Letters to the Editor

Dear Editor,

    The particularly apt title of the June editorial - "The Perfect Storm" (Ostomy/Wound Management. 2004;50(6):6-8) - is most definitely not hyperbole. As a country, we will have to make a clear and decisive choice within the next few years regarding whether healthcare is a right or a privilege.

The patchwork of healthcare systems throughout this country is costing us all dearly and yielding absolutely no incremental benefits in terms of improved health. This issue is inextricably linked to another "third rail" issue - malpractice reform. Healthcare consumers will have to grapple with the net effect of their demands/expectations: that healthcare providers anticipate and avoid virtually all complications, causing mass exits of practitioners from high risk fields.

    These are critical issues and the "troops on the ground" - nurses - are in prime position to provide the intelligence we need to fix our healthcare system. This editorial, has no doubt, inspired your readers to look around and see what they can do to contribute to a solution.

Marge Meehan, RN, MIM
Executive Director, F.R.A.I.L.
(For Recognition of the Adult Immobilized Life)

Reply

    I learned from caring for the uninsured that they do not receive any "pre-negotiated" discounts and their bills usually end up with a collection agency until the last penny has been paid. Sadly, we now know that the uninsured not only have to pay "full price," but also that hospitals often charge them much higher fees than they charge the insured. During a June 24, 2004 congressional hearing before the House of Representatives Energy and Commerce Oversight Subcommittee, experts testified that hospitals commonly employ aggressive collection techniques to collect the higher fees. While members of both parties voiced their disapproval, some Republicans noted that the uninsured do not take advantage of the tax-free health savings account option.

    I should have thought of that! The next time I see someone who doesn't dare set foot in a hospital for much-needed blood work or an X-ray, I will tell them they should have put all the extra money from their minimum wage job in a savings account so they can pay the inflated bills that help subsidize the hospital and, ultimately, the insurance companies who were able to negotiate cut-throat rates.

Lia van Rijswijk

Dear Editor,

    In an excellent article, "Long-Term Outcomes of Full-Thickness Pressure Ulcers: Healing and Mortality" (Ostomy/Wound Management. 2003;49[10]:42-50), Gregory Brown, RN, BSN, CWOCN, discusses the topic of acute and chronic skin failure. The concept of end-stage skin failure is an important one for many reasons. If, in fact, pressure ulcers are indeed a result of skin failure and not the lack of pressure relief, the entire clinical and medico-legal approach to pressure ulcers needs to be reassessed.

    Unfortunately little clinical research regarding the etiology of pressure ulcers has been published for a variety reasons (eg, funding and ethical issues) but opportunities for study are available because the concept of skin failure as a cause of pressure ulcers raises several interesting questions. If a patient is end-stage and diagnosed with skin failure, why does the patient primarily develop pressure ulcers over bony prominences? If skin failure were the true cause, why wouldn't patients develop ulcers in non-pressure areas? Clinicians might reasonably argue that "skin failure" makes those patients more susceptible to pressure ulcers over bony prominences. But it still begs the question, "Are pressure ulcers due to "skin failure" or "lack of pressure relief?" I would like to believe the former, but data may not yet be forthcoming to support the concept of "skin failure." Anecdotally, with few exceptions, all of the pressure ulcers I see, regardless of the patient's condition, come from the lack of adequate pressure relief. However, anecdotal impressions are not adequate to scientifically answer the questions about skin failure.

     How do we get those answers? Unfortunately, chart documentation in a normal clinical record regarding turning schedules is not totally reliable. Nurses are busy and often "turned Q2h" is the option checked off when, in reality, times may vary.

    In order to begin to not only delineate the concept of skin failure but also to determine if pressure ulcers are preventable, the following types of studies need to be done. Because of ethical and control group issues, the first study could start with "the ideal situation" and observe if pressure ulcers develop. The study would enroll the highest risk patients (eg, end-stage, low Braden scores). Every patient would be placed on an air-fluidized bed and properly turned and positioned once an hour. This care would be supervised and documented by study monitors present at the bedside 24 hours a day to ensure that turning and positioning are performed as the study dictates. Vital signs, oxygen saturation, and other tests could be monitored as well. Each patient's skin would be checked daily for breakdown. All pressure ulcers would be recorded. If skin failure is determined to be the cause of pressure ulcers, this type of study might yield additional insight into their etiology. If any pressure ulcers developed in such a scenario, our consideration of pressure ulcer etiology would have to change. Clinicians need to advocate for more true scientific data in order to be able to make a dent in the incidence of pressure ulcers.

Kenneth Olshansky, MD
Clinical Professor, Plastic Surgery
Virginia Commonwealth University/
Medical College of Virginia
Richmond, Va.

Reply

    Certainly, there are avoidable and unavoidable pressure ulcers (PUs). The current literature notes that PUs result from pressure that exceeds what the interfacing tissues can tolerate. The question is: What could the individual's tissue tolerate at the point in time the ulcer developed? A human being is a dynamic organism and skin is a reflection of this reality. Although pressure-induced ischemia routinely occurs between a surface and a bony prominence, skin failure is observed on unusual areas of the body in the morbidly obese due to their different body geometry, as well as in unusual shapes and locations in persons with spinal cord injury. Therefore, pressure ulcer prevention must be highly individualized in the severely acute and chronically ill and those with atypical body-surface interface. Unfortunately, the literature does not offer a great deal of guidance to assist with these challenging populations. The technology is available to keep vital organ systems alive indefinitely, but ultimately something is going to fail. Internal organ systems acutely and chronically fail all the time but this damage is not visible to the eye. Because external organ system failure is visible and "esthetically displeasing," a double standard exists in that this type of damage should not occur. As Dr. Olshansky states, more research is needed into etiology of pressure ulcers and skin failure, especially in patients with extensive acute and chronic illnesses and atypical body geometry.

    Excellent studies in the acute and long-term care arenas indicate that an aggressive, comprehensive PU prevention program can significantly reduce, but not eliminate, pressure ulcer incidence. Medical providers and society as a whole need to determine how much money should be allocated for pressure ulcers prevention. Medical costs continue to increase at many times the rate of inflation, as does medical insurance. If the "standard of care" is increased to either air-fluidized beds for all patients at a certain risk level or "Turn Q1" or even "Turn Q15 minutes," who would pay for the additional equipment and personnel necessary for such a change? Ultimately, everyone would - in higher insurance premiums and taxes. And if this particular standard of care is enhanced, what other standards (and, therefore, costs) should correspondingly be improved?

    Pressure ulcers versus skin failure will be an area of debate for quite some time. Clinicians must question conventional wisdom when our eyes, heart, and gut tell us otherwise - and back up concerns with objective data.

Greg Brown, RN, BSN, CWOCN