Hospital Medicine

Pressure ulcers/decubiti

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Pressure Ulcers

I. What every physician needs to know.

A pressure ulcer is a localized area of necrosis to the skin and underlying soft tissue caused by unrelieved pressure between a bony prominence and external surface over a prolonged period of time.

Pressure ulcers may be caused by a combination of three factors: extrinsic forces (pressure, friction, or shearing), impaired blood flow, and diminished quality of tissue. It is believed that inadequate blood flow from prolonged compression results in reperfusion injury when blood re-enters the tissue. Hyperemia (redness of the skin) develops within the first 30 minutes of continuous pressure. If pressure is not reduced, ischemia will follow within 2-6 hours and eventually lead to necrosis. Reversal of hyperemia takes approximately 1 hour, however ischemia will require 36 hours for changes to resolve.

Also known as: Decubitus ulcer or Bedsores

II. Diagnostic Confirmation: Are you sure your patient has Pressure Ulcers?

National Pressure Ulcer Advisory Panel (NPUAP) - Staging of Pressure Ulcers:

  • Stage 1: Skin intact, superficial, nonblanchable redness.

  • Stage 2: Damage involves epidermis and extends to dermis; looks like abrasion or ulcer, blister.

  • Stage 3: Full thickness skin loss and extends into subcutaneous tissue, does not penetrate fascia or muscle.

  • Stage 4: Full thickness skin loss with extensive damage to muscle, tendons, and/or bone.

  • Unstageable: Covered by eschar (brown/black) or dead tissue/slough (yellow, gray, green, tan, brown film).

  • Deep tissue injury: Purple or maroon colored localized area of intact skin or blood filled blister due to damage of underlying tissue. Appears like a deep bruise.

A. History Part I: Pattern Recognition:

Non-infected Pressure Ulcers:

  • Redness over bony prominences OR;

  • Open wound over bony prominences;

  • Pain.

Infected Pressure Ulcers:

  • Open wound over bony prominences;

  • Pain;

  • Malodorous;

  • Large amount of drainage or pus;

  • Fever;

  • Hypotension.

Our typical patient:

Elderly individuals with multiple co-morbidities (i.e. coronary artery disease, cerebrovascular event with residual hemiparesis, advanced dementia, diabetes, chronic kidney disease), or younger individuals with neurological or psychiatric illness who are brought to the hospital with decreased oral intake, altered mental status (hyper- or hypo-delirium), and/or fever and other signs of infection.

B. History Part 2: Prevalence:

Approximately 2.5 million pressure ulcers are treated annually, with prevalence and incidence varying depending on the care setting. In acute care, the incidence of pressure ulcers ranges from 0.4% to 38% and prevalence ranges from 10% to 18% in the United States. Some estimate total United States expenditures on treatment of pressures ulcers at $11 billion dollars annually. Pressure ulcers are particularly common in frail, multimorbid patients who are usually elderly and with impaired mobility, as well as younger patients with spinal cord injuries or paralysis.

C. History Part 3: Competing diagnoses that can mimic Pressure Ulcers.

Many different types of skin ulcers exist, with different underlying pathophysiologic mechanisms. Ulcers that can appear similar to pressure ulcers include diabetic ulcers, ischemic ulcers, venous ulcers, malignant ulcers, hypertensive ulcers, and gangrene. Location of the ulcer is a helpful factor in distinguishing between ulcer types. By definition, a pressure ulcer occurs due to sustained external pressure, and therefore should occur in typical areas, such as bony prominences. Other ulcers occur via different mechanisms:

  • Diabetic ulcers are most commonly found in areas of repeated trauma on the foot secondary to neuropathy and vascular insufficiency.

    Ischemic ulcers/arterial insufficiency ulcers are most commonly found in the lower extremities. These ulcers are associated with increased pain on exertion and relief of symptoms when the extremity is at rest or in a dependent position. The skin surrounding the wound is often tight with loss of hair.

  • Venous ulcers are most commonly found between the knee and ankle (especially between the medial and lateral malleoli). It is not usually associated with severe pain unless infected; and there is surrounding dermatitis around the wound with hyperpigmentation of the skin.

  • Malignant ulcers from metastatic growth are a sign of advanced cancer. Sometimes they can be difficult to distinguish and may appear similarly to a venous ulcer. Skin biopsy would be warranted if the wound does not show signs of healing after approximately 2-3 months of treatment.

