1. Bain, Michael A. MD, MMS
  2. Wirth, Garrett MD
  3. Murphy, Robert X. Jr MD, MS, CPE, FACS

Article Content

With great interest, we read the article by Mary Brennan, MBA, RN, CWON, "Who Should Assess and Stage Pressure Injuries in Hospitalized Patients?" (September 2022) regarding the staging of pressure injuries (PIs) and who might be best suited to perform this task. She cites several concerning statistics regarding nursing education, especially among new graduates. Unfortunately, the statistics are not surprising.


Whether a new nursing graduate or a medical school graduate, a large volume of information is absorbed during school and clinical rotations. Many factors may determine the healthcare professional's knowledge and application of this information: mentors, the weight of that information as it was taught, whether it was part of the graduate's first or early job responsibilities, ongoing education in this area, and so on. For skin assessment, clinical experience; anatomic knowledge; and clear, up-to-date knowledge of PIs, deep-tissue injuries, and moisture-related injuries are the necessary hallmarks for proper PI staging.


In 2010, the President and First Vice President of the American Nursing Association, Rebecca Patton, MSN, RN, CNOR, and Debbie Hatmaker, PhD, RN-BC, SANE-A, responded to a letter regarding this issue.1,2 Can and should an RN identify and diagnose a PI? Is it within their scope of practice? In their response, they state that it is within the scope and standard of practice for any nurse to stage PIs before a provider in order to implement the proper plan of care:


The purpose for identifying and staging a pressure ulcer and differentiating them from other wounds is to determine nursing care needs, plan for a strategy of care, and implement the care. Nursing information on pressure ulcers and staging is entered into the nurse's admission assessment and nursing notes. As such, nurses enter this information in the nursing record that is part of the medical record.


"Alteration in skin integrity" is, we believe, universal as part of the nursing intake assessment. This initial risk assessment should lead to documentation protecting the facility and, more importantly, the initiation of proper treatment/interventions. It is essential for the early identification of at-risk patients. Without this assessment and identification, the immediate initiation of protocols for at-risk patients could be delayed.


Facilities have addressed this in various ways; for example, in Dr Murphy's facility network (Lehigh Valley Hospital, Allentown, Pennsylvania), an amendment to the bylaws was incorporated many years ago enabling consultation to the wound care service to be within the purview of the unit nurse without physician cosignature.


In many hospitals, certified wound and ostomy nurses (CWONs) are a limited resource and work only during regular business hours. Patients admitted during off hours or in facilities without properly trained providers could experience delayed treatment initiation if education is not ongoing and required. For example, a patient admitted on a Friday evening of a holiday weekend might not be seen by a CWON until the following Tuesday morning. This would be a very long time without an appropriate diagnosis. Failure to initiate appropriate protocols could potentially lead to negative patient outcomes.


If nurses are to address issues of skin integrity, educationally, we see the following issues:


Deep-tissue injuries are challenging to identify without experience, especially if the skin is intact and the underlying muscle is injured. In patients with darker skin pigmentation, this can be even more challenging. It is necessary to understand the anatomy and physiology of pressure points and concurrently evaluate surrounding tissue to assess an abnormal area of tissue. If nurses suspect deep-tissue injury, this should trigger enlisting a more senior colleague or automatic consultation of the wound service.


Unstaged PI (eschar) is potentially easily identified, and an at-risk patient should be easily identified as well. However, as correctly identified in the article, patients with higher levels of skin pigmentation may present challenges, and nurses may lack confidence to correctly identify or diagnose them.


Stage 1 PI (blanchable vs nonblanchable erythema or the identification of reperfusion or lack of perfusion). These patients are at risk for worsening issues, and stage 1 PIs can be difficult. Are the nurses empowered by their facility to diagnose and intervene? Because allowing this should arrest the progression of the problem and improve the patient's ability to heal.


Stage 2 PI (breakdown of the epidermis) is also still a nursing issue. Only early identification and initiation of treatment protocols can prevent progression. Nursing interventions at this level can greatly impact wound healing. How can we instill confidence and knowledge in nurses for correct staging?


Stage 3 and 4 PIs require the ability to identify dermis or lack of dermis and muscle/fascia, respectively. The article identifies statistics and personal experience that support a lack of confidence and reproducibility to stage these injuries correctly.



Physician education and experience are also a problem. Internal medicine physicians, general surgeons, emergency medicine, and plastic surgeons are expected to identify and properly stage PIs on physical examination. These are on the board examinations of the respective specialties. However, simply having this diagnosis fall on physicians is not the best solution because there could be a significant delay in diagnosis and treatment. Further, many physicians are simply not educated well enough in this area, do not continue their education in this area, are not involved enough with these patients to maximize outcomes, and so on.


In our opinion, a four-eye approach, with the second set of eyes being a more experienced nurse, should be a protocol for all facilities upon identification of skin injury of any kind. This can further advance the opportunities in education, mentoring, a more refined and correct diagnosis, and earlier level-appropriate set of interventions.


A fascinating area addressed briefly in the article is the role of coders. The possibility of coders creating medical or legal issues for the providers and the hospital or facility, in general, cannot be understated and should be addressed in earnest, in our opinion.


Education for all providers, whether nursing or physician, is an ongoing problem in all specialties. Hospital-based physicians are often overly reliant on CWONs to evaluate, stage, and initiate treatments for at-risk patients. Documentation of the physical examinations by these doctors often states "skin warm and dry," with no mention of the examination of PIs, even in patients with infected stage 4 PIs. Issues include both both identification of risk with associated initiation of treatment/preventive strategies and the proper documentation for medical and legal purposes. Assessment on admission is imperative to avoid a CMS penalty as "present on admission." Documentation needs to be clear and concise.


Increased reliance on wound experts may be problematic for many health systems. Because CWONs tend to be more experienced nurses, they are difficult to replace when they retire. Emphasis on physician involvement could improve documentation and, ultimately, education for those lacking in experience if the physician maintains a focus in this area of healthcare.


There is no simple answer regarding who should assess and stage these injuries in hospitalized patients. Systems must maximize education, mentoring, protocols, interventions, and so on, while minimizing risks to the providers on the frontline of care, such as reprimands or even legal repercussions. As we all work to remain patient-focused, it is still about caring for each patient[horizontal ellipsis] one at a time.



-Michael A. Bain, MD, MMS


Medical Director, The Sally & Joseph Warpinski Wound


Healing & Hyperbaric Medicine Center, Hoag Memorial Hospital,


Newport Beach, CA


-Garrett Wirth, MD


Clinical Professor, Department of Plastic Surgery, Aesthetic and


Plastic Surgery Institute, University of Californa - Irvine Medical


Center; Medical Director - Wound Healing Center - Memorial Care


Long Beach, Wirth Plastic Surgery,


Newport Beach, CA


-Robert X. Murphy, Jr, MD, MS, CPE, FACS


Professor of Surgery, Morsani College of Medicine, Leonard Parker


Pool Chair in Community Health & Health Studies, Lehigh Valley


Health Network, Allentown, PA




1. Lyder CH, Krasner DL, Ayello EA. Clarification from the American Nurses Association on the nurse's role in pressure ulcer staging. Adv Skin Wound Care 2010;23(1):8. [Context Link]


2. Patton R, Hatmaker D. Response from the ANA. Adv Skin Wound Care 2010;23(1):8-10. [Context Link]




I appreciate your comments and response to my article. Education and confidence in a skill set are such key components of assessment and documentation of PIs. Many facilities across the nation have embraced a "four-eye" approach when first staging a PI, and there is agreement that the lack of wound experts during weekends, holidays, and overnight shifts does not support timely assessments. Knowing this and understanding how visual assessment and documentation may create challenges for direct care nurses, this issue continues to be my area of concern.


Coding is also another area of great concern for the reasons I cited and within my hospital system is frequently discussed with our wound specialists and hospital administration. Increased education for all healthcare professionals will certainly assist us in this endeavor, and hopefully improved imaging tools may assist us at the bedside to understand what changes are occurring that cannot be seen with the naked eye.


-Mary Brennan, MBA, RN, CWON


Clinical Professional Development Educator, North Shore


University Hospital, Manhasset, New York