Guest Editorial: Pressure Ulcer Prevention: Where Did We Go Wrong?

   Recently, I was asked to consult on a 70-year-old gentleman who had extensive pressure ulcers on both heels. Following repair of a fractured hip a few months before, and while in the hospital, he developed small ulcers on both heels. An insulin-dependent person with diabetes and poor circulation, his ulcers had progressed to where he will probably require bilateral below-the-knee amputations.

   His case is not unique. Over the past few years, I have treated several patients who developed severe sacral ulcers while in the ICU, and although they recovered from their initial illnesses, they have spent years trying to heal their ulcers. Not long ago, I was making rounds in the ICU, and it became obvious to me that the prevention of pressure ulcers is not an important concern. The knowledge exists, turning orders are written, support surfaces ordered, but pressure ulcers simply do not appear to be a priority.

   I am constantly called to consult on pressure ulcers in patients in hospitals and nursing homes, and I often walk away feeling that we’re still in the dark ages. I understand about budget cuts, poor reimbursement, and understaffing, but what I am addressing here is not high tech. We are simply talking about implementing common sense pressure relief.

   In our country, we are fortunate to have some of the most brilliant, dedicated professionals who are concerned about quality care and pressure ulcer prevention. But if we were to measure the quality of our pressure ulcer prevention efforts, I think most of us would get a failing grade. The incidence of pressure ulcers has not improved dramatically through the years. For a problem that is essentially preventable, we need to take a hard look at where we are in the healthcare scheme in general and in our own healthcare sphere in particular.

   Many of us have been asked by attorneys to review cases of patients who have developed pressure ulcers. Some pressure ulcers have developed despite the provision of good care; these cases are understandable and defendable. However, most pressure ulcers were preventable and due to lack of diligence. Where does this leave us? Do we wait for more government regulations and expensive lawsuits or do we tackle the problem head on?

   We need a new approach. We have gone wrong not through lack of knowledge, but rather, lack of implementation. The process should begin with a root cause analysis to answer these questions: Why do patients develop pressure ulcers in intensive care units? Is it lack of knowledge or are there too few nurses? Are nurses too busy saving the patient’s life to the extent that pressure ulcer prevention becomes secondary and patients are not turned? Are more pressure-reducing/relieving beds needed or necessary? Are the support surfaces we use effective? Is more physician participation needed in the care process? Should more accountability for quality issues be required? What are quality outcomes regarding pressure ulcer prevention? What is the incidence of pressure ulcers in our institutions over the last 10 years? Is it improving? Worsening? Staying the same? What is the quality review process when a patient develops a pressure ulcer? How many institutions use benchmarks and clinical pathways for their pressure ulcer prevention? Do staff have the core knowledge needed to achieve high quality outcomes? Hard questions, certainly, but basic to ensuring the ability to implement appropriate preventive measures. Once answers to these questions are ascertained, another question undoubtedly will follow: Why aren’t doctors and nurses taking the necessary steps to prevent ulcers in our sophisticated hospitals and nursing homes when we have the knowledge to do so?

   In its recent report “Priority Areas of National Action: Transforming Health Care Quality,”¹ the Institute of Medicine observes, “We spend more than $1 trillion on healthcare annually, we have extraordinary knowledge and capacity to deliver the best care in the world, but we repeatedly fail to translate that knowledge and capacity into clinical practice.” I submit that, compared to many other clinical problems, the issue of preventing pressure ulcers is relatively straightforward.

   It is time to tap the resources of available experts and address the issue of preventing pressure ulcers in a positive, scientific, and caring way, and translate our knowledge of pressure ulcer prevention into practice. It is time for all of us to direct our energy and resources to solving the problem so the question “Could this ulcer have been prevented?” becomes irrelevant.