  • Hypertensive ulcers are very rare and are associated with diabetes and uncontrolled hypertension. They are most commonly found right above the lateral aspect of the ankle and/or Achilles tendon on both legs.

  • Gangrene is usually found in distal areas/extremities of the body where blood supply is compromised leading to necrosis. The affected areas turn green, black, or yellowish brown.

D. Physical Examination Findings.

Wound assessment:

Document location of wound: Examine high risk sites -

  • in a supine patient: occiput of head, scapula, elbow, buttock, heel, toes.

  • in a patient sitting up: head, scapula, sacrum, buttock, heel.

  • in a patient laying on his side (lateral): ear, shoulder, elbow (outer side), hip, both knees, ankle, heel.

Stage the wound based on NPUAP guidelines and comment upon the following -

  • Area - length, width, and depth of the ulcer. Use a probe to determine the presence of undermining or depth of sinus tracts.

  • Appearance of the wound - presence of necrotic tissue, eschar, slough, granulation tissue.

  • Drainage - amount, degree of odor, type (purulence, serosanguinous), color, bleeding.

  • Cellulitis - differentiate between thin rim of erythema around most healing wounds. Look for tenderness, warmth, redness especially if there is progression around the periwound.

E. What diagnostic tests should be performed?

1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

The diagnosis of a pressure ulcer is purely clinical; laboratory studies are not required for diagnosis. However, laboratory studies may be valuable in long-term management of comorbid conditions that may affect wound healing, as well as to manage complications such as infection. These may include:

  • complete blood count and differential (CBC) to assess for anemia or leukocytosis;

  • basic metabolic panel (BMP) to assess for renal dysfunction;

  • albumin/prealbumin to assess nutritional status for wound healing;

  • hemoglobin A1c to assess glucose control;

  • liver function tests (LFTs) to assess for hepatic disease;

  • Erythrocyte sedimentation rate/C-reactive protein (ESR/CRP) to assess or monitor osteomyelitis;

  • blood, wound or bone cultures, if progression to infection is suspected.

2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

Imaging studies are not needed to diagnose pressure ulcers. When signs and symptoms raise suspicion for underlying osteomyelitis, MRI, bone scan or CT scan should be ordered to assess.

F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.

Wound cultures - swab cultures from wounds are often not helpful in determining the organisms causing infection and are often polymicrobial.

III. Default Management.

Relief of pressure:

Relief of pressure is the number one priority. Do not place patients on bedrest when admitted to the hospital unless absolutely necessary. Order physical therapy for the patient. If the patient is bedbound or limited in movement (e.g. stroke with hemiparesis, advanced dementia), enlist the help of the nurses/aides to turn the patient every 2 hours. Place pillows between the knees and ankles to prevent rubbing of the bony prominences when laying on the side. If laying supine, elevate heels off the bed with pillows or use heel protective boots. Order specialized beds that have power pressure reducing mattresses that alternate pressure every few minutes.

Debridement:

There are five types of debridement and their application depends on the circumstances of the pressure ulcer. Removing devitalized tissue prevents pathologic organisms from growing. The type of debridement used is dependent on the patient's health condition, ulcer presentation, and presence or absence of infection, and whether the patient is able to tolerate the procedure.

  1. Mechanical debridement is the use of physical forces to remove devitalized tissue (e.g. wet to dry dressing, hydrotherapy). The disadvantage is that it removes both vitalized and devitalized tissue and can be painful.

  2. Surgical debridement is the use of a scalpel, scissor, or forceps to remove devitalized tissue (eschar/slough) to allow new tissue to grow in. It is a quick and easy way to clean out the wound however it can be painful and cause bleeding.

  3. Enzymatic (Chemical) debridement is the use of topical debriding agents to dissolve devitalized tissue. It is helpful in wounds that are not locally infected, however it can damage the good skin surrounding the ulcer.

  4. Autolytic debridement is the use of synthetic dressings to allow devitalized tissue to self digest from enzymes found in ulcer fluids. This is helpful in patients who are not able to tolerate other forms of debridement but is used only in those where local infection is not suspected. The disadvantage is that healing may take a longer period of time.

  5. Biosurgery is the use of larvae (maggots) to digest devitalized tissue. It is very quick and effective however it has fallen out of favor in the United States even though the FDA had approved its use in 2004 as a live medical device. It is more widely used in Europe.

