The National Decubitus Foundation is committed to the eradication of 
the hospital-caused bedsore.

Expert Witness

Jeffrey M. Levine MD
928 Broadway, Ste.305
New York, NY 10010
Telephone: 212-253-5601 
Fax :212-253-6602

Jayne Ritz, Pharm.D.
East: 212-330-7073
West: 858-793-1917
Address East: P.O.Box 250127, New York, NY 10025
7770 Regents Rd., Suite 113-390, San Diego, CA 92122 
Wound Care 
Jeffrey M. Levin 

Kenneth Olshansky, MD

Copyright 1998 Springhouse Corporation. 
Used with permission from Advances in Wound Care 22 (2):90. 
A RECENT ARTICLE IN ADVANCES IN WOUND CARE (1) leads me to conclude that we, as clinicians, still are not being honest with ourselves about the etiology of pressure ulcers. Several aspects of the article are worthy of discussion.

The principal investigator determined a Braden Scale score for each patient admitted to the study, then recorded subsequent nursing interventions. There was, however, no discussion of the type of interventions used. The results of the study showed 28% of the patients developed pressure ulcers--11 Stage I and 3 Stage II. Four patients with Braden Scale scores that indicated they were not at risk for a pressure ulcer eventually developed Stage I ulcers, and six patients who were believed to be at risk did not develop pressure ulcers.

The authors conclude that their study is "further evidence of the predictive validity of the Braden Scale" but that investigation is needed to determine why those six patients did not develop pressure ulcers. "Three of these patients had the following factors in common. All three were placed on alternating pressure air mattresses at admission or within 24 hours of admission. One of the three was also placed on a turning schedule and given topical skin treatments. A third patient was also given heel protectors." (Should these not be routine interventions for all at-risk patients?)

The article further indicates, "Three of the first 25 patients (12%) developed pressure ulcers compared with 11 of the final 25 patients (44%) ... the Hawthorne effect may have caused nurses, aware that a pressure ulcer study was being conducted, to respond initially with more preventative actions. As this study progressed, this effect may have decreased."

Predicting pressure ulcers
After reading this study, I am convinced that there is no accurate predictive value in pressure ulcer assessment scales. There is, in my opinion, only one predictive factor that will determine whether at-risk patients will develop pressure ulcers: who is caring for these patients. Like most risk assessment scales, the Braden Scale measures only the patient. It does not measure the staff. The incidence of pressure ulcers is related directly to the care given by the nursing staff.

Let us assume that there are 100 sets of identical twins with the lowest possible Braden Scale scores. One-half of the at-risk twins are admitted to an understaffed facility with poorly prepared personnel and no pressure-relieving beds. The other half are admitted to the finest facilities with well-prepared nurses, fully staffed shifts, pressure-relieving beds for each patient, and enough staff to turn each patient every 2 hours. It is my contention that the latter group will have dramatically fewer pressure ulcers than the former, despite identical Braden Scale scores.

We, as health care professionals, continue to blame our patients for their pressure ulcers, and most of the assessment scales do the same. In other words, the scales imply that at-risk patients are expected to develop pressure ulcers. When are we going to accept responsibility? If one of my patients develops a pressure ulcer, and some of them certainly do, I take responsibility. At some time during the patient's course in the hospital or nursing home, the nursing staff and I fell down on the job, pure and simple. The sicker and more at risk the patient, the harder we must work to prevent ulcers.

When I say this to hospital and nursing home administrators, I hear complaints that they are understaffed, overworked, have too many patients, too little money, and not enough specialty beds. My answer is that they are probably right. However, we need to acknowledge this and stop blaming patients because they have low Braden Scale scores. The time has come to be honest. A patient develops a pressure ulcer because, at some point, he or she had inadequate pressure relief.

Preventing pressure ulcers
The Braden Scale is an excellent nursing assessment tool for evaluating a patient's general condition. It should alert us that a patient requires our utmost vigilance. However, implementing preventive measures should be similar to implementing universal precautions - every at-risk patient, no matter what the Braden Scale score, should be afforded the best preventive care possible. There should be zero expectation that any patient will develop a pressure ulcer. The Braden Scale has no predictive validity unless the assumption is that the care is going to be inadequate.

