A recently revised guideline for the prevention and treatment of pressure injuries may require quality leaders to reassess how they address this issue.1

The guideline was released recently by an international coalition that includes the National Pressure Injury Advisory Panel (NPIAP), an independent, not-for-profit professional organization in Westford, MA, that addresses the prevention and management of pressure injuries. NPIAP worked with the European Pressure Ulcer Advisory Panel, and the Pan Pacific Pressure Injury Alliance.

The groups developed evidence-based recommendations for the prevention and treatment of pressure injuries. NPIAP President Janet Cuddigan, PhD, RN, FAAN, issued a statement saying the groups analyzed a large body of international research to develop evidence-based clinical recommendations. “The guideline bridges a critical gap by accelerating the translation of research into practice to improve patient outcomes,” she said.2

Time to Reassess

The guideline is an opportunity for reflection, says Martin Burns, CEO of Bruin Biometrics, a company in Los Angeles that provides consulting and technology to address pressure injuries.

The guideline expands the visual indicators that should indicate a risk of pressure injuries, he says. Previous guidelines instructed clinicians to watch for redness on the surface of the skin, indicating the first stage of a pressure ulcer under ICD-11, but only when it was non-blanchable (i.e., the skin did not turn white when pressed with a finger).

The revised guideline also includes blanchable erythema, a condition in which the skin is red, turns white when pressed with a finger, and then immediately turns red again when pressure is removed. “Any redness requires attention, whether it is blanchable or not,” Burns stresses. “There is a real recognition in these guidelines that there are a lot of biological processes that are occurring underneath the skin surface, invisibly, before you can claim that a pressure ulcer has manifested at the skin’s surface. That’s a huge advance in the understanding of the science behind this problem.”

The updated guideline also emphasizes the role inflammation plays in pressure injuries. The combination of deformation from pressure, inflammation, and ischemia determine the amount of cell death, the guideline explains.

In addition, the guideline recognizes a biophysical marker of that damage that the groups refer to as biocapacitance, the ability of skin and tissue to change its physical features in the presence or absence of moisture. Biocapacitance is “one of the earliest signs of cell death” in pressure injuries, the guideline states.

Skin temperature also is key to assessing the risk of pressure injuries, the guideline notes, even when it is assessed by a nurse simply touching the patient’s skin to see if it is noticeably warm.

“That is hugely beneficial, because it now gives nurses the ability to rely on changes in temperature as an indicator of risk, with simple palpation,” Burns says. “This is an acknowledgment that nurses can detect this risk through their normal interactions with a patient and using their own knowledge of what seems normal and what does not.”

One new development in the guideline is endorsement of subepidermal moisture (SEM) measurement devices. Bruin Biometrics produces SEM devices. Another company that produces SEM devices is Delfin Technologies in Greenwich, CT.

“Pressure injuries are still among the most reported patient safety events in any care setting across the country. Nurses have been relying on their own ability to try to assess and diagnose the onset of an early stage pressure ulcer so that they can take the right action to keep the skin intact, but this is very subjective,” Burns notes.

“It puts nurses on the hook to try to identify cell damage, which no one can do definitively by sight and touch,” Burns continues. “The guideline says they need help from a device to assess these changes going on at the skin and tissue level.” Research has indicated the effectiveness of SEM devices, with studies revealing that the measurements are an objective determination of the risk of pressure injuries. (See the story later in this issue for more on that research.)

The revised guideline does not encourage sole dependence on SEM devices for assessing pressure injury risk, Burns notes. In fact, it reinforces the primacy of nurse assessments as the key method for protecting patients.

“That’s very encouraging, because it means that though this is a time to pause and reflect on new opportunities, nurses can keep doing what they are doing because they are effective and the best advocates for their patients,” Burns explains. “The addition of any technology can help them and give them an ability to measure risk in a way that they didn’t have before, but it is not a substitute for good nursing practice.”

Dark Skin a Factor

Burns notes that the updated guideline addresses the challenge of diagnosing early stage pressure injuries in darkly pigmented skin because the nurse cannot see redness, one of the clearest and earliest indicators of damage.

Research indicates a significantly smaller proportion of black nursing home admissions see their pressure ulcers heal, compared to a similar group of white patients.3 Recommendation 2.7 says that “When assessing darkly pigmented skin, consider assessment of skin temperature and subepidermal moisture as important adjunct assessment strategies.”1

That highlights the need to pay particular attention to patients with darker skin, which should help address the higher incidence of death among these patients, Burns says.

The guideline also emphasizes the need to protect patients from device-related pressure injuries, particularly those tied to tubing and face masks. It also expands the effort to protect neonates and children from pressure injuries.

“That is a good development because this has been a neglected cohort for some time now,” Burns says. “Unfortunately, children and neonates suffer from pressure injuries at quite an intensive rate, with the guideline citing a study in Spain showing a 23% worldwide pressure injury prevalence in NICUs.”4

Major Financial Risk

Burns suggests that quality improvement and patient safety professionals should work with clinical leaders to use the guideline as a tool for reassessing current practice in the organization regarding pressure injuries. The revised guideline provides a concise analysis of the latest information on etiology and a roadmap to the best practices for prevention and treatment, he says.

Aside from the effect on patients, healthcare organizations are strongly incentivized to properly assess and prevent pressure injuries because CMS has stopped reimbursing hospitals for the care required to treat most pressure injuries acquired during a hospital stay, Burns notes. Medicare also can penalize hospitals 1% of reimbursement for high rates of hospital-acquired conditions such as pressure injuries.5

“Take the opportunity to update your understanding of the scientific advancement. Think about it in terms of what you do on admission, how you scan for patients at risk, and how you record the biomarkers recognized in the guideline when you’re entering data in the patient record,” Burns recommends.

Admission Testing Crucial

Hospitals should ensure their present-on-admission testing is up to date according to the research and recommendations in the guideline, Burns says.

During the inpatient stay, assessment and prevention efforts should focus particularly on perioperative patients and the cohorts known to be at high risk for pressure injuries, including neurology, stroke, and orthopedic trauma.

“At discharge, make absolutely sure you have a record in your notes of what assessment was done and how it was done. In the event a patient is discharged and gets readmitted within 30 days, you’ve documented that the patient was discharged with the signs of a developing pressure ulcer, and those signs were adequately communicated to the next caregiver,” Burns says.

CMS and the Agency for Healthcare Research and Quality are likely to follow the international guideline with updated standards that are binding on American healthcare organizations, Burns predicts.

Meanwhile, organizations can get ahead of the coming regulations by using the international guideline to more closely match their pressure injury practices with current research.

“Get ahead of it by looking at screening on admission and at discharge,” Burns suggests. “Focus hard on those cohorts that have been called out as high risk. Dark-skinned people is the big one, and also neonates and children. Working to address their needs now will put you in a better place when CMS follows through with new standards.”


  1. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure/injuries: Quick reference guide 2019. Available at: https://bit.ly/34q7BOy. Accessed Dec. 2, 2019.
  2. National Pressure Ulcer Advisory Panel. New international clinical practice guideline for the prevention and treatment of pressure injuries, Nov. 18, 2019. Available at: http://bit.ly/2LcKDCK. Accessed Dec. 2, 2019.
  3. Bliss DZ, Gurvich O, Savik K, et al. Racial and ethnic disparities in the healing of pressure ulcers present at nursing home admission. Arch Gerontol Geriatr 2017;72:187-194.
  4. García-Molina P, Alfaro-López A, María S, et al. Neonatal pressure ulcers: Prevention and treatment. Research and Reports in Neonatology 2017. Available at: http://bit.ly/2RcQaNF. Accessed Dec. 2, 2019.
  5. Centers for Medicare & Medicaid Services. Hospital-acquired conditions (present on admission indicator). Available at: https://go.cms.gov/2Yad6yz. Accessed Dec. 2, 2019.


  • Martin Burns, CEO, Bruin Biometrics, Los Angeles. Phone: (310) 268-9494.