Wound, Ostomy and Continence Nurses Society
National Pressure Ulcer Advisory Panel
American Professional Wound Care Association
Medical Malpractice Attorneys

Kinetic Concepts, Inc.


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The Ugly Secret
Dedicated to the Eradication of Hospital-Caused Bedsores
4255 S. Buckley Rd.  Ste. 228   Aurora, CO 80013                            

NDF Paper to be Published
Advances in Skin & Wound Care

The NDF was notified of the decision to publish its study on bedsore prevention by com-munication from the publisher on April 17, 2007.  “We are pleased to notify you of the acceptance of…your manuscript, “Reducing Pressure Ulcer Incidence through Braden Scale Risk Assessment and Support Surface Use” for publication in Advances in Skin & Wound Care.  Your manuscript will be assigned to a staff editor for final editing.  Prior to publication, you will receive an edited version for your approval.”  

It was this study for which the Christopher Reeve Foundation awarded a grant to the NDF,  enabling  it to present study results to hospitals and boards of public health nationwide.  This will be accomplished as soon as reprints of the published study are available.

Letters Sent to Board of Health
State Reporting Standards Requested

Letters have been sent to directors of boards of public health in each state asking if they have reporting requirements similar to those of concern to Attorney General Richard Blumenthal of Connecticut  (see story next page).

What is a Disruptive Innovation? 
NDF Enters Competition 

A disruptive innovation is a completely new way of doing things that brings better services to the public. is sponsoring a competition in the healthcare category.  Three prizes of $5000 each will be awarded.

The NDF is proposing that its plan of requiring risk assessment for all admitted patients, followed by provision of specialized support surfaces for all those at risk, is such an innovation.  Entries are due July 18, 2007.

Board of Directors Linked
Email List Facilitates Communication

The NDF Board of Directors is far-flung, with members located across the country.  In order to facilitate communication, the NDF has contracted with LISTSERV to provide email list hosting.  This is a closed list, with members limited to the NDF Board of Directors

Discussion of a topic by any member will be automatically seen by all, so that each member can easily provide input and see the contributions of all fellow members.   Meetings will take place by posting an agenda and setting a time period, probably one week, for completion of discussion of agenda topics.

Medicare Pay for Performance
CMS Responds to NDF Request

Medicare has been paying increased reimbursements to those hospitals that meet certain criteria.  In a Fact Sheet dated January 2007, Centers for Medicare and Medicaid Services (CMS) announced, “The Premier Hospital Quality Incentive Demonstration” recognizes and provides financial rewards to hospitals that demonstrate high quality performance in a number of areas of acute care.

Mark Wynn, Ph.D. of CMS, in his letter of March 2007, told the NDF that, although no measure for decubitus ulcers had been included in years 1-3 of the program, such a criteria will be included in the recently approved extension of the hospital incentive program for FY 2007 through FY 2009.  Infections due to medical care will also be added as a factor.
Wound Staging Updated
NPUAP Proposes New Categories

The National Pressure ulcer Advisory Panel has updated its staging system, in general use for the past several years. Biomechanical analysis has long shown that maximum pressure and greatest potential for tissue damage occur right at the bony prominence.  In recognition of this fact, the NPUAP has added the category “Suspected Deep Tissue Injury” to the existing Stages I – IV.  In addition, a category termed “Unstageable” has been added to account for wounds that require removal of slough and/or eschar  in order to expose the base of the wound and therefore its actual depth.

Deep tissue injury may be involved in virtually all pressure ulcer development. This is why all admitted hospital patients judged to be at risk for bedsores must be placed on a specialized support surface without waiting for the first superficial indication of bedsore initiation.

Conn. Atty Gen Acts on Bedsores
Proposes Hospital Reporting Penalties

Richard Blumenthal, Attorney General of the state of Connecticut, has proposed daily fines for hospitals that fail to report Stage 3 and Stage 4 bedsores to the Department of Public Health as required by Connecticut law.  Fines would be levied for every day and for every case for which the required reporting fails to take place.  

Attorney General Blumenthal, interviewed February 2007 on NBC30 in Hartford, Conn. by  reporter Deborah Bogstie, stated that he was “absolutely appalled” at what he had learned of the bedsore situation at Milford Hospital, Milford, CT.  But as readers of The Ugly Secret know, many by their own experience, the appalling sight he witnessed is a regular occurrence at nearly all of our nation’s hospitals.

The hospital was investigated by the Connecticut Dept of Public Health after com-plaint by the daughter of the victim, Naomi K. Press, her 85 year old mother who was allowed to develop a stage IV bedsore, then shipped to the nursing home to die.  The hospital was cited for seven violations.