Pressure ulcer prevention, to use the old cliche, is a 24-hour-a-day job. On a daily basis, we are entrusted with the care of thousands of at-risk patients. Are we honestly up to the challenge?


Medicare Policy Regarding Pressure Reducing Support Surfaces
Note: This article was revised and re-issued in its entirety on August 17, 2010.
Provider Types Affected
Suppliers and health care providers, such as home health agencies, who bill Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for pressure reducing support surfaces for Medicare beneficiaries, are affected.
Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) is issuing Special Edition (SE) 1014 to clarify existing support surface medical policies and coverage requirements. This article does not present new policy, but only reinforces existing policy. Be certain that your billing staffs are aware of these policies as outlined in the Background section of this article.

In August of 2009, the Department of Health and Human Services (HHS), Office of Inspector General (OIG) issued a report entitled “Inappropriate Payments for Pressure Reducing Support Surfaces" (report numbered OEI-02-07-00420),

Pressure reducing support surfaces are a type of durable medical equipment (DME) used for the care of pressure sores, also known as pressure ulcers. Pressure ulcers are lesions caused by unrelieved pressure resulting in damage of underlying tissue. Support surfaces are coded under one of 16 different Healthcare Common Procedure Coding System (HCPCS) codes. A major distinction between support surfaces is that some are powered by electricity and others are not. They may be categorized into the following three groups:

Group 1 support surfaces are generally designed to either replace a standard hospital or home mattress or as an overlay placed on top of a standard hospital or home mattress. Products in this category include mattresses, pressure pads and mattress overlays (foam, air, water, or gel).

Group 2 support surfaces are generally designed to either replace a standard hospital or home mattress or as an overlay placed on top of a standard hospital or home mattress. Products in this category include powered air flotation beds, powered pressure reducing air mattresses, and non-powered advanced pressure reducing mattresses.

Group 3 support surfaces are complete bed systems, known as air-fluidized beds, which use the circulation of filtered air through silicone beads.

Although LCDs are published by the four DME MAC contractors, inappropriate payments are still being made, and other problems continue to adversely affect Medicare reimbursement for this equipment. Therefore, CMS is taking additional steps listed here to reduce the extent of inappropriate support surface payments.

Required Documentation in Patient's Medical Record

For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient’s diagnosis and other pertinent information including, but not limited to, duration of the patient’s condition, clinical course (worsening or improvement), prognosis, nature and extent of
MLN Matters® Number: SE1014 Related Change Request Number: N/A

Functional limitations, other therapeutic interventions and results, past experience with related items, etc.

Suppliers should note that neither physicians’ orders, nor supplier-prepared statements, nor physician attestations by themselves provide sufficient documentation of medical necessity, even though they may be signed by the treating physician or supplier. There must be information in the patient’s medical record that supports the medical necessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if applicable) or information on a supplier prepared statement or physician attestation (if applicable). (See Medicare’s Program Integrity Manual (PIM), Chapter 3 (, Section, for additional instructions, regarding review of documentation during pre- and post-payment)

The patient’s medical record is not limited to the physician’s office records. It may include hospital, nursing home, or home health agency (HHA) records and records from other health care professionals.

The documentation in the patient’s medical record does not have to be routinely sent to the supplier or to the DME MACs, DME Program Safeguard Contractors (PSCs), or Zone Program Integrity Contractors (ZPICs). However, the DME MACs, DME PSCs, or ZPICs may request this information in selected cases
Required Supplier's Documentation

Before submitting a support surface claim to the DME MAC the supplier must have on file a dispensing order, the detailed written order, information from the treating physician concerning the patient's diagnosis, and any information required for the use of specific modifiers or attestation statements as defined in certain DME MAC policies. The supplier should also obtain as much documentation from the patient's medical record as they determine they need to assure themselves that coverage criteria for an item have been met. If the information in the patient’s medical record does not adequately support the medical necessity for the item, then on assigned claims the supplier is liable for the dollar amount involved unless a properly executed advance beneficiary notice (ABN) of possible denial has been obtained.

Documentation must be maintained in the supplier's files for seven (7) years.

Suppliers are required to maintain proof of delivery documentation in their files. The three proof of delivery requirements are:

Supplier delivering directly to the beneficiary or authorized representative;

Supplier utilizing a delivery/shipping service to deliver items; and
MLN Matters® Number: SE1014 Related Change Request Number: N/A

Delivery of items to a nursing facility on behalf of the beneficiary.

Proof of delivery documentation must be available to the DME MAC, DME PSC, and ZPIC on request. All services that do not have appropriate proof of delivery from the supplier will be denied and overpayments will be requested. Suppliers who consistently do not provide documentation to support their services may be referred to the OIG for imposition of civil monetary penalties (CMPs) or administrative sanctions.
Medicare Coverage of Support Surfaces
For all three support surface groups, patients should have a care plan established by their physician or home care nurse, which is documented in their medical records. This plan generally should include, among other things, education of the patient and regular assessment by a healthcare practitioner. Coverage for all three groups continues until the patient’s pressure ulcer is healed.
In addition to the above common requirements, coverage for specific groups of support surfaces varies as follows:

GROUP 1 - A group 1 support surface is covered if the patient is completely immobile. Otherwise, he or she must be partially immobile, or have any stage pressure ulcer and demonstrate one of the following conditions: impaired nutritional status, incontinence, altered sensory perception, or compromised circulatory status. A physician order must be obtained prior to delivery of the equipment and should be kept on file by the supplier.

GROUP 2 - A group 2 support surface is covered if the patient has a stage II pressure sore located on the trunk or pelvis, has been on a comprehensive pressure sore treatment program (which has included the use of an appropriate group 1 support surface for at least one month), and has sores which have worsened or remained the same over the past month. A group 2 support surface is also covered if the patient has large or multiple stage III or IV pressure sores on the trunk or pelvis, or if he or she has had a recent mycutaneous flap or skin graft for a pressure sore on the trunk or pelvis and has been on a group 2 or 3 support surface.

GROUP 3 – A group 3 support surface is covered if the patient has a stage III or stage IV pressure ulcer, is bedridden or chair-bound, would be institutionalized without the use of the group 3 support surface, the patient is under the close supervision of the patient’s treating physician, at least one (1) month of conservative treatment has been administered (including the use of a group 2 support surface), a caregiver is available and willing to assist with patient care and all other alternative equipment has been considered and ruled out.

The National Decubitus Foundation is committed to the eradication of 
the hospital-caused bedsore.
Expert WitnessWound Care 

Jayne Ritz, Pharm.D.
East: 212-330-7073
West: 858-793-1917
Address East: P.O.Box 250127, New York, NY 10025
7770 Regents Rd., Suite 113-390, San Diego, CA 92122

John L. Baeke, MD
5116 W 164th St.
Overland Park, KS 66085
Telephone: 913-406-2262
Fax: 913-499-1004


Steven Peck

Jonathan Rosenfeld
John Baeke, MD
1080 Viendra Dr.
Solvang, CA 93463
tel. 913-406-2262
Eli S. Schessel, MD
108-33 70th Road
Forest Hills, NY 11375
Fax: 718-268-8373
- New Jersey Requires Nursing Home Bed Upgrades

In April  2009, New Jersey Governor Jon Corzine signed a bill requiring the state's nursing homes to provide residents with pressure-relieving mattresses that prevent bedsores.

The law gives the facilities three years to replace all their mattresses with pressure-redistribution mattresses. The new mattresses shift support of a patient's weight away from the areas where pressure ulcers -- commonly referred to as bedsores -- are most likely to occur.

Research shows that more than one in 10 nursing home residents develops bedsores, most often over bony, prominent surfaces, such as the elbow, heel, hip, shoulder, back and back of the head. 
According to the text of the legislation, New Jersey nursing home patients have a higher incidence of bedsores than the national average.
The pressure ulcers often occur in patients who are immobile, resulting from lack of blood flow to the affected area. This causes the tissue to begin to break down, progressively creating sores that become portals for infections that are potentially fatal. Bedsores range from Stage 1, indicated by persistently red, unbroken skin to Stage 4, the most severe, in which open sores expose muscle and bone.

Treating one of these painful, often preventable, sores can cost between $38,000 and $55,000, according to national health care data.

