General profile of pressure

sores
Ashwani Gupta, Jiten Jaipuria
Department of General Surgery
V.M.M.C. and Safdarjung Hospital
Pressure sores-The devil within
the care….the problem profile
∗ Surprise Surprise !!!!!!–
 The Agency for Health Research and Quality
(AHRQ)
 recently released a survey showing a 63%
increase in
 pressure ulcer occurrence in acute care
hospitals from ```1993 to 2003’’’ (Russo,
2006)


WHY???? WHAT WENT WRONG?????......can



you guess…. Lessons from history....answer

towards the end of discussion
Problem statement contd…

In a review of 218 research articles (Lyder, 2002),

it was reported the cost of treatment to range from
$500 to $40,000 per ulcer and that a single
hospital stay due to a pressure ulcer often exceeds
$200,000 in costs. These financial considerations
fail to take into account the additional pain and
suffering experienced by the patients.


The Advisory Board Company estimated that

60,000 deaths
each year are associated with complications from

pressure
ulcers (Hiser, 2006; Brem & Lyder, 2004).
 Pressure sores – are they similar across
different settings….the clinical
epidemiological profile
∗ Risk factors for pressure ulcer development and their
profile differ significantly across different health
care scenarios with an underlying common
denominator underscoring the necessity to
understand the pathophysiology of their
development.
∗ In acute care settings the incidence is highly variable-
5% to 15% (some reporting even higher values)
∗ In long term settings the incidence varies between
20% to 33%
∗ In home care settings incidence varies between 0% to
17%
∗ Some wards have reported 0% pressure ulcer rates
for long periods of time!!!!
∗ Some obstetric wards have reported pressure ulcer
rates in excess of 0.2% with a bias towards under
reporting!!!!!
∗ What is gong on?? Why is the risk so variable????
What is the profile of the patient who is at
risk of pressure ulcer develoment
∗ Patients at risk of pressure ulcer development –
PROBLEM AREA 1 –

Traditionally certain patient subgroups have been

considered to be high risk for pressure ulcer

development –
-Elderly

-Those with physical impairments due to a

multitude of causes (neurological deficits, poly

trauma, malignancies, thermal burns etc.)
Traditionally physicians and nurses undertook a

more specific assessment of pressure ulcer

development in only these specific settings often
identifying points for intervention too late when
manifest pressure ulcers emerged.
FORGOT PREVENTION, DIDN’T VALUE

PATHOPHYSIOLOGY
So Finally…. What is the profile
of patient at risk….??
∗ Any patient who is bed fast and or chair fast
should be considered at risk for pressure
ulcer development.*
∗ So don’t harp on the illness in the scenario-
offer screening assessment to all patients
with above risk characteristics – points of
intervention will obviously depend on the
illness in scenario.
∗
∗ *latest NPUAP and EPUAP pressure ulcer prevention guidelines
∗ * Did you realize the pathophysiologic basis underlying this zealous
search ????
Presentation profile of pressure
ulcers-

∗ CAUTION -1
∗ Pressure ulcers take hours to develop but
may take >7 days to manifest.
∗ (what is seen today may be the result of
minor neglect in continuum of patient care
many days ago)
∗ CAUTION -2
∗ Destruction in deeper tissues may be more
than what is apparent on the surface
 OF COURSE NOW WE DECIDED TO ASSESS FOR
RISK…..but IS THERE ANY RISK ASSESSMENT TOOL
WHICH QUANTIFIES THE RISK IN A PARTICULAR CASE
AND IS SAME RISK ASSESSMENT TOOL APPLICABLE TO
ALL PATIENT PROFILES????
∗ THANK YOU 1962 THANK YOU 1987
∗ There have been a multitude of scales available for
researchers which are still being validated across
different clinical scenarios.
∗ But EPUAP and NPUAP have suggested following scales
to be used across different clinical profiles –
∗ GENERAL SURGICAL PATIENT - BRADEN SCALE*
∗ INDIVIDUAL RECEIVING PALLIATIVE CARE - Marie Curie
Centre Hunters Hill Risk Assessment Tool OR
Braden Scale OR Norton Scale.
∗ PEDIATRIC PATIENTS – BRADEN Q SCALE.
∗ ICU PATIENTS – Cubbin Jackson Scale**
∗
∗ **this scale and clinical scenario is not mentioned in the EPUAP and NPUAP clinical
guidelines.
∗ *this scale has also been validated in an ongoing study in similar subset of Indian
patients (163) in Safdarjung Hospital “Assessment of risk factors in
pressure sores-A Tertiary Care Centre Experience”, Chintamani,
Kashish,Aliza mittal, BhatnagarD Department of Surgery, Vardhman Mahavir
Medical College & Safdarjang Hospital, New Delhi
 BRADEN Scale for
predicting pressure sore
SENSORY
risk
Completely Very limited Slightly limited No Impairment score
PERCEPTION limited

