Understanding the prevalence of pressure injuries in long term care
Pressure injuries, also known as bedsores, pressure sores, or decubitus ulcers, are a major public health concern, particularly within the long-term care setting. These wounds are caused by prolonged, unrelieved pressure on the skin and underlying tissue, often occurring over bony prominences such as the heels, sacrum, and hips. The development of these injuries can lead to significant pain, infection, and increased health care costs. For older adults and individuals with limited mobility, the risk is especially high, and the statistics reveal a concerning picture.
Key prevalence statistics and figures
Recent meta-analyses and studies have provided clear data regarding the scope of this problem. A comprehensive review of thirty studies found a pooled prevalence for any stage pressure injury in older people residing in long-term care of 11.6%, with a 95% confidence interval of 9.6–13.7%. This means that roughly one in ten residents has a pressure injury at any given time. Excluding stage I injuries, which are less severe, the pooled prevalence was still a significant 7.2%.
- Higher stages are prevalent: While stage I and II injuries are most common, more severe stage III and IV injuries still occur, representing about half of all reported ulcers in some studies. These deeper wounds pose a much greater risk for serious infection and complications.
- Location matters: The most frequent anatomical locations for pressure injuries are the heel (34.1%), sacrum (27.2%), and foot (18.4%). This is directly related to the high-pressure points associated with prolonged sitting or lying down.
- Incidence versus prevalence: It is important to distinguish between prevalence (the total number of cases at a specific time) and incidence (the number of new cases over a period). One meta-analysis reported a pooled pressure injury incidence rate of 14.3%, indicating a substantial rate of new injuries developing over time.
Risk factors in the long-term care population
The vulnerability of residents in long-term care to pressure injuries is influenced by a combination of factors. The aging process itself contributes, as older skin is thinner and less resistant to pressure and shear forces. Several other key risk factors further exacerbate the situation:
- Immobility: This is arguably the most significant risk factor. Many long-term care residents are bedfast or chairfast and cannot reposition themselves frequently to relieve pressure. Conditions causing immobility include neurological impairment, paralysis, and general deconditioning.
- Malnutrition and dehydration: Poor nutritional status can severely compromise skin integrity and the healing process. Inadequate protein, vitamin, and caloric intake weakens the skin, making it more susceptible to breakdown. Dehydration also affects tissue health.
- Incontinence: Exposure to excessive moisture from urine or stool can cause maceration of the skin, making it fragile and increasing the risk of injury.
- Comorbidities: Underlying health conditions such as diabetes, cardiovascular disease, and peripheral vascular disease can impair blood flow and further increase risk.
- Sensory perception impairment: Residents who have a reduced ability to feel pain or discomfort are less likely to notice the warning signs of a developing pressure injury.
- Polypharmacy: Taking multiple medications can be associated with increased prevalence of pressure injuries.
Comparison of long-term care and hospital settings
Pressure injuries pose a challenge across all healthcare settings, but there are notable differences in prevalence rates and contributing factors. In general, prevalence is higher in long-term care facilities than in typical hospital settings, often due to the chronic nature of resident conditions and longer stays.
| Feature | Long-Term Care | Acute Hospital Care |
|---|---|---|
| Prevalence | Pooled prevalence is approximately 11.6%, with some studies showing higher rates. | Prevalence can range from 5% to 15%, but may be higher in specific units like ICU. |
| Risk Factors | Chronic immobility, malnutrition, comorbidities, long length of stay. | Acute illness, surgical procedures, sedation, device-related pressure. |
| Injury Location | Heel, sacrum, and foot are most common. | Location varies but can include medical device sites in addition to bony prominences. |
| Patient Population | Primarily older adults with chronic conditions and limited mobility. | Patients of varying ages with acute, short-term needs. |
| Prevention Focus | Consistent, long-term strategies, education, and nutrition management. | Frequent, diligent assessment, repositioning, and support surfaces during shorter stays. |
Best practices for prevention
Preventing pressure injuries is a primary measure of quality care in long-term settings. The Joint Commission emphasizes that most pressure injuries are avoidable with effective preventive measures. The cornerstone of an effective prevention program relies on a combination of staff training, comprehensive risk assessment, and targeted interventions.
