1311
EDITORIALS
Preventing
pressure
sores
irremediable afflictions of sign of acute illness-that longstay patients much is slowly being realised. They are caused by failure of the peripheral circulation, which is less immediately fatal than systemic failure but often much longer lasting in its effects. In their inaugural study of pressure sores in elderly patients, Norton et all suggested the connection with illness by their observation that 70% of sores occurring in hospital did so within the first two weeks (ie, when patients are most ill), and by including general condition, confusion, and incontinence-important non-specific signs of illness in old people-in their pressure sore Pressure
sores
are
not
but
a
The only specialty in which doctors have accepted responsibility for pressure sores-spinal cord injuryhas evolved very successful protocols for prevention and management. However, much of its skill is employed in repairing the appalling sores that result from the lack of training of primary care teams in the district general hospitals. All too often measures for pressure relief are instituted only after evidence of necrosis has already appeared. Sick patients in highrisk groups-ie, those with old spinal cord injury, neurologicalor vascular disease12,13 and elderly patients2-are still nursed for long periods in chairs in the belief that this practice prevents bedsores, although numerous studies have shown that patients in chairs are more likely to have sores than patients in
However, by continuing to regard pressure chiefly as a failure of nursing care, they unfortunately helped to perpetuate an extraordinary practice-pressure sores must be the only remaining major disorder, affecting about 10% of patients in developed countries,2-4 for which most doctors do not accept responsibility. Leg ulcers, another very neglected area, have sporadically challenged the ingenuity of surgeons5 or
2,14,15 Posture and pressure relief must form part of the general medical care of all acutely ill patients-in accident and emergency departments, operating theatres, and intensive care and recovery wards.16 General practitioners also need to ensure that they have immediate access to pressure-relieving equipment when illness strikes elderly and disabled
the consciences of dermatologists,6but pressure sores probably still do not figure in any undergraduate curriculum. Even consultants in departments of medicine for the elderly, where up to 30% of patients in the acute wards are likely to be at risk,1,3have seldom had any training in methods of prevention and management. Action groups such as the Tissue Viability Society’ and the King’s Fund Pressure Sore Study Groups in the UK and the National Pressure Ulcer Advisory Panel9 in the USA have addressed themselves mainly to nurses and paramedical workers. Most astonishing of all, the courts, which have recently made awards of up to C 100 000 for a pressure sore,1O have confined their investigations almost entirely to nursing management, although the acute ischaemic episode which precipitated the necrosis is more likely to have occurred in the accident and 11 emergency department or on the operating table,l1 and therefore to have been the responsibility of the admitting doctor, anaesthetist, or surgeon rather than of the nurses who subsequently had to care for the
It is still unclear why illness exacerbates liability to pressure necrosis. Reduced sensation and mobility;17 sedation; pain;18 vasomotor failure;19 low blood pressure;20 peripheral vasoconstriction due to shock, heart failure, or sympathomimetic drugs;13 dehydration causing increased tissue defonnability;21 septicaemia ;22 nutritional deficiency ;23 and endothelial changes22 probably all play a part and should be treated if possible. Meanwhile, emergency prevention must depend on modifying pressure on the body. Modem methods of measuring tissue viability21,24 have revealed the importance of the high interstitial pressures and capillary deformation produced by bony prominences inside the body in the production of deep sores ’25as distinct from the superficial tissue distortion associated with humidity and friction26 that causes dermal sores. These observations explain why soft pressure-relieving mattresses that rely on low interface pressures26 may help to prevent superficial sores but are usually unable to prevent deep sores in very sick patients unless the patients are also repositioned regularly.27 Since two-hourly turning is
prediction
score.
sores
patient.
patients.
