Review

Pressure Sores in Bedridden Elders After Prolonged Power Outages From Severe Weather: Examining Two Underutilized Disaster Resources

Shirley M. Neitch, MD, FACP
Christine Gilkerson, MD
Angela M. Brammell, PA-C
Volume 21 - Number 11 - November 2013

Affiliations:

1Joan C. Edwards School of Medicine, Marshall University, Huntington, WV

2Hanshaw Geriatric Center, Marshall University, Huntington, WV

Abstract: With an increase in the number of severe weather events making nationwide headlines lately, including heat waves, tornados, and hurricanes, healthcare providers need to be more knowledgeable about emergency preparedness in their communities and be able to advise patients, particularly those who are bedridden and receiving home care, on resources to use in the event of prolonged power outages. In this article, the authors describe two cases in which patients developed progressive pressure sores because their usual level of care had been disrupted by a power outage following a severe storm. Because no power company can guarantee timely restoration of service after such an event, the authors present two available but relatively unknown options for families and caregivers requiring assistance in emergency medical situations.

Key words: Pressure sores, frailty, storm effects, vulnerable needs registry.
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It seems that we are experiencing increasingly severe weather events every year, and this trend is projected to continue.1 Subsequently, these events give rise to an increase in resulting medical problems, such as direct trauma, dehydration/malnutrition, and infections from exposure to the elements and less-than-ideal living conditions; however, serious medical complications can arise even from the loss of home electricity for prolonged periods of time. Such problems may include pulmonary complications from loss of oxygen and respiratory equipment, problems caused by an inability to refrigerate food and medications, and exposure to extreme environmental temperatures due to loss of heating or cooling.

We describe two cases of an underreported complication arising from a prolonged power outage that occurred following a severe derecho (intense, widespread, and fast-moving windstorm). Both patients had late-stage dementia and were bedridden, and both developed complicated pressure sores after being without power for several days. After these case presentations, we share some of the lessons we learned from these experiences. We also describe two available programs for persons seeking assistance after such an event, both of which seem to be virtually unknown in the medical community. Finally, we provide a tip sheet that healthcare providers can share with community-dwelling older adults and their caregivers to alert them to these resources and help them prepare for disasters.

Case One

The first case patient was a 91-year-old woman with progressive dementia who was being cared for by friends and family at home. Her medical history included a significant stroke, which occurred 11 years earlier, and Parkinson’s disease, which was diagnosed 10 years earlier. She was nonambulatory, nonverbal, and had contractures of her upper and lower extremities. She was occasionally placed in a wheelchair when she had to leave the house, but was otherwise bedridden. Within the past few years, she intermittently had stage I or, rarely, stage II pressure sores over her right ischial area, which the family had been able to resolve by turning her frequently and providing localized wound care. In March 2012, we noted that she had a 2-cm stage II sore on her right buttock, which was treated with a menthol/zinc oxide ointment. Although the sore did not resolve, it remained at stage II, did not increase in size, and did not develop evidence of infection over the following 3 months.

Then on June 29, 2012, a derecho ravaged the upper Midwest and mid-Atlantic area of the United States. Because of the severe wind damage, the patient’s family was without power for approximately 5 days, during which time the average daytime temperature reached approximately 98 degrees. After this event, the patient’s pressure sore began to enlarge and deepen. We suggested several different kinds of aggressive treatment modalities, which were attempted by the family. These included use of colloidal and alginate dressings, Granulex spray (ie, a commercial product formulated with trypsin for enzymatic debridement, the mild topical antiseptic Peru balsam, and castor oil), and collagenase ointment (ie, another enzymatic debriding agent). Despite these interventions, by October, the pressure sore had grown to 3 cm and progressed to stage III. The patient was referred to receive home hospice, where comfort measures were maximized. She died in early November of that year.

Case Two

The second case patient was an 89-year-old woman with a 12-year history of progressive debility due to Alzheimer’s disease. Two years before the derecho, she became confined to her home after a hip fracture left her with significantly impaired mobility, and about a year before this storm, she became completely bedridden. No pressure sores developed while she was being cared for by her daughter and using an electric-powered alternating pressure air mattress. 

