Prevention of pressure-induced skin and soft tissue injury
- 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
- Professor of Surgery
- SIU School of Medicine
Pressure-induced skin and soft tissue injuries are among the most common conditions encountered in hospitalized patients or those requiring long-term institutional care . Prevention is a cost-effective approach that positively impacts health status [2-6]. As of October 2008, guidelines from the Center for Medicare and Medicaid Services (CMS) in the United States state that hospitals will no longer receive additional payments when patients develop stage 3 or 4 pressure induced injuries (table 1) . Failure to provide appropriate prevention and care may also expose providers to liability .
The prevention of pressure-induced skin and soft tissue injuries will be reviewed here. The treatment, epidemiology, pathogenesis, clinical manifestations, and staging are discussed separately. (See "Epidemiology, pathogenesis, and risk assessment of pressure ulcers" and "Clinical staging and management of pressure-induced skin and soft tissue injury".)
CLASSIFICATION AND TERMINOLOGY
The National Pressure Ulcer Advisory Panel (NPUAP) made changes to their classification in April 2016 and suggested using the terminology "pressure injury" instead of "pressure ulcer" to describe these wounds. (See "Clinical staging and management of pressure-induced skin and soft tissue injury", section on 'NPUAP staging'.)
These changes were made to recognize the fact that lesser degrees of skin damage due to pressure may not be associated with skin ulceration (Stage 1) and that deep tissue injury can occur without overlying skin ulceration (suspected deep tissue injury) (table 1). However, their generalized term "pressure injury" does not address the many other types of injury that can result from pressure, such as rhabdomyolysis in an unconscious patient. Thus, we will use the term "pressure-induced skin and soft tissue injury" to encompass the broad range of ischemic damage that can be caused by prolonged pressure. The terms "pressure-induced skin injury" or "pressure-induced soft tissue (or deep tissue) injury" are used where specifically applicable. We use the term "pressure injury" when referring to the staging of a specific lesion as defined by the NPUAP classification (eg, unstageable pressure injury) or to replace the term "pressure ulcer" in studies published prior to this classification change that use "pressure ulcer" generically when the stage is not specified. We use the term "pressure ulcer" for the specific circumstance where the integrity of the skin surface is disrupted.
Risk assessment, which includes a comprehensive history and physical examination, should identify patients at risk for pressure-induced skin and soft tissue injuries who will benefit from preventive measures as well as factors that are potentially correctable . The pathogenesis, risk factors, and risk prediction tools for pressure-induced skin and soft tissue injuries are discussed in detail separately. (See "Epidemiology, pathogenesis, and risk assessment of pressure ulcers", section on 'Risk factors' and "Epidemiology, pathogenesis, and risk assessment of pressure ulcers", section on 'Risk prediction'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- de Laat EH, Pickkers P, Schoonhoven L, et al. Guideline implementation results in a decrease of pressure ulcer incidence in critically ill patients. Crit Care Med 2007; 35:815.
- 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.
- Padula WV, Mishra MK, Makic MB, Sullivan PW. Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis. Med Care 2011; 49:385.
- Pham B, Teague L, Mahoney J, et al. Early prevention of pressure ulcers among elderly patients admitted through emergency departments: a cost-effectiveness analysis. Ann Emerg Med 2011; 58:468.
- Pham B, Teague L, Mahoney J, et al. Support surfaces for intraoperative prevention of pressure ulcers in patients undergoing surgery: a cost-effectiveness analysis. Surgery 2011; 150:122.
- Pham B, Stern A, Chen W, et al. Preventing pressure ulcers in long-term care: a cost-effectiveness analysis. Arch Intern Med 2011; 171:1839.
- Pronovost PJ, Goeschel CA, Wachter RM. The wisdom and justice of not paying for "preventable complications". JAMA 2008; 299:2197.
- Bennett RG, O'Sullivan J, DeVito EM, Remsburg R. The increasing medical malpractice risk related to pressure ulcers in the United States. J Am Geriatr Soc 2000; 48:73.
- 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.
- 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.
- National Pressure Ulcer Advisory Panel Support Surface Standards Initiative. Terms and definitions related to support surfaces. www.npuap.org/NPUAP_S3I_TD.pdf (Accessed on December 11, 2008).