Management of bacterial load of the wound:

If the wound appears infected, increasing wound cleansing and/or dressing changes are important. Topical antimicrobials (silver sulfadiazine, mupirocin or metronidazole) and topical antiseptics (iodine, chlorhexadine, sodium hypochlorite, or hydrogen peroxide) may be helpful in decreasing bioburden of the ulcer but are not helpful in treating infection. Therefore, non-healing ulcers with cellulitis, bacteremia, osteomyelitis, and sepsis all require systemic antibiotics.

Selection of proper topical dressing for the wound based on staging:

The optimal wound healing environment is moist, as opposed too wet or dry. This can serve as a guiding strategy for choosing among various dressings.

Stage 1: Wound cleansing with normal saline and cover with liquid barrier film or moisture barrier cream (trade names include A+D ointment, Baza Protect®, Dermagran®) every shift.

Stage 2: Cleanse wound with normal saline or dermal wound cleanser (trade names include Saf Clens®).

Minimal to no drainage: Cover with hydrocolloid (trade names include Duoderm®, Comfeel®, 3M© Tegaderm Hydrocolloid®) and change every 3 days (or as needed from soiling)

Drainage: Cover with foam (trade names include Mepilex®, Allevyn®, Biatain®) and change every 1-3 days as needed

Stage 3: Cleanse wound with dermal wound cleanser

Wounds with a dry/moist base:

  • With depth - Hydrogel impregnated gauze (trade names include Restore® or Curafil®) and cover with secondary dressing (foam, dry sterile gauze and tape, or gauze and thin film).

  • Without depth - Hydrogel (trade names include Woun'Dres®, Carrasyn®, or Dermasyn®) and cover with secondary dressing. Change every 1-3 days as needed

Wounds with drainage:

  • With depth - Hydrofiber (trade name include Aquacel®) and cover with secondary dressing (preferably foam-good absorption).

  • Without depth - Cover with foam. Change every 1-3 days as needed.

Stage 4 or Unstageable ulcer: Cleanse wound with dermal wound cleanser.

Surgical consult or wound consult for debridement and assistance of management - surgical versus debriding enzymes (trade names include Collagenase®, Accuzyme®).

Wounds with a dry/moist base:

  • With depth - Hydrogel impregnated gauze and cover with secondary dressing. Change every 1-3 days as needed.

  • Without depth - Debriding enzyme alone or Hydrogel with secondary dressing. Change every 1-3 days as needed.

Wounds with drainage:

  • With depth - Hydrofiber and cover with secondary dressing (preferably foam). Change every 1-3 days as needed.

  • Without depth - Debriding enzyme alone and cover with secondary dressing.

Nutritional support:

A formal nutrition consult is necessary to address any nutritional deficiencies that are important in the role of healing. Taking adequate calories and protein can help healing and prevent further pressure ulcers. Protein intake should be approximately 1.2 to 1.5 grams/kilogram (g/kg) body weight daily.

Prevention - See below under Long Term Management.

Educating the caregiver - See below under Long Term Management.

A. Immediate management.

If there is sepsis, osteomyelitis, abscess, or cellulitis, complete blood work (CBC, Comprehensive metabolic panel, blood cultures), X-ray of region with wound, and systemic antibiotics should be started.

B. Physical Examination Tips to Guide Management.

Pressure ulcers require time to heal. Stage 2 ulcers may take approximately 6-8 weeks of good wound care to resolve, while stage 3-4 ulcers may take up to a year for complete healing. In the hospital setting we may not see the resolution of pressure ulcers. However, periodic visualization of the ulcer is advised to ensure that ulcers are not worsening or becoming infected. The Pressure Ulcer Scale for Healing (PUSH) tool is one of the most widely used scales to objectively assess wound healing and is available at the NPUAP website. Lack of improvement in one week may require alteration in management strategy.

C. Laboratory Tests to Monitor Response to, and Adjustments in, Management.

Laboratory monitoring is not necessary for pressure ulcers, unless complicated by infection, in which case CBC, BMP, ESR, CRP and cultures data is advisable. In patients with poor nutritional status, periodic assessment of albumin and pre-albumin may be helpful.

D. Long-term management.

Prevention is KEY!

