Localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result
of pressure, or pressure in combination with shear force and/or friction.^[3]

Pressure ulcers occur in about 15% of general acute care patients at risk and about 40% of spinal
cord injured patients. The most frequent site for pressure ulcers is the sacrum or coccyx, followed
by the heel."

"Reasonably Preventable"

"The debate about the preventability of pressure ulcers ostensibly is over. Last year, the federal
Centers for Medicare and Medicaid Services (CMS) announced that they would no longer reimburse
hospitals for treatment of new pressure sores in Medicare patients. The ruling, known as the
Inpatient Prospective Payment System (IPPS) final rule, adopts a new Medical Severity Diagnosis
Related Group (MS-DRG) classification system that expands the current number of DRGs from
538 to 745, with weighting factors that will be phased in over a 2-year period.

Starting with discharges that occur on October 1, 2008, inpatient facilities will not receive payment
for 8 "reasonably preventable" hospital-acquired conditions including pressure ulcers.
(The rest of the list: mediastinitis following coronary artery bypass grafting; catheter-associated
urinary tract infections; vascular catheter-associated infections; air embolisms; blood incompatibility;
objects left in the body during surgery; and hospital-associated injuries including fractures, dislocations,
intracranial injury, crushing injury, and burns. In addition, CMS has proposed expanding this list to
include surgical site infection, Legionnaires' disease, extreme blood sugar derangement, iatrogenic
pneumothorax, delirium, ventilator-associated pneumonia, deep vein thrombosis/pulmonary embolism,
Staphylococcus aureus septicemia, and Clostridium difficile-associated disease.)

Pressure ulcers are the most common and costly of these conditions. Under the new payment plan,
pressure ulcers present on admission will qualify for a higher reimbursement only if the presence
of Stage III or IV ulcer is noted in the medical record within 2 days of inpatient admission. Pressure
ulcers identified after day 2 will not be eligible for additional reimbursement.

The new ruling captured the attention of the nation's hospitals and the wound care community.
With the headline, "Hospitals Combat Dangerous Bedsores," the Wall Street Journal led its coverage
of this new development with the story of a hospital that plays music over the loudspeaker to cue
nurses to conduct turning rounds.^"

But...Are All Pressure Ulcers Really Preventable?

"The basis for the new regulation is that pressure ulcers are a high-cost, high-volume condition
that can reasonably be prevented by applying current evidence-based guidelines, a view that
remains controversial. In time, with adequate data, we will find out if the CMS's new pay-for-performance
plan achieves the goal of fewer Stage III and Stage IV pressure ulcers.

Nonetheless, Krapfl and Mackey make several points that argue against the preventability of all
pressure ulcers. For example, the onslaught of improved products aimed at decubitus ulcer prevention,
such as high-tech pressure-reducing bed and chair support surfaces, skin cleansers, skin protectants,
and incontinence products, has not changed the national pressure ulcer rate; nor have widespread
quality improvement initiatives or the threat of negligence litigation.

The data from individual hospitals reporting reduced pressure ulcer rates are more encouraging.
Quality improvement projects implementing best practices have successfully lowered pressure ulcer
incidence rates in some facilities. Members of the New Jersey Hospital Association's Pressure Ulcer Collaborative
achieved a 70% reduction in the incidence of new pressure ulcers after nearly 2 years of applying shared
best practices and preventive techniques."

The Skin as an Organ

"The skin is an organ," explains Lee Ann Krapfl, BSN, RN, CWOCN, a wound care nurse at Mercy Medical Center
in Dubuque, Iowa, "and like other organs, it sometimes fails, even with excellent care." Furthermore, the skin
and underlying tissues depend upon the proper functioning of other organs and systems of the body. In patients
with major organ failure, the skin is also compromised.  The simplistic, narrow view that pressure ulcers form
"from the outside in" when there is unrelieved pressure on the skin has been replaced with the theory of deep
tissue injury. Externally applied pressure increases pressure and damage in the deep tissues near bony prominences
before causing visible damage at the skin surface.  Ischemia caused by capillary occlusion, reperfusion injury,
impaired lymphatic drainage of metabolic waste, and prolonged mechanical deformation of tissue cells are the
processes presumed to damage the soft tissues."

"Deep tissue injury is a newly defined concept," remarks Krapfl. "We are still learning about it and trying to identify
under what, if any, circumstances these pressure ulcers can be rescued." Our increasingly sophisticated
understanding of the pathogenesis of pressure ulcers recognizes both the intrinsic factors (the individual's health)
and extrinsic factors (mechanical influences) that contribute to pressure ulcer formation. Comorbidities such as
diabetes, heart disease, renal disease, dementia, and malnutrition also enter the equation because they affect
both the development and healing of pressure ulcers.   We also do not fully appreciate the role that acute illness
and the body's stress response may have on the skin."

