Pressure injuries the ‘scarlet letter’ of patient care
Linda Murphy visited her mother-in-law regularly at her nursing home, noting she was becoming more isolated as her Alzheimer’s disease advanced. She was already mostly bedridden after breaking both hips in two separate falls. But Murphy never looked at her mother-in-law’s skin.
“I never made a habit of checking her feet or legs,” says Murphy, who lives in Ottawa. “We were just pretty ignorant of all of what could happen.”
So Murphy was stunned when staff from the nursing home called to say they’d sent her mother-in-law in an ambulance to a hospital for an emergency consultation with a surgeon. A raw spot on her heel mentioned earlier that week had suddenly developed into an infected pressure sore.
“The surgeon was very, very blunt,” Murphy remembers. “Her leg had to go. I think you can imagine how that caught us off guard. Not to mention my mother-in-law.”
The surgeon amputated the leg from the knee down to keep the wound from causing further damage.
“The experience after that was pretty brutal,” Murphy says. “With dementia, you don’t understand what’s happened to you and can’t necessarily recall that you’ve had an operation. It was pretty grim for her.”
While Murphy’s mother-in-law represents an extreme case of what can happen, pressure injuries – also called bedsores or pressure ulcers – can be extremely painful. Since they’re caused by prolonged sitting, leaning or lying, they can also be associated with neglect.
“We all felt pretty angry, disappointed, confused,” Murphy says. “Guilty too.”
“It’s the scarlet letter,” says Heather Orsted, director of education and professional development at the Canadian Association of Wound Care, noting that pressure injuries most often strike the healthcare system’s most vulnerable: people who are the sickest, most frail or immobilized.
Putting pressure on prevention
A class action lawsuit served last month against Revera, a Canadian chain of nursing homes, is putting pressure injuries in the spotlight. A statement of claim submitted to court to help certify the suit focuses on a 68-year-old man with Parkinsons who died in June 2014 with an infected pressure injury.
Preventing pressure injuries requires first identifying patients at risk, then finding ways to relieve the pressure, either by frequently turning or repositioning a person or by utilizing a device, like an air mattress or a foam cushion, to help soften the stress on skin.
Clinicians use what’s called the Braden Scale to assess the risk of developing a sore based on:
- a patient’s level of sensation, such as numbness caused by stroke or a total lack of sensation cause by paralysis;
- whether they’re mobile or can walk, stand or turn on their own;
- whether their position means they’re sliding, which can produce chafing;
- whether there is incontinence;
- and a person’s level of nutrition, amongst other factors.
By far the biggest factor for preventing a pressure sore is routinely assessing the skin. “Nobody knows there’s a problem until they lift a sheet,” Orsted says.
But prevention also requires resources – both human and financial. Having to arrange for specialized equipment or turn a patient every two hours can create a heavy burden on nurses or paid caregivers who are already juggling care for 10 to 12 people, says Jonathan Ailon, an internist and palliative care specialist at St. Michael’s Hospital.
“There’s this huge skill set that occupational therapy and physiotherapy can bring to help these patients. We can get them up or moving, we can help them off-load [the pressure] so that they’re still able to participate in everyday life,” says Deirdre O’Sullivan-Drombolis, a physical therapist and wound care resource at Riverside Healthcare in Fort Francis, Ontario.
A dearth of data
A persistent lack of quality data makes it difficult to get a true picture of the extent of the problem.
“Data collection is a huge problem. Hospital coding systems only allow the provider to input information on one wound, so if you have six or seven pressure sores, or even a surgical site, those data never get captured properly,” says Valerie Winberg, president of the Ontario Wound Care Interest Group, a group of interdisciplinary health care professionals who promote wound prevention and treatment.
“The impact of that is huge because wound care is taking up a lot of our healthcare dollars – and not just in institutions,” Winberg says. “Fifty percent of homecare visits are for wounds. A pressure injury can cost more than a heart bypass just because of the long-standing nature of it, if they can even heal it.”
A 2013 Canadian Institutes of Health Information (CIHI) report found that more than 2,800 pressure injuries were reported in Canadian complex continuing care settings, nearly 9,340 in long-term care and more than 2,500 in a home care setting in 2011-2012. One in eight patients are estimated to develop pressure ulcers in acute care.
