Setting the Stage for Treating Unstageable Pressure Ulcers

When it comes to pressure injuries (PIs), wound care providers have seen and treated all kinds, in all places and among virtually all demographics. From the hospital patient admitted with a pre-existing condition to those in long-term care facilities unable to move to a patient receiving care at home from a loved one who may be unable to reposition them routinely, the list continues.

However, these examples just begin to highlight the complexity of treating PIs or, in lay terms, bed sores. While “pressure injury” is now the most accepted industry term, “pressure ulcer” might be a more familiar term for practitioners. It was only in 2016 when the National Pressure Ulcer Advisory Panel recommended changing its terminology to “pressure injury”.

There are also different classifications of PIs. There are hospital-acquired pressure injuries, which are perhaps better known as the infamous “HAPI” (ask a patient or nurse; there’s simply nothing happy about HAPIs). Those that occur in skilled nursing facilities (SNF) or nursing homes are known as facility-acquired PIs, and there are also medical device-related (MDRPI), community-acquired (CAPI), and more.

In this blog, we’ll explore unstageable pressure ulcers, and examine best practices, promising advances on the horizon, and what providers should know.

What Are Unstageable Pressure Ulcers?

An unstageable pressure ulcer is characterized by full-thickness skin and tissue loss where the extent of tissue damage within the injury cannot be determined because it is obscured by slough or eschar. Slough is typically yellow, tan, gray, green, or brown in color, while eschar is usually tan, brown, or black and may be hard or soft. Until enough of this covering is removed to expose the base of the wound, the true depth and stage cannot be assessed.

These types of PIs typically occur in areas of the body with prolonged pressure, especially over bony prominences. Common locations include the sacrum, heels, hips and coccyx, to name a few.

Patients with limited mobility, older individuals, those with incontinence, and those with reduced sensory capabilities due to spinal cord injuries are among those most vulnerable.  Unstageable pressure ulcers are serious, not only because of patient condition, but also because the hidden damage can be extensive, potentially involving the underlying muscles, bones, tendons, or other structures.

The condition presents no small problem for providers. In a 2020 article, the International Wound Journal notes that more than 3 million people suffer from HAPIs each year; about 7.3% of those had an unstageable wound.  Additionally, according to a recent article in Science Direct, about 11% of nursing home residents have pressure wounds, with a notable proportion being unstageable due to their severity and the presence of slough or eschar obscuring the wound bed.

The Stages of Pressure Injuries

PIs occur in different settings and among a wide range of patients. They also have varying levels of severity and treatment needs. In 1989, clinicians developed a numerical system to show a wound’s stage.

Staging these wounds is crucial for providing standardized assessments, guiding tailored treatments, and monitoring progress. It ensures consistent diagnosis and care and helps clinicians adjust interventions effectively.

Staging also facilitates clear communication among healthcare providers and supports research and quality improvement initiatives. This comprehensive framework ultimately enhances the quality of care for patients with pressure injuries, promoting better outcomes and efficient resource utilization. Before we dive deeper into unstageable pressure ulcers, let’s review the primary stages for context.

Stage 1

This is the earliest stage, where the skin is intact but shows signs of redness and does not blanch (turn white) when pressed. The area may be painful, firm, or soft, and it may be warmer or cooler than adjacent tissue.

Stage 2

At this stage, the skin breaks open, and the dermis loses some thickness. This presents as a shallow open ulcer with a red-pink wound bed. It can also appear as an intact or open/ruptured blister.

Stage 3

This stage involves full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed. The depth of the ulcer varies by anatomical location.

Stage 4

The most severe stage, where there is full-thickness tissue loss with exposed bone, tendon, or muscle. These ulcers can extend into muscle and/or supporting structures, increasing the risk of osteomyelitis.

What Makes Unstageable Pressure Ulcers Different?

Unstageable pressure ulcers differ from the other stages because their severity cannot be immediately determined. This is often because, as mentioned, the wound bed is obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black). Until enough of the slough and/or eschar is removed (read more on wound debridement) to expose the base of the wound, the actual depth, and therefore stage, cannot be known.

This presents a significant challenge for wound care providers. Proper staging is crucial for determining the appropriate treatment plan. Knowing the depth of the PI is necessary to assess the extent of tissue damage and the best course of action.

Best Treatment Practices

Because they are so challenging to accurately assess and treat, which is a crucial element of caring for these wounds, clinicians have developed several best practices to tackle the challenges of these wounds over time. Effectively managing unstageable pressure ulcers requires a careful and systematic approach. Here are some key considerations.