The New Jersey law requires nursing homes to begin replacing mattresses a year after the bill's signing. Every time a home replaces a mattress, it must be with a pressure-redistribution mattress. By 2012, all mattresses must be replaced with bedsore-preventing types.

The bill's sponsors acknowledge that pressure-redistribution mattresses cost more up front, but they say an expected reduction in spending on bedsore treatment, combined with better health for nursing home residents, will more than make up for the additional initial costs
NDF Study No. 3, "Reducing Pressure Ulcer Incidence through Braden Scale Risk Assessment and Support Surface Use",  demonstrated that hospital investment in a supply of suitable support surfaces is able to both nearly eliminate pressure ulcers and result in cost savings (compared to funds spent on rental of very expensive support surfaces needed to provided a healing environment once pressure ulcers have been allowed to develop).  The National Decubitus Foundation, in order to provide guidance to hospitals regarding selecton of suitable support surfaces for their investment, has initiated a program of  evaluation of such surfaces for suitability.

Support surfaces are evaluated based on criteria of reported effectiveness based on published clinical studies, pressure reduction potential based on engineering analysis, and potential for cost savings.  Engineering analysis is by the method of finite elements, able to derive stress and displacement distributions under a variety of patient load and size configurations.
Initial support surface selections are as follows:

1. ZoneAire by Hill-Rom Corporation.
This was the support surface most often cited by those hospital incidence reduction programs reviewed in NDF Study No. 3.

2. Isoflex by Gaymar Industries, Inc.
This support surface was also shown to be effective in hospital incidence reduction programs reviewed in the NDF study.

3. Pegasus Airwave by Huntliegh Healthcare.
Dr. John L. Baeke, plastic surgeon, reports that he has used this surface over 16 year with more than 200 patients, none of  whom has ever developed a pressure ulcer.

4. VersaCare by Hill-Rom

5. AtmosAir by KCI

6. Low-G Skin Pressure Protection System

by John L. Baeke, M.D.   

A health problem of epidemic proportions is afflicting our elderly and incapacitated.  An inexpensive solution exists, yet remains elusive because of special interests and flat out ignorance.  I am referring to pressure ulcers. The medical literature, and more worrisome, the legal literature, have well documented the high risk rate for any patient to develop a pressure ulcer during the course of a hospitalization.  Certainly, patients of nursing homes and extended care facilities are at highest risk, but even our finest medical centers should hang their heads in shame.  As actor Christopher Reeve’s recent death even attests, wealth can not prevent what ignorance does wreak. I am told even our beloved President Reagan, died with a pressure ulcer as well.

The problem has many root causes.
First, most of us (this includes almost every health care practitioner and hospital administrator) are operating under the mistaken notion that every pressure-preventative mattress is equally efficacious.  This belief has never been challenged, thus seems well embedded as a time-honored, universally accepted mantra.  This attitude has unfortunately allowed health care facility administrators the luxury of believing that which ever brand of mattress system they place on their formulary will equally satisfy whatever moral obligation they might have to care for their infirmed.  Therefore, the only factor apparently motivating the institution’s selection of  pressure preventative mattress systems, is monetary.  This is dangerous.

Second, physicians too often give little or no thought to pressure sore risk and prevention when authoring admission orders.  Many attending physicians have tunnel vision when writing admitting orders, and fail to properly contemplate the patient’s needs for pressure relief.  Many physicians are totally unaware of what the term “MDS” means, and where to find this important Minimal Data Set in the medical record or how to act on this information.  Other physicians operate under the naive notion that the admitting nurse’s assessment can be faithfully relied upon to properly provide whatever measures are needed for pressure sore prevention, thus absolving them of further responsibility.
Third, too many nurses fail to show proper diligence when completing the important MDS or similar pressure risk assessment forms.  Sadly, random audit of  institutional medical records,  often finds simple data entry to be absent or incorrect.  Amazingly, elementary mathematical addition is even a problem for some who are completing Norton and Braden scales.  Whether this is a result of staff being over burdened by the deluge of paperwork required by modern medical records, or because of too little manpower, these important data sheets are frequently being neglected.  Then, even when the MDS or risk assessment forms have been properly completed, all too often the nursing staff will not act on that information.  Weary hospital staff must resist the temptation of  robotically entering data, without taking a moment to consider the nursing care plan these same MDS forms are designed to trigger.  It is simply unconscionable for any health care facility to not timely and correctly complete the pressure sore risk assessment and then not immediately act on that determination.  Yet this happens every day.