The Pressure Is on Nurses

"Pressure ulcers are viewed as a quality-of-care indicator. Reducing healthcare-associated pressure ulcers is
both a Joint Commission National Patient Safety Goal  and a goal for Healthy People, 2010.   Pressure ulcer
prevalence is number 2 on the National Quality Forum's "15 National Voluntary Consensus Standards on
Nurse-Sensitive Care."   Add to this the economic incentive and the message is clear: zero tolerance for pressure ulcers.
Although it is theoretically a multidisciplinary issue, nurses, as the primary caregivers, will shoulder the burden of
preventing pressure ulcers in hospitals and long-term care facilities.

And when pressure ulcers occur, nurses will be blamed,  in spite of the fact that they have little or no control
over the factors that affect their ability to provide quality care, such as staffing, census, budgets, or purchasing
of equipment and supplies.

It's a no-brainer that staffing levels affect our ability to provide the care necessary to prevent pressure ulcers.
Research shows that lower pressure ulcer rates can be achieved with a higher proportion of RN staff, and a staff
mix heavier on more experienced nurses, findings that will surprise no one. In long-term care, patients who receive
more direct care from RNs have fewer pressure ulcers. Despite such evidence, a recent article describing how to
reduce the pressure ulcer rate to zero does not address the need for adequate nurse staffing levels and staff mix."

Present on Admission

Timely, thorough, and accurate documentation of preventable conditions that are present at the time of a patient's
admission to the hospital is going to be critical. The requirement to document a present on admission indicator for
every diagnosis, including secondary diagnoses such as pressure ulcers, began on October 1, 2007. The definition
of present on admission is:

Present at the time the order for inpatient admission occurs -- conditions that develop during an outpatient
encounter, including emergency department observation or outpatient surgery, are considered as present
on admission.

The patient's provider is the individual responsible for documenting the conditions that are present on admission.
Official coding guidelines define provider as:

A physician or any qualified healthcare practitioner who is legally accountable for establishing the
patient's diagnosis.

The requirement for provider documentation doesn't mean that admission assessments by nurses won't be important.
To the contrary, this documentation will be exceedingly important. If a nurse charts on day 3, for example, that a
pressure ulcer is present that was not included in the provider's admission diagnoses, it will be considered a
hospital-acquired pressure ulcer. As the ruling stands now, issues related to inconsistent, missing, unclear, or,
as in this case, conflicting documentation must be resolved by the provider.

Under the new rules, it won't be sufficient to record that a pressure ulcer is present or to document only meager
details such as location and size of the wound. If the patient has a Stage I or Stage II pressure ulcer on admission,
the hospital will not be reimbursed for the higher MS-DRG. A Stage III or Stage IV pressure ulcer present on
admission will qualify for the higher MS-DRG payment unless it is on the elbow or an unspecified location,
in which case the hospital will receive the intermediate MS-DRG payment.^[7] The bottom line is that accurate
staging of pressure ulcers present on admission will be mandatory for proper reimbursement.

Pressure Ulcer Staging

"Staging is an assessment method used to classify pressure ulcers according to anatomic features, such as
wound depth, and to describe soft tissue damage. Wounds are constantly changing, so staging is like taking
a snapshot of the wound at a single point in time. Staging is the only appropriate method for documenting the
depth of tissue damage. In order to do this accurately, necrotic tissue must first be removed, allowing complete
visualization of the ulcer bed.

There are 4 stages, I-IV (Table) plus 2 other choices: one to describe deep tissue injury, and the other to
indicate that the wound is unstageable. The unstageable category is reserved for wounds that contain too
much necrotic tissue to visualize the true depth of the wound. Wounds that are obscured from view by dressings,
braces, or casts should not be classified as unstageable.

Stage I, defined as unblanchable erythema of intact skin, is assessed by gently pressing your finger on the
reddened area of skin. Failure to blanch (color change to white followed by refilling of capillaries) is caused
by extravasation of blood from the capillaries -- evidence of underlying ischemic damage.   Stage I can't be
visually determined in individuals with pigmented skin. Stage I is theoretically the first in the series of clinically
progressive stages, but lesions characterized as Stage I frequently already have deeper tissue damage.

To apply the pressure ulcer staging system, it is necessary to understand and identify the anatomy of the skin
and deeper layers of tissue, fat, fascia, muscle, and bone.   Misidentification of structures can result in misapplication
of the pressure staging system. An area of frequent confusion is the difference between Stage II, Stage III, and
lesions caused by moisture and/or friction. Herpetic, fungal, and moisture lesions have all been misclassified as
pressure ulcers.

An important caveat to the staging of pressure ulcers is found in the description of the Stage II ulcer. Superficial
dermal lesions caused by friction or skin maceration from urinary or fecal incontinence, but not from prolonged
pressure, should not be classified as pressure ulcers.   When the visual assessment discloses such a lesion,
even if it is over a bony prominence, caution must be used before ascribing the lesion to pressure.^"

One-Way Only

"The staging system does not include a stage for granulating (healing) pressure ulcers. The NPUAP cautions
that the pressure ulcer staging system should not be used to "reverse stage" (or "down stage") pressure ulcers.
Reverse staging is inappropriate because it implies that as pressure ulcers heal, they go backwards through
the stages of wound advancement. This isn't what happens physiologically in a healing ulcer. A healing pressure
ulcer fills with granulation tissue and becomes progressively more shallow but doesn't replace lost muscle, fat, or dermis.
According to the NPUAP:  (National Pressure Ulcer Advisory Panel)

When a Stage IV ulcer has healed, it should be classified as a healed Stage IV pressure ulcer, not a Stage 0
pressure ulcer. If a pressure ulcer reopens in the same anatomical site, it retains its original staging -- eg,
"once a stage IV, always a stage IV."

