Introduction
Pressure ulcers (PUs), also known as decubitus ulcers, pressure sores, pressure injuries or bedsores, are “localized injuries to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear” (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance
2014, 12). Pressure ulcers can start to develop deep in the body when sitting (Bliss
2004; Thorfinn, Sjoberg, and Lidman
2009; Linder-Ganz et al.
2007) or lying in one position without pressure relief (Bliss and Simini
1999; Bliss
2004; Schoonhoven, Defloor, and Grypdonck
2002; Moore and Cowman
2012). Notably, PUs may not become visible on the skin for several hours (Schoonhoven, Defloor, and Grypdonck
2002) or up to three weeks (Allman, Goode, and Patrick
1995; Sundin et al.
2000).
Pressure ulcers are a common condition at the end of life for residents in residential aged care facilities (RACFs) (Doupe et al.
2016; Jaul
2010; Jaul and Calderon-Margalit
2015). They can be extremely painful (Ahn, Stechmiller, and Horgas
2013; Pieper, Langemo, and Cuddigan
2009; Kwong et al.
2011) and the pain is often unrelenting (Woo et al.
2017; Gorecki et al.
2009; Bliss
2009). Screening residents for risk of PU as a strategy to introduce prevention interventions involves using a numerical screening tool and clinical judgement. However, the level of evidence for classifying residents using risk criteria from numerical tools is low (Sharp and McLaws
2006; Anthony et al.
2010; Chou et al.
2013). Unlike other screening tools in medicine, none of the commonly used PU risk screening tools has undergone rigorous testing for reliability or validity and none has been identified as a good predictor of PUs (Sharp and McLaws
2006; Franks, Moffatt, and Chaloner
2003; Defloor and Grypdonck
2004; Webster et al.
2011; Black
2015). Many nurses do not use screening tools (Samuriwo and Dowding
2014; Sharp et al.
2005; Wann-Hansson, Hagell, and Willman
2008; Defloor and Grypdonck
2004; Webster, Gavin, and Nicholas
2010; Sharp et al.
2000) but screen residents using clinical judgement to determine PU risk (Sharp and White
2015; Sharp and McLaws
2006; Anthony et al.
2010; Sharp et al.
2005,
2000).
One reason for the poor predictive ability of screening tools is many contain items that are not needed, do not contain items that would be clinically useful, have sub-scores that are not scaled optimally, and include items that are not independent predictors (Anthony et al.
2010; Sharp and McLaws
2006). Moreover, routine PU risk screening and screening for many other risks, such as pain in residents with dementia (Herr, Bjoro, and Decker
2006), falls (Lester et al.
2008), delirium (Weinhouse et al.
2009; O’Keeffe and Lavan
1999) and nutrition (Hamirudin et al.
2013) have become commonplace and consume considerable nursing resources with little benefit (Webster, Gavin, and Nicholas
2010). Screening tools may have some value in detecting residents who will develop PUs but have a high level of false positive responses. Falsely labelling residents as at-risk has resource implications when providing prevention strategies for residents who will not develop PUs (Franks, Moffatt, and Chaloner
2003).
The international
Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline (henceforth
Clinical Practice Guideline) recommends that screening is conducted “as soon as possible and within a maximum of eight hours after admission” (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance
2014, 16). But this recommendation for time to screen is not evidence-based or physiologically-based (Black
2015; Sharp and White
2015). Inflammatory mediators are released within the first four hours of exposure to pressure (Stojadinovic et al.
2013). Therefore, the consequences of leaving a patient or resident for up to eight hours prior to screening may increase the risk of PUs because unrelieved pressure anywhere from half an hour (Bliss
1994) to six hours is sufficient for PUs to develop (Salcido
2004; Linder-Ganz and Gefen 2007; Gefen
2008; Exton-Smith, Overstall, and Wedgewood
1982).
