The US spends $1 trillion on healthcare waste care with avoidable complications, inappropriate care, preventable readmissions, and treatments at low-value sites of care.1 Although this seems unfavorable to healthcare stakeholders, its professionals—nurses, doctors, pharmacists, therapists—remain the most trusted US professionals.2 Most Americans do not view the US Congress in the same light. An Economist/YouGov Poll (August 13–16, 2022) reported that the Congressional job approval rating remains near all-time lows (only 6% of Americans approve and 14% somewhat approve with how Congress is doing its job). However, Congress is continually focused on legislation that provides financial incentives for improving quality and safety of the patient experience in wound care. These efforts include passage of successful healthcare bills throughout the 2000s ranging from the Medicare Modernization Act to the Affordable Care Act.3 We, members of the Public Policy Committee leadership for the National Pressure Injury Advisory Panel (NPIAP), especially want to thank Congress for increasing national attention on ways to repair the negative health and cost consequences of pressure injuries (PIs). In particular, we are referring to the 2022 appropriations bill that the US House of Representatives passed this spring to fund the US Department of Veterans Affairs’ (VA’s) adoption of the International Guideline for Prevention and Treatment of Pressure Ulcers/Injuries.4

This legislation has important messages regarding quality and safety. Given the impact of PIs in US VA facilities, the VA appropriations bill recommends incorporating best practices for PI prevention,5 specifically the Standardized Pressure Injury Prevention Protocols (SPIPP) checklist.6 The SPIPP checklist is a one-page tool based on the International Guideline4 to implement key components of prevention including skin check and risk assessment, repositioning, moisture and incontinence management, support surfaces, and nutrition.

Further, the National Institutes of Health (NIH) has added PIs to its funding tracker for research grant dollars. Although the amount currently cited for funded studies at NIH may not seem like a lot, this is the exact lever the NPIAP can push on to work with NIH toward more targeted spending on PI prevention and treatment research to improve outcomes.

When Americans consider public health crises, they usually think about substance use disorder, infectious diseases, or diabetes. It may be surprising to the general public that hospitals face a concern of epidemic proportions related to patient safety and outcomes. In fact, PIs have become so prevalent that without a dedicated clinical course correction in acute and postacute care, poor outcomes due to PIs could become a public health crisis. As healthcare professionals with decades of experience, we know firsthand the depth of problems PIs bring to patients and families, including mortality.

Approximately 2.5 million US patients per year develop a PI.7 The harm is not merely damage to skin and soft tissue; PIs cause extreme pain and complications including chronic wounds, amputations, and infections. Further, 60,000 deaths each year result from PIs, and costs to US healthcare could exceed $26 billion per year.8 Pressure injuries cause more deaths than the ninth leading causes of death that the CDC currently tracks: influenza and pneumonia (57,062 deaths).9

The real tragedy? Most PIs are preventable. Thankfully, due to Congress’ encouragement, public officials and government healthcare agencies have started taking notice of the issue, recognizing that more must be done to reduce PIs. In 2017, Representative Tom Cole (R-OK) and Doug Collins (R-GA) led House floor discussions concerning significant harm from PIs.10 Further, recent Congressional reports accompanying annual funding bills to the Department of Health and Human Services have explicitly noted Congress’ interest in reducing PI harm. We welcome this acknowledgment as we map out further steps.

Outside of Congress, the NPIAP, which copublishes the International Guideline,4 has been actively updating best practices to guide clinicians to better outcomes. In November 2019, the NPIAP released the revised International Guideline in partnership with our European and Pan-Pacific counterparts. Overlapping with these new guidelines is SPIPP, a comprehensive PI prevention checklist that bundles recognized quality improvement interventions into a checklist to enhance guideline adherence by combining concepts and technologies with evidence to prevent PIs.6 The financial resources to implement SPIPP are what the VA appropriations bill covers. There are separate budget items in this large bill to pay for personnel for items beyond PI care, such as medication management and infection control. This type of budgeting helps PI care be financially sustainable in VA facilities.

