1. Villare, Robert C. MD

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In Advances in Skin & Wound Care's November 2008 Guest Editorial, "10 Most Important Questions Concerning Pressure Ulcers and Quality of Care," Kenneth Olshansky, MD, discusses issues pertaining to the subject of wound care. In that article, Dr Olshansky cites caregivers as a cause of pressure ulcers (PrUs), suggesting that they fail to adequately prevent wounds. Although I agree with some of his discussion, it is important to give alternative viewpoints on issues concerning wounds and quality of care.


Dr Olshansky asks why the incidence of PrUs has not decreased over the last 20 years. He claims that failure on the part of bedside caregivers has contributed to this problem. However, we must consider that 20 years ago, the technological ability to document and study wounds with computers did not exist. There was no emphasis, and few resources, directed toward data entry to document the incidence of PrUs.


If one considers no reporting and the underreporting that has occurred in the last 20 years, the lack of a decrease in the number of wounds becomes simply a reflection of the lack of emphasis and capability to report all wounds. With accurate reporting mechanisms and mandates, the amount of wounds that are treated should be much higher than in the last 2 decades, and the true incidence may be decreasing substantially. For instance, we now report nearly every incident of PrUs in every hospital and nursing facility in the country. We also have the capability to keep the sick and severely injured alive, whereas, years ago, many individuals died before developing the wounds that we see today. Science and technology have increased our chance of survival, but have also led to the development of other complications, including wounds.


In addition, the science of prevention and treatment of such wounds is incomplete. Telling caregivers that they are the problem and must work harder is not the answer. To borrow from the flight metaphor that Dr Olshansky uses in his article, this solution is similar to telling pilots to fly more safely and yet not giving them an altimeter, radar, or computer flight system to make their work safer. I believe that most patients, faced with the choice of "death" versus "survival with a treatable wound," will choose the latter. The tradeoff with survival is worth the effort to treat subsequent problems. I agree with Dr Olshansky that continued emphasis on education and prevention is an area in healthcare that needs our diligent attention. But that teaching must be undertaken without attributing blame to caregivers.


Dr Olshansky raises the issue of staffing care as a quality indicator, stating that staff performance is a better indicator of PrU risk assessment than a patient's condition and environment. He calls for consideration of our own shortcomings. While the creation of flaps to cover major wounds and cosmetic surgery for skin and aesthetics are familiar to a plastic surgeon such as Dr Olshansky, we must consider the real world of patient care. Imagine a 300-lb trauma patient in the intensive care unit (ICU) who has adult respiratory distress syndrome, hypoxia with kidney failure, and cardiac dysfunction. The patient is unconscious and immobilized after sustaining fractures and internal organ injuries and is also on a ventilator but is difficult to ventilate. The patient's abdomen is packed open after surgery, to prevent compartment syndrome, with bilateral chest tubes in place.


Now visualize a 120-lb critical care registered nurse at that same patient's bedside, doing all he/she can to care for this patient but is impeded by physical limitations. The nurse is the caregiver that Dr Olshansky suggests we look to as an indicator for PrU risk assessment. He also suggests that if the patient develops a skin (wound) problem, then we should look at the quality of care that the nurse and other hospital staff are providing. He insinuates that the attending nurse or other caregivers are to blame when the patient develops skin breakdown.


Dr Olshansky then draws the comparison of wound problems in healthcare to flight safety and the prevention of a plane crash. The analogy of healthcare to the airline industry is often used to develop tools for patient safety in medical settings. However, what authorities fail to realize is that when we, caregivers, board the "aircraft" that is our patient, the plane-or our patient-is already crashing. The public and governing authorities seem to criticize healthcare providers from a distance when problems occur. I ask how many of those authorities would board a crashing airplane and attempt to bring it to a safe landing, similar to jumping in to care for a trauma patient. The injured aircraft is in a spiraling descent with no power to control itself, much like our powerless patient lying comatose on an ICU bed. Similar to the "Miracle on the Hudson," when a US Airways Airbus A320 made an emergency landing in the Hudson River, if you land a plane safely in a crisis, you can repair the dents on the skin and give it a new paint job. Yet, Dr Olshansky focuses only on the skin in his article, like the paint on the exterior of the plane.


In light of the diminishing resources provided to healthcare professionals and hospital nursing staff, I remind critics to remain vigilant about real priorities in patient care. The 120-lb registered nurse at a patient's bedside is consumed by duties to monitor, report, react to, and maintain equilibrium with all the organ system changes that happen to the patient-our airplane. If a patient's nervous system is not responding, it is much like the radar being down in an airplane and the autopilot is not responding. Or if a patient is in heart failure, like a plane that loses an engine, the patient loses "power." At the most dire of trauma care, when a patient is lying in bed, pinned against the mattress, unable to move or respond, the patient is like a crashing airplane that fails to respond to the pilot's efforts to save it.


Dr Olshansky questions why it is rare to hear administrators say that "PrUs are unacceptable." I cannot comment on discussions at hospitals and nursing homes where Dr Olshansky works, but in our region, wounds are at the top of our quality-of-care discussion list. The Centers for Medicare and Medicaid Services (CMS) and other payers are refusing to pay the higher diagnosis-related group rates for services and products to treat wounds or infections acquired while the patient is in a hospital or nursing home.


The public demands, and the government and corporate payers legislate, that physicians and nurses, our pilots and copilots, do everything that they can to provide the best, highest-quality patient care. Yet, like an unfunded mandate, when the government demands that you provide a service but will not pay additional fees for it, payers reduce and may deny payment to hospitals and staff for the additional, necessary care.


Because of cutbacks, there are not enough skilled nurses, technicians, physicians, and equipment in hospitals to deliver the desired perfect results. But according to Dr Olshansky, if the patient develops an ulcer or treatable wound infection, the less-than-expected impeccable result, the caregiver must have contributed to the problem. However, many factors contribute to this issue.


To summarize, Dr Olshansky presents a frightening trend in the legal system, and a detrimental trend in society's attitude, that someone else must be responsible and liable for every individual, negating the value and empowerment of self-responsibility. When negative results occur, those results must be someone else's fault, with someone else who can be blamed. Dr Olshansky's editorial delivers yet another attack on nurses and providers who work diligently at patients' bedsides, delivering labor-intensive patient care. We lose focus on the fact that the patient's condition, disease, or injuries may inevitably lead to wounds and a cascade of problems. It is true that the healthcare providers and the nurses to whom Dr Olshansky refers can do better. Continual medical education, risk awareness, and improvement in skills are crucial to improving care. I believe we must also empower and expect patients and their families to develop self-responsibility. We will, and certainly do, give patients all the help we can.


Robert C. Villare, MD


Senior Scholar, Department of Health Policy


Thomas Jefferson University Hospital


Philadelphia, Pennsylvania


and Medical Director, Wound & Vascular Center


Community Health Systems' Salem Hospital


Salem, New Jersey