Epidemiology, pathogenesis and risk assessment of pressure ulcers
- Dan Berlowitz, MD, MPH
Dan Berlowitz, MD, MPH
- Boston University Schools of Public Health and Medicine
- Section Editors
- Kenneth E Schmader, MD
Kenneth E Schmader, MD
- Editor in Chief — Geriatric Medicine
- Section Editor — Geriatrics
- Chief, Division of Geriatrics
- Duke University
- Director, Geriatric Research Education and Clinical Center
- Durham VA Medical Centers
- Hilary Sanfey, MD
Hilary Sanfey, MD
- Section Editor — General Surgical Principles; Quality and Safety
- Professor of Surgery
- SIU School of Medicine
Pressure ulcers are lesions caused by unrelieved pressure that results in damage to the underlying tissue. Generally, these are the result of soft tissue compression between a bony prominence and an external surface for a prolonged period of time [1,2]. The consequences of pressure-induced skin injury range from nonblanchable erythema of intact skin to deep ulcers extending to the bone.
The ulcer imposes a significant burden not only on the patient, but the entire health care system. Reducing the frequency of pressure ulcers is an important component of current goals for patient safety as evidenced by the Institute for Healthcare Improvement (IHI) 5 Million Lives Campaign, and the decision by the United States Center for Medicare and Medicaid Services to not reimburse hospitals for the treatment of hospital-acquired pressure ulcers [3-5].
Knowledge of factors contributing to the pathogenesis of pressure ulcers allows the identification of patients at risk for ulcer development such that preventive measures may then be targeted to those specific patients. The epidemiology, pathogenesis, risk factors, and risk assessment of pressure ulcers will be reviewed here. Prevention and treatment are discussed separately. (See "Prevention of pressure ulcers" and "Clinical staging and management of pressure-induced injury".)
Pressure ulcers are among the most common conditions encountered in acutely hospitalized patients or those requiring long-term institutional care. The incidence of pressure ulcers varies widely by clinical setting [6-8]. An estimated 2.5 million pressure ulcers are treated each year in acute care facilities in the United States alone [6,7].
Methods of studying and reporting pressure ulcer incidence include direct patient examination , use of databases , and surveys . These studies tend to be small, and often involve only a single facility, making generalizability uncertain. Caution is required when interpreting the reported incidence and prevalence rates for pressure ulcers since the methodology and duration of follow-up varies between studies. The most accurate estimates are derived from studies where clinician-researchers have directly examined the patients. Studies have also differed on whether they included superficial ulcer stages (stage 1 ulcers (table 1)). Although stage 1 ulcers are frequently encountered, many epidemiological studies have elected not to include them since they are difficult to reliably detect.
- Thomas DR. The new F-tag 314: prevention and management of pressure ulcers. J Am Med Dir Assoc 2006; 7:523.
- Sibbald RG, Krasner DL, Woo KY. Pressure ulcer staging revisited: superficial skin changes & Deep Pressure Ulcer Framework©. Adv Skin Wound Care 2011; 24:571.
- Duncan KD. Preventing pressure ulcers: the goal is zero. Jt Comm J Qual Patient Saf 2007; 33:605.
- Armstrong DG, Ayello EA, Capitulo KL, et al. New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient hospital care present on admission indicators/hospital-acquired conditions policy: a consensus paper from the International Expert Wound Care Advisory Panel. Adv Skin Wound Care 2008; 21:469.
- McCannon CJ, Hackbarth AD, Griffin FA. Miles to go: an introduction to the 5 Million Lives Campaign. Jt Comm J Qual Patient Saf 2007; 33:477.
- Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA 2006; 296:974.
- Lyder CH. Pressure ulcer prevention and management. JAMA 2003; 289:223.
- http://www.npuap.org/wp-content/uploads/2012/03/Nutrition-White-Paper-Website-Version.pdf (Accessed on May 08, 2013).
- Bergstrom N, Braden B, Kemp M, et al. Multi-site study of incidence of pressure ulcers and the relationship between risk level, demographic characteristics, diagnoses, and prescription of preventive interventions. J Am Geriatr Soc 1996; 44:22.
