A Review of Deep Tissue Injury Development, Detection, and Prevention: Shear Savvy
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Index: Ostomy Wound Manage. 2013;59(2):26–35.
Pressure ulcer prevention strategies include the prevention, and early recognition, of deep tissue injury (DTI), which can evolve into a Stage III or Stage IV pressure ulcer. In addition to their role in pressure-induced ischemia, shearing forces are believed to contribute substantially to the risk of DTI. Because the visual manifestation of a DTI may not occur until many hours after tissues were damaged, research to explore methods for early detection is on-going. For example, rhabdomyolysis is a common complication of deep tissue damage; its detection via blood chemistry and urinalysis is explored as a possible diagnostic tool of early DTI in anatomical areas where muscle is present. Substances released from injured muscle cells have a predictable time frame for detection in blood and urine, possibly enabling the clinician to estimate the time of the tissue death. Several small case studies suggest the potential validity and reliability of ultrasound for visualizing soft tissue damage also deserve further research. While recommendations to reduce mechanical pressure and shearing damage in high-risk patients remain unchanged, their implementation is not always practical, feasible, or congruent with the overall plan of patient care. Early detection of existing tissue damage will help clinicians implement appropriate care plans that also may prevent further damage. Research to evaluate the validity, reliability, sensitivity, and specificity of diagnostic studies to detect pressure-related tissue death is warranted.
Keywords: pressure ulcer, shear, deep tissue injury, pressure redistribution, rhabdomyolysis, ultrasound
Potential Conflicts of Interest: none disclosed
The most recent estimates published by the Agency for Healthcare Research and Quality1 (AHRQ) reveal the incidence of pressure ulcers in United States hospitals increased 80% from 1993 to 2006 (from 301,944 to 503,300); during the same time frame, admissions to hospitals for a primary diagnosis of a pressure ulcer increased from 35,800 to 45,500. Pressure ulcers are associated with increased morbidity and mortality. A nonexperimental, retrospective analysis2 of pressure ulcer quality assurance data conducted from October 1997 to October 2002 to ascertain the relationship among the occurrence of nosocomial full-thickness pressure ulcers, healing, and mortality revealed 68.9% of people who developed full-thickness pressure ulcers died within 180 days. Although these deaths were not all related to pressure ulcer pathology, they suggest severe pressure ulcers and end of life are common co-occurrences, an observation underscored by a consensus statement issued by the 2008 Skin Changes at Life’s End (SCALE) Expert Panel.3
Litigation and reimbursement issues add to the burden of pressure ulcers in healthcare.4 Since October 2008, the Centers for Medicare and Medicaid Services5 (CMS) no longer reimburse healthcare expenditures related to nosocomial pressure ulcers. Identifying and documenting pressure ulcers “present on admission” has become a focus in hospitals and nursing homes in order to avert reimbursement and litigious repercussions.6
The National Pressure Ulcer Advisory Panel7 (NPUAP)classifies pressure ulcer severity in one of six categories, ranging from Stage I pressure ulcers (the least severe, although Farid et al8 demonstrated substantial disruption of the underlying vasculature is believed to occur in nonblanchable erythema) to Stage IV pressure ulcers, with visible soft tissue loss extending into deep muscle and possibly to the bone.