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Pressure Sores-A Multifaceted Approach to Prevention and Treatment WILLIAM E. STAAS, Jr, MD, and HELEN M. CIOSCHI, MSN, CRNP, Philadelphia, Pennsylvania

The incidence and effect of pressure sores on the disabled and elderly population have created a challenge to physicians and health care professionals, from emergency departments to rehabilitation units, and in the community. If not prevented, the morbidity and mortality of patients and the direct and indirect costs to both patients and the health care system are radically increased. In this article we define the impact on our health care system of pressure sores, provide an overview of a multifaceted approach to their prevention and management, and introduce successful behavioral and educational approaches for patients with chronic, recurrent sores. A coordinated approach with patients as informed participants and their care givers enhances the chances for success. (Staas WE Jr, Cioschi HM: Pressure sores-A multifaceted approach to prevention and treatment, In Rehabilitation Medicine-Adding Life to Years [Special Issue]. West J Med 1991 May; 154:539-544)

continue to be a major societal health problem, greatly affecting patients and their caretakers. Pressure sores are a major cause of admissions to hospitals for patients with impaired mobility and sensory function and for elderly patients. In 1987, more than 532,000 Medicare hospital days were used by patients having pressure sores or decubitus ulcers as the primary diagnosis. In addition, about 1,759,000 Medicare hospital days were used with pressure sore or decubitus ulcer as the secondary diagnosis. Direct charges associated with each of these categories range from $3.4 million to $1. 1 billion dollars. I Beyond the cost issues, pressure sores are associated with a high mortality rate. Allman and co-workers identified mortality rates ranging from 23% to 37% related to elderly patients being admitted to hospitals and to institutions with pressure sores.2 According to Brody, if "untreated or allowed to reach advanced stages, bedsores can result in life-threatening complications that cause an estimated 60,000 deaths a year" (J.E. Brody, "Personal Health," New York Times, August 6, 1986, p C-6). As a result of increased knowledge regarding the causative factors and critical determinants of pressure sores, there has been an altered focus in the management of pressure sores from one of treatment only to prevention and early intervention. Pressure sores are not simply a natural sequela of disease and disability. Critical risk factors, both intrinsic and extrinsic, are now known by most physicians, nurses, and other health care professionals. Accordingly, it is incumbent on health care professionals to identify, protect, and educate those persons at risk. As the public becomes more knowledgeable about optimal health care outcomes, disease prevention, and containing health care costs, it will also demand a proactive rather than reactive approach to maintaining skin integrity and preventing this costly complication. In Brody's article, in which she discusses the concerns related to the prevention rather than the cure of pressure sores, she instructs the public to "insist that appropriate preventive Pressure sores

steps be taken and [to] check periodically to see that they are consistently practiced." This message serves patients well in that their knowledge of potential complications may result in changes in reactions to hospital stays and disability as they seek and demand preventive interventions rather than expensive curative approaches.

The adage "an ounce of prevention is worth a pound of cure" relates well to this important problem in terms of cost and morbidity and mortality. The costs associated with pressure sores, however, are not strictly financial. Pressure sores also have a considerable impact on lost personal time for patients and care givers. Many nursing care hours are taken up with the prevention and treatment of this problem. Nurse specialty groups, including the Association of Rehabilitation Nurses and the Association of Enterostomal Therapists, have recognized and responded to the need for specialty education and collaborative research with the pharmaceutical and medical equipment industries regarding specialty beds, cushions, and the like to prevent this complication and to manage it appropriately and in a timely manner. The Medicare prospective payment system has also fostered a restrictive approach toward this problem, as patients with pressure sores are frequently confronted with limited reimbursement and limited hospital days. Prevention techniques must be used to reduce hospital costs and to effect optimal patient outcomes. Pressures imposed by the prospective payment system have resulted in the premature discharge of patients to the community. Caretakers have demonstrated the ability to manage pressure sores in the home setting. If pressure sore management becomes complex, however, families or care givers may consider sending the patients to institutions. This poses a difficult problem for caretakers because many extended care facilities will not admit patients who have extensive pressure sores. Pressure sores are often a secondary complication for persons with disabilities. Perhaps the disability most investi-

From the Magee Rehabilitation Hospital, Philadelphia, Pennsylvania. Reprint requests to William E. Staas, Jr, MD, President and Medical Director, Magee Rehabilitation Hospital, 6 Franklin Plaza, Philadelphia, PA 19102.

