In response:

I want to thank the editors of Advances in Skin & Wound Care for giving me the opportunity to respond to Dr Robert C. Villare's thoughtful and pertinent comments.

First, let me state that I have worked with bedside nurses almost every day of my career and have only the highest respect for the work that they do. As a plastic surgeon who has treated thousands of PrUs, I have firsthand experience with how hard nurses work and what challenges they face. Next, I would like to note that, for years, no one really addressed PrUs as a quality issue. I agree with Dr Villare that statistic keeping is complicated and has changed over the years. However, I think we can all agree that the incidence of acquired PrUs in hospitals and long-term-care facilities is too high.

In Dr Villare's letter, he cites that I blame caregivers (myself included) and that "telling caregivers that they are the problem and must work harder is not the answer." Although that may come across as blaming, let's look at the facts.

Studies in the literature do not show what percentage of PrUs is preventable and what is not. However, there are thousands of articles that discuss hospitals and nursing homes that have implemented PrU prevention programs because they were not satisfied with their incidence of PrUs. In almost every single study, when the nursing staff improved their care, the incidence of PrUs decreased. The most important point in these studies was that the level of care improved while the acuity of the patients remained the same. These articles did not blame the nurses but found that the incidence of PrUs was directly related to the quality of care given. Dr Villare is correct: Education is a key factor.

I believe the point I was trying to make with the airline safety analogy was lost. As I stated in my article, in my opinion, airline safety in this country has a higher priority than hospital and nursing home safety. I give the example that when an airplane crashes, the National Transportation Safety Board (NTSB) does an extensive investigation and determines the cause of the crash. Everyone learns from the investigation, and if changes need to be made, they are implemented. When patients develop a PrU, what measures do we take to ensure that it does not happen again? Most of the time, we attribute this to the patient being so sick, but rarely do we ask ourselves, what did or did we not do to contribute to the problem? Dr Villare gave an excellent example of a critically ill 300-lb patient in the ICU and a 120-lb critical care nurse caring for that patient. This is not an uncommon scenario. Dr Villare states that I "suggest that if a patient develops a PrU, then we should look at the quality of care that the nurse and other hospital staff are providing." That is exactly what I am suggesting.

If every 300-lb critically ill patient cared for by a 120-lb nurse was to develop a PrU, it would be disastrous. We have no control over patient acuity, so we must adjust the intensity of our care to meet the challenges. It is a testament to the great care that patients receive that the incidence of PrUs is not higher.

In our hospitals, I work with nurses to review all Stages III and IV PrUs that occur. I would encourage everyone to do the same. We essentially have conducted an "NTSB-like" investigation. We have learned a great deal about each ulcer with few surprises. When reviewing each case, almost every one showed 1 or more of the following deficiencies:

* After skin risk assessments were performed, the appropriate preventive measures were not implemented or sustained.

* Use of appropriate pressure-reducing or pressure-relieving beds or mattresses was an issue.

* Turning schedules were not adhered to, and often, patients with sacral ulcers, as an example, would be positioned on their back or stayed in 1 position for hours at a time.

* When Stage II ulcers were identified, there were delays in setting into motion heightened preventive measures.

These are not findings that blame our wonderful nurses. These are everyday facts that point out to all of us that we need to raise the level of quality of our care. If we are not professional enough to accept the fact that we do need to try harder and do better, then the status quo will not change. I include myself in this whole process, and I can also try to do better.

Major organizations like CMS and the Institute for Healthcare Improvement have recognized that PrUs are a quality-of-care issue. As clinicians, we can respond in 1 of 2 ways. We can say, "Stop blaming us for PrUs," or we can say, "We recognize this is a quality issue, and we're up to the challenge to improve our care."

Contrary to how it may seem, I agree with Dr Villare more than I disagree. He notes the issues that we all face everyday. One issue that we did not mention is that the physician community must get more involved in PrU prevention and give more support to our nurses.

In summary, I want to emphasize that my intention is not to blame nurses. My intention is to get all of us to admit that PrUs are a serious quality-of-care issue. Until we, as caregivers, honestly address the problem, our PrU incidence will not change. I'm sure I join Dr Villare and journal readers in committing ourselves to this goal.

-Kenneth Olshansky, MD

Clinical Professor, Plastic SurgeryVirginia Commonwealth University

Richmond, Virginia