I would like to congratulate the authors of the March 2019 CE/CME on their excellent review article, "Reexamining the Literature on Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries." One of the most difficult aspects of pressure injury research is developing accurate criteria. Setting up randomized, prospective, controlled, blinded studies is extremely difficult. Therefore, as the article states, much of our knowledge is based on anecdotal experience, hypotheses, speculation, and a lack of reliable data. This is not to say these are not of value or our clinical experience is incorrect, but that much of what we believe cannot be validated by accurate data.

For example, healthcare providers (especially nurses) are overworked, but they are doing the best they can within their work environment. This begs the question: how accurate are our medical records and documentation? This is especially important when performing retrospective reviews of medical records. For example, it is all too common to see charts where turns every 2 hours are religiously checked off at the end of a shift, when in fact each turn may have occurred after 1 or 4 hours. This is not to blame anyone, but to point out that this may confound data used in research. Further, when examining avoidable versus unavoidable pressure injuries, the criteria state that as long as the documentation says everything was done in accordance with the standard of care and a patient develops a pressure injury, then it was unavoidable. However, the documentation may not have been accurate. In reality, there are only two ways to accurately assess repositioning of patients. One is to document by continuous timed video at the patient's bedside; the other is to have proctors by the bedside to observe the actual turning and the time recorded. Obviously neither is practical, so we may have to accept less than accurate data.

Skin changes at life's end (SCALE) also raise many questions. What is the etiology of these changes? It is obvious to everyone that patients at end of life are susceptible to pressure injuries. They may be immobile, bedridden, malnourished, or emaciated. Often, their cardiac output drops, or they go into shock, causing significant hypoperfusion and rendering the patient extremely susceptible to pressure. Because SCALE occur primarily over bony prominences, is it unreasonable to infer pressure played a primary role? Just because patients die a few weeks after the development of skin breakdown, should we infer that it happened as an unavoidable end-of-life event, or could it be that inadequate pressure relief was applied? Again, no one is saying that preventing pressure injuries at the end of life is easy, and I understand the desire to characterize skin breakdown at end of life as a Kennedy terminal ulcer or SCALE, but how do we know for sure this was not a result of inadequate intervention?1

The article includes Dr La Puma's oft-repeated quote, "If the heart, lungs, and kidneys are showing signs of failing, isn't it logical that the skin would also show signs of failing?" In fact, this hardly ever happens if one's definition of skin failure is simply visible changes to the skin. If in fact the skin as an organ was actually failing, one would expect to see skin breakdown all over the body, not primarily over bony prominences. Examples of true skin failure are conditions such as Stevens-Johnson syndrome, necrotizing fasciitis, pemphigus, epidermolysis bullosa, and meningococcemia, all of which are diffuse skin failures. Ultimately, the definition of skin failure is not consistent and challenges us to create criteria that all healthcare professionals can agree upon.2-4

Finally, as healthcare providers and wound care professionals, we must ensure that the definitions of avoidable and unavoidable are not abused. When we say that a pressure injury is unavoidable, can we attest with certainty that every reasonable preventive measure was implemented? The bottom line is that we must hold ourselves to the highest standards; if pressure injuries occur, we must do a root-cause analysis, so we can improve on our quality outcomes in the future.

This excellent article is an honest review of what we know and what we do not know. I agree that it is critical to develop consistent diagnostic criteria, especially in relation to skin failure; further, if we label skin breakdown as unavoidable, we must have accurate documentation to support our conclusions.

Kenneth Olshansky, MD

Clinical Professor Plastic Surgery (Ret.), Medical College of Virginia/Virginia Commonwealth University, Richmond, Virginia

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