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Bruin Biometrics, LLC (BBI) is pleased to provide this series of white papers to help lay readers understand commonly

debated topics in pressure ulcer research and


clinical practice. These papers are the distillation of a comprehensive literation search and review, rather than the result of primary research.

White Paper
Paper
White
AUGUST 2013
OCTOBER 2013

Why do Pressure
Pressure
Ulcers:
Ulcers
Occur?
An Overview of a
Pathophysiology
Painful
Problem of
Pressure Ulcers
BY: KINDAH JARADEH

Education

Evidence

Evaluation

Pressure Ulcers:
An Overview of a Painful Problem
Introduction
Pressure ulcers, commonly known as bedsores, are a problem experienced
internationally. They affect patient quality of life and impose a heavy resource
and financial burden on healthcare systems.

A pressure ulcer is localized injury to the skin and/or underlying tissue


usually over a bony prominence, such as a heel or an elbowi (see Illustration
I). This injury is caused by the inability of the skin and the supporting tissues
to redistribute external pressure, including mechanical loading, friction, and
shear (parallel force).ii Most pressure ulcers occur over bony prominences
where there is less tissue for compression and the pressure gradient within
the vascular network is altered.iii,iv The most common anatomic location of all
pressure ulcers is the sacrum (28.3%), followed by the heel (23.6%) and
buttocks (17.2%) v (see Illustration I). Based on the 2008 and 2009
International Pressure Ulcer Prevalence Survey, the overall prevalence of
pressure ulcers was 12.3% across all care settings.vi Long-term acute care
settings that serve patients with complex medical problems who require
extended hospital stays have the highest overall prevalence of any care
setting at 29.3%, with rehabilitation next at a range of 16.3% to 19.4%, and
acute care settings at approximately 11.9%.vi

Illustration I: Common sites of pressure ulceration in individuals at-risk of pressure


ulcers.vii

Pressure ulcers present a significant health and economic concern. They


account for 60,000 deaths, 2.3 million incremental hospital days and an
estimated $9.1-$11.6 billion per year of care costs in the United States.viii,ix
The cost of individual patient care ranges from $20,900 to $151,700 per
pressure ulcer, which adds $43,180 to a hospital stay.ix


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Similarly, in the United Kingdom, pressure ulcer care costs the healthcare
system 2.1 billion per year ($3.4 billion).x These costs are driven by nursing
time to monitor, assess, and dress wounds, utilization of appropriate
treatment therapies, as well as duration of hospital stay, based on the
severity of the pressure ulcer. For example, the most severe pressure ulcers
(Stage IV) require an average of 155 days recovery timex and $129,248 for
treatment of the ulcer and related complications during a single hospital
admission.xi The result is an average hospital length of stay (LOS) that is 4.5
times longer than patients without pressure ulcers.xii

Pressure Ulcer Classification


The current standard of detection for pressure ulcers relies mainly on visual
inspection. Visual inspection is used to detect and classify pressure ulcers
according to the ulcers depth, width, degree of tissue loss, and presence of
granulated tissue. The National Pressure Ulcer Advisory Panel (NPUAP) in
conjunction with the European Pressure Ulcer Advisory Panel (EPUAP)
categorizes pressure ulcers into one of six stages; 4 depth stages (Stages IIV) and 2 additional stages to indicate deep tissue injury or an ulcer that
cannot be classified. The NPUAP/EPUAP developed this classification
system to ensure consistent and accurate wound categorization as a means
to achieving proper treatment, as well as to help with diagnosis coding for
reimbursement (ICD-9 and ICD-10 codes). Details about each stage are
included in Table 1.
Stage

Normal or
Healthy Skin

Stage I:
Non-blanchable
erythema

Stage II:
Partial
Thickness Skin
Loss

Description

Example

Intact skin
No visible bruising or skin discoloration
Skin is pain-free, and temperature is consistent across surface
Intact skin with non-blanchable redness of a localized area,
usually over a bony prominence
Darkly pigmented skin may not have visible blanching; its
color may differ from the surrounding area
The area may be painful, firm, soft, warmer or cooler as
compared to adjacent tissue
Partial thickness loss of dermis presenting as a shallow open
ulcer with a red pink wound bed, without slough
May also present as an intact or open/ruptured serum-filled or
sero-sanginous filled blister
Presents as a shiny or dry, shallow ulcer without slough or
bruising


