Pressure Ulcers

Excerpt from Textbook of Chronic Wound Care

The following is an excerpt from Textbook of Chronic Wound Care, editors Jayesh B. Shah, MD, Paul J. Sheffield, PhD, and Caroline E. Fife, MD.

Introduction and epidemiology

Pressure ulcers continue to be a significant health-care issue in the United States and around the world. The two most common groups that develop pressure ulcers are the elderly and individuals with spinal cord injuries. The main risk factor in both of these populations is immobility. An estimated 2.5 million patients are treated for pressure ulcers in the acute-care setting yearly.(1-2) The cost of pressure ulcers to the health-care system in the United States ranges from $9.1–11.6 billion per year. As per Medicare data from 2007, treatment of a pressure ulcer added an additional $43,180 in cost to a hospital stay.(3) The additional cost includes additional hospital days, dressings, nursing time, and therapeutic modalities, such as negative pressure therapy or electrical stimulation therapy. If the patient experiences complications from pressure ulcers, additional costs might include IV antibiotic therapy, surgical debridement, and more complex treatments such as diverting colostomy or rotational flaps to promote wound healing. In addition, patients who develop pressure ulcers during hospitalizations are more likely to require long-term care placement as opposed to going home, adding additional cost to the health-care system. The development of a single pressure ulcer can increase the length of stay in the hospital fivefold.(4)

Despite the advances in technologies, dressings, and support surfaces, the prevalence and incidence of pressure ulcers has not significantly decreased in the last 20 years. Although the average life expectancy has increased, we have not significantly impacted functional status or chronic medical conditions; therefore these conditions continue to plague individuals into their older years.(5) As of 2012, 11.5% of the world’s population was over the age of 60.(6) Given the global aging population, it is estimated that 20% of the population will be over the age of 65 by the year 2030, with the fastest-growing segment of the population being individuals over the age of 80.(7) Seventy percent of pressure ulcers occur in individuals over the age of 70, which is by far the largest group in which pressure ulcer occurs.(4) In the spinal cord injury population, it is expected that 25%–40% of individuals will develop a pressure ulcer in their lifetime.(8)

I. Pathophysiology

The National Pressure Ulcer Advisory Panel has changed the terminology for pressure ulcer staging by removing the word “ulcer” and replacing it with “injury.” The NPUAP definition of a pressure injury as revised in April 2016 now reads:

“A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities and condition of the soft tissue.”(9)

Since the term “injury” is now used by the NPUAP to denote both changes in skin color which are not yet open ulcers as well as open ulcers requiring some sort of dressing, in this chapter we will use the term “ulcer” to designate open skin lesions. The amount of time and the amount of pressure can vary among individuals, but it is well documented that pressures above 32 mmHg will cause capillary collapse. The amount of time is dependent on the amount of pressure. The more pressure is placed on a specific area of tissue, the less time necessary to lead to tissue necrosis.(10-11)

Contributing factors to the development of pressure ulcers include both intrinsic and extrinsic factors. Intrinsic factors are those inherent to the patient, including medical conditions, age, functional status and nutrition.(12) In addition, a history of previous pressure ulcers would also be a consideration. These factors cause changes to the skin that may predispose the patient to skin breakdown. The more comorbidities a patient has, the more significance it may have on skin integrity. For example, if a patient has a history of congestive heart failure, end stage renal disease on dialysis, incontinence secondary to diuretics, hypotension due to dialysis, limited mobility from being short of breath, and that patient also requires dialysis three times a week which will impact mobility, fluid status and potentially blood pressure, the cumulative effect of these various factors will increase that individual’s risk for the development of a pressure ulcer. It is therefore important to take a holistic view of the patient when assessing risk factors.