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gated has been spinal cord injury. Despite more than 40 years of research in the area of tissue or pressure sore research related to spinal cord injuries, preventable pressure sores continue to be a major cause of hospital admissions, temporary alterations in life-style, and lost vocational time in this population. About 30% of all persons with spinal cord injuries will have pressure sores develop during the years immediately after their initial rehabilitation program. Young and Burns reported that at least 5% to 7% of those persons will require readmission to a hospital for the management of severe pressure sores during their follow-up years.3'4 Reuler and Cooney found that the complications of pressure sores are multiple and life-threatening and account for 7% to 8% of the deaths of persons with spinal cord injuries.5 Costs associated with pressure sore management in patients disabled with spinal cord injuries are also staggering. These costs are typically based on the duration of hospital stay and direct costs of these hospital stays. Reports identifying costs do not provide complete data as they relate to actual total costs, such as consultant, special medical or surgical, and anesthesia costs. In any event, escalating costs are apparent as evidenced by reported estimates per admission of $15,000 in 1969, $30,000 in 1982, and, most recently, $120,000 in 1988.6 Although these costs are staggering, the costs to patients in lost income, productivity, progress towards vocational goals, independence, and self-esteem are also significant.7 According to Redd and Woodbury, persons who sustain spinal cord injuries are typically young adults who, notwithstanding their injury, must come to terms with the process of physical maturation and expression and self-esteem through physical activities. Pressure sores interfere with these developmental activities.8 The patients are constantly faced with the need to prevent skin breakdown. They should be instructed in their initial rehabilitation program to learn and apply preventive skills, to develop a new repertoire of behavioral approaches for keeping healthy, and to know when and how to intervene if signs of impending skin breakdown are identified. As stated earlier, there is increased awareness of prevention and treatment interventions by health care professionals. Despite this, many persons with traumatic or progressive disability may not have been instructed in assessing normal states, recognizing changes from the norm, exploring the cause, seeking help, and taking action to prevent further trauma or illness. There are also instances wherein the ability to adhere to a basic regimen is not present because of a lack of support systems or personal dedication to follow through with these activities. Classifications of Pressure Sores Various classification systems exist to define the degree (grade) of a pressure sore. Each classification system is limited in that while they describe the extent of tissue damage as it relates to tissue and bone involvement, they do not provide descriptive wound characteristics. Classification systems are also restrictive in that they do not describe the causative factors related to the sore development. A commonly used grading system devised by Shea9 is as follows: Grade I .... Limited to superficial epidermis and dermal layers Grade II.... Involving the epidermal and dermal layers and extending into the adipose tissue

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Grade III ... Extending through the superficial structures and adipose tissue and down to and including muscle Grade IV ... Includes the destruction of all soft tissue structures down to the bone, with communication with bone or surrounding structures. Shea also describes the closed pressure sore that at the surface appears limited in extent, has some drainage, but covers a large bursalike cavity extending to deep fascia or bone.9 Other classification systems differentiate grades based on partial or full-thickness tissue involvement, the presence of tracking, and fistula sites. 10 Despite their limitations, classification systems are essential in defining a wound in a consistent manner. Classifying wounds through the use of one system, at least within a single institution, may assist with assessment and treatment. Clinical Methods of Measuring Wounds Various approaches have been used to identify the extent of wound involvement. A simple measurement with a tape measure or acetate ruler, photographs taken serially, and wound tracings provide a limited dimensional perspective. Another method recently described involves volumetric measurement with the use of a saline solution, transparent dressing, and a syringe. This approach, developed by Berg and others, provides practitioners with surface diameters and depth assessment.'I It is more time-consuming, however, and the assistance of another practitioner is occasionally required to complete the measurement.