A recent USA Today article11 provided a comprehensive comparison between VA medical centers and other healthcare facilities regarding various healthcare factors. The VA had higher rates of preventable infections and severe PIs, which signal patient safety concerns.11 Part of this problem may be that not all VA facilities are treated equally when it comes to healthcare resources. A VA in New York or Los Angeles metropolitan areas is located along a supply chain where all necessary resources reach it efficiently, and there are human resources departments to fill specialized positions such as board-certified wound care specialists more easily. However, VA facilities in more remote, rural locations in the US have limited, more expensive supply chains for the same resources and fewer specialists available to serve in close proximity. These are classic variations that remain constant in healthcare delivery from VA facilities to public and private health systems.12

We must recognize and thank Congress’ foresight and willingness to bring further attention to this public health crisis, especially in VAs. The VA has 9 million veterans enrolled at more than 170 medical centers. It is refreshing to see Congress go beyond just highlighting concerns and explicitly ask VAs to take tangible steps to reduce PIs. We hope that behind the scenes, Congressional members and their staffs ask VAs to provide implementation plans to meet Congressional expectations.

Although there is no silver bullet to eliminate PIs, research indicates that preventive actions significantly reduce patient harm and healthcare costs. We thank Congress for its leadership and ask them to continue working with VAs to achieve measurable progress. We encourage our lawmakers to continue promoting action in other federal agencies and top decision-makers to stress the importance of prevention guidelines and concepts such as SPIPP across the public and private sectors.

1. Pronovost PJ, Urwin JW, Beck E, et al. Making a dent in the trillion-dollar problem: toward zero defects. NEJM Catalyst 2021;2(1). 2. Lewis L, Shanahan M, Andrus VJT. Nurses leading the way. J Nurs Adm 2014;44(9):441–3. 3. YouGov. The Economist/YouGov Poll: August 13-16, 2022. https://docs.cdn.yougov.com/jf179lebaq/econTabReport%20%282%29.pdf. Last accessed October 26, 2022. 4. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan-Pacific Pressure Injury Alliance. Haesler E ed. Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide. EPUAP/NPIAP/PPPIA; 2019. 5. HR 4355. Military Construction, Veterans Affairs, and Related Agencies Appropriations Act, 2022. www.congress.gov/bill/117th-congress/house-bill/4355. Last accessed October 27, 2022. 6. Padula WV, Black JM. The Standardized Pressure Injury Prevention Protocol for improving nursing compliance with best practice guidelines. J Clin Nurs 2019;28(3-4):367–71. 7. Reddy M, Gill SS, Kalkar SR, Wu W, Anderson PJ, Ronchon PA. Treatment of pressure ulcers: a systematic review. JAMA 2008;300(22):2647–62. 8. Padula WV, Delarmente BA. The national cost of hospital-acquired pressure injuries in the United States. Int Wound J 2019;16(3):634–40. 9. Ahmad FB, Anderson RN. The leading causes of death in the US for 2020. JAMA 2021;325(18):1829–30. 10. Collins D, Cole T. Department of the Interior, Environment, and Related Agencies Appropriations Act, 2018. Congressional Record 2017;163(143):H6695–H7072. www.govinfo.gov/content/pkg/CREC-2017-09-06/html/CREC-2017-09-06-pt1-PgH6695.htm. Last accessed October 27, 2022. 11. Kelly J, Sergent J, Slack D. Death rates, bedsores, ER wait times: where every VA hospital lags or leads other medical care. USA Today 2019. www.usatoday.com/in-depth/news/investigations/2019/02/07/where-every-va-hospital-lags-leads-other-care/2511739002. Last accessed October 27, 2022. 12. Wennberg J, Gittelsohn. Small area variations in health care delivery. Science 1973;182(4117):1102–8.