Also interviewed for the report was Prof. Lowell S. Levin of Yale University and consultant to the World Health Organization.  Dr. Levin is author of the book Medicine on Trial: The Appalling Story of Ineptitude, Malfeasance, Neglect, and Arrogance. He called for daily oversight of hospitals with regard to their bedsore problem, and he stated that this was a “modest” proposal in view of the severity of the problem.

The NDF was asked to provide statistical information with regard to the extent of the bedsore problem as background for this special NBC30 report.  Please send an email to if you would like to receive an emailed copy of this video. 

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The Ugly Secret
Dedicated to the Eradication of Hospital-Caused Bedsores
Fall-Winter 2006
4255 S. Buckley Rd.  Ste. 228  Aurora, CO 80013                            

NDF Receives Grant
Christopher Reeve Foundation

The Christopher Reeve Foundation has awarded a “Quality of Life Grant” for 2007 to the National Decubitus Foundation.  This award will provide funds allowing the NDF to widely disseminate its recent study regarding bedsore prevention.

NDF Study No. 3, expected to be published soon in a prominent wound management journal, reviews the success in reducing bedsore incidence achieved by nine hospitals that followed a specified protocol.  A pressure ulcer risk assessment was conducted for each admitted patient.  Those patients judged to be at risk were placed on a special pressure-reducing support surface, even though no sign of a developing bedsore had yet appeared.  Statistical analysis was used to demonstrate conclusively that the reductions in wound incidence achieved were substantially greater than could be explained by chance.

This grant will allow the NDF to bring these results to the attention of hospital administrators nationwide.  The backing of nursing associations will be sought.  State hospital overseers will be urged to mandate that the practices followed by successful hospitals be required of all.

Bedsore Mechanism Studies
Biomechanics Research Advances

Engineering studies of the mechanism of bedsore development generally agree that the pressure maximum, and the site of ulcer initiation, occurs in deep tissue at the location of the bony protuberance.  A key issue addressed by recent papers is how the pressure at the support surface–body interface relates to these deep tissue forces.

Wounds are a Medical Error
Medicare Defines Hospital Failures

The Center for Medicare and Medicaid Services (CMS), on its website, defines never events as “serious and costly errors in the provision of health care services that should never happen.” CMS provides criteria for inclusion on its list of medical errors that should never happen: Serious, Usually preventable, Unambiguous.

Under the category Care Management Events is listed: Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility.  Thus the debate about preventability of pressure wounds is over.  It is time that hospitals no longer are able to escape all penalties when they continue to bring this affliction on a significant fraction of admitted patients

Regulators Must Get Involved
Hospitals Escape Punishment

The penalties for nursing home operators found guilty of allowing conditions to prevail that facilitate bedsores are severe.  The American Journal of Forensic Medicine and Pathology (the Official Journal of the National Association of Medical Examiners) reported on a landmark case in 2002.

A nursing home operator in Hawaii was caring for a 79-year old woman.  Her doctor discovered multiple bedsores, and referred his patient for surgical treatment.  The nursing home operator was told to bring the patient for a follow-up visit in a week, but that appointment was never kept.  A few weeks later, the patient died of septic shock, which an autopsy found was directly due to the pressure wound.

The State charged the nursing home operator with negligence.  The result was a conviction for manslaughter.  

The authors of the Journal article conclude, “With the introduction of criminal prosecution for gross neglect, a new weapon against poor nursing care has appeared….The risk of criminal prosecution for gross patient neglect may eventually extend from nursing homes to hospitals and hospital personnel.”

Nurse Retention
Bedsore Problem Does not Help

Hospitals are paying a great deal these days in an attempt to solve the nurse retention problem.  If some of those dollars were spent to provide high risk patients with suitable pressure-reducing support surfaces, one very unpleasant aspect of the nursing profession could be nearly eliminated.  Nurses are held responsible, but have no control over the surface provided.

New NDF Pamphlet Available
Individual and Corporate Memberships

The National Decubitus Foundation has published an updated version of its pamphlet.  It will serve as an important tool to recruit members and contributors.  

“Friends of the NDF” are asked to send an annual fee of $30.00, in exchange for which the NDF newsletter THE UGLY SECRET will be e-mailed regularly, news of special developments will be provided, and members-only pricing will be provided for books and events.

Corporations working to prevent bedsores, or wishing to support this cause, are asked to become supporting members with acknowledgement on the NDF website and in the NDF newsletter.  Those wishing to receive the new pamphlet should e-mail their request to

Medicare Pay for Performance
NDF Asks that Bedsores be Evaluated

Medicare has been paying increased reimbursements to those hospitals that meet certain criteria.  In a Fact Sheet dated January 2007, CMS announces, “The Premier Hospital Quality Incentive Demonstration” recognizes and provides financial rewards to hospitals that demonstrate high quality performance in a number of areas of acute care.

Incentive awards are based on quality measures for inpatients with heart attack, pneumonia, coronary artery bypass graft, and hip and knee replacements.  Over 250 hospitals have been selected to participate in this demonstration.  

The NDF has written CMS urging that a measure of pressure ulcer incidence be used as one criterion for determining those due awards.

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The Ugly Secret
Dedicated to the Eradication of Hospital-Caused Bedsores
Spring-Summer    2006
4255 S. Buckley Rd.  Ste. 228  Aurora, CO 80013                            

Donations by Credit Card
NDF Links with “Just Give”

The National Decubitus Foundation is now listed with  Donors can now be assured that contributions to the NDF are tax deductible according to IRS guidelines.

Your contributions are needed to further the education program of the NDF.  Patients are almost never warned of the real dangers of developing bedsores at the time of hospital admission.  Patients and their families must be educated to ask the hospital if a risk assessment has been performed, and if so, what the results were.

Donors now have the opportunity to use their credit cards to make a contribution to the National Decubitus Foundation.  JustGive.Org and ETapestry have each provided the NDF with credit card processing and donor acknowledgement services.  The only charge is a fee of just over three percent, so donors can be certain that nearly all of their contribution is available for the intended cause.

Most initial visitors to the NDF website are seeking information to help a loved one suffering from a pressure wound.  We ask that, on a subsequent visit, consideration be given to making a donation. 

NDF Seeks Members
Bring Message to Local Hospitals

NDF members will be asked to visit their local hospital in order to bring the NDF message of  bedsore prevention in person.  Hospitals are asked to implement a program of risk assess-ment at admission using the Braden Scale, dis-cussion with the patient and his or her family of the results of that assessment, and provision of a specialized support surface for all judged to be at risk.

The Braden Scale was developed in 1988 by 
Barbara Braden as a means of assessing the degree of risk of wound development any individual patient faces.  Six factors are con-sidered:  Sensory perception, Moisture, Activity, Mobility, Nutrition, and Friction / Shear.  A score is assigned for each factor, resulting in a final score being arrived at by a prescribed me-thod.  Admitted patients are deemed to be at risk depending on the score achieved.

NDF Study #3 demonstrates that those hospitals that have implemented such a program have been successful in greatly reducing bedsore inci-dence.  This document should be a useful dis-cussion tool when visiting hospital adminis-trators.  The text of this study and membership sign-up are both available on the NDF website,


Pressure Ulcer Mechanism
Deep Tissue Injury Studied

The severity of a pressure ulcer has long been classified according to a staging system, whereby the wound is considered to progress from displaying a redness on the skin surface (Stage I) through to an open ulcer characterized by full thickness skin loss, tissue necrosis, muscle damage, down to the bone (Stage IV).  However, biomechanical analysis of the manner in which pressure on bony prominences is transmitted reveals that the highest pressure exists at the bone/muscle interface.  It is now believed that most if not all wounds have their origin in deep tissue under an intact epidermis.

The National Pressure Ulcer Advisory Panel (NPUAP) is considering recommendations to do away with the current staging system based on this new understanding.  Now it is clear why the current common practice of waiting for the appearance of Stage I or Stage II bedsores before providing specialized support surfaces usually leads to failure.  Now it is clear why the NDF program of pressure-reducing support surfaces for all admitted patients deemed to be at risk, before there is any sign of a wound, is the only policy with any hope for success.
Expert Witness Resource
NDF Gets Many Requests

Lawyers across the country contact the NDF from time to time asking for recommendation of an expert witness.  Litigation, unfortunately, is often the only way to convince the hospital that avoiding the investment needed to reduce pressure ulcer incidence is false economy.  Health care professionals willing to have their name listed on the NDF website as a competent expert witness are asked to contact the NDF at  Interested attorneys would be asked to make contact directly.

Paper Submitted for Publication
NDF Study Shows Bedsores Preventable

The third in a series of studies undertaken by the National Decubitus Foundation has been completed.  It has been submitted for publication, and will be posted shortly on the NDF website,

The first NDF study had as its objective the demonstration of the serious economic nature of the problem, having an annual cost of about 50 billion dollars.  The second study showed that the air-fluidized bed has been demonstrated to provide a superior healing environment

The present study demonstrates that those hospitals that have adopted a policy of assessing risk for all admitted patients, followed by provision of pressure-distributing support surfaces for those at risk, have been able to greatly reduce incidence rates.

E-Mail Database Created
Regular Updates to Friends of NDF

A database of e-mail addresses of those who have contacted the NDF has been developed.  It will be updated regularly.  Messages will be sent to those friends of the NDF to apprise them of important new developments.  From time to time, there will be a reminder of the need for donations.  

E-mail will be used to correspond with members of the NDF as a supplement to The Ugly Secret.  Annual dues reminders will be managed using this system.  Occasional action items will be suggested for presentation to local hospitals.

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