- Risk assessment: Use standardized, evidence-based tools like the Braden Scale to identify at-risk residents upon admission and periodically thereafter.
- Repositioning: Implement a scheduled repositioning protocol for bedfast and chairfast residents. For bedridden individuals, this may be as frequent as every two hours. For those in wheelchairs, repositioning every hour is recommended.
- Use of specialized equipment: Utilize pressure-relieving support surfaces such as special foam mattresses, air mattresses, and gel cushions to redistribute pressure over a larger area. Heel-lifting devices can also protect vulnerable areas.
- Skincare and moisture management: Keep skin clean and dry, especially for incontinent residents. Use pH-balanced cleansers and barrier creams to protect fragile skin from moisture and irritants.
- Nutrition and hydration: Ensure residents receive adequate nutrition, with sufficient protein, vitamins, and fluids to maintain skin integrity. A dietitian may be consulted for high-risk residents.
- Staff education: Ongoing training for all staff, including nurses and aides, is crucial for early identification of skin changes and adherence to prevention protocols.
- Resident and family engagement: Educating residents and their families encourages participation in prevention efforts and early reporting of potential issues.
Conclusion
The prevalence of pressure injuries in long-term care remains a significant indicator of care quality and a serious health concern for residents. With pooled prevalence rates around 11.6%, it is clear that continuous vigilance and proactive strategies are necessary. By focusing on comprehensive risk assessment, individualized care plans, staff training, and the strategic use of preventative equipment, facilities can work to reduce the incidence of these painful and dangerous injuries, ultimately improving the quality of life for their residents. For further information and clinical guidelines, you can consult resources from the National Pressure Injury Advisory Panel (NPIAP).
Frequently asked questions
What are the primary causes of pressure injuries in long-term care? Pressure injuries are primarily caused by unrelieved pressure that damages skin and underlying tissue, often compounded by shear force, friction, and moisture. In long-term care residents, immobility, malnutrition, incontinence, and advanced age are major contributing factors.
How is pressure injury risk assessed in long-term care? Risk is commonly assessed using validated tools like the Braden Scale, which evaluates six factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. This assessment helps staff identify residents most at risk and implement targeted prevention strategies.
What are the different stages of a pressure injury? Pressure injuries are staged based on the depth of tissue damage. Stages range from Stage 1 (non-blanchable redness of intact skin) to Stage 4 (full-thickness tissue loss with exposed bone or muscle). There are also classifications for unstageable injuries and deep tissue pressure injuries.
Can pressure injuries be prevented completely? While most pressure injuries are preventable, especially with proper care and attention, individual factors can make prevention challenging. A proactive, consistent, and person-centered approach focusing on risk assessment and interventions like repositioning, nutrition, and skin care is key to minimizing risk.
What is the difference between incidence and prevalence in pressure injury data? Prevalence refers to the proportion of a population with a pressure injury at a single point in time, while incidence refers to the rate of new pressure injuries developing over a specific period, such as a year. Both metrics are crucial for understanding the scope of the problem.
What are the common locations for pressure injuries in long-term care residents? Due to prolonged pressure on bony areas, pressure injuries in long-term care residents most commonly develop on the heels, sacrum (tailbone area), and hips. Other areas include the elbows, ankles, and back of the head.
How can families of residents help with pressure injury prevention? Families can assist by understanding the risk factors, asking about the facility's prevention protocols, participating in education, and reporting any observed skin changes to staff immediately. They can also encourage movement and healthy eating habits in their loved ones.
What are the complications of pressure injuries if not treated properly? If left untreated or improperly managed, pressure injuries can lead to severe complications, including serious local and systemic infections like cellulitis, sepsis, and osteomyelitis (bone infection). They can also cause significant pain and increase the risk of mortality.