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Stage

Stage III:
Full Thickness
Skin Loss

Stage IV:
Full Thickness
Tissue Loss

Description
Full thickness tissue loss
Subcutaneous fat may be visible but bone, tendon, or muscle
is not exposed or directly palpable
Slough may be present but does not obscure the depth of
tissue loss
May include undermining and tunneling
Full thickness tissue loss with exposed bone, tendon or muscle
Slough or eschar* may be present.
Often includes undermining and tunneling
Category/Stage IV ulcers can extend into muscle and/or
supporting structures such as fascia, tendon or joint capsule
Exposed bone/muscle is visible or directly palpable

Unstageable:
Full Thickness
Tissue loss with
Unknown Depth

Full thickness tissue loss

Actual depth of the ulcer is completely obscured by slough


(yellow, tan, gray, green or brown) and/or eschar (tan,
brown or black) in the wound bed

Deep Tissue
Injury (DTI) with
Unknown Depth

Purple or maroon localized area of discolored intact skin or


blood-filled blister due to damage of underlying soft tissue from
pressure and/or shear
The area may be preceded by tissue that is painful, firm,
mushy, boggy, warmer or cooler as compared to adjacent
tissue
Evolution may include a thin blister or eschar over a
dark wound bed
Evolution may be rapid, exposing additional layers of tissue
even with optimal treatment

Example

Table 1: NPUAP/EPUAP Pressure Ulcer Classification Systemxiii

Progression and Reverse Staging


Pressure ulcers do not always progress chronologically (through Stages I, II,
III, etc.) in formation or healing. xiv For example, tissue damage does not
always present as Stage I pressure ulcer, which then develops into higher
stage ulcer. In some instances, the first sign of a pressure ulcer is a deep III
or IV ulcer, because the subcutaneous tissue can become necrotic before the
epidermis erodes. This finding suggests that a small surface ulcer may in fact
represent extensive subcutaneous damage.xv
Once a pressure ulcer develops, tissue damage is not easily reversed.
Previously, it was generally accepted that a pressure ulcer would reverse
stage throughout the healing process and be re-classified at a lower stage.
*

xxxii

Eschar: Dried, black, hard, necrotic tissue


xxxiii
Tunneling: A tract heading away from the wound base in any direction

xxxiii
Slough: Soft, yellow, brown, or gray material and is characterized by its stringy, adherent quality


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(Stage IV becomes Stage III, then Stage II, Stage I, until the skin is again
healthy). However, experts now dismiss this practice because it is
physiologically incorrect. While pressure ulcers do heal to a progressively
shallower depth, a healing wound is not filled by normal tissue; lost muscle,
subcutaneous fat, and dermis is not replaced. xvi Rather, the wound is
replaced by scar tissue that is composed of endothelial cells, fibroblasts,
collagen, and extracellular matrix.xvi Therefore, it is not appropriate to say that
a Stage II pressure ulcer will heal to a Stage I assessment.xvii Instead, a
pressure ulcer maintains its first classification stage, and the term healing is
added as a prefix. For example, a Stage IV pressure ulcer that is improving is
designated a healing Stage IV pressure ulcer; it is no longer reverse
staged to Stage III or II.

