Pressure Ulcers in Elderly Hospital Patients: Prevention & Care

Introduction

Pressure ulcers are potentially fatal skin lesions that develop especially in frail, elderly patients on bony or cartilaginous areas such as the sacrum, elbows, and ankles. Within acute care in the United States, the incidence of pressure ulcers lies between 0.4% and 38%. The incidence within long-term and home care is significantly lower, while intensive care units report that 8% to 40% of ICU patients develop pressure ulcers during their hospital stay (Cuddigan, Berlowitz & Ayello, 2001). An epidemiological study of pressure ulcers reports that hospital-acquired pressure ulcers cost the U.S. $2.2 to $3.6 billion per year as of 1999 (Vandenkerkhof, Friedberg & Harrison, 2011).

These statistics carry important implications for guidelines on the identification and treatment of pressure ulcers in the United States. Given the complexity of the medical system, the application of Jean Watson's Theory of Nursing Caring and the developing role of the nurse practitioner may play a vital role in preventing pressure ulcers and improving care for patients.

Literature Review

Growing evidence suggests that many pressure ulcers begin to develop after only a few hours of immobility-induced pressure. In response to this observation, Baumgarten et al. examined the incidence of hospital-acquired pressure ulcers in the first two days of a hospital stay and identified common patient characteristics associated with higher incidence (2006). The authors examined patients using standardized diagnostic criteria and classified pressure ulcers as preexisting, possibly hospital-acquired, or definitely hospital-acquired. The overall incidence of pressure ulcers in patients examined after two days in the hospital was 6.2%. The findings show strong, statistically significant associations between pressure ulcer incidence and patients needing help to turn in bed, living in nursing homes before hospitalization, being hospitalized in the previous six months, having a BMI of less than 18.5, being at risk for nutrition-related complications, and experiencing moisture due to urinary and fecal incontinence.

In a related study, Baumgarten et al. examined the extrinsic risk factors for pressure ulcers early in the hospital stay (2008). Based on the understanding that treatment in the emergency department of acute care facilities is often associated with lengthy waiting times—and thus increased risk for developing pressure ulcers—the authors aimed to identify the impact of extrinsic factors of care such as length of emergency department stay, night or weekend admission, and potentially immobilizing procedures. The findings show that an ICU stay is associated with a twofold increase in the likelihood of developing at least one possibly or definitely hospital-acquired pressure ulcer. One proposed explanation for this association is that regular repositioning of the patient, a standard prevention technique, may be difficult in ICU patients due to its impact on hemodynamic stability and ventilator management.

Responding to conflicting evidence regarding body mass index and its association with pressure ulcers, Compher and colleagues conducted a study examining the influence of obesity on the incidence of pressure ulcers in elderly hospitalized patients (Compher, Kinosian, Ratcliffe & Baumgarten, 2007). The findings suggest that extra body fat reduces the risk of pressure ulcers in elderly patients when compared to underweight and optimally-weight patients. Conversely, patients who were underweight had a significantly higher risk of developing pressure ulcers in the hospital.

Rigor Analysis and Theoretical Framework of Research

Extensive research has been conducted on pressure ulcers. One limitation of these studies is the heavy reliance on subjective diagnostic procedures. Nurses are most frequently recruited to evaluate the presence and extent of pressure ulcers in study subjects. Differences in training and personal judgment can naturally introduce a degree of variability in pressure ulcer diagnoses. Many studies conduct inter-rater variability testing to enhance the quality and consistency of the diagnoses. In the studies cited from Baumgarten et al., the sensitivity and specificity of the research nurses' diagnostic ascertainment of pressure ulcers from digital photographs was 97% (Baumgarten et al., 2006). Such analyses were cited in many, but not all, studies encountered in the literature review on pressure ulcers.

Another limitation of observation-based studies—and specifically of studies on pressure ulcers—is the determination of pressure ulcer onset. One important implication for these studies is the distinction between preexisting pressure ulcers and hospital-acquired pressure ulcers. In order to study the development of pressure ulcers early in a patient's hospital stay, patient examinations were consistently performed on admission and again on the third or fourth day of hospitalization. This was done to ensure that the risk interval was long enough for pressure ulcers initiated early in the hospital stay to become clinically apparent, but short enough that observed pressure ulcers were not preexisting ones (Baumgarten et al., 2008). Most studies employ a convenience sample and therefore fail to achieve a cross-sectional study population. However, the methodology—which seeks to eliminate all confounding variables, including comorbid diseases that may influence the development of pressure ulcers—is rigorously enforced.

Most studies on pressure ulcers are predicated on the theoretical assumption that greater focus on the identification of pressure ulcers early in a patient's hospitalization can lead to prevention, improve the patient's quality of life, and reduce medical costs. The theoretical framework for studying pressure ulcers appears to revolve around preventative measures. The theory that emerges from these studies is that pressure ulcers are a natural product of immobility in the elderly, and that research should be targeted toward identifying the risk factors and prevention techniques that can delay or minimize the incidence of these skin lesions. This rationale is reasonable for the goals of any medical clinic—that is, to improve patient outcomes and limit preventable medical costs. The studies by Baumgarten and Compher cited above operate under this theoretical framework.

The evidence across studies is generally consistent and yields a reasonable level of confidence. Pressure ulcers are consistently associated with longer hospital stays—especially in the intensive care unit—with reduced mobility, poor dietary health, and urinary and fecal incontinence. Obesity was frequently cited as a protective factor. The rigor of the studies is high, and each consistently identifies major limitations and restrictions of the methodology. The studies offer different interpretations of the data and tentatively declare general outcomes. The consistency across studies validates the evidence and strengthens the credibility of each individual study. The primary underlying implication to emerge from the literature review—the one most pertinent to the role of the nurse practitioner—is that pressure ulcer treatment relies on prevention and extensive monitoring of the patient.

Conclusion

The incidence of pressure ulcers in the U.S. healthcare system remains high. They significantly increase the cost of hospital stays and can often be fatal to a frail, elderly patient. The overload and extreme financial pressure on many healthcare organizations undermines the extensive monitoring required for patients at risk for pressure ulcers. Early detection can be improved by raising awareness of risk factors, which include low body mass index, immobility, dry skin, and poor nutritional status. System-wide implementation of the PUSH diagnostic tool and greater staffing that enables an advanced practice nurse to give personal attention to each patient can improve preventative treatment of pressure ulcers and overall patient outcomes.

References

Baumgarten, M., Margolis, D.J., Localio, A.R., Kagan, S.H., et al. (2006). Pressure ulcers among elderly patients early in the hospital stay. The Journals of Gerontology, 61(7), 749–754.

Baumgarten, M., Margolis, D.J., Localio, A.R., Kagan, S.H., Lowe, R.A., Kinosian, B., Abbuhl, S.B., Kavesh, W., Holmes, J.H., Ruffin, A., Mehari, T., et al. (2008). Extrinsic risk factors for pressure ulcers early in the hospital stay: A nested case-control study. The Journals of Gerontology, 63(4), 408–413.

Cara, C. (2003). Continuing education: A pragmatic view of Jean Watson's caring theory. International Journal of Human Caring, 7(3), 51–61.

Clegg, A., Bradley, M., Smith, P., & Kirk, Z. (2006). Developing the nurse's role in the care of older people. Nursing Older People, 18(5), 26–30.

Compher, C., Kinosian, B.P., Ratcliffe, S.J., & Baumgarten, M. (2007). Obesity reduces the risk of pressure ulcers in elderly hospitalized patients. The Journals of Gerontology, 62(11), 1310–1320.

Cuddigan, J., Berlowitz, D.R., & Ayello, E.A. (2001). Pressure ulcers in America: Prevalence, incidence, and implications for the future: An executive summary of the National Pressure Ulcer Advisory Panel monograph. Advances in Skin & Wound Care, 14(4), 208–215.

Gardner, S.E., Frantz, R.A., Bergquist, S., & Shin, C.D. (2005). A prospective study of the Pressure Ulcer Scale for Healing (PUSH). The Journals of Gerontology, 60(1), 93–97.

Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. (2000). To err is human: Building a safer health system. Institute of Medicine Committee on Quality of Health Care in America.

Schroeder, J.L. (2008). Acute care nurse practitioner: An advanced practice role for RN first assistants. Association of Operating Room Nurses, 87(6), 1205–1215.

Sergi, G., Coin, A., Mulone, S., Castegnaro, E., et al. (2007). Resting energy expenditure and body composition in bedridden institutionalized elderly women with advanced-stage pressure sores. The Journals of Gerontology, 62(3), 317–322.

Vandenkerkhof, E.G., Friedberg, E., & Harrison, M.B. (2011). Prevalence and risk of pressure ulcers in acute care following implementation of practice guidelines: Annual pressure ulcer prevalence census 1994–2008. Journal of Healthcare Quality [Epub ahead of print].