Floating Heels: More Than Just Pillow Talk

The way you float the heels matters: new guidelines mean better patient care and lower risk of citations.

Floating Heels

When it comes to wound care, the term “float the heels” means that a patient’s heel should be positioned in such a way as to remove all contact between the heel and the bed. So given this context, is the following statement true or false?

Patients on support surfaces do not require their heels to be floated. 

If you guessed false, then give yourself a gold star. Yes, all patients at risk of breakdown, and those with pressure ulcers on the heel, must have their heels totally offloaded.  This requirement has not changed.

But here’s the catch – what has changed is the manner in which we should be accomplishing this.

Official Floating Heels Guidelines

Traditionally, the most common approach to floating the heels has been by placing pillows under the lower leg, positioned so as not to place pressure on the Achilles tendon and the heel.  Unfortunately, there has always been a problem with this method.

While you might position your patients perfectly in bed, with heels properly floated, the chances that they’ll remain perfectly still once you’re gone is slim to none. Patients naturally move and reposition themselves for comfort, which means upon returning, you will most likely find that the legs and heels are no longer in that same position.

This repositioning is a common occurrence, and leaves your patients vulnerable to the forces of friction, shear and pressure on the heel.  This traditional heel-floating technique often leads to unnecessary heel breakdown, and a failure to protect our patients properly. Additionally, facilities may be cited for floating Stage III heel ulcers on a pillow.

So what’s the official word on the subject? The 2014 International Guidelines on the Prevention and Treatment of Pressure Ulcers tell us that:

  • You can continue to float the heels with pillows under the full length of the calf for short-term use in alert and cooperative individuals.
  • For individuals with Stage I or II pressure ulcers on the heel, you can float the heels, or use a heel suspension device.
  • For individuals with Stage III, Stage IV or Unstageable pressure ulcers, heel suspension devices are strongly recommended.

What is a proper heel suspension device?

First of all, let’s talk about what a heel suspension device is not. A padded bootie (the kind we’ve used for years) simply doesn’t qualify.  Padding will never offload the tissues, it will only serve to somewhat cushion the skin.

What you do need is a lower leg boot specifically constructed to place the heel in a cup-like device that does not allow the heel any contact at all with any surface.   Patients can then reposition themselves in bed without fear of losing the pressure offload.  Some devices also have stabilization bars that can be used to prevent outward or inward rotation of the lower extremity.   When selecting a heel suspension device, it’s important to assess how much heat and humidity will be trapped on the skin underneath the boot.  This is a potential issue, since heat and humidity on the skin can predispose it to breakdown.

Is this a legal matter?

Wound care clinicians often ask if these revised techniques are lawfully required. The short answer is no, they are not. But – and it’s a big but -it is not uncommon for lawyers to refer to these guidelines in court, and question whether practices were in accordance with these standards.

So if you or your practice were subjected to such inquiries in a court setting, would you want your reply to be no? Of course not.  Citing ignorance when it comes to the change in heel-floating standards will not excuse wound care clinicians from the consequences.

Have you changed your practice to reflect these new guidelines? 

As responsible wound-care professionals, we know the use of heel suspension devices is the best way to offload.  And because current guidelines support this, if your practice hasn’t already done so, it’s time to implement them now.

Are heel suspension devices already used in your work setting? If so, have you seen a noticeable difference in patient care, compared to the traditional use of pillows and positioning? If not, do you have plans to foster change within your practice? We’re curious to hear your stories. Please leave your comments below.

What do you think?

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Floating Heels: More Than Just Pillow Talk.  

The way you float the heels matters. New guidelines mean better patient care and lower risk of citations.

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