Kristy Warren, Encompass

While a newly published AHRQ report shows an overall decrease in hospital-acquired conditions between 2014 and 2017, the good news, unfortunately, doesn’t extend to pressure injuries.

The rate of PIs rose by 6% over the study period. In patient terms, this uptick represents an increase of 119,000 pressure wounds, resulting in close to 5,000 deaths.

The average length of hospital stay more than doubles for patients who acquire PIs during their care. And when you add the PI incident rate of 2.2% to 23.9% in long-term care facilities, the estimated cost of healthcare use and medical management approaches $11 billion annually in the U.S.

The Centers for Medicare & Medicaid Services has called PIs a serious medical condition causing pain, decreased quality of life and increased mortality in aging populations. Such wounds interfere with activities of daily living and functional gains made during rehabilitation, predispose patients to osteomyelitis and septicemia, and are strongly associated with longer hospital stays, and longer rehab facility stays, and mortality.

While not all PIs can be prevented, caregivers are able to prevent many by adhering to best practices. As our population ages, the risk associated with developing a pressure injury increases. Surgical patients that may not have presented as at-risk prior to surgery have an increased risk during and post-operatively of developing a PI. When patients are discharged from acute care, it is imperative that a full clinical assessment report is given.

When conducting a risk assessment, consider all patients to be at risk for pressure injuries. This includes not only bed-bound or chair-bound patients but also those patients whose ability to reposition is impaired.

Use a valid, reliable and age appropriate method of risk assessment that ensures a systematic evaluation of individual risk factors. Assess all patients at admission, at regularly scheduled intervals and whenever there is a change in the patient’s condition. The assessment schedule should be based on the acuity level of the patient and the patient care setting.

Identify all individual risk factors to guide specific preventive treatments. Risk factors for development may include decreased mental status, incontinence, exposure to moisture, device related pressure, friction, shear, immobility, inactivity, nutritional deficits and recent surgery with an extended period of time on the operating table. Care should be modified according to the patient’s individual factors. 

Currently, proper identification of the pressure injury creates a challenge for the extended care environment. The acute care world is being pushed to discharge patients as soon as possible and decrease length of stay. Often times, patients are discharged to long term care facilities with a report of a possible stage 1 pressure injury. Days later this injury becomes a stage III or IV.  

An acute care nurse may have identified what appears to be the beginning stage of a pressure injury, when in reality the injury is developing from the deep within. Deep tissue injuries can take several days to become visible as an open wound on the surface and, as a result, effective measures to prevent the injury progression may be delayed at the SNF.

With the new ICD-10 codes, the hope is that clinicians will be able to better identify and track PIs and specifically deep-tissue injuries. New codes focus on deep tissue damage that is pressure induced. The previous codes described the skin as intact, as a stage 1; unfortunately, the DTI may also present with intact skin but may subsequently result in an open, full-thickness wound as time prevails.   

Federal regulations allow surveyors to impose fines and withhold federal reimbursement for failure to implement and document evidence-based practice for pressure injuries.

Pressure can be minimized or mitigated by utilization of a specialized support surface.  Support surfaces, including mattresses and beds, are used to redistribute pressure on skin and subcutaneous tissue or alternate which parts of the body are exposed to pressure. These surfaces can use air, gel, water or various types of foam. Support surfaces may have additional features such as alternating pressure, air fluidization, low air loss, multi-zones, turn assist or lateral rotation.

When selecting a support surface, take into account the patient’s level of immobility and inactivity and the need for shear reduction and microclimate management. Selection should include a surface with a perimeter that has firm foam borders for stability during ingress/egress. According to research, 51% of falls occur when getting into or out of bed. 

Skilled nursing provides should consider options with pressure-redistribution solutions and floating heel feature that redistributes weight of the leg along the calf to prevent pressure on the Achilles tendon and heels.

Other important factors include comfort, size and weight, risk for PI development as well as the severity and location of existing PIs. Implementation of the correct surface should be expedient.

Pressure injuries prevention guidelines consistently support the use of pressure redistribution surfaces, which provide therapy with or without the addition of alternating pressure therapy. The selection of a specific support surface should be based on the assessment of the clinical characteristics or condition of the patient and support surface characteristics. Incorporating the specific needs of the patient in the care planning will help ensure the most effective clinical outcome possible.