Skin Failure Clinical Indicator Scale

Proposal of a Tool for Distinguishing Skin Failure From a Pressure Injury

Richard Hill, RN, CWCN, FACCWS; Amy Petersen, RN, BSN


Wounds. 2020;32(10):272-278. 

In This Article

Abstract and Introduction


Introduction: Skin failure may be both visually similar in appearance and can occur concomitant to a pressure injury, but it has a fundamentally different etiology. To date, no validated assessment tools or clinical indicators are available that can help definitively distinguish skin failure from a pressure injury.

Objective: The Skin Failure Clinical Indicator Scale (SFCIS), a proposed tool that uses readily available variables to assist in more definitively identifying skin failure, was developed and assessed.

Methods: A retrospective case-control study was conducted among acute care hospital patients who experienced acute skin breakdown before death. Data were extracted from the electronic medical records of deceased acute care patients who experienced acute skin breakdown prior to death between January 1, 2017, and March 1, 2019, in 2 US hospitals. Using ICD-10 coding, patients were separated into 2 groups depending on if the skin breakdown occurred at locations typical for pressure injury formation or atypical (non-pressure) locations. Patient diagnostic and clinical data were compared between the 2 groups. Univariate and multivariate data analyses were performed via backward stepwise logistic regression in order to identify significant predictors of skin failure; regression coefficients were converted into integers in order to create a tool that could assist in probable identification of skin failure.

Results: Of the 52 patients included in this study, 16 experienced skin breakdown at locations typical for pressure injury and 36 had skin breakdown in atypical locations, which was assumed to be indicative of skin failure. Factors found to help distinguish between skin failure and pressure injury included a serum albumin level less than 3.5 mg/dL (P = .07), impaired blood flow (P = .05), presence of sepsis/multiorgan dysfunction syndrome (P = .001), vasopressor/inotrope use (P < .001), and mechanical ventilation (P = .06), which ultimately correctly identified 83.7% as cases of probable skin failure.

Conclusions: This scale may provide a means to correctly recognize and diagnose skin failure, initiate appropriate interventions, and decrease potential reimbursement penalties to facilities. Further testing will be necessary in order to validate the specificity and selectivity of this instrument.


Skin failure is a concept that includes multiple similar phenomena described in the literature as Kennedy Terminal Ulcers, Skin Changes at Life's End (SCALE), and Trombley-Brennan Terminal Tissue Injuries (TB-TTI).[1] These phenomena result in ulcerations that, although somewhat visually similar in appearance to pressure injuries, have a fundamentally different etiology despite the ability to occur concomitantly with a pressure injury.[2] Current consensus holds that skin failure may occur during an acute illness as a result of chronic illness or as part of the dying process.[1] Skin failure manifests with objective, observable characteristics such as a rapid onset, an acute progression, full-thickness tissue involvement, and ill-defined (often purpuric) borders.[1]

Promotion and maintenance of skin integrity is a fundamental part of nursing. Pressure injuries seem to dominate the discussion in the literature, but this comes as no surprise when it is noted that pressure injuries alone carry a substantial cost burden to facilities, an estimated $9.1 to $11.6 billion annually.[3] The Centers for Medicare and Medicaid Services[4] modified its Inpatient Prospective Payment System in 2008 to reduce hospital reimbursements for pressure injuries not present-on-admission and, in 2015, began to penalize hospital reimbursements of the lowest performing quartile of hospitals. As a result of these reimbursement changes, misdiagnosis of skin failure as a facility-acquired Stage 3 or Stage 4 pressure injury can have a substantial financial impact.

Skin Failure Clinical Indicator Scale proposal

Currently, discernment of wound etiology is heavily reliant on visual analysis and patient history. A survey of 100 certified wound care nurses showed that, if limited to purely visual analysis, the correct etiology was determined 17% more often than by chance alone.[5] To further complicate the issue of etiology, no validated assessment tools or clinical indicators are available that can assist in determining etiology or providing a more definitive diagnosis of skin failure.[6]

The purpose of this study was to develop a novel, objective scoring system, the Skin Failure Clinical Indicator Scale (SFCIS); this scale, in conjunction with pertinent history and readily available lab work, could assist in distinguishing between plausible instances of skin failure versus pressure injury.