1312
unacceptable to most old people and seldom practicable in busy wards or in the community, much effort has been expended on the design of pressurerelieving mattresses that prevent sores without the need to turn the patient. Flotation beds28 can do this, but are not portable and are unsuitable for emergency use. Moreover, they cannot be used for orthopaedic patients (one of the groups most in need of pressure care") and are disliked by most old people because of their instability. Air flotation beds are also prohibitively expensive. 27 Alternating pressure air mattresses (APAMs) provide a more physiological approach. Like repositioning, they aim to represent the natural method of preventing pressure damage over bony prominences-ie, by constantly changing the areas of support, thereby allowing restoration of the blood supply and reactive hyperaemia and cell repair to take place. Large-celled APAMs have been shown in controlled trials to prevent and heal pelvic and heel sores without repositioning29,3o and have the added advantage of providing a firm surface for nursing care. Unfortunately, ill-considered demands for cheap APAMs in the past resulted in the production of poorly designed unreliable machines,31 but stronger models are now available30 and the publication of a British Standard should ensure better performance in future. The Pegasus bed3O is portable and easy to use in the community as well as in hospital, and even simpler machines may be sufficient for most patients. Foolproof arrangements for distribution and servicing are essential.16 Only when every patient with a suspected spinal cord injury, new stroke, or femoral neck fracture can be routinely admitted onto an APAM and nursed on it-or provided with an equivalent manual method of pressure reliefthroughout the acute phase of his or her illness will we begin to see the end of pressure sores. D, McLaren R, Exton-Smith AN. An investigation of geriatric nursing problems in hospital. Edinburgh: Churchill Livingstone, 1975.
1. Norton
SM, Clark MO. Incidence of pressure in the Greater Glasgow Health Board area. Lancet 1977; ii: 548-50. 3. Warner U, Hall DJ. Pressure sores: a policy for prevention. Nursing Times 1986; 82: 59-61. 4. Allman RM. Epidemiology of pressure sores in different populations. Decubitus 1989; 2: 30-33. 5. Blair SD, Wright DDI, Backhouse CM, Riddle E, McCollum CN. Sustained compression and healing of chronic venous ulcers. Br Med J 1988; 297: 1159-61. 6. Ryan TJ. The management of leg ulcers. Oxford: Oxford University Press, 1983. 7. Editorial. The TVS—has it achieved better patient care? Care Sci Pract 2. Barbenel JC, Jordan MM, Nicol sores
1989; 7 (no 2): 30. Livesley B. The prevention and management of pressure sores in Health districts. King’s Fund Centre for Health Services Development: a document produced by the Pressure Sore Study Group 1989. Available from the Academic Unit for the Care of the Elderly, Charing Cross Hospital, London. 9. Editorial. Pressure points. Decubitus 1990; 3: 10-11. 10. Robertson JC. £100 000 damages for a pressure sore. Care Sci Pract 1987; 5 (no 3): 2. 11. Versluysen M. How elderly patients with femoral neck fracture develop pressure sores in hospital. Br Med J 1986; 292: 1311-13. 12. Versluysen M. Pressure sores in an orthopaedic population: an epidemiological survey. City and Hackney Health District, London: Nursing Research Papers 1983, no 1. 8.
13. Strunk H, Osterbunk J. Pressure induced skin lesions in cardiac surgery. Care Sci Pract 1988; 6 (no 4): 113-15. 14. David J. The size of the problem of pressure sores. Care Sci Pract 1981; 1 (no 1): 10-13. 15. Nyquist R, Hawthorn PJ. The prevalence of pressure sores within an area health authority. J Adv Nursing 1987; 12: 183-87. 16. Hibbs PJ. Pressure area care for the City and Hackney Health Authority. City and Hackney Health Authority, London, 1988. 17. Exton-Smith AN, Sherwin RW. The prevention of pressure sores—the significance of spontaneous bodily movement. Lancet 1961; ii: 1124-26. 18. Barrett E. A review of risk assessment methods. Care Sci Pract 1988; 6 (no
2): 49-52. 19. Guttman L. The prevention and treatment of pressure sores. In: Kenedi RM, Cowden JM, Scales JT, eds. Bedsore biomechanics. London: Macmillan, 1976: 153-59. 20. Leung KH. Interface pressure: can blood pressure be the equation? Decubitus 1989; 2: 8. 21. Bader DL, Grant CA. Changes in transcutaneous oxygen tension as a result of prolonged pressure at the sacrum. Clin Physics Physiol Meas 1988; 9: 33-40. 22. Barton A, Barton M. The management and prevention of pressure sores. London: Faber and Faber, 1978. 23. Kaminski MV, Pinchcofsky-Devin R, Williams S. Nutritional management of decubitus ulcers in the elderly. Decubitus 1989; 2: 20-30. 24. Clark M, Rowland LB, Wood HA, Crow RA. Measurement of soft tissue thickness over the sacrum of elderly hospital patients using B-mode ultrasound. Decubitus 1989; 2: 63. 25. Young JB. Aids to prevent pressure sores. Br Med J 1990; 300: 1002-04. 26. Lowthian P. Pressure sore prevention. Nursing 1989; 3: 17-23. 27. Bliss MR. Prevention and management of pressure sores. Update 1988; 36: 2258-68. 28. Krouscop T, Williams R, Krebs M. The effectiveness of air flotation beds. Care Sci Pract 1984; 4: 9-11. 29. Bliss MR, McLaren R, Exton-Smith AN. Preventing pressure sores in hospital: controlled trial of a large celled Ripple mattress. Br Med J 1967; i: 394-97. 30. Exton-Smith AN, Overstall PW, Wedgewood J, Wallace G. Use of the ’Air Wave System’ to prevent pressure sores in hospital. Lancet 1982; i: 1288-90. 31. Bliss MR. The use of Ripple beds in hospitals. Hosp Health Serv Rev 1979; 74: 190-93.
