Imagine that every day, hundreds of patients of all ages were suddenly admitted to hospitals around the country whose preventable conditions required the spending of NIS 80,000 to NIS 160,000 apiece to treat them; 10% of them nevertheless die. Milder degrees of the condition, which are less expensive to deal with, occur in tens of thousands.
Surely, the newspapers would run frontpage banner headlines, prime-time TV news shows would interview experts, MKs would demand special sessions to investigate the resulting financial crisis and the health and finance ministers would hold an urgent joint press conference presenting a program to grapple with this growing epidemic.
In fact, this situation exists today in Israel, right under our noses – and with the growth and aging of the population, it is getting worse. The Health Ministry has issued a few internal memos in the last two decades but no press releases to inform the public; and apparently none of the dozens of health ministers since 1948 has given a speech about it. As a result, the media have ignored the issue, and the public at large remains unaware of it.
The condition is pressure ulcers, which used to be known to physicians as “pressure sores” and before that as “bedsores” (the terminology was changed as they develop not only in bed). PUs most often occur in deep underlying tissue and on parts of the skin that are close to bones, such as the back, tailbone, ankles, elbows, heels and hips. PUs develop in areas of damaged tissue caused by staying in one position for too long in bed, on a regular chair or in a wheelchair.
Although most common in the elderly, they occur also in children, young adults, the middle aged and even premature babies.
Pressure-associated injuries in hospital settings and care facilities occur to as many as 20% of patients, says biomedical engineering Prof. Amit Gefen of the engineering department of Tel Aviv University. The only Israeli scientist involved in basic research into how to prevent PUs from developing (there are those who carry out clinical research into the subject), Gefen served two years president of the European association on pressure ulcers.
“Research costs money, and it’s hard to find. Fortunately, a few months ago I received NIS 1.5 million from the Science, Technology and Space Ministry and the Technion-Israel Institute of Technology for a study on preventing PUs in the elderly; it was the largest-ever grant in this field here,” he revealed.
Last week he organized the first interdisciplinary conference on pressure sores.
Held at the Leonardo City Tower Hotel in Ramat Gan, it was attended by more than 300 physicians, nurses, researchers and representatives of the Health Ministry and the health funds.
One of 10 patients with spinal injuries will die from pressure sores, he said, and 20% to 30% of patients in internal medicine and geriatric departments develop pressure sores.
He completed degrees at TAU in mechanical engineering, a master’s degree in biomedical engineering and a doctorate on the biomechanics of the “diabetic foot,” in which uncontrolled sugar levels can lead to nerve damage, causing diabetics to lose feeling in their feet. They may not feel a sharp object underneath when they walk barefoot, causing a sore, blister or cut that results in ulcers and infections.
He has published a large number of technical articles in scientific journals on subjects ranging from perspectives on PU prevention using prophylactic dressings to computer modeling studies to an assessment of the risk of deep-tissue injury in the heels of diabetics and tissue changes following spinal-cord injuries and the use of wheelchair cushions.
In an interview with The Jerusalem Post before the conference, Gefen said that “one doesn’t hear about pressure ulcers because the subject doesn’t have strong lobbies like those for cancer, cardiovascular diseases or osteoporosis that are able to get large budgets for research. It isn’t a specific discipline in medicine.”
He added that from his conversations with people at medical and nursing schools and their graduates, “the subject gets about a half an hour of class discussion.” Moreover, Gefen said, “the hospitals don’t like to talk about it because they are exposed to liability and lawsuits from patients who claim improper behavior of staffers or medical equipment caused their pressure ulcers.”
A few years ago, the Health Ministry started to publish health indicators as reflected by how well their staff repair fractured hips; prevent infections by giving antibiotics to surgical patients; perform CT/MRI scans soon after stroke patients arrive; do heart catheterization within 90 minutes of hospitalization for coronary infarction; and assess pain. All these benchmarks are provided to compare quality in medical centers, but the ministry has never included the number of pressure ulcers in patients among its indicators; it doesn’t have the right tools to measure it.
“PUs are caused by the environment and are preventable. A nurse in a geriatric hospital takes a patient out of bed and puts him on a plain plastic chair to watch TV... He may return to his bed with a pressure ulcer that can take weeks, months or a year to heal – or it may not heal at all and result in the patient’s death. There is plenty of room for improvement on training medical professionals,” Gefen said.
THE PROBLEM is widespread throughout the world, “but in England, nurses are taught in special courses on tissue viability.
There is nothing like that here; our Health Ministry must do as the British National Health Service does, collecting statistics and giving special training. There are PU nurses in our health funds, but there is only one for several of their branches, which is really inadequate for their patients’ needs,” he continued.
Doctors and nurses in intensive care units and emergency rooms are busy with other medical priorities, such as saving lives and stabilizing the patients. Pressure sores, according to Gefen, “do not have top priority.”
While the too-high rate of nosocomial (in-house) infections in Israeli hospitals makes it beneficial for families to take care of chronic patient at home, relatives are busy and not well trained in prevention of PUs, so they develop at home, too, as patients lie too long in one position in their beds.
In addition, when the causes of death are collected by the Central Bureau of Statistics for the ministry, they never give pressure ulcers as one of them. Instead, it is infections or organ failure, for example.
