Article Archive

Summer 2010

Eliminating Bedsores
By Lindsey Getz
Aging Well
Vol. 3 No. 3 P. 20

Getting the pressure off patients—literally—is the key to preventing bedsores.

Whether or not you’ve encountered decubitus ulcers in your professional career likely dictates exactly how you feel about them. After all, bedsores, as they are more commonly known, don’t sound that bad. But if you’ve seen a bedsore, you know that couldn’t be further from the truth. In reality, these pressure ulcers are excruciatingly painful and very dangerous. In fact, if left untreated or discovered too late, decubitus can be deadly. That’s why it’s critical for practitioners and caregivers working with older adults to be educated on these ulcers and how to prevent them in the first place.

A bedsore is caused by pressure on an area having a bony prominence with a thin covering of flesh, explains Edward H. Comfort, PhD, executive director of the National Decubitus Foundation. This would likely happen on areas such as the tailbone, heels, elbows, hip socket, and shoulder blades. “The pressure exerted can be far greater than that required to drive blood through capillaries,” says Comfort. “When this pressure is maintained for a matter of hours, the occlusion of the blood flow can result in the death of the tissue and necrosis sets in.”

Because all it takes for an ulcer to form is pressure caused by a bony prominence in contact with a bed for a matter of hours, it’s often asked why healthy or younger individuals wouldn’t develop pressure ulcers while they sleep. “Studies have shown that a healthy person shifts position while sleeping an average of every 15 minutes,” Comfort explains. “That’s why it’s the patient who either does not sense the discomfort or is too weak or ill to move that develops these wounds. Most victims are in their 70s or 80s.”

While those with paralysis may be at the highest risk of developing such ulcers, elders who are bedridden, confined to a wheelchair, or are unable to change positions on their own are at risk. It’s estimated that 2 million Americans suffer from pressure ulcers each year. While the Centers for Disease Control and Prevention does not keep a record of decubitus fatalities, they certainly do occur. Former actor Christopher Reeve died of a pressure ulcer infection in 2004 following years of paralysis.

In addition to immobility issues, older adults are at higher risk because of their thinner and more fragile skin as well as other underlying conditions that prolong the healing process, says Zachary J. Palace, MD, FACP, CMD, medical director of The Hebrew Home at Riverdale in New York. “Other conditions can have an impact on the bedsore,” he explains. “For instance, patients with anemia heal a lot slower because their hemoglobin is low and carrying less oxygen to the tissue. In another case, patients with diabetes also may have trouble healing, as the effect of high blood sugars slows down the healing process as well. As it is, bedsores heal slowly, even in a person who doesn’t have other conditions.”

Pressure ulcers are classified in stages 1 through 4, based on their severity. A pressure ulcer is considered to be in the first stage when its presence is initially acknowledged, says Laura E. Edsberg, PhD, director of the Center for Wound Healing Research and the Natural & Health Sciences Research Center, assistant professor in the natural sciences department at Daemen College in Amherst, N.Y., and president of the National Pressure Ulcer Advisory Panel (NPUAP). “Stage 1 may just look like unrelieved redness,” she explains. “Stage 4 is an actual hole and you can see bone. That’s incredibly serious if it’s gotten that far.”

In stage 4, the ulcer is so deep that there is actually damage to the surrounding muscle and bone. Tendons and joints can also be damaged in this stage and infection can occur. If a pressure ulcer becomes infected, it heals more slowly and puts the patient at risk for the infection to spread to other areas of the body. It’s important that pressure ulcers are discovered in their very early stages and treated effectively because they can progress rather quickly, Palace advises. “It can be a very long road toward recovery as the underlying reason these often develop is immobility and that’s not something that often changes,” he says. “They do ultimately heal, but it’s a very long process.”

Prevention Is Key
Preventing pressure ulcers is critical because they are easier to avoid than to treat. The Braden Scale can be an effective assessment tool for patients at risk of developing these ulcers. “Under the Braden Scale, patients are evaluated on six factors: sensory perception, moisture, activity, mobility, nutrition, and friction and shear,” says Comfort. “So those unable to respond to discomfort, suffering from incontinence, confined to bed, unable to shift body position, not eating well, and unable to be moved without dragging are at the greatest risk.”

The National Decubitus Foundation (NDF) has developed a prevention protocol that is described in the Foundation’s research paper Reducing Pressure Ulcer Incidence through Braden Scale Risk Assessment and Support Surface Use, published in the July 2008 issue of Advances in Skin & Wound Care. “Our study identified the few hospitals that had actually been able to achieve lower incidence rates,” says Comfort. “We found what they had in common was a policy of evaluating all admitted patients for risk using the Braden Scale, followed by provision of a special pressure redistribution bed for all at-risk patients.

“Realization that most, if not all, pressure wounds have their origin in deep tissue explains why the practice of providing specialty support surface only after the appearance of stage 1 or stage 2 indicators, followed by most hospitals, has so often met with failure. The only policy with any hope for success must include the provision of these support surfaces to all at-risk patients at admission. Our paper demonstrates that such a policy does substantially and meaningfully reduce pressure ulcer incidence in hospitals,” he says.

With a grant from the Christopher and Dana Reeve Foundation, the NDF was able to distribute copies of this study to every acute-care hospital with more than 125 beds and to the public health departments in each state. As a result, New Jersey mandated that every nursing home in the state must replace all inner-spring mattresses with beds having special pressure redistribution surfaces within the next three years. Comfort is hopeful that other states will follow suit.

Recently, United Health Services, which operates Binghamton General and Wilson hospitals in New York, avoided the development of pressure ulcers in patients at both hospitals in the last quarter of 2009 following NDF protocol, and is making a substantial investment in new pressure redistribution support surfaces. “We do not know that these developments were a direct result of our study, but they do show that this protocol has great promise,” says Comfort.

Another study, published in The Journal of the American Geriatrics Society in 2007, found that a team approach—encompassing everyone from nurses to nutritionists and even laundry workers and beauticians—may bring the most success in preventing these ulcers from occurring. The study involved 52 nursing homes across the country and found that a team effort reduced the number of severe ulcers acquired in-house by 69%. For instance, at Lutheran Home in Fort Wayne, Ind., laundry workers noticed that some clothing fit poorly and restricted the skin. In the same facility, the in-house beauty shop recognized the need to decrease waiting times so residents weren’t sitting for extended periods. Beauticians also realized that residents may require repositioning, even while getting their hair done.

At David Place, a nursing home in David City, Neb., the staff was diligent about assessing risk factors and documenting care. This ultimately led to fewer bedsore occurrences because high-risk patients were treated accordingly. For instance, those who were at high risk were scheduled to be the last up for meals and the first down after meals so they were not in their wheelchairs for extended periods of time. In addition, residents at a higher risk of weight loss were served meals on yellow plates so that staff members were reminded to encourage these patients to eat more.

Taking Action
Caregivers or other practitioners working with elders can help prevent these ulcers from occurring in the first place. If a patient is being admitted to a hospital or a nursing home, caregivers should become their advocates by ensuring they are properly assessed for risk factors. If elders are at higher risk for developing an ulcer, make sure they are provided with the best support surface to address their needs. Cushioning should be placed between the patient’s legs and ankles to maintain alignment and prevent bony prominences from touching. According to the NPUAP, commercially available pressure-reducing mattresses include foam, static air, alternating air, gel, and water.

Inquire whether one of these types of support surfaces is available. Some patients may also need support surfaces with greater ability to reduce pressure, shear friction, and moisture, which could include products with low air loss or air-fluidized support surfaces. Those who are confined to wheelchairs or seated for long periods of time also require proper seating surfaces that will reduce pressure while offering stability and support. Donut cushions can actually cause tissue ischemia, so patients requiring seated support should speak to their doctors about other options.

When older adults are admitted to a hospital or a nursing home, caregivers should inquire how often patients will be repositioned, Edsberg says. She suggests ascertaining the facility’s policy on repositioning. “It’s recommended that the patient be repositioned every two hours,” she says. “Caregivers might want to consider being proactive in enforcing this by setting a timer in the patient’s room so that it’s not forgotten.”