Most Pressure Ulcers Are Avoidable


When a caregiver follows the guidelines for patient care that include
repositioning bed-ridden patients approximately once every hour, the risk of
developing a pressure ulcer dramatically decreases. In 2010, the National
Pressure Ulcer Advisory Panel (NPUAP) hosted a multidisciplinary
conference to establish consensus on whether or not pressure ulcers are
avoidable. Eighty-two percent of the clinicians on the conference panel
agreed that most pressure ulcers are avoidable. The instance when the
development of a pressure ulcer was considered unavoidableby a
unanimous vote of all 24 panelistswas hemodynamic instability (a state
requiring pharmacologic or mechanical support to maintain a normal blood
pressure or adequate cardiac output), which is worsened by physical
movement.xviii
The rationale for agreeing that pressure ulcers are largely preventable stems
from the fact that when a care-giver follows well-established guidelines for
patient care, which include but are not limited to mobilizing patients regularly,
ensuring proper nutrition, effectively managing moisture at the skins surface,
the likelihood that a patient will develop a pressure ulcer dramatically
decreases.
The Center for Medicare & Medicaid Services (CMS) also concluded that
most pressure ulcers are avoidable. As of October 2013, CMS
reimbursement for hospital-acquired Stage III and IV pressure ulcers will
cease. Because pressure ulcers are reasonably preventable, CMS has
deemed them never events, namely events that should never happen in a
provider setting. Private insurers in the United States are also adopting these
reimbursement restrictions.xix Similarly, the United Kingdom has adopted a
zero tolerance approach toward pressure ulceration.xx


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Failure to Detect Pressure Ulcers Have Serious Consequences

Forty-two percent of patients with a Stage I pressure ulcer progress to higher


stages of ulceration. Treatment costs quadruple, from Stage I (1,214 or
approximately $1,966) to Stage II (5,241 or approximately $8,485).x A 1998
study found that Stage I ulcers deteriorated to a higher stage in 23.3% of the
patients undergoing surgery lasting more than 4 hours.xxi,xxii In acute care
hospitals, more than 1-in-5 Stage I pressure ulcers deteriorated to higher
stages in one week.xxii The failure to identify a Stage I pressure ulcer during a
skin assessment leads to increased incidence of Stage II ulcers, particularly
in patients with darker skin tones.v Acknowledged difficulties with commonly
accepted practices of pressure ulcer detection help explain incidence rates.
1. Sensitivity & Specificity: Visual inspection, even when combined
with paper and pencil risk assessment tools (e.g., Braden Scale,
Norton, Waterlow) lack sensitivity and specificity (see Table 2).xxiii
Differentiating between epidermal irritation and sub-epidermal
injury becomes more a matter of individual perception than
science.
Sensitivity

Specificity

Odds
Ratio

95%
Confidence Interval

Braden
Scale

57.1%

67.5%

4.08

2.56-6.48

Norton
Scale

46.8%

61.8%

2.16

1.03-4.54

Waterlow
Scale

82.4%

27.4%

2.05

1.11-3.76

Clinical
Judgment

50.6%

60.1%

1.69

0.76-3.75

Tool

Table 2: Risk Assessment Tool Comparisonxxiv

2. Dark Skin Tones: Data show Stage I pressure ulcers are missed
in patients with dark skin tones; instead, such patients develop
four times as many Stage II pressure ulcers as compared to Stage
I pressure ulcers.


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Stage I
45%
40%

38%
37%

35%

39%

41%

Stage II
Stage III

32%

Stage IV

30%

Eschar

25%
20%
13%

15%
10%

6% 5% 9%
6%

7% 6% 9%
7%

13% 13%
11%
9%

5%
0%
Light
Medium
Dark
Figure 1: Prevalence of Pressure Ulcers by Skin Color.v

3. DTI and the Bottom-Up Formation model: Stage II and higher


pressure ulcers often occur suddenly without significant visual
cues appearing on the skin surface in time to prevent them:xxv,xxvi
injury deeper in the tissue is the suspected cause. If surface
ulceration is hard to detect, identifying injury deep in the tissue is
near impossible without a method of interrogation.