Patients at risk are still not being diligently turned.  This critical function, is too often relegated to the least trained, least paid, and least motivated worker.  Some nurses feel it beneath their dignity, preferring to delegate.  Others neglect this duty, because of being overworked or merely fearing that in the process of turning, a soiled sheet might be discovered, thus creating more work. Still others will fail to seek proper assistance, as with the morbidly obese patient. Yet still, others who have truly honorable intentions, fail to understand basic concepts of off-loading, and then improperly turn the patient.  Finally, others naively believe that some at risk patients should not be turned at all (for example; those on ventilators, those with orthopedic external fixators or those already on pressure-reducing mattresses). Egads!
Fourth, some institutions do not require q2 hour charting, conveying the message that with no oversight, this is a responsibility which lacks importance.  Other institutions have designed records allowing proper q2 hour charting, yet do not perform any internal audit to follow up when dereliction of duty occurs.

And the most unforgivable sin of all, is “nursing's dirty little secret”.  Charting that proper and timely patient turning occurred, when indeed, none was performed. Unfortunately, many times only the facility’s negligent employee, the  injured patient and God, truly know what happened behind the closed door.

Fifth, far too many in the medical profession have received woefully inadequate and incorrect basic training as to pressure sore prevention and pathogenesis.

For example:  True, there are various factors which may place an individual at increased risk for developing and healing a pressure ulcer.  These include, immobility, incontinence, diabetes, vascular disease, malnutrition, smoking, neurological disorders, dementia, etc., etc., etc.  It is a pervasive notion that individuals with any of these risk factors are predisposed to developing pressure ulcers, and little can be done to ward off the inevitable.  THAT NOTION IS DANGEROUSLY WRONG!  None of these physical maladies ever caused a pressure ulcer.  Yet, a recent survey by Brandeis [Adv Skin and Wound Care. 2001; v14, n5] of members of various health care professions confirmed that the majority of respondents subscribe to this naive notion. Remember, there is a reason these wounds are called Pressure Ulcers and not Mystery Ulcers.  That is because we know exactly what causes them.....PRESSURE.  It matters not how many  predisposing risk factors an individual might have.  Provide an environment of no pressure, and there will never be a pressure sore.  NEVER.  I would invite any of my learned colleagues to share clinical examples of any patient who developed a pressure ulcer in spite of what could be proven as proper diligence with pressure relief.  After years of hearing defense experts make this claim, no one has ever accepted my challenge of showing me one such example.
Most in the medical and nursing professions have been trained as to the clinical differences between Stage I to Stage IV ulcers.  Unfortunately, most received this knowledge from flawed charts, one often sees posted on the walls at nursing stations.  These colorful diagrams (provided by companies e.g. Calgon Vestal / Merck, ConvaTec and KCI, et. al.) erroneously convey the message that pressure sores initially begin with some surface injury to the skin (noted by erythema) and as the soft tissue damage extends, the wound then involves progressively deeper structures (i.e. fat then muscle).  Except for the subgroup of “sheer type” pressure ulcer patients, this concept is unfortunately erroneous. However, I would imagine that most still subscribe to it today. 

Pressure between a hard external surface (e.g. a conventional mattress) and a bony prominence (e.g. the ischium), dissipates in a funnel shaped pattern, with the highest intensity of pressure focused against the bony prominence.  Furthermore, for a variety of reasons,  the skin is the soft tissue structure most resistant to the effects of unrelenting pressure, i.e. the last structure to show signs of damage.  What this means clinically, is that many pressure sores will have been developing for a long time before they have progressed to involve the skin.  The practical implications is, when the skin becomes red many providers will treat the area as if a stage I wound, and merely rub the surface with some soothing lotion (just as instructed by the aforementioned charts), when in reality what is seen is often the tip of the Stage IV iceberg.  The future of that wound has been cast, and no amount of rubbing or lotion will heal the damage.

Since the knowledge and technology exists to prevent nosocomial pressure ulcers either with mere diligent turning or proper mattress selection, then I have to believe ALL pressure ulcers are preventable.  In other words, all pressure ulcers are caused by negligence. 
Like many of you, from time to time I have been asked if a pressure ulcer could have been prevented.  After many years as a plastic surgeon with a large wound care population, it occurred to me that my answer to this question, has always been the same,  “Yes”.  It mattered not whether the patient was a young paraplegic or elderly and demented; whether the patient was well nourished or  found on the concrete in an alcoholic stupor; the result of my probing into the wound etiology always came to the same conclusion.  The pressure ulcer(s) was (were) preventable. Upon reflection, I have been unable to contrive of any situation where a pressure ulcer was not preventable
To me the litmus test for this belief is this:  Hypothetically, if it could be proven that the patient in question would still have developed the same pressure ulcers even if (theoretically) suspended from the ceiling by strings (i.e. zero pressure), then either a) indeed the pressure ulcer was unpreventable, and/or b) the etiology of the wound was obviously something other than pressure. Since, I believe no patient would pass such a test, we must assume all pressure ulcers are preventable.

As stated above, not all of the responsibility for this problem rests at the hands of the front-line care givers.  Many if not most health care institutions feel comfortable that they have adequately provided for the at-risk patient by merely providing pressure-reducing mattresses on their formulary. These mattresses at most, only provide temporary comfort to the patient, and at their worst, allow staff a dangerous sense of compassion. Ask yourself this,

If mere “pressure-reducing” mattresses were so effective, why do nursing protocols still have them turning patients while on these devices?  It doesn’t seem to me that this expensive mattress has resulted in a net gain for the facility, over their standard hard mattress.  Thousands of patients a year develop pressure ulcers, when resting atop popular pressure-reducing mattresses.

Pressure-reducing mattresses are not the same as Pressure-relieving (or zero-Pressure) mattresses.

I have used “zero-pressure” mattresses on well over two hundred patients, including my quadriplegic father.  By physician order, I would even instruct the nursing staff to NOT turn my patients.  What pressure relief  has one gained if a wedged pillow is still jammed against the back?  During the 16 years I have used the Pegasus mattresses, none of my patients have developed any pressure ulcers.  None!  Furthermore, I have had no hesitation to place patients supine on top of fresh skin grafts and flaps!!!
What can be done?  Infirmed patients deserve a better product.  Instead of a mere pressure-reducing mattress, these at-risk individuals should be resting on a pressure-relieving or zero-pressure mattress.  What is the difference?  A pressure-reducing mattresses does not offload the soft-tissue / bony interface by the critical capillary filling pressure.  In other words, if a pressure-reducing mattress can not reduce the pressure to something less than ~ 15mm HG, the small vessels, especially those on the venous side of the microcirculatory loop, are still collapsed.  A truly preventative mattress must therefore be pressure-relieving or zero-pressure. To my knowledge, only one such product exists, today.  These were manufactured by Pegasus Airwave, Inc. of Boca Raton, FL.  I am told they have the patent on zero-pressure technology.  Pegasus manufactured two models of zero-pressure mattresses: the Renaissance and Biwave.

To look at a Pegasus mattress, one observes no apparent difference from more familiar brand name products.  The key difference is that the transverse air cells in the mattress do not just passively deflate to some lower pressure, but rather they actively implode, thus collapsing the air cell and temporarily suspending that portion of the body between the two adjacent inflated air cells.  This cycle alternates every few seconds.  This process not only creates periods of zero pressure, but causes a reactive hyperemia, which further aids in healing wounds in those with established ulcers.

In the past few years, the corporate story of the Pegasus company is one of little fish eaten by bigger fish.  Pegasus Airwave was acquired by Arjo, A..G. (Switzerland) who seemingly was acquired by Huntleigh HealthCare (United Kingdom) who was acquired by Getinge, A.B. (Sweden). None of this bodes well for the end-consumer.  For patients and physicians wanting to promote sales and research of the Pegasus mattress, attempts to pierce the corporate veil have always been frustrating.  Today, with three new corporate parents, little seems to have changed.  A wonderful product;  a not-so wonderful company.

