What are the dangers of spending time in hospital? It sounds like a funny question – why be admitted if you risk getting sicker? – but one with potentially deadly consequences. If nothing else, that became clear during the pandemic, when 24% of British hospital patients contracted Covid in December 2020. On the contrary, the Centre for Disease Control and Prevention (CDC) warns that Americans suffer from a bewildering 1.7 million healthcare-associated infections every year, with surgical wounds and urinary tract infections hovering near the top of the list. These figures make a grim kind of sense. With an average of 342 stroke victims entering NHS hospitals on an average Wednesday, wards across the developed world, and many more beyond, are necessarily going to be heaving. That obviously gives opportunities for diseases to spread, especially since many patients are being admitted precisely because they suffer from some kind of infectious disease to begin with. In a sense, though, all these eminently comprehensible reasons for hospital infections make the fact that patients also suffer from avoidable, non-infectious illnesses even more shocking.

This is surely most clear when it comes to pressure ulcers. Known colloquially as bed sores, they typically form, as the name suggests, through pressure – for instance the pressing of skin against a hospital bed. Friction and shearing – when two surfaces move in opposite directions – are frequent triggers too. But what unifies all these sparks is the fact that they can be defeated without isolating patients or making them wear masks. Remove the pressure, as the theory goes, and the pressure ulcer is far less likely to form. As so often in contemporary healthcare, theory and practice are rarely happy bedfellows, meaning the fundamental problems of pressure ulcers show little sign of abating.

Unwelcome bedfellows

Few people are better placed to understand the dangers of bed sores than Dr Marissa Carter. A student of pressure ulcers for decades, in 2000 she founded Strategic Solutions, a company that helps design clinical trials. And as Carter explains, pressure ulcers, or as she calls them ‘pressure injuries’, have become an almost unavoidable part of medical life. “There’s been a great deal of discussion on how to prevent pressure injuries,” she says. “One of the things that is really annoying is that the top view – that all pressure injuries are preventable – is not entirely true.” With the average hospital patient or care home resident spending hours in bed each day, there are ample opportunities for the sheets to rub against the body, or for the way someone is lying to put pressure on vulnerable joints. From there, and especially in vulnerable areas like the spine, it’s often just a matter of time before this disrupts the flow of blood through the skin, starving the area of oxygen and nutrients and leading to the formation of an ulcer.

In practice, these ulcers can presage a number of serious health problems. While the first two ‘stages’ of an ulcer generally just cause redness and itching of the skin, the third affects the fatty tissue underneath. The fourth and final stage, for its part, can ultimately make tissue die, heightening the risk of infection and even leaving muscle and bone exposed. All told, a shocking 69% of people with stage four ulcers die within 180 days of them forming – which explains Carter’s insistence on calling the condition an ‘injury’. A few decades ago, she stresses, it was “shown very clearly” that neglect in nursing homes caused a lot of pressure ulcers in elderly patients – “and that was avoidable”.

Tossing and turning

This last point – the potential avoidability of pressure ulcers or injuries – really strikes at the heart of the problem. For if a lack of movement, and the pressure that results, can bring about an ulcer, it follows that the opposite is also true. Not that warding off pressure ulcers is simply a matter of prodding patients to shift their weight.

In large part, that’s a question of capacity. UK bodies like the National Institute for Clinical Excellence – and its cousins overseas – may boast detailed guidance on offloading weight from patients. But in a country like England, where around 40,000 nursing positions are currently unfilled, finding the time to physically turn hundreds of patients can prove challenging. Special mattresses made out of foam or gel exist to help prevent pressure ulcers, but Carter is sceptical: “I’m not aware of any literature that says those mattresses show superiority over proper offloading by other means.”

She stresses that teaching people outside the average hospital ward about the tell-tale signs of pressure ulcers is one important strategy for prevention. “Primary care physicians get to see pressure ulcers when they’re not being caught in other areas of medicine,” she says. “Those are the ones that do need to start the education process with the patients.”

The blame game

Once again, however, simply educating patients about what they can do to defeat pressure ulcers is easier said than done. What, for instance, to do about people in care homes, many of whom suffer from dementia and who can’t possibly be expected to move themselves every few hours? “In a sense,” Carter says of these examples, “the patient is going to be their own worst enemy.” Perhaps it makes more sense to focus on longer-term strategies to fight the causes of the disease.

We know, after all, that avoiding cigarettes and drinking more fluids can drastically reduce the underlying conditions that promote ulcers, even if pressure is almost always the spark. Just as well, then, that organisations as varied as the Mayo Clinic and the NHS are promoting these healthy lifestyle choices on their websites.

As for offloading, Carter emphasises that patients can only be kept safe if hospitals and care homes develop strict protocols for turning them regularly. Especially in a world of chronic staff shortages, she argues managers need to make ward nurses into “stakeholders” and understand exactly how much capacity they have. This spirit of collaboration, must also encompass different institutions. Historically – and especially in the US, where these questions often have a financial angle – hospitals and care homes have tended to blame each other for the emergence of pressure ulcers in patients. “It’s a blame game,” Carter laments. “They’re claiming ‘well it started in your facility, not ours, so it’s not our problem’.”

It goes without saying that this approach is not good for patients. Far better, Carter continues, to leave the bickering over responsibility aside in favour of practical medical results. “How do these injuries propagate? How do they initiate? What can we do to prevent them from the very beginning?”

All these are eminently reasonable questions. Yet as so often with pressure ulcers, actually asking them in the real world is far from straightforward. No matter how easy pressure ulcers are to beat in theory, then, they seem destined to worry nurses and patients for many years to come.

2.5 million

The number of people who develop pressure ulcers across the US every 12 months – 700,000 people develop these ulcers in Britain each year.

Agency for Healthcare Research and Quality