An estimated 2.5 million hospital-acquired pressure injuries occur annually in the US, extending hospital stays by 57%, and increasing 30-day readmissions by 22%.

For patients with obesity, these risks intensify due to immobility challenges, atypical pressure distribution, and limitations of standard prevention protocols. Success depends on early recognition of high-risk patients combined with practical adaptation of evidence-based strategies.

Identifying High-Risk Patients and Vulnerable Areas

“The highest risk is from the bed and chairs being too small,” said Precious Barnes, DO, MS, concierge physician at Bespoke Concierge MD, Scottsdale, Arizona, and hospitalist at Skagit Regional Hospital in Mount Vernon, Washington. “If the bed is too small, patients can develop pressure injuries from a leg being pushed up against a railing for too long.” 

The most vulnerable sites include the sacrum, heels, areas under the pannus, and bony prominences like the trochanters.

Ryan Buck, MD, hospitalist and assistant professor of medicine at the Feinberg School of Medicine, Northwestern University, in Chicago, identifies additional high-risk profiles.

“Patients that have impaired mobility at their baseline (such as folks who use motorized chairs), patients with new or worsening pain that makes it difficult to move, patients with neurologic conditions that cause weakness or balance problems, and patients with cognitive issues or confusion would all be at very high risk of getting a pressure ulcer complication while admitted,” he said.

Alexander Watson, MD, physical medicine and rehabilitation physician and diplomate of the American Board of Obesity Medicine, emphasized weight-related comorbidities.

“Most commonly, I see patients with weight-related comorbidities like hip/knee osteoarthritis and low back pain as the most impactful contributors to mobility challenges due to pain, joint instability, or neurologic effects from spinal disorders,” he said.

“The intubated patient or wheelchair-bound patients are some of the hardest to protect,” Barnes said. “Those who are intubated are unaware of painful positions.”

Practical Prevention Strategies

The evidence base centers on repositioning every 2 hours, early mobility consultation, specialized support surfaces, and meticulous skin assessment. Translating these principles into practice requires adapting to equipment delays, staffing constraints, and patient-specific barriers.

“The more they move or turn in a bed or chair, the less likely they will develop pressure injury,” Barnes said.

Equipment matters. “Some great equipment to have are waffle pads which are air filled and essentially float the body in bed,” Barnes said.

External catheters help maintain skin integrity while overhead grab bars enable patient autonomy.

“For the obese patient sometimes it is hard for them to use the side railing to get up but having the overhead pull bar is helpful for them to be able to move independently,” Barnes said.

Buck acknowledged the gap between writing orders and executing them.

“It’s easy for me as the doctor to write an order that says turn them every 2 hours — but then the overworked nurses and patient care technicians have to find the time to do that along with all of the other responsibilities,” he said.

Patient factors complicate adherence.

“Patients that have a lot of pain may really hate having to move so much,” Buck said. “And on a busy unit where patients with obesity might require multiple staff members to help move them or specialized equipment to get them up out of bed, it can be really challenging to keep up.”

Watson emphasized addressing psychological barriers.

“The best strategies are to address the self-perceived limitations head-on, explaining how while the pain is real, it shouldn’t function as a ‘red light’ telling them to stop and sit down,” he said.

He described a transformational case.

“I had one patient with class III obesity who was in the facility for rehabilitation after a decompression/fusion of her lumbar spine. She had longstanding spinal stenosis with significant weakness and neuropathic pain from chronically compressed nerves. Using a combination of an overhead lift, parallel bars, and passionate physical therapists, she was able to trust her feet underneath her to begin walking again. Ultimately, she was able to walk out the door herself on her day of discharge.”

Barnes described a similar success with a morbidly obese patient admitted with pressure injuries. The team implemented an external catheter, used a Hoyer lift for chair transfers, obtained a bariatric bed with ceiling grab bar, and coordinated with physical therapy. “Implementing these things in the hospital allowed the patient to be more mobile and independent,” she said. “The patient was able to be discharged home and social work was able to assist in getting some of the same equipment we were using in the hospital to the patient’s home, so she was able to continue healing at home.”

Top Three Practical Tips for Hospitalists

• Request bariatric equipment early: Don’t wait for visible skin changes. Standard beds and chairs increase pressure injury risk from day one.
• Engage family members as mobility partners: Family presence encourages movement between nursing rounds.
• Coordinate pain management with therapy schedules: Strategic use of multimodal analgesia before physical therapy enables better participation.

Coordinating Teams and Systems

“It really is a collaborative effort,” Buck said. “Nurses often take the lead in doing the assessment and implementing pressure ulcer prevention strategies. Physical and occupational therapists are key to getting patients mobile and moving. Wound care specialists are excellent at identifying signs of injury early and helping with more precise recommendations to intervene.”

Barnes described the typical coordination structure. “Generally, there are multidisciplinary rounds daily in most hospitals. At that time the physical therapist, the doctor, the social worker, and nursing meet to discuss the patient and the barriers to discharge,” she said.

Staffing ratios directly affect prevention capacity. “If you have a nursing assistant who has 15-20 patients, it is going to be difficult for that one assistant to be able to assist 3-4 nurses with turning every patient every 2 hours, on top of helping patients with feeding, getting to the bathroom, walking in the halls, and helping them to shower,” Barnes said.

Vicki Huber, RN, MSN, chief nursing officer at Atlas Mobility, San Ramon, California, pointed to an often-overlooked quality issue. “We identified that patients were being repositioned on schedule but were not consistently maintaining the recommended lateral position,” she said. “Without objective insight into turn quality, this type of issue can persist unnoticed and increase pressure injury risk over time.” 

Watson identified sleep optimization as an underutilized intervention. “Sleep is the single most potent factor in recovery and early mobility that we can influence as physicians,” he said. “We have the ability to schedule most of these interruptions to occur during waking hours, utilize time-release medications to control pain during sleep, and optimize sleep by addressing apnea and insomnia.”

Preventing pressure injuries and mobility complications in hospitalized patients with obesity requires early identification of high-risk patients and practical adaptation of evidence-based strategies. Success depends on matching equipment to patient needs from admission, engaging families as mobility partners, and addressing both physical and psychological barriers to movement.

Huber is an employee of Atlas Mobility. Barnes, Buck, and Watson reported no relevant financial relationships.