Patient positioning:

In bedbound individuals, reposition patient every 2 hours to shift the weight and relieve pressure over bony prominences (especially sacrum, hips, knees, ankles and heels) and maintain circulation. Turn gently to avoid friction and shearing forces. Patients should be placed at 30-degree angle and not higher to avoid sliding and friction. Foam or pillows should be placed in between knees and ankles to avoid pressure at these sites. Heel protectors or placing a pillow under the lower legs to elevate the heels are very important. In chairbound individuals, they should be repositioned every hour with tilting of the seat.

Support surfaces:

There are 3 groups of special mattresses classified by the Centers of Medicaid and Medicare Services (CMS).

  • Group 1 includes non-powered mattresses or overlays and are used in prevention of pressure ulcers or those who have Stage 1 ulcers.

  • Group 2 are power pressure reducing mattresses and are used in patients who have Stage 2-3 ulcers.

  • Group 3 are air fluidized beds and are used in patients who have Stage 3-4 pressure ulcers.

There are extensive criteria measures that must be met to justify use of Group 2 and Group 3 beds.

Mobility:

Encourage the patient to be active. Even if patients have limited mobility, physical therapy can decrease stiffness and strengthen muscles.

Skin Care:

Keeping the skin clean and dry without excessive dryness is very important. Avoid hot water and use mild cleaning agents. Moisturize dry scaly skin with lotion. Cleaning should be done regularly to minimize exposure to moisture from incontinence, sweating or wound drainage. Managing fecal and urinary incontinence is important to prevent breakdown of skin. Occasionally, diverting colostomy may be recommended by the surgery consultant for non-healing pressure ulcers that are frequently soiled by fecal matter.

Educating the caregiver:

Whether it be nursing home staff or families, it is important to provide information on how and why pressure ulcers form and how to prevent them from occurring.

E. Common Pitfalls and Side-Effects of Management.

Heel ulcers with stable eschar - DO NOT DEBRIDE! Call podiatry for assistance.

IV. Management with Co-Morbidities.

A. Renal Insufficiency.

Individuals who have chronic kidney disease or end stage renal disease on hemodialysis have a uremic state that slows down different organ systems including the gastrointestinal tract. These patients tend to have decreased appetite (anorexia) and overall decreased protein intake. The recommended protein intake is approximately 0.6g/kg of body weight/day in a non-dialysed patient and 1.2grams/kg of body weight/day. If there are pressure ulcers, there is a higher need for protein.

B. Liver Insufficiency.

Individuals with liver disease also may have a uremic state similar to those with chronic kidney disease. They also lack the ability to produce certain proteins that are necessary in the healing process.

C. Diabetes or other Endocrine issues.

Uncontrolled hyperglycemia can prevent proper healing of wounds. Therefore, individuals need tighter control of their diabetes and adjust their medications accordingly.

D. Malignancy.

Individuals with malignancy are at risk for pressure ulcers. Controlling pain and encouraging mobility are important in these patients.

E. Immunosuppression (HIV, chronic steroids, etc.).

Chronic use of steroids and immunosuppressive medications can affect the integrity of the skin and prevent healing of pressure ulcers.

F. Primary Lung Disease (COPD, Asthma, ILD).

Chronic use of steroids for COPD or other lung diseases can affect the integrity of the skin and prevent healing of pressure ulcers. Maintaining mobility is important in these patients.

G. Gastrointestinal or Nutrition Issues.

Nutrition is important for wound healing. Maintaining adequate protein, vitamin C and zinc should be considered if there is a deficiency.

H. Hematologic or Coagulation Issues.

Anemia can decrease adequate transfer of nutrients and oxygen to promote tissue healing.

I. Dementia or Psychiatric Illness/Treatment.

Individuals with dementia or psychiatric illness often get agitated and confused. Many also have feeding difficulties and need assistance. Physical restraints and chemical restraints should be minimized in these individuals to prevent being tied down in one position. Having an aide at bedside to redirect and feed the patient may be a better option.

V. Transitions of Care.

A. Sign-out Considerations While Hospitalized.

If pressure ulcers are complicated by infection, would monitor wound daily. If worsened, adjust treatment as needed.

If non-complicated pressure ulcer, no urgent sign out is necessary. Pressure ulcers are easily overlooked, and should be actively mentioned by the primary inpatient provider when handing off care to the next inpatient team.

