In his recent review of pressure ulcers in the nursing home [1], Dr. Smith correctly emphasizes the interdisciplinary nature of this problem. We further assert, however, that the nursing aides and nurses who provide actual hands-on care are key to the prevention and management of pressure ulcers. Galvanizing and coordinating the efforts of this frontline staff is an important team activity, one in which physicians must take an active leadership role.

In the extended care unit of our Veterans Affairs Medical Center, we instituted "skin rounds," in which an interdisciplinary team—consisting of a physician, geriatric nurse practitioner, enterostomal therapist, nursing staff directly assigned to the patient, and rotating residents from various disciplines—make weekly rounds together to evaluate patients who have been identified during initial nursing assessment as being at risk (Braden score < 17 [2]) for the development of pressure ulcers or who had pressure ulcers on admission. Individualized assessment and treatment are done at the bedside and are incorporated into the patient's overall care plan. Treatment plans are based on published guidelines [3, 4]. Evaluation of effectiveness and changes to the care plan are made on the basis of feedback from the nurses and aides directly caring for those patients. Weekly measurements of the dimensions, stage, and character of ulcers are documented in the chart. This team-based approach is aimed not only at reducing the incidence of ulcers and improving healing of existing ulcers but also at educating the staff.

Since the institution of skin rounds, our 6-month cumulative incidence of pressure ulcers has decreased from 11.5% in 1993 to 0% in the last two semi-annual surveys. Furthermore, our frontline staff has learned to handle routine skin problems and now only refers complicated cases (stage III and IV ulcers) to the skin rounds team. All staff members involved with skin rounds have expressed high satisfaction with the educational experience, including the physicians in training whose first practical exposure to a rational approach to skin care was participation in these rounds. This approach has been so effective that the skin rounds concept is now being expanded to include the families and informal caregivers of patients expected to return to the community.

Convincing overworked staff of the importance of ulcer prevention and getting them to invest time and effort in such undertakings were difficult. We believe that active physician involvement at the bedside was key to the success of skin rounds. Bedside teaching reinforced the theoretical principles that the staff had learned from inservices and provided a forum in which frontline staff could air their concerns. Finally, it allowed physicians in training to observe successful implementation of team-based care and to actively participate in a rational approach to skin care.