The underclass The underclass, the hostile alternative society of the dispossessed and excluded, haunts modem America and is coming to haunt Britain too, as board and lodging houses, cardboard "Thatcher bungalows" under bridges, and proliferating beggars attest.’ Moreover, the British Government seems strangely attracted to this brainchild of the American political scientist, Charles Murray. Murray has espoused the topic, often in print; his latest book, The Pursuit of Happiness, is not yet published but Kenneth Baker, Chairman of the Conservative Party, has seen a copy. "Brilliant", he commented, when he deviated from his prepared keynote speech before a small audience at the Centre for Policy Studies on May 9.3 Murray was also speaking at the conference. However, there is nothing new about the underclass: awareness of a submerged, angry, and unbiddable society under the surface of their wellordered cities is an old fear of the bourgeoisie, fed, in Europe, by memories of what happened during the French revolution. One of its greatest exponents was Zola, in his Rougon-Macquart novels. He contrived then to raise a great many of the issues which sociologists are raising now, from social injustice to genetic determinism (this latter notion is presumably what appeals to Mr Baker).
EDITORIALS
Preventing
pressure
sores
irremediable afflictions of sign of acute illness-that longstay patients much is slowly being realised. They are caused by failure of the peripheral circulation, which is less immediately fatal than systemic failure but often much longer lasting in its effects. In their inaugural study of pressure sores in elderly patients, Norton et all suggested the connection with illness by their observation that 70% of sores occurring in hospital did so within the first two weeks (ie, when patients are most ill), and by including general condition, confusion, and incontinence-important non-specific signs of illness in old people-in their pressure sore Pressure
sores
are
not
but
a
The only specialty in which doctors have accepted responsibility for pressure sores-spinal cord injuryhas evolved very successful protocols for prevention and management. However, much of its skill is employed in repairing the appalling sores that result from the lack of training of primary care teams in the district general hospitals. All too often measures for pressure relief are instituted only after evidence of necrosis has already appeared. Sick patients in highrisk groups-ie, those with old spinal cord injury, neurologicalor vascular disease12,13 and elderly patients2-are still nursed for long periods in chairs in the belief that this practice prevents bedsores, although numerous studies have shown that patients in chairs are more likely to have sores than patients in
However, by continuing to regard pressure chiefly as a failure of nursing care, they unfortunately helped to perpetuate an extraordinary practice-pressure sores must be the only remaining major disorder, affecting about 10% of patients in developed countries,2-4 for which most doctors do not accept responsibility. Leg ulcers, another very neglected area, have sporadically challenged the ingenuity of surgeons5 or
2,14,15 Posture and pressure relief must form part of the general medical care of all acutely ill patients-in accident and emergency departments, operating theatres, and intensive care and recovery wards.16 General practitioners also need to ensure that they have immediate access to pressure-relieving equipment when illness strikes elderly and disabled
the consciences of dermatologists,6but pressure sores probably still do not figure in any undergraduate curriculum. Even consultants in departments of medicine for the elderly, where up to 30% of patients in the acute wards are likely to be at risk,1,3have seldom had any training in methods of prevention and management. Action groups such as the Tissue Viability Society’ and the King’s Fund Pressure Sore Study Groups in the UK and the National Pressure Ulcer Advisory Panel9 in the USA have addressed themselves mainly to nurses and paramedical workers. Most astonishing of all, the courts, which have recently made awards of up to C 100 000 for a pressure sore,1O have confined their investigations almost entirely to nursing management, although the acute ischaemic episode which precipitated the necrosis is more likely to have occurred in the accident and 11 emergency department or on the operating table,l1 and therefore to have been the responsibility of the admitting doctor, anaesthetist, or surgeon rather than of the nurses who subsequently had to care for the
