Defining Unstageable Pressure Ulcers as Full Thickness Wounds: Is this Definition Consistent with Clinical Outcomes?

Abstract

Hospital acquired pressure ulcers affect millions of patients in the U.S. annually. The incidence of hospital acquired pressure ulcers internationally is hard to gauge as there is no internationally accepted tracking process, nor does a pressure ulcer registry exist at this time. Pressure ulcers are associated with patient pain and suffering, decreased quality of life, increased morbidity and mortality, increased length of stay, and increased cost of care. Full thickness pressure ulcers (Stage III, IV, and unstageable) are considered events that should never happen in hospital settings by the National Quality Forum and are included in a list of serious occurrences alongside events such as wrong site surgery, patient death due to medication errors, and sexual abuse or assault of a patient. Given that there is consensus that not all hospital acquired pressure ulcers are avoidable and some life-saving interventions increase the risk of pressure ulcer development, it may be argued that it is inappropriate to include pressure ulcers in this grouping. The designation of pressure ulcers as never events has spurred policy which prevents funding for care of these events by insurers and requires public reporting. Significant time and dollars are spent by facilities in the care of these ulcers, associated intensive review proceedings, and reporting of these ulcers. Unstageable pressure ulcers, ulcers in which the wound base is obscured by slough or eschar, are defined as full thickness wounds and, as such, are included in the never events list. However, there is currently no literature to support this definition. Clinicians have difficulty in correctly identifying unstageable pressure ulcers and there are no existing histopathologic exams, lab studies, or other means to confirm unstageable pressure ulcers. Therefore, clinicians are forced to rely on their clinical expertise for diagnosis. Clinical observations on the healing trajectory of unstageable pressure ulcers shared in this dissertation indicate that these ulcers do not always heal consistently with full thickness wounds. The two studies described in this dissertation attempt to address the healing trajectories of unstageable hospital acquired pressure ulcers. The purpose of these studies is to answer the question of whether unstageable pressure ulcers are appropriately defined as full thickness wounds, or if there are cases in which these ulcers are partial thickness, indicating less severity of tissue damage. Studies on unstageable pressure ulcers help increase understanding of these wounds and have the potential to improve patient care, outcomes, and current policy measures.