Pressure Sores

By: David K. Jaffe

The 12/19/89 Omnibus Budget Reconciliation Act (Public Law 101-239) established the Agency for Health Care Policy and Research (AHCPR). The AHCPR Publication number 92-0047, Pressure Ulcers in Adults: Prediction and Prevention, Clinical Practice Guideline Number 3, May 1992 provides what is still a state of the art review of pressure sores/decubitus ulcerations.

Stage I ulcers are defined as non-blanchable redness of intact skin.

Stage II ulcers are partial thickness skin loss involving the epidermis and/or the dermis which present as an abrasion, blister, or shallow crater.

Stage III ulcers are full thickness skin loss "involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia and present as a deep crater with or without undermining of adjacent tissues

Stage IV ulcers involve extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures [such as tendon or joint capsule]."

Deep Tissue Injury is a pressure-related injury to subcutaneous tissues under intact skin, initially presenting with the appearance of a deep bruise. Unstageable: Eschar covered pressure sores are considered unstageable 1 . Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.

Agency for Health Care Policy and Research (AHCPR) 2

The Agency for Health Care Policy and Research (AHCPR) was established in December 1989 under Public Law 101-239 (Omnibus Budget Reconciliation Act of 1989) to enhance the quality, appropriateness, and effectiveness of health care services and access to these services.

AHCPR guidelines recommend assessing bed- and chair-bound individuals for risk factors including immobility, incontinence, impaired nutrition, and altered level of consciousness. They recommend use of a validated risk assessment tool such as the Braden scale. The guideline recommends reassessment at periodic intervals. Skin inspection is recommended once daily. The authors advocate minimizing exposure to moisture due to incontinence.

Furthermore, they emphasize that "skin injury due to friction and shear forces should be minimized through proper positioning, transferring and turning techniques…friction injuries may be reduced by the use of lubricants (such as corn starch, and creams), protective films (such as transparent film dressings, and skin sealants), protective dressings (such as hydrocolloids, and protective padding." They stress that interventions should be monitored and documented.

The AHCPR recommends repositioning every 2 hours, that a written schedule for systematically turning and repositioning be used, and that positioning devices such a pillows or wedges be used "to keep bony prominences from direct contact with one another, again according to a written plan."

See also:

  1. American Medical Directors Association Guidelines
  2. National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP) Pressure Ulcer Prevention and Treatment Clinical Practice Guideline, Second Printing, February 2010
  3. OBRA F-tag 314

All of the above also delineate guidelines and standards which relate in more detail to accepted wound pressure and other nursing home care "avoidable" and "unavoidable events" and proper documentation and reporting.

In Connecticut, the applicable regulations, relate more to licensing, administration, staffing, and facility requirements, budgeting and reporting requirements for convalescent home representatives. See, for example, example http://www.hpm.umn.edu/nhregsplus/NHRegs by State/Connecticut/CT%20Complete%20Regs.pdf

The most important regulations begin at RCSA, Section 19-13D8T, et al.


1 The National Pressure Ulcer Advisory Panel promulgated a 5th pressure ulcer category, "Deep Tissue Injury," a pressure-related injury to subcutaneous tissues under intact skin, initially presenting with the appearance of a deep bruise. Eschar covered pressure sores are considered unstageable.

2The AHCPR was later renamed the Agency for Healthcare Research and Quality (AHRQ).