Pressure Ulcers/injuries (PU/PI’s) have been defined as a localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear (Reference EPUAP / NPUAP / PPPIA, 2014).

Pressure-induced tissue damage occurs when too much pressure is applied to one area for a prolonged period of time resulting in small blood vessel collapse and ischemia, or a restriction of blood supply and lymphatic flow to the tissue. Effects of pressure can be exacerbated by lateral shear forces and skin moisture – the latter affects the tensile strength of the skin making it more vulnerable to damage.

Areas of damage

Common sites of damage are highlighted in red in figure 1 (above).

Areas of damage are more common over bony prominences where the bone is closer to the skin.

If pressure is relieved before a critical time, reactive hyperemia, restores tissue nutrition and compensates for compromised circulation- it is now understood that most PU/PI damage starts at the cellular level and and is invisible until redness appears on the skin.

Figure 2

Inflammation is the body’s reaction to tissue damage (figure 2).

The purpose of initial inflammation is to:

  • Eliminate injurious agents and to remove damaged tissue components so that the body can begin to heal
  • Increase vasodilatation and permeability of blood vessels which results in leakage of plasma and fluid creating localised oedema in the skin and tissue

Localised oedema is termed sub-epidermal moisture (SEM).

To learn more about SEM click here

It is irrefutable that tissue damage occurs at the cellular level

Oomens C.J. 2016

Oomens C.J. 2016, Your Content Goes Here

Risk Factors

Classification of Pressure Ulcers/Injury

EPUAP / NPUAP / PPPIA (2014) have developed a globally-adopted classification system that define six stages / categories characterise wounds with increased severity of tissue loss. (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.)

Category/Stage 1

Intact darkly pigmented skin may not have visible blanching: its colour may differ from the surrounding area.
The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.
Category I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons.

Category/Stage 2

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.

Category/Stage 3

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon and muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Category/Stage 4

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. Exposed bone/muscle is visible or directly palpable.
Can extend into muscle and/or supporting structures (e.g. fascia, tendon or joint capsule).

Suspected Deep Tissue Injury

Purple or maroon localised area or discoloured 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.
Deep tissue injury may be difficult to detect in individuals with dark skin tones.

Unstageable

Full thickness tissue loss in which actual depth of the ulcer in completely obscured by slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined.

The Extent of the Issue

9% PU/PI prevalence in Acute Care in the USA1

11.8% PU/PI prevalence in Long Term Care in the USA1

8.3%-23% PU/PI prevalence Internationally1,2,3

£2.1bn spent on PU/PI care in the UK per year3

186,617 hospitalised patients per annum in UK develop PU/PI4

Up to 3 million patients affected per year in the US5

Majority of PU/PI reported to be preventable6,7

Most commonly reported patient harm in the UK8

Sacrum and heels are the most common sites for ulceration/injury

$25bn annual cost to treat PU/PI in the USA9

The Economic and Personal Burden

Personal Burden
– reported to cause

Pain

Distress

Reduced activity

Isolation

Reduced quality of life

Increased morbidity

Economic burden

£2.1bn annual cost to UK HealthCare System1

$43,000 incremental direct cost of a PU/PI per single hospital admission10

Cost to treat is 2.5 times the cost to prevent11,12

£14.5m total cost of PU/PI claims in England 2015/1613

Average settlement of PU/PI lawsuit US $250,00014

Failure to improve accuracy of diagnosis and wound healing rates has potential to increase expenditure on wound care by more than 50% for average CCG / Health Board over next 5 years15

1. Vangilder C. et al. (2008)  2.Vand erwee K. et al. (2007)  3. Bennett G. et al. (2004)  4. Stop the Pressure Campaign. (2017)  5. Joint Commission. (2007)  6. Lyder C. et al. (2008)  7. Black J. (2011)  8. NHS Safety Thermometer  9. H6846 Congressional Record (2017)  10. Agency for Healthcare Research and Quality. 11-0053EF  11. Oot-Giromini B. et al. (1989)  12. Schuurman J.P. et al. (2009)  13. NHS Resolution FOI 2913  14. Petrone K. (2017)  15. Guest J. et al. (2017)

The Economic and Personal Burden

Personal Burden – reported to cause

Pain

Distress

Reduced activity

Isolation

Reduced quality of life

Increased morbidity

Economic burden

£2.1bn annual cost to UK HealthCare System1

$43,000 incremental direct cost of a PU/PI per single hospital admission10

Cost to treat is 2.5 times the cost to prevent11,12

£14.5m total cost of PU/PI claims in England 2015/1613

Average settlement of PU/PI lawsuit US $250,00014

“Failure to improve accuracy of diagnosis and wound healing rates has potential to increase expenditure on wound care by more than 50% for average CCG / Health Board over next 5 years”

1. Vangilder C. et al. (2008)  2.Vand erwee K. et al. (2007)  3. Bennett G. et al. (2004)  4. Stop the Pressure Campaign. (2017)  5. Joint Commission. (2007)  6. Lyder C. et al. (2008)  7. Black J. (2011)  8. NHS Safety Thermometer  9. H6846 Congressional Record (2017)  10. Agency for Healthcare Research and Quality. 11-0053EF  11. Oot-Giromini B. et al. (1989)  12. Schuurman J.P. et al. (2009)  13. NHS Resolution FOI 2913  14. Petrone K. (2017)  15. Guest J. et al. (2017)