Following the aforementioned derecho, which struck on June 29, 2012, this family was also without power for 5 to 6 days, during which time the patient was exposed to excessive heat and could not use the alternating pressure air mattress. Within the week of the power outage, she developed small areas of skin breakdown on her sacrum and her right heel. By early October, despite use of a low air loss mattress and receiving progressively aggressive treatments per our recommendations, including alginate dressings and enzymatic debridement, she had six measurable pressure sores, the largest of which was a 6-cm by 2-cm stage III ulcer. The woman was referred to home hospice for palliative care and died in early November.

Discussion

Pressure sores have long been a vexing clinical problem due to their many contributory factors. In addition to the pressure itself and patient-specific factors, such as nutritional status, an agent is moisture, especially from urinary and fecal incontinence.2,3 The families of our patients had been able to maintain pressure sore prevention and control for a very long time until the prolonged storm aftereffects interrupted their care routines. In these two cases, both elderly debilitated patients had been receiving conscientious home care for several years; one had been fully bedridden for approximately 1 year and the other for at least 4 years. The first case patient had intermittent but minor problems with skin breakdown, and the second case patient had no previous skin issues. However, after a derecho caused a prolonged power outage during a period of extreme heat, both patients developed irreversible pressure sores that ultimately contributed to their deaths. We speculate that the adverse environmental conditions resulting from the power outage were primarily responsible for these patients’ pressure sores. High humidity and excess sweating led to an increase in moisture on their skin. It was likely difficult for their caregivers to keep them clean and dry in the absence of electricity for light, air conditioning, and heated water (ie, for bathing and cleaning the wounds).

Scope of the Problem
In the United States, the most common type of disaster is flooding, which includes flash flooding, overland flooding, and flooding from broken dams and levees.4 In March 2012, the Union of Concerned Scientists published a document outlining the risks of flooding in the presence of climate change.5 The document notes that extreme rainfall events have become more common in the United States as the climate has warmed, and with Earth’s average temperatures projected to continue climbing upward, flooding events are expected to become even more common. In addition to causing immediate ill effects, such as trauma, drowning, and infections from contaminated water, the report notes that many adverse effects can manifest well after the floodwaters have receded, including respiratory problems from mold exposure and psychological problems from experiencing the event. The report warns that the elderly are especially vulnerable to these immediate and lingering adverse effects5; however, the scope and impact of many of these lingering effects, especially as they relate to the elderly, are not as readily recognized. For example, in addition to damaging homes, flooding and severe weather can damage industrial sites, causing oil and chemical spills. Although the impact of such events on the environment and wildlife are readily acknowledged, these events can affect communities even many miles away from where the disaster took place.6 For instance, fumes that are generated can be carried by the wind and lead to or exacerbate respiratory problems in any persons who become exposed. While younger and more physically fit individuals may be able to leave such areas until conditions improve, vulnerable elders may not have the ability to find respite. Even when elders are able to evacuate, simply being displaced from their homes or usual care environment can lead to adverse effects. A study that examined the Medicare records of older adultswho remained displaced 12 months after hurricane Katrina found that prolonged displacement was associated with an increased risk of fractures.7 Based on their findings, the study authors concluded that clinicians should regard displaced older adults as a vulnerable population in need of interventions, such as risk communication messaging.

Obviously,flooding is only one type of disaster.Tornadoes, hurricanes, blizzards, fires, earthquakes, and windstorms are other common disasters in the United States,8 and each of these events can lead to prolonged displacements and/or power outages. In addition, regardless of which form disasters take, the Centers for Disease Control and Prevention (CDC) notes that they affect older adults disproportionately, and those with chronic diseases and disabilities are especially vulnerable.9

After encountering our case patients, we searched the medical literature to see if there were any previous reports that addressed the development or worsening of pressure sores in bedridden patients following a power outage from a severe weather event. The closest we found was an online article authored by a registered nurse who notes that home care patients may have electrically operated beds and mattresses, which require consideration; however, she does not specifically address the risk of pressure sores.10 Subsequently, there is a paucity of evidence to help guide healthcare providers in advising home caregivers on the procedures for preventing pressure ulcers in bedridden patients during prolonged power outages.

The Challenge of Power Outages
Dedicated family caregivers, even when personally stressed, have routinely shown themselves capable of providing high-quality care to their loved ones; however, when storms or other disasters damage structures and lead to prolonged power outages, even the best caregivers may be unable to maintain the same level of scrupulous cleanliness and general care. Even if home care patients require no specific equipment, it is apparent that they need electrical power to be safe and properly cared for.

Many power companies allow persons who have electrically powered medical equipment at home to register their needs with the company for high-priority restoration status in the event of a power outage. This generally requires these individuals to have their physician complete a special form, which can often be downloaded from the power company’s Website. Although these companies carefully note that they cannot guarantee power restoration within a given timeframe to anyone, they will prioritize customers within the constraints of each situation.Patients seem to be well aware of their right to register for high-priority status when they have life-sustaining equipment, such as ventilator support. Our office, however, has never handled a single request for high-priority restoration for a bedridden patient in home care whose power need was for a special bed or mattress, or for cooling or heat only. And we could find nothing in various power companies’ Websites to suggest that one can request early restoration at all unless there is ongoing use of “life-sustaining” powered equipment.

Healthcare providers caring for vulnerable patients should advise these patients and/or their caregivers to seek high-priority restoration status with their local power companies before an emergency occurs and then carefully assist them with completing any necessary documentation. Because these forms may not recognize certain medical equipment as life saving, it may be necessary to provide more comprehensive explanations as to the need for power in these cases.

Working Toward a Solution With Two Underused Resources
We believe our cases illustrate the need for continuous power service for all bedridden patients, especially if they are on beds or mattresses requiring electrical power. Of course, we understand that electrical power companies do not and cannot guarantee continuous service or early restoration to all who need it. However, we must ensure that, if power is not available, other steps are taken to maximize care for those vulnerable home care patients whose conditions, without such care, may decline precipitously.

While there has been no widespread attention in the medical literature to the specific problems of home care patients who lose electrical power, there are two important nationwide initiatives that may help address certain aspects of this issue: the 211 Call Center system, and the Vulnerable Needs Registry system.

  • The 211 Call Center System—In July 2000, the Federal Communications Commission established “211” as a nationwide access number for community information and referral services.11 Strongly supported nationwide by the United Way, statewide and community-wide 211 systems have additional support from both public and private sources. Anyone calling 211 will be routed to that particular community’s agencies or organizations for an extraordinary variety of services, including basic human needs, such as food and shelter, disaster relief, and mental health resources. Physicians know well that patients in emergencies will likely call 911; they likewise need to know that patients in need of assistance should be informed about 211 for help in locating the services they need. It is important to note, however, that 211 is not yet available everywhere, and it may not be available in more remote areas. Caregivers can visit www.211us.org to see if it is available in their area.
  • The Vulnerable Needs (or Special Needs) Registry System—The Vulnerable Needs (or Special Needs) Registry System is a little-known but very useful resource. Generally managed by local health departments with developmental input from the Federal Emergency Management Agency and the CDC, this system enables people with special needs to register so that in an emergency situation, such as a natural disaster, authorities will know to check on them. People who are likely to need more assistance than what is available to the general public, including the frail elderly, disabled persons, and caregivers who provide care to vulnerable patients in facilities such as personal care homes, should register so that emergency responders will be aware of their needs and their locations. Registration allows not only for more rapid and better-equipped responses to individuals in times of need, but also assists agencies in their planning for such times.

 

The Vulnerable Needs Registry is not as widespread as 211 systems, but they are sometimes also supported by the United Way, and may cooperate with or even work through the local 211 systems. The registries use different names and methods of contact in different states. For help in some Pennsylvania counties, the registry may be found at www.specialneedspa.org. Since these registries are called different things in different locations, and there is no centralized directory available to locate these registries, physicians or patients/caregivers should call their local health department to see if their community offers such a service.

Despite providing individuals with access to a variety of special health and other services, both 211 and the Vulnerable Needs Registry are largely unknown among physicians. We informally surveyed the 13 members of our General Internal Medicine Section and discovered that only two individuals had any awareness at all of these two programs, and neither had detailed knowledge. Yet healthcare providers could be instrumental in informing the public of the availability of these resources. In addition to sharing this information with patients, flyers posted in the office and/or handed out to those who provide home care would be a very effective method of notification; consider distributing the tip sheet that accompanies this article (download a PDF of the tip sheet here>>). In addition, local media outlets often seek to engage health professionals for segments on news or public affairs programming, and this information would provide a great service through such a forum.

Conclusion

A myriad of recent disastrous weather events have forced the medical community to deal with the hazards of severe weather, the nature and scope of which were unheard of even a decade ago. Even with the attention of a broad range of authorities refocused on the issue, one group of patients—the frail homebound elderly—have been neglected in the medical literature. Our report details one serious outcome of a severe weather event in such a population: the development and worsening of pressure sores due to an interruption of care routines following a prolonged power outage.

We also identified two key resources that are underutilized, but that may be invaluable following a disaster: the 211 call center system and the Vulnerable Needs Registry systems. Because these resources have not been well publicized, they remain unknown to many practitioners as well as to the very people they seek to assist. We should be making more efficient use of these preexisting federal, state, and private resources to better protect our vulnerable patients from the detrimental long-term effects caused by the increasing number of severe weather events.

References

  1. IPCC confirms that human activity will further warm the Earth, with dramatic effects on weather, sea-levels and the Arctic [press release]. Geneva, Switzerland: World Meteorological Association/United Nations Environment Programme. Published September 27, 2013. Accessed November 11, 2013.
  2. Theaker C, Mannan M, Ives N, Soni N. Risk factors for pressure sores in the critically ill. Anesthesia. 2000;55(3):221-224.
  3. Cox J. Predictors of pressure ulcers in adult critical care patients. Am J Crit Care. 2011;20(5):364-375.
  4. Federal Emergency Management Agency (FEMA). The national flood insurance program update. http://www.fema.gov/news-release/2013/10/08/national-flood-insurance-program-update. Accessed November 11, 2013.
  5. Perera EM, Sanford T, Cleetus R; Union of Concerned Scientists. Climate Change and Your Health. After the Storm: the Hidden Health Risks of Flooding in a Warming World.www.ucsusa.org/assets/documents/global_warming/climate-change-and-flooding.pdf. Published March 2012. Accessed June 15, 2013.
  6. Peeples L. Arthur Kill oil spill: Hurricane Sandy’s surge into New Jersey waterway. Huffington Post. November 1, 2012. www.huffingtonpost.com/2012/11/01/arthur-kill-oil-spill-clean-up-diesel-shell_n_2058723.html. Accessed June 15, 2013.
  7. Uscher-Pines L, Vernick JS, Curriero F, Lieberman R, Burke TA. Disaster-related injuries in the period of recovery: the effect of prolonged displacement on risk of injury in older adults. J Trauma. 2009;67(4):834-840.
  8. Federal Emergency Management Agency (FEMA); Ready. Natural disasters. http://www.ready.gov/natural-disasters. Accessed November 11, 2013.
  9. CDC’s disaster planning goal: protect vulnerable older adults. Centers for Disease Control and Prevention Website. www.cdc.gov/aging/pdf/disaster_planning_goal.pdf. Published 2007. Accessed June 15, 2013.
  10. Quan K. Power outages and oxygen or other care issues. Netplaces Website.  http://www.netplaces.com/caring-for-aging-parents/in-case-of-emergency/power-outages-and-oxygen-or-other-care-issues.htm. Published 2009. Accessed June 15, 2013.
  11. Consumer guide: Dial 211 for Essential Community Services. Federal Communications Commission Website. www.fcc.gov/guides/dial-211-essential-community-services. Updated December 7, 2012. Accessed June 18, 2013.

 

Disclosures: The authors report no relevant financial relationships.

Address correspondence to: Shirley M. Neitch, MD, FACP, Marshall University / Joan C. Edwards School of Medicine, Department of Internal Medicine, 1249 15th Street, Huntington, WV 25701; neitch@marshall.edu