Bed sores aren't always a sign of negligent care

Until recently, most experts believed that bed sores were an unambiguous indicator of bad care. With frequent turnings, skin care, and good nutrition, the thinking went, these painful and deadly pressure sores that commonly occur on the buttocks and heels could be eliminated almost entirely.

The sentiment was so strong that numerous nursing homes paid large legal settlements to families of patients who developed the sores, also known as pressure ulcers, under their care. Some nursing home administrators even ended up in prison. But new research is challenging this notion.

"At least some pressure ulcers are unavoidable," said Dr. Dan Berlowitz, a professor of medicine at the Boston University School of Medicine. "Sometimes pressure ulcers can simply be an indicator that the patient is very sick."

The shift is due to advances in the understanding of how pressure ulcers -- which affect roughly 11 percent of hospitalized patients and 23 percent of patients in nursing homes -- occur. Most experts now believe that these ulcers develop not only as a result of lying in the same position for hours at a time but also because of a malfunctioning of the blood vessels that supply the skin and underlying tissue.

"We know that many sick patients have poor blood flow to organs such as the brain and kidneys," said Berlowitz, also director of the VA Center for Health Quality, Outcomes and Economic Research. "It makes sense that the same would also be true of the skin."

After a healthy person puts pressure on the skin for an extended period of time, blood flow increases dramatically as soon as the pressure is relieved. For example, blood rushes to the buttocks immediately after a long car ride, bringing oxygen and glucose to nutrient-deprived tissues.

This response seems to fail in many sick patients, however. As a result, even when patients are repositioned in bed frequently, some -- like the late actor Christopher Reeve who presumably received the best of care and yet died from an infection resulting from a bedsore -- still develop pressure ulcers.

The impairment in blood flow seems to involve tissue underneath the skin as well. Increasingly, researchers are recognizing that many pressure ulcers actually develop below the surface, making them almost impossible to detect before it's too late.

Even in research studies in which all available preventive strategies are used, a substantial number of patients still develop ulcers. A 2006 study published in The British Medical Journal, for example, found that approximately 10 percent of hospitalized patients over the age of 55 who slept on a specialized mattress that minimizes pressure on the buttocks developed ulcers anyway.

Which ulcers are unavoidable and which are the result of negligent care is not always clear, but according to Berlowitz, those that develop during or shortly after a major illness are often unavoidable, while those that develop in stable nursing home patients probably represent a "quality issue." Additionally, for reasons that are not entirely clear, many pressure ulcers in patients with spinal cord injuries, like Reeve, may also be unavoidable.

In patients who don't have spinal cord injuries and aren't acutely ill, there's a lot that can be done to reduce the risk of developing pressure ulcers and prevent their complications -- which include blood stream infections, infections of the underlying bone, and intractable pain.

One of the most important preventive measures is repositioning patients in bed frequently, according to Joyce Black, an associate professor of nursing at the University of Nebraska Medical Center and the president of the National Pressure Ulcer Advisory Panel.

"Turning patients every two hours is a tremendous amount of work, but it is very important," Black said. "It can be difficult for nursing staff to get around to everyone every two hours, but that's what we have to do."

Many experts also believe that adequate nutrition -- in particular a high-protein diet -- is essential for lowering the rates of pressure ulcers. "When family members can be present during meal time it makes a big difference," Black said. "The more they encourage their loved one to eat, the better off they are in all aspects of their health."

Finally, Black said, all facilities should have specific guidelines for treating pressure ulcers when they do occur. Topical creams, antibiotic ointments, and frequent dressing changes can help wounds heal more quickly and lower the rate of infections. Appropriate pain management is essential, she said.

Although many hospitals and nursing facilities have instituted these measures, pressure ulcers are a growing concern. According to data from the Agency for Healthcare Research and Quality, the number of pressure ulcers in US hospitals increased by 63 percent between 1993 and 2003.

Most of this increase may be attributable to an aging population. However, a lack of awareness among doctors may be contributing as well.

"Overall, physician knowledge of pressure ulcers is not particularly high," Berlowitz said. "It's not taught in medical school, and yet doctors are supposed to know about it."