Once referred to as bed sores, pressure injuries can have a profound impact on health, even leading to death, as well as costing billions of dollars to treat.
Now there is new expert advice on how to prevent and manage them.
By Cathy O’Leary
Pressure injuries usually occur over a bony prominence but may also be related to a medical device or object.
While bed sores were once seen as the domain of the elderly and infirmed, pressure injuries are a potential risk for anyone whose mobility is compromised.
If a person is so unwell or physically disabled that they stop moving for prolonged periods of time, there is a serious risk of pressure injuries.
This includes people with spinal cord injuries, as well as patients of all ages temporarily immobilised or needing to wear monitoring or breathing equipment which causes pressure on the skin.
New guideline for busy doctors
Wounds Australia, which has more than 18,000 stakeholders including doctors, nurses, pharmacists, researchers, allied health and aged care professionals, estimates that each year more than 450,000 Australians are faced with a chronic wound.
It defines chronic wounds as sores that have not progressed through normal healing stages within 30 days. They may heal very slowly, partially or reoccur. Warning signs include pain and heat, odour, excess fluid and excess healing time.
Leg ulcers and pressure sores are the most common types.
The group co-launched the new advice – The Prevention and Management of Pressure Ulcers/Injuries: Clinical Practice Guideline: The International Guideline 4th Ed – in March this year.
Considered the gold standard in evidence-based care for common and costly wounds, the guideline was produced by an international consortium of leading wound experts from more than 40 countries.
Wounds Australia chief executive Jeff Antcliff said the launch represented an important opportunity for healthcare workers and carers to proactively adopt leading practices for preventing and managing pressure injuries.
Pressure injuries affect 13% of the world’s population, causing physical pain and distress to individuals and costing Australian public hospitals $9 billion a year to treat.
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Co-hosts of the guideline launch, Forward Ability Support (FAS), operates Sydney’s Ferguson Lodge, a high-level residential personal and clinical care facility for people living with spinal cord injury.
FAS clinical advisor Dr Dinesh Palipana shared his personal experiences living with quadriplegia. A Gold Coast emergency medicine doctor, he was the first quadriplegic medical intern in Queensland.
While studying medicine at Griffith University, Dr Palipana was in a catastrophic car accident in 2010 which left him paralysed from the chest down.
“I nearly died in that car accident, so I’ve come to learn that life is short,” he said at the launch.
“For a human being, a wound is a huge thing, and if a wound gets out of control, it can stop life for a month, two, three, maybe longer. Some people need surgery, and some people end up in hospital for a long period of time.
“Pressure injuries are not just a physical problem for a person. There can be a life-threatening issue or a limb-threatening issue.
“Guidelines are a critical tool, especially for clinicians to provide good care for their patients, and with this guideline there’s even a quick reference guide for people who are busy.”
WA expert advice
A key speaker at the launch was Curtin University Professor Keryln Carville, who has worked with Silver Chain for 35 years, and is a leading pressure injury expert and chair of guideline co-publisher the Pan Pacific Pressure Injury Alliance.
She noted that insufficient wound care education for primary health and aged care workers in non-metropolitan regions could lead to poorer patient outcomes and higher treatment costs.
Pressure injuries were the number one reported or penalised hospital-acquired complication in public hospitals, but they also impacted on individuals, increasing morbidity and mortality.
Prof Carville told Medical Forum that the new edition of the guideline would offer the most contemporary evidence for prevention and treatment.
“Anybody who has a mobility issue is potentially at risk of pressure injury, so that means anyone for whatever reason who is unable to reposition themselves,” she said.
“That presents challenges for people who have spinal cord injuries, people who are unconscious due to surgery or trauma, or people who have cognitive difficulties such as advanced dementia and are not able to reposition.
“You know yourself that if you sit in a place for too long you can get a numb backside or a tight elbow, so you wriggle to get off that position. That’s the normal physiological response that comes to you day and night, even when you’re sleeping. You probably reposition every 20 or 30 minutes, moving something even slightly.
“But if you’re in a position because of a change in your condition such as trauma, surgery, being under anaesthetic, some cognitive difficulty that affects your mental ability to focus on what you’re doing, then you can’t do that.”
Prof Carville said the change in terminology for pressure injuries over the past 30 years was very deliberate. Australia had led the way in calling them injuries rather than sores or ulcers because it reminded everyone that they were largely preventable.
Not a new phenomenon
Pressure injuries have been around since the ancient Egyptian times, with scientists putting mummies through MRI scanners able to see them.
