Special to OWM: The NPUAP Dual Mission Conference: Reaching Consensus on Staging and Deep Tissue Injury

    In the course of its biennial conference held February 26-26, 2005 in Tampa, Fla., the National Pressure Ulcer Advisory Panel and attendees achieved consensus regarding changes needed to the current staging system, which include acknowledging deep tissue injury as a form of pressure ulcer.

    Presentations and discussions reflected shortcomings inherent to the staging system definitions of Stage I and Stage II pressure ulcers. The current staging system does not accurately describe Stage I and Stage II pressure ulcers and does not capture deep tissue injury (DTI) pressure ulcers. The Stage I definition is lengthy and uses terms such as “purple” that may inadvertently encourage deep tissue injuries to be classified as a Stage I pressure ulcers; Stage II definitions include wounds not exclusively related to pressure, such as friction injury and excoriation from incontinence. Proposed solutions to these concerns included revising the current Stage I and Stage II definitions and dropping the staging labels and instead using the labels “partial- and full-thickness wounds.” Advantages to this new approach stemmed from reality that the process of staging pressure ulcers can be difficult even for skilled practitioners and that staging has evolved into more than an anatomic description of an ulcer — ie, staging is used for measuring the quality of care, reimbursement, and comparison of outcomes. Disadvantages include concerns that 1) terms such as full-thickness do not describe only pressure ulcers and other wounds would again be included in the labeling and 2) the difference between Stage III and Stage IV must be noted, particularly when antibiotics to address osteomyelitis are prescribed.

    Deep tissue injury of intact skin due to pressure is a diagnostic label introduced by the NPUAP in 2002. This form of pressure ulcer initially looks like a bruise on the skin but can quickly deteriorate into a full-thickness ulcer despite proper care. No formal study on DTI has been conducted but conference attendees acknowledged its complex pathogenesis and that reliable, valid clinical indicators are needed. Identifying DTI may improve outcomes and would affect statistical reports of prevalence and incidence. The consensus group concluded that DTI should be included in the staging definitions and the identification of these lesions as pressure-induced would help guide more aggressive, early, appropriate treatment interventions that may lead to better outcomes.

    The considerations of this consensus conference, which was attended by clinicians including nurses, physicians, attorneys, physical therapists, