In today's health care settings, we need to be more diligent than ever in our efforts to prevent and treat pressure ulcers. Most of us are already very conscientious about treating pressure ulcers. We use expensive gels and colloids, enzymes, vacuum-assisted devices, silver dressings, and nonsilver dressings. I use all of these products or devices at one time or another, and yet I still feel I am in the dark ages when treating and healing pressure ulcers. We all work very hard to heal pressure ulcers. The real question is, "How successful are we?"

When we see a pressure ulcer, how often do we ask ourselves, "Why did it occur and how can we prevent it next time?" Would our answer be always, sometimes, or rarely?

As I see it, the primary problem is that we may have limited ability to completely heal many of the Stages III and IV pressure ulcers. On the other hand, we have the ability to prevent almost all pressure ulcers. In my opinion, those of us who care for patients with pressure ulcers should consider the following 10 questions in our quest to help prevent pressure ulcers.

1. Why hasn't the incidence of pressure ulcers significantly decreased in the past 20 years?

Answer: The incidence of pressure ulcers has essentially not changed because, in my opinion, until now, protecting the skin has not been a major priority in most of our hospitals and nursing homes. Some hospitals, however, such as a number of them in New Jersey, have initiated collaborative efforts in recent years that have reduced the incidence of pressure ulcers.1

2. Why does almost every submitted journal article reporting on pressure ulcer etiology concentrate on patient risk factors and risk assessment scales, rather than on the diligence of the staff taking care of the patients?

Answer: I find this to be one of the most frustrating areas of pressure ulcer prevention. Whenever we read journal articles concerning pressure ulcers, most of them seem to concentrate only on the patients' risk factors as the major cause of pressure ulcers. It is rare to discuss staff performance. The Braden Scale for Predicting Pressure Sore Risk addresses the following factors in determining pressure ulcer risk: sensory perception, moisture, activity, mobility, nutrition, friction, and shear.2 However, the most important risk factor is never mentioned, and that is the quality of patient care provided by the staff. It is my opinion that the level of how staff performs is a much better indicator for pressure ulcer risk assessment than the physical indicators that assess the patient.

3. Why is it rare to see wound care professionals submit articles and papers to our wound care journals and meetings with an emphasis on pressure ulcers as a quality issue?

Answer: We as health care professionals have fallen into the trap that accepts the inevitability of pressure ulcers. Until we change our thinking and begin to approach pressure ulcers as a quality issue, nothing will change. The new Centers for Medicare & Medicaid (CMS) rulings that went into effect October 2008 should clearly be a strong motivator in how we think and act regarding this issue.

4. Why do we accept such low standards of quality when dealing with pressure ulcers, as compared to how we deal with medication and airline safety?

Answer: Very few people die or are injured in airline crashes. However, thousands of patients develop pressure ulcers every year. Why is it that our priority on airline safety is light-years ahead of our priority on pressure ulcer prevention? If an airline crash occurs, whether it's a 747 jumbo jet or a small Cessna, the National Transportation Safety Board performs an intensive investigation to determine the cause of the crash and how to prevent it in the future. If there was negligence, those responsible are held accountable. The government and the airlines have made a commitment and have an incredible safety record. Let's hope the new CMS reimbursement regulations are a first step toward accountability.

5. Why doso many pressure ulcers occur in our hospitals, especially in our "high-tech" ICUs?

Answer: It is disturbing to me that so many patients in ICUs develop pressure ulcers. I'd expect the ICU to be one of the last places a patient would develop a pressure ulcer. Sure, these patients are at the highest risk and have multiple problems. But I think the bigger problem, however, is that as caregivers we are so focused on the patient's other major organs and illnesses that we forget about the skin. Most of the time, the patients recover, but some will have to deal with their Stage IV pressure ulcer for months to years. It is my opinion that the skin can also be made a priority without compromising other organ systems.

6. Why is it so rare to hear hospital or nursing home administration say that "pressure ulcers are unacceptable?"

Answer: We as caregivers, most of the time, not only meet, but also exceed expectations. We have to honestly ask ourselves what are the expectations placed upon us by the institutions where we work regarding pressure ulcers. How many administrators, directors of nursing departments, or medical leaders have said that, "With few exceptions, pressure ulcers are unacceptable." The point is, if we are expected and challenged to do better, we will. The time has now come that we must raise our expectations.

7. Why is it when asking why a patient developed a pressure ulcer, we rarely say, "It's because we failed to relieve their pressure," in addition to all of the other presumed causes?

Answer: The practice of medicine and nursing is both an art and a science. As scientists, we have to be intellectually honest. When a patient develops a pressure ulcer, we must be able to take responsibility, analyze where we might have gone wrong, and do better next time. When asked why our patients developed a pressure ulcer, we mostly blame the patient's risk factors and rarely admit to our own shortcomings.

8. What percentage of pressure ulcers do we think are preventable?

Answer: This will be debated ad infinitum because there are no scientific studies to answer the question. We each have to answer this question on a personal basis. I am willing to go out on a limb, based on my own clinical experience, that probably more than 95% of pressure ulcers could have been prevented with ideal care.

9. Can we accept some pressure ulcers as being inevitable or is this truly a quality issue?

Answer: The time has come for the health care community to once and for all decide whether most pressure ulcers are preventable or inevitable. For those of us who fall into the "most pressure ulcers are preventable" category, we must then treat this as a major quality issue and dedicate ourselves to making a difference.

10. Are we as wound care professionals truly involved in quality improvement and pressure ulcer prevention efforts?

Answer: If we were to look at the programs of lectures and courses at our wound healing meetings, most would not focus on discussions about pressure ulcers in terms of a quality of care issue. This is a shame because all of us are in the best position to effect change. Until we change our emphasis, the incidence of pressure ulcers will not decrease.

Preventing pressure ulcers is among the new interventions from the Institute for Healthcare Improvement's (IHI's) 5 Million Lives campaign. IHI recognizes that pressure ulcers require attention as a major quality issue; a realization we must all make. It is finally time to say, "With few exceptions, pressure ulcers are unacceptable."*

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