Who Should Assess and Stage Pressure Injuries in... : Advances in Skin & Wound Care

Who Should Assess and Stage Pressure Injuries in... : Advances in Skin & Wound Care

Pressure injuries (PIs) in the US are estimated to affect 2.5 million patients annually with incidence ranging from 2.9% to 69% and the highest incidence occurring in ICU patients. Costs for the care and management of a PI range from $9.1 billion to $11.6 billion in the US alone, and these costs are thought to increase the cost of a hospital stay by an additional $43,000 for any patient who develops a PI. The incidence of hospital-acquired pressure injuries (HAPIs) is also associated with a financial impact on the hospital’s reimbursement, a decrease in the hospital’s quality standards, and an increased risk of medical malpractice claims.

The assessment and staging of PIs, whether they are present on admission or develop during a hospitalization, are tasks that have traditionally been assigned to the RN, whereas the management and care of these PIs may be covered under a medically approved protocol or by specific physician orders. Currently, an RN completes a risk assessment score on any patient admitted into the hospital using a risk assessment tool; in the US, this is either the Braden or a Braden QD Scale (from prematurity to 21 years of age). Based on the score, a hospital’s policy or procedure would outline the preventive interventions to be implemented. If a PI were present or acquired during the hospitalization, documentation would then begin.

Correctly staging and assessing PIs have become an essential part of nursing assessments. This need for accuracy in data reporting affects hospital measures, a facility’s standing in the provision of care, and funding/reimbursement. This article will briefly discuss the issues associated with PI development in an acute care hospital as they relate to risk, quality, legal implications, and documentation before addressing the question, “Should a bedside nurse be expected to accurately stage and assess a PI?”

Throughout the past few decades, regulatory healthcare agencies have reported annual data detailing incidence and prevalence of PIs in acute care facilities. Currently, HAPIs are one of the nursing-sensitive quality measures being reported to regulatory agencies and factored into a hospital’s quality star ratings. The hospital’s star rating is based on reported quality measures and is a summary of the five overall areas of quality (mortality, safety of care, readmission, patient experience, and timely and effective care). In conjunction with this reporting, a facility with poor data risks a loss of reimbursement as well.

Are the reported data accurate? In 2018, Weller and colleagues found many inconsistencies in the data being reported, with issues related to the identification and staging of PIs, timing of assessments, and documentation. Currently, hospital-based coders identify and note the presence of a PI, whether this documentation from the physician is accurate or not. Are physicians and providers knowledgeable and comfortable with PI staging and assessment? Cox found that physicians surveyed about their knowledge of PIs reported that they had not received adequate education in PI care, with most (69%) reporting inadequate training. Many physicians also reported that they had never attended a PI lecture.

With the inclusion of HAPIs as a nursing-sensitive quality indicator, litigation in this area has increased significantly. Patients and families have become more familiar and aware of the terminology of “bedsore” or “pressure sore,” and placing either of these words in a search bar will yield numerous articles, forums, and discussion points. Many law firms have advertised for patients and families to consult with them for a potential lawsuit as any HAPI is viewed as a negative, preventable outcome.

The hospital’s policies and procedures establish the standard of care provided. Because documentation in the medical record serves as evidence of care and adherence to policies and protocols, any deviation in documentation may provide evidence to question the care and add to the challenges in a hospital’s defense. Nursing staff may not document skin assessments accurately or notes from clinicians may be conflicting and inaccurate, posing clinical and legal liabilities. Among claims involving ICU nursing care, PI was the most common diagnosis in malpractice claims with a hospital as the defendant. In addition, Padula and Delarmente noted that patients experience additional pain and medical issues arising from HAPIs. These costs may be incurred over months and years and add to the cost of care. For patients who develop these conditions secondary to a PI, legal action is seen as an eventual and appropriate recourse to compensate for their pain and suffering.

The important task of identifying a PI resides with the direct care RN, who usually initiates the first documentation of any skin alteration. When it comes to skin assessment, a nurse’s knowledge, expertise, and comfort level may affect their assessment of the patient’s skin.

How well trained are nurses to take on skin assessments? Many hospitals and health systems have initial training processes in place to orient new staff to their role expectations as well as the policies, procedures, and equipment specific to the facility and unit. Skin and wound care interventions typically are reviewed during the precepting aspect of the orientation process.

Is this training adequate? In 2010, Zulkowski et al assessed undergraduate nursing students’ knowledge level of PIs, and the results were concerning. Using the Pressure Ulcer Knowledge Test (a 47-item test covering PI prevention, staging, and wound assessment), Pieper and Mott found that nursing students scored at a C or C+ knowledge base. Ayello and colleagues revisited PI knowledge levels in nursing education in the US in 2017. Their work reviewed PI education at the undergraduate level and the overall challenges with nurses maintaining competency in PI content and knowledge. In reviewing prior studies and published work, the authors noted that educators’ awareness and skill sets were also lacking. There was a shortage of opportunities for continuing education specific to skin and wound care in many learning sites. They further identified low levels of PI content in the textbooks and curriculum offered to students.

In a dissertation, Kelemete and colleagues compared the accuracy of direct care nurses with wound experts completing a bedside PI assessment on the same patients using photographs and clinical history in a 1-day point prevalence. The work included 63 patients with one to seven PIs. The direct care nurses first assessed, photographed, and documented the PIs, and a wound care expert then reviewed the data provided on that day to identify all patients with a PI. An expert panel composed of two nurses and two physical therapists with a minimum of 15 years of PI assessment experience then reviewed these patients’ assessments, documentation, and photographs. The authors found that direct care nurses diagnosed PIs more frequently than the experts (105 PIs vs 96 PIs), and there was 54% disagreement between groups on the staging of the PIs. There were concerns that the nurses may have counted incontinence-associated dermatitis (IAD) as a PI and that some deep-tissue injuries (DTIs) may not have been true PIs. In the discussion of their results, the researchers noted that DTIs were the most common type of PI identified by direct care nurses and questioned if ethnicity and skin pigmentation may have resulted in mistaken identifications of PIs. In addition, the two groups disagreed 64% of the time when judging present-on-admission PIs. The authors concluded that a nurse’s lack of experience may contribute to improper identification of skin alterations.

Many researchers outside the US have noted comparable results in their reviews of PI education. Usher and colleagues surveyed undergraduate nursing students in seven universities across Australia and found that 51% of respondents had little knowledge of preventive strategies. Dalvand and colleagues published a systematic review and meta-analysis that revealed nurses’ knowledge level of PI prevention was lower than expected. All authors recommended further education and training to equip nursing staff with the skills and knowledge needed to provide both preventive and PI care.

Of note, these articles were published prior to the COVID-19 pandemic. Healthcare facilities are currently finding that nursing staff who were in their final years of study during the time that COVID-19 impacted healthcare facilities could not engage in direct patient care in their last year or two of study. For new nursing graduates, skill sets may have been weakened by this lack of exposure. Will this limited patient care exposure further undermine comfort and appreciation for PI prevention and management moving forward? At present, new graduate nurses’ accuracy in identifying and reporting is unknown but must be a concern for reporting institutions.

Adding to this complexity is a question raised by several authors about differentiating skin changes in varying skin tones. Sullivan reported a 5-year retrospective study aimed at identifying descriptors in darkly pigmented skin. Gunowa and colleagues also explored this issue in 2021, noting that Baker previously reported in 2016 that people with darker skin tones have a higher prevalence of severe PIs. In assessing for skin changes, erythema is frequently referenced as a potential descriptor, and yet, this is not a visual change easily seen in patients of color. This descriptor continues to be used in various assessment tools (redness, discoloration, and skin that does not blanch) and may not pertain to patients of color. Educational efforts addressing skin tone diversity are lacking around the world. These authors noted limitations in educators’ knowledge of skin tone diversity and their overall comfort assessing the skin of patients with dark skin tones.

Although several tools address PI risk assessment, few tools assist with PI assessment and staging. Some companies provide “realistic” models of the PI staging system with full-thickness wounds offering tunneling and undermining for teaching purposes. Unfortunately, there are varying skin tones that cannot be replicated, and these models currently only illustrate fair or light skin or dark to very dark skin tones.

Researchers have investigated various additional approaches to improve PI assessment. Koerner and colleagues studied the use of thermal imaging to identify DTIs prior to their visual presentation. They found that temperature increases or decreases as compared with adjacent normal tissue may be an early indicator of a DTI, thereby enabling a facility to identify that area as a present-on-admission PI. In 2000, Houghton and colleagues completed a reliability study of wound photographs taken of PIs and leg ulcers. The Photographic Wound Assessment Tool incorporates size, depth, necrotic tissue type, necrotic tissue total amount, granulation tissue type, granulation tissue total amount, edges, and periulcer skin viability. This tool may be useful in evaluating treatment and response of a PI or wound without the need for a bedside assessment. Subepidermal moisture sensors have also been described in the literature, with noted potential for predicting PI development. However, these tools are expensive and require staff training, which may preclude them from widespread use.

After looking at the number of articles citing difficulties with ensuring adequate education at the undergraduate level, I asked random unit-based nurses in my own facility their thoughts and issues with PI documentation. Many nurses were concerned about the accuracy of their assessments when documenting the stage. They were concerned with differentiating a stage 2 PI from an area of IAD. If a patient presented with incontinence of bowel and bladder, this diagnosis was an easy one to document. If, however, a patient was incontinent of bowel but did not have diarrhea, then a diagnosis of dermatitis did not “come to mind.” Dermatitis with superficial epidermal erosion easily blurred the lines and led to confusion. Physicians were also unclear about differentiating between a stage 2 PI and IAD. Davey defined IAD as consisting of multiple open lesions presenting on a background of inflamed skin. He concluded this definition would differentiate a PI from IAD. Nurses were not confident in this differentiation, however. When a nurse was asked how she differentiated between stages 3 and 4 PIs, her response was that if bone was apparent in the wound, then she was confident that it was a stage 4. Without this presence, there was hesitation regarding identification of the wound stage. Some nurses said they would go to the highest stage because they were not to reverse-stage a PI. Others said they would choose a higher stage because they did not want to “understage.” All the nurses were quick to point out that they would ask for the wound experts to come and assess.

Despite receiving education through the hospital’s ongoing annual mandatory modules, nurses had doubt and confusion when needing to document their findings during a real-world scenario. In addition, descriptions and choices in the electronic medical record only served to further confuse inexperienced nurses who were already feeling overwhelmed in their new role. Why the concerns? Nurses are expected to correctly identify a HAPI and document it appropriately with a full assessment. As an example, if a patient had fallen and was now admitted with a reddish-brownish tissue alteration, there was confusion about whether this skin change indicated a PI or a bruise. Many nurses said they would document it as a DTI present on admission. If this was incorrect, and it was a traumatic injury or bruise, then it was easier to correctly document the change than to document a HAPI that was not identified on admission.

With a focus during the past 3 decades on reducing or eliminating PI occurrence, there have been incremental increases in our knowledge and understanding of PIs’ origins and causes. Factors influencing PI occurrence continue to be examined, along with the risks associated with surgery and ICU stays, impact of pressors on the skin, and effects of mechanical ventilation and enteral feeds on the body. In addition, debate continues as to whether PIs are avoidable or not.

Should direct care nurses assess and stage PIs? Perhaps not. Numerous studies have identified errors in staging among both staff nurses and wound experts. Proper PI documentation requires accuracy in both identification and staging; many articles have noted that differentiating and staging PIs can be overwhelming for nurses. In addition, decisions regarding what information to document in the electronic medical record may further complicate the assessment and frustrate the direct care nurse. Poor or inadequate lighting in patient rooms or ED hallways can also make assessments more challenging. Varying skin tones and a lack of clear direction/indicators with dark skin assessment only add to the confusion. Unless a direct care nurse can correctly and accurately document a PI, he/she should not be responsible for this task because an error in judgment has financial, quality, and legal ramifications. This work is best entrusted to wound care experts who have the training and knowledge required to accurately assess and stage PIs. The direct care nurse could alert the wound care expert when there is a skin alteration noted on admission or during a hospitalization. Then the expert could fully assess and document, set up the interventions and treatment plans, and communicate the results to all members of the healthcare team. Although this approach would eliminate errors in assessment and documentation, it would require the hospital or facility to have enough wound care experts on staff who are available to render timely consultations.

An alternate proposal would be not to use the staging system in bedside skin assessments of PIs. Documenting partial-thickness or full-thickness PIs may help limit current challenges and errors and lessen staff nurses’ concerns. In reviewing interventions present in the author’s health system’s guidelines, many treatment options pertain to tissue type and depth and not necessarily to the stage. This may allow the nursing staff to feel more comfortable in their skill set during skin assessment.

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