The confusion over reverse staging is perpetuated by minimum data set (clinical assessment) regulations
that actually require long-term care facilities to reverse stage healing pressure ulcers. Until this is changed,
the NPUAP encourages long-term care health professionals to also document appropriate descriptions of
pressure ulcer healing (depth, width, presence of granulation tissue and epithelization) in the medical record
or use a validated pressure ulcer healing tool. A simple tool, the Pressure Ulcer Status for Healing (PUSH),
based on the wound's size, exudate amount, and tissue type, is still being evaluated.

The pressure ulcer staging system should not be used to describe other types of wounds, such as neuropathic
foot ulcers, epidermal stripping, surgical wounds, or ulcers from venous or arterial insufficiency. Inappropriately
using the NPUAP staging system to stage nonpressure ulcer wounds results in diagnostic inaccuracies and can
have quality, economic, or legal ramifications.

Subjectivity is another concern with staging of pressure ulcers. There is little doubt that, even with a standardized
staging system, subjectivity will affect the diagnosis and classification of pressure ulcers. Wachter raises the possibility
that the "early decubitus ulcer" will become the next diagnostic epidemic, as hospitals preemptively defend
themselves against lower reimbursements should at-risk patients develop pressure ulcers during hospitalization.^"

Risk Assessment

Many facilities conduct 2 pressure-ulcer related assessments on every patient admitted to the hospital: (1) a
skin assessment for evidence of pressure ulceration, and (2) an assessment of the patient's risk for developing
a pressure ulcer. Risk factors for developing a pressure ulcer are fairly well known. Immobility, impaired sensation,
moisture, poor nutritional status, incontinence, advanced age, mental confusion... the list is long and overlaps
with risks for other conditions and problems. The elderly and spinal cord injured patients are most prone to pressure ulcers.

There are many pressure ulcer risk assessment tools, some of which have been widely researched and validated.
These tools are useful for determining which patients are at risk for pressure ulcers and should receive pressure-ulcer
preventive measures. Formal risk assessment tools may not be any better than the nurse's judgment of which patients
are at risk for developing a pressure ulcer. Still, the search continues for the ideal pressure ulcer risk assessment tool.

Unanswered Questions

Here's a scenario: an elderly woman is admitted to the emergency department after she was found on the floor in
her bathroom. She fell after having a stroke and lay on the floor all day until her daughter discovered her.
On admission, the nurse noted a large bruise on the woman's left hip. A few days later, while the patient is still
in the ICU, this bruise has developed into a full-thickness pressure ulcer.

Another scenario: a patient in respiratory failure is admitted from home. He has what appears to be a sacral
pressure ulcer. The nurse informs the physician, who writes an order for an evaluation by the wound care nurse.
The wound care nurse assesses the wound, classifies it as a Stage III pressure ulcer, and records her findings in the medical record.

These scenarios represent 2 of the many questions that remain unanswered in current CMS rule change guidance
documents: (1) What about the pressure ulcer that develops from a deep tissue injury that occurred prior to admission?
Will these deep tissue injuries and unstageable pressure ulcers "count" as being present on admission and qualify for
higher reimbursements?^[  (2) Will coders be able to use the documentation of nurses, particularly those who are
certified wound specialists, when assigning "present on admission" indicators to the patient's diagnoses?

Perhaps the most important questions of all: How will decreasing reimbursements affect the allocation of
resources to address problems such as pressure ulcers? Will hospitals react by devoting more resources to
improving nursing care quality, or will they respond with fiscal restraint and workforce cutbacks that weaken
the ability of nurses to maintain quality inpatient care?"

Wound, Ostomy and Continence Nurses Society (WOCN)

Founded in 1968, the Wound, Ostomy and Continence Nurses Society (WOCN) is a professional, international
nursing society of more than 4200 healthcare professionals who are experts in the care of patients with wound,
ostomy, and incontinence. The WOCN supports its members by promoting educational, clinical, and research
opportunities to advance the practice and guide the delivery of expert healthcare to individuals with wounds,
ostomies, and incontinence.

Authors and Disclosures

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Author

Laura A. Stokowski, RN, MS
Staff Nurse, Inova Fairfax Hospital for Children, Falls Church, Virginia; Editor, Medscape
Ask the Experts Advanced Practice Nurses

Disclosure: Laura A. Stokowski, RN, MS, has served as a consultant for Draeger Medical.

Editor

Susan Yox, RN, EdD
Editorial Director, Medscape Nurses

Disclosure: Susan Yox has disclosed no relevant financial relationships.