Preventive, Medical, and Equipment Interventions for Pressure Sore Management Interventions directed at pressure sores can be divided into categories that include preventive, medical (both local and systemic), functional (which includes the use of special equipment), and behavioral or educational. Preventive interventions include proper positioning and posturing, frequent weight shifts and pressure relief interventions, prone positioning at night, the elimination of shear and friction activities, the proper use of equipment, and frequent skin inspections. These techniques direct care providers and patients toward the goal of maintaining intact skin. Preventive interventions are directed at educating patients to prevent or reduce the development of pressure sores by avoiding or minimizing the major contributing risk factors of pressure and shear. Another preventive intervention developed by health care professionals is the use of a risk assessment tool to create awareness and to assess and then direct the health care management. Risk assessment typically involves using scales with rating categories such as mobility, cognition, continence, nutritional status, and activity. 2'I3 Each category is given a rating, and the degree of risk for the development of pressure sores is determined by the total score. Scaling is usually done at the time of admission and periodically thereafter. The use of rating scales has been successful in acute and geriatric care settings in predicting persons at risk and possibly preventing the development or further progression of a sore. Patients admitted to rehabilitation centers typically have impaired mobility and sensation and perhaps cognitive impairment; therefore, the sensitivity of these scales in these

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settings may require further investigation. More studies of their applicability and validity are needed. As a screening tool, however, the scaling instrument promotes the use of early intervention and reminds evaluators that certain areas must be assessed and monitored on an ongoing basis. Other preventive interventions include the use of specialty mattresses, overlays and "high tech" beds, and wheelchair cushions. The critical issue of pressure distribution and its effect on pressure sore development has been identified by Kosiak, Lindan, and others."4,5 The other critical component of "time at pressure" is the intensity and direction of pressure in contributing to pressure sore formation. In Kosiak's study, no changes were noted in tissues subjected to pressures of 35 mm of mercury for as long as four hours or to varying pressures of as much as 190 mm of mercury for an hour.'4 The constant application of a pressure of 70 mm of mercury, however, produced irreversible cellular changes after two hours. This points to the need to frequently relieve pressure over time or to reduce tissue surface pressure. Based on these early studies, most "surface" interventions were directed toward keeping surface pressures below capillary pressures (15 mm of mercury venous to 32 mm arteriolar to reduce the external compression of capillary blood flow and thus to prevent ischemia and necrosis.'6 During the past 30 years, a variety of mattress overlays, including foam, sheepskin, gel, and air products, has become available. For the most part, these devices provide comfort by partly but not substantially reducing pressure in a supine or side-lying position. They also may decrease pain. Certain studies involving normal, healthy subjects have shown that mean trochanteric and sacral interface pressures at slightly below capillary pressure were achieved in a supine and side-lying static position. One study by Maklebust and colleagues compared the sacral, trochanteric, and heel pressures among hospital mattresses, 2-in foam, a flotation foam pad, and an air cell cushion.'7 In this study, the air cell cushion achieved below capillary pressures for sacral and trochanteric readings. As would be expected, the highest pressures for all mattress overlays were in the heels. In selecting a product, caution should be exercised about generalizing these results to a compromised patient or to a patient at high risk. A generational growth of these products has led to the development of the high-technology bed, which is typically a hospital bed that is modified to provide pressure relief through a fluidized air system or a pulsating, alternating, and possibly oscillating system. These beds suspend the patient on the support surface, providing the same concept and success as a water mattress. Air fluidized therapy provides for the prevention and management of pressure sores in postsurgical patients with sacral, trochanteric, or ischial rotation flaps; assists with positioning of patients who have severe contractures and spasticity; and provides a comfortable support surface for cancer and burn patients who typically experience pain with repositioning and from constant surface pressure. The limitations of high technology beds include temperature control, potential dehydration, limited mobility from bed to chair or other surfaces, patient adjustment to flotation, bed design, cost, and limited applicability to the home setting. The water mattress, or water-filled insert mattress, has been shown to provide significant pressure measurements below capillary closing pressures. 8 In a flotation device, the