- Brandeis GH, Morris JN, Nash DJ, Lipsitz LA. The epidemiology and natural history of pressure ulcers in elderly nursing home residents. JAMA 1990; 264:2905.
- Guralnik JM, Harris TB, White LR, Cornoni-Huntley JC. Occurrence and predictors of pressure sores in the National Health and Nutrition Examination survey follow-up. J Am Geriatr Soc 1988; 36:807.
- Russo, CA, Steiner, C, Spector, W. Hospitalizations related to pressure ulcers among adults 18 years and older, 2006. HCUP Statistical Brief #64. December 2008. Agency for Healthcare Research and Quality. Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb64.pdf. (Accessed on January 29, 2009).
- Petzold T, Eberlein-Gonska M, Schmitt J. Which factors predict incident pressure ulcers in hospitalized patients? A prospective cohort study. Br J Dermatol 2014; 170:1285.
- Lyder CH, Wang Y, Metersky M, et al. Hospital-acquired pressure ulcers: results from the national Medicare Patient Safety Monitoring System study. J Am Geriatr Soc 2012; 60:1603.
- Li Y, Yin J, Cai X, et al. Association of race and sites of care with pressure ulcers in high-risk nursing home residents. JAMA 2011; 306:179.
- Baumgarten M, Margolis DJ, Localio AR, et al. Pressure ulcers among elderly patients early in the hospital stay. J Gerontol A Biol Sci Med Sci 2006; 61:749.
- Inman KJ, Sibbald WJ, Rutledge FS, Clark BJ. Clinical utility and cost-effectiveness of an air suspension bed in the prevention of pressure ulcers. JAMA 1993; 269:1139.
- Baumgarten M, Margolis DJ, Orwig DL, et al. Pressure ulcers in elderly patients with hip fracture across the continuum of care. J Am Geriatr Soc 2009; 57:863.
- Spector WD, Kapp MC, Tucker RJ, Sternberg J. Factors associated with presence of decubitus ulcers at admission to nursing homes. Gerontologist 1988; 28:830.
- Shepard MA, Parker D, DeClercque N. The under-reporting of pressure sores in patients transferred between hospital and nursing home. J Am Geriatr Soc 1987; 35:159.
- Reed JW. Pressure ulcers in the elderly: prevention and treatment utilizing the team approach. Md State Med J 1981; 30:45.
- Spector WD, Fortinsky RH. Pressure ulcer prevalence in Ohio nursing homes: clinical and facility correlates. J Aging Health 1998; 10:62.
- Hing, E. Characteristics of nursing home residents, health status and care received; National Nursing Home Survey, United States, May-December 1977. Hyattsville, MD: US Department of Health and Human Services; Public Health Service; Office of Health Research, Statistics, and Technology; National Center for Health Statistics 1981.
- Scheckler WE, Peterson PJ. Infections and infection control among residents of eight rural Wisconsin nursing homes. Arch Intern Med 1986; 146:1981.
- Berlowitz DR, Ash AS, Brandeis GH, et al. Rating long-term care facilities on pressure ulcer development: importance of case-mix adjustment. Ann Intern Med 1996; 124:557.
- Bergstrom N, Braden B. A prospective study of pressure sore risk among institutionalized elderly. J Am Geriatr Soc 1992; 40:747.
- Hartmann CW, Shwartz M, Zhao S, et al. Longitudinal Pressure Ulcer Rates After Adoption of Culture Change in Veterans Health Administration Nursing Homes. J Am Geriatr Soc 2016; 64:151.
- Ferrell BA, Josephson K, Norvid P, Alcorn H. Pressure ulcers among patients admitted to home care. J Am Geriatr Soc 2000; 48:1042.
- Schwien T, Gilbert J, Lang C. Pressure ulcer prevalence and the role of negative pressure wound therapy in home health quality outcomes. Ostomy Wound Manage 2005; 51:47.
- Bergquist S, Frantz R. Braden scale: validity in community-based older adults receiving home health care. Appl Nurs Res 2001; 14:36.
- Reuler JB, Cooney TG. The pressure sore: pathophysiology and principles of management. Ann Intern Med 1981; 94:661.
- Smart H. Deep tissue injury: what is it really? Adv Skin Wound Care 2013; 26:56.
- Thomas DR. Does pressure cause pressure ulcers? An inquiry into the etiology of pressure ulcers. J Am Med Dir Assoc 2010; 11:397.
- KOSIAK M. Etiology and pathology of ischemic ulcers. Arch Phys Med Rehabil 1959; 40:62.
- Gefen A. How much time does it take to get a pressure ulcer? Integrated evidence from human, animal, and in vitro studies. Ostomy Wound Manage 2008; 54:26.
- Berlowitz DR, Brienza DM. Are all pressure ulcers the result of deep tissue injury? A review of the literature. Ostomy Wound Manage 2007; 53:34.
- Ham W, Schoonhoven L, Schuurmans MJ, Leenen LP. Pressure ulcers from spinal immobilization in trauma patients: a systematic review. J Trauma Acute Care Surg 2014; 76:1131.
- Bauer J, Phillips LG. MOC-PSSM CME article: Pressure sores. Plast Reconstr Surg 2008; 121:1.
- Stekelenburg A, Gawlitta D, Bader DL, Oomens CW. Deep tissue injury: how deep is our understanding? Arch Phys Med Rehabil 2008; 89:1410.
- Fromy B, Lingueglia E, Sigaudo-Roussel D, et al. Asic3 is a neuronal mechanosensor for pressure-induced vasodilation that protects against pressure ulcers. Nat Med 2012; 18:1205.
- Cooney LM Jr. Pressure sores and urinary incontinence. J Am Geriatr Soc 1997; 45:1278.
- Coleman S, Nixon J, Keen J, et al. A new pressure ulcer conceptual framework. J Adv Nurs 2014; 70:2222.
- Lowthian, PT. Underpads in the prevention of decubiti. In: Bedsore biomechanics, Kenedi, RM, Cowden, JM, Scales, JT (Eds), University Park Press, Baltimore, MD 1976. p.141.
- Zappolo, A. Discharges from nursing homes. National Nursing Home Survey (Publication #PHS S81-1715). Hyattsville, MD: US Department of Health and Human Services, 1981.
- Brandeis GH, Ooi WL, Hossain M, et al. A longitudinal study of risk factors associated with the formation of pressure ulcers in nursing homes. J Am Geriatr Soc 1994; 42:388.
- Allman RM, Laprade CA, Noel LB, et al. Pressure sores among hospitalized patients. Ann Intern Med 1986; 105:337.
- Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. J Am Geriatr Soc 2007; 55:780.
- Barbenel JC, Ferguson-Pell MW, Kennedy R. Mobility of elderly patients in bed. Measurement and association with patient condition. J Am Geriatr Soc 1986; 34:633.
- EXTON-SMITH AN, SHERWIN RW. The prevention of pressure sores. Significance of spontaneous bodily movements. Lancet 1961; 2:1124.
- Berlowitz DR, Wilking SV. Risk factors for pressure sores. A comparison of cross-sectional and cohort-derived data. J Am Geriatr Soc 1989; 37:1043.
- Takeda T, Koyama T, Izawa Y, et al. Effects of malnutrition on development of experimental pressure sores. J Dermatol 1992; 19:602.
- Yatabe MS, Taguchi F, Ishida I, et al. Mini nutritional assessment as a useful method of predicting the development of pressure ulcers in elderly inpatients. J Am Geriatr Soc 2013; 61:1698.
- Berlowitz DR, Brandeis GH, Morris JN, et al. Deriving a risk-adjustment model for pressure ulcer development using the Minimum Data Set. J Am Geriatr Soc 2001; 49:866.
- Bliss M, Simini B. When are the seeds of postoperative pressure sores sown?. Often during surgery. BMJ 1999; 319:863.
- Preventing pressure sores. Lancet 1990; 335:1311.
- Schubert V. Hypotension as a risk factor for the development of pressure sores in elderly subjects. Age Ageing 1991; 20:255.
- Mawson AR, Biundo JJ Jr, Neville P, et al. Risk factors for early occurring pressure ulcers following spinal cord injury. Am J Phys Med Rehabil 1988; 67:123.
- Allman RM, Goode PS, Patrick MM, et al. Pressure ulcer risk factors among hospitalized patients with activity limitation. JAMA 1995; 273:865.