When physical or chemical restraints of residents have been associated with PU development, it is thought to be likely correlated with the residents’ inability to move to relieve pressure (Mott, Poole, and Kenrick
2005; Brower
1993). Residents may be restrained physically by belts, vests, and jackets in an effort to protect them from inflicting injury on themselves or others (Ben Natan et al.
2010; Chaves et al.
2007; Brower
1993) and to prevent residents from falling (Bellenger et al.
2017). Highly restrictive restraints have been associated with death from asphyxiation (Chaves et al.
2007), neck compression, and entrapment (Bellenger et al.
2017). The development of PUs in restrained residents in RACFs increases the facility’s exposure to legal action (Voss et al.
2005; Toolan et al.
2014; Brower
1993; Tsokos, Heinemann, and Puschel
2000). Successful litigants in Australia (Nelson
2003), the United Kingdom (Toolan et al.
2014) and the United States (Stevenson and Studdert
2003) may be awarded compensatory and/or exemplary damages. In the United States, lawsuits against RACFs have risen and nearly half have involved wrongful death, PUs, or both (Stevenson and Studdert
2003).
Commonly, once a patient or resident has been identified as at risk of PUs, two-hourly repositioning, twenty-four-hours-a-day, seven-days-a-week (24/7) is routinely instituted as the preventive strategy in hospitals and RACFs (Hagisawa and Ferguson-Pell
2008; Krapfl and Gray
2008; Clark
1998; Rich, Margolis, and Shardell
2011; Defloor, De Bacquer, and Grypdonck
2005; Gillespie et al.
2014). However, the evidence for this strategy is equivocal (Defloor, De Bacquer, and Grypdonck
2005; Gunningberg and Stotts
2008; Versluysen
1985; Rich, Margolis, and Shardell
2011) because PUs have continued to develop (Krapfl and Gray
2008; Gillespie et al.
2014). One explanation for the low level of evidence for two-hourly repositioning is an absence of evidence for the optimal frequency for repositioning (Peterson et al.
2013; Krapfl and Gray
2008; Clark
1998; Gillespie et al.
2014; Rich, Margolis, and Shardell
2011). Yet, alternating pressure air mattresses (APAMs) have been shown to prevent PUs (Bliss, McLaren, and Exton-Smith
1967; Manzano et al.
2013; Exton-Smith, Overstall, and Wedgewood
1982). In contrast to a punitive approach (such as exemplary damages), regulatory tools can be used in the spirit of prevention. For example, section 3 (item 3.2) of the Australian
Quality of Care Principles 2014 (
Cth) could be used to advance efforts to prevent PUs in RACFs by providing residents with “an air mattress appropriate to each care recipient’s condition.”
Although the cost to provide PU prevention to patients at risk can significantly increase health care services’ budgets, the costs to treat a severe PU were found to be substantially higher (Demarré et al.
2015). Lapsley and Vogels (
1996) identified the average additional bed day cost in Australia associated with PUs in 1990–1992 at A$483. Even when patients are discharged, the additional costs continue due to outpatient and/or home visits from the community nurse (Lapsley and Vogels
1996). In one systematic review, the cost of PU prevention and treatment differed considerably between studies. More recently, the cost of PUs in both hospital and RACFs in Australia totalled US$1.65 billion, with a standard deviation of US$1.05 billion (Graves and Zheng
2014).
Twenty-three years ago, APAMs were found to be more cost-effective than repositioning (Xakellis, Frantz, and Lewis
1995), and in a very recent randomized, controlled study, APAMs were found to be more cost-effective than a foam mattress in preventing PUs in elderly patients bedridden for more than fifteen hours per day (Sauvage et al.
2017).
According to the
Clinical Practice Guideline, “if changes in skin condition should occur, the repositioning care plan needs to be re-evaluated” (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance
2014, 23)
. The focus on skin condition is used as an early sign of pressure damage (Stojadinovic et al.
