Pressure Ulcers in the Nursing Home Setting

Pressure ulcers, also known as bedsores or decubitus ulcers, are a localized injury to the skin and/or underlying tissues. They are caused by either excessive pressure or a combination of pressure and shearing forces. They most commonly occur over a place in which the bones are near the skin’s surface or where the skin rubs against a medical device or prosthesis.¹

Pressure ulcers currently affect nearly 3 million adults in the United States. They are associated with:

• Decreased quality of life
• Impaired functionality
• Increased cost of care
• Pain
• Disfigurement

Pressure ulcers often lead to complications like:

• Hospitalization
• Infection
• Surgery
• Increased mortality, especially if left untreated²

Pressure ulcers are a persistent problem in nursing home settings. The Agency for Healthcare Research and Quality (AHRQ) estimates a median annual pressure ulcer prevalence of 7.5 percent in nursing homes; other studies estimate that up to 20 percent of nursing home residents have at least one pressure ulcer.³ Pressure ulcers cost approximately $3.3 billion to treat in the US annually.²

Risk Factors

Several risk factors increase a patient’s likelihood of developing a pressure ulcer. These include:

• Increased age
• Cognitive impairment
• Physical impairment
• Medical conditions that affect tissue integrity and healing

Medical conditions that can increase the risk of pressure ulcers include:

• Diabetes
• Urinary incontinence
• Edema
• Impaired microcirculation
• Hypoalbuminemia
• Malnutrition

The National Pressure Injury Advisory Panel (NPIAP) lists four progressive stages for pressure ulcer injuries, along with three alternative classifications for pressure ulcers:

• Stage 1 - Non-blanchable erythema of intact skin
• Stage 2 - Partial-thickness skin loss with exposed dermis
• Stage 3 - Full-thickness skin loss
• Stage 4 - Full-thickness loss of skin and tissue
• Unstageable Pressure Injuries - Obscured full-thickness skin and tissue loss
• Deep Tissue Pressure Injuries - Persistent non-blanchable deep red, maroon, or purple discoloration
• Mucosal Membrane Pressure Injuries⁴

Nursing staff play an integral role in identifying, documenting, and managing pressure ulcers. Recent studies indicate there is room for improvement in nursing staffs’ knowledge of pressure ulcers.

A study of nurses’ knowledge of pressure ulcers between 1995 and 2017 found that nurses scored 51.4 percent on average on a test of their knowledge of facts and management regarding pressure ulcers.⁵

In a UK study of nursing home staff and their knowledge of pressure ulcers, researchers found that several factors affected staff members’ ability to adhere to pressure ulcer prevention guidelines:

• Knowledge of pressure ulcer identification, documentation, and management
• Skills in pressure ulcer identification, documentation, and management
• Social influences
• Available resources of identification, documentation, and management
• Beliefs about the consequences of pressure ulcers
• View of their professional role regarding pressure ulcers
• Beliefs about patients’ capability to address their own pressure ulcers⁶

The AHRQ notes that “nursing home staff have difficulty preventing adverse events [such as pressure ulcers] because clinical information needed to intervene on risk factors is often not easily available. They cannot easily identify residents with increasing risks, or easily assemble the clinical information needed to appropriately intervene before the adverse event occurs.”²

Several types of risk assessments are available to determine whether a patient has a higher-than-average risk of developing pressure ulcers. Available tools include:

• Braden Scale
• Norton Scale
• Waterlow Scale
• Ramstadius Tool (a combination of risk assessment and intervention protocol)
• Machine Learning Algorithms⁷

Even in patients without a higher-than-average risk for pressure ulcers, pressure ulcers can occur if inadequate prevention strategies are used.⁸

Prevention strategies are essential for hospitalized or immobilized patients, especially in a nursing home setting. It is more efficient to prevent pressure ulcers than to treat them after they form.

