Wound Series Part 3: Pressure Ulcers and Injuries-Risk Factors, Diagnosis, Staging, Management

Pressure ulcers have been known as “bedsores” for hundreds of years. Historically, the term decubitus ulcer or decubiti has also been used to describe these wounds related to pressure and/or immobility. The term “pressure ulcer” was replaced by “pressure injury” in the updated National Pressure Ulcer Advisory Panel Pressure Injury Staging System by the National Pressure Ulcer Advisory Panel (NPUAP) and Pan Pacific Pressure Injury Alliance in April, 2016.¹ The NPUAP now defines a pressure injury as, “localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.”¹ Many, but not all healthcare organizations have adopted the new terminology. However, coding systems such as the International Statistical Classification of Diseases and Related Health Problems – version 10 (ICD-10) continue to use the term pressure ulcers (L89 codes). For the purpose of this educational course, we will be using the term pressure ulcer (PU) with no disrespect intended to the NPUAP. The presence of avoidable facility acquired PUs are recognized internationally as a quality of care indicator for healthcare organizations.² Despite this, CMS reports PUs were present in 3.7 to 7.3 % of residents in the majority of long term care facilities (nursing homes) in the United States (US) in 2014, with no change in the rate between 2013 and 2014. This represents an annual cost of over 3.3 billion US dollars for PUs in long term care settings alone.³ In a National Inpatient Sample of over 6 million persons discharged from acute care facilities (hospitals) in the US, 94,758 individuals had a discharge diagnosis of pressure ulcer.⁴ However, this number only accounts for patients who had a pressure ulcer diagnosis code documented at discharge. The real numbers of incident PUs (those that start in the facility) are difficult to estimate since studies report widely varied rates of PUs across healthcare settings and most of these rates are prevalence rates (any PU present over a given time span).^5,6 Furthermore, individuals with spinal cord injuries (SCI) are particularly vulnerable to PUs. The National Spinal Cord Injury Statistical Center 2017 Annual Statistical Report⁷ indicates about 25% of all persons with SCI in their surveillance program have developed a PU within the first 12 months of the SCI, and 35% have developed at least one PU past the 1st 12 months post-SCI. Others estimate approximately 30 to 60% of all persons with spinal cord injuries (SCI) will experience a PU in their lifetime,^8,9 and 7 to 8% of deaths in persons with SCI are attributed to PUs.¹⁰ The Agency for Healthcare Research and Quality (AHRQ)¹¹ report about 60,000 persons in the US die each year as a direct result of pressure ulcers, but it is unclear where this statistic comes from, or how it was calculated, though it has been cited in many manuscripts.

It is evident from the scientific literature PUs are painful, prone to infection, reduce quality of life, and create a world-wide economic dilemma.^4,5,12 Health care costs related to the management and treatment of chronic wounds (including PUs) in the U.S. exceeds $20 billion annually.¹¹ While the quality of health care and medical technology has improved in the United States during the past 20 years, facility-acquired pressure ulcers have not been eliminated.^3,13 Concurrent with this advancing technology, modern-day patients live longer and are typically hospitalized with higher acuity levels than patients hospitalized years ago. Healthcare organizations must continuously improve in order to adequately impact this important quality of care indicator.^6,14,15

Historically, pressure ulcers have been described in medical literature since at least the 1500_s when Fabricius Hildanus first documented his hypotheses of the causes and characteristics of bedsores. He highlighted the role of “internal supernatural” and “external natural” factors that interrupt the supply of blood and nutrients to tissue as causes of bedsores. Mechanical pressure and incontinence were first identified and key factors in the development of PUs by French surgeon de la Motte in 1722.¹⁶ Major risk factors identified for PU development in the scientific literature since 1987 include increased age, impaired mobility, decreased physical activity, poor nutrition, urinary and/or fecal incontinence, and sensory impairment.^5,17,18,19 Other studies have identified additional risk factors including smoking status, diabetes mellitus (DM), coronary artery disease (CAD), intensive care unit (ICU) stay greater than 3 days, ventilator dependency, pneumonia, sepsis, obesity, surgery, female gender, and peripheral vascular disease (PVD).^20,21,22 Most PUs are considered to be avoidable, therefore, preventable.^1,2,23,24 An “avoidable” PU means that the patient developed a PU and the facility or health caregivers did not perform (or document) one or more of the following: evaluate the patient’s / resident’s clinical condition and PU risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Thomas (2001)²⁵ suggests there may be a few instances where PUs are unavoidable. “Unavoidable” means the patient/resident developed a PU despite the fact that the facility and health care providers had evaluated (and documented) the resident’s clinical condition and PU risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate – all within a timely manner.²⁶ Kennedy ulcers (a specific type of PU often seen at the end of life due to organ/system failure) are one example of “unavoidable” PUs.

Fogerty et al.⁴ conducted a very large retrospective case-control study reviewing admission and discharge data from over six million subjects in the Nationwide Inpatient Sample (NIS) to identify risk factors and demographic differences between those who developed PUs and those that did not. Some may describe their study as a nested case-control²⁷ because they identified a cohort (inpatients in the NIS dataset), followed their records retrospectively from their hospital admission until hospital discharge (during 2003), and separated them into 2 groups: those who developed PUs (cases) and those that did not (controls). There were 94,758 incident PUs documented among a final discharge sample of 6,610,787 persons. Utilizing multivariate logistic regression analysis on 45 common diagnoses identified in persons with PUs, they reported odds ratios (estimate of relative risk) for the most significant risk factors associated with developing PUs. Analysis was also conducted stratifying the sample by age, race and gender. Age over 75 years was the strongest PU risk factor identified with an Odds Ratio (OR) of 12.63 (meaning people over 75 years are almost 13 times more likely to develop PUs than younger age groups). Other strong risk factors identified (listed in descending order) include: diagnosis of gangrene (OR 10.94, 95% CI 10.43-11.48), septicemia (OR 9.78, 95% CI 9.33- 10.26), osteomyelitis (OR 9.38, 95% CI 8.81-9.99), nutritional deficiencies (OR9.18, 95% CI 8.81-9.99), pneumonitis (OR 8.70, 95% CI 8.33-9.09), urinary tract infection (OR 7.17, 95% CI 6.96-7.38), paralysis (OR 10.30, 95% CI 9.69-10.96), age 59 to 75 years (OR 5.99, no CI reported), and African American race (OR 5.71, 95% CI 5.35-6.10). Fogerty et al. also reported a statistically significant interaction between race and age, such that as African Americans age, their risk of developing PUs increases faster than the risk Caucasians experience as they age, indicating noteworthy racial disparities. Other significant findings identified in their study highlight some of the strongest risk factors are non-modifiable (age, paralysis, race) while others are potentially modifiable (infection, nutritional deficiencies). Therefore, exploration is needed to determine when interventions are most effective in those persons with non-modifiable risk factors (such as age > 75, darker skin, or paralysis) or if interventions should be initiated in all persons over 75 years old, with darker skin, or with paralysis. Investigations should also examine the most effective interventions to reduce or eliminate the identified modifiable risk factors (infection and nutritional deficiencies) and ways to accurately identify them in patients.

The purpose of identifying a risk factor is to intervene and lower the associated risk. Identifying the strongest PU risk factors is important to be able to provide evidence-based interventions and thereby lower the likelihood of someone developing a PU or halting the progression of the PU. PU risk assessment tools provide a tangible way to quantify potential risk so that interventions may be reserved for those at highest risk and avoid unnecessary interventions and higher financial expenditures on those who may not need them.²⁸

Cowan et al. (2012)²² conducted a retrospective analysis in a Veteran population to identify the strongest PU predictive model which demonstrated four medical factors (malnutrition, surgery, pneumonia, candidiasis) were more predictive of PU than total Braden Scale for Predicting Pressure Ulcer scores. The finding of a diagnosis of candidiasis as a risk factor for PUs may be related to medical conditions where candidiasis is most common (could it be a proxy variable for impaired immune function?). More research is needed to explore these relationships. Nevertheless, this research provides valuable information that may enhance current risk factor assessments. Identification of factors affecting the development of PUs is imperative in the present day population in order to select patients for effective prevention interventions. Furthermore, evaluation of the efficacy of existing preventive interventions must be ongoing, and new innovative interventions must be explored in order to impact PU incidence and prevalence significantly.^4,29