MOISTURE Constantly Very Moist Occasionally Rarely Moist

Moist moist
ACTIVITY Bedfast Chairfast Walks Walks
Occasionally Frequently
MOBILITY Completely Very limited Slightly limited No limitation
immobile
NUTRITION Very Poor Probably Adequate Excellent
Inadequate
FRICTION & Problem Potential No apparent
SHEAR Problem Problem
 GREAT…  NOW I WILL USE SCALES, NOW THE
ULCER INCIDENCE WILL BE ZERO !!!
∗ PROBLEM AREA 2 -
∗ Strangely, this will NEVER HAPPEN with this
measure alone –
∗ “There is no decrease in pressure ulcer incidence
was found which might be attributed to use of
an assessment scale.
∗ However, the use of scales increases the
intensity and effectiveness of prevention
interventions” *
∗
∗ Why ??? Further answers in anatomical and
pathophysiological and psychosocial profiles of
pressure sores and the derived prevention and
treatment philosophy.


∗ *PANCORBO-HIDALGO P.L. , GARCIA-FERNANDEZ F.P. , LOPEZ-MEDINA I .M.

 & ALVAREZ-NIETO C. (2006) Journal of Advanced Nursing 54(1), 94–110
 Risk assessment scales for pressure ulcer prevention: a systematic review
FIRSTLY OBVIOUS FACTS
Anatomical profile of pressure
sores
∗ Where do ulcers develop most when a
person is supine –
∗
∗ Where do pressure ulcers develop when a
patient is wheelchair bound –
∗
Anatomical profile of sores…
∗ Which part of body is expected to be most
vulnerable in case of pediatric patients
∗ Which parts of body are expected to be most
vulnerable in case of parturient females.
∗ Be careful to assess while grading pressure sores
in areas where there is little fat. (depth can be
misleading)
∗
∗
∗ GOD HAS HELPED ALREADY (3d anatomical
profile of human anatomy)… CAN YOU
HELP????
 CAN YOU SEE THE BASIC
PHYSICS OF BAD POSITIONING
TECHNIQUES -
∗ What if this patient is turned laterally 90
degrees or what if the head end is raised
∗ Concept of friction and shear forces and role
while transfers and turning (did you know that the
concept of continuing care in pressure ulcer patients in transition from
one point of care to another evolved only recently and is yet to acquire a
common place status )
What if the ergonomics of this
patient in the wheel chair are
altered?
(did you know that guidelines for wheelchair bound patients were first widely
issued as late as in 2007)
Obviously apparent facts from
above data in the presentation
profile
∗ Can you see how patient is vulnerable to multiple bed sores at
the same time.
∗ Actually the average number of bed sores noted over a period
of time in persons susceptible to bed sores is >1 (1.7 in
many studies)
∗ Can you see how effects of nearby areas can alter the
microbiological profile of bacteria found in pressure sores ( E
coli in wounds near the anus) (beta hemolytic streptococci
and coagulase negative staph in wounds over occiput and
other areas). Surprisingly pseudomonas aeruginosa is
infrequently found in pressure ulcers found in Indian studies
(unless cocomitantly diabetes was present) *. Many bacteria
may be present in chronic wounds which may be mere
contaminants and colonisers but not critical colonisers or
infective (how about acinetobacter isolated in non
progressive and slowly healing wounds)
∗
* A Prospective, Descriptive Study to Identify the Microbiological Profile of Chronic
Wounds in Outpatients
Ostomy Wound Management VOLUME: 55 Issue Number:  2009;55(1)

author:  Somprakas Basu, MS; Tetraj Ramchuran Panray, MBBS; Tej Bali Singh, PhD; Anil K.