2013; Gefen, Farid, and Shaywitz
2013) and for residents’ skin tolerance for two-hourly routine repositioning (Wann-Hansson, Hagell, and Willman
2008). The focus on skin condition may overshadow the importance of immobility (Sharp and McLaws
2006; Tschannen et al.
2012; Woo et al.
2017; Allman, Goode, and Patrick
1995) and duration of unrelieved pressure as risk factors for PUs (Linder-Ganz et al.
2007; Lindgren et al.
2004; Baumgarten et al.
2006; Sharp and White
2015; Bouten et al.
2003; Kemp et al.
1990). Having previously examined PU prevalence and prevention practices in hospitals in a major area health service (Sharp et al.
2005,
2000) and a community nursing service in Sydney, Australia (Sharp
2006), we focused this current survey on the elderly in Sydney RACFs.
Discussion
We focused our examination of eighty records from eight RACFs on the last week of life for this labour intensive retrospective cross-sectional survey. Validation of our prevalence of PUs during the last week of life could not be performed using death certificates because documentation of PUs by medical staff, on the death certificates, was poor. Similar poor documentation on death certificates was noted in the United Kingdom (Cutting and White
2015).
There are 379 RACFs across the five Sydney local health districts (LHDs) (New South Wales Health Department
2017). The selection of the eight RACFs from two LHDs may limit the generalizability if our participating RACFs had lower rates of PUs than non-participating RACFs. We believe the results from our eight RACFs can be generalized to the remaining fifty-seven RACFs within the same LHD, as each RACF was randomly selected and represents eight different postal codes within the two LHDs.
There is a temporal limitation in prevalence surveys. The temporal limitation in our study is the missing documentation of the period of immobility from the notes. Although causality between the period of immobility for our fifteen residents who developed a new PU after admission cannot be determined, it is accepted that damage to skin and deeper tissue occurs during periods of immobility as short as half an hour (Bliss
1994) and up to four to six hours (Salcido
2004; Linder-Ganz and Gefen
2004; Gefen
2008; Exton-Smith, Overstall, and Wedgewood
1982). Regardless of the limitation to the design of all prevalence surveys, the measure of prevalence emphasizes the burden of painful PUs in 70 per cent, the majority, of our residents. The incidence indicates the success of preventive practices during residency at the study RACFs. However, 21 per cent of residents developed a new PU suggesting that routine two-hourly repositioning failed.
A final possible limitation of this survey was a poor temporal relationship between the development of each PU and the timing of restraints. Regardless of timing before or after PU development, restraints prevent voluntary repositioning, and unrelenting pressure will result in discomfort and persistent pain (Woo et al.
2017; Gorecki et al.
2009; Bliss
2009).
Admissions from hospital accounted for half of our residents, and these residents were more likely to have a PU than residents admitted from the community or from other RACFs. Over a third of our RACF residents admitted from hospital had suffered a fall and fractures that would have resulted in periods of immobility, placing them at risk of PU. Three decades ago, a study revealed that sixty patients with hip fractures in the United Kingdom developed 124 PUs, mainly on the sacrum (45 per cent) and heels (23 per cent), supporting our concerns that immobility due to fractures may be a proxy risk for PU (Versluysen
1985). Residents with a fracture need relief of pressure. However, residents with a fracture may suffer pain and distress during manual repositioning. This can be avoided with an APAM while preventing a PU.
In 635 patients with hip fractures in six European countries, 10 per cent had a PU on arrival to hospital, while twice as many, 22 per cent, had a PU on discharge from hospital (Lindholm et al.
2008). Most commonly, PUs develop on the sacrum and heels in bed-bound residents (Rich, Margolis, and Shardell
2011; Exton-Smith and Sherwin
1961) and the ischial tuberosities in wheelchair-bound residents (Chaves et al.
2007; Anthony, Barnes, and Unsworth
1998).
