LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this continuing education course, you will have increased your understanding of pressure injury assessment, prevention, and treatment. Specific learning objectives to address potential knowledge gaps include:

• Discuss the impact of pressure injuries on individuals, healthcare facilities, and society.
• Explain the risk factors for developing pressure injuries.
• Describe the process of conducting risk assessments and measuring risk associated with pressure injuries.
• Identify actions to help prevent pressure injuries.
• Describe the staging of pressure injuries.
• Discuss effective wound treatment and management of pressure injuries.
• Describe the factors affecting pressure injury healing.
• Explain the essential information for documentation of pressure injuries in the patient record.

INTRODUCTION

When individuals, including healthcare clinicians, are asked about organs in the human body, their responses range from brain, heart, lungs, liver, to kidneys. However not many healthcare professionals stop to consider the skin as an organ. The skin is in fact the largest organ in the human body—and essential to life and well-being.

Human skin serves many vital functions, the most critical of these being to provide a barrier between the external environment and the internal environment of the body. Similar to any other organ in the body, the human skin is susceptible to disease and injury. Wounds involving the skin are a frequent occurrence in all age groups.

A pressure injury is a wound unlike any other, in that its cause is not surgery or trauma but death of the skin and underlying tissues from ischemia due to intense and/or prolonged pressure. A pressure injury can also result from a combination of pressure and shear. There are many factors that contribute to the development of a pressure injury and whether or not it will heal, but the biggest factor in all of these is pressure.

Pressure injury is not new, and the terminology to describe it has varied over time:

• Decubitus (18th century)
• Decubitus ulcer (ca. 1950s)
• Bed sore (ca. 1970s)
• Pressure sore (ca. 1980s)
• Pressure ulcer (ca. 1990s)
• Pressure injury (2016–present)
  (PA DOH, 2017)

Defining “Pressure Injury”

The four-stage progressive classification of pressure injury, which became the gold standard for healthcare clinicians, was created in 1975 by Dr. J. Darrell Shea, who was an orthopedic surgeon and spinal injury specialist (Levine, 2019). Over the years, the definition of a pressure injury has been refined as medical knowledge and understanding of the disease process has advanced, along with improvements in treatment approaches and imaging technology.

In April 2016, the National Pressure Injury Advisory Panel (NPIAP) (at that time called the National Pressure Ulcer Advisory Panel, or NPUAP) updated the term pressure ulcer to pressure injury, updated the staging system, replaced the use of Roman numerals with Arabic numerals, and updated the definition of a pressure injury. This process of change started in 2014 when a task force was set up by the NPIAP to evaluate the existing staging terminology. One prominent outcome of the task force review was the adoption of the term pressure injury instead of pressure ulcer. The two main reasons cited for this change were:

• Stage 1 pressure injuries and deep tissue injuries were never ulcers.
• An ulcer cannot be present without an injury, but an injury can be present without an ulcer.

The overriding aim of the changes was to encompass the current knowledge of the causes of pressure injuries, along with clarifying the anatomical characteristics existent or nonexistent in each stage of injury (Edsberg et al., 2016).

The NPIAP definition states:

A pressure injury is localized damage to the skin and 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, comorbidities and condition of the soft tissue (NPIAP, 2016a).

(Changes in the staging system will be discussed later in this course.)

The localized damage in pressure injury is the result of compression of soft tissue, which interferes with the tissue’s blood supply, leading to vascular insufficiency, tissue anoxia, and cell death. Pressure injuries can develop within 24 hours of the initial pressure but may take as long as a week to present themselves. The first tissues to die are nearest the bone, and as the pressure and anoxia continue, the remaining layers of tissue begin to die. The skin is the last to die. The damage resembles an iceberg, with a smaller amount of damage visible at the surface and a large amount of damage below the surface.

Pressure injury usually occurs over bony prominences such as the sacrum, ischium, heel, and trochanter, where there is less tissue to compress. Other factors—such as shearing, skin moisture, heat, poor nutrition, comorbidities, and incontinence—also contribute to the tissue breakdown.

