Pressure injuries (PIs) are one of the biggest challenges facing wound care practitioners. Formerly known as pressure ulcers, decubitus ulcers or pressure sores, these wounds are notoriously difficult to prevent and manage. They also are very costly, causing pain, extensive and expensive treatment, longer institutional stays and, in some patients, premature death.

Pressure injuries affect patients in all healthcare settings, but the highest incidence is in acute care settings. The Agency for Healthcare Research and Quality (AHRQ) reported that 2.5 million hospital patients develop a pressure injury each year, and 60,000 patients die as a direct result of their wounds. AHRQ states that PIs are one of the five most common harms hospital patients experience, and the only preventable harm that is increasing rather than decreasing. 

2.5 million hospital patients develop
a pressure injury each year, and 60,000 die.

Furthermore, the coronavirus pandemic is deepening PI concerns. Patients hospitalized with COVID-19 are at significant risk for pressure injury. Moderate to severe coronavirus-related infections can cause significant debility, and recovery is often slow, creating an unfortunate environment for pressure injury development among already vulnerable patients.2 

Because they are so stubbornly ubiquitous, pressure injuries are tremendously costly. 

  • PIs cost the U.S. healthcare system an estimated $26.8 billion a year3 
  • Hospital patient care per PI ranges from $20,900 to $151,7004 
  • Hospital PIs result in excess length of stay of 4.31 days and a higher 30-day readmission rate (AHRQ, 2019) 

Fortunately, there are methods we can employ to bring these numbers down .

What is a Pressure Injury? 

A pressure injury is caused when skin integrity is broken down by some type of unrelieved pressure, leading to the destruction of normal structure and function. The National Pressure Injury Advisory Panel (NPIAP), the preeminent U.S. professional organization dedicated to prevention and management of PIs, defines it this way: 

A pressure injury is localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device. 

The injury can present as intact skin or an open ulcer and may be painful. 

The injury occurs as a result of intense pressure, prolonged pressure or pressure in combination with shear. 

The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities and condition of the soft tissue. 

Common places for PIs to develop include the back of the head, shoulders, elbows, buttocks, hips, ankles and heels.5 

The 4 Stages of Pressure Injuries 

NPIAP also provides descriptions of the stages of pressure injuries, which are used to determine the degree of injury and direct treatment. Here are the four stages of PIs as outlined by the NPIAP. 

Stage 1 – Non-blanchable erythema of intact skin 

Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. 

Stage 1 in Darkly Pigmented Skin

Research indicates that people with darker skin tones are more likely to develop higher stage pressure injuries, possibly because skin assessment protocols are less effective in identifying damage earlier.6

Pigmentation of the skin may prevent visualizing the reactive hyperemia in the pressure injury, says former NPIAP President Joyce Black, PhD, RN, CWCN, FAAN.7
Her advice:

• Moisten the skin to aid in visualizing
color change.
• Ask about pain in the area.
• Palpate the skin for induration.

Stage 2 – Partial-thickness skin loss with exposed dermis 

Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible, and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD), including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI) or traumatic wounds (skin tears, burns, abrasions). 

Stage 3 – Full-thickness skin loss 

Full-thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. 

Stage 4 – Full-thickness skin and tissue loss

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. 

Unstageable Pressure Injury  – Obscured full-thickness skin and tissue loss

Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 Pressure Injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. 

Deep Tissue Pressure Injury – Persistent non-blanchable deep red, maroon or purple discoloration

Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full-thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use deep tissue pressure injury to describe vascular, traumatic, neuropathic, or dermatologic conditions. 

Mucosal Membrane Pressure Injury

Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury. These ulcers cannot be staged. 

Above from NPIAP 

Preventing Pressure Injuries 

Digital Documentation

Digital imaging has earned its reputation as the gold standard in wound documentation. This advanced technology reduces the subjectivity in wound assessments and provides comprehensive, consistent, compliant documentation.

When digital techniques are used, the results are dramatic. For example, Tissue Analytics’ digital photo technology has a 95+% accuracy rate, whereas measuring wounds with rulers is only 40% accurate and subject to significant variabilities.8 

Digital imaging also speeds workflow because it enables clinicians to capture and upload wound images and other documentation, including automated measurements, quickly and easily. Tissue Analytics’ imaging solution has been shown to save five to ten minutes per patient in documentation time, resulting in a minimum of 2.5 hours of charting time saved daily. This means clinicians are no longer “paper wranglers;” they have extra time to discuss more informed treatment decisions for the patient’s wound outcome management pathway.

Tissue Analytics’ technology also makes it safe and simple for patients to take pictures of wounds on a mobile device and deliver high-quality information to a clinician that then moves seamlessly into the electronic medical record through Net Health’s Wound Care system. 

The following testimonial from the head wound, ostomy and continence nurse at a leading wound care center about the Net Health/Tissue Analytics system drives this home. 

“I ran a report to see how many reportable pressure injuries we had in-house and to ensure we had reported them. A nurse had entered ‘unstageable’ for nose injuries that were not present on admission. I was able to quickly pull up the photo and noted that neither wound was unstageable nor unreportable. I spoke with the RN and went through the staging process. She noted that the wounds were not full thickness and did not have necrotic tissue, and thus were not unstageable, full thickness wounds. We had the visits unlocked, and she changed her responses.

This system allows us to avoid penalties associated with incorrectly reporting a high-staged injury, or worse, not reporting an injury we find in the chart years later. Big win!”

Caring for patients with pressure injuries today is more demanding than ever before. People are living longer and have more comorbidities, both of which contribute to the chronicity of PIs. Timely and accurate assessment and documentation supported by the latest technology is essential for managing pressure injuries and ensuring that patients receive the care they deserve.


Finally, the return on investment from digital documentation and assessment technology is substantial. With pressure injury per patient costs averaging $20,900 to $151,700, these systems pay for themselves many times over.


1“Hospital-Acquired Pressure Ulcers/Injuries (HAPU/I) Prevention,” Results Update, Joint Commission Center for Transforming Healthcare, 2020.
2NPIAP February Webinar: COVID and the Skin,
3Padula, William V. and Delarmente, Benjo A., “The national cost of hospital-acquired pressure injuries in the United States,” International Wound Journal, Jan. 28, 2019.
4“Are we ready for this change?” Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.
5Pressure Ulcer Sore Stages,
6Gunowa, Neesha Oozageer, Hutchinson, Marie, Brooke, Joanne, Jackson, Debra, “Pressure injuries in people with darker skin tones: A literature review,” Journal of Clinical Nursing, October 2017.
7Black, Joyce, “The 2016 NPUAP Pressure Injury Staging System,” Presentation for the Lake Superior Quality Innovation Network, March 2017.
8Budman J, Keenahan K, Acharya S, Brat GA, “Design of A Smartphone Application for Automated Wound Measurements for Home Care,” iProc, October 2015.
9“Module 1: Preventing Pressure Injuries in Hospitals—Understanding Why Change Is Needed,” AHRQ, 2017.