Most facility administrators have never heard of the Pegasus Airwave or Huntleigh mattresses.  Shame on Getinge, A.B..  The Pegasus mattress is available internationally, but the internal mechanisms of the company prevent any semblance of effective marketing in the United States.  Current competitors such as K.C.I. ( San Antonio, TX) and Hill-Rom (Batesville, IN) site a lack of published research by Pegasus as evidence of their inferiority.  Again, shame on Pegasus/Arjo/Huntleigh/Getinge for ignoring offers by physicians to partner with clinical research.
As attending physicians we should routinely order Pegasus Airwave mattresses (any of their models are satisfactory) for all our at risk patients. I am told that with Getinge, A.B.’s recent acquisition of Pegasus, that same technology is now embraced with their “Trinova” mattress ( Even if this is off-formulary we physicians should order it by name.  Well-meaning case managers and other hospital soldiers will attempt to substitute for other devices owned by the facility.  No substitutions should be allowed.

My suggestion for individuals searching to purchase a zero-pressure mattress would be to preferentially locate a renovated Pegasus Renaissance or Pegasus Biwave mattress. I can attest, they are built like a tank, have idiot-proof controls (just an on/off switch) and work. The customer service people at Huntleigh (1-800-223-1218) are unpredictable and vary as to whether or not they have any reconditioned Pegasus mattresses available.  I get the sense, they are wanting the public to forget that name.  With some persistence, one ought to be locatable.  As a last resort, consider eBay.
If you are a hospital administrator, consider this.  Which will cost more, the rental of an off-formulary mattress or the out-of-court settlement for your next pressure-sore claim?  With a Pegasus (or Trinova) mattress, you can tolerate the indifference of the unmotivated  nurse’s aid.

I am not employed by Pegasus Airwave or Getinge.  I have no financial interest nor own stock in either company.  I receive no financial compensation from either  company (although I should).  Pegasus Airwave simply made the state-of-the-art mattress in pressure-ulcer prevention.  They have a fine network of field representatives and service technicians, however, the company continues to be paralyzed by junior varsity corporate officers.
They are resistant to subsidizing research needed to publish in peer-reviewed journals.  They are resistant to financing aggressive marketing campaigns, and they  even turn a deaf ear  to their small but extremely devoted group of medical supporters.
With this apparently cavalier business philosophy, I fear the Pegasus Airwave/Getinge company is not long for this world.  Our patients deserve this product, and if Pegasus Airwave/Getinge is not willing to  better promote their product to penetrate the American marketplace, I hope that this company is acquired by another, who is more committed to the cause of pressure ulcer prevention.

One final word.  In 1999, my father, Dr. John O. Baeke, was rendered a quadriplegic as a result of a subdural hemorrhage.  For the next six years, he lived with me, while bed-ridden.  If my wife and I were able to keep him free of any pressure ulcers while maintaining a full work load,  certainly any hospital should be able to do the same.

I applaud the editor for allowing this possibly volatile commentary when other publications e.g. Advances in Skin and Wound Care are so apparently encumbered by ties to special interests that they can not publish a frank discussion, without placing a spin on this crucial subject.

Why are so few of us willing to go out on a limb and say, “Yes, all pressure ulcers are preventable”?

© John L. Baeke, M.D.
Park Place Plastic Surgery
5116 W. 164th St
Overland Park, KS   66085

NDF Exhorts 49 States To Follow New Jersey
The scourge of bedsores is being confronted
Published on July 31, 2009

The National Decubitus Foundation ( is a 501(c)(3) tax-exempt public charity dedicated to the eradication of  hospital-caused bedsores.  Since its founding in 1996, the NDF has seen some amazing developments.  The ongoing controversy concerning whether or not bedsores are preventable was resolved when Medicare declared pressure ulcers (bedsores) a “never event”, i.e. a medical error. This was followed by the decision by major insurers, including Medicare, to cease reimbursement to hospitals for expenses connected with treatment of pressure ulcers developed in the hospital.
The NDF published a study in the July 2008 issue of Advances in Skin & Wound Care showing that those few hospitals that had been able to reduce bedsore incidence far below the national average had adopted a common policy.  They each evaluated all patients for pressure ulcer risk upon admission, then placed all at-risk patients on a special pressure redistribution support surface, designed to prevent bedsores.  With the aid of a grant from the Christopher and Dana Reeve Foundation, the NDF was able to distribute this study to almost all acute care hospitals and to every state public health department.

