Annals of Long Term Care

Key words: Long-term care, pressure ulcers, skin failure, skin integrity. 

Pressure ulcers in long-term care (LTC) facilities and other settings are largely, but certainly not always, preventable. Since late 2008 in the United States, the Centers for Medicare & Medicaid Services (CMS) has considered a hospital-acquired stage III or stage IV pressure ulcer to be a serious reportable event. Therefore, it will no longer reimburse providers for the treatment of these conditions, according to a letter from Herb B. Kuhn, acting deputy administrator, CMS, and director, Center for Medicaid and State Operations, to state Medicaid directors.¹ As of 2011, the National Quality Forum was assembling a technical advisory panel to consider expanding the scope of serious reportable events to include those occurring in LTC and skilled nursing facilities.² Although these efforts to ensure quality care should be applauded, considerations must be made for an aging population and for sustaining life beyond the norm, which is a phenomenon we are increasingly seeing.

The baby boomer generation is turning 65 years old, and as that population ages, it will represent the “oldest-old” group (age >85 years) by 2030.³ It is anticipated that the baby boomer population will grow from 5.7 million in 2008 to 19.0 million in 2050.³ Some research suggests that the death rate will continue to decline,³ which is not surprising given the influx of medical advances that are continuing to prolong life, enabling more people to reach ages beyond which the skin can maintain its integrity.⁴ Organ failure is often seen with advanced age and in the setting of a critical illness, and the skin is no exception. In view of an aging and growing critically ill population, skin failure and pressure ulcers will likely be an increasing occurrence. This article reviews skin failure and how it differs from pressure ulcers, outlines tools that can be used to predict the occurrence of skin failure, and reviews plans of care for patients with skin failure.

Discussion

Consisting of about 10% to 15% of a person’s body weight, the skin is the largest organ of the body. Intrinsic aging makes the skin particularly susceptible to insult in older adults. Difficulties with thermoregulation, tensile strength, immunity, and vascularity worsen during the aging process. Clinically, these problems cause the skin to become more dry, thin, and prone to shear, leading to prolonged healing times.⁵ When these conditions are compounded by an acute illness, one can appreciate how skin can fail in frail older adults and critically ill individuals. Nevertheless, few studies have addressed skin failure. Instead, currently available data mainly focus on whether certain pressure ulcers are avoidable,^6,7 and the relationship between skin failure and pressure ulcers has yet to be properly defined.

Skin Failure Versus Pressure Ulcers

Pressure ulcers and skin failure are not the same. The National Pressure Ulcer Advisory Panel (NPUAP) and the European Pressure Ulcer Advisory Panel (EPUAP) define a pressure ulcer as “localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear.”⁸ Skin failure occurs without the presence of pressure and/or shear, whereas pressure, shear, or both are responsible for pressure ulcer development. A pressure ulcer and skin failure can and often do occur together, as an area of skin failure exposed to pressure and/or shear would have greater vulnerability to breakdown. This is not uncommon in an individual with hemodynamic instability, whose position cannot be changed or can only be changed minimally. A pressure ulcer would understandably develop more quickly in an area where the skin has failed. The key difference is that pressure alone or in combination with shear must be present for the development of a pressure ulcer. Researchers’ understanding of pressure ulcers versus skin failure has evolved over the past decade.

In 2006, Langemo and Brown⁴ had defined skin failure as “an event in which the skin and underlying tissue die due to hypoperfusion that occurs concurrent with severe dysfunction or failure of other organ systems.” In 2009, an interdisciplinary panel of 18 experts in wound healing convened to develop SCALE (Skin Changes at Life’s End), a consensus statement on the changes that occur to the skin at the end of life.⁹ The panel adopted the 2006 definition of skin failure by Langemo and Brown,⁴ thus identifying skin failure as a real condition that can occur in the last days or weeks of life. The panel reported that our knowledge of this condition is limited and requires further research, and they also acknowledged that skin failure can occur in both acute and chronic illnesses. Another point of discussion for the panel was the Kennedy Terminal Ulcer, which was first described in 1989 and is now often explained by researchers as an unavoidable skin breakdown that occurs during the dying process.^10,11 The ulcer often presents as a red, yellow, or purple pear-shaped lesion on the coccyx or sacrum. Afterward, the lesion will darken deeply and may deteriorate into a full-thickness ulcer in a matter of days. According to the NPUAP and EPUAP pressure ulcer staging criteria,⁸ this lesion would be considered a suspected deep-tissue injury before the full-thickness ulcer becomes evident. Despite the assertions that skin failure does exist, there has been little investigation into the pathophysiology of such an ulcer, and the topic therefore remains controversial.¹²

In 2011, the NPUAP stated that not all pressure ulcers are avoidable.¹³ This position was the outcome of a consensus conference involving a wide array of wound care professionals. The panelists asserted that there are clinical conditions that lead to the unavoidable nature of some pressure ulcers, and they emphasized that skin failure and pressure ulcers are two separate conditions that can occur concomitantly. Any further attempts to define skin failure were beyond the scope of the NPUAP.¹³ 

Based on statements from the SCALE panel and the NPUAP, there are two conditions necessary for establishing skin failure: skin hypoperfusion and severe organ dysfunction or failure. For the frail older adult living in an LTC facility, these conditions are easily met; however, not all LTC residents experience skin failure at the end of life. There may be an as yet undefined predisposition to this type of organ failure.

Pathophysiology of Skin Failure

Researchers have theorized that when multiorgan failure occurs with the resultant conservation of blood for the vital organs, the skin will become hypoperfused and ischemic, leading to difficulty with metabolite management and, ultimately, to necrosis.¹⁴ Observational studies show that skin failure will often begin as a stage II pressure ulcer or suspected deep-tissue injury and progress rapidly to necrosis.^10,11 Animal models suggest that there is an ischemia-reperfusion cycle at work when deep-tissue injury occurs. During reperfusion, instead of restoring oxygen and washing out waste products, there may be an activation of free radicals, resulting in swelling and inflammation. These animal models may indicate that repeated ischemia-reperfusion cycles cause more damage to tissues than one long ischemic episode.^15-17 More studies are needed to delineate the pathophysiology of skin failure.