The Bruin Biometrics Solution


Bruin Biometrics, LLC (BBI) has created the SEM Scanner, a diagnostic
medical device intended to objectively detect pressure-induced tissue
damage beneath the skins surface and measure the progression both of
wound development and healing. Conceived by Barbara Bates-Jensen, PhD,
RN, CWOCN, FAAN, one of the worlds leading wound care experts, the SEM
Scanner is a hand-held, portable device that noninvasively detects levels of
subepidermal moisture (SEM), a biophysical marker that is correlated with
pressure ulcer formation and healing.xxvii,xxviii
BBI believes that early detection of pressure ulcer formation is the best form
of prevention. The SEM Scanner introduces an evidence-based, objective,
method to pressure ulcer detection, enabling early intervention to treat tissue
damage, and ultimately, prevent pressure ulcers.


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Endnotes
i

European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory
Panel, 2009. Prevention and Treatment of Pressure Ulcers: Clinical Practice
Guidelines. Washington, DC: National Pressure Ulcer Advisory Panel.

ii

Bates-Jensen, B., 2012. Pressure ulcers, Comprehensive Wound Care Review


Course. Clinical Symposium on Advances in Skin and Wound Care: The Conference
for Prevention and Healing.

iii

Sussman, C. and Bates-Jensen, B. 2012. Wound care. Philadelphia: Wolters, Kluwer,


Lippincott, Williams & Wilkins Health.

iv

Lindan, O., Greenway, R.M. and Piazza, J.M., 1965. Pressure distribution of the
surface of the human body. Arch Phys Med Rehabil, 46, pp. 378-385.

Vangilder, C., Macfarlane, G., Meyer, S. and Others. 2008. Results of nine
international pressure ulcer prevalence surveys: 1989 to 2005. Ostomy Wound
Management, 54 (2), p. 40-54.

vi

Vangilder, C.M., Amlung, S., Harrison, P. and Meyer, S. 2009. Results of the 20082009 International Pressure Ulcer prevalence Survey and a 3-year, acute care,
unit-specific analysis. Ostomy Wound Management, 55 (11), pp. 39-45.

vii

Marois, C.L., 2010. Pressure Ulcer Reduction and Elimination. Covidien. Available
at: <http://www.covidien.com/imageServer.aspx?contentID=20369&contenttype=
application/pdf> [Accessed 29 August 2013].

viii

The Joint Commission Perspectives on Patient Safety Strategies for Preventing


Pressure Ulcers, 2008. Strategies for Preventing Pressure Ulcers 8, pp. 57.

ix

Agency for Healthcare Research and Quality (AHRQ). Preventing pressure ulcers in
hospitals: A toolkit for improving quality of care. Available on:
<http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressureulcers/pressureulcertoolkit/putoolkit.pdf> [Accessed 1 July 2013].

Dealey, C., Posnett, J. and Walker, A. 2012. The cost of pressure ulcers in the United
Kingdom. Journal of Wound Care, 21 (6), pp. 261-266.

xi

Brem, H., Maggi, J., Nierman, D., Rolnitzky, L., Bell, D., Rennert, R., Golinko, M.,
Yan, A., Lyder, C. and Vladeck, B. 2010. High cost of stage IV pressure ulcers. The
American Journal of Surgery, 200 (4), pp. 473-477.

Allman, R., Laprade, C., Noel, L., Walker, J., Moorer, C., Dear, M. and Smith, C.
1986. Pressure sores among hospitalized patients. Annals of Internal Medicine, 105
(3), pp. 337-342.

xiii

National Pressure Ulcer Advisory Panel, 2007. NPUAP pressure ulcer


stages/categories, (online) Available at:
<http://www.npuap.org/resources/educational-and-clinical-resources/npuappressure-ulcer-stagescategories/> [Accessed 15 November 2012].

xiv

Bluestein, D. and Javaheri, A. 2008. Pressure ulcers: prevention, evaluation, and


management. American family physician, 78 (10), pp. 1186-1194.

xiii

Merckmanuals.com. 2013. Pressure Ulcers: Merck Manual Professional. [online]


Available at:


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<http://www.merckmanuals.com/professional/dermatologic_disorders/pressure_ulcer
s/pressure_ulcers.html> [Accessed: 30 Aug 2013].
xvi

