At 85, my father-in-law, Jon, a widowed, retired school superintendent was a regular at Tuesday bingo and Thursday poker at his senior apartment. He and Ralph, his neighbor down the hall, enjoyed sparring about politics and sports during their daily meal together in the community dining room, and his days typically ended with a nightly cigar on the balcony. He motored around the neighborhood on his scooter blinged out with custom initial license plates that read: “J. Lo”.
But, gradually, Jon’s medical issues began to disrupt his routine. His long-standing diabetes resulted in peripheral neuropathy, limiting his ability to feel his feet. Cardiac issues made it difficult to sleep lying flat so he transitioned to nights spent in his recliner. Venous insufficiency caused leg swelling and peripheral arterial disease caused leg pain which limited his ability to walk. Growing progressively weaker and after several falls at his apartment, Jon was admitted to acute care for assessment.
During the subsequent rehabilitation stay, it became clear that Jon would need more support than was available at his apartment. He transitioned to assisted living and struggled. Not only was it difficult to get out of bed, even just sitting up in his chair was uncomfortable. He didn’t feel well enough to participate in physical therapy and ultimately, he missed his old home. Our encouraging, then concerned, long-distance calls grew more frequent. Less than 10 days later, Jon was re-admitted to the hospital with lower leg cellulitis due to a stage 4 pressure ulcer/injury on his left lateral malleolus. Given his medical complexities, peripheral arterial disease and lipodermatosclerosis caused by his chronic venous edema – limb salvage was not an option. He underwent an above the knee amputation, going from independent living to amputation in just 30 days.
Pressure injuries acquired at home can be more common.
Unfortunately, this type of situation is all-too common. The term "community-acquired pressure injury" refers to pressure injuries which develop while the patient is at home, experiencing or requiring a lower level of everyday care. The research of these types of pressure injuries frequently takes a back seat to hospital-acquired pressure injuries.
However, research looking at the prevalence of pressure injuries that are present on admission to acute care, showed their rates to be much higher than that of hospital-acquired pressure injuries. A recent retrospective study found that over a 3-year study period, an average of 6.5% of patients admitted to a large academic medical center had a community-acquired pressure injury, versus an average hospital-acquired pressure injury point prevalence of just 1.09% during that same timeframe.1 The majority of these were admitted to the hospital from home (70.4%) versus skilled nursing facilities (29.6%).
Prevention through awareness and assessment.
The realities of community-acquired pressure injuries will grow as our elderly population continues to “age in place”. 2 Since most pressure injuries develop in the community, there is a need for heightened awareness and education on the importance of skin assessment, pressure injury risk assessment, and early intervention. Home care providers, primary care providers, as well as patients or family members all need to be included in this effort.
Further research is needed to determine if pressure injuries acquired at home, and pressure injuries that are acquired in hospitals present different risk factors. Additionally, continued research regarding the implementation of prevention strategies outside of acute care is necessary.
Some areas to consider:
- Is a unique community-acquired pressure injury risk assessment tool needed?
- Should a total body skin assessment for patients determined to be at high risk be completed at primary care appointments?
- How can the importance of basic prevention strategies be emphasized to community-dwelling individuals and their caregivers?
- Can home care services be implemented for high-risk clients – focusing on skin assessment, education, and prevention strategies – before a wound develops?
- How can pressure injury prevention interventions be addressed in the plan of care at the time of acute care discharge?
Further research that addresses these questions can help us determine how to better prevent community-acquired pressure injuries before patients experience serious complications. For anyone who is in a position of care for older individuals, understanding the essential nature of assessment and intervention is an important step in prevention and care.
What could have been done to change the trajectory of Jon’s situation? Would earlier intervention have made a difference? Perhaps. As healthcare providers, we can learn from this story. Learn more about pressure injury solutions by visiting our pressure injury solutions and information page.
1. Kirkland-Kyhn H, Teleten O, Joseph R, Shank J. The origin of present-on-admission pressure ulcers/injuries among patients admitted from the community: results of a retrospective study. Wound Mgmt Prev. 2019 Jul;65(7):24-29.4
2. Corbett LQ, Funk M, Fortunato G, O’Sullivan DM. Pressure injury in a community population: A descriptive study. J Wound Ostomy Continence Nurs. 2017 May/Jun; 44(3):221-227.