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Most bedsores are preventable. Why do they keep happening?

Elderly woman supporting sick husband
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Written by Paul Taylor

Question: My father is in a long-term care home in Ontario. We recently discovered he has a horrible-looking bedsore on his backside. How could this have happened?

Answer: Bedsores, medically known as pressure ulcers or pressure injuries, result from being in one position for too long. They usually develop on a patch of skin that’s located over a bony protrusion such as a hip, tailbone, shoulder blade, or heel.

Medical conditions that limit a person’s ability to move, or feel sensations, increase the risk of such injuries occurring.

The constant pressure of sitting in a wheel chair or lying down, without periodically shifting positions, can inhibit blood flow to a part of the skin – and deprive it of necessary nutrients and oxygen. Eventually, the skin and surrounding tissue become damaged, sometimes resulting in an open sore that’s vulnerable to infection.

However, proper care and support can usually stop a pressure injury from forming – although a lot depends on the underlying condition of the patient, says Dr. Morty Eisenberg, a hospitalist and wound consultant at Sunnybrook Health Sciences Centre in Toronto.

“Skin is an organ. When you are near the end of life, the organs start to fail – and the skin is one that can fail,” explains Dr. Eisenberg, who is also president of Wounds Canada, a non-profit advocacy and educational group.

“So, someone in palliative care, even with the best of treatment, can develop a pressure injury, and it is not anybody’s fault.”

But end of life cases are the exception rather than the rule. “The great majority of pressure ulcers are preventable,” say Dr. Eisenberg. Even so, they continue to happen at a fairly predictable rate to patients in health institutions as well as those receiving care at home.

Each year, more than 3,000 cases are reported at acute-care hospitals across Canada (excluding Quebec), according to patient discharge summaries analyzed by the Canadian Institute for Health Information (CIHI).

Data from other sources have found that about 7 per cent of long-term care patients, 14 per cent of complex-continuing care patients, and 2.4 per cent of home-care patients suffer from pressure injuries, which vary in severity.

These figures don’t represent all cases, says Tracy Johnson, director of emerging issues at CIHI. Some incidents are not documented in ways that can be easily tracked. “But you don’t need an exact number to understand whether you have a problem,” she adds.

Indeed, the general consensus in the medical community is that pressure-injury prevention represents “a huge opportunity for improvement” says Dr. Irfan Dhalla, vice-president of evidence development and standards at Health Quality Ontario (HQO). In other words, we could be doing a better job.

Two years ago, HQO, a provincial government agency with a mandate to improve health care, released Quality Standards for the prevention and treatment of pressure injuries. Although the guidelines are mainly aimed at health-care professionals, they state that patients and their families also need to be properly informed about these wounds.

When patients are sent home from a health-care facility, family members often become the primary care givers. Simply being aware of the risk factors can aid in prevention efforts.

For instance, the likelihood of a getting a bedsore increases with “shear forces” – in which the skin is pulled in a different direction than the bony structures underneath.  This can happen when a patient is propped up in bed and begins to slowly slide into a new position. The surface of the skin may stick to the bed but the underlying tissue is forced downward, raising the risk of injury.

In addition to regularly repositioning the patient, specialized mattresses and cushions can help redistribute pressure away from vulnerable skin areas.  “But there still needs to be vigilance on the part of the care givers,” says Linda Norton, an occupational therapist with expertise in pressure injuries.

“If a wheelchair cushion looks worn or the patient feels something is different, then it may be time to contact the heath-care provider for a re-assessment.”

Good nutrition also plays an important role in safeguarding the skin. “Essentially, nutrition gives us the building blocks of our skin,” explains Ms. Norton. People who enter a health-care facility in a malnourished state face an elevated chance of getting a bedsore.

Pressure injuries vary in severity depending on the level of damage to the skin. In some cases, the skin might simply look red in appearance.  Others, if left untreated, may progress to a deep sore that affects muscle, bone, tendons and ligaments.

Dr. Eisenberg is concerned that some health-care providers may lack the specialized skills needed to properly deal with these complex injuries.  Putting a dressing on the wound isn’t enough, he says. “If you don’t relieve the pressure, it’s not going to go away.”

The Quality Standards produced by HQO also drew attention to the fact that “there are variations in access to services and in the quality of care received by people who have developed or are at risk of developing a pressure injury.”

That means it’s often critically important for family members to be on the lookout for pressure injuries and to communicate their concerns to health-care staff, says Dr. Dhalla.

“Of course, we should not be putting the burden on the family members to make sure the right things are happening. The onus should be on us – the health-care professionals – to provide appropriate care,” he adds.

“But an informed and engaged family will be a better advocate for their loved one than a family who doesn’t even know that a pressure ulcer has developed.”

About the author

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Paul Taylor

Paul Taylor, Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families, relying heavily on medical and health experts. Email your questions to AskPaul@sunnybrook.ca
and follow me on Twitter @epaultaylor