B. Anticipated Length of Stay.

Length of stay can be prolonged if there are complications associated with pressure ulcer such as cellulitis, osteomyelitis, endocarditis, or bacteremia/sepsis. However, if acute illness is treated and under control, it is in the best interest of the patient to discharge him or her from the hospital as soon as possible to prevent colonization of resistant hospital acquired bacteria and encourage mobility.

C. When is the Patient Ready for Discharge.

Patient is medically ready for discharge when infection, if present, is under control (fever free, cultures are negative) and the logistics of long-term antibiotics, if deemed necessary, have been arranged.

D. Arranging for Clinic Follow-up.

1. When should clinic follow up be arranged and with whom.

Patients who are discharged from the hospital may either go home or to a skilled nursing facility. In skilled nursing facilities there are wound care teams that usually consist of a wound care nurse and/or physician (plastic surgeon, general surgeon and/or internal medicine doctor) who perform weekly wound rounds. Nursing staff who perform daily wound care are trained to monitor progression of pressure ulcers and alert the wound care team for adjustment of management.

If patients are discharged home, home care is often set up and a visiting nurse will assess the patient at home. Caregivers are also taught to clean and dress the pressure ulcer.

Many of these patients have limited mobility, and physician house call visits should be provided as an option.

2. What tests should be conducted prior to discharge to enable best clinic first visit.

NA

3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.

NA

E. Placement Considerations.

If the pressure ulcer results in a condition necessitating long-term intravenous antibiotics, such as osteomyelitis, the receiving skilled nursing facility should be alerted early.

F. Prognosis and Patient Counseling.

Pressure ulcers are usually coded as a secondary diagnosis rather than a principal diagnosis. Prognosis is usually determined by other co-morbidities. Expected hospital length of stay for osteomyelitis from a stage 4 pressure ulcer is estimated to be approximately 6 days to as long as 12 days. Patients who have stage 4 ulcers usually have a life expectancy of less than 6 months.

VI. Patient Safety and Quality Measures.

A. Core Indicator Standards and Documentation.

Pressure ulcers need to be documented on admission. Stage 3 or 4 pressure ulcers that develop in the hospital are considered a "never event" and will not be reimbursed by CMS.

B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.

See above under Long Term Management.

VII. What's the evidence?

"European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Treatment of pressure ulcers: Quick Reference Guide". National Pressure Ulcer Advisory Panel. 2009.

Fonder, MA, Lazarus, GS, Cowan, DA, Aronson-Cook, B, Kohli, AR, Mamelak, AJ. "Treating the chronic wound: a practical approach to the care of non-healing wounds and wound care dressings". J Am Acad Dermatol. vol. 58. 2008. pp. 185-206.

Bluestein, D, Javaheri, A. "Pressure ulcers: prevention, evaluation, and management". Am Fam Physician. vol. 78. 2008. pp. 1186-1194.

"Pressure ulcers in America: prevalence, incidence, and implications for the future. An executive summary of the National Pressure Ulcer Advisory Panel monograph". Adv Skin Wound Care. vol. 14. 2001. pp. 208-15.

Kaltenthaler, E, Whitfield, MD, Walters, SJ, Akehurst, RL, Paisley, S. "UK, USA and Canada: how do their pressure ulcer prevalence and incidence data compare". J Wound Care. vol. 10. 2001. pp. 530-535.

Garcia, AD, Thomas, DR. "Assessment and management of chronic pressure ulcers in the elderly". Med Clin North Am. vol. 90. 2006. pp. 925-944.

Whitney, J, Phillips, L, Aslam, R. "Guidelines for the treatment of pressure ulcers". Wound Repair Regen. vol. 14. 2006. pp. 663-679.

Reddy, M, Gill, SS, Rochon, PA. "Preventing pressure ulcers: a systematic review". JAMA. vol. 296. 2006. pp. 974-984.

Thomas, DR. "Improving outcome of pressure ulcers with nutritional interventions: a review of the evidence". Nutrition. vol. 17. 2001. pp. 121-125.

Cuddigan, J, Berlowitz, DR, Ayello, EA. "Pressure ulcers in America: prevalence, incidence, and implications for the future: an executive summary of the National Pressure Ulcer Advisory Panel monograph". Adv Skin Wound Care. vol. 14. 2001. pp. 208.

Russo, CA, Steiner, C, Spector, W. "Hospitalizations related to pressure ulcers among adults 18 years and older, 2006. HCUP Statistical Brief #64". Agency for Healthcare Research and Quality. 2008.

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