The authors of the 2013 CIHI report on compromised wounds note that “inadequate documentation, particularly of lower-stage [pressure] ulcers, is common in both nurses’ and doctors’ notes” and suggest this has a negative effect since it reduces the ability to produce an accurate picture of who is at risk for developing pressure injuries.
“It does impact on how institutions or health care facilities or even ministries look at budgeting for managing or preventing these problems,” says Michael Stacey, a vascular surgeon and chair of the research committee for the Canadian Association of Wound Care. “Without having some accurate information, it makes it difficult to appropriately budget preventative strategies, ideally, or treatment strategies.”
But a lack of numbers shouldn’t stop institutions from taking action.
“People know it’s a big issue,” Orsted says.
A ‘never’ event?
Accreditation Canada has also mandated since 2012 that long-term care facilities must outline their process for treating pressure ulcers in what are called Required Organizational Practices.
Last year, the Canadian Patient Safety Institute listed Stage Three and Four pressure ulcers acquired in hospitals as a “never event” – meaning pressure injuries developed in hospital should never get to the stage where a crater in the tissue appears or, worse, where the sores go so deep they harm muscle, bone or tendons.
But there is disagreement as to whether pressure injuries can always be avoided.
The designation came after consultations with clinical leaders, patients and quality and safety leaders, as well as a thorough literature review, says Sandi Kossey, senior director of Strategic Partnerships & Priorities at the Canadian Institute of Patient Safety.
“These things can be prevented for the most part, especially the very serious ones,” she says. “They can be reversed before getting too serious.”
But others say that as a patient’s health declines, the difficulty in preventing pressure injuries goes up. For example, a stroke patient who’s lost the ability to swallow may need to be positioned upright to avoid aspiration pneumonia, but that puts pressure on the tailbone, one of the most common sites for pressure injuries. Some patients may resist turning protocols. Or a palliative patient may resettle into a position that’s most comfortable.
“If you have an unwell person lying in a bed who can hardly move and they’re poorly nourished and not aware of their surroundings, their risk is so high. The care needs to be so good to prevent [pressure injuries], if they can be prevented at all,” Orsted says.
That’s why allied health professionals – occupational or physical therapists, dietitians and wound care specialists – are often included in hospital protocols, and why provincial funding has been made available to support physiotherapists in long-term care facilities.
“In some instances, pressure injuries are not avoidable,” Winberg agrees. “You can do everything right – you can have a pressure relieving surface, you can be maximizing every resource and they’ll still develop a pressure injury because their body is breaking down.”
“Skin is an organ that can fail, just like other organs in the body,” adds Laura Teague, a renowned wound care expert. An aspirational goal of reducing pressure injuries might be more realistic, she says.
“They’re not all preventable. But when we look at what the rates are in different hospitals, there’s definitely an opportunity to reduce that rate,” says Stacey.
See something, say something
Language around “pressure injuries” is changing to reflect that family and caregivers need to be on the watch for more than just ulcers or sores. Heels and elbows are the most susceptible to pressure injuries, which initially appear as redness, like chafing or rawness.
“If you call it a pressure ulcer, people are looking for hole in skin,” Orsted says. But this misses early stage injuries or deep tissue injuries, which look like bruises until they erupt, revealing wounds that have worked down into the tissue before reaching up to the skin.
“If [family members] see something, they should say something,” Orsted says. “Ideally it should be picked up by the [paid] caregiver, but we encourage families to become a partner in care. We really count on caregivers and family members communicating.”
The experience with her mother-in-law made Murphy and her family much more aggressive about her own mother’s care when she too developed a pressure injury.
“It was the size of a quarter when we first noticed it,” she says. “I was pretty determined that this would not go the route that this went with my mother-in-law. We all were. It did deteriorate to a degree. But we were able to get a specialized mattress to help her.” The family also requested visits from a specialized wound care nurse, ordered an air seat for her mother’s wheelchair as well as monitoring to ensure she got more frequent repositioning.
That’s the advice she gives to others who are putting their loved ones into nursing home care: be vigilant and be vocal.
“The occupational therapist would say, have you asked for this, have you asked for that? And I would think: how would I know to ask about that?” Murphy says. “You have to just keep asking and asking and asking for advice on how to be an informed caregiver.”