One criticism of existing PU risk assessment tools is that “neither risk factors nor the weights attributed to them have been identified using adequate statistical techniques.”³⁰ Risk factors are those factors or conditions that are noted to be most strongly associated with the outcome of interest. In order to provide evidence-based measures in the prevention of PUs, an effective means of identifying those at highest risk is imperative. Other criticism of PU risk assessment tools includes the lack of clear evidence that risk assessment tools have significant impact on clinical outcomes such as PU incidence rates,^31-33 the subjective nature of some of the assessments,^32,33 the lack of tools for specific settings such as the perioperative environment,^34,35 and the fact that no one assessment tool could account for every risk factor.³³ Current risk assessment tools may require further development, improved statistical evaluation, and possible modification in order to remain applicable to present-day populations.

Thomas²⁵ posits an explanation for an unchanging incidence of PUs as “a failure of known effective prevention treatment to be applied, or the failure of prevention strategies to be effective despite being applied” (p.298). Effective preventive measures may not be applied if individuals are not appropriately identified as being at risk. Risk-screening tools are useless if they are not applicable to the population being screened, if they are used inconsistently, or scored incorrectly.^25,32,36

Pressure ulcer staging provides a way to communicate the degree of tissue damage in pressure ulcers. The staging system was defined by Shea in 1975 and provides a name to the amount of anatomical tissue loss. The original definitions were confusing to many clinicians and lead to inaccurate staging of ulcers associated or due to perineal dermatitis and those due to deep tissue injury.⁵⁹ The original stages ranged from Stage I (less obvious and potentially reversible damage) to Stage IV (damage extending to muscle, tendon and/or bone). “Unstageable” and “suspected Deep Tissue Injury” (sDTI) were added as additional ‘stages’ or descriptors in 2007.⁵⁹ In April, 2016, the NPUAP again revised their PU staging system to include new “pressure injury” terminology to replace “pressure ulcer” terms, deleting “suspected” from Deep Tissue Injury classification, clarification about moisture-related skin damage, specifics on assessment of darkly pigmented skin, adding medical device-related pressure injury and mucosal pressure injury definitions, and using Arabic numbers to replace Roman numerals.^1,60,61 Please see the new NPUAP Staging system in the clinical pearls box below.

It is important to note PUs (pressure injuries) should never be “back-staged,” meaning once a wound is identified as a Stage 3 pressure ulcer/injury, it is never referred to as a Stage 1 or 2. Rather, the Stage 3 pressure ulcer/injury which is healing would be referred to as a “healing Stage 3 pressure ulcer/injury.” In addition, only pressure ulcers/injuries are “staged.” Diabetic foot ulcers may be “graded” (such as Wagner Grades) but no other wounds are “staged.”

Whittington & Briones⁴⁹ estimated annual medical costs in the United States (US) associated with treating pressure ulcers exceed $5 billion dollars annually. Fogerty et al.⁴ estimated this cost to be higher at $10,845 per patient, exceeding a total $18.5 billion dollars annually. Furthermore, studies suggest it costs less to prevent a pressure ulcer than to treat a pressure ulcer.^{23, 62} Individuals with pressure ulcers have higher mortality rates^{63, 64} and up to five-fold increased hospital length of stay.^65,66 Updated in 2014, the AHRQ document “Preventing Pressure Ulcers in Hospitals: 1. Are we ready for this change?” reports Medicare estimated each pressure ulcer added $43,180 in costs to a hospital stay in 2007.¹¹ Additionally, AHRQ indicates the cost of pressure ulcers is $9.1-$11.6 billion dollars annually in the US with costs of individual patient care related to PUs go from $20,900 to 151,700 per pressure ulcer.¹¹ Interestingly, Barbara Braden gave a NPUAP lecture, “Costs of Pressure Ulcer Prevention: Is it really cheaper than treatment?” Given May 9, 2013, she discussed the fact that when pressure ulcer prevention interventions are put in place, patient falls are also noted to decrease.⁶⁷

Please see the AHRQ toolkit for preventing PU in hospitals (content last reviewed in October, 2014)¹¹ online here. The approach to managing pressure ulcers should always focus on PREVENTION. Prevent the ulcer in the first place! If the patient develops pressure related injury (despite preventive measures), then evidence-based practice related to wound healing should be administered but always with PREVENTION in the treatment plan. Prevent further breakdown. Prevent the pressure ulcer from deteriorating or worsening to a deeper stage. Evidence suggests that offloading and pressure reduction/redistribution should be a primary goal of treatment of pressure ulcers, along with eliminating shearing and friction forces. Addressing other key contributing or risk factors is also critical. Knowing what intrinsic and extrinsic factors contribute to skin breakdown is important. Intrinsic factors such as age, immune function, nutrition and disease states (co-morbid conditions) should be considered. Extrinsic factors such as dry skin, friction, transfer equipment, medications, and moisture should also be addressed.

