Monday, March 7, 2016

Pressure Ulcers: An Underappreciated Public Health Issue

by Jeffrey M Levine MD

As a geriatric fellow back in the 1980's I became intrigued by the wide prevalence of pressure ulcers and how little literature there was on this disease.  Three decades later, they have not gone away and it amazes me that they are not on the list of recognized public health threats.  

According to the Agency for Healthcare Quality and Research, pressure ulcers affect up to 2.5 million patient per year, and related costs range from $9.1 to $11.6 billion per year in the US. Complications include pain, scarring, infection, prolonged rehabilitation, and permanent disability. They are largely preventable, and 60,000 patients die as a direct result of pressure ulcers each year. They are common across the healthcare continuum, and as many as 42% of patients in ICUs and 28% of hospice patients have pressure sores. According to a recent NPUAP monograph, pressure ulcer prevalence in long-term care ranges from 4.1% to 32.2%.  Pressure ulcers are closely associated with the perception of quality, and have become a risk-management burden for practitioners and facilities caring for patients with this disease. Despite these pressing concerns, pressure ulcers are not on the research funding agenda of the CDC

The statistics on pressure ulcers are eye-opening when compared to other, more widely recognized public health threats including influenza and gun related deaths. Influenza results in 36,000 deaths per year, and deaths in America from guns number roughly 32,000 per year. Pressure ulcers therefore cause nearly as many deaths per year as influenza and guns combined. The 2016 fiscal year budget for the CDC includes a request for $10 million for gun violence prevention research. There is already $187.5 million allocated for influenza planning and response. But there are no CDC funds allocated or requested for research on prevention and treatment of pressure ulcers. 

Given their prevalence, morbidity, and cost, it is puzzling that pressure ulcers are underappreciated as a public health issue. Plaintiff attorneys have certainly caught on, with more than 17,000 lawsuits annually. Perhaps it’s time to face this issue squarely by recognizing its importance and scope and increase funding toward research on pathophysiology, prevention, and treatment. Here are some avenues that require resource allocation:

  • Defining skin failure and the pathophysiology of skin changes at life’s end, and its impact upon prevention and avoidability.
  • Development of improved prevention technologies. 
  • Development of technologies for early detection of deep tissue injury. 
  • Development of improved electronic records that explicitly incorporate systems impacting skin assessment, prevention, and treatment.
  • Defining molecular mechanisms of tissue tolerance including inflammation, endothelial dysfunction, oxygen homeostasis, mitochondrial dysfunction, and vascular hyperpermeability.
  • Defining the unavoidable pressure ulcer, with development of a sound algorithm for determining when these wounds are preventable.
  • Developing evidence based, cost effective wound treatments. 
  • Defining when wounds become palliative and applicable treatment protocols.

In the 1800’s one of the greatest minds in medicine, Jean Martin Charcot, studied pressure ulcers but his example was not followed. Over a century and a half later, wound care shares little space in the medical school curriculum and most doctors receive little training on pressure ulcers. However the imperative for physicians to become more involved in wound care has grown as their prevalence increases with the elderly demographic and improved technologies to keep people alive. As pressure ulcers are an acknowledged geriatric syndrome, geriatricians are in a perfect position to help fill this gap. However pressure ulcers are a problem that geriatricians cannot tackle alone. Preventing and curing pressure ulcers is a multidisciplinary endeavor that will require allocation of resources to research, technology, systems improvement, and manpower.

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References for this post include:

Pieper B (ed). Pressure ulcers: Prevalence, incidence, and implications for the future. NPUAP 2012.  

Inouoye et al. Geriatric Syndromes: Clinical, Research and Policy Implications of a Core Geriatric Concept. J Am Geriatr Soc. 2007 May; 55(5): 780–791.

Molinari et al. The annual impact of seasonal influenza in the US: Measuring disease burden and costs. Vaccine, 2007; 25 (27), 5086-5096.

AHRQ. Preventing Pressure Ulcers in Hospitals.

Burt T. Palliative Care of Pressure Ulcers in Long-Term Care. Ann Long-Term Care 2013; 21(3).


Joanne Lynn said...

I agree - much insight needed! One thing to keep in mind is that the old MDS counted every pressure ulcer - including Stage 1. The physiology of Stage 1 and 2 is probably different from Stage 3 and 4. And virtually all stage 1 and 2 can be healed (and many can be prevented). This is very different in Stage 3 and 4. And they probably are not sequential. We need much work on the basics about generation and healing of pressure ulcers. Almost all of the research data is funded by manufacturers of products to prevent or treat - making it hard to tell the merits. Perhaps this could be on the agenda for NINR and NINDS and AHRQ as well as CDC.

JeffreyLevineMD said...

Joanne I totally agree. The way wound care has evolved most of the literature is industry sponsored. A huge conundrum is disengagement of the medical community with practically all issues involving pressure ulcers, even though it is a medical disease. Also, the staging system was never intended to be progressive, just descriptive.

Peg Graham said...

Dr. Levine: VERY appreciative of your advocacy, calling attention to this issue. My family had a small scare with this, caring for our Mom who aged at home with post-polio syndrome. Despite everyone's best intention, she started to develop a very painful ulcer on her ankle during her hospitalization for a heart valve replacement, It took quite some time to turn that around. We know our scare was small compared to the pressure ulcers that can arise. We want you to know that this was one example of what we saw as less-than ideal choices re her mobility, going as far as inventing a new self-lift&transfer bedside commode. We did not want to just complain, we wanted to do something about the physical aspects of caregiving. We see this as falling into the "Preventive Technology" suggestion on your list, given the fact that self-mobility aids go a long way towards keeping people "moving" as it were . . .See for more information.

Marie Lejarde said...

I'm a new fan and follower...Like you I'm passionate about pressure ulcers and constantly looking for ways to prevent them particularly among the geriatric population. My frustration is the lack of involvement and training of physicians in the management of pressure ulcers. I strongly advocate for including pressure ulcer staging, prevention and management in the residency program. Working in a teaching hospital, it is a frustration having to convince an intern or a resident why a wet to dry dressing should not be a treatment of choice.....

JeffreyLevineMD said...

Thanks Marie for the comment. I am totally in agreement with your observation that PrU's are not adequately taught in physician training. Geriatricians are all the more important because of the designation of PrU as a "geriatric syndrome." This of course does not negate the fact that these wounds need better coverage in the medical profession.

Healt Articles said...

Thanks so much for the update.

Ruth Martin said...

De. Levine
Like Peg Graham, I also have the experience that our clients (I am the owner of a home care agency) came home from hospital stays with pressure ulcers on heels and coccyx.
With 24 hours care at home we could heal it.
One of our clients has been for almost two years bed-bound and he developed NEVER any pressure sore/ulcers. Be aware that pressure ulcer is often lack of adequate care.
Ruth Martin
Home Care/Sr.Consulting, Inc.
Santa Cruz County,CA

Anthony said...

Pressure injuries are a huge global health problem that hospitals everywhere face. The most important thing to note about pressure injuries is the fact that they are completely preventable. Nurses must perform the proper preventative measures so their patients do no develop pressure injuries. If a patient has developed a pressure injury, then the nurse must do everything they can to treat and prevent further injury. The fact that 2.5 million patients are affected by pressure injuries shows that it is obvious that nurses are not following guidelines.
As pointed out, pressure injuries are a huge cost on hospitals and patients. Patients already have to deal with paying their initial bills and the added costs for a preventable injury makes the patient’s life that much more difficult. Hospitals are also forced to use their resources to treat the injury, which means they have less to help other patients. Pressure injuries are also important to prevent because of the complications that they create and the inevitability of patient death. Preventative measures need to be emphasized in the clinical setting so patients stay safe and their health is well-kept.
With all of this in my, it is definitely odd how pressure injuries seem to be looked at so little. The recommended resource allocation would be a huge step in finally dealing with the issue of pressure injuries. The first thing on that list should be that pressure injury training should be provided to nurses throughout the hospital. Doing this would keep the patient population safe throughout their patient stay and leave as healthy as be. To have such vital information from Jean Martin Charcot, from all the way in the 1800s, how can pressure injuries still be a global health problem? It is time to bring pressure injuries in the spotlight and deal with the issue now. There is no point in a preventable injury being prevalent across the world, putting patient’s lives at risk.