: history of previous pressure injuries (PI), localized pain, diabetes, poor perfusion, vasopressors, hypoxia, increased temperature, advanced age, spinal cord injury, neuropathy, prolonged surgery/treatment time >2hrs, critical illness, organ failure, sepsis, mechanical ventilation, medical devices, sedation, darker skin
Assess skin/tissue for signs of skin damage and pressure injuries (PI)
Assess skin upon admission and every shift (comprehensive, visual, tactile) for redness, color changes, swelling, and temperature changes
Assess skin under medical devices every shift
Check heels every shift
For individuals with darker skin, ensure adequate lighting and moisturize skin to enhance visual assessments
Consider enhanced skin assessment methods – thermal infrared imaging, SEM skin color charts
Preventive skin care – manage moisture/incontinence
Clean after each incontinence event and use appropriate moisture barriers
Avoid using alkaline soaps/cleansers
For high-risk individuals, consider urine/fecal management systems
Use single-layer, breathable, and highly absorbent pads for incontinence
Consider using low-friction textiles
When appropriate, use soft absorbent materials in skin folds
Pressure Redistribution
For individuals unable to move independently in bed, turn/reposition every 2-3 hours, and increase frequent micro-adjustments unless contraindicated (Braden activity/mobility score ≤2)
For immobile individuals, use high-specification pressure-relieving mattresses (Braden activity/mobility score ≤2)
Utilize positioning management aids to minimize friction/shear (pillows, wedges). Use turning/lifting devices (if available). Correct side-lying position with the upper leg positioned forward on the lower leg
Add local pressure-relieving protective pads or multilayer structured dressings in high-risk areas (i.e., sacrum, lower buttocks, or heels) (Braden activity/mobility score ≤2)
Use pressure-relieving soft pillows, heel pressure-relief pads, or specialized heel boots to elevate heels (Braden sensory perception score ≤3)
Ensure adequate positional changes when side-lying (30 degrees). Position the upper leg forward and use a pillow between the legs to support the upper leg
When the overall condition of the patient is unstable, perform slow, gradual, frequent, and small positional changes
For individuals unable to adequately change positions, use pressure redistribution cushions when seated
Seated patients should change positions at least once an hour, and can also shift weight direction to relieve pressure
Consult a physical therapist for activity plans when appropriate (Braden activity/mobility score ≤2)
Consider alert systems, pressure monitoring, movement sensors
Implement early mobilization plans
Nutrition
Use validated tools for malnutrition screening upon admission
For individuals with existing malnutrition or at risk of malnutrition, reduced nutritional intake, NPO >48hrs, or with 2 or more stage pressure injuries (PI) (Braden nutrition score ≤2), consult a nutritionist
Provide additional calories, protein, fluids, and nutritional supplements (i.e., multivitamins, arginine, glutamine, HMB) as per nutritional care plan or as needed
Continuously assess goals regularly and consult a nutritionist as needed
Note: The following content abbreviates Pressure Injury (Pressure Injury) as PI.
On June 22, 2023, the National Pressure Injury Advisory Panel in the United States released the Standardized Pressure Injury Prevention Protocol version 2.0 (SPIPP 2.0) and welcomes industry peers to reference it! The following content provides an overview and main checklist of the protocol:
In the context of clinical guidelines, creating a simple, operational version that is easy for clinical use has become increasingly necessary. Therefore, on June 22, 2023, the National Pressure Injury Advisory Panel in Massachusetts released the second edition of the Standardized Pressure Injury Prevention Protocol, abbreviated as “SPIPP” (pronounced S – PIP). SPIPP is a streamlined bedside prevention checklist, with the main content adapted from the 2019 Clinical Practice Guidelines for Pressure Injury Prevention and Management.
SPIPP 2.0 targets populations with limited mobility and more severe conditions. The SPIPP 2.0 checklist considers the patient’s current or anticipated mobility as a significant risk factor, which is also of considerable importance for perioperative patients. Additionally, because mild pressure injuries in patients with darker skin tones may not be easily detected under insufficient lighting, SPIPP 2.0 highlights darker skin as an important item to raise awareness and promote implementation in practice, enhancing protective measures.
SPIPP 2.0 provides clear and concise items for managing skin cleanliness, moisture, and other aspects. The protocol specifically states that staff should actively explain the risks of pressure injuries (PI) and the prevention plan to patients and their families, which helps achieve timely and adequate preventive effects through their cooperation.