Now the state of New Jersey has mandated that all nursing homes must replace all beds with these special pressure redistribution mattresses over the next three years. The vote in the New Jersey Assembly in favor of this measure was 78 – 0.  The NDF urges New Jersey to also require that hospitals invest in a supply of these specialized beds sufficient to accommodate all at-risk patients.  And the NDF urges all states to follow the New Jersey lead.

For more information visit
SACRAMENTO, Oct. 24, 2011 /PRNewswire-USNewswire/ -- Pressure ulcers - also known as bed sores - are among the five most common types of healthcare-acquired conditions experienced by hospitalized patients.  But efforts underway at hospitals across California are showing dramatic results in the prevention of these skin lesions.
White Memorial Medical Center/Adventist Health in Los Angeles and hospitals within Northern California’s Sutter Health network are among the many hospitals leading the way toward reducing the incidence of pressure ulcers.  Case studies from both health care organizations can be found on the California Hospital Association’s (CHA’s) new patient
safety website -

“Health care professionals know that quality improvement is an ongoing, continuous process,” said CHA President/CEO C. Duane Dauner.  “Key to these efforts is the use of proven, evidence-based practices such as those which enable clinicians to quickly identify those patients who might be at risk of developing pressure ulcers.” Pressure ulcers develop when pressure against the skin decreases a patient’s blood flow, causing the surrounding tissue to deteriorate and a sore to appear.  Patients with fragile skin or who cannot move their body freely due to injury, extended illness, impaired mobility or end-of-life issues are most at risk of developing a pressure ulcer.  
At White Memorial, clinicians in 2009 launched a comprehensive program to reduce severe bedsores among its patients.  The effort proved so successful that the hospital expanded the program to focus on eliminating all pressure ulcers.  In addition to a screening process that quickly identifies at-risk patients, the hospital provides regular staff training on wound care and has designated “wound care champions” on each hospital unit.  These efforts, along with the replacement of all mattresses and pillows in the hospital, have resulted in an 85 percent drop in pressure ulcers over the past two years.

Sutter Health also has implemented an aggressive program to prevent pressure ulcers in all patients receiving care across the organization’s 24 Northern California hospitals.  Clinicians have implemented a wide-ranging program including a $10 million investment in special pressure-relieving mattresses and surfaces for all patient beds, including those in emergency departments, surgical suites, diagnostic imaging and patient transport gurneys.  Health care professionals also conduct enhanced screening practices that quickly identify and respond to the needs of at-risk patients. As a result of these initiatives, hospitals within the Sutter Health network have reduced the rate of pressure ulcers by 86 percent since 2003.  In addition to these two case studies, the website features patient safety success stories from nearly a dozen hospitals throughout California.

SOURCE California Hospital Association 10/24/2011

/CONTACT: Jan Emerson-Shea, +1-916-552-7516, +1-916-804-0663 - Cell


Please be aware that 10 – 15% of patients in this hospital, as is true of most hospitals, are suffering from pressure ulcers (bedsores).    The elderly are most at risk.  .

To combat the possibility that you will develop a pressure ulcer during your stay:

Change your position frequently.

If unable to do so, have a family member insure that the nursing staff turns you frequently.

In case of incontinence, insist that you be changed promptly.

When the bed is raised as for eating, lift yourself or be lifted so that there is no stretching or shearing of the skin on the lower back.

Ask that a formal pressure ulcer risk assessment be conducted and the results shared with you.

If you are found to be at significant risk, have your doctor require that you be placed on a special pressure-reducing support surface.

National Decubitus Foundation

Do Assessment Scales Predict Pressure Ulcers?

Medicare Policies

New Jersey Requires Pressure Reditribution Mattresses

NDF Prevention Protocol - Support Surfaces

All Pressure Ulcers are Preventable - Dr.John L. Baeke

NDF Urges 49 States to Follow New Jersey

California Hospital Association "Endorses" NDF Prevention Protocol

Notice to Admitted Patients
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