Can We Talk?: Implementing the NPUAP pressure injury changes

Bed sore. Decubitus ulcer. Pressure sore. Pressure ulcer. Pressure ulcer terminology has changed through the years. The National Pressure Ulcer Advisory Panel (NPUAP)¹  has proposed a new term — pressure injury — as well as a new Pressure Injury Staging System to more accurately describe pressure phenomena. The NPUAP has long been an author of pressure injury terminology. Founded in 1986, the NPUAP “serves as the authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education, and research”.¹ 

In an inpatient health care setting, the terminology affects electronic medical record (EMR) documentation, prevention orders, and policies and procedures for providers, students, and instructors. Any organization that reports pressure injuries (eg, the National Database of Nursing Quality Indicators® [NDNQI^®], the Health Research and Educational Trust, and the Hospital Engagement Network), will need to update terminology.

Evidence-based practice (EBP) guidelines^2-5 support immediate implementation of the change, the effect of which, along with an emphasis on EBP, can have a profound impact on preventing a hospital-acquired pressure injury (currently referred to as a hospital-acquired pressure ulcer [HAPU] by NDNQI^®). Because pressure injuries also inflict a $9.1 billion to $11.6 billion burden per year in the United States,² incorporating the new terminology and stressing EBP is anticipated to improve patient outcomes and reduce costs.  

The NPUAP’s proposed changes are intended to reduce confusion in staging. Previously, Stage I and suspected deep tissue injury were described as injured intact skin, while the other stages described open ulcers. The word pressure describes the etiology; the word injury encompasses both intact skin and open ulcers. Pressure injury will now be defined as localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities, and condition of the soft tissue.¹ Specific stages include: 1) Stage 1 pressure injury — nonblanchable erythema of intact skin; 2) Stage 2 pressure injury — partial-thickness skin loss with exposed dermis; 3) Stage 3 pressure injury — full-thickness skin loss; 4) Stage 4 pressure injury — full-thickness skin and tissue loss; 5) unstageable pressure injury; and 6) deep tissue pressure injury. Additional pressure injury definitions include medical device-related pressure injury and mucosal membrane pressure injury. A table of the updated staging definitions and pictorial representation are available at: www.npuap.org/. 

Our facility is part of a 715-bed, 2-community hospital health care system with Hospitals and Health Networks “Most Wired Hospital” designation. From our perspective, once the pressure injury is staged, several factors should be considered before intervention: 1) variations in knowledge of nurses, the effects of which can translate to suboptimal clinical practice; 2) nursing prelicensure education requirements; 3) continuing education opportunities; and 4) reporting and monitoring programs. Our organization viewed implementing the new NPUAP terminology as an opportunity to break old habits and to rely on EBP rather than intuition and past experience. Coordinating use of the new terminology facilitated a conversation that could correct inconsistencies in treatment and management.

The change process. Two (2) Masters’ prepared nurses — a certified wound ostomy continence (WOC) nurse and a clinical nurse specialist certified nurse (CNS-BC) — led the transition to implement the terminology change. Advanced practice nurses often are in a unique position to help recognize, prioritize, and implement EBP into a health care system’s culture. Discussions regarding needed interventions began within days of the April 13 NPUAP announcement; within 1 month, all interventions were well underway and included: 

Intervention 1. A review of the health care system’s EMR documentation was initiated by submitting a service request to the information technology (IT) department. Preliminary approval to search and replace ulcer with injury was provided in 1 day. The changes occurred within 2 weeks after submitting the verbiage. A complete search of orders, medications, and supplies is ongoing.  

Intervention 2. All interventions for pressure injury prevention were reiterated based on level of risk. For all patients assessed at high or very high risk for pressure injury, based on the Braden Scale for Pressure Ulcer Risk® , 6 current practice requires turning every 2 hours and elevating their heels, usually with protective boots. In addition, our current best practice calls for prophylactic use of a multilayer, silicone foam sacral dressing for all patients in the Critical Care Units, all patients with fractures below the waist, patients with a Braden Scale score <10, and any other patient assessed to be at particular risk. Current best practice also emphasizes limiting layers of linen between the patient and the mattress and preventing incontinence-associated dermatitis.^2-5

Intervention 3. Policies and Procedures in our online manual were reviewed to identify documents that included pressure ulcer terminology. Titles that include pressure ulcer (eg, “Photographing pressure ulcers” and “Pressure ulcer prevention”) were easy to find. Others required more thought regarding what is involved in prevention and care, such as indwelling urinary catheters and nursing scope of practice.

Intervention 4. Communication with staff was accomplished through e-news and a PDF attachment in an email along with a link to the intranet. The e-news was designed within a few days with photos used with permission from NPUAP and screen shots of the new documentation screens. It was reviewed by key stakeholders for clarity and readability and emailed to staff, including nurses, patient care technicians, therapists, physicians, and midlevel providers. These materials were printed and distributed. Facility publications addressing the NPUAP changes included the following text:

• The National Pressure Ulcer Advisory Panel has announced that pressure ulcer should be referred to as pressure injury and use of the new Pressure Injury Staging System should be instituted to standardize documentation.
• EMR integumentary documentation has been updated with changes highlighted in screen shots.
• A description/definition of the new pressure injury stages.
• Please note: Our updated pressure injury terminology has not changed our evidence-based prevention measures or care.
• Email us with any implementation issues — we are here to help!

Intervention 5. Instructors and prelicensure nursing students were encouraged to use the new terminology. An email was sent to affiliated schools that included our inhouse communications and education materials. We have shared our plan in order to encourage other facilities to implement this terminology change and promote incorporating EBP into nurses’ daily practice. By addressing an old problem with new language, we hope to reduce pressure injury rates. The sustainability and usefulness of changing the terminology to pressure injury should be monitored and evaluated as health care systems and national organizations embrace the new order.

This article was not subject to the Ostomy Wound Management peer-review process.