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patient's weight is distributed over a greater surface area, thus decreasing the pressures over bony prominences. According to Staas and LaMantia, [S]ome water mattresses when properly inflated will float the patient over

the surface with documented mean capillary pressure of 11 mm Hg per square centimeter of body surface in the supine position. Since all water mattresses will not accomplish these low pressures and some mattresses will not have enough structural capacity to float the patient properly, care should be taken in prescribing the proper mattress.9(p4"4)

Although more cost effective, water mattresses, similar to air-fluidized therapy, cause added mobility difficulties such as with transfers, may worsen spasticity, and may cause motion sickness. Despite these limitations, water mattresses may be used effectively in hospitals and in the home. In addition, patients can remain in a supine position for a prolonged period (as long as eight hours) without showing any signs of compromise to the skin. Regardless of the type of mattress, mattress overlay, pressure-relieving device, or specialty bed, great consideration must be given to the initiation, progression, and assessment of a patient's turning regimen and bed positioning. Patients and care givers should not develop a false sense of comfort through the use of any device, as no device is fail-safe. Before a device is selected, the risk-benefit ratio should be determined by including information regarding pressure measurements, comfort, costs, mobility, and care delivery. For patients who require wheelchair mobility, static wheelchair cushions are designed to provide some degree of pressure relief and a base of support for posture and mobility. Few cushions achieve these objectives. Wheelchair cushions are either dynamic (alternating pressures dependent on an external source) or static. As defined by Donovan and associates, the primary function of wheelchair cushions is to relieve pressure, distribute weight away from bony prominences, and stabilize the body for balance and functional positioning.20 As with pressure relief devices for beds, cushions typically fall into the categories of air-filled, flotation-filled, flotation gel, or polyurethane foam. The role of the wheelchair cushion is to provide a support surface that distributes weight under the ischial tuberosities, buttocks, greater trochanter, and thighs. Pressure readings of 40 to 60 mm of mercury in the ischial area, 60 to 80 mm of mercury in the posterior trochanter, and 80 to 100 mm of mercury over the thighs have been recorded in published

studies.2I123 Unlike mattress overlays and specialty beds, wheelchair cushions rarely achieve ischial pressure readings below capillary pressure. This is a direct result of the smaller surface area bearing the upper body weight; 50% of the body weight is supported on 8% of the sitting area at or near the ischial tuberosities. Despite cushion use, weight shifting and pressure relief continue to be necessary to avoid pressure sore development. In addition to this, symmetric postural alignment is critical in avoiding uneven weight bearing that leads to ischial, trochanteric, sacral, or trunk pressure sores. Independent pressure relief for quadriplegic or substantially neurologically impaired patients can be achieved through the use of an electric reclining wheelchair. Technologic advancements have created wheelchair seating systems that significantly reduce or eliminate shearing with back reclining. The advantages and disadvantages of wheelchair cushions should be evaluated according to their purpose, material,

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weight, portability, patients' functional status, cushion durability, and initial and replacement costs. Patients need to be educated on their proper use and on when to seek help with wheelchair cushion management (including repairs). Changes in physical status, changes in posture due to age, contractures, spasticity, or surgical skin repair, and changes in activities of daily living may necessitate reevaluating a cushion in use. Specialty clinics have been developed that manage equipment issues related to wheelchairs and cushions and provide patients with the opportunity for an annual equipment evaluation if needed. The literature also describes the availability of certain devices directed at training patients to do wheelchair push-up exercises to relieve pressure at recommended intervals of 30 minutes. These newer systems record the frequency of weight shifts and remind patients with alarm sounds to perform pressure relief interventions.24 Although these devices may be used in rehabilitation programs to train patients to incorporate these behaviors into activities of daily living, they have only limited use in the community.

Medical Management of Pressure Sores Managing preexisting medical conditions is essential for the optimal healing of wounds and for the prevention of pressure sores. Certain medical problems that contribute to the development of pressure sores include, but are not limited to, altered cognition; altered sensation and mobility; hemodynamic changes; anemia; edema; musculoskeletal problems including contractures, heterotopic ossification, and spasticity; infection; malnutrition-undernourished or overnourished-incontinence; and iatrogenic causes. Aging patients, trauma patients, and neurologically impaired patients typically experience many of these problems throughout their hospital stays and in the community. The early recognition of these medical problems will help to reduce the risks of pressure sores. The field of the medical management of pressure sores and wounds is rapidly growing and changing. Controversy continues over the use of cleansing agents, wet to dry dressings, and certain topical agents for the management of wounds. Although various articles identify the potential cytotoxicity of these agents, many practitioners continue to use solutions to cleanse the wound and to provide bacteriostatic control. According to Baxter and Rodeheaver, Antiseptic solutions and washing agents, such as free iodine, alcohol, merbromin, chlorhexidine, soaps/detergents, and hydrogen peroxide, while suitable for healthy, unbroken skin surrounding the wound, are too caustic for the wound itself.25(PB3)

In addition, the authors say the actual volume and force of irrigation are more important than the solution itself for cleansing the wound of debris, necrotic tissue, and bacteria. They also question the use of topical antibiotics in wound management and recommend that, due to their unestablished efficacy, they should be used cautiously and for a limited time. When a clinical infection is suspected, the use of parenteral antibiotics should be considered. Wound cleansing and debridement are usually provided through mechanical, chemical, or autolytic means. Mechanical debridement typically includes surgical debridement, irrigation with a saline solution and other agents, and wet to dry dressings. These methods are effective in removing necrotic tissue so that a wound bed for stimulating granulation is provided. Chemical debridement includes the use of en-

zyme preparations that break down fibrin clots and exudate, providing an optimal wound environment for new tissue growth. These agents must be used cautiously, however, because they may be nonselective and could impair new tissue growth. To work most effectively, these agents require a moist wound bed. Chemical debridement includes the use of products such as dextranomers, granular absorbers, and gels that absorb exudate and create a moist wound environment. These products should be selected carefully and used with caution, particularly in grade III and IV pressure sores. Finally, autolytic debridement through the use of occlusive dressings (Duoderm) causes the reduction of eschar formation through the autolytic digestion of necrotic material and creates a moist wound environment for healing. Occlusive dressings provide opportunities for cost control in clinical and home settings by reducing the frequency of dressing changes. Again, they should be used cautiously and changed often in patients with wounds that have excessive moisture to avoid maceration and wound border extension. Other newer topical products include calcium alginate, a product made from seaweed, to provide a high absorptive capacity and conformability to wounds for healing.26 The use of topical growth factors to stimulate angiogenesis and promote wound healing is receiving recognition as studies have reported favorable results.2" These growth factors accelerate wound healing by promoting neovascularization, collagen formation, increased fibroblast and macrophage activity, protein synthesis, and epithelialization.

Behavioral and Educational Management of Pressure Sores There is a dearth of research examining the behavioral, educational, and psychosocial factors that influence or contribute to pressure sore development. Probably the most cited study is that of Anderson and Andberg.28 These researchers attempted to determine factors other than physiologic and mechanical that relate to the development of pressure sores in quadriplegic and paraplegic persons. The results of this study showed a strong association between pressure sore incidence and psychosocial variables. A relationship was found between the level of injury and the presence or absence of help with skin care. Probably the most important factor noted in this study was the influence of self-esteem and life satisfaction on a person's feelings about practices and responsibility in skin care. According to Anderson and Andberg, these psychosocial factors were most related to the extent of "persistence"-occurrence, recurrence, and duration-of pressure sores in persons with paraplegia. While recognizing and responding to the multifactorial nature of pressure sore development in persons with disability, it was through our experience as the rehabilitation component of a regional spinal cord injury program that we identified the need to develop a comprehensive educationalbehavioral program for the management of pressure sores. In the early 1980s, a subgroup of our spinal cord-injured population had an 80% recurrence of pressure sores within three months of successful treatment of the pressure sore as an inpatient or outpatient in our Spinal Cord Follow-up Program. This prompted an interdisciplinary team to develop a pressure sore readmission program. The goals of this program include learning specific information and behaviors related to skin