Expert panels from across the United States have assessed that the content validity index of SPIPP 2.0 is 0.93. Below are the main items of the Standardized Pressure Injury Prevention Protocol version 2.0 (SPIPP 2.0: Standardized Pressure Injury Prevention Protocol):
|
Standardized Pressure Injury Prevention Protocol Version 2.0 (SPIPP 2.0:Standardized Pressure Injury Prevention Protocol) |
||
|
Assessment Items |
Completion Status |
Evaluation |
|
Assess risk factors for pressure injuries (PI) to guide prevention |
||
|
Current or anticipated significant mobility issues |
||
|
Use structured risk assessment methods upon admission (such as Braden or other validated risk assessment tools) |
||
|
Reassess risk factors during each shift and when there are significant changes in the patient’s condition |
||
|
Explain the risks of pressure injuries (PI) and the prevention plan to the patient/family |
||
|
Other risk factors to consider: history of previous pressure injuries (PI), localized pain, diabetes, poor perfusion, vasopressors, hypoxia, increased temperature, advanced age, spinal cord injury, neuropathy, prolonged surgery/treatment time >2hrs, critical illness, organ failure, sepsis, mechanical ventilation, medical devices, sedation, darker skin |
||
|
Assess skin/tissue for signs of skin damage and pressure injuries (PI) |
||
|
Assess skin upon admission and every shift (comprehensive, visual, tactile) for redness, color changes, swelling, and temperature changes |
||
|
Assess skin under medical devices every shift |
||
|
Check heels every shift |
||
|
For individuals with darker skin, ensure adequate lighting and moisturize skin to enhance visual assessments |
||
|
Consider enhanced skin assessment methods – thermal infrared imaging, SEM skin color charts |
||
|
Preventive skin care – manage moisture/incontinence |
||
|
Clean after each incontinence event and use appropriate moisture barriers |
||
|
Avoid using alkaline soaps/cleansers |
||
|
For high-risk individuals, consider urine/fecal management systems |
||
|
Use single-layer, breathable, and highly absorbent pads for incontinence |
||
|
Consider using low-friction textiles |
||
|
When appropriate, use soft absorbent materials in skin folds |
||
|
Pressure Redistribution |
||
|
For individuals unable to move independently in bed, turn/reposition every 2-3 hours, and increase frequent micro-adjustments unless contraindicated (Braden activity/mobility score ≤2) |
||
|
For immobile individuals, use high-specification pressure-relieving mattresses (Braden activity/mobility score ≤2) |
||
|
Utilize positioning management aids to minimize friction/shear (pillows, wedges). Use turning/lifting devices (if available). Correct side-lying position with the upper leg positioned forward on the lower leg |
||
|
Add local pressure-relieving protective pads or multilayer structured dressings in high-risk areas (i.e., sacrum, lower buttocks, or heels) (Braden activity/mobility score ≤2) |
||
|
Use pressure-relieving soft pillows, heel pressure-relief pads, or specialized heel boots to elevate heels (Braden sensory perception score ≤3) |
||
|
Ensure adequate positional changes when side-lying (30 degrees). Position the upper leg forward and use a pillow between the legs to support the upper leg |
||
|
When the overall condition of the patient is unstable, perform slow, gradual, frequent, and small positional changes |
||
|
For individuals unable to adequately change positions, use pressure redistribution cushions when seated |
||
|
Seated patients should change positions at least once an hour, and can also shift weight direction to relieve pressure |
||
|
Consult a physical therapist for activity plans when appropriate (Braden activity/mobility score ≤2) |
||
|
Consider alert systems, pressure monitoring, movement sensors |
||
|
Implement early mobilization plans |
||
|
Nutrition |
||
|
Use validated tools for malnutrition screening upon admission |
||
|
For individuals with existing malnutrition or at risk of malnutrition, reduced nutritional intake, NPO >48hrs, or with 2 or more stage pressure injuries (PI) (Braden nutrition score ≤2), consult a nutritionist |
||
|
Provide additional calories, protein, fluids, and nutritional supplements (i.e., multivitamins, arginine, glutamine, HMB) as per nutritional care plan or as needed |
||
|
Continuously assess goals regularly and consult a nutritionist as needed |