Documenting and treating pressure ulcers

A wound care expert reviewed the stages of pressure ulcers (or injuries).


Beware of the skin exam abbreviation WNL. Instead of “within normal limits,” in many cases, the clinician means “we never looked,” said Christi M. Cavaliere, MD.

The staff plastic surgeon and medical director of wound care at the Cleveland Clinic in Ohio said wound care tends to fall into a silo separate from medical care for complex hospitalized patients.

“I don't think this is ideal,” said Dr. Cavaliere. “I think that we need to merge these two parts because the wound is really a reflection of something going on....Why do we make this one diagnosis so unimportant in the patient's overall picture?”

During her session at Hospital Medicine 2018, she explained why proper documentation and management of pressure ulcers (or injuries) are of utmost importance for all clinicians.

Docs and documentation

In 2016, the National Pressure Ulcer Advisory Panel (NPUAP) changed the term to “pressure injury,” but health care professionals have not fully embraced this update, she said. “It is a little controversial when you adopt ‘injury’ because it sort of insinuates liability and preventability,” said Dr. Cavaliere, who used both terms in her talk.

Pressure ulcers are a costly problem. “The cost of managing a pressure ulcer in 2006 dollars was about $70,000, so I'm sure that this is much higher today,” said Dr. Cavaliere. Also in 2006, there were 503,300 U.S. hospital stays with pressure ulcer as a diagnosis, an increase of almost 80% since 1993, according to a 2008 Agency for Healthcare Research and Quality (AHRQ) report.

Government agencies took action in subsequent years. In 2008, CMS announced it would stop reimbursing hospitals for various hospital-acquired conditions, including some pressure ulcers, depending on their timing. “You have to document it within 24 hours of admission, or you're going to be docked for a hospital-acquired pressure ulcer,” said Dr. Cavaliere.

Typically, patients receive a skin assessment within six hours of admission, and this is usually OK for nursing to do, she noted. However, if a patient has a pressure ulcer, the diagnosis needs to be made by a physician or other licensed independent practitioner, Dr. Cavaliere said. “It can't be the wound nurse” or bedside nurse, who are allowed to stage ulcers but not allowed to assign diagnoses, she said.

In addition to the reimbursement stipulations, AHRQ Patient Safety Indicators (PSI) keep track of hospitals' rates of stage 3, stage 4, and unstageable pressure ulcers. If a pressure ulcer stage 1 or 2 is present on admission and progresses to a stage 3, stage 4, or unstageable injury, “That's going to hit your PSI ratings, as well,” Dr. Cavaliere said. “So accurate staging at the time of admission is really key.”

Deep-tissue pressure injuries also fall into the PSI category, even though these wounds may evolve rapidly, either revealing the actual extent of tissue injury or resolving with no tissue loss, she said. In other words, the hospital will be responsible for the ulcer, but it might go away. “So it really doesn't make sense, the way that we code these versus the way that we're penalized for them,” said Dr. Cavaliere.

Relieving the pressure

Dr. Cavaliere reviewed the different stages of pressure injury, as outlined most recently in 2016 by the NPUAP, and offered tips for treatment and management.

Stage 1: These injuries, nonblanching redness without the presence of a wound, are usually found on the heels or the sacral area and often resolve on their own, she said.

“You don't need to address this; you just need to protect it” by avoiding pressure and shear, Dr. Cavaliere said, adding that dressings are not mandatory. Consider using a pillow under the calves, or skin protectants like foam and moisturizer, she recommended.

Stage 2: In this stage, the injury extends beyond the epidermis into the dermis (but not into adipose or deeper tissues), revealing a wound bed that is viable, pink or red, and moist. “This is going to look like the base of a blister, so a clear fluid-filled blister would be categorized as a stage 2 if it was from pressure,” said Dr. Cavaliere.

Treat these injuries like any partial-thickness skin loss: Foam placement, some petroleum jelly, and antibiotic ointment could do the trick, she said. “If you relieve the pressure, keep it moist, and keep the patient clean, this really has a good chance of healing on its own as well,” Dr. Cavaliere said.

Stage 3: This kind of injury involves full-thickness loss of skin, exposing adipose tissue in the ulcer and often involving granulation tissue and epibole (i.e., rolled wound edges). Tunnels, slough, and eschar may also be visible, although bone, tendon, and muscle are not exposed.

These wounds can progress because they involve full tissue loss, “but it's hard to define if you're looking at a wound that's been there for a while,” Dr. Cavaliere said. If you are unsure whether to stage an advanced wound as a 3 or 4, which are both in the PSI category, “Usually, I would say call it a 4 if you think it's a 4,” she said.

Keep the surface of these wounds moist, but not too wet, Dr. Cavaliere said. If the wound is shallow, use foam alone or hydrocolloid dressings to absorb moisture but also to remain against the wound so that it doesn't dry out, she said. If the wound is draining, Dr. Cavaliere recommended applying moist gauze or hydrogel dressings, which facilitate autolysis in dead tissue, allowing it to break down for debridement.

Stage 4: As in stage 3, stage 4 injuries involve full-thickness skin and tissue loss, but stage 4 ulcers include exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone. Depth varies by anatomical location, but slough, eschar, epibole, and tunneling often occur.

Again, keep the surface moist (but not too wet) by using alginates/hydrofiber, moist gauze, or salt-impregnated gauze, Dr. Cavaliere said. In addition, assess the risks and benefits of negative-pressure wound therapy, which can be used for most types of wounds with depth, she said, but be aware that a 2015 Cochrane review concluded that there is limited evidence available comparing it to alternative pressure ulcer treatments. Of note, negative-pressure wound therapy is contraindicated in patients with untreated osteomyelitis.

Dr. Cavaliere added that pressure injuries cannot be downstaged. “You don't go from a 4 and it's mostly healed to a 2,” she said. “If it's a 4, it's a healing 4.”

Unstageable: Some pressure ulcers are clearly full-thickness injuries but will require some digging to figure out their true extent. With unstageable ulcers, which are obscured by slough or eschar, “You're not going to know where the base lies until you take the dead stuff off and get to the bottom of this,” said Dr. Cavaliere. “These are considered to be something that's at least stage 3 or 4.”

If these injuries are in a dry area, such as the heel or scalp, “Just leave them alone or treat them with betadine, and those should be OK,” she said. “But the ones that start to get really boggy are the ones that you need to worry about.” These boggy areas may require debridement and should be watched closely for infection, Dr. Cavaliere said.

Deep-tissue pressure injury: Pressure-related damage of underlying soft tissue creates this localized area of purple or maroon intact skin or a blood-filled blister. Because of this type of wound's ability to rapidly worsen or resolve, Dr. Cavaliere said this is her least favorite of the stages. “This is a huge percentage of the ones that we get at the Cleveland Clinic, especially patients who are anticoagulated, but you've really just got to watch these and see over time,” she said.

One strategy is to monitor the patient, noting in the chart that he or she has evidence of a pressure injury but that it is evolving, so its stage is unclear, she suggested. “These are patients who are going to need follow-up because if they do have a full-thickness injury and deep-tissue dying, they're going to get worse,” Dr. Cavaliere said.