Updated February 29, 2016
Bedsores, also known as pressure ulcers or pressure sores, are a patient safety issue dating back at least to the 19th century and the time of the nursing/public health pioneer Florence Nightingale. Today, the development of bedsores remains a major public health problem, mainly for elderly patients. However, this pervasive and expensive problem is also highly preventable, as long as patients receive proper care, early diagnosis and appropriate treatment.
Bedsores are injuries to the skin and surrounding tissues as the result of a prolonged pressure at one or more locations on the skin. They typically involve some kind of friction or shearing to the skin, likely from the patient sitting or lying in one position for too long or when bedridden and/or confined to a wheel chair. These ulcers are caused by pressure that gets trapped between the bone and a surface, which restricts blood flow and results in skin cells and tissues being damaged and sometimes eventually dying.5
According to the National Pressure Ulcer Advisory Panel (NPUAP) there are four stages of bedsore development:
Stage 1: The skin is red, swollen or sensitive, but the skin is not broken.
Stage 2: The outer layer of skin or dermis is damaged and/or lost with blisters that may rupture.
Stage 3: There is a deep wound that may extend beyond the primary wound.
Stage 4: There is a large loss of tissue and damage beyond the primary wound that exposes muscles, bones and tendons to infection. This stage is very dangerous and life threatening.3,4
In the U.S. alone, bedsores affect approximately 2.5 to 3 million adults annually, with related complications and infections leading to 60,000 deaths a year at a cost of $11 billion.1 One alarming study found that 60% of elderly patients with a diagnosis of pressure ulcers die within one year of discharge from the hospital.2 At this rate, an estimated 160 people a day in the U.S. will die from complications caused by infections due to bedsores, making them one of the most prolific dangers facing a patient today.
AN ESTIMATED 160 PEOPLE A DAY IN THE U.S. WILL DIE FROM COMPLICATIONS CAUSED BY INFECTIONS DUE TO BEDSORES
Bedsores are also a major financial burden on nursing homes, long-term care facilities and hospitals. The Centers for Medicare and Medicaid (CMS) will not reimburse healthcare facilities for the treatment of pressure ulcers that developed after the patient is admitted, as they are classified as “never events.”5 In other words, they never should have happened and CMS is prohibited by federal law from reimbursing healthcare facilities for their treatment. Since the average cost to treat an acute case is over $43,000, this only adds to the seriousness of this long standing public health problem.1 Hospitals, nursing homes and long-term care facilities may also face malpractice lawsuits and/or fines as a result of bedsore infections that are developed post-admission.
Many researchers believe the problem is getting worse due to the aging of the population and an ongoing nursing shortage, along with our continued fragmented healthcare system.
Complications from Bedsores
There are several serious infections from bedsores that can develop in a matter of hours, which is the reason many researchers and wound care experts believe patients at risk should be examined every two hours, 24 hours a day.3, 4
Patients with bedsores who suffer from incontinence can easily become susceptible to sepsis, a life threatening infection caused when bacteria enters the blood stream through broken skin and spreads rapidly through the body, eventually leading to organ failure. Another potential serious complication is cellulitis, which is caused by an infection that spreads to connected soft tissue. Cellulitis can cause severe pain, and it can also lead to life threatening conditions. In addition, elderly patients with bedsores may develop bone and joint conditions, such as osteomyelitis and squamous cell carcinoma, which can lead to chronic and/or life threatening conditions.3
One major global public health question is whether or not bedsores that develop after patient admission into a healthcare facility is a sign of negligent nursing care. Many public health researchers and nursing professionals believe it is and call it “inexcusable.” Florence Nightingale in 1859 stated; “If he (the patient) has a bedsore, it’s generally not the fault of the disease, but of nursing.”2 Another researcher was quoted as saying; “Bedsores are a visible mark of a caregiver’s sin associated with poor or non-existent nursing care.” 2
NURSING PROFESSIONALS BELIEVE IT IS AND CALL IT “INEXCUSABLE.”
Gladys Miller, APN, a former hospital-based nursing supervisor and nursing school professor told me that, “No patient should progress beyond stage one or the initial identification and diagnosis of a bedsore.” When I asked her to react to the Florence Nightingale quote Ms. Miller stated, “It’s true. It really is the result of poor nursing care.”
There very well may be negligence involved in many cases, due to the lack of proper recognition and treatment of bedsores. However, Ms. Miller stated; “It is not because of insensitivity or lack of training on part of the nurse, but rather staffing shortages and nurses being overwhelmed with many patients and other patient care and administrative issues.”
One of the truly alarming things about bedsores is the wide variance of incidence rates of infection within similar healthcare settings. NPUAP research has found a wide-range of bedsore infection rates among hospital patients ranging from 0.4% to 38%. Among skilled nursing home facilities the range was 2.2% to 23.9% and within home health agencies the range was 0% to 17%.4 There are many questions that come to mind from such a wide range of incidence rates including patient- mix adjustment, nurse and staffing ratios, etc. What is known is that the majority of cases occur within the early stages of the admission process, typically within the first two weeks.
Early Diagnosis and Treatment is Key
The good news is that bedsores can be accurately diagnosed and treated in the very early stage of development. Many wound care experts also strongly believe that bedsores should never get past the first stage.
The U.S. Center for Medicare and Medicaid (CMS) recommends nurses consider all risk factors of a patient for bedsore infections and not rely solely on any validation tools or physical examinations they may routinely use.5 In a study by Moore (2002), it was recommended that patients receive a full skin pressure ulcer risk assessment during patient intake.5,6 This will identify predisposing risks to the patient, and healthcare workers can take the proactive step fo regularly moving the patient, or by provided a number of bed sore aides, including as the XSENSOR’s ForeSite PT Patient Turn System, or the Monitor Alert Project which provides a visual representation of areas that are prone to bedsores.7,8
What is known about healthcare facilities with low incidence rates of bedsore infections is that they have three fundamental characteristics in common:
- There is significant management and nursing buy-in and support.
- There is the development of an actual process of integrating risk reports of patients from the moment of admission into their daily quality assurance program.
- There is an internal “Champion.”4
The NHS (United Kingdom) has launched an online initiative (Stop the Pressure) to educate the public and health care sectors on the incidence and dangers of bedsores. As part of their education program, are their “5 Simple Steps to Prevent and Treat Pressure Ulcers” through the SSKIN system9:
S– Surface: Make sure your patients have the right support.
S– Skin Inspection: Early inspection means early detection. Show patients and carers what to look for.
K– Keep your patients moving.
I– Incontinence/Moisture: Your patients need to be clean and dry
N– Nutrition/Hydration: Help Patients have the right diet and plenty of fluids
Through this program, the NHS has already reported a 50% decrease in the development of new ulcers.9
New Technology on the Horizon
In addition to education, a number of companies are developing state of the art technology to combat the incidence of bedsores. To improve awareness, two companies (XSENSOR’s ForeSite PT Patient Turn System, or the Monitor Alert Project) have recently been featured as designing monitoring systems to visually show healthcare workers areas of concern for the development of pressure ulcers. In addition to these integrated mattress monitoring systems, some new companies such as Rubitection (www.rubitection.com) are developing handheld diagnostic devices and software system designed to monitor patients for early detection of bedsores. Being aware of the ulcer prone areas, in conjunction with more education may be the key to eliminating unnecessary pressure ulcers in healthcare environments.
A 2015 systematic review of support surfaces to prevent ulcers evaluated 59 completed and ongoing clinical trials.10 From the study, it was concluded that patients at high risk for the development of pressure ulcers use higher specification foam mattresses as an alternative to standard foam mattresses. The amount and quality of evidence supporting alternating pressure devices was not in complete agreement. However, the use of alternating-pressure mattresses was found to be more cost effective than alternating-pressure overlays.10
Florence Nightingale may very well be pleased.
- Preventing Pressure Ulcers in Hospitals(2014, October). Agency for Healthcare Research and Quality. Accessed February 18, 2016:http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool1.html
- Lyder, Courtney and Ayello, Elizabeth (2008).Pressure Ulcers: A Patient Safety Issue. Patient Safety and Quality: An Evidence-Based Handbook for Nurses, Chapter 12. Accessed February 18, 2016:http://www.ncbi.nlm.nih.gov/books/NBK2650/
- Bedsores (Pressure Sores)(2014, December). Mayo Clinic, Diseases and Conditions. Accessed February 28, 2016:http://www.mayoclinic.org/diseases-conditions/bedsores/basics/definition/con-20030848
- National Pressure Ulcer Advisory Panel. Accessed February 28, 2016:npuap.org
- MooreZ (2002) Wound assessment. Nursing in the Community. 3, 3, 22.
- MooreZ (2004) Have we the tools for assessing risk? The World of Irish Nursing. 12, 3, 39-40. http://www.inmo.ie/tempDocs/Wound%20Care%20Have%20we%20Got%20the%20Tools%20WIN%2012%20%283%29%202004%20Pressure%20sores%202-39+40%20qxd.pdf
- Lim, D. H., Chun, K. J., Hong, J. S., & Choi, H. H. (2015). S. Patent No. 8,984,686. Washington, DC: U.S. Patent and Trademark Office.
- Ajami, S., & Khaleghi, L. (2015). A review on equipped hospital beds with wireless sensor networks for reducing bedsores. Journal of Research in Medical Sciences, 20(10), 1007.
- NHS (2016) Stop the Pressure. Accessed February 26, 2016. http://nhs.stopthepressure.co.uk/http://nhs.stopthepressure.co.uk/
- McInnes, E., Jammali-Blasi, A., Bell-Syer, S. E., Dumville, J. C., Middleton, V., & Cullum, N. (2015). Support surfaces for pressure ulcer prevention.status and date: New search for studies and content updated (no change to conclusions), published in, (9).