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“The bed was often perceived to be the problem and if you think about the early 1800s era, particularly around the period time of Florence Nightingale, unless you were extremely wealthy, if you had a mattress it was probably made of horse hair or straw so it was very hard,” Prof Carville said.
“Because the bed was seen as the problem, people did all sorts of things like cut doughnut shapes in the mattress to try to relieve pressure. Today we know that’s the last thing you want to do because you just concentrate pressure outside the doughnut.
“We know that what causes pressure injuries is unrelieved pressure – perpendicular or direct force – but the other thing is shear – parallel – force.
“If you’re sitting on a hard spot and nothing’s relieving it, that’s pressure, but if the person was to be dragged up a chair or slide down a bed or chair then that’s shear.
“And then under the heels you get rubbing where the person moves their heels up and down to reposition in the bed and that’s friction. So, pressure, shear and friction all impact on the skin, and the type of force and duration are important.”
Prof Carville said another critical factor in pressure injury development was a person’s skin tolerance.
“If a person is in good health, they’re well hydrated and nourished and their skin is clean and dry then they’ll be able to tolerate more pressure, shear and friction than if they’re malnourished and in a poor health state, or if their skin is wet because of sweat, or urine or faeces.”
A prevailing belief was that pressure injuries only affected the bed-bound elderly, however they impact across all populations.
“We get pressure injuries in neonates, infants and children but in hospitals they’re related to the devices we use with them, so things like catheters,” she added.
“Neonates, because of their light weight, don’t have so much of a problem with pressure but they have significant pressure injuries because of the devices attached to their skin.
“Often in the frail elderly, whether they be in the community or nursing homes or hospitals, they turn their chairs into their world.
“They often sleep in their chairs, and they have what I call bed clutter – the TV remote, the telephone, the cutlery that they missed from lunch – and they lie on these objects.”
A staged approach
Pressure injuries are now classified according to four stages and two other conditions.
“The first stage is intact skin which is damaged, it’s red, so it’s technically not an ulcer because there’s no break in the skin,” Prof Carville explained.
“With a stage one, when you turn the person over the skin is red, and if you press on it, normal skin blanches, and the skin is still intact. If you get them off that point 50% will resolve, while 50% will go on to become deeper wounds.
“Stage one, which is intact skin, and stage two, which is superficial skin loss, are the most common pressure injuries in Australia, but a large portion go on to become deeper stage three and four, or another condition we call unstageable because it’s covered in dead tissue so we can’t see the depth.”
Prof Carville said that while superficial wounds were more common, they had the potential to become significant wounds that could increase co-morbidities and even lead to death.
“And that’s the reason why we have prevention strategies, first and foremost to do anything we can do to encourage mobility and repositioning, so that could be prompts or asking families in the home or the hospital staff to turn them frequently if they can’t do it themselves.
“Repositioning is number one, but of course you must keep the skin clean and dry, and then you have to make sure they’re well-nourished. Being overweight or underweight can lead to changes in the skin, and that can mean the skin is more vulnerable to pressure shear.”
Education is key
Prof Carville recognised that as more elderly people wanted to stay in their homes, family members were needing to take on some of the role with pressure injury prevention. And staffing constraints in facilities like hospitals and aged care could not be ignored.
“The important thing is that we educate the individual who is potentially affected, and their carers, and we need a good education program for our health professionals too,” she said.
“I teach undergraduate nurses that every time we turn someone, we’re checking their skin and it’s their responsibility to make sure they don’t have any pressure injury or are at risk of injury, such as finding something in the bed that shouldn’t be there, like their phone.”
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Prof Carville said the guideline was research driven and updated about every five years.
The key difference with the latest guideline was that it was a living document that would allow new evidence to be added as it became available rather than waiting for five years.
“The work on this document is quite novel and dynamic, so what we’re saying is yes we have guideline evidence for prevention now, and it’s available across the world for free, but it stays dynamic with the evidence that is constantly emerging from research, and then we have the evaluation on that research.”
Everyone’s responsibility
She added that it was important to keep challenging the notion that pressure injuries were inevitable. While it was often nurses or other staff doing the moving, it was something that doctors needed to be across.
“Every health professional – the physio, the OT, doctors – everyone needs to be aware that a pressure injury is a problem, because with every injury you cannot reposition the person that increases their risk for more pressure injuries.
“So it’s every health practitioner’s goal, I’d like to say responsibility, to stay abreast of the evidence and how best we can intervene to avoid these preventable wounds.
“If you look at the cost – $9 billion spent on pressure injury treatment in public hospitals in Australia in a year – just think what you could do with that money?
“The important message is that prevention is the best cure, and it’s the cheapest cure.”
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