Guest Editorial: Changing Pressure Ulcer Terms: Consensus or Conspiracy?

The National Pressure Ulcer Advisory Panel (NPUAP) held a consensus conference April 8–9, 2016 in Chicago, IL where numerous reforms to pressure ulcer-related terminology and definitions were decided. As an attendee, I question some of the decisions and the process through which the changes were made.

Most notably, it was decided the term pressure ulcer would now be known as pressure injury. Gregory Bohn, MD, ABPM/UHM, MAPWCA, the President of the Association for the Advancement of Wound Care (AAWC), questioned what this change clarified. He noted the NPUAP deemed it necessary to change the terminology because ulcer implied an open area when actually the skin could remain intact with both a deep tissue injury and a Stage I pressure ulcer.¹ 

The NPUAP’s previous definition of pressure ulcer begins with “A pressure ulcer is localized injury to the skin and/or underlying tissue, usually over a bony prominence....”² The definition itself clarified the term ulcer. The NPUAP now defines pressure injury as “localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device ....”³ Given the definitions, why is a change necessary? In addition, the NPUAP’s staging system supports skin damage occurs from the surface of the skin down to the bone. Dr. Bohn noted some research supports damage occurs from within and not top down.⁴ Caroline Fife, MD stated the pathophysiology of pressure ulcer formation is not reflected in the staging system. She also noted, “Plaintiffs are anxious to link the development of pressure ulcers to elder abuse in order to avoid the cap on punitive damages. It seems highly likely that using the term injury will advance the agenda of plaintiffs to equate pressure ulcers with elder abuse.”⁵

Also of note is that the NPUAP’s original pressure injury definition included typically painful. This was not part of the consensus consideration, but after concern from participants, the wording was changed to may be painful. Similarly, prolonged pressure, used to describe the etiology of pressure, was not a consensus decision; some participants wanted prolonged removed. As a result, prolonged was replaced by intense and prolonged pressure. This wording is not based on scientific evidence, because all pressure ulcers are not caused by intense and prolonged pressure. Further, the sentence, “A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated,” was eliminated from the pressure injury definition, despite objections from participants. This also was not up for consensus, nor was the decision to use Arabic instead of Roman numerals to denote the stages (eg, Stage II is now Stage 2). 

Also not subject to consensus was the proposed definition of deep tissue pressure injury (DTPI), which included great and prolonged pressure. Because great and prolonged was meant for DTPI only, attendees questioned why the prolonged was in the general definition of a pressure injury. Ultimately, despite a lack of scientific evidence, the wording was changed to intense and prolonged pressure. The sentence, “Evolution may be rapid, exposing additional layers of tissue even with optimal treatment,” was removed from the definition under objection from some participants and without consensus. 

Wording that was subject to consensus was the staging of DTPI. Options included placement before or after Stage 1 or after unstageable. Some participants immediately noted one of the problems with the staging system is the implication of linear progression, which all agreed is not accurate. The NPUAP sought consensus despite no linear progression, and DTPI was placed after unstageable injury. Dr. Fife noted, “Numbering these categories (no matter how you do it) and calling them ‘stages’ implies progression between the stages, regardless of your efforts to state otherwise, and the drawings of the stages on the (NPUAP) website are used in court to demonstrate that all pressure ulcers form from the outside-in and progress from Stage 1 to [Stage] 4. Numbering them allows attorneys to successfully make the case that a Stage 4 (which occurred from the inside-out, for example, in a nursing home) actually began with the Stage 2 documented in the hospital, and then progressed ‘through the numbers’. It is nearly impossible to convince jurors otherwise. Hospitals are paying large sums of money in damages as a direct result of the NPUAP ‘staging’ system.”⁵

The Panel initially stated pressure injuries of the occiput, ear, and bridge of the nose could not be Stage 3 pressure injuries because these areas had no subcutaneous tissue; therefore, if the wounds were classified as Stage 2 and deteriorated, they then would be a Stage 4. Not everyone agreed; this part of the definition was withdrawn.

The Panel determined a need for 2 additional pressure injury categories: medical device pressure injuries and mucosal pressure injuries. Despite an attorney in the audience advising against singling out medical devices as causing pressure ulcers, a category was created for medical devices and they are specifically described in the pressure injury definition. It was agreed the staging system did not work for mucosal injuries, but it would not be a surprise if the NPUAP develops a staging system for mucosal injuries. 

The NPUAP was asked to consult the Centers for Medicare and Medicaid Services (CMS) and legal experts before making any changes. The Panel informed the participants this was a clinical matter and not a legal matter. I stated it was foolish to ignore the legal implications of our actions at this meeting; the fact that many Panel members work with attorneys makes it necessary to discuss legal ramifications. I noted that with regard to legal cases, the deck was stacked against the opposing attorney — meaning, whichever side the Panel member was on, Panel membership stacked the deck. I stated a fair amount of the Panel’s work was for plaintiff attorneys and the proposed changes to the staging system made it a plaintiff attorney’s dream. The Panel’s work with attorneys, especially the amount of plaintiff work, needs to be public knowledge.

Toward the end of the conference, the Panel showed wound photographs with case histories and the audience was asked to stage the wounds. Inter-rater reliability with scores of 42%, 47%, and 52% on several of the case studies indicated staging remains a problem. In addition, one study involved a patient with a heel ulcer who had diabetes and peripheral arterial disease. Although this ulcer could have been the result of the 2 comorbidities, 92% of the audience and the Panel stated it was a Stage 4 ulcer  (approximately 7% stated it was not a pressure ulcer). With all the categories the NPUAP proposes, no mention is made of diabetic or arterial wounds that could be mistaken for pressure ulcers. 

This attendee believes the NPUAP meeting was not a consensus conference. Comments regarding any of the changes, other than those preselected, were strongly discouraged or not allowed. The NPUAP Staging Task Force predetermined participants would not be allowed to give consensus on all parts of the definitions. I was informed this was acceptable because they were the experts.

It behooves the wound care community to come together as a whole to determine the best course of action regarding the revised staging system. For now, the changes should be put on hold. Thousands of health care dollars and man hours should not be wasted on this revision. 

References

1. Bohn G. Can We Talk? Pressure injury replaces pressure ulcer: provider thoughts on changes to pressure ulcer staging. Ostomy Wound Manage. 2016;62(5):47–48.

2. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Washington DC: National Pressure Ulcer Advisory Panel;2009. 

3. National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury. Available at: www.npuap.org/national-pressure-ulceradvisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury. Accessed May 26, 2016.

4. Gefen A, Gefen N, Linder-Ganz E, Margulies SS. In vivo muscle stiffening under bone compression promotes deep pressure sores. J Biomechanic Engineer. 2005;127(3):512–524.

5. Wound Source Blog. National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury. April 21, 2016. www.woundsource.com/blog-category/industry-news. Accessed May 29, 2016.