Volume 27 Number 2

Key messages

• Improved clinical assessment skills and education on pressure injury (PI) classification are essential to reduce errors.
• Accurate wound diagnosis ensures appropriate treatment, preventing mismanagement and improving outcomes.
• Only 36.2% of reported DTIs were accurately assessed, with many misclassified as other PI stages or non-PIs.

Introduction

Pressure injuries (PIs) represent a significant global healthcare challenge, affecting both hospitalised patients and individuals in community settings. Defined as localised tissue damage of varying severity, PIs typically develop over bony prominences due to sustained pressure, friction, shear forces or the use of medical devices.¹ These injuries not only result in physical harm but also contribute to prolonged pain, emotional distress, extended hospital stays, increased healthcare costs, and poorer clinical outcomes.^2-4 Furthermore, research highlights the profound psychosocial consequences of PIs, including grief, psychospiritual distress, strained relationships and social isolation.⁵ A systematic review of 39 studies found that the global prevalence of PIs, based on point and period prevalence measures, was 14.8% and 11.6%, respectively, in hospital settings.⁶ The overall mean incidence was 6.3%.⁶ In Singapore, the prevalence of pressure ulcers was reported at 18.1% (95% CI: 15.5–20.9%), with an incidence of 8.1% (95% CI: 6.1–10.4%).⁷

Deep tissue injury (DTI) is one of the classifications of pressure injuries (PI). DTIs are characterised by a purple or maroon area of intact skin or a blood-filled blister due to underlying tissue damage from pressure or shear forces.¹ Unlike typical pressure injuries, DTIs originate near the bone, affecting subcutaneous tissue and muscle without breaking the skin. Their presentation and pathogenesis also differ significantly from standard pressure injuries.⁸ Though DTIs may remain closed and not be associated with broken skin, they can progress to severe, deep wounds, leading to significant patient impact and healthcare costs.^{8, 9} Patients with light skin tones present with classic skin discolouration of purple or maroon tissue with a well-defined border around the area of injury, with often surrounding erythema being evident. One challenge in assessing pressure injuries in patients with dark skin tones is that persistent erythema and hyperpigmentation, rather than blanching, should be used as key indicators.¹⁰ Evidence on wound care for different skin tones is generally lacking. Studies have shown that patients with darker skin tones are often diagnosed with more advanced-stage PIs.^11,12 This trend is linked to challenges in accurate assessment and early identification in these populations. Medical conditions such as diabetes, stage 2 pressure injuries, incontinence-associated dermatitis, terminal skin ulcers, vascular diseases, and high melatonin serum levels may be considered as a higher risk for deeper tissue damage and also as a differential diagnosis to DTI.^10,13

This may impact the accuracy of DTI assessment and underestimate the risk in patients who are genuinely at risk for DTI. DTIs mostly occur on the heels (41%) and the sacrum (19%), as these areas lack a distinct main blood supply and rely on dense collateral capillaries for perfusion.¹⁴ Apart from anatomical sites, DTI can also occur due to pressure-related damage from a medical device.⁸

Using validated clinical tools such as the Bates-Jensen Wound Assessment Tool, the Pressure Ulcer Scale for Healing, and the Triangle of Wound Assessment Tool is essential for nurses to accurately assess wounds, implement evidence-based interventions, and apply appropriate preventive measures.^15-18 Practical wound assessment enables skilled nurses to determine appropriate management strategies, promote optimal healing, and minimise the risk of complications. However, a descriptive study found that many nurses lack sufficient knowledge of DTI and stage 1 PI prevention and management.¹⁹ Visual assessment alone is often inadequate for detecting early DTI signs, underscoring the importance of considering patients’ comorbidities.^{8, 9}

Accurate assessment and diagnosis of DTIs are crucial, as they can mimic various skin conditions, resulting in inconsistent reporting and potentially inadequate or inappropriate treatment measures.¹⁰ Early identification enables timely clinical interventions, preventing further tissue damage and improving patient outcomes. Detail-oriented nurses can detect subtle changes in skin appearance, texture, and temperature, enabling early intervention. Their keen observation skills allow for the prompt implementation of appropriate skincare regimens and the application of proper dressings, promoting healing and preventing further complications. DTIs often require distinct treatment strategies compared to superficial pressure injuries, given the extent of underlying tissue damage. Accurate assessments empower nurses to develop holistic, individualised care plans by selecting the most effective wound dressings, positioning strategies, and pressure redistribution devices. This tailored approach optimises healing, prevents complications, and enhances overall patient outcomes.

Thorough documentation is essential for effective communication among healthcare providers, ensuring continuity of care. Accurate records of wound stage, location, size, and surrounding tissue condition enable ongoing monitoring, assessment of intervention effectiveness, and timely adjustments to care plans.¹⁵ Consistent and precise documentation supports individualised care, reduces reporting inconsistencies, and enhances patient outcomes. Additionally, comprehensive records facilitate personalised education for patients and their families, ensuring a smooth transition from hospital to community care.

Method

Aim

To evaluate the accuracy of ward nurses’ assessments of DTIs compared to assessment by Wound, Ostomy and Continence (WOC) nurses.

Specific objectives

To identify common misclassification errors in DTI assessment.

To identify the accuracy between the assessment of the ward nurse and the two WOC nurses.

Study design, sample and setting

This audit was conducted in one of the largest tertiary acute care hospitals. The data collection period was over 15 months, from August 2022 to November 2023. We conducted a cross-sectional audit of electronic patient records to capture baseline demographic, clinical, and wound-related information at the time of admission. To ensure staging accuracy, a WOC nurse subsequently performed a physical reassessment of patients within a few days of admission. A total of 100 patient records were retrieved, with DTIs documented.

A structured data-collection form was developed based on established wound assessment domains to capture information on PIs. The form included sections on patient demographics, admitting diagnoses, the number of PIs present on admission, and the Charlson Comorbidity Index (CCI). The PI audit section recorded the initial assessment documented by ward nurses, including the presence and location of DTIs and neurovascular findings. This was compared with the assessment performed by the WOC nurse after direct patient examination, documenting the date of assessment, Fitzpatrick skin type, actual PI stage, and lower-limb neurovascular status if the injury was on the lower limbs.

Patients: Patients with PIs were identified from electronic wound care documentation retrieved from the hospital’s PI wound dashboard. They were from general medical, surgical and isolation wards.

Ward nurses assessing patients: Ward nurses added information about of patients’ PI wounds to the electronic wound care document upon admission.

WOC nurse: Physically checked patients personally and verified the accuracy of the documentation and the staging of the DTI within three days of admission.

Ethical considerations

This study adhered to the principles of the Declaration of Helsinki (2024). Ethical approval was obtained from the SingHealth Centralised Institutional Review Board (Reference: 2022/2362) before commencement. Verbal consent was obtained from patients and/or their next of kin to assess DTI sites during the recruitment process.

Data extraction, study variables, and outcomes

The Principal Investigator, a WOC nurse, extracted data from the hospital’s electronic PI dashboard. Patients with DTIs were idenitified and subsequently reviewed in the wards by the Principal Investigator and a second WOC nurse. A structured data collection form was used to retrieve the information on PIs. The data collection included patient demographics, admitting diagnosis, the number of pressure injuries on admission, and the CCI. The PI audit section included the data from the ward nurses’ initial assessment of the DTI, location of DTI and neurovascular assessment, comparison of the intial data with the WOC nurse information from the date the re-assessment was performed after physically checking the patients’ Fitzpatrick skin tone type, actual stage of PI and neurovascular assessment of lower limbs if PI present on the lower limbs.

Data analysis

Statistical analysis was carried out using IBM SPSS v26.0. An independent study team member conducted cross-checks to ensure the accuracy of the data before analysis. Descriptive statistics were reported using percentages for categorical variables and means with standard deviations for continuous variables.

Results

Patient demographics

A total of 100 patient records were reviewed, encompassing 149 DTIs. The cohort was predominantly elderly, with a mean age of 79 years (SD=8.6), and had a comparable distribution of males and females. Most patients were of Chinese ethnicity (78%) and were admitted via the Emergency Department (77%). The majority were admitted to medical wards (65%), followed by surgical (25%) and isolation wards (10%). Community-acquired PIs were more common (n=82) than hospital-acquired PIs (n=18).

The CCI indicated high comorbidity burden, with a mean score of 5.7 (SD=1.9); two-thirds (67%) of patients scored ≥5, representing a medically complex population. Based on Fitzpatrick skin tone classification, most patients (70%) had Type II skin tones, which range from light to dark brown. WOC nurse reviews were typically conducted within the first four days of admission (median=3 days, IQR=2–5). However, among patients with hospital-acquired PIs, assessments were often delayed beyond the first week (Table 1).

 

Table 1. Demographics of patients (n=100) with DTIs (n=149) reported

 

Wound characteristics and accuracy of assessment

Table 2 presents wound-related characteristics. Overall, 71% of patients (n=71) had at least one documented DTI, most frequently located at the sacrum (42%) and heels (33%). Of the 149 DTIs documented by ward nurses, 58 (38.9%) were confirmed as true DTIs by WOC nurses, indicating low accuracy in initial DTI identification. Among these, 54 (36.2%) also had accurately recorded anatomical locations (Figure 1). The remaining cases were misclassified as other PI stages, non-PIs, or wounds at different anatomical sites. Because only ward-flagged DTIs were reviewed, complete inter-rater reliability across DTI and non-DTI categories could not be calculated.

 

Table 2. Other wound aetiologies

 

Figure 1. Number of patients reviewed, overall number of patients with DTIs (staging, location and type of wound)

 

Many cases initially labelled as DTI were subsequently reclassified as Stage 1 or Stage 2 PIs (n=29) or non-PIs (n=14). A total of 79 DTIs were reported on the lower limbs across 51 patients, yet none had documented neurovascular assessments in the nursing notes. This suggests that several wounds may have been misinterpreted as PIs rather than manifestations of peripheral arterial disease or other ischemic etiologies. These findings underscore a significant discrepancy in wound identification accuracy between ward nurses and expert reviewers, highlighting the need for standardised neurovascular assessment in differentiating DTI from vascular-related ulcers.

In summary, this audit identified significant variability in the accuracy of DTI assessments conducted by ward nurses and WOC nurses. Although DTIs were frequently documented (71% of patients), fewer than half were correctly classified upon expert review. The high rate of reclassification, especially of suspected DTIs later confirmed as Stage 1 or 2 PIs or non-PIs, suggests a tendency to overdiagnose DTIs during initial ward evaluations. Misclassification was most evident in lower-limb wounds, where neurovascular assessment was absent in all reviewed cases, implying that PAD or other ischemic changes may have been mistaken for pressure-related injuries. Collectively, these findings highlight critical knowledge and skill gaps in differentiating pressure-induced versus ischemic tissue damage.

Discussion

In this study, only 38.9% of the DTIs were accurately assessed and reported by the ward nurses. There are relatively few studies available that have analysed the reporting accuracy of PI staging assessment. Studies conducted by Lee and Kim²⁰ in 2016 in South Korea and Liu and colleagues²¹ in 2022 in China assessed the knowledge of nurses in PI staging.

Both studies reported that nurses had significantly lower rates of correct identification for stage 3 PI, unstageable PI, and DTIs. In our research, we have investigated PI reporting accuracy only for DTI. This snapshot of DTI assessment and staging provides important benchmarking information for other facilities nationally and internationally, as well as indicating areas of educational need. The main finding of this study is that approximately one-third of PIs initially assessed and reported as DTIs were found to have been evaluated incorrectly upon review by WOCs. Importantly, more than half of the injuries that were misreported were found to be non-PIs on review.

Inappropriate staging

It is essential that general ward nurses can recognise the clinical presentations of all PIs, including DTIs, and their classifications, to provide appropriate preventive care and management, helping prevent further ischemic damage to local tissues. Recognising a blistering DTI is crucial, as it can often be mistaken for other conditions. At this stage, DTIs may appear as shallow ulcers with detached epidermis around the wound edges, changes in dermal colour, and signs of necrosis.¹⁰ This evolving phase is frequently misidentified as stage 2 PIs, and this concides with our results where stage 2 PIs were identified commonly (n=9; 31%). A key distinguishing feature is that stage 2 PIs lack the characteristic dark maroonish wound bed seen in DTIs. Additionally, blistering DTIs are sometimes incorrectly classified as skin tears, even in the absence of trauma to the affected area. Healthcare providers frequently misinterpret DTIs as superficial conditions like skin tears, incontinence-associated dermatitis (IAD), or stage 2 PIs. Likewise, in a descriptive study, the authors reported that nurses understand the PIs’ classification system and IAD but have limited visual discrimination of stage III, DTI, and unstageable PIs (p<0.001).²²

Accurate PI staging requires a thorough evaluation of the dermis and exposed structures, rather than relying solely on discolouration and depth. This challenge is further compounded in patients with darker skin tones, where early signs, such as discolouration or induration may go unnoticed. Often, it is only during follow-up assessments that clinicians observe the epidermis peeling away, revealing the true nature of the injury. Conducting visual skin assessments for patients with darker skin tones necessitates additional effort, such as utilising risk assessment tools and providing ongoing training and education.²³ Skin colour can be constitutive or facultative. Constitutive skin colour refers to the genetically determined levels, types, and distribution of epidermal melanin, which is not influenced by exogenous or endogenous factors. Facultative skin colour refers to an increased epidermal melanin content as a result of environmental (such as sunlight) or hormonal factors.

Accuracy of staging

Although WOC nurses confirmed 38.9% of ward-documented DTIs, the majority were misclassified, demonstrating considerable variability in DTI identification and documentation. The absence of inter-rater reliability reflects the limited variation in ward nurse classifications, as all wounds were initially recorded as DTI. This likely inflated the chance of agreement and prevented the calculation of a valid kappa statistic. Misclassification may be attributed to challenges in differentiating DTIs from early pressure-related changes, moisture damage, or ischemic lesions, as well as inconsistent neurovascular assessment and variation in skin tone interpretation. These findings underscore the need for enhanced competency in systematic wound assessment and more precise staging criteria.

Improving the accuracy of documentation

Thorough documentation of a patient’s condition, care plan and treatments is a vital aspect of delivering high-quality nursing care. Thoroddsen et al²⁴ highlighted that incomplete or inaccurate documentation can lead to missed opportunities for effective hand-off communication, potentially negatively impacting patient safety and outcomes.

Limitations

The authors acknowledge several limitations in this study. A power analysis was not performed to determine the required sample size. The lack of a sample size justification limits the ability to assess the representativeness of the study population and raises concerns regarding the statistical validity and generalisability of the findings. Instead, this study aimed to provide a snapshot of current care practices and identify gaps in DTI staging and documentation to enhance the quality of patient care.

While we designed this study as a cross-sectional audit, the physical reassessment by WOC nurses occurred within a few days after admission (mean 3.5 days) rather than at a single time point. This introduces a limited temporal component that deviates from a strict cross-sectional design and may have influenced the accuracy of PI classification, particularly for hospital-acquired injuries identified after the initial timepoint. Future studies using a purely cross-sectional approach or a prospective cohort design could provide a clearer understanding of PI onset and documentation practices over time.

We assumed that WOC nurse assessments were the reference standard for PI classification. Although inter-rater reliability between the two WOC nurses was not evaluated, both had nine years of dedicated WOC nursing experience, assuring a high level of competency and consistency. Future work should incorporate formal inter-rater reliability testing to validate expert agreement. As a result, the reliability of our review method may be lower than that of studies that have included multiple assessors or standardised reliability measures. Furthermore, we did not explore whether skin tone affected assessment accuracy, despite 70% of the patients having Fitzpatrick Type II skin tone. We also examined other contextual factors, such as the type of wards and patient conditions, that were associated with misclassification rates. Inter-rater reliability testing and stratified analyses by ward type, patient characteristics, and skin tone were not performed in this study. These analyses should be incorporated into future work to understand diagnostic variability better and improve the accuracy of PI classification.

 

Table 3. Other PI stages identified

 

This audit included only wounds that were initially documented as DTI by ward nurses. Because wounds classified as non-DTI were not reviewed, a complete 2×2 agreement matrix could not be constructed, preventing full inter-rater reliability analysis (such as Cohen’s κ). The resulting κ=0.00 reflects a statistical artefact caused by zero variation in ward nurse ratings rather than a true absence of agreement. Future studies should include all wounds assessed by both ward and WOC nurses and conduct independent dual assessments to enable robust calculation of inter-rater reliability and diagnostic performance metrics.

In addition, neurovascular assessment for lower limb DTIs was not included as a pre-specified audit criterion, limiting our ability to evaluate vascular risk in this subset. Additionally, the audit did not examine documented interventions for DTIs, as this was not a predefined objective of the study. Another notable limitation was the absence of recorded Braden scores for the audited patients. The Braden Scale is a crucial tool for PI risk assessment, evaluating factors such as sensory perception, moisture, activity, mobility, nutrition and friction/shear. This omission is particularly significant in distinguishing DTIs from other PI stages. DTIs often present as intact but discoloured skin with underlying tissue damage, making differentiation from Stage 1 PI or bruising challenging. Recording Braden scores would have provided valuable context on patient risk factors, allowing for a more comprehensive assessment of preventive measures and early interventions. Furthermore, Braden scoring supports clinical decision-making, ensuring timely and appropriate management to prevent progression to more severe wounds. We also noted that the Braden Scale demonstrates variable accuracy, with evidence showing only moderate predictive validity in hospitalised patients.²⁵ While overall inter-rater reliability is reported to be high, agreement on individual sub-scale items remains weak.²⁶

The finding that only 38.9% of DTIs were identified correctly suggests potential system-level contributors, such as inconsistent documentation practices, varying knowledge of nurses on different PI staging, limited clinical experience, and inadequate ongoing training for ward nurses. Although this study did not directly investigate these factors, future research should explore whether structured training programs, integration of decision-support tools into electronic records, or regular competency assessments could improve staging accuracy.

Conclusion

This study highlights the challenges in accurately staging and categorising DTIs within routine clinical practice by nurses. More than half of the misclassified cases were found to be non-pressure injuries, indicating a need for improved assessment accuracy and standardised protocols. However, due to the study’s limitations, including reliance on single-expert validation, these findings should be interpreted with caution. Future research with larger samples and stronger methodological rigour is necessary before making broader institutional recommendations or implementing systemic changes.

Implications for clinical practice

PIs are a significant patient safety concern that can often be prevented or minimised through thorough bedside assessments by nurses and timely referrals to specialist wound care nurses. When PIs develop or worsen, they can lead to prolonged hospital stays, increased risk of infection, reduced mobility, and higher rates of morbidity and mortality. This audit identified that ward nurses face challenges in accurately assessing, staging, and documenting PIs. Accurate assessment and staging are critical for implementing effective prevention and treatment strategies. Additionally, hospital staff must recognise the urgent need to enhance current practices, particularly in the assessment, staging and documentation of DTIs and other PI stages.

Recommendations

To address these challenges, a task force composed of specialist nurses and quality management nurses should be formed to design and implement comprehensive educational strategies focused on PIs. The delivery of healthcare professional education should be multifaceted, incorporating didactic lectures, computer-based learning and interactive training programs. Essential content relevant to PIs, including prevention, assessment and management, will be prioritised to ensure healthcare professionals are equipped with the knowledge and skills to provide optimal patient care. Mandatory participation in these educational initiatives, combined with ongoing feedback to ward nurses on the accuracy of their assessments, staging and documentation, is essential. This effort can be further supported by ward-based wound care champions and WOC nurses, ensuring a structured and collaborative approach.

Furthermore, skin inspection should be carried out, along with an understanding of the patient’s normal skin tone, to help detect any changes early.²⁷ Failing to identify these changes promptly may result in missed warning signs, leading to avoidable skin and tissue damage. The skin tone tool is a validated classification tool that shows a range of skin tones.²⁸ The skin tone tool is a user-friendly and cost-effective method for assessing skin tone, suitable for various healthcare settings. Unlike basic classifications of “light” and “dark,” this tool includes a broader range of gradients, making it more practical for clinical use.

Neurovascular assessment should be part of routine checks for PIs on the lower limbs. This assessment helps identify issues with peripheral vascularity or nerve function, which can worsen PIs. It includes checking capillary refill, skin temperature, colour, sensation and peripheral pulses. Any signs of poor circulation or nerve damage, such as delayed capillary refill or numbness, increase the risk of developing pressure injuries. Regular neurovascular checks enable early detection of underlying medical conditions, allowing timely referrals to specialists, such as vascular surgeons. This proactive approach helps prevent further tissue damage and supports optimal patient outcomes. According to the European Pressure Ulcer Advisory Panel (2019)¹, incorporating these checks into routine care helps prevent complications and improve patient outcomes.

Annual nursing competency programs should incorporate PI assessment, staging, the use of a skin tone tool, and documentation requirements to reinforce consistent practice. The National Database of Nursing Quality Indicators (NDNQI) PI training modules can serve as a valuable foundation to enhance nurse knowledge; however, this online training alone may not be sufficient. To strengthen skills, regular skin surveillance rounds with direct feedback from clinical experts should be complemented by the training. Hospitals must evaluate their available resources to support improvements in the accurate assessment, staging, and documentation of DTIs and other PI stages. A coordinated effort that includes education, ongoing feedback, and expert support will ensure that appropriate interventions are implemented effectively and consistently across all levels of nursing practice.

Acknowledgments

We sincerely thank the following individuals for their invaluable support: Our chief nurses: A/Prof Tracy Ayre (SingHealth Group Chief Nurse) and Ms Ng Gaik Nai (SGH Chief Nurse). Also I would like to thank Ms Wong Min Jia for data management support.

Funding

This research did not receive any forms of funding.

Author contributions

All authors reviewed and extensively edited the manuscript and approved the final version.

Author(s)

Nanthakumahrie Gunasegaran¹* MSc (Clinical Leadership), Hui Ru Chong¹ BN, Wee Ting Goh¹ BN,
Shin Yuh Ang¹ MBA (Healthcare Management), Fazila Aloweni MSc (Health Research Methodology)
¹Nursing Division, Singapore General Hospital

*Corresponding author email nanthakumahrie.gunasegaran@sgh.com.sg

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