Understanding Deep Tissue Injury

Ethel Gonzales

A deep tissue injury (DTI) is commonly mistaken for a stage 1 pressure ulcer or a bruise. This is a serious error and can have a profound impact on patient outcomes, liability, and reimbursement.

What is a deep tissue injury (DTI)?

Deeper, full-thickness damage to underlying tissue which may appear as purple areas or dark necrotic tissue should not be confused with Stage 1 pressure ulcers. The National Pressure Ulcer Advisory Panel has defined wounds such as these as;

A pressure-related injury to subcutaneous tissue under intact skin. Initially, these lesions have the appearance of a deep bruise (NPUAP, 2002).

DTI’s require rapid identification, as they may quickly progress to Stage 3 and 4 pressure ulcers despite aggressive and optimal treatment.

How do DTI’s form?

Fleck (2007) explains that DTI’s form over areas of bony prominence and occur from the inside out. Superficial damage is not seen until later, when tissue undergoes necrosis, reaching the outer layer of skin and resulting in the formation of an external wound. She further stresses that DTI’s can be differentiated from Stage 1 ulcers by their rapid deterioration despite proper care.

What are the legal implications of DTI’s?

DTI’s that are not recognized for what they are can have legal implications due to their ability to deteriorate despite stringent wound management practices. They result in increased costs and hospitalization, not to mention pain and suffering for the patient who develops one of these wounds, putting the health care practitioner and the facility at risk for litigation.

Salcido (2008) discusses the current Medicare changes that are scheduled to take effect October 1, 2008. These changes will have a huge impact on how hospitals are reimbursed. In regards to wound care, pressure ulcers will be considered hospital acquired (and therefore not reimbursed) unless these wounds are documented within 48 hours of admission. The onus is now on us, as healthcare professionals, to ensure that these wounds never develop, and if they do, they should be well documented and aggressively treated. This new policy is forcing us to examine our wound care management practices.

Documentation of DTI’s

Wounds that are suspected as being a DTI should be afforded a full description and the word -DTI- should be mentioned. For those practitioners who work in long-term care with the Minimum Data Set (MDS) documentation system, the word -unstageable- should be used to describe those wounds that are suspicious for DTI. Thorough and ongoing documentation is crucial in respect to DTI’s, as their rapid deterioration may make these wounds particularly tempting targets for litigation.

Education is the key to recognition and management of DTI’s

Understanding the etiology of DTI’s and learning how to differentiate these wounds from bruises, hematomas, and other closed wounds that may have a similar appearance is the key to prevention and treatment of these wounds, which have the potential for significant morbidity for patients, as well as being potentially litigious.

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