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The question

My father is in a long-term-care home in Ontario. We recently discovered he has a horrible-looking bedsore on his backside. How could this have happened?

The answer

Bedsores, medically known as pressure ulcers or pressure injuries, result from being in one position for too long. They usually develop on a patch of skin that’s located over a bony protrusion such as a hip, tailbone, shoulder blade or heel.

Medical conditions that limit a person’s ability to move, or feel sensations, increase the risk of such injuries occurring.

The constant pressure of sitting in a wheelchair or lying down, without periodically shifting positions, can inhibit blood flow to a part of the skin – and deprive it of necessary nutrients and oxygen. Eventually, the skin and surrounding tissue become damaged, sometimes resulting in an open sore that’s vulnerable to infection.

However, proper care and support can usually stop a pressure injury from forming – although a lot depends on the underlying condition of the patient, says Dr. Morty Eisenberg, a hospitalist and wound consultant at Sunnybrook Health Sciences Centre in Toronto.

“Skin is an organ. When you are near the end of life, the organs start to fail – and the skin is one that can fail,” explains Eisenberg, who is also president of Wounds Canada, a non-profit advocacy and educational group.

“So, someone in palliative care, even with the best of treatment, can develop a pressure injury, and it is not anybody’s fault.”

But end-of-life cases are the exception rather than the rule. “The great majority of pressure ulcers are preventable,” Eisenberg says. Even so, they continue to happen at a fairly predictable rate to patients in health institutions as well as those receiving care at home.

Each year, more than 3,000 cases are reported at acute-care hospitals across Canada (excluding Quebec), according to patient-discharge summaries analyzed by the Canadian Institute for Health Information (CIHI).

Data from other sources have found that about 7 per cent of long-term-care patients, 14 per cent of complex-continuing-care patients and 2.4 per cent of home-care patients suffer from pressure injuries, which vary in severity.

These figures don’t represent all cases, says Tracy Johnson, director of emerging issues at CIHI. Some incidents are not documented in ways that can be easily tracked. “But you don’t need an exact number to understand whether you have a problem,” she adds.

Indeed, the general consensus in the medical community is that pressure-injury prevention represents “a huge opportunity for improvement” says Dr. Irfan Dhalla, vice-president of evidence development and standards at Health Quality Ontario (HQO). In other words, we could be doing a better job.

Two years ago, HQO, a provincial government agency with a mandate to improve health care, released quality standards on the prevention and treatment of pressure injuries.

Although the guidelines are mainly aimed at health-care professionals, they state that patients and their families also need to be properly informed about these wounds.

When patients are sent home from a health-care facility, family members often become the primary caregivers.

In addition to regularly repositioning the patient, specialized mattresses and cushions can help redistribute pressure away from vulnerable skin areas. “But there still needs to be vigilance on the part of the caregivers,” says Linda Norton, an occupational therapist with expertise in pressure injuries.

“If a wheelchair cushion looks worn or the patient feels something is different, then it may be time to contact the heath-care provider for a reassessment.”

Good nutrition also plays an important role in safeguarding the skin. “Essentially, nutrition gives us the building blocks of our skin,” Norton says. People who enter a health-care facility in a malnourished state face an elevated chance of getting a bedsore.

Eisenberg is concerned that some health-care providers may lack the specialized skills needed to properly deal with these complex injuries. Putting a dressing on the wound isn’t enough, he says. “If you don’t relieve the pressure, it’s not going to go away.”

The quality standards produced by HQO also drew attention to the fact that “there are variations in access to services and in the quality of care received by people who have developed or are at risk of developing a pressure injury.”

That means it’s often critically important for family members to be on the lookout for pressure injuries and to communicate their concerns to health-care staff, Dhalla says.

“An informed and engaged family will be a better advocate for their loved one than a family who doesn’t even know that a pressure ulcer has developed,” he adds.

Paul Taylor is a patient navigation adviser at Sunnybrook Health Sciences Centre. He is a former health editor of The Globe and Mail. Find him on Twitter@epaultaylor and online at Sunnybrook’s Your Health Matters.

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