Template for Referral of a Stage 3 Sacral Pressure Injury
Surgical consultation is indicated for a stage 3 sacral pressure injury to achieve rapid and durable closure of the soft tissue defect, resulting in reduced pain, reduced risk of infection, and improved quality of life. 1, 2
Patient Information to Include in Referral
Clinical Assessment
- Pressure Injury Classification: Stage 3 (full-thickness tissue loss exposing subcutaneous fat, without visible bone, muscle, or tendon)
- Location: Sacral region
- Wound Measurements: Length, width, and depth in centimeters
- Wound Characteristics:
- Presence of slough/necrotic tissue
- Exudate amount and characteristics
- Undermining or tunneling (measure and document direction)
- Periwound skin condition
- Signs of local infection (increased pain, erythema, edema, purulent drainage, malodor)
Current Management
- Debridement methods used
- Current dressing regimen
- Pressure redistribution devices in use
- Repositioning schedule
- Nutritional interventions implemented
Patient Risk Factors and Comorbidities
- Mobility status
- Nutritional status (albumin, pre-albumin, hemoglobin levels)
- Comorbidities (especially diabetes, cardiovascular disease, neurological conditions)
- Incontinence status (urinary/fecal)
- Current medications (especially immunosuppressants, anticoagulants)
Relevant Laboratory and Diagnostic Studies to Include
- Recent wound cultures (if signs of infection present)
- Complete blood count
- Basic metabolic panel
- Albumin and pre-albumin levels
- Inflammatory markers (ESR, CRP)
- Imaging studies (if performed):
- MRI to assess for deep tissue involvement or osteomyelitis
- X-ray if bone involvement suspected
Reason for Referral
Clearly state the reason for referral:
- Evaluation for surgical debridement
- Assessment for potential flap reconstruction
- Consideration for advanced wound care interventions
Current Interventions Attempted
- Document all previous wound care interventions
- Response to current treatment
- Duration of current treatment approach
- Wound progression/deterioration despite conservative management
Special Considerations
- Include any barriers to healing (e.g., nutritional deficiencies, inability to offload)
- Note any previous surgical interventions for this wound
- Document patient's goals of care and functional status
Urgency of Referral
- Indicate if urgent evaluation is needed (e.g., signs of systemic infection, rapid deterioration)
- Suggest timeframe for consultation based on wound severity
Provider Contact Information
- Include your direct contact information for follow-up questions
- Note availability for care coordination discussion
Additional Documentation to Include
- Recent wound photographs (with measurement scale)
- Wound assessment flow sheet showing progression over time
- Nutritional assessment documentation
- Pressure redistribution protocol in place
This comprehensive referral template addresses the multidisciplinary approach needed for stage 3 sacral pressure injuries, which represent 28.52% of pressure injuries requiring plastic surgery consultation 3. Research indicates that stage 3 pressure injuries often require surgical intervention when conservative management fails to show improvement 4, 5.