care

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and to define and attain goals related to psychosocial and vocational outcomes. The team recognized that the inciment

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dence of recurrent pressure sores was related not only to biomechanical, biochemical, medical, and functional issues but also to psychosocial and vocational ones. As noted by Anderson and others, the ability to initiate, perform, or direct care, the availability of a health care professional, and the knowledge to seek help seemed to have a substantial effect on a person's ability to maintain intact skin and good health. Our program is based on the premise that a multifaceted approach to educating patients will help alter behaviors to reduce the incidence of recurrent pressure sores. According to the Rosenstock "health belief model," a person's behavior is motivated by the perception of the value and the probability of success.29 Krouskop also found that a multifaceted program of patient assessment, individualized prescription of equipment, education, and follow-up involving teaching and counseling could reduce the number and severity of pressure sores.30 Through the assistance of a coach, a pressure sore program team, and patients already in the program, a new patient learns new skills. The role of the coach is to assist the patient with program participation and completion, to enhance learning and compliance, and to facilitate optimal patient outcomes. The coach meets weekly with the patient, reviews individual and program goals, administers tests before and after program completion and reviews the results, assists with resolving program agreement violations, and monitors the patient's progress and readiness for progression or discharge from the program. Before entering the program, the patient formally agrees to the goals mutually established by signing a written agreement. The agreement outlines staff responsibilities for assuring program success and the patient's responsibilities for participating in the program. Patients are also informed of hospital policies and procedures, including those related to the use of substances not prescribed by the attending physician. Screening for substance use is done periodically, and a positive urine or serum screen may result in discharge from the inpatient program with ongoing monitoring provided on an as-needed basis in the outpatient follow-up system. The program has evolved into three phases. Phase I (core) is for patients admitted for the first time with a primary diagnosis of pressure sore (grade II or greater). It is also for persons who previously participated in the program but were unable to complete it, either as a result of agreement violation or acute illness requiring readmission to the hospital. Phase II is designed for persons who successfully complete the program but who are readmitted with another skin problem. Successful completion is defined as a 70% or higher score in the postprogram tests or if a patient shows an adequate knowledge of proper skin care. Phase II classes, titled "Challenge and Enrichment," focus on community and other psychosocial issues as well as on medical-functional and equipment issues. Phase III is a specialized program for patients admitted with a primary diagnosis other than skin breakdown. In this phase, the program team coordinates the rehabilitation components with the educational needs of a person as they relate to the major classes within the core. The pressure sore program is coordinated through a continuum of care that begins in the outpatient follow-up system. Preprogram screening is done by a physician, nurse clinician, and social worker. The preadmission process focuses on a complete initial assessment with goals and anticipated

