Pressure Ulcer Treatment:
A comprehensive rehabilitation approach
Most people with SCI are well aware that they have a high lifetime risk of developing pressure ulcers and try to avoid them by following good skin care practices. Yet pressure ulcers continue to be one of the most frequent medical complications of SCI, one which is costly, disabling and potentially life-threatening.
The Model SCI System Statistical Center recently reported that the risk of getting a pressure ulcer is about 15% in the first year after injury and increases steadily thereafter, to about 27% at 25 years postinjury. 1 The recurrence rate is even higher: between 40% and 80% of patients who have had a pressure ulcer develop another one. 2 At any given time, an estimated 17% to 39% of the SCI population suffers from a pressure ulcer. 3
Pressure ulcers that don't heal with medical (also called conservative) treatment-pressure reduction, wound care, good nutrition-may require myocutaneous flap surgery, which involves covering the wound with a flap of connected skin and muscle tissue and requires a lengthy hospital stay.
What do patients and their providers need to know in order to prevent pressure ulcers, or at least reduce their severity and recurrence?
Pressure ulcer treatment at Harborview
Pressure ulcers do not usually have a single cause but are due to a complex combination of medical, behavioral and lifestyle factors. For this reason, treatment of open ulcers and the prevention of future breakdown should ideally address all these issues. At the University of Washington's Harborview Medical Center, pressure ulcers are managed collaboratively by the departments of rehabilitation medicine and plastic surgery , using a comprehensive rehabilitation protocol that addresses wound healing, seating, mobility, nutrition, exercise, co-morbid conditions, activities of daily living, habits (such as smoking and drinking), and psychosocial issues. If the wound involves underlying bone infection, the infectious disease department may also assist in management.
Harborview receives referrals from all over the region for treatment of pressure ulcers that have not healed with conservative treatment. Many of these referrals are for wounds that could have been avoided or treated earlier with non-surgical methods, according to Dr. Barry Goldstein , UW associate professor of rehabilitation medicine. He and Dr. Loren Engrav , UW professor of plastic surgery, co-direct Harborview's outpatient pressure ulcer treatment program.
"There are many misconceptions about the prevention and treatment of pressure ulcers," Goldstein said. "From the referrals that we get, we see that there is a lack of knowledge on the part of many primary care practitioners and surgeons in the community."
"Getting a pressure ulcer can be so life-shattering," said Rosemary Buchmeier, RN, a nurse in Harborview's rehab clinic. "Patients are forced to put their lives on hold for six months to a year while a severe pressure ulcer is healing."
"Often people come to us when they have already failed elsewhere," Buchmeier added. "Typically, the patient had surgery at another facility for a severe wound and was sent home. But the pressure ulcer recurred, and now they're considered too complex for the original facility to handle. So they come to us."
Patients who come to Harborview with a pressure ulcer enter a protocol designed to put them in the best possible condition to heal the ulcer, undergo surgery and help prevent recurrences after they return home. If adherence to the protocol heals the wound without surgery, all the better. Research suggests that a protocol such as this may reduce pressure ulcer recurrence following surgery. 2
"Dr. Engrav wants to change the attitude from 'the patient is coming for flap surgery' to 'the patient needs comprehensive rehabilitation care that might include surgery,'" said Cathy Miller, RN, who works alongside Buchmeier in Harborview's rehab clinic. "We take a functional and realistic look at the life of the person," assessing all the factors (medical, behavioral, equipment, lifestyle) that contribute to pressure ulcers and helping the patient make the necessary changes.
If the wound does not heal after following the protocol, the patient is evaluated and, if appropriate, scheduled for surgery. "Not everyone is an appropriate candidate for surgery," Goldstein explained. "Some patients are not healthy enough to have surgery and need extra weeks or months to get ready for surgery. Others have problems with alcohol and drug abuse or their living situation. Until such problems are treated, treatments directed at the pressure ulcer (dressings, seating correction, physical therapy, surgery) are ineffectual and a waste of limited resources. This is why patients with severe pressure ulcers are referred to social work and psychology. Other life and mental health problems are evaluated and treated, if related to the pressure ulcer problem."