Extrinsic factors include pressure, friction, shear, and moisture. Pressure is the major risk factor for pressure ulcers. The main cause is immobility, although there can be pressure from external sources such as medical devices as well. Poor mobility may be secondary to underlying comorbidities such as cerebrovascular accident, spinal cord injury or progressive neurologic disorders, or advanced age leading to functional decline. When assessing the patient’s risk from mobility, it is important to look not only at the patient’s ability to transfer and ambulate, but at bed mobility as well. Patients with limited bed mobility in the home environment still need to be repositioned frequently by caregivers if they cannot make shifts in body positioning. Friction is defined as the force when two objects rub against each other. In patients at risk for pressure ulcers, friction can cause additional damage to the skin. Some examples commonly noted are patients using their heels to push themselves up in the bed or patients who are dragged across the sheets instead of being lifted. In both these scenarios, friction can lead to superficial damage to the epidermis or blisters when fluid enters the space between the epidermis and dermis. Preventive strategies would be the use of trapezes to allow the patient to use his or her upper body for mobility, use of offloading boots to prevent use of heels for pushing up in the bed, and appropriate turning strategies to prevent dragging patients instead of lifting them with draw sheets. Shear force occurs when the head of the bed is elevated above 30 degrees, and the patient begins to slide down the mattress. The blood vessels in the sacral area are sheared by the opposing forces and can lead to skin breakdown in the sacral/coccyx area. In some clinical situations, the clinician has no choice but to elevate the head of the bed due to underlying medical issues. In these scenarios, prevention strategies such as sacral dressings to minimize tension on the tissue might be utilized. Moisture is another extrinsic factor in the development of pressure ulcers. Moisture can occur from numerous sources including urinary and bowel incontinence, wound drainage, obesity, and excessive sweating. When the skin is exposed to excess moisture, it leads to maceration of the tissue. This makes the skin friable and more susceptible to damage from friction and shear forces.

II. Pathway

© Best Publishing Company, Wound Care Certification Study Guide 2nd edition Adapted with permission by Jayesh B. Shah, MD

Case study: evaluation of the pressure ulcer patient

See Pressure Ulcer Management Pathway. Mrs. S is an 88-year-old female who lives in an assisted-living facility. The patient has multiple medical problems including a history of cerebrovascular accident, hypertension, diabetes mellitus, and early dementia. The staff at the assisted-living facility noted Mrs. S had not been seen in the dining room in the past 24 hours. Upon entering her room, they found Mrs. S sitting in her recliner. She was noted to be very confused and lethargic and had incontinence episodes. 911 was called, and the patient was sent to the emergency room. Upon evaluation, she was noted to have a urinary tract infection and be dehydrated. On evaluation of the patient’s skin, she was noted to have an area of skin breakdown on the sacrum measuring 3.5 x 2.5 cm, partial thickness with no noted necrotic tissue. There is minimal serous drainage, no odor, and no surrounding erythema.

When the clinical team evaluates a patient, a wound-care history needs to be performed. In the same way that a comprehensive history is obtained to find out the background of any clinical problem, a wound-care history incorporates many elements to gain insight into the wound.(13) Some questions that might be asked specifically in the case of a pressure ulcer include the following items:

  • How long has the pressure ulcer been present?
  • What treatments have been implemented for wound healing?
  • What comorbidities are present that might impact wound healing?
  • Has the patient had previous pressure ulcers, and if so, where? What stage?
  • Has there been a change in functional status?
  • Is the patient able to offload?
  • Are there any preventive devices currently being used, such as a wheelchair cushion or specialty support surface?
  • Does the patient have any social support?

After a comprehensive history has been completed, there needs to be a comprehensive wound assessment done of the wound. Please refer to Chapter 5: Wound Assessment. The patient also needs to have a risk assessment done. A risk-assessment tool does not replace clinical judgment, but it does give the wound-care team a basis on which to implement protocols for prevention. Risk assessment should be done at the time of initial evaluation of the patient and at scheduled intervals, depending on the facility’s protocol. A new assessment should also be completed when there is a change in clinical condition. The most-validated pressure ulcer risk assessment tool is the Braden Scale. Other validated risk-assessment tools include the Norton and the Waterloo scales. The Braden Scale contains six domains to determine risk: sensory perception, activity, mobility, moisture, nutrition, and friction/shear. The highest number that can be achieved is 23.(14) A patient is considered at risk when the score is 18 or below. The lower the score on the scale, the higher the clinical risk for pressure ulcer development. The Norton Scale has five domains: physical condition, mental condition, activity, mobility, and incontinence. A score of 14 or less denotes clinical risk.(15) The Waterloo Scale was developed in 1987 and is used mostly in Europe. It looks at the BMI, continence, skin type, mobility, age, and nutrition. In addition, it takes into account special conditions such as tissue malnutrition, surgery or trauma, medications, and neurologic deficit.(16) Whatever risk-assessment tool is used at the clinical site, the health-care providers need to understand the elements and levels of risk associated with the different tiers. There are elements, such as underlying clinical diagnoses, that are not included in these scales, so the clinician needs to make a comprehensive assessment of the patient’s risk in addition to the risk-assessment tool.