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outcomes mutually developed by the patient and the team. The patient's medical status is evaluated and managed. This includes, but is not limited to, controlling spasticity, treating infection, improving respiratory and nutritional status, evaluating the patient's possible response to pressure sore treatments and interventions, maintaining or improving bowel and bladder status, and addressing functional and homemaker activities. If surgical debridement is indicated, consultation is provided by the program's plastic surgeon. Preoperative education regarding the surgical procedure, postoperative care, and rehabilitation management is provided before hospital admission. Functional and equipment issues are coordinated by a nurse clinician in consultation with a physical or occupational therapist. The surgical phase (10 to 14 days) involves admission to an acute care hospital. During this admission, the patient is monitored by a follow-up nurse clinician to assure that the acute care team adheres to disability-specific issues, such as bowel, bladder, or spasticity management, and facilitates a timely admission to the rehabilitation phase of the program. During the rehabilitation phase, the patient actively participates in an individually designed program comprising classes based on program placement, successful testing, or both. The program has expanded to more than 40 possible educational sessions in topics such as skin management, functional-equipment issues, assertiveness classes, and vocational and community survival issues. During this phase the patient is expected to attend a "community" meeting, patient and team meetings, and a coping group. Also during this phase, the goals are to facilitate wound healing, educate, reinforce behavioral skills, and provide a progressive sitting and therapy program directed at maintaining skin integrity. In an initial unpublished study by LaMantia, the participants of this program demonstrated a positive association between learning, the reinforcement of specific behaviors, and healed skin. According to LaMantia, the "results may indicate that behavioral changes achieved during the program are sustained short term and that certain program elements could act as predictors of success" (unpublished data, July 1986). A follow-up study will be conducted on program participants to assess their ability to sustain behavioral change and to maintain intact skin over time. During the four years of the program, 131 patients have participated, with 85% requiring only one admission to complete the program. * A second admission was required by 15 (11%) of the 131. This was due to a lack of program completion, agreement violations, or readmission to an acute care hospital because of medical or surgical complications. Four of the patients (3% of the total) have required three admissions to this program, and two patients (1%) required four admissions. Of the 15 persons who required repeated program admissions, 9 (or 7% of the total) have required radical surgical intervention, which included bilateral hip disarticulations, hemipelvectomy, or hemicorporectomy. The mortality rate among the 131 patients has been 5% (7 patients). The causes of death included pulmonary embolus, respiratory failure, gastrointestinal bleeding, status epilepticus, pyelonephritis with disseminated intravascular coagulation, and pneumonia. Men made up 78% (102) of the patients. This statistic is *Data were collected by Carol Goodman, MSN, and Vernice Wooden, MSSA, program coordinators for the Pressure Sore Program, Magee Rehabilitation Hospital,

Philadelphia, Pennsylvania.

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similar to national distributions of patients with spinal cord injuries, which is often the primary diagnosis of patients participating in this program. Of the 124 surviving patients, 91, or 73%, have maintained intact skin six months to four years after completing the program. The remaining 27% have had repeated episodes of skin breakdown ranging from grade II to grade IV pressure sores. Further analysis ofthose patients requiring readmission is being conducted. This subgroup is similar to the group in the study by Anderson and Andberg. These persons have limited family support or resources, challenging environmental barriers and home situations, limited financial resources, and may also have limited ability or motivation to complete or direct self-care. Although education and behavioral "knowhow" have heightened patients' awareness to seek early intervention through the follow-up system, the recurrence of pressure sores in this small number presents a challenge to the patients and the program team. Of 124 participants, 60 (48%) have returned to a productive life-style, 29 ofthem returning to school and 31 to a work situation. The multifaceted approach of this program, combined with a strong focus on patients developing accountability for self-care, has contributed to the successful outcomes experienced by this group. REFERENCES 1. Medical Technology Forum: Public Policy Implications Related to Use of the Air-flotation Bed Treatment in the Home Setting. Washington, DC, Medical Technology and Practice Patterns Institute, 1988 2. Allman RM, Laprade CA, Moell LB, et al: Pressure sores among hospitalized patients. Ann Intern Med 1986; 105:337-342 3. Young J, Burns P: Pressure sores and the spinal cord injured. Model Systems SCI Dig 1981; 3(Pt 1):9-18 4. Young J, Burns P: Pressure sores and the spinal cord injured. Model Systems SCI Dig 1981; 3(Pt II): 1 1-26 5. Reuler JB, Cooney TG: The pressure sore: Pathophysiology and principles of management. Ann Intern Med 1981; 96:661-666 6. Wharton G, Milani J, Dean L: Pressure Sore Profile: Cost and Management (Abstr). Proceedings of the American Spinal Injury Association meeting, 1987, pp 115-1 19 7. LaMantia JG, Hirschwald J, Goodman C, Wooden V, Delisser 0, Staas W: A