Gulati, MD; and Vijay K. Shukla, MS, MCh(Wales), FAMS

∗ Can you see how complex issue of psychosocial
status and family support can affect the simple
issue of positioning of the patient.
∗ What if the patient is unable to afford higher end
mattresses. What if he was the sole bread
winner.
∗ What if the patient to bed ratio is too high.
∗ What if the genetic and nutritional profile of the
population in question different from the
western standards.
∗ What if clinical care givers are not following the
recommended guidelines.
∗ What if the quality of nursing care is poor.
∗ What if the patient and attendants are
uneducated and are difficult to initiate into
complex education process of wound
prevention.
∗ What if the patient is too depressed to follow
commands.
∗ WELCOME TO THE GREAT INDIAN SCENARIO
∗ It became clearly apparent to policy makers
upon closer inspection that expensive
mattresses and elaborate scoring systems
alone would give unsatisfactory results if
continuing care philosophy at all points of
health care including home did not include
the comprehensive elements of patient
education and training, health provider
awareness, structured risk assessment,
skin care and appropriately goal directed
interventions including nutritional
interventions.
 Re evaluation of profiles of patients with risk
for/presence of pressure ulcerations in the light of
new understanding

∗ Dictum - 1
∗ “ It is obsolete to think in terms of
preventable and non preventable pressure
ulcerations”
∗ “ All pressure ulcers are now seen as
preventable except in the rare
circumstance of terminally ill patient near
the end of life who refuses nutrition”
 Risk factors common to
patients across all profile
characteristics
 Pressure ulcer characteristics in specific
scenarios – spinal cord injuries and neural
deficits
∗ Annual incidence rates in developed world – 20% to 30%
and prevalence rates 10% to 30% with most common
sites being ischium, sacrum and trochanter.
∗ 25% of pressure ulcers in the community were classified as
severe (Grade 3 or 4).
∗ Other epidemiological studies indicate that 36% to 50% of
persons with SCI who develop pressure ulcers will
subsequently develop another ulcer within 1 year
following initial healing.
∗ Individuals with paraplegia have the highest rate of
 recurrence, estimated at 80% (Wilhelmi &
Neumeister,2002).
∗ Our experience at Safdarjung Hospital (83 patients)–
∗ Patients with polytraumaand spinal cord injury as a group
developed pressure ulcers more commonly than other
group of patients.
∗ Hemiplegics were least prone to develop pressure ulcers
over the duration of hospital stay.
∗ Paraplegic patients constituted the maximum number of
patients in the cohort but were found to develop pressure
ulcers at a rate similar to quadriplegics over the duration
Interesting insight into the behavioral patterns and risk of developing
pressure ulcers once patients with SCI are discharged home

∗ Patients who remain ulcer free perform on an

average 7.8 transfers from the wheelchair as
compared to 4.2 transfers for the patients who
frequently develop ulcers.
∗ Patients who remained ulcer free were more
likely to be found with a positive employment
status.
∗ Finally, each group was asked what self-practices
they believed to be the most important in
preventing serious pressure ulcers. Statistically
significant differences between groups, ps < .
05, were noted for three success factors:
Participants in the ulcer-free group were more
likely to identify general activity level or
“squirming” (shifting in their chair) and
sensation in the buttocks as important success
factors; those in the pressure ulcer group were
more likely to identify frequent skin checks and
What we interestingly found in
our subset of patients at our
hospital
∗ 96.3% of patients enrolled into the study
received “satisfactory physiotherapy” but yet
developed pressure ulcers.*
∗ Most of the physiotherapy in Indian setting was
found to be provided by the relatives.*
∗ It was strangely noted that “54% of the patients
with duration of stay <1 week used waterbeds
as compared to only 27% of patients with
duration more than a week”.
∗ Possible cause – “Wrong emphasis in the advise”,
“bias in the ears hearing the advise” , “right
person not giving the advise”
∗
∗ “Assessment of risk factors in pressure sores-A Tertiary Care Centre
Experience”, Chintamani, Kashish,Aliza mittal, BhatnagarD Department of Surgery,
Vardhman Mahavir Medical College & Safdarjang Hospital, New Delhi

∗
 Overall profile of patients developing
pressure ulcers in a tertiary care hospital
(V.M.M.C. & S.J.H.) in India -
∗ Over 163 patients that were studied data
was showing a heavy gender bias towards
males
∗
 THE AGE AND SEX DISTRIBUTION OF THE
COHORT ( n = 163 )

AGE(YRS)
Mean age = 44.52ears
Range = 7-90years
 Distribution of Cases According to Diagnosis
Patients
No. Of
 *

*Grade 1 – Non blanchable erythema with intact skin .

Grade 2 - Partial thickness skin loss i . e . epidermis is interrupted as
an abrasion , blister or shallow crater .
Grade 3 - Full thickness skin loss involving damage of subcutaneous
tissue that may extend to the underlying fascia .
Grade 4 - Full thickness skin loss with extensive destruction , tissue
necrosis or damage to muscle , bone or supporting structures .
 COMORBID CONDITIONS

(One patient may have more than one

condition)

Patients with comorbid conditions

developed higher grade of
bedsores ( 3 / 4 ).
[Chi Square = 8.34; df = 1; p = 0.0038]
 OBSERVATIONS:
∗ n = 163
∗ Mean Age = 44.52 yrs. , Range - 7 to
90 yrs.
∗ Mean Duration of Hospital Stay = 4.25
Weeks
∗ Mean Time Interval (Between
hospitalization and development of
bedsores ) = 1.88 weeks
∗ 86.53% were anaemic , Average
Hb=9.27gm%
∗ Average Waist Hip Ratio = 0.848(Range
0.7 to 1.2),
 The Braden scale
Assessment
NO . OF PATIENTS

SCALE ( 6 TO 23 )

AVEARGE=13 . 12
 BRADEN SCALE SCORE V/S
PRESSURE SORE GRADE
BRADEN SCALE GRADE 1, 2 GRADE 3, 4
SCORE
>15 13 25

< 15 62 63

The lower the Braden ’ s scale score , the

higher is the risk for developing pressure
sores .
Patients with score < 15 , develop grade 3 , 4
pressure sore more often than those with a
score>15 (chi
square=3.977,df=1,p=0.0461)
 AGE V/S GRADE

AGE
(years)
It was observed that in the age group of 21-40yrs.and 41-60yrs.,
patients more often developed grade 2 /3 bed sores than grade 1/4.No
significant association was found between the age and the grade.
 58
( 31 . 6 %)
105
(68.3%)

54% of the patients with duration of stay <1 week

used waterbeds as compared to only 27% of patients
with duration more than a week.
Patient profile characteristics of patients
developing pressure ulcers in ICU
∗ In addition to the usual risk factors, certain additional risk factors have
been identified –
∗ history of vascular disease
∗ treatment with Dopamine® or Dobutamine®, intermittent haemodialysis
(IHD) or continuous veno-venous haemofiltration (CVVH)
∗ mechanical ventilation.
∗ Also preventive measures were statistically positively associated with
pressure ulcers grade 2-4: turning, floating heels, alternating
mattresses, adequate prevention.*
∗
∗ But some recent studies have concluded that “There is no relationship
between pressure ulcer development and APACHE II score, or any
medication that affects skin integrity. The frequency of turning and
repositioning and patients with an emergency admission to the
ICU/HCU can be the prognostic indicators for developing scoring
system in critical care settings. Relevance to clinical practice”**
∗
∗
∗
∗
∗ *Incidence and risk factors for pressure ulcers in the intensive care unit
Authors: Nijs, Nele; Toppets, Adinda; Defloor, Tom; Bernaerts, Kris; Milisen, Koen; Van Den Berghe,