- European Pressure Ulcer Advisory Panel (EPUAP). Guidelines on treatment of pressure ulcers. EPUAP Review 1999; 1:31.
- Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA 2006; 296:974.
- McInnes E, Jammali-Blasi A, Bell-Syer SE, et al. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev 2015; :CD001735.
- Rich SE, Shardell M, Hawkes WG, et al. Pressure-redistributing support surface use and pressure ulcer incidence in elderly hip fracture patients. J Am Geriatr Soc 2011; 59:1052.
- 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.
- Brown S, Smith IL, Brown JM, et al. Pressure RElieving Support SUrfaces: a Randomised Evaluation 2 (PRESSURE 2): study protocol for a randomised controlled trial. Trials 2016; 17:604.
- Iglesias C, Nixon J, Cranny G, et al. Pressure relieving support surfaces (PRESSURE) trial: cost effectiveness analysis. BMJ 2006; 332:1416.
- Brienza D, Kelsey S, Karg P, et al. A randomized clinical trial on preventing pressure ulcers with wheelchair seat cushions. J Am Geriatr Soc 2010; 58:2308.
- Thomas DR. The new F-tag 314: prevention and management of pressure ulcers. J Am Med Dir Assoc 2006; 7:523.
- Makhsous M, Priebe M, Bankard J, et al. Measuring tissue perfusion during pressure relief maneuvers: insights into preventing pressure ulcers. J Spinal Cord Med 2007; 30:497.
- Knox DM, Anderson TM, Anderson PS. Effects of different turn intervals on skin of healthy older adults. Adv Wound Care 1994; 7:48.
- Vanderwee K, Grypdonck MH, De Bacquer D, Defloor T. Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions. J Adv Nurs 2007; 57:59.
- Gillespie BM, Chaboyer WP, McInnes E, et al. Repositioning for pressure ulcer prevention in adults. Cochrane Database Syst Rev 2014; :CD009958.
- Defloor T, De Bacquer D, Grypdonck MH. The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers. Int J Nurs Stud 2005; 42:37.
- Moore Z, Cowman S, Conroy RM. A randomised controlled clinical trial of repositioning, using the 30° tilt, for the prevention of pressure ulcers. J Clin Nurs 2011; 20:2633.
- Young T. The 30 degree tilt position vs the 90 degree lateral and supine positions in reducing the incidence of non-blanching erythema in a hospital inpatient population: a randomised controlled trial. J Tissue Viability 2004; 14:88, 90, 92.
- Bergstrom N, Horn SD, Rapp MP, et al. Turning for Ulcer ReductioN: a multisite randomized clinical trial in nursing homes. J Am Geriatr Soc 2013; 61:1705.
- Anderson C, Rappl L. Lateral rotation mattresses for wound healing. Ostomy Wound Manage 2004; 50:50.
- Lyder, CH, Ayello, EA. Chapter 12. Pressure ulcers: a patient safety issue. www.ahrq.gov/qual/nurseshdbk/docs/LyderC_PUPSI.pdf (Accessed on April 01, 2013).
- Walia GS, Wong AL, Lo AY, et al. Efficacy of Monitoring Devices in Support of Prevention of Pressure Injuries: Systematic Review and Meta-analysis. Adv Skin Wound Care 2016; 29:567.
- Pressure ulcers in adults: Prediction and prevention. Clinical Practice Guideline Number 3, AHCPR Publication no. 92-0047, May 1992.
- Allman RM, Goode PS, Patrick MM, et al. Pressure ulcer risk factors among hospitalized patients with activity limitation. JAMA 1995; 273:865.
- Torra i Bou JE, Segovia Gómez T, Verdú Soriano J, et al. The effectiveness of a hyperoxygenated fatty acid compound in preventing pressure ulcers. J Wound Care 2005; 14:117.
- Ohura T, Nakajo T, Okada S, et al. Evaluation of effects of nutrition intervention on healing of pressure ulcers and nutritional states (randomized controlled trial). Wound Repair Regen 2011; 19:330.
- Langer G, Fink A. Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database Syst Rev 2014; :CD003216.
- Finucane TE. Malnutrition, tube feeding and pressure sores: data are incomplete. J Am Geriatr Soc 1995; 43:447.