Repositioning is currently the method of PU prevention globally as well as in Australia (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance
2014). Therefore, our observation that PUs remain highly prevalent suggests that two-hourly repositioning has not sufficiently impacted this prevalence. Bearing in mind that wide variation exists in the prevalence and incidence rates of PUs in the elderly, 34 per cent of residents with PUs in our study is in line with global findings of a wide variety of staging in PU from 9 per cent (Moore and Cowman
2012), 10 per cent (Clinical Excellence Commission
2017), 15 per cent (Wilborn, Halfens, and Dassen
2006), 26 per cent (Keelaghan et al.
2008), 37 per cent and 53 per cent (Davis and Caseby
2001). The variation in the rates may be due to differences in the population of patients studied, data collection, study methodology, and care provided (Tannen, Dassen, and Halfens
2009; Baharestani et al.
2009). Repositioning two-hourly 24/7 did not prevent PUs in many of our residents. Pressure relief should be provided in the form of an APAM, not waking residents up for the purpose of repositioning. An APAM provides pressure relief to all parts of the body every few minutes throughout the twenty-four hours without waking residents, whereas repositioning for pressure relief is usually only carried out two-hourly. It is unacceptable that this prevalence of PUs be allowed to continue.
In the last week of life, nearly all (91 per cent) residents were judged to be at risk of a PU and nearly all of those at risk (96 per cent), were repositioned two-hourly 24/7. Yet, one third of residents who were repositioned 24/7 had one or more PUs at the time of death, raising the question that a PU risk screening tool in clinical practice is not protecting vulnerable residents (Anthony et al.
2010; Kottner and Balzer
2010). The speed of screening is imperative, and following the “golden hour” rule for risk of PU encourages rapid screening (Sharp and White
2015) by a multidisciplinary team (Kayser-Jones, Beard, and Sharpp
2009; Sharp and White
2015; Bliss
2005) who then provide at-risk residents with an APAM (Exton-Smith, Overstall, and Wedgewood
1982; Bliss, McLaren, and Exton-Smith
1967) within an hour (Gefen, Farid, and Shaywitz
2013; Stekelenburg et al.
2008). This rapid intervention reduces the likelihood of a new PU and disruption to sleep.
Neglect or Abuse
It is difficult to determine whether the development of PUs is neglect and/or abuse when nurses and care staff in RACFs lack the authority to procure pressure-relieving equipment such as APAMs. Pressure ulcers can start to develop in four to six hours (Salcido
2004, Linder-Ganz and Gefen
2004; Gefen
2008; Exton-Smith, Overstall, and Wedgewood
1982) or even as little as half an hour according to Bliss (
1994), yet access to pressure relieving equipment can take up to two days (Sharp et al.
2000) or may never be accessed. Consistent with public health principles, we believe that a better approach is the use of the available legal tools. For example, section 3(item 3.2) of the Australian
Quality of Care Principles 2014 (
Cth) of the
Quality of Care Principles (Cth) provides care staff with an option that may prevent PUs: “… an air mattress appropriate to each care recipient’s condition.”
Regardless of dementia, the use of two-hourly repositioning is harmful, and residents with dementia have no ability to provide informed consent.
We concur with others who have shown that the ritualistic practice of waking residents every two hours for the purpose of repositioning contributes to severe sleep deprivation and behaviours of concern (Cohen-Mansfield and Marx
2016). Sleep is a fundamental phenomenon in most organisms and the sleep–wake cycle is a physiological rhythm which modulates endogenous neuronal activity in the brain (Roh and Holtzman
2015). Similar to smoking or drug use, the immediately visible physical impact does not reflect the dysfunction caused in brain mechanisms due to sleep deprivation. Chronic sleep deprivation can cause significant and cumulative physiological deficits and the disruption of normal neurophysiological mechanisms (Chittora et al.
2015; Seyffert and Berofsky-Seyffert
2015). However, in clinical practice, it is often difficult to distinguish pain-related behaviour from behavioural symptoms related to other disorders, such as anxiety disorder, or to dementia-related behaviours (van Dalen-Kok et al.
2018).
We also believe that this clinical practice of two-hourly repositioning may breach the
Optional Protocol to the Convention Against Torture 2002 (OPCAT). In some cases, the OPCAT may provide a mechanism for complaints about elder abuse. The OPCAT promotes independent, regular visits by international and national bodies to monitor conditions within settings where people are deprived of their liberty (Weller
2017, 44). The OPCAT requires states to establish a national system of inspections of all places of detention, and this could include RACFs (Australian Law Reform Commission
2014, 247).
Because Australia is a dualist jurisdiction, international documents must normally be incorporated into domestic legislation. Australia has not yet ratified the OPCAT (Australian Law Reform Commission
2017, 155). However, according to a growing number of commentators, ratification may not be necessary (Simma and Alston
1992; Weller
2017). Commentators have recently emphasized that there is arguably a “common law of human rights” which jettisons the need for formal ratification (Simma and Alston
1992; Weller
2017, 20).
We have described examples of “triggers” for behaviours of concern possibly caused by sleep disruption. The prevalence of behaviours of concern displayed by our residents with dementia was significantly greater than by residents without dementia. Just a few years ago, 53 per cent of all residents in Australian RACFs suffered from dementia (Australian Institute of Health and Welfare
2011) and that was similar to the prevalence of dementia (54 per cent) in a Belgian RACF study (Vandervoort et al.
2013). But the majority (70 per cent) of our residents suffered from dementia. Adults with dementia may forget how to move (Reisberg
1984), and the neuro-pathology of dementia is thought to disrupt sleep (Vitiello and Borson
2001). Poor night-time sleep, regardless of dementia, results in excessive daytime sleepiness (Weinhouse et al.
2009, Cole and Richards
2007). With the majority, 73/80, of all residents having been repositioned two-hourly 24/7 we believe the genesis of behaviours of concern is likely to be severe sleep deprivation.
There is no empirical evidence that anyone with dementia experiences less pain, and therefore behaviours of concern may also have a genesis of pain. Cognitively impaired elderly persons whose verbal fluency has declined have been identified as having an altered expression of pain (Horgas, Elliott, and Marsiske
2009), making the location of pain or cause of the pain difficult for staff to identify (Manfredi et al.
2003).
Restraint authorizations were documented for twenty-two residents exhibiting behaviours of concern, yet pain due to PU development (Dallam et al.
1995; Pieper, Langemo, and Cuddigan
2009; Ahn, Stechmiller, and Horgas
2013) can result in residents screaming. If residents are unable to inform staff that they are in pain, the screaming may be interpreted by staff as behaviours of concern. Restraints used on one-third of our residents may have been responsible for 15 per cent developing a PU or responsible for unrelenting pain, with residents with late dementia being unable to express pressure pain and discomfort.
Currently there is a dearth of evidence for the prevention of PU. The international
Clinical Practice Guideline (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance
2014) includes only seventy-seven evidence-based statements. The remaining 498 statements, including repositioning frequency, are based on expert opinion only (Black
2015). Two-hourly repositioning 24/7 has not resulted in the elimination of PUs (Krapfl and Gray
2008; Clark
1998, Gillespie et al.
2014, Rich, Margolis, and Shardell
2011) but care staff are required to follow the RACF care plans and reposition residents two-hourly. This practice continues despite the adverse effects to residents we have documented. We believe the practice of 24/7 two-hourly repositioning may be unintentional institutional abuse of elders.
The World Health Organization has estimated that the prevalence rate of elder abuse in high- and middle-income countries ranges from 2 to 14 per cent (Australian Law Reform Commission
2016, 11). We believe these figures are an underestimation for several reasons. First, the abused person may not want the abuser to be investigated or prosecuted (Australian Law Reform Commission
2017, 392). Second, elder abuse tends to be invisible (New South Wales Parliament
2016). Third, two-hourly repositioning 24/7 is carried out to prevent PUs, but it is not currently recognized as a form of unintentional institutional elder abuse.
Potential Legal Implications
The rise in litigation against RACFs in Australia (Nelson
2003), the United Kingdom (Toolan et al.
2014), and the United States (Stevenson and Studdert
2003) suggests RACF service providers who fail to meet standards of care may be legally liable. As outlined in the results section above, there are numerous legal options (such as patients’ rights) to improve the quality and safety of care for the elderly in RACFs and prevent PUs.
Patients’ Rights
In addition to the domestic
Charter of Rights that we discussed in the results section above, there is international law which recognizes patients’ rights. The United Nations International Plan of Action adopted by all countries in April 2002 recognizes the importance of elder abuse and includes it in the framework of the
Universal Declaration of Human Rights (
UDHR). Preventing elder abuse in an ageing world is the responsibility of all who interact with the elderly (World Health Organization
2002). Pursuant to article 5 of the
UDHR, and article 7 of the International Covenant on Civil and Political Rights, “no one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment.” These international instruments may also be used to advance efforts to protect our elders because they may be applied to the unlawful use of restraints and unlawful repositioning.
Competent patients have a legal right to refuse treatment (
Re PVM [2000] QGAAT;
Schloendorf v Society of New York Hospital 195 NE 92 [1914]). Consent is both a defence to claims of wrongful touching of the body and a negligence-based duty to provide information to patients (Stewart
2017). Repositioning elderly residents may be unlawful if residents do not consent to repositioning and/or if they refuse to be repositioned. In
Dean v Phung,
3 Basten JA set out how consent would be given in this context: consent is validly given for medical treatments where the patient has been given basic information about the nature of the treatment. Despite the problems of obtaining informed consent, nurses use the following instructions to residents as consent, “We have to roll you over [reposition you] so you don’t get pressure ulcers.” Regardless of our residents objecting to being repositioned, nurses will continue to reposition residents as directed and in accordance with the RACF’s care plan. Regardless of a diagnosis of dementia or not, the use of two-hourly repositioning is harmful. For residents with dementia, the harm continues as there is no ability for them to make or withdraw consent. We did not search for any documentation referring to consultation with the enduring guardian. Even with an enduring guardian or “person responsible,” this practice may still constitute unintentional elder abuse. Sometimes, protective measures may conflict with a person’s autonomy, such as where an older person refuses to accept support. Where possible, the ALRC has sought to recommend changes to the law that both uphold autonomy and provide protection from harm, but where this is not possible, greater weight is often given to the principle of autonomy (Australian Law Reform Commission
2017, 20).
The courts have attempted to establish principles. For example, in
Re MB (Medical Treatment)4 the court considered that the inability to make a decision (incapacity) exists in the following circumstances:
-
when a person is unable to comprehend and retain information which is material to a decision, especially the likely consequences of not having the treatment;
-
where he or she is unable to use the information which is material to a decision, especially the likely consequences of not having the treatment;
-
where he or she is unable to use the information and weigh it up as part of the balancing process in arriving at the decision.
Coronial Jurisdiction
As we outlined in the results section above, the coronial jurisdiction is another legal avenue which has the potential to advance efforts to prevent PUs. Coronial jurisdiction commentators increasingly recognize the powerful preventive potential of coroners’ recommendations (Freckelton and Ranson
2017, 584; Moore
2016). Coronial information is of particular importance to policymakers, organizations, practitioners, and researchers who have an interest in mortality and morbidity prevention. Many organizations analyse coroners’ recommendations for patterns, so that these trends can inform and improve their work. Autopsies are rarely performed on RACF residents with PUs. Visual inspection suffices the diagnosis of a PU, and we are not suggesting PU is usually the cause of death, rather residents died with a PU. Consequently, death certificates rarely include mention of a PU or state that PU is a cause of death. Coroners’ recommendations about PUs could be used by RACFs as a prevention tool. Therefore, we argue that coroners’ recommendations have the potential to prevent PUs and deaths attributable to PUs. Unfortunately, in relation to RACF deaths in Australia, coroners’ recommendations were made in less than 2 per cent for external cause of deaths (Bugeja, Woolford, and Willoughby
2017). The paucity of such recommendations in deaths in RACFs highlights potentially missed opportunities for the identification and promotion of injury prevention interventions (Bugeja, Woolford, and Willoughby
2017).
