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Introduction To Pressure Injuries/Ulcers (PI/PU)

“A PI/PU is defined as localized damage to the skin and/or
underlying tissue, as a result of pressure or pressure in combination with shear. PI/PU usually occur over a bony prominence but also may be related to a medical device or other objects.”1

Most Common Locations for
Pressure Injuries/Ulcers

glassman from the front

Patients may develop PI/PU in a variety of locations – Vanderwee et al. (2011) identified that the heels and sacrum account for more than 80% of all PI/PUs.2 Occurrence is common over bony prominences but in recent years PI/PU related to medical devices or other object have become more commonly reported.

glassman from the back

Risk Factors

Specific risk factors have been identified and should be
considered1,3 when planning patient care.

mobility icon

Mobility / activity

icon showing water dripping onto skin


icon showing moisture on the skin

Skin moisture

icon showing a pain in the heel


icon showing perfusion of cells

Perfusion including diabetes and previous PI/PU status

icon representing haematological

Hematological measures

icon showing a family from a baby to a person with a cane

Nutrition and general health status

icon showing impaired sensation

Impaired sensation

Risk Assessment

There are many risk assessment tools (RATs) available – estimates suggest there could be as many as 90 different versions,4 however there is no real consensus as to the optimal RAT to use.

RATs have been reported to be subjective and open to interpretation – additionally results are dependent on the expertise of the assessor.5 In a Cochrane systematic review, Moore & Patton (2019)6 found that neither the Braden nor the Waterlow risk assessment tools made any significant difference to PI/PU incidence rates, when compared to clinical judgement alone.

Skin and Tissue Assessment

The 2019 International Clinical Practice Guidelines1 state that “skin and soft tissue assessment is a key component of PI/PU prevention, classification, diagnosis and treatment”. Routine skin assessment should include for example a visual assessment for erythema, palpation for differences in temperature and tissue consistence.1 The same Guidelines note the challenges in assessing darkly pigmented skin where areas of redness may be more diffcult to see.

The Extent of the Issue

26.8 billion dollers

Annual cost of PI/PUs to the US healthcare system

2.5 million

Patients in the US that develop PI/PUs each year

2.1 billion pounds

Annual cost of PI/PUs to the UK healthcare system

13.1 % prevalence

European Pi/PU prevalence identified in Systematic Review

Most commonly reported

Most commonly reported patient harm in the UK

Sacrum and heels

The most common sites for ulceration/injury

1. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance (2019). Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide. Emily Hasler (Ed.). EPUAP/NPIAP/PPPIA
2. Vanderwee K., et al (2011). Assessing the adequacy of pressure ulcer prevention in hospitals: a nationwide prevalence survey. BMJ Qual Saf. 20(3):260-7
3. Guy, H. (2012). Pressure ulcer risk assessment. Nursing Times.
4. Moore Z., et al. (2018). Meeting Report: Enhancing the efficiency of pressure ulcer/pressure injury care and patient outcomes with the SEM Scanner. Wounds UK; vol 14; no 1
5. Moore Z., et al (2014). Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews, Issue 2, Art No.: CD006471. DOI: 10.1002/14651858.CD006471.pub3
6. Moore Z., et al. (2019). Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD006471. DOI: 10.1002/14651858.CD006471.pub4
7. Padula W., et al. (2019) The national cost of hospital-acquired pressure ulcers in the United States. International Wound Journal, 1-7
8. Berlowitz D., et al. (2012). Agency for Healthcare Research and Quality (AHRQ). Preventing Pressure Ulcers in Hospitals. A Toolkit for Improving Quality of Care. [online] Available at: (Accessed 7 April 2018)
9. Bennett G., et al. (2004). The cost of pressure ulcers in the UK. Age and Ageing. 33(3):230–235
10. Moore Z., et al. (2019). The prevalence of pressure ulcers in Europe, what does the
European data tell us: a systematic review. Journal of Wound Care. Vol 28:no 11: 710-719
11. NHS Safety Thermometer.
12. AHRQ Agency for Healthcare Research and Quality (2014) Preventing Pressure Ulcers in Hospitals. Accessed January 2020
13. Oot-Giromini B., et al. (1989). Pressure ulcer prevention versus treatment, comparative product cost study. Decubitus, 2(3): 52–4
14. Schuurman JP., et al. (2009). Economic evaluation of pressure ulcer care: a cost minimization analysis of preventive strategies. Nurs Econ; 27(6): 390–400, 415
15. NHS Resolution. (2019). FOI 2913
16. Petrone K. (2017) Pressure Ulcer Litigation: What is the Wound Center’s Liability? Today’s Wound Clinic Vol 11 Issue 9

The Economic and Personal Burden


  • Estimates suggest PI/PU adds $43,180 in costs to a hospital stay in the US12
  • Cost to treat is 2.5 times the cost to prevent13,14
  • £14.5m total cost of PU/PI litigation claims in England 2015/1615
  • Average settlement of PU/PI lawsuit US $250,00016

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Pressure Injuries/Ulcers (PI/PUs)

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