Following surgery, recovery in the hospital takes several weeks-for the wound to heal, for progressive seating and physical activity, and to reinforce patient education.
Sending the patient home in good health, with proper equipment and healthy behaviors, is extremely important for a successful outcome, as is adherence to the follow-up appointment schedule.
Seek treatment early
"Patients and providers don't call us when the wound is small," Miller noted. "The problem is: it may look small, but it may be bigger underneath."
It's important to know how to recognize the early stages of a pressure ulcer (see "Stages of Pressure Ulcers" sidebar). Damage often begins deep beneath the skin, in the muscle tissue. 4 Therefore, a large deep pressure ulcer may present with a very small blister or opening on the skin surface. Waiting to see if it worsens is the worst possible course of action.
|A pressure ulcer (pressure sore, decubitis ulcer, bedsore) is any redness or break in the skin caused by too much pressure on the skin for too long.|
Stage III :
"If you see something red, get off it," Miller warned. "If it comes back or doesn't fade after being off it overnight, see a physician." If the wound is significant, the physician can refer a patient for a seating assessment, including pressure mapping, to correct problems that may be causing the pressure. Other potentially correctable problems are also evaluated. "It might be as simple as solving incontinence," Buchmeier said.
"It's in the very early stages that getting the pressure off makes the most difference," Miller said. "And it's the hardest part because people think it's too small to bother with. But getting off that spot for two weeks may make all the difference."
"It's hard to know if the sore is larger underneath," she continued. "We look for heat, color, a bruised look, hardness, drainage. You need an experienced wound practitioner to look at it."
If the wound is open and draining, "you need to see someone with expertise in wound care, pressure issues, and wheelchair seating," Miller warned. "At that point, you need a comprehensive approach, preferably at a facility that treats people with SCI."
Most primary care doctors have limited experience treating SCI, so patients themselves must have a good grasp of the problem. "I had a client who got her first pressure ulcer after being injured 20 years, went to her primary care doc, and got the wrong advice," Buchmeier said. "The information needs to be inside the head of the injured person."
"Pressure sores are strongly behavioral," Miller said, but it is unclear whether they are always preventable. "The early message used to be: It's your fault if you get a pressure ulcer." For this reason, patients are sometimes too embarrassed to seek help when they see a sore, and simply hope it will go away. The Harborview rehabilitation team encourages patients to detect pressure ulcers early, take pressure off the site immediately, and call at the first sign of a pressure ulcer.
"We don't know all the reasons why people get pressure ulcers," Buchmeier said, "but by doing a comprehensive approach, we put the person in the best possible position for healing and preventing recurrence."
The rehab team recommends scheduling periodic health evaluations with a rehabilitation medicine physician because these check-ups provide an opportunity to review and correct problems that might increase risk for pressure ulcers, like poor seating, malnutrition, incontinence, and lifestyle issues. Even if a person has gone decades without a problem, aging causes changes that make the skin more vulnerable. And the longer the time since injury, the greater the risk becomes.
Rosemary Buchmeier , RN, and Cathy Miller, RN, welcome calls from physicians or patients who have questions about a skin problem (206-731-2581).
Online illustrations & information :
. Medline Medical Encyclopedia : "Pressure Ulcers" - www.nlm.nih.gov/medlineplus/ency/article/007071.htm
. Wound Care Information Network : "Staging Pressure Ulcers" - www.medicaledu.com/staging.htm
2 . Kierney PC, Engrav LH, Isik FF, Esselman PC, Cardenas DD, Rand RP. Results of 268 Pressure Sores in 158 Patients Managed Jointly by Plastic Surgery and Rehabilitation Medicine. Plastic Reconstr Surg. 102(3):765-772, 1998.
4 . Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health Care Professionals. Consortium for Spinal Cord Medicine. Paralyzed Veterans of America. 2000.