- Horn SD, Bender SA, Ferguson ML, et al. The National Pressure Ulcer Long-Term Care Study: pressure ulcer development in long-term care residents. J Am Geriatr Soc 2004; 52:359.
- Sanada H, Nagakawa T, Yamamoto M, et al. The role of skin blood flow in pressure ulcer development during surgery. Adv Wound Care 1997; 10:29.
- Moore ZE, Cowman S. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database Syst Rev 2014; :CD006471.
- Chou R, Dana T, Bougatsos C, et al. Pressure ulcer risk assessment and prevention: a systematic comparative effectiveness review. Ann Intern Med 2013; 159:28.
- Stechmiller JK, Cowan L, Whitney JD, et al. Guidelines for the prevention of pressure ulcers. Wound Repair Regen 2008; 16:151.
- Stansby G, Avital L, Jones K, et al. Prevention and management of pressure ulcers in primary and secondary care: summary of NICE guidance. BMJ 2014; 348:g2592.
- Pressure ulcers in adults: Prediction and prevention. Clinical Practice Guideline Number 3, AHCPR Publication no. 92-0047, May 1992.
- Shekelle PG, Ortiz E, Rhodes S, et al. Validity of the Agency for Healthcare Research and Quality clinical practice guidelines: how quickly do guidelines become outdated? JAMA 2001; 286:1461.
- http://ahrq.gov (Accessed on August 25, 2011).
- http://npuap.org/ (Accessed on August 25, 2011).
- Balzer K, Köpke S, Meyer G. NICE recommendation on the use of pressure ulcer risk scores is flawed. BMJ 2014; 348:g3638.
- Webster J, Coleman K, Mudge A, et al. Pressure ulcers: effectiveness of risk-assessment tools. A randomised controlled trial (the ULCER trial). BMJ Qual Saf 2011; 20:297.
- European Pressure Ulcer Advisory Panel (EPUAP). Guidelines on treatment of pressure ulcers. EPUAP Review 1999; 1:31.
- Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden Scale for Predicting Pressure Sore Risk. Nurs Res 1987; 36:205.
- Xakellis GC, Frantz RA, Arteaga M, et al. A comparison of patient risk for pressure ulcer development with nursing use of preventive interventions. J Am Geriatr Soc 1992; 40:1250.
- Bergstrom N, Demuth PJ, Braden BJ. A clinical trial of the Braden Scale for Predicting Pressure Sore Risk. Nurs Clin North Am 1987; 22:417.
- Schoonhoven L, Haalboom JR, Bousema MT, et al. Prospective cohort study of routine use of risk assessment scales for prediction of pressure ulcers. BMJ 2002; 325:797.
- Perneger TV, Gaspoz JM, Raë AC, et al. Contribution of individual items to the performance of the Norton pressure ulcer prediction scale. J Am Geriatr Soc 1998; 46:1282.
- Smith DM, Winsemius DK, Besdine RW. Pressure sores in the elderly: can this outcome be improved? J Gen Intern Med 1991; 6:81.
- Goldstone LA, Roberts BV. A preliminary discriminant function analysis of elderly orthopaedic patients who will or will not contract a pressure sore. Int J Nurs Stud 1980; 17:17.
- Baumgarten M, Rich SE, Shardell MD, et al. Care-related risk factors for hospital-acquired pressure ulcers in elderly adults with hip fracture. J Am Geriatr Soc 2012; 60:277.
- O'Brien DD, Shanks AM, Talsma A, et al. Intraoperative risk factors associated with postoperative pressure ulcers in critically ill patients: a retrospective observational study. Crit Care Med 2014; 42:40.
- Nixon J, Cranny G, Iglesias C, et al. Randomised, controlled trial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pressure ulcers: PRESSURE (pressure relieving support surfaces) trial. BMJ 2006; 332:1413.
- Takahashi PY, Chandra A, Cha SS. Risk factors for pressure ulceration in an older community-dwelling population. Adv Skin Wound Care 2011; 24:72.
- Berlowitz DR, Brandeis GH, Anderson JJ, et al. Evaluation of a risk-adjustment model for pressure ulcer development using the Minimum Data Set. J Am Geriatr Soc 2001; 49:872.