PRESSURE SORES program design to reduce chronic readmission for pressure sores. Rehabil Nurs 1987; 12:22-25 8. Redd C, Woodbury B: Psychological adjustment to SCI, chap 6, In Buchanan L, Nawoczenski D (Eds): Spinal Cord Injury: Concepts and Management Approaches. Baltimore, Md, Williams & Wilkins, 1987 9. Shea JD: Pressure sores: Classification and management. Clin Orthop 1975; 112:89-100 10. Parish LC, Witkowski JA, Crissey J: The Decubitus Ulcer. New York, NY, Masson Publishing, 1983 11. Berg W, Traneroth C, Gunnarsson A, Lossing C: A method for measuring pressure sores. Lancet 1960; 1:1445-1446 12. Gosnell DJ: An assessment tool to identify pressure sores. Nurs Resources 1973; 22:55-59 13. Braden B, Bergstrom N: A conceptual schema for the study of etiology of pressure sores. Rehabil Nurs 1989; 12:8-16 14. Kosiak M: Etiology of decubitus ulcers. Arch Phys Med Rehabil 1961; 42:1929 15. Lindan M: Etiology of decubitus ulcers, an experimental study. Arch Phys Med Rehabil 1961; 42:774-783 16. Landis EM: Microinjection studies of capillary blood pressure in human skin. Heart 1930; 15:209-228 17. Maklebust J, Mondoux L, Sieggreen M: Pressure relief characteristics of various support surfaces used in prevention and treatment of pressure ulcers. J Enterostomal Ther 1986 May/Jun, pp 85-89 18. Weinstein JD, Davidson BA: A fluid support mattress and seat for the prevention and treatment of decubitus ulcers. Lancet 1965; 2:625-626 19. Staas WE, LaMantia JL: Decubitus ulcers, In Ruskin AP (Ed): Current Therapy in Physiatry: Physical Medicine and Rehabilitation. Philadelphia, Pa, WB Saunders, 1984, pp 410-419 20. Donovan W, Garger S, Hamilton S, Krouskop T, Rodriquez G, Stal S: Pressure ulcers, chap 25, In DeLisa JA, et al (Eds): Rehabilitation Medicine: Principles and Practices. Philadelphia, Pa, JB Lippincott, 1988, pp 476-491 21. DeLateur B, Hongladarom G: Wheelchair cushions designed to prevent pressure sores: An evaluation. Arch Phys Med Rehabil 1976; 57:129-135 22. Garber S, Krouskop T, Carter R: A system for clinically evaluating wheelchair pressure-relief cushions. Am J Occup Ther 1978; 31:565-570 23. Garber SL, Campion LG, Krouskop TA: Trochanteric pressures in spinal cord injury. Arch Phys Med Rehabil 1982; 63:549-552 24. Fordyce WE, Simmons BC: Automated training system for wheelchair pushups. Public Health Rep 1968; 83:527-528 25. Baxter C, Rodeheaver GT: Interventions: Hemostasis, cleansing, topical antibiotics, debridement, and closure, chap 6, In Wound Care Manual. Princeton, NJ, Convatec, a Squibb Company, 1990, pp 71-82 26. Chapius A, Dolfus P: The use of a calcium alginate dressing in the management of decubitus ulcers in patients with spinal cord lesions. Paraplegia 1990; 28:269-271 27. Frylling C: Comprehensive wound management with topical growth factors. Ostomy/Wound Management 1989 Summer, pp 42-51 28. Anderson TP, Andberg MM: Psychosocial factors associated with pressure sores. Arch Phys Med Rehabil 1979; 60:341-346 29. Rosenstock IM: Historical origin of the health belief model. Health Educ Monogr 1974; 2:329-335 30. Krouskop TA: A synthesis of the factors that contribute to pressure sore formation. Med Hypoth 1983; 11:255-257