“As a result,” said the engineer, “decision makers such as health ministers and directors- general make decisions on the basis of these official statistics.”
Another problem with PUs is that patients or relatives of patients don’t know where to go for treatment – “a general practitioner, a dermatologist, a physiotherapist, a diabetes specialist, a plastic surgeon, a gerontologist? Who? If you have chest pains, you know where to go. A team that treats PUs has to be interdisciplinary and give holistic care, as there are many factors. As the sores develop deep into the body, they often appear on the skin when it is too late to treat it properly. Only recently has the scientific understanding of imaging deep in the body – and not just the skin – advanced. One has to notice changes carefully before the sore develops necrotic tissue.”
Unbelievably, even healthy children in hospital can develop PUs, which in their case are related to medical devices that are left under them in their beds or attached to their bodies. A catheter or an electrocardiogram electrode in a young heart patient could be forgotten. Premature babies with very tender skin, said Gefen, could suffer sores from oxygen face masks that are produced by making smaller versions than for children or adults. But, he continued, premature babies’ faces are structured differently than for their elders, so rubbing can cause sores.
“They heal faster in children than in adults, but they can still cause permanent damage.”
Teenagers who were seriously injured in road accidents and lost their sense of feeling often develop sores without the medical staff noticing.
“My research concentrates on younger people, because they can live for 60 or 70 years more if they are treated right. But I also do research on preventing PUs in the elderly.”
Gefen does not blame doctors and nurses but rather the medical equipment industry, which has not designed devices specially for children who are hospitalized.
“They miniaturize, just as bicycle helmets for children are smaller versions of those designed for adults. But youngsters have different compositions of fat vs. muscles, and their skin is not mature. 3-D printing could be used to make suitable items. In my lab we are developing devices that are age specific and are biomechanically compatible.”
The subject of PUs is “not hopeless,” concludes Gefen. “Breast cancer used to be considered hopeless, but today, it is largely regarded as a chronic disease that can be handled.”
THE YAD Sarah organization, whose 105 branches lend out medical equipment for home (and sometimes hospital) use, have a basic mattress. Its showrooms of equipment that can be borrowed or purchased is excellent, said Gefen. But the mattresses and special beds are inexpensive, and expensive ones needed to treat patients who already have serious sores can cost tens of thousands of shekels. Air-cell based cushions are generally more effective in protecting patients with a history of severe pressure injuries, compared to flat foam cushions. Hospitals never have enough of the most expensive ones; nurses use a point system to determine who gets them.”
Adjustability, he said, is a key component when it comes to adequate design; selection of wheelchair cushions should take into account external and internal anatomy, as well as tissue structure.
“An ideal cushion should be carefully tailored to the individual and be adequately adjustable to accommodate the physical changes that occur over time. Cushions also wear out, so people should be assessed and the cushions evaluated and replaced regularly to protect from pressure injuries.”
Yad Sarah occupational therapist Noa Wachtel-Spector, who runs the organization’s Tel Aviv showroom and advises on PUs, told the Post she encourages families to look at its website to understand what equipment can best suit the patient and how to use it.
“We could buy 1,000 simple mattresses for preventing sores in some patients for a few hundred shekels or a handful of very-expensive ones that cost up to NIS 40,000 to treat patients with severe sores; we decided to do the latter. In the old days, families used cheap eggshell-foam mattresses. Today, we lend out more advanced models with a motor that blows air into them. It is important not to inflate them too much.”
DR. EPHRAIM Jaul, a veteran geriatrician and director of the complex nursing department at Jerusalem’s Herzog Hospital, told the Jerusalem Post that the subject of PUs is important and too neglected. He and his Herzog colleague Dr. Oded Meiron have just published a breakthrough article in the Journal of Alzheimer’s Disease suggesting that there is a close pathophysiological connection between having this type of dementia and developing pressure sores due to a specific peripheral biomarker and pathway from the brain. Even anemia can be a factor in causing PUs, he said.
Sores develop not only from pressure but also from moisture from urine, stools and other liquids, from friction and from spasticity.
“A third of the patients in our 36-bed unit from other hospitals or from homes come with pressure ulcers. The subject is not discussed enough in the medical community.”
Finally, although pressure ulcers involve all ages, the Health Ministry did not allow medical administrators dealing with all ages to comment on the subject. Instead, Dr. Aaron Cohen, the chief of the geriatrics department, was permitted to speak. His assistant sent the Post a list of seven directives on PUs issued by the ministry to institutions since 1997.
“It is not an attractive subject for the public, but with the aging of the population, it is becoming a higher priority. If the situation of PUs improves for the elderly, it will get better for all who suffer from them.”
He could not say how much is taught about PUs in medical and nursing schools.
The last ministry survey on pressure ulcers was released to the health system in 2001, he conceded. A newer one was launched in 2015, “but its findings have not yet been published.”
There are 40,000 bedridden patients cared for at home, and they are a high-risk group.
“We want to give incentives to the four public health funds to deal more seriously with the subject – especially prevention. We will issue guidelines on taking people at high risk for sores out of bed. We want the National Insurance Institute to finance more at-home nursing hours. I think there is awareness of the subject, but more needs to be done.”