- Bourdel-Marchasson I, Barateau M, Rondeau V, et al. A multi-center trial of the effects of oral nutritional supplementation in critically ill older inpatients. GAGE Group. Groupe Aquitain Geriatrique d'Evaluation. Nutrition 2000; 16:1.
- Berlowitz D, VanDeusen Lukas C, Parker V, et al. Preventing pressure ulcers in hospitals: A toolkit for improving quality of care. Agency for Healthcare Quality and Research; 2011. http://ahrq.gov/research/ltc/pressureulcertoolkit (Accessed on August 29, 2011).
- Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. Ann Intern Med 2013; 158:410.
- Niederhauser A, VanDeusen Lukas C, Parker V, et al. Comprehensive programs for preventing pressure ulcers: a review of the literature. Adv Skin Wound Care 2012; 25:167.
- Soban LM, Hempel S, Munjas BA, et al. Preventing pressure ulcers in hospitals: A systematic review of nurse-focused quality improvement interventions. Jt Comm J Qual Patient Saf 2011; 37:245.
- Yap TL, Kennerly SM, Simmons MR, et al. Multidimensional team-based intervention using musical cues to reduce odds of facility-acquired pressure ulcers in long-term care: a paired randomized intervention study. J Am Geriatr Soc 2013; 61:1552.
- Rosen J, Mittal V, Degenholtz H, et al. Ability, incentives, and management feedback: organizational change to reduce pressure ulcers in a nursing home. J Am Med Dir Assoc 2006; 7:141.
- Zinn JS, Brannon D, Weech R. Quality improvement in nursing care facilities: extent, impetus, and impact. Am J Med Qual 1997; 12:51.
- McKenna, MJ, Moyers, J, Feuerberg, M. Review of Non-regulatory Quality Improvement Interventions. Pp.339-384 in HCFA Report to Congress: Study of Private Accreditation (Deeming) Nursing Homes, Regulatory Incentives and Non-regulatory Initiatives, and Effectiveness of the Survey and Certification System, Vol II, HCFA, Washington, DC 1998.
- Baier RR, Gifford DR, Lyder CH, et al. Quality improvement for pressure ulcer care in the nursing home setting: the Northeast Pressure Ulcer Project. J Am Med Dir Assoc 2003; 4:291.
- Berlowitz DR, Young GJ, Hickey EC, et al. Quality improvement implementation in the nursing home. Health Serv Res 2003; 38:65.
- Rosen J, Mittal V, Degenholtz H, et al. Pressure ulcer prevention in black and white nursing home residents: A QI initiative of enhanced ability, incentives, and management feedback. Adv Skin Wound Care 2006; 19:262.
- Olsho LE, Spector WD, Williams CS, et al. Evaluation of AHRQ's on-time pressure ulcer prevention program: a facilitator-assisted clinical decision support intervention for nursing homes. Med Care 2014; 52:258.
- Horn SD, Buerhaus P, Bergstrom N, Smout RJ. RN staffing time and outcomes of long-stay nursing home residents: pressure ulcers and other adverse outcomes are less likely as RNs spend more time on direct patient care. Am J Nurs 2005; 105:58.
- Comondore VR, Devereaux PJ, Zhou Q, et al. Quality of care in for-profit and not-for-profit nursing homes: systematic review and meta-analysis. BMJ 2009; 339:b2732.
- Davis MA. On nursing home quality: a review and analysis. Med Care Rev 1991; 48:129.
- Hillmer MP, Wodchis WP, Gill SS, et al. Nursing home profit status and quality of care: is there any evidence of an association? Med Care Res Rev 2005; 62:139.
- 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.
- Black JM, Edsberg LE, Baharestani MM, et al. Pressure ulcers: avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound Manage 2011; 57:24.
- CLASSIFICATION AND TERMINOLOGY
- RISK ASSESSMENT
- PRESSURE REDISTRIBUTION
- Support surfaces
- Static positioning
- - Position and inclination
- - Repositioning
- - Repositioning interval
- Continuous rotation
- SUPPORTIVE INTERVENTIONS
- Improve mobility
- Improve skin perfusion
- Provide proper skin care
- - Minimize excess moisture
- Correct malnutrition
- QUALITY INITIATIVES
- PROVIDER EDUCATION AND STAFFING
- FAILURE OF PREVENTIVE MEASURES
- COST EFFECTIVENESS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS