Pressure Injury Prevention and Staging
Pressure injuries (formerly called pressure ulcers or bedsores) are a significant patient safety concern and a quality indicator tracked by most healthcare organizations. The National Pressure Injury Advisory Panel (NPIAP) provides the staging system and prevention guidelines that CPHQ candidates should understand.
Staging System
Stage 1 presents as intact skin with a localized area of non-blanchable erythema. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. In individuals with darker skin tones, blanching may be difficult to detect, making careful assessment essential. Stage 2 involves partial-thickness loss of skin with exposed dermis, presenting as a shallow open wound with a red or pink wound bed, or as an intact or ruptured blister. Stage 3 is full-thickness skin loss in which subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed. Stage 4 is full-thickness skin and tissue loss with exposed bone, tendon, fascia, or muscle. Slough or eschar may be present in both Stage 3 and Stage 4 injuries.
Additional Categories
Unstageable injuries involve full-thickness skin and tissue loss in which the base of the injury is obscured by slough or eschar, making the true depth indeterminate. Once the slough or eschar is removed, the injury can be staged. Deep tissue pressure injury presents as persistent non-blanchable deep red, maroon, or purple discoloration, or an epidermal separation revealing a dark wound bed or blood-filled blister. These injuries may evolve rapidly to reveal the full extent of tissue damage.
Risk Assessment
The Braden Scale is the most widely used risk assessment tool for pressure injuries. It evaluates six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Scores range from 6 to 23, with lower scores indicating higher risk. Assessment should be performed on admission, at regular intervals, and whenever the patient's condition changes. Accurate and consistent risk assessment is the foundation of an effective prevention program.
Evidence-Based Prevention Strategies
Prevention strategies include regular repositioning (at least every two hours for bed-bound patients), use of pressure-redistribution surfaces (specialized mattresses and cushions), skin assessment and moisture management, adequate nutrition (particularly protein intake), minimizing friction and shear during repositioning, and elevating heels off the bed surface. Staff education on proper turning techniques and documentation is essential. For surgical patients, attention to positioning, padding, and duration on the operating table helps prevent intraoperative pressure injuries.
Quality Monitoring
Organizations should track hospital-acquired pressure injury (HAPI) rates as a quality indicator. Prevalence and incidence studies help identify trends and evaluate prevention program effectiveness. CMS considers Stage 3 and Stage 4 hospital-acquired pressure injuries as "never events," and reimbursement may be affected. Accurate staging, documentation of present-on-admission status, and consistent prevention protocols are all responsibilities of the quality professional.