Also, caregivers and family members must take the time to personally check a patient for ulcers. Though the hospital or nursing home staff should already be doing this, such facilities are busy places, and the task may not be performed frequently enough or may be overlooked completely. Considering that it takes only a matter of hours for an ulcer to begin forming, it’s a situation that requires constant attention. Nutrition considerations play a role in pressure ulcers’ formation. Protein and adequate amounts of calories and nutrients are vital, says Edsberg. If patients aren’t eating enough food or are experiencing weight loss, they are at increased risk for developing decubitus. This may mean adopting special nutritional considerations for certain patients, including assistance with meals (eg, opening food containers or repositioning the bed so that elders can eat more easily) or switching to a soft-foods diet to ensure they are eating enough. As part of the Braden Scale, it’s important to assess whether nutrition meets individual needs. Nutrition also plays a role in healing existing sores. If patients are not consuming enough calories, protein, and nutrients—particularly vitamin C and zinc—their bodies will not be able to heal.

Taking good care of the skin is also important in preventing pressure ulcers, as healthy skin is less likely to be damaged. Take note of whether older adults are independently caring for their skin properly. The skin should be kept clean and dry: Washing with mild soap and warm water is a must, and skin should be cleaned as soon as it is soiled. Moisturizers should be applied to help prevent skin from getting too dry.

Practitioners should be proactive in preventing and treating bedsores. When looking for ulcers, the very first noticeable indicator would be redness and warmth in the area, says Edsberg. “If you reposition the person and the redness is still there, even after relief of pressure from that spot, then it’s likely an ulcer in stage I,” she says. “If you’ve found a stage I ulcer forming, you should avoid any pressure being put on that area at all. This is no easy task and can certainly be a challenge. If it’s on the sacrum, for instance, then it’s a case where the person cannot sit on it and a solution will have to be found so that the person can still be comfortable.”

When bedsores do occur, removing the pressure from that location is the first step, says Palace. This will help reverse the process and prevent recurrence. “Then it largely comes down to wound care,” he says. “Keeping the area clean and free of infection is important. If the area is dry, keep the wound bed moist. If it’s too moist, then use dressings that will absorb some of that discharge. You want an environment that will encourage new cells to grow.”

Caregivers should also ensure that pain is well managed. “No patient should have to deal with pain associated with wound care, as it can be managed,” Palace says. “We treat the patient with the medication that is appropriate for their condition, at least a half hour before wound care occurs. For some that may just be Tylenol. For others, it might involve a stronger pain killer like Percocet.”

Even with a variety of factors taken into consideration and preventive measures being exercised, it’s basic care that makes the biggest difference. Repositioning and relieving pressure is key to both preventing new pressure ulcers and healing existing ones. “The bottom line is that the most important thing—no matter what else you’re doing to help the patient—is to get the pressure off,” says Edsberg. “If you don’t get the pressure off of a spot where you’ve found an ulcer or the start of one, nothing else you do is going to help. When it comes to pressure ulcers, there’s no magic bullet. Success comes down to the most basic care—repositioning the person regularly and, if they do have an ulcer forming, keeping the pressure off completely.”

— Lindsey Getz is a freelance writer based in Royersford, Pa.


Provider Perspective
• On admission to a hospital or nursing home, assess older adults’ risk for pressure ulcers.
• Provide adequate support surfaces to minimize the possibility of bedsore formation.
• Reposition older adults frequently to reduce the potential for bedsores or decrease pressure on existing ones.
• Ensure sufficient nutrients and hydration for elders suffering from bedsores.
• Keep elders’ skin clean and dry. Use moisturizers if indicated.


Post It!           
The National Decubitus Foundation suggests that the caregivers, physicians, families, and others involved with a patient being admitted to a hospital or nursing home help take an active role in preventing pressure ulcers from happening in the first place. They’d like to see the following warning posted in all facilities. It’s also available on their webpage for printing: