Dr. Jeffrey Levine is a well known and respected geriatric doctor who specializes the prevention and treatment of pressure ulcers.  He recently wrote an article on his blog about new research on hospital acquired pressure ulcers from the new study published in the Journal of the American Geriatrics Society.  Below are excerpts from Dr. Levine’s article.

The study sheds light on hospital acquired pressure ulcers (HAPU) with data on epidemiology, mortality, and patient characteristics. Its results are certain to fuel the debate on avoidability of pressure ulcers.

The majority of HAPU’s were located on the coccyx or sacrum (41%) followed by hip and buttocks (23%) and heels (23%). Several patient characteristics were associated with HAPU including age, obesity and use of corticosteroids. Associated diagnoses included cancer, congestive heart failure, emphysema, stroke, and diabetes mellitus. Patients with HAPU had higher in-hospital mortality, increased mortality within 30 days of discharge, and higher readmission rates within 30 days. Patients with HAPU had significantly longer hospital length of stay (11.6 ± 10.1 days) compared to those without (4.9 ± 5.2 days).

This study is valuable because it provides the first reliable national benchmark rate for HAPU occurrence. But is this rate of 4.5% acceptable for an outcome known to be associated with deficits in quality of care? In their discussion, the authors suggest that the rate “might be acceptable” because of prevention programs currently implemented in hospitals across America. Such a view would support the theory that pressure ulcers can develop independent of good care, supporting the “unavoidable” theory. However this research does not supply any supportive date for the assumption that HAPU developed in the presence of preventive measures.

It is not surprising that HAPU were associated with higher in-hospital and post-discharge mortality, and the authors carefully note that their data do not infer a causal relationship between pressure ulcers and death.  However, these findings might provide new support for the SCALE theory – or Skin Changes at Life’s End – which states that pressure ulcers might be an unavoidable consequence of impending death.

The study does not offer explanation for the wide geographic variation in hospital acquired pressure ulcer rates. Why is the HAPU rate in Pennsylvania nearly twice the rate in Wisconsin? The answers could include quality of prevention measures, quality of documentation, array of co-morbidities, or other population characteristics of hospitalized patients. It would be interesting to follow HAPU rates to determine the effect of CMS policy changes which deny payment to hospitals for new stage 3 and 4 pressure ulcers, a rule which which went into effect October 2010 — after the study period for this article. Hopefully these questions will be addressed in future research.

For further information, we encorage you to vist Dr. Levine’s blog which has many excellent articles on this issue.


A new clinical study spearheaded by UCLA’s School of Nursing has found a direct correlation between pressure ulcers — commonly known as bedsores — and patient mortality and increased hospitalization.  The research is the first to use data directly from medical records to assess the impact of hospital-acquired pressure ulcers on Medicare patients at national and state levels.
According to the study, featured as the lead article in the current issue of the Journal of the American Geriatrics Society, seniors who developed pressure ulcers were more likely to die during their hospital stay, to have longer stays in the hospital, and to be readmitted to the hospital within 30 days of their discharge.

The study found that 4.5 percent of the patients tracked acquired a pressure ulcer during their stay in the hospital. The majority of these bedsores were found on the tailbone or sacrum, followed by the hip, buttocks and heels. The study also revealed that of the nearly 3,000 individuals who entered the hospital with a pressure ulcer, 16.7 percent developed at least one new bedsore on a different part of their body during their hospitalization.

On July 23rd, I posted an article about the Brown University study on feeding tubes and pressure ulcers.  The well-respected expert on geriatric pressure ulcers, Dr. Jeffrey Levine wrote the below article in response to the study that you can find on his website.  See link here.

The medical literature concerning patients with advanced dementia has consistently shown that feeding tubes provide little benefit.  Complications of feeding tubes can include aspiration pneumonia, diarrhea, agitation, need for physical and chemical restraint, and insertion complications such as wound infection. A new article has shown that feeding tubes can increase risk for pressure ulcers, and do not promote healing of pre-existing ulcers. This article will fuel discussion not only of risks and benefits of tube feeding, but the avoidability or unavoidability of pressure ulcers. However there were issues not addressed by this paper, such as the adequacy of nutritional content once the tube is inserted.

The paper was entitled Feeding Tubes and the Prevention or Healing of Pressure Ulcers and it was published in the Archives of Internal Medicine. The authors studied whether feeding tubes inserted directly into the stomach (PEG tubes, acronym for percutaneous endoscopic gastrostomy) are associated with pressure ulcer development and/or healing in nursing home residents. Using a very robust data set, they found that feeding tubes were not associated with prevention or improved healing, and that PEGs were associated with increased risk for pressure ulcers.

Pressure ulcers are costly, often preventable, and can result in infections, painful surgical procedures, prolonged rehabilitation, disfigurement, and death. The controversy over the avoidability of pressure ulcers has escalated over the last several years, particularly since the 2008 Medicare rule which placed hospital acquired pressure ulcers on the “no pay” list. The National Pressure Ulcer Advisory Panel jumped into the fray by issuing a consensus statement saying that not all pressure ulcers are avoidable. New theories have been developed accounting for the unavoidability of some pressure ulcers, particularly the expert consensus statement called SCALE, or Skin Changes at Life’s End.

One important variable that was not studied in the feeding tube paper was the adequacy of tube feeding content. Tube feeding delivers nutrients that include protein, calories, and vitamins, and if feeding is inadequate a state of malnutrition will ensue, and pre-existing nutritional deficits will worsen. The research evidence to support nutrition as a factor in pressure ulcer prevention has been inconclusive, but that does not mean that this relationship does not exist.  Indeed most experts and clinicians, including myself, will say that malnutrition is an important factor in pressure ulcer occurrence, and nutritional support is critical for wound healing. The commonly accepted caloric requirement for wound healing is 30-35 Kcal/Kg – a factor not considered in the Archives paper.

It makes sense that tube feeding increases the risk for pressure ulceration. Patients with tube feedings must be positioned with the head of the bed elevated to lower the risk for aspiration pneumonia – but this increases shear forces and decreases the ability to turn, thereby increasing risk of developing pressure ulcers over the buttocks or sacrum. Once a tube is inserted however, the patient must receive adequate protein and calories as determined by a competent nutritionist and ordered by a physician who understands the issues. In all cases of end of life decision making, the risks and benefits of tube feedings must be thoroughly explored, and patients and their families need to make informed decisions. The growing body of research shows that tube feeding in persons in advanced dementia offers very limited benefits.


Brown University released a study funded by the National Institute on Aging and published in the May 14th edition of the Archives of Internal Medicaine.  The new study led by Brown University researchers reports that percutaneous endoscopic gastric (PEG) feeding tubes may make the pressure ulcers more likely to develop or not improve.

“This study provides new information about the risks of feeding tube insertion in people with advanced cognitive impairment,” said lead author Dr. Joan Teno, a gerontologist and professor of health services, policy, and practice in the Public Health Program at Brown. “We see a substantial risk of people developing a stage II and higher pressure ulcer. We believe these risks should be discussed with family members before a decision is made to insert a feeding tube in a hospitalized nursing home resident with advanced cognitive impairment.”

Over a particular timeframe, they compared thousands of patients with and without ulcers who received a feeding tube to three times as many statistically similar patients with and without ulcers who did not get a tube.

–35.6 percent of those with a feeding tube ended up with at least a stage II ulcer.

–19.8 percent of patients without a feeding tube did.

The chance of getting an ulcer was 2.27 times higher for people with feeding tubes than for those without. The risk of developing a more serious stage IV ulcer was 3.21 times higher for those with feeding tubes compared to hospitalized nursing home residents without a feeding tube.

Among patients who already had an ulcer, the researchers found that 27.1 percent of patients with a feeding tube saw short-term improvement, but 34.6 percent of those without a feeding tube experienced healing in a comparable timeframe.

The odds of an ulcer getting better for people with a tube were 0.7 times as high for people without a tube, meaning their chances for improvement with a tube were less than for people without a tube.

The new findings should lead doctors, nursing homes, and families to ask more questions about whether feeding tubes are appropriate treatments, compared to careful hand feeding with assistance and encouragement, for patients who have become so cognitively impaired that they can no longer eat independently.


McKnight’s had an article about a recent report from the Agency for Healthcare Research and Quality about nursing home residents with pressure sores.  The numbers have fallen over the last decade.  "Both long- and short-stay nursing home residents saw improvements in rates of pressure sores, according to the report. Among short-stay patients, the rate fell from 22.6% in 2000 to 18.9% in 2008. The percentage among long-stay patients fell from 13.9% in 2000 to 11.7% in 2008. 

The AHRQ report also found that the percentage of long-stay nursing home residents who require help with activities of daily living has generally held steady since 2000. But while the overall percentage remained at 16.2% between 2000 and 2008, the percentage of long-stay residents up to 64 years old needing help with ADLs did increase from roughly 10% to 12%. AHRQ is an agency within the U.S. Department of Health and Human Services.


The Department of Health & Human Services recently released its annual report on the quality of health care Americans receive, and hospitals still have work to do to put an end to the ongoing – but solvable – problem of Healthcare-Associated Infections (HAIs).  To help achieve this goal, Kimberly-Clark Health Care launched "Not on My Watch" (www.haiwatch.com), a website that provides tools and information to help health care professionals and facilities eliminate HAIs.

For more information, contact:
Barbara Dunn

Standard definitions of infections for use in long-term care facilities would be helpful, both as guidelines for surveillance and as outcome measures for studies of infections and infection control in these facilities.  A new set of definitions was developed at a consensus conference held in January 1989 and subsequently revised by a modified Delphi technique involving consensus conference participants.

Discussion at the conference was based on definitions developed at Yale University (Checko P, et al., unpublished manuscript) and revised by the Co-operative Infection Control Committee1 and on detailed reviews of these definitions written by a sample of 62 infectious disease physicians,
geriatricians, infection control practitioners from long-term care facilities, and authors of published
research in the field. They are intended specifically for use in facilities that provide homes for elderly residents who require 24-hour personal care under professional nursing supervision.

Caymanmama.com had an article about problems found at Mustang Manor Assisted Living Center including 27 nutrition and sanitation-related issues..  The Oklahoma State Department of Health (OSDH) found problems with on-site cleanliness, nourishment, and the overall welfare of the elderly residents. Reports show the Mustang Manor has been cited for numerous unspecified violations of safety and health in the last two years. These issues amounted to an excess of $35,000 in OSDH-issued penalties. 

Beyond claims of safety and health hazards at the nursing home, officials from the Mustang Police Department have received complaints of criminal activity at the establishment. According to Mustang Police Capt. Willard James, “We received a call that a resident had actually written checks to an employee of the business and had them cashed to have the money returned to her, and she had not received those funds.”

Often the two major areas where a nursing home can cut operating costs to improve profits is staffing and nutrition.  Many nursing homes cut staffing especially of RNs and LPNs to make more money for their corporate owners. 

Nutrition and sanitation are very important to prevent pressure ulcers and infections.

There have been several articles about the lawsuit filed against Everett Rehabilitation and Care Center that neglected a resident’s penis until it rotted off.  See articles here, here, and here.

A lawsuit has been filed against a Washington state nursing home accused of neglecting Charles Bradley’s penile infection.   The lawsuit states that Bradley was taken to an emergency room, where doctors discovered his penis had decayed, leaving only a gaping wound. He died 18 days later, in March 2008.   The lawsuit cites an investigation by the state Department of Social and Health Services, which shows the nurse told a manager in November 2007 that the man had a wound on his penis. Staff noticed that Bradley’s skin was breaking down while changing his diaper in November 2007.  The records say the manager forgot about the report and neglected to properly care for the wound.  Though staff notified a care manager, that manager failed to notify Bradley’s doctor. Instead, the manager went on a three-week vacation and when she returned she forgot about the nurse’s report.

Bradley’s family claim staff at the nursing home left a wound on the elderly man untreated for months. Nursing home records allege that staff changed the man’s diaper daily and provided him weekly baths between November 2007 and March 13, 2008.  During the four months that followed the initial notice of the wound, Bradley’s genitals essentially broke apart bit by bit while the elderly man steadily lost weight.   By allowing Bradley’s injury to fester and worsen for months, the nursing home and parent company SunBridge Healthcare Corp. violated a promise to care for him. "They trusted that the nursing home would provide the care they said they would provide," family spokesman said Wednesday. "We’re not talking about extraordinary care. We’re talking about basic daily needs."

An investigation conducted by the center’s director of nursing "did not find any impropriety" by staff. State regulators, though, issued the center a citation for failing to meet quality of care requirements set by federal law.  The state determined that the home failed to meet a federal standard for care. The man didn’t receive timely medical attention and the facility failed to notify his family or his doctor of changes in his health, the state determined. 

"There was no evidence the facility had contacted the resident’s physician … to allow for timely medical intervention," the state investigators said in an investigatory report provided by DSHS. "There was no evidence the facility had contracted their social services department or the resident’s family."  A financial penalty was not assessed.

“They definitely should have seen it. There was no documentation that his penis was beginning to fall off,” Gooding said. “We believe they chose not to put it in the records.”  Sounds like a cover up but no monetary fine was issued!



The NY Daily News had the tragic story of Verda Henry.  She entered a Westchester County nursing home in 2005 after she fell and injured her arm, thinking she would receive therapy and be home in a month.  Two years later, after repeated denied requests to go home, she in the  nursing home because of a horrific, infected bedsore.

Her daughter, Patricia Henry, said she and her children visited her normally active mother every day at Sutton Park, often for eight hours. The family complains that the facility was short-staffed.  "There would be a nurse and she would run between floors and they had no time," Henry said. "Nobody checks on her. Nobody feeds her. Every time we asked to take her home there was a reason we couldn’t."

One day, Patricia Henry went to change her mother’s gown and noticed the bedsore, already in an advanced stage, over her mother’s tail bone.   Within days the sore was infected and she heard her mother’s last words – screams – as doctors scraped at blackened skin.

"You could put your whole hand down in her back," she said. "You could see the bones and spinal cord. It was like raw meat. Mommy screamed until she couldn’t scream no more."   Henry wants justice for her mother, who died a painful death because of a negligent system.

Bedsores, or pressure ulcers, are lesions caused by unrelieved pressure on the skin. They are largely preventable with adequate nutrition and by making sure a patient is regularly moved or turned every two hours, but are also often fatal once infected.