Beyond Staging: The Role of Pressure Ulcer Site and Multiplicity in Hospital Mortality and Length of Stay

Abstract

Highlights: What are the main findings? The anatomical site and presence of multiple pressure ulcers were stronger predictors of prolonged hospital stay and increased mortality than ulcer stage alone. Certain ulcer sites, such as sacral, hip, head, buttock, and upper back, were independently associated with a higher risk of poor outcomes. What are the implications of the main finding? Risk assessment and prevention strategies should integrate ulcer site and multiplicity, not rely solely on staging frameworks. Systematic documentation, early detection, and patient safety protocols can reduce both clinical harm and the hospital resource burden of pressure ulcers. Background/Objectives: Pressure ulcers are an important patient safety concern. While staging frameworks guide clinical management, the association between anatomical site, stage, and multiple PU presence and outcomes such as length of stay (LOS) and mortality in Medicare patients has not been fully characterized. The study objective is to examine the relationship between PU site, stage, and multiplicity and inpatient LOS and mortality among hospitalized Medicare patients. Methods: A cross-sectional study was conducted with 1,123,121 inpatient Medicare admissions from a 2019 Centers for Medicare and Medicaid Services (CMS) medical claims dataset. PUs were identified using ICD-10-CM codes classified by anatomical site and stage (1 through 4, unstageable, unspecified). Multiple regression models examined associations between PU characteristics and LOS and mortality, adjusting for age, sex, primary diagnosis, and hospital transfer. An analysis was conducted using SPSS version 29. Results: Stage 2 ulcers were the most common (28.6%), while unstageable or unspecified ulcers were frequent in the heels and head. The sacral region, buttocks, and heels were the most common anatomical sites. LOS gradually increased from Stage 1 (9.4 days) to Stage 4 (15.2 days). While the death rate did not increase consistently with stage, it was highest for upper back (14%), head (12.8%), and unspecified hip (12.8%) sites. Multiple regression was conducted to examine the association between PU locality, stage, and multiplicity and mortality (logistic regression) and LOS (linear regression). After controlling for patient demographics, admission, and clinical information, the regression results showed that the presence of multiple PUs, as well as anatomical sites of sacral, hip, head, buttock, and upper back ulcers, is associated with prolonged LOS and increased mortality. The presence of an advanced PU stage was found to be associated with prolonged LOS but not with inpatient mortality. Conclusions: The anatomical site and presence of multiple pressure ulcers were stronger predictors of prolonged hospital stay and increased mortality than ulcer stage alone. Certain ulcer sites, such as sacral, hip, head, buttock, and upper back, were independently associated with a higher risk of poor outcomes.