Pressure Sores

A pressure sore is an area of skin and/or tissue that becomes damaged due to prolonged pressure on an area, generally occurring when a person is in a sitting or lying in a position for too long without shifting his or her weight. Multiple factors including debility and malnutrition predispose, but it is generally avoidable with careful and skilled nursing. It is called a pressure ulcer when it fails to heal in a reasonably short period of time which should occur in minor cases when the area is protected from further pressure and properly dressed.

Constant pressure against the skin causes a decreased blood supply to that area. Without a blood supply, the area cannot survive and the affected tissue dies leaving an ulcer. Perfection in care is not always attainable and there will probably always be a low incidence of pressure injuries and ulcers, but their incidence is a reflection of the number and skills of staffing.

Pressure sores cause extensive suffering and premature deaths from sepsis. They are hard to miss as hopefully every resident is washed or showered. When pressure sores are detected early and treated effectively, the serious Level 3 and 4 ulcers are preventable.

Pressure ulcers can take a long time to heal and can leave a weakened area. The wound can be painful, destroy tissue, fat, muscle and can lead to death. Pressure as small as 60 mm Hg. to a body surface for 1-2 hours initiates the process of skin breakdown. Shear, friction, moisture and chemical irritants exacerbate the process. Occasionally plastic surgery is required to bring in undamaged tissue.

A 2-hour time frame is a generally accepted maximum interval that the tissue can tolerate pressure without damage. A patient who cannot change position without assistance should be turned and repositioned at least every two hours, more frequently if needed, with the use of pillows as support.

The Minister, the data, and the Better Practice Conference (Oct 2017)

The problems with data and transparency were illustrated by the difficulty the Minister's office had when Aged Care Crisis queried the vast differences in the prevalence of pressure injuries incidence of 32% quoted in the Minister’s speech (video below) to an industry related audience - nearly three times more than the published figure of 10.3% given to citizens published via the media hub.

The more accurate and apparently most recent 32% figure was never publicly proclaimed and a different, much lower figure of 10.3% was published instead. After we highlighted the differences and asked for clarification, even this figure was removed from the speech transcript.  The Minister and his staff with all their resources, were not able to tell us where the 10.3% figure given to the public came from. 

When we pressed for the source of the Minister's data, we were pointed to figures that were more than 20 years out of date - different statistics again, 3.4% and 5.4% (average of 4.4%), derived from studies prior to policy changes and the introduction of the Aged Care Act in 1997. 

We suspect that the figures were reduced and then reduced again at the insistence of the government's PR experts, who do not understand the significance of what they are doing.

It is because people now realise that this is happening, that there is so much disillusionment with politics.  It is little wonder that citizens have lost all faith when the creation of a positive image is so dominant that the accuracy of the information they are given is compromised.

The problem here is much more than just the incidence of pressure injuries.  It illustrates the way aged care policy has been developed and managed in the past.  

The real problem here is that none of us, even the Minister responsible for making aged care policy and his Senior Adviser, have any accurate recent data on what the incidence of pressure injuries is.  They are using dated figures that range from 3% to 46% for a complication that has been a marker of poor nursing for as long as some of us can remember – at least 60 years!

In contrast, the USA continuously monitors the incidents of pressure injuries in 15,000 nursing homes and updates them regularly (average 6%).

Pressure injuries in hospitals

In hospitals where many patients may be anaesthetized, paralysed, ventilated, and given pain relief, increasing the risk, the incidences of pressure injuries are taken very seriously.

In Queensland, Pressure Injuries (PI) are classified as an ‘adverse event’ that incurs funding penalties of $30,000 and $50,000 for the more serious injuries[1]. By improving nursing care and allowing nurses who do have knowledge and experience to drive the process the incidence of hospital acquired pressure injuries has been reduced - in some hospitals by over a third.

Aged care has looked the other way.

[1]   Miles SJ et al Decreasing pressure injury prevalence in an Australian general hospital: a 10-year reviewWound Practice and Research Volume 21 Number 4 – November 2013 pages 148-56

FAQs

Where do pressure sores appear?: The most common places for pressure injuries are over bony prominences (bones close to the skin), such as the elbow, heels, hips, ankles, shoulders, back, coccys/tailbone, and the back of the head.

Who's at risk of acquiring a pressure sore?: Anyone who must stay in a bed, chair or wheelchair because of illness or injury, or who cannot change position without help is at high risk.

Why are seniors more vulnerable to this deadly medical condition?: In a nursing home setting, having enough skilled staff on hand to reposition residents can be difficult in the absence of federal legislation which lacks staffing levels or skills in aged care. The use of restraints on residents and/or the lack of incontinence rehabilitation compound the problem.

Seniors are particularly vulnerable because their skin usually becomes thinner and more fragile with age.

How long does it take to happen?: Pressure sores can develop in a matter of hours.

Pressure injury stages

Stage 1: The skin is intact but shows a persistent pink or red area that does not turn white when you press it with your finger. The wound may look like a mild sunburn. The affected skin may be tender, painful or itchy. It may feel warm, spongy or firm to the touch.

The wound is superficial and heals spontaneously when pressure is relieved.

A Stage 1 pressure sore is an early warning of a problem and a signal to take preventive action.

Stage 2: The skin starts to breakdown and there is partial thickness skin loss. The wound looks like an abrasion, a blister (broken or unbroken) or a shallow crater.

The skin outer layer is broken, red and painful.

Surrounding tissues may show areas of pale, red or purple discoloration. Some swelling and/or oozing may be present.

The wound is no longer superficial and the ulcer is an open sore that does not extend through the full thickness of the skin.

A Stage 2 pressure sore can usually be treated successfully. With quick attention, the wound can heal rapidly.

Stage 3: The skin has broken down and the wound now extends through all layers of the skin. The sore has become a crater involving damage or necrosis of subcutaneous tissues.

The pressure sore has become deeper and very difficult to heal. At this stage, a large percentage of patients may require treatment of up to one year. The wound is now a primary site for a serious infection to occur.

Stage 4: There is full-thickness skin loss with extension beyond the deep fascia and involvement of muscle, underlying organs, bone, and tendon or joint space. This deep open wound may show blackened tissue called eschar.

The decubitus ulcer is now extremely deep, having gone through the muscle layers and now involving underlying organs and bone. Surgical removal of the necrotic or decayed tissue is often used on wounds of larger diameter. Surgery is the normal course of treatment.

The wound is very serious and can produce a life threatening infection, especially if not treated aggressively.