Maintaining adequate nutrition and hydration should be an essential component of PU management plans. Nutritional assessments should include: current and usual weight, history of involuntary weight loss, nutrition intake (protein, calories, fluid), appetite, dental health, chewing, swallowing or feeding problems, medical or surgical history affecting intake or absorption, drug / nutrient interactions, psychosocial factors (mood, finances, cooking ability, culture, preferences) and appropriate laboratory values. Common laboratory analysis includes serum albumin (20 days half-life indicates chronic disease state, values below 3.5g/dl indicates increased risk); serum pre-albumin has a 2 to 3 day half-life, which some providers feel may provide a more current reflection of protein stores (values below 15 mg/dl indicates increased risk); a total lymphocyte count is an indicator of protein-calorie malnutrition (values below 1,800 mm³ indicates risk); serum transferring is also a malnutrition indicator (values below 200 mg/dl indicates risk).

Managing excessive moisture (incontinence, sweat, spilled liquids) on the skin surface of patients at risk for PU is another critical preventive and management goal. Managing incontinence includes establishing a bowel and bladder program, cleansing the skin after soiling with pH balanced cleansers, and using incontinence skin barriers (creams, ointments, etc.) to protect and maintain intact skin. Consider a pouching system or collection device to protect from effluence if fecal incontinence is an issue. Indwelling catheters may be indicated for short term use with severe incontinence-related dermatitis and difficult to manage urinary incontinence. In addition, limit the use of diapers, but if briefs, diapers or underpads are used, make sure they are the type that wick moisture from the skin.

Addressing impaired mobility includes patient and caregiver education and establishing a turning/repositioning schedule for patients confined to the bed or a chair. This should include repositioning the patient every 2-4 hours with the support of bony prominences. Keep the head of the bed at 30 degrees or less except for tube fed patients (but allow elevation for 1 hour after meals). Avoid “donuts” (rings meant for under coccyx areas), and pulling of the patient across the bed or a chair surface. Place pressure-redistribution surfaces on bed and chair surfaces.

Prevention is paramount! Off load!

Address healing impediments, especially nutrition, moisture, friction and shear.

Use appropriate mnemonics to help guide wound bed preparation and wound healing approaches.

Any topical wound therapy that you select should show expected improvement in 2 to 4 weeks. If not, then re-evaluate the wound and evaluate for possible infection (quantitative tissue analysis). Consider measures to address etiologic and systemic factors (nutrition, shear, and diabetes or comorbid disease control). Change to another product. If the wound continues to worsen or does not improve after doing these things, consider malignancy (biopsy for histopathology) or autoimmune disease(s) as potential contributing factors such as Pyoderma Gangrenosum.

Summary. As stated before, many changes have occurred in health care over the past 20 years. Nursing care delivery, hospital organizational frameworks, quality improvement, financial coverages, not to mention technology (including electronic records), and perhaps the overall face of our present-day patient population.^74-80 Yet, even with multiple pressure ulcer prevention programs implemented nationwide, pressure ulcer incidence and prevalence (and number of deaths attributed to pressure ulcers annually by the CDC) have not changed significantly in many facilities. Researchers need to determine why and develop innovative approaches to solve this dilemma. The effectiveness of pressure ulcer prevention and treatment interventions must be determined. Guidelines must be based on current, high-quality scientific evidence, and impediments to guideline implementation must be addressed. There are significant gaps in the scientific literature regarding pressure ulcer risk assessment, particularly in regard to present-day populations, and how pressure ulcer risk assessment may impact patient outcomes.³³ New conceptual models of pressure ulcer development, risk assessment, and effective pressure ulcer prevention interventions may need to be developed.^5,11,29

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