Thomas D.R., Rodeheaver G.T., Bartolucci A.A., Franz, R.A., Sussman, C., Ferrell,
B.A., Cuddigan, J., Slotts, N.A., and Maklebust, J., 1997. Pressure ulcer scale for
healing: Derivation and validation of the PUSH tool. Adv Wound Care, 10(5), pp.96101.

xvii

National Pressure Ulcer Advisory Panel. The facts of reverse staging in 2000,
(online) Available at: < http://www.npuap.org/wp-content/uploads/2012/01/ReverseStaging-Position-Statement > [Accessed 19 November 2012].

xviii

Black, J.M., Edsberg, L.E., Baharestani, M.M., Langemo, D., Goldberg, M.,
McNichol, L., Cuddigan, J. and the National Pressure Ulcer Advisory Panel, 2011.
Pressure ulcers: avoidable or unavoidable? Results of the National Pressure Ulcer
Advisory Panel consensus conference. Ostomy Wound Management, 57(2), pp. 24
37.

xix

Mattie, A. S., & Webster, B. L. Centers for Medicare and Medicaid Services never
events: an analysis and recommendations to hospitals. The health care manager,
27(4), pp. 338349.

xx

Wounds-uk.com. 2013. Zero tolerance approach results in reduced pressure ulcer


incidence News Wounds UK. [online] Available at: <http://www.woundsuk.com/news/zero-tolerance-approach-results-in-reduced-pressure-ulcer-incidence1> [Accessed: 30 Aug 2013]

xxi

Schoonhoven L. (1998) Incidentie Van Decubtius Op de Operatietafel (Incidence of


Pressure Ulcers at the Operating-room). Universiteit Utrecht, Utrecht.

xxii

Halfens, R., Bours, G. and Van Ast, W. 2001. Relevance of the diagnosis stage 1
pressure ulcer: an empirical study of the clinical course of stage 1 ulcers in acute
care and long-term care hospital populations. Journal of Clinical Nursing, 10 (6), pp.
748-757.

xxiii

Kottner, J. and Dassen, T., 2010. Pressure ulcer risk assessment in critical care:
Interrater reliability and validity studies of the Braden and Waterlow scales and
subjective ratings in two intensive care units. International Journal of Nursing
Studies, 47(6), pp. 671-677.

xxiv

Thomas, D.R., 2001. Issues and dilemmas in managing pressure ulcers. J Gerontol
Med Sci, 56, pp. 238-340.

xxv

Bethell, E., 1992. Controversies in classifying and assessing grade 1 pressure ulcers.
Nursing Times 99, pp. 7375.

xxvi

Quintavalle, P. R., Lyder, C. H., Mertz, P. J., Phillips-Jones, C. and Dyson, M.,
2006. Use of high-resolution, high-frequency diagnostic ultrasound to investigate the
pathogenesis of pressure ulcer development. Advances in Skin Wound Care 19, pp.
498505.

xxvii

Bates-Jensen, B., McCreath, H.E., Pongquan, V., and Apeles, N.C.R., 2007. SubEpidermal Moisture Differentiates Erythema and Stage I Pressure Ulcers in Nursing
Home Residents. Wound Repair and Regeneration, 16, pp. 189-197.

xxviii

Harrow J.J. and Mayrovitz H.N., 2006. Initial assessment of tissue water content
surrounding pressure ulcers in spinal cord injury patients. [Abstract]. Available at: <


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ttp://clinsoft.org/drmayrovitz/POSTER-ABSTRACTS/23.html> [Accessed 29
August 2013].
xxxii

Ncbi.nlm.nih.gov. 2006. ABC of wound healing: Pressure ulcers. [online] Available


at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1382548/ [Accessed: 30 Aug
2013].

xxxiii

Lin, V., Cardenas, D., Cutter, N., Frost, F., Hammond, M., Lindblom, L., Perkash, I.,
Waters, R., Woolsey, R., Priebe, M. and Others, 2003. Principles of Pressure Ulcer
Management. Demos Medical Publishing.


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