It is still unclear why illness exacerbates liability to pressure necrosis. Reduced sensation and mobility;17 sedation; pain;18 vasomotor failure;19 low blood pressure;20 peripheral vasoconstriction due to shock, heart failure, or sympathomimetic drugs;13 dehydration causing increased tissue defonnability;21 septicaemia ;22 nutritional deficiency ;23 and endothelial changes22 probably all play a part and should be treated if possible. Meanwhile, emergency prevention must depend on modifying pressure on the body. Modem methods of measuring tissue viability21,24 have revealed the importance of the high interstitial pressures and capillary deformation produced by bony prominences inside the body in the production of deep sores ’25as distinct from the superficial tissue distortion associated with humidity and friction26 that causes dermal sores. These observations explain why soft pressure-relieving mattresses that rely on low interface pressures26 may help to prevent superficial sores but are usually unable to prevent deep sores in very sick patients unless the patients are also repositioned regularly.27 Since two-hourly turning is
prediction
score.
sores
patient.
patients.
1312
unacceptable to most old people and seldom practicable in busy wards or in the community, much effort has been expended on the design of pressurerelieving mattresses that prevent sores without the need to turn the patient. Flotation beds28 can do this, but are not portable and are unsuitable for emergency use. Moreover, they cannot be used for orthopaedic patients (one of the groups most in need of pressure care") and are disliked by most old people because of their instability. Air flotation beds are also prohibitively expensive. 27 Alternating pressure air mattresses (APAMs) provide a more physiological approach. Like repositioning, they aim to represent the natural method of preventing pressure damage over bony prominences-ie, by constantly changing the areas of support, thereby allowing restoration of the blood supply and reactive hyperaemia and cell repair to take place. Large-celled APAMs have been shown in controlled trials to prevent and heal pelvic and heel sores without repositioning29,3o and have the added advantage of providing a firm surface for nursing care. Unfortunately, ill-considered demands for cheap APAMs in the past resulted in the production of poorly designed unreliable machines,31 but stronger models are now available30 and the publication of a British Standard should ensure better performance in future. The Pegasus bed3O is portable and easy to use in the community as well as in hospital, and even simpler machines may be sufficient for most patients. Foolproof arrangements for distribution and servicing are essential.16 Only when every patient with a suspected spinal cord injury, new stroke, or femoral neck fracture can be routinely admitted onto an APAM and nursed on it-or provided with an equivalent manual method of pressure reliefthroughout the acute phase of his or her illness will we begin to see the end of pressure sores. D, McLaren R, Exton-Smith AN. An investigation of geriatric nursing problems in hospital. Edinburgh: Churchill Livingstone, 1975.
1. Norton
SM, Clark MO. Incidence of pressure in the Greater Glasgow Health Board area. Lancet 1977; ii: 548-50. 3. Warner U, Hall DJ. Pressure sores: a policy for prevention. Nursing Times 1986; 82: 59-61. 4. Allman RM. Epidemiology of pressure sores in different populations. Decubitus 1989; 2: 30-33. 5. Blair SD, Wright DDI, Backhouse CM, Riddle E, McCollum CN. Sustained compression and healing of chronic venous ulcers. Br Med J 1988; 297: 1159-61. 6. Ryan TJ. The management of leg ulcers. Oxford: Oxford University Press, 1983. 7. Editorial. The TVS—has it achieved better patient care? Care Sci Pract 2. Barbenel JC, Jordan MM, Nicol sores
1989; 7 (no 2): 30. Livesley B. The prevention and management of pressure sores in Health districts. King’s Fund Centre for Health Services Development: a document produced by the Pressure Sore Study Group 1989. Available from the Academic Unit for the Care of the Elderly, Charing Cross Hospital, London. 9. Editorial. Pressure points. Decubitus 1990; 3: 10-11. 10. Robertson JC. £100 000 damages for a pressure sore. Care Sci Pract 1987; 5 (no 3): 2. 11. Versluysen M. How elderly patients with femoral neck fracture develop pressure sores in hospital. Br Med J 1986; 292: 1311-13. 12. Versluysen M. Pressure sores in an orthopaedic population: an epidemiological survey. City and Hackney Health District, London: Nursing Research Papers 1983, no 1. 8.
13. Strunk H, Osterbunk J. Pressure induced skin lesions in cardiac surgery. Care Sci Pract 1988; 6 (no 4): 113-15. 14. David J. The size of the problem of pressure sores. Care Sci Pract 1981; 1 (no 1): 10-13. 15. Nyquist R, Hawthorn PJ. The prevalence of pressure sores within an area health authority. J Adv Nursing 1987; 12: 183-87. 16. Hibbs PJ. Pressure area care for the City and Hackney Health Authority. City and Hackney Health Authority, London, 1988. 17. Exton-Smith AN, Sherwin RW. The prevention of pressure sores—the significance of spontaneous bodily movement. Lancet 1961; ii: 1124-26. 18. Barrett E. A review of risk assessment methods. Care Sci Pract 1988; 6 (no
2): 49-52. 19. Guttman L. The prevention and treatment of pressure sores. In: Kenedi RM, Cowden JM, Scales JT, eds. Bedsore biomechanics. London: Macmillan, 1976: 153-59. 20. Leung KH. Interface pressure: can blood pressure be the equation? Decubitus 1989; 2: 8. 21. Bader DL, Grant CA. Changes in transcutaneous oxygen tension as a result of prolonged pressure at the sacrum. Clin Physics Physiol Meas 1988; 9: 33-40. 22. Barton A, Barton M. The management and prevention of pressure sores. London: Faber and Faber, 1978. 23. Kaminski MV, Pinchcofsky-Devin R, Williams S. Nutritional management of decubitus ulcers in the elderly. Decubitus 1989; 2: 20-30. 24. Clark M, Rowland LB, Wood HA, Crow RA. Measurement of soft tissue thickness over the sacrum of elderly hospital patients using B-mode ultrasound. Decubitus 1989; 2: 63. 25. Young JB. Aids to prevent pressure sores. Br Med J 1990; 300: 1002-04. 26. Lowthian P. Pressure sore prevention. Nursing 1989; 3: 17-23. 27. Bliss MR. Prevention and management of pressure sores. Update 1988; 36: 2258-68. 28. Krouscop T, Williams R, Krebs M. The effectiveness of air flotation beds. Care Sci Pract 1984; 4: 9-11. 29. Bliss MR, McLaren R, Exton-Smith AN. Preventing pressure sores in hospital: controlled trial of a large celled Ripple mattress. Br Med J 1967; i: 394-97. 30. Exton-Smith AN, Overstall PW, Wedgewood J, Wallace G. Use of the ’Air Wave System’ to prevent pressure sores in hospital. Lancet 1982; i: 1288-90. 31. Bliss MR. The use of Ripple beds in hospitals. Hosp Health Serv Rev 1979; 74: 190-93.
The underclass The underclass, the hostile alternative society of the dispossessed and excluded, haunts modem America and is coming to haunt Britain too, as board and lodging houses, cardboard "Thatcher bungalows" under bridges, and proliferating beggars attest.’ Moreover, the British Government seems strangely attracted to this brainchild of the American political scientist, Charles Murray. Murray has espoused the topic, often in print; his latest book, The Pursuit of Happiness, is not yet published but Kenneth Baker, Chairman of the Conservative Party, has seen a copy. "Brilliant", he commented, when he deviated from his prepared keynote speech before a small audience at the Centre for Policy Studies on May 9.3 Murray was also speaking at the conference. However, there is nothing new about the underclass: awareness of a submerged, angry, and unbiddable society under the surface of their wellordered cities is an old fear of the bourgeoisie, fed, in Europe, by memories of what happened during the French revolution. One of its greatest exponents was Zola, in his Rougon-Macquart novels. He contrived then to raise a great many of the issues which sociologists are raising now, from social injustice to genetic determinism (this latter notion is presumably what appeals to Mr Baker).
