Pressure injuries are one of the oldest and most persistent problems we face in long-term care. Some of our residents come in with them (document the living daylights out of that.) Some of our residents, despite our best efforts, acquire them in-house. We try to mitigate the risk and frequently succeed. But what to do about the times we don’t?
You’ll notice I didn’t say decubitus ulcers, bed sores, or pressure sores. They’re pressure Injuries now and are graded with Arabic numbers 1, 2, 3, etc. And they’re not always from the bed.
Sometimes you’ll see injuries behind the patient’s ear from the oxygen cannula. Sometimes you’ll see perineal injuries from a badly-positioned catheter. Those are called Medical-Device-Related Pressure Injuries. Why do they happen? When forces push down on live tissue, the force squeezes the blood out. Without oxygenated blood, the tissue dies and the injury occurs.
A study in Texas showed that 39% of all spinal cord injuries developed pressure injuries. The average stay in the hospital was 150 days (!!), and the average cost to the insurance companies was $150,000. Remember Christopher Reeve? The Ivy League-trained actor, philanthropist, and spinal cord-injury victim/advocate survived for 10 years after his injury, but died because a pressure injury went bad and turned into sepsis.
The pressure injuries that we need to monitor, prevent, and heal are those from the bed, the mattress, and the chair. How many times have you had a patient complain about pain, and notice there’s not only no pressure-redistributing device in the chair, there’s no cushion at all? This happens all the time.
You’ll notice I didn’t say “pressure-relieving device?” Because there’s no such thing. There is no cushion, mattress, or bolster that is universally pressure-relieving, because every patient we see, and every body-type we see, is different. Let’s talk about the two-hour turning schedule. Where did that originate? As it turns out, two hours is arbitrary and there’s no science that shows it works. The turning schedule was determined by the most expedient way to maximize staff intervention during WWII. It doesn’t consider the patient’s BMI (bony people break down faster), nutrition, shear, moisture, etc.
Have you ever purchased a mattress for your bed that was solid firm perfection in the store and when you get it home, your significant other decries it as “too hard” and returns it? Have you wound up trying to sleep in a cloud of pillowy softness that you nearly suffocate in? (Asking for a friend.)
Our practice uses pressure-mapping as a solution for the patient who shows redness, discomfort, and worse on the most expensive “pressure-relieving” mattress. Typically, when someone has a problem with a mattress, we switch it out and keep our fingers crossed for a couple of weeks until we know if the new one works. When we pressure map the patient on the mattress, we know right now if the mattress is the right one. And just because it works today doesn’t mean the same mattress will be the right one six months from now. Because that patient will change over time and we need to re-map and re-think when that happens.
There was a facility I worked with in the early aughts that purchased a plastic gel-filled wheelchair cushion for every patient. I tried it myself. Aside from offering some pressure relief, it was wildly unstable and caused back pain for virtually everyone who used it. Then we pressure mapped those on the cushions and discovered that, though theoretically they should have worked, they frequently still showed red areas of pressure for many of the trials, and the expensive cushions were discarded.
Before you invest in the most expensive cushions and mattresses available for those at risk, find a provider that can help you with pressure mapping and find out exactly what you’re getting and maximize your outcomes. Minimize your risk and theirs with the best options available.
Jean Wendland Porter, PT, is a Regional Director of Therapy Operations at Diversified Health Partners.