Pressure Injury Prevention: Hospitals’ Best Defense

Despite medical facilities’ best efforts, pressure injury development is a significant issue. Health research estimates that about three million hospital patients will develop a PI each year, and 60,000 will die as a direct result of their wounds. These injuries affect the entire health care system by redirecting resources and time to treating preventable injuries and eroding public trust in facilities with high rates of pressure injury occurrence.

Pressure injuries that occur during hospitalization create a strain on the health care system, a financial burden on insurance companies and hospitals, and are a dangerous prospect for patients with limited mobility or underlying conditions such as diabetes, making pressure injury prevention an important and worthwhile pursuit.

Pressure injury prevention points are crucial in a comprehensive prevention strategy. All health care facilities need to have detailed plans for assessing at-risk patients regularly and treatment plans for intervening when pressure injuries do occur to prevent further deterioration of the skin, bone, muscle, and tendons that can result in life-threatening conditions. Because of how serious even small PIs are, all hospitals must remain vigilant and responsive to signs of skin damage.

Heightened Federal Interest in Pressure Injuries

The Hospital-Acquired Condition Reduction Program is part of the value-based care system for Medicare. It encourages hospitals to prevent hospital-acquired infections and conditions by reducing the payments to facilities that do not score well on performance outcomes related to these conditions. Pressure injuries that reach stage three or four are considered “never events” and will receive no reimbursement at all for expenses related to treating them.

Despite this financial burden, pressure injuries developed while in the hospital continue to rise in the United States. In fact, 23% of global cases occur in the US and it costs more than $26.8 billion to treat them. In skilled nursing facilities, the recommended frequency for monitoring the skin for pressure injuries has recently lowered from every 48 hours to every 24 hours.

These are national guidelines, but many states also have regulations related to the development and reporting of PIs. For example, in California, facilities have five days to report new PIs as adverse events. New York requires both hospitals and residential care facilities to have programs dedicated to the prevention of pressure injuries.

Why Hospitals Must Be Concerned About Pressure Injuries

Besides the financial disincentives of patients developing pressure injuries, outcomes are also worse for affected patients. An estimated 95% of all pressure injuries are preventable, and yet they remain a highly expensive and resource consuming drain on hospitals and SNFs. That makes it essential for clinicians, patients, and their support teams to understand how and where pressure injuries develop and take proactive measures to prevent them. Severe complications associated with pressure sores, such as infections and the potential for serious medical outcomes like sepsis, underscore the importance of prevention.

Education for providers and patients has been shown as an effective method for preventing pressure injuries. Being aware of the symptoms and risk factors makes providers more thorough and improves patient safety at the facility. Recognizing signs of tissue injury during patient assessments, particularly over bony prominences, is crucial, as underlying medical conditions can exacerbate the risk. If left too long, pressure injuries can develop infections like blood poisoning or cellulitis. Stage four PIs can become gangrene and eventually need amputation. Emphasizing the importance of preventing pressure sores through effective skin care and monitoring is crucial to avoid these severe outcomes.

Severe bedsores are often a sign of hospital or nursing home neglect and can be prosecuted as such. Public charges against a facility for injury and death related to pressure injuries can decrease the local perception of the facility and cause portions of the responsible workforce to look for employment elsewhere..

Stages of Pressure Injuries

Pressure injuries are measured in stages in order to assess their severity. While there are several classification systems, the National Pressure Injury Advisory Panel instructions are commonly used.

• Stage 1: While there may be signs of irritation and discomfort, the skin is still intact on these wounds. They may feel warm, spongy, or hard, but these are the least severe types of ulcer that can typically be treated quickly and efficiently. It is important to note that pressure injuries may present differently on individuals with darkly pigmented skin, where visual changes might not be as evident.
• Stage 2: These look like open wounds or blisters. There may be skin loss, redness, pain, or discoloration. Now that the injury has become an open sore, it will need to be treated with bandages, healing ointments, or possibly antibiotics if there are signs of infection.
• Stage 3: These PIs look like deep wounds. The entire thickness of the skin and underlying tissue is affected, but the bone and muscle are still intact. Granulation tissue may be present in these full-thickness stage injuries, playing a crucial role in the wound healing process.
• Stage 4: This is the most severe pressure injury. The wound has progressed to damage the bones, muscles, joints, or tendons. Stage four can be life threatening and require immediate medical attention.
• Unstageable: Occasionally, stage three or four injuries will be covered with dead black skin or slimy tissue that makes it impossible to determine the extent of the injury. Severe pressure injuries that can’t be evaluated correctly can be labeled unstageable.
• Deep Tissue Pressure Injury: These are distinct because of their maroon or purple color and indicate a sheer injury or a blister that has filled with blood.

Accurate staging and quick and appropriate treatment should be a top priority for all hospitals. See our resources for more information about determining the stage of pressure injuries and tips for documenting thoroughly.

Best Practices for Risk Assessment and Reducing Pressure Injuries in Hospitals

In 2019, the European Pressure Ulcer Advisory Panel (EPUAP), NPIAP, and the Pan Pacific Pressure Injury Alliance (PPPIA) published The International Guideline (Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline). The guidelines were updated in 2023 and will be again in 2025, so keep an eye out for new research and best practices in the coming months. Some of the current guidelines include:

• Performing a skin and soft tissue assessment as part of every risk analysis for patients who are at higher risk for developing pressure ulcers.
• Keeping skin clean and managing skin moisture.
• Providing high-calorie, high-protein foods or supplements to support tissue repair.
• Frequently repositioning patients with low mobility and providing opportunities for patients to regain movement as quickly as possible after surgeries or injuries.
• Using supportive surfaces that redistribute the patient’s weight and keep the skin comfortable and dry.
• Keeping medical devices away from sensitive skin, padding it with dressing, or regularly changing the position of the device to prevent pressure injuries.
• Debriding, treating with antibiotics as needed, or providing healing wound dressings if PIs start to appear.
• Ensuring that all care givers, medical providers, and the patient understand these best practices and have the ability to maintain a standard of care that prevents further PIs from forming.

Technology Is Key to Pressure Injury Prevention

Digital imaging is a necessity in wound documentation. With impressive accuracy, driven by machine learning models, digital imaging virtually eliminates the subjectivity that plagues wound assessments, providing comprehensive, consistent, and compliant documentation. It also plays a crucial role in the accurate assessment and documentation of injured tissue, helping to identify signs of damage to the skin and underlying tissues due to pressure.

AI-powered wound imaging platforms can be an integral part of a PI surveillance program that will help simplify and streamline wound care documentation workflows. These applications use artificial intelligence and machine learning algorithms to automatically calculate and measure wound boundaries, which sidesteps common errors of traditional measurements using paper rulers.

This tech makes it much easier to consistently and accurately measure the surface area and volume of a wound, without the variation from using a straight-edge ruler. In hospitals that previously relied on paper documentation and ruler measurements, digital imaging can produce dramatic results.

When wounds are properly assessed and accurately documented at the outset, positive outcomes result. In the high-stakes PI reduction game, the technology provided by digital and AI-powered wound imaging gives hospitals the winning hand.

A National Goal for Reducing Pressure Injuries

Health care workers will be familiar with the term “zero harm,” which heralds back to the Hippocratic oath. The concept of zero harm has an aim to reduce the 10-12% of patients who experience injuries while hospitalized. Research indicates that about half of these injuries are preventable and front-line health care workers will be highly responsible for this objective. Pressure injuries comprise many of these injuries that occur at a facility.

While the goal of eliminating pressure injuries is unrealistic, increased effort and legislation forces health care facilities to do everything they can to prevent or provide early intervention for PIs. Maintaining adequate blood flow is crucial in preventing pressure injuries, as inadequate blood flow to the skin due to prolonged pressure can lead to skin cell death and the formation of sores.

In addition to negative outcomes for patients with hospital-acquired pressure injuries, the facilities themselves suffer financially and can lose public trust. Medicare and Medicaid have policies that no longer reimburse hospitals for the treatment of HAPIs, placing the financial burden on the hospital, which typically ranges from $20K-$151K per patient.

Pressure injuries are also the frequent subjects of lawsuits. In the United States, more than 17,000 lawsuits are brought to court each year that are related to pressure injuries. Many of these are for wrongful death or emotional distress. This additional financial disincentive may be coupled with local loss of trust in the hospital or additional regulatory oversight or being subject to corrective actions.

Better Tracking for Pressure Injury Prevention and Monitoring

Preventing serious pressure injuries starts with education and assessment. Every employee and provider is responsible for assessing skin that’s at risk, monitoring areas of concern, and providing quick and comprehensive treatment for PIs. Digital tracking technology will empower health care providers to accurately evaluate ulcers and track changes over time.

Using an AI-powered wound imaging tool improves accuracy by 90% and allows providers to intervene quickly when necessary. Predicative analytics and the ability to compare the injury with millions of other examples will help providers make better treatment decisions, save time and money, and prevent further skin deterioration.