Staging of the wound is the next step in management. Many health-care settings have developed protocols based on the staging of pressure ulcers. There are six stages of pressure ulcers as defined by the National Pressure Ulcer Advisory Panel, and as per the 2016 NPUAP consensus conference they are defined as the following:(9)

STAGE I. Pressure injury: non-blanchable erythema of intact skin
The skin is intact with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Since the ICD-10 coding system continues to use the term “ulcer”, we will use that term for this chapter.

STAGE II. Pressure Injury: partial-thickness skin loss with exposed dermis
The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions).

STAGE III. Pressure injury: full-thickness skin loss
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury.

STAGE IV. Pressure Injury: full-thickness skin and tissue loss
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer can occur. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury.

Unstageable pressure injury: obscured full-thickness skin and tissue loss
Full-thickness skin and tissue loss occurs, in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.

Deep tissue pressure injury (DTPI): persistent nonblanchable deep red, maroon or purple discoloration
Intact or nonintact skin occurs with localized area of persistent nonblanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The injury may evolve rapidly to reveal the actual extent of tissue damage and subsequent ulceration, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.

Two additional definitions related to pressure ulcer include the following:

Medical device related pressure injury
This describes an etiology. Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.

Mucosal membrane pressure injury
Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue, these injuries cannot be staged.

If the provider is unsure how to stage the pressure ulcer or is unsure that the wound is a pressure ulcer, it is better to describe the wound clinically than to assign a diagnosis or stage. Many regulatory bodies such as Centers for Medicare & Medicaid Services (CMS) will withhold payment or penalize health-care systems for development or worsening of pressure ulcers. If a wound that is not a pressure ulcer is described as such, or if a wound is incorrectly staged, the facility can face fines that are not justified. If there is any doubt, it behooves the provider to obtain a wound history and describe the wound per the assessment as outlined in Chapter 5: Wound Assessment and to obtain a wound-care consult for assessment of the site.

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FIGURE 1. Redness on right buttock; checking for blanching.

Courtesy of Caroline E. Fife, MD

FIGURE 2. Nonblanchable redness on right buttocks; NPUAP Stage 1 Pressure Injury

Courtesy of Caroline E. Fife, MD

FIGURE 3. NPUAP: Stage I Pressure Injury Left buttock - intact skin with nonblanchable redness on buttock.

Courtesy of Caroline E. Fife, MD

FIGURE 4. NPUAP -Stage II Pressure Ulcer Both buttocks - partial thickness loss of dermis presenting as a shallow open ulcer

Courtesy of Caroline E. Fife, MD

FIGURE 5. Stage II on sacrum

Courtesy of Caroline E. Fife, MD

FIGURE 6. Stage II on heel

Courtesy of Caroline E. Fife, MD

FIGURE 7. Stage III on sacrum

Courtesy of Caroline E. Fife, MD

FIGURE 8. Stage III on ischium

Courtesy of Caroline E. Fife, MD

FIGURE 9. NPUAP - Stage III Pressure Ulcer - full thickness tissue loss; sacrum - subcutaneous fat may be visible but bone, tendon, or muscle is not exposed.

Courtesy of Jayesh B. Shah, MD

FIGURE 10. Stage IV on ischium

Courtesy of Caroline E. Fife, MD

FIGURE 11. Stage IV on sacrum and coccyx.

Courtesy of Caroline E. Fife, MD

FIGURE 12. Unstageable Pressure Ulcer Full - thickness tissue; left buttock - loss with exposed bone, tendon, or muscle.

Courtesy of Jayesh B. Shah, MD

FIGURE 13. Deep tissue injury of heel.

Courtesy of Caroline E. Fife, MD

FIGURE 14. Deep tissue injury of bilateral buttocks

Courtesy of Caroline E. Fife, MD

FIGURE 15. Deep tissue injury of both gluteal regions

Courtesy of Caroline E. Fife, MD

After risk assessment and staging have been performed, the clinician needs to determine how best to offload the patient. A turning regimen needs to be developed as part of routine, overall care. The current standard of turning every two hours was based entirely on animal data. Until recently, this “standard of care” had never been subjected to a prospective, randomized, controlled study in humans.

