Pressure Injuries: Key Practices for Patient Care and Documentation

Pressure injuries (PIs) are localized injuries to the skin and underlying tissue, typically occurring over bony prominences due to prolonged pressure and/or shear forces. Proper identification, documentation, and coding of PIs are essential not only for patient care but also for ensuring compliance and avoiding hospital-acquired condition (HAC) penalties.

Understanding Pressure Injuries

• Presentation: PIs may appear as open ulcers (e.g., pressure or decubitus ulcers) or as intact skin.
• Documentation Requirements: For coding purposes, a physician, PA, or NP must document the presence and location of the PI. Details such as staging can be determined from the Media Tab (photo review), nursing documentation, or the wound care team’s assessment.

Why Accurate Documentation Matters

Establishing the present-on-admission (POA) status of a PI is crucial. PIs that worsen during hospitalization—advancing to Stage 3, Stage 4, or unstageable will be categorized as HACs even if they were initially present on admission. Timely and accurate documentation can make a significant difference in determining POA status and avoiding HAC triggers.

Best Practices

1. Skin Inspection: Thoroughly inspect at-risk patients upon admission and throughout their stay.
2. Early Diagnosis: Identify and diagnose PIs as soon as possible.
3. Accurate Documentation: Clearly document findings, including location and staging. When a patient is admitted due to complications from a PI, ensure the relationship is documented (e.g., Sepsis due to infected Stage 4 sacral pressure ulcer with acute sepsis-related organ dysfunction evidenced by metabolic encephalopathy and acute kidney injury).

Distinguishing Pressure Injuries from Other Conditions

It is essential to differentiate PIs from other skin injuries or conditions that are not pressure-related, including:

• Moisture-Associated Skin Damage (MASD): Includes incontinence-associated dermatitis (IAD) and intertriginous dermatitis (ITD).
• Medical Adhesive-Related Skin Injury (MARSI).
• Traumatic Wounds: Such as skin tears, burns, and abrasions.
• Non-Pressure Chronic Ulcers: Diabetic, ischemic, neuropathic, venous stasis, or vasculitis-related ulcers.

Acute Skin Failure

Acute Skin Failure (ASF) is an emerging concept describing skin injuries in critically ill patients caused by severe hypoperfusion or multisystem organ failure. These injuries can be pressure or non-pressure related and should be documented distinctly from traditional PIs.

Conclusion

Effective prevention, early diagnosis, and precise documentation of pressure injuries are essential for quality patient care and accurate coding. By adopting these best practices, clinicians can mitigate the risk of HACs and improve outcomes for at-risk patients.

Back to the December 2024 issue of Premier Pulse