Pressure Injuries in the Acute Care Hospital Setting: Opportunities for Change

Despite National Pressure Injury Advisory Panel public policy initiatives, its collaboration with the Centers for Medicare and Medicaid Services on coding and reimbursement issues, and its role in establishing evidence-based clinical practice guidelines and providing educational conferences and webinars, many concerns related to pressure injuries remain. There is a paucity of evidence-based medicine (ie, Class I and Class II research) that is needed to establish generalized guidelines that can impact acute care hospitals. For instance, although the definition of skin failure remains unclear, skin failure that occurs in the acute care hospital setting can lead to the determination of a hospital-acquired pressure injury (HAPI). Unavoidable pressure injury that occurs in hospital is considered a HAPI because in acute care there is no allowance or code for an unavoidable PI; the occurrence of a pressure injury in the home care setting does not have similar repercussions. Additionally, skin failure in a skilled nursing facility patient can be termed unavoidable, although what is avoidable  (ie, preventable) and unavoidable (ie, nonpreventable) is not clearly defined. Even literature on  palliative care lacks a clear definition of tissue injury or skin failure. How a wound is categorized will affect not only the clinical care rendered, but also may result in financial and reimbursement penalties for an acute care hospital. 

Moreover, consideration for medical device use has only recently been incorporated into pressure injury guidelines. In clinical practice, medical devices such as braces, oxygen delivery devices, and pressure-relief support mattresses are increasingly used in hospital settings, but their impact has not been established (ie, are injuries from device use reportable or not?).

Additionally, in most facilities, risk for pressure injury is determined by the Braden score, but the literature disputes the tool’s effectiveness for providing reason/support for preventive care. More evidence-based research is needed to identify what prevention tools/measures are reliable and valid.

Despite best efforts to educate wound care practitioners in various disciplines, many practicing clinicians may not be aware of relevant guidelines nor the resulting repercussions of not following them. Improved communication and education on a multidisciplinary level are needed among leading wound care organizations to ensure proper clinical practice guidelines are created. We all need to speak with 1 language that is clearly understood by all practitioners.

Can we establish sound guidelines that impact our clinical delivery when we have not yet established fundamental, basic definitions of skin injury and failure? As noted, the clinical implications of pressure staging guidelines in an acute care setting differ from other settings and present a new opportunity to develop an algorithm of best practice for skin failure from a clinical perspective. 

Pediatric pressure injury prevention is (not to make a pun) in its infancy. Pediatric pressure injury risk assessment scales (RAS) are evolving; some are generic (ie, applicable across general pediatric populations), some are based on specific characteristics (eg, of neonates), all are derived from adult versions, and only 1 or 2 recently were modified to include medical devices. Discussion about RAS utility is ongoing. A 2013 study¹ and a 2019 Cochrane review² concluded there is no reliable evidence to suggest that use of structured RAS reduces the incidence of pressure injury. Although countless hours and resources have been allocated to educate providers on RAS and assessment is mandated in the electronic medical record, pressure injuries continue to occur. If prevention guidelines are followed and the patient still develops a pressure injury, has the prevention guideline failed? Acute care practitioners may be more successful when providing prevention based on a clinical evaluation, reviewing devices in use, and assuming that every patient with a device or presenting with certain clinical characteristics is at risk, rather than simply applying a scale to their patients. The fact is that 50% to 60% of pediatric pressure injuries are medical-device related,³ perhaps owing to the reality that few devices are produced from a neonatal or pediatric model. Most are simply a reduced-in-size adult version, with little consideration of different shape, fit, skin quality, tolerance for deformation, and temperature conduction. One of the greatest challenges (and perhaps opportunities) in the pediatric arena is to partner with industry for dedicated pediatric products.

What about assessment tools and instruments dedicated to prevention? Studies have concluded that visual assessments are subjective, unreliable, untimely and generally ineffective.^4,5  By the time we recognize the signs of pressure injury, tissue is already damaged. Thermography devices, subepidermal moisture scanners, pressure mapping, and tissue load calculators used on adults have not yet been applied to neonatology or pediatrics in general. In our opinion, the biggest obstacle is their size, as well as industry’s discomfort in studying young children, ironically 1 of the populations most affected by medical device-related pressure injury³ — a situation that perhaps, presents yet another opportunity for change.

Finally, what about staging? Can the same staging system be applied to a collumelar pressure injury on a 500-g neonate as to a nasal septal injury of a 30-year-old man? Is a stage 2 occipital pressure injury on a 2-year-old cachectic cardiac patient the same as a 50-year-old recovering after a prolonged surgery? Should a separate pressure injury scale be developed for certain populations, such as neonatal patients?

We write this editorial as practicing members of Northwell Health System. Northwell is composed of 23 facilities with 750 ambulatory sites and had 5.5 million patient encounters in 2018. In addition, 2500 clinical research studies have been conducted by The Feinstein Institute for Medical Research, the home of research for Northwell Health. With a nod to the impact of hospital-acquired conditions and nursing-sensitive quality indicators, standards of care are held in strong regard; as such, in 2007 the Pressure Injury Task Force was assigned the responsibility in to identify and improve prevention, treatment, and management of patients at risk and with pressure injuries. As many health systems struggle with guidelines and recommendations, reliance on specialty wound care organizations to research and maintain standards of care has become an issue. Despite the admirable efforts of these organizations, guidelines and standards of care leave bedside providers with difficulties and challenges in supporting care. The lack of scientific evidence underpinning elements of care continues to foster litigation opportunities and often leaves the nursing staff feeling defeated and that the care that was provided was inadequate. 

We are grateful for this opportunity to discuss some of the issues we encounter each day in caring for our patients, and we hope to begin a dialogue with practitioners across the country in seeking best evidence for the care we provide.

Dr. Boyar is Director, Neonatal Wound Service, Neonatal-Perinatal Medicine, Cohen Children’s Medical Center of NY, Northwell; and Assistant Professor, Zucker Hofstra Medical School, Long Island, New York. Dr. Oropallo is Director, Northwell Comprehensive Wound Center; attending surgeon, Department of Vascular Surgery, Northwell; Associate Professor, Zucker Hofstra Medical School; and Associate Professor, Feinstein Institutes for Medical Research. Ms. Brennan is Assistant Director of Wound and Ostomy Care, North Shore University Hospital, Northwell.