The Impact of Pressure Injury

Each year about 1.7 million individuals in the United States develop a pressure injury. The overall prevalence of pressure injury can be as high as 17% of the general population (Cowan, 2019). Pressure injury represent a major burden of sickness and reduced quality of life for patients and their caregivers, and the impact of pressure injury is staggering.

• First and foremost, these wounds are very painful, causing patients a great deal of suffering.
• Quality of life is affected, as the patient must alter activities to help heal the wound, and they may face long-term hospitalization.
• The anatomical location of the injury may result in a loss of dignity.
• The burden of dealing with a chronic wound can result in stress, anxiety, depression, less autonomy and security, and impaired social functioning.
• A nonhealing injury is at high risk for infection, which can be life threatening.
• Pressure injury treatment may require surgical procedures such as debridement, colostomies (for those injuries located near the anus), amputations, and grafts or flaps that the patient would otherwise not have to face.
• An injury that heals forms scar tissue, which lacks the strength of the original tissue and is more easily reopened again and again.

Pressure injury is a particular problem for bedbound individuals who are hospitalized, in nursing homes, or have spinal cord injuries. Data indicate that around 2.5 million patients in acute-care facilities develop a pressure injury annually (referred to as a hospital-acquired injury), and that 60,000 patients die as a result of the complications of a hospital-acquired injury (HRET, 2017).

In hospitalized patients, pressure injuries are more likely to occur among older adults (65 years and older), and patients with pressure injuries are three times more likely to be discharged to a long-term care facility than those with other diagnoses. Approximately 70% of pressure injuries develop in those over 70 years of age. Pressure injury in older patients who sustain hip fractures is a comparatively frequent occurrence, particularly in fragile elderly patients (WOCN, 2016a; Shah, 2018; Forni, 2018).

Pressure injuries also increase healthcare professionals’ workloads, as additional time and care must be provided to manage and treat patients’ pressure injuries—more dressing changes, more medications, and more documentation.

Healthcare costs due to pressure injury are immense. The cost of care for a full-thickness pressure injury can be as much as $70,000, and the overall financial burden for treatment of pressure injuries in the United States has been estimated at $11 billion yearly (HRET, 2017).

Litigation may be brought against a hospital and its staff for neglect, malpractice, and elder abuse if a patient develops a pressure injury while in the hospital. Awards can be in the millions of dollars. And the bad publicity that follows will damage the hospital’s reputation, bottom line, and the trust patients have that they can be cared for safely.

Pressure injuries are reportable to state and federal agencies. The information is placed in published reports accessible by the public, which then allows the public to compare facility outcomes. Regardless of the care setting (acute, skilled nursing facility, home health, and inpatient rehabilitation facilities), all providers must account for the number of pressure injuries that were present on admission and on subsequent reassessments, whether they have closed or worsened (CMS, 2019a).

Governmental agencies may levy fines against a hospital for pressure injuries. The Centers for Medicare and Medicaid Services no longer pays a hospital for the additional care needed for a patient who develops a hospital-acquired pressure injury, and the hospital must provide the care nonetheless. Similarly, the Affordable Care Act established a financial incentive program for hospitals to improve patient safety by applying a 1% payment reduction to hospitals who score poorly with respect to the occurrence of hospital-acquired conditions, of which pressure injuries are one (CMS, 2019b).

The Agency for Healthcare Research and Quality reported that between 2014–2017 the number of hospital-acquired pressure injuries (HAPI) increased by 6% in the United States. In 2018, the Joint Commission Center for Transforming Healthcare began an initiative to find root causes and solutions to decrease HAPI. Once completed, the Joint Commission will analyze the findings from the study, with the goal of identifying solutions and interventions that have widespread applicability to all facilities. Once formulated these will be made available to all hospitals (TJC, 2019).

Thus, the assessment, prevention, and treatment of pressure injuries are of major importance to healthcare professionals and to the facilities at which they practice. Most facilities have developed pressure injury prevention programs to put these ideas into practice and prevent negative outcomes for both the patient and the facility.