The Pathophysiology of Skin Failure vs. Pressure Injury

Conditions That Cause Integument Destruction and Their Associated Implications

Michael Bain, MD, MMS; Junko Hara, PhD; Marissa J. Carter, PhD, MA

Disclosures

Wounds. 2020;32(11):319-327. 

In This Article

Abstract and Introduction

Abstract

Introduction: Although integument failure commonly is attributed to pressure alone, especially when a wound develops over a bony prominence (pressure injury), all skin failure should not be attributed to pressure injuries.

Objective: A systematic review of the literature was conducted to: (1) differentiate the types of integument injury and etiology; (2) describe the anatomic and pathophysiologic factors affecting integument failure; (3) differentiate avoidable vs. unavoidable integumentary injury of nonpressure-related sources; (4) describe factors leading to integument injury, including comorbid and risk factors; and (5) briefly discuss clinical and economic importance of delineating pressure injuries from integument failure and associated risk factors in order to determine the pathophysiology underlying wound development and multiple factors capable of interacting with pressure to synergistically influence integumentary failure.

Methods: The PubMed database was searched for English-language studies during March 2020 using the key words pathophysiology, etiology, pressure ulcers, pressure injury, pressure wounds, and risk factors.

Results: The PubMed search yielded 1561 publications in total; of these, 59 were selected for review based on their relevance, timeliness, and subject matter, including 50 original studies of any study design, 5 review articles, and 4 public agency reports that addressed the 5 study purpose components.

Conclusions: Clinicians need to better understand the pathophysiology and classification of integument injuries by underlying etiologies both avoidable and unavoidable. A more accurate diagnosis would lead to more appropriate treatment strategies, an improved quality of care for affected patients, less wasted resources and reduced financial penalties for healthcare providers, and decreased medicolegal claims.

Introduction

With the medical advancements in past decades, patients frequently survive acute and/or chronic conditions that once relegated them to immediate death. Consequently, medical conditions, such as integument failure, once without time to manifest, are now commonly observed.

Skin is the largest organ in the body, and like other organ systems can fail.[1,2] Integument failure of various etiologies is a significant issue for severely ill patients in both acute and chronic care settings.[2] Indeed, of the more than 5 million patients treated annually in intensive care units (ICUs) in the United States, 12% to 42% will suffer from skin breakdown.[3,4] Yet, the pathophysiology and anatomic etiology underlying integument failure are not clearly described.

In 2014, the Centers for Medicare and Medicaid Services (CMS) set a goal to reduce the number of hospital-acquired conditions (including pressure injuries) by 20%.[5] The most recent Agency for Healthcare Research and Quality report[6] indicates that, while the number of hospital-acquired cases were improved from 2014 to 2016, conditions such as pressure injuries can (and should) be further reduced.

Since the CMS initiative,[5] the reported incidence of hospital-acquired pressure injuries (HAPIs) has increased from 2014 to 2016 by 10% in ICUs in the United States.[3,4] However, whether this increase is due to higher awareness about HAPIs or a combination of increased awareness and/or misidentification of the primary cause of injury is not clear.

Because of the complexity of the underlying mechanism leading to integument failure, it is imperative not only to better understand its underlying pathophysiology, but also to accurately classify integument injury by the avoidable and unavoidable factors responsible for injury (primary cause), including pressure. This may lead to better and more appropriate treatment strategies, an improved quality of care, and better outcomes for affected patients, while potentially reducing wasted health care resources (eg, prolonged hospital stays, repeated emergency room visits), financial penalties for health care providers, and medicolegal claims.

The purpose of this study was to review existing studies and case reports to systematically present the (1) different types of integument injury and etiology; (2) anatomic and pathophysiologic factors affecting integument failure; (3) various ways to differentiate avoidable versus unavoidable integumentary injury regarding nonpressure-related sources; (4) factors leading to integument injury, including comorbid and risk factors; and (5) clinical and economic importance of delineating pressure injury from integument failure and associated risk factors.

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