A recent study by Bergstrom et al. demonstrated in a prospective trial that even among patients at high risk for pressure ulcers, according to the Braden Scale, the patients did not have an increased incidence of ulcer formation if they were turned every four hours rather than every two hours.(17) This study has profound implications for clinical care and supports the findings of Defloor et al. that pressure ulcer formation is lowest among patients turned every four hours.(18) However, there are patients for whom turning every two hours is insufficient to prevent pressure ulcer formation; therefore, clinical judgement is required when turning schedules are recommended on a given patient.

Given that incontinence is a major factor in the moisture-associated risk for pressure ulcer development, it should be part of the clinical evaluation of the patient to assess their level of incontinence. For urinary incontinence, scheduled voiding methods can be used to help the patient remain dry. Use of a Foley catheter may be indicated if risk of wound contamination is high, but there needs to be a clear understanding that an indwelling Foley catheter will increase the patient’s risk of urinary tract infection. With fecal incontinence, management may be easier. The patient can be put on a bowel regimen to regulate the bowel movements, which makes perineal care easier to control. In patients with loose stools or diarrhea, use of a fecal containment system may be appropriate. When there is high risk of fecal contamination to the wound bed, the clinical team may consider a diverting colostomy to bypass the rectum until the pressure ulcer is healed.

The evaluation of nutrition is another clinical component that requires clinical assessment. In the geriatric population, nutritional compromise is common. Appetite decreases as individuals age, but in addition, factors such as dentition, poor health conditions, medications, or lack of access to food can put patients at nutritional risk. Patients with underlying malignancy or significant weight loss, regardless of age, are also at risk for nutritional compromise that can impact the skin and increase the risk for pressure-ulcer development or poor wound healing. Health-care providers used the prealbumin or albumin levels as markers of underlying nutrition. These markers may be helpful to assess overall clinical prognosis, but they do not necessarily correlate well with clinical assessment of nutritional status. The NPUAP white paper on nutrition indicates that these markers are not good markers of nutrition as they are affected by many underlying clinical conditions.(19) A study by Langkamp- Henken and colleagues concluded that use of a mini-nutritional screening tool was superior to use of visceral protein screening in determining atrisk patients.(20) Obtaining a nutritional consult early in the evaluation of an at-risk patient is a good clinical practice to address underlying nutritional risk at the beginning of the clinical course and potentially impact nutrition to decrease risk or increase wound healing.

Managing infection in a pressure ulcer patient

Infection can be an issue when dealing with pressure ulcers, especially when the area of breakdown is in the buttocks/ perineal area. In this region, there is a high risk of contamination of the wound bed if the patient is incontinent of bowel and bladder. It is important to understand that every pressure ulcer is colonized with bacteria, since our skin and the environment are colonized with bacteria. This does not mean a wound is infected. The gold standard of assessment of a potentially infected wound is tissue biopsy for quantitative culture. With this technique, a sample of tissue is obtained and cultured for growth of bacteria so that the number of bacterial colonies can be reported in relation to grams of tissue. Quantitative cultures allow a clinician to determine whether the bacteria present in a wound are merely colonizing agents or are likely to represent an infection requiring treatment.

A superficial swab of the wound will only grow the organisms that are on the surface of the wound, and not necessarily the organism that is actually causing clinical infection, if present. If a superficial swab is the only method available for quantitative analysis, the Levine method should be utilized. Areas of necrotic tissue or slough should be avoided and the deepest part of the wound selected. Before culture by the Levine technique, it is recommended to clean the wound with normal saline. Once the wound is cleaned, the swab is applied to a clean area (1 cm2 area) in the deepest section for 30 seconds. That sample is then sent for analysis.(21)