Recommendations
We propose seven major changes in an effort to reduce harm and unintended abuse of the elderly:
-
Cease 24/7 repositioning.
-
Provide every RACF bed an APAM, or at the very least provide an APAM to residents identified at-risk of PU without delay.
-
Cease physical restraints.
-
Introduce a Convention on the Rights of Elders.
-
Clarify the legal definition of institutional elder abuse for RACFs and include this definition in national legislation.
-
Amend the Coroner’s Court legislation in all Australian jurisdictions to provide coroners with a mandatory, statutory authority to investigate deaths from PUs in RACFs.
-
Provide training for RACF service providers, registered nurses, and care staff on health and human rights (pursuant to General Comment 14, para 44 (2000) as adopted by the Committee on Economic Social and Cultural Rights).
The
Clinical Practice Guideline (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance
2014) must be amended to ensure risk screening is carried out within a “golden hour” (Sharp and White
2015) and an APAM provided immediately. Optimal time for screening for risk is not a replacement for two-hourly repositioning as a preventive intervention. A rapid and accurate identification of at-risk residents for PUs would enable an immediate intervention, such as use of an APAM.
A new Convention on the Rights of Older People is essential in order to understand and disseminate the basic facts about preventing PUs. The elderly at risk of PUs suffer because even if policies are put in place for the provision of APAMs, these policies are rarely implemented. The majority of our residents were not placed on an APAM, so when PUs developed in a third of residents, their lives were imperilled and possibly shortened. Submissions to the ALRC Inquiry (2017) have already identified PUs as a problem (Australian Law Reform Commission
2017, 122).
To be effective, components of a new Convention on the Rights of Older People should include, but would not be limited to, APAMs on every bed in every RACF, training of all care providers and healthcare personnel, and access to healthcare workers with relevant training in geriatric, dementia, and palliative care
These recommendations will enable residents to sleep undisturbed all night. Being able to sleep may reduce or eliminate behaviours of concern and prevent daytime sleepiness. Exploration by staff to determine the exact nature of sleep problems of agitated residents may identify other sleep-waking practices that need to be discontinued.
Conclusion
Within the RACF environment where 24-hour nursing care is provided, a lack of suitable equipment or staff are not acceptable excuses for PU development (Needleman et al.
2011). We believe two-hourly repositioning could be unintentional institutional abuse rather than a preventive safety practice. It is time to protect our elderly in RACFs in the last years of their lives. On occasions it may be necessary to physically restrain residents for safety if they pose a threat to themselves or others (Kerridge, Lowe, and Stewart
2013) but for short periods only and with an alternating pressure air cushion or APAM. If medication is required to settle residents, it must be for short periods only and with an alternating pressure air cushion or APAM if the medication causes immobility.
We cannot prevent PUs without acknowledging that PUs still occur in a third of our most frail residents at the end of their lives. Two-hourly repositioning is a poor preventive practice of PUs (Hagisawa and Ferguson-Pell
2008; Krapfl and Gray
2008; Clark
1998; Rich, Margolis, and Shardell
2011; Defloor, De Bacquer, and Grypdonck
2005; Gillespie et al.
2014). Repositioning results in severe sleep deprivation, and restraints may be unlawful. Unlawful repositioning and restraining of residents is elder abuse and should cease immediately.
Most RACF service providers strive to provide lawful and ethical quality of care for all residents. However, the evidence points away from this conclusion in relation to PU prevention.
Service providers in RACFs need to better recognize harm to residents, manage legal risks, and enhance the quality and safety of care provided to institutionalized elders.