1. Assessment and Monitoring: Regular assessment is vital. Keep a close watch on the ulcer for any changes. Document the appearance, size, and any signs of infection.
2. Debridement: To uncover the true depth of the ulcer, slough and eschar must be removed. Various methods, including surgical, enzymatic, autolytic, or mechanical debridement, can be used. The choice of method depends on the patient’s overall condition and the clinical setting.
3. Infection Control: Be vigilant for signs of infection. Given the presence of necrotic tissue, unstageable pressure ulcers are at high risk for infection. Appropriate wound cleaning and possibly systemic antibiotics may be necessary.
4. Moisture Balance: Maintaining the proper moisture balance is crucial for wound healing. Overly dry wounds can delay healing, while too much moisture can lead to maceration.
5. Patient Education: Educate the patient and their caregivers about the importance of pressure relief, nutrition, and skincare. Proper repositioning and support surfaces can prevent further pressure ulcers.

Avoiding Penalties and Increasing Reimbursement

In addition to ensuring optimal patient care, managing all kinds of PIs is more crucial than ever in today’s healthcare landscape, especially within value-based care (VBC) programs. In these rapidly expanding models, providers are reimbursed based on the quality of care they deliver rather than the quantity of services. This shift means healthcare providers must prioritize effective wound management to avoid significant financial penalties.

As Medicare and Medicaid increasingly focus on VBC programs, understanding potential penalties and rewards will become increasingly important. Both of these crucial government payers penalize facilities with high rates of facility-acquired pressure injuries. Penalties can lead to reduced reimbursement rates and, in severe cases, exclusion from payment programs.

According to Definitive Healthcare, for  the 2021 fiscal year, more than 773 hospitals faced penalties for hospital-acquired conditions (HACs), including PIs. The average revenue loss due to these penalties is approximately $328,800. Keep in mind that this amount can vary based on hospital size, performance, and specific circumstances. The top 25 hospitals with the largest penalties also lost nearly $43 million, averaging about $1.7 million each. 

Also, keep in mind that CMS classifies Stages 3 and 4 PIs as ‘Never Events.’ These injuries, when not recognized on admission, aren’t reimbursed at the MS-DRG rate. Hospitals treating such injuries may not receive additional reimbursement, and those scoring above the 75th percentile for rates of PIs face a 1% Medicare penalty.

The overall cost to the facility must also be considered. According to 2021 data from the National Pressure Injury Advisory Panel (NPIAP), the average cost to a facility for treating a Stage 3 or Stage 4 pressure injury can range from $21,000 to over $151,000 per injury​.

Facilities that demonstrate excellence in wound care management, including the prevention and proper treatment of pressure ulcers, can achieve higher reimbursement rates and financial incentives. Conservatively, if a 300-bed hospital were to reduce HAPIs by 50%, it could save nearly $1 million a year.

New Advancements in Treating an Unstageable Pressure Ulcer

A combination of awareness that many PIs are preventable, new technologies, and advanced therapies offer hope for patients and providers dealing with complex, unstageable pressure ulcers.

One of many new promising avenues is cell-based therapies. These cells promote angiogenesis, tissue regeneration, and re-epithelialization. Notable cell types include bone marrow mononuclear stem cells (BM-MNCs), hematopoietic-derived stem cells (HSC), macrophages, and cryopreserved placental membrane containing viable cells (vCPM). Studies have reported complete wound closure, faster healing rates, and improved granulation tissue formation with these therapies.

Beyond cell-based approaches, negative-pressure wound therapy, platelet-derived growth factors, and biophysical agents are also showing promise. Plus, data is showing that personalized treatment plans, especially those incorporating social determinants of health (SDOH), ensure better patient outcomes.

Technology, too, plays a significant role in helping identify, prevent, and treat unstageable pressure ulcers. AI-powered digital wound care platforms that incorporate smart devices like cell phones and tablets enable providers to gather color 3D images that can show a wound’s characteristics, like depth and level of infection. Access to these insights, available in real-time in the palm of a hand and at the touch of a button, provides information that helps providers develop effective care plans.

Unstageable Pressure Ulcer: Moving Forward

Unstageable pressure ulcers are a unique challenge in wound care. Their hidden depths necessitate a thoughtful and proactive approach to treatment. The NPIAP estimates that up to 95% of pressure injuries can be prevented with appropriate preventive measures—which means wound care providers must constantly strive to find ways to do more.

Treating unstageable wounds effectively requires more than just understanding pressure injury stages and focusing on proper assessment, debridement, and infection control. It demands innovative technologies, the latest proven therapies, education and research, and a focused effort to manage complex wounds that significantly impact the wound care continuum.

Wound care professionals must also stay informed about the latest advancements, providing the best possible care for patients. Additionally, recognizing that each patient is unique and adopting a personalized approach is crucial for optimal outcomes. Perhaps most essential in the quest to thwart unstageable wounds, dedicated wound care providers should engage with patients, collaborate with peers, and strive to continually adapt and advance their practices.