The levels of infection of a wound are defined as colonization, critical colonization, and cellulitis. Colonization is bacteria in the wound bed, but not to a level where the bacteria are negatively affecting wound healing. Every wound is colonized, but not every wound is infected. Critical colonization is when bacteria have reached a level where they are now affecting the wound bed and inhibiting healing. This is defined as 1 x 105 bacteria. Depending on the time frame the wound has been open, different types of bacteria are more likely to be present. For wounds present less than one month, gram-positive organisms will be more prevalent. For wounds present greater than one month, or if the patient has medical conditions that make him or her immunocompromised, the clinician should also consider gram-negative and anaerobic organisms. At this point, there are no systemic signs of infection, although local signs such as change in the quality of the tissue in the wound, increased drainage, pain, friable granulation tissue, and odor may be present. Critical colonization may also be noted when a clean wound is not showing signs of healing within a 14-day period despite appropriate wound care.(22) It is important to note that when critical colonization is present, systemic antibiotic therapy is not indicated. Treatment of the critical colonization should be done at the level of the wound with a topical antimicrobial or antiseptic agent. Antimicrobial agents for wounds include topical antibiotics, manuka honey, cadexomer iodine, and silver dressings. Antiseptic agents include povidone iodine, chlorhexidine, acetic acid, and sodium hypochlorite. The provider should become familiar with the products available in his or her health-care setting. These agents should only be used for a limited time to decrease bacterial load and achieve bacterial balance in the wound, at which time treatment should be changed to moist wound healing. Topical antibiotic use is becoming increasingly common for wounds that have moderate or high bacterial loads. A more aggressive stage of infection is cellulitis. It is defined as a soft-tissue infection where bacteria has now invaded the deeper tissue and is causing tissue necrosis and clinical signs and symptoms of infection, which include edema, erythema, pain, and odor. At this level, systemic antibiotic therapy with oral or intravenous agents is indicated. A deeper infection should also be considered any time a wound probes to bone. If bone is visible or palpable, a work-up for osteomyelitis may be appropriate depending on the plans for surgical debridement and/or closure. In some cases, the infected bone can be removed at the time of surgery and/or debridement, or a bone biopsy may be obtained for definitive treatment. Thus, an extensive work up for osteomyelitis prior to a planned surgical procedure may not be appropriate.

Plastic surgery approach in management of a pressure ulcer

If a pressure ulcer is full thickness or affecting quality of life, surgical intervention might be indicated for management. Prior to pursuit of surgical intervention, the clinician needs to manage the underlying factors that may affect healing. Factors such as nutritional maximization, management of underlying infection, and pressure redistribution must be managed, or the likelihood of postoperative complications will increase. If there is significant fecal soiling occurring in the wound bed, a diverting colostomy may be indicated. Referral to a general or plastic surgeon will depend on what type of surgical intervention is required. If excisional debridement of a pressure ulcer is needed, general surgery is appropriate, but if a surgical flap procedure is warranted, a plastic surgery consult is required. The decision to pursue a specific surgical intervention is going to be dependent on the surgeon’s level of expertise and his or her preference.(23) Surgical procedures may include debridement, deep cultures, or flap procedures. When a surgical debridement is performed, the surgeon will remove all devitalized and nonhealing tissue from the wound bed. This may include subcutaneous tissue, fat, muscle, or bone. Removal of necrotic tissue will decrease bacterial load in the wound bed and facilitate wound healing. At this point, the surgeon can choose to heal the wound via secondary intention, or he or she will consider primary closure with a flap. Factors the surgeon will consider prior to determination of what procedure he or she will pursue will be location of the pressure ulcer and the size and the depth of the wound. The most commonly used flaps in the treatment of pressure ulcers are musculocutaneous and fasciocutaneous flaps, as these surgical interventions provide vascularized tissue for coverage of the defect. A posterior lateral thigh V-Y procedure is also indicated for pressure ulcer management. There has been no study that has compared the effectiveness of myocutaneous flaps versus fasciocutaneous flaps.

The decision to pursue surgical intervention is not without inherent risk. A review of the literature of all of the previously mentioned flaps performed for ischial pressure sores found an overall complication rate ranging from 0% to 80% and a recurrence rate from 0% to 33.3%.(24) The most-common complication after a flap surgery is suture line dehiscence.(25) If the patient has surgical resection of bone prior to flap surgery, the incidence of dehiscence increases. Hospitalized patients who develop pressure ulcers tend to have multiple underlying comorbidities including osteomyelitis and are at increased risk for death.(26)

Support surfaces for patients with pressure ulcers See Pathway 11. Management of a pressure ulcer begins with pressure redistribution, as this is the primary factor that caused development of the wound. A Cochrane analysis of 52 randomized trials reported that patients at high risk for pressure ulcers should have a specialized support surface as opposed to a standard hospital mattress.(27) The first step is evaluation of the patient’s functional status. Is the patient bedbound, or does he or she spend the majority of time in a chair? Pressure redistribution should be considered for both settings. For the wheelchair, the patient should be referred to occupational or physical therapy for evaluation. Wheelchair cushions should be ordered for all patients who spend significant time in a wheelchair, since the seat upholstery is not designed to offer support.(28) The therapist will assess seating balance and will determine what type of seating surface is most appropriate. The four basic categories of cushions include foam, air, viscous fluid, and elastomeric cushions. The therapist will choose the correct type of cushion depending on patient’s functional status, ability to transfer, continence status, and seating balance.

The choice of mattress support surface is going to depend on whether the patient has a pressure ulcer or not. If the patient has no open wounds, most payers will not cover the cost for a preventive support surface unless the patient is completely immobile in the bed or has partial mobility and skin breakdown. Many facilities have purchased their own pressure redistribution surfaces for prevention, and if the facility has these support surfaces, a static air, gel, or foam mattress can be used for prevention. As per CMS, the categories for ordering of a pressure redistribution surface are as follows:(29)

  • Group 1 - Support surfaces are generally designed to either replace a standard hospital or home mattress or as an overlay placed on top of a standard hospital or home mattress. Products in this category include mattresses, pressure pads, and mattress overlays (foam, air, water, or gel).
  • Group 2 - Support surfaces are generally designed to either replace a standard hospital or home mattress or as an overlay placed on top of a standard hospital or home mattress. Products in this category include powered air flotation beds, powered pressure reducing air mattresses, and non-powered advanced pressure reducing mattresses.
  • Group 3 - Support surfaces are complete bed systems, known as air-fluidized beds, which use the circulation of filtered air through silicone beads.

CMS and most payers will only cover the cost of a support surface with appropriate documentation of clinical need. The patient has to meet certain criteria for each type of mattress. CMS requirements are outlined below:(29)

  • Group 1 - A Group 1 support surface is covered if the patient is completely immobile. Otherwise, he or she must be partially immobile, or have any stage pressure ulcer and demonstrate one of the following conditions: impaired nutritional status, incontinence, altered sensory perception, or compromised circulatory status. A physician order must be obtained prior to delivery of the equipment and should be kept on file by the supplier.
  • Group 2 - A Group 2 support surface is covered if the patient has a Stage II pressure sore located on the trunk or pelvis, has been on a comprehensive pressure sore treatment program (which has included the use of an appropriate Group 1 support surface for at least one month), and has sores which have worsened or remained the same over the past month. A Group 2 support surface is also covered if the patient has large or multiple Stage III or IV pressure sores on the trunk or pelvis, or if he or she has had a recent myocutaneous flap or skin graft for a pressure sore on the trunk or pelvis and has been on a Group 2 or 3 support surface.
  • Group 3 – A Group 3 support surface is covered if the patient has a Stage III or Stage IV pressure ulcer, is bedridden or chair-bound, would be institutionalized without the use of the Group 3 support surface, the patient is under the close supervision of the patient’s treating physician, at least one month of conservative treatment has been administered (including the use of a Group 2 support surface), a caregiver is available and willing to assist with patient care, and all other alternative equipment has been considered and ruled out. The other situation in which a Group 3 surface would be utilized would be in a patient who had a post-flap procedure or a patient in which multiple turning surfaces are affected by pressure ulcers, therefore limiting the ability of the patient to be turned and repositioned.

In 2015, McNichol et al. created an evidence-based and consensus-based algorithm to help clarify the selection of specialty support surfaces.(30)

A group of clinical experts convened to look at systematic reviews and publications related to support surfaces. When evaluating a patient for a support surface, a multitude of factors should be considered. Some of the factors include the patient’s weight, rehab potential, level of pain, and whether the patient has any contraindications to being on a support surface. The type of support surface used in the past for prevention and treatment of pressure ulcers is also a consideration. Once a support surface is selected, the clinician must implement a turning and repositioning schedule, as a specialty support surface will not decrease pressures below capillary closing pressure and pressure necrosis can still occur. The only category of specialty support surface on which a patient does not have to be turned and repositioned is a high-air-loss mattress. The other aspect noted by the consensus panel is that for the support surface to effectively offload the patient, it must be in good working order and must be used appropriately by the clinical staff to achieve maximum benefit.

Preventing recurrence of pressure ulcers

The majority of publications on recurrence of pressure ulcers are focused on the spinal cord injury population. Studies have shown a recurrence rate of 31% to 79%. Some of the characteristics associated with a higher recurrence rate in this population include male, younger patients, African American ethnicity, residence in a nursing home, and a history of previous pressure ulcer surgery.(31) In the elderly population, clinical evidence supports the fact that a patient who has developed a pressure ulcer in the past is usually at high risk for further development of pressure ulcers unless the factors leading to development are modified.

Full-thickness pressures heal with scar tissue. A Stage 1 pressure ulcer heals with offloading. There is never a break in the skin, therefore no re-epithelialization or scar tissue formation occurs. A Stage 2 pressure ulcer is partial thickness and therefore heals with re-epithelialization. In Stage 3 or Stage 4 pressure ulcers, healing of the pressure ulcer occurs with laying down of scar tissue as these injuries are full thickness and involve the subcutaneous tissue. Based on the wound-healing cascade, the time frame for remodeling can be up to 1.5 years. The tensile strength of the scar tissue is at maximum 70%–80% of the surrounding tissue; therefore the patient is always going to be more susceptible to having recurrence of a pressure ulcer at that site.(32) Once a patient is identified as having a history of a healed, full-thickness pressure ulcer in an area, it is important to be especially vigilant. This includes monitoring of the patient’s skin closely, maintaining moisture balance, and attenuating underlying internal and external risk factors. Maintenance of moisture balance may include use of moisture-barrier creams to protect the skin from excessive moisture, such as bowel or bladder incontinence. If the skin is excessively dry, use of emollients to keep the skin hydrated are utilized to prevent cracks and fissures in the skin.

Prevention requires the use of proper equipment to minimize the risk of recurrence. As discussed previously, a correct pressure redistribution cushion for a wheelchair is necessary if the patient spends many hours a day up in a chair. Other types of seating surfaces also need to be considered, such as Gerichairs. If a patient is spending multiple hours a day on this type of seating surface, the patient needs to be turned and repositioned, and pressure needs to be offloaded if the patient is at risk for pressure ulcers. In terms of a prevention surface for the bed, there is no current CMS payment source for prevention unless the patient is completely immobile. Use of Group 1 support surfaces are usually adequate for prevention of pressure ulcers. For heel pressure ulcers, prevention includes floating the heels with pillows and use of offloading boots. If the patient is in a wheelchair, use of appropriate footwear to prevent excessive pressure from the footrests is required. The patient’s skin should be assessed on a daily basis and during routine clinical care.

Given that immobility is one of the main risk factors for pressure-ulcer development, improvement of activity and mobility will decrease risk of pressure-ulcer recurrence. Referral of a patient to physical and occupational therapy, if appropriate, can improve strength, balance, and mobility. The individual will then need to maintain that level of activity to prevent losing any forward progress. Nutritional assessment and maximization should be achieved. The use of prophylactic dressings might also be considered. As per the NPUAP clinical practice guidelines, there were four studies that demonstrated a reduction in the occurrence of pressure ulcers with polyurethane foam dressing applied to at-risk anatomical locations. These clinical trials included patients that were critically ill and immobile patients in critical care setting.(33)


Pressure ulcers continue to be a significant and costly clinical condition. As a health-care system, we need to utilize consistent protocols to identify and minimize the risk of pressure ulcer development. Although there is no way to eliminate the risk of pressure ulcers completely, we can continue to develop clinical strategies to attenuate the impact to patient care and quality of life.


  1. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA. 2006;296:974.
  2. Lyder CH. Pressure ulcer prevention and management. JAMA. 2003;289:223
  3. Agency for Healthcare Research and Quality [Internet]. Rockville (MD): Department of Health and Human Services (US). Preventing pressure ulcers in hospitals. Available from:
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Additional Resources

  1. Allman R, Good PD, Burst N, Bartolucci AA, Thomas DR. Pressure ulcer, hospital complications, and disease severity: implications of hospital costs and length of stay. Adv Wound Care. 1999;12(1):22-30.
  2. National Pressure Ulcer Advisory Panel [Internet]. Washington DC: National Pressure Ulcer Advisory Panel. Available from:
  3. Levine SM, Sinno S, Levine JP, Saadeh PB. An evidence-based approach to the surgical management of pressure ulcers. Ann Plast Surg. 2012 Oct;69:482-4.
  4. Becker H. The distally based gluteus maximus muscle flap. Plast Reconstr Surg. 1979;63:653-656.
  5. Kroll SS, Rosenfield L. Perforator-based flaps for low posterior midline defects. Plast Reconstr Surg. 1988;81:561-566.
  6. Park C, Park BY. Fasciocutaneous V-Y advancement flap for repair of sacral defects. Ann Plast Surg. 1988;21:23-26.
  7. Brown G. Long-term outcomes of full-thickness pressure ulcers: healing and mortality. Ostomy Wound Manage. 2003;49:42–50.

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