Current prevention measures vary according to facility resources and patient risk. Generally, recommended prevention measures include:

• Support items that redistribute pressure on the body, such as mattresses, heel supports, and wheelchair cushions designed to adapt to changing pressure patterns.
• Static mattresses/overlays, also known as reactive mattresses and topper, which mold to the body to redistribute pressure across the mattress surface.
• Repositioning, typically every two hours with either a 30- or 90-degree tilt.
• Skin care, including wound care and incontinence hygiene.
• Nutritional supplementation.⁹

Studies indicate that some prevention methods are more effective than others. Studies are mixed regarding the use of static mattresses and overlays, for example: some studies show a lower incidence of pressure ulcers when static mattresses and overlays are used, while others show no statistical significance.¹⁰

Once a pressure ulcer develops, healing rates can be difficult to predict. Patients vary widely in their rate and quality of healing from pressure ulcers. Comorbid conditions like diabetes, obesity, medication intake, and impaired mobility can complicate both the progression of a pressure ulcer and its healing.¹¹

Pressure ulcer treatment costs about $11 billion yearly in the United States. Treatment costs average $37,800 to $70,000 per patient per ulcer.¹²

To treat a pressure ulcer effectively, medical teams need detailed documentation of each wound. Several industry-standard tools exist to help nursing home staff evaluate and document pressure ulcers, including the Bates-Jensen Wound Assessment Tool (BWAT) and the Pressure Ulcer Scale for Healing (PUSH).² Other treatment modalities include interventions to prevent the worsening of the ulcer, to protect the ulcer site, and to promote healing. In some cases, surgical repair is required.

Treatment Delays

Several factors can slow pressure ulcer healing, including:

• Desiccation or excessive drying of the wound
• Infection
• Maceration, a breakdown of the skin’s structural integrity, which can increase the risk of disfigurement
• Necrosis, or the death of tissues subjected to prolonged ulceration
• Pressure, which compromises blood flow to the wound, increasing the risk of infection and slowing healing
• Malnutrition and dehydration
• Trauma and swelling at the wound site¹¹

The presence of other medical conditions that affect healing or mobility can also slow the healing of pressure ulcers.

• Large-scale studies have mixed results indicating whether any particular method of prevention is superior to the others
• Many studies surrounding pressure ulcers are low-powered and vastly heterogenous and not suited for meta-analysis
• Studies on pressure outcomes and delays in treatment are limited

• Clear guidelines exist surrounding the nursing role in the prevention of pressure ulcers.
• Tools are widely available to aid in the implementation of these guidelines, which have proven to increase patient safety and quality of life.
• While not all tools are cost-effective in all settings, tools like the AHRQ’s On-Time program integrate with a facility’s existing electronic medical record system, making them simple and cost-effective to access.

Regulatory Responses

CMS Manual System. Guidance to Surveyors for Long Term Care Facilities. The Centers for Medicare & Medicaid Services (CMS) guide for review of processes and procedures in long term care facilities related to the prevention and treatment of pressure sores.

Agency for Healthcare Research and Quality (AHRQ). Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care.

Legal Research

Medico-legal aspects of pressure sores. A guide to establishing causality for decubitus ulcers from a forensic pathology perspective.

Medico-legal implications. Textbook chapter reviewing medico-legal implication of pressure ulcer development, including charting requirements and quality measurements.

Pressure sores: epidemiology, medico-legal implications and forensic argumentation concerning causality. Study on the frequency and grading of pressure sores and discussion of aspects of forensic argumentation concerning causality.

Assessment of malpractice claims associated with pressure ulcers. A retrospective analysis of pressure sore cases from 1987 to 2019, examining causes of action, plaintiff and defendant demographics, and outcomes.

Evidence for prevention of pressure ulcers: HIGH

• Clear guidelines exist for nursing staff in preventing, documenting, and managing pressure ulcers. A wide range of tools, checklists, and assistance exist to implement prevention guidelines.

Evidence for treatment of pressure ulcers: MODERATE

• While many options exist, data is mixed on which treatment strategies are superior to others. Not all treatment options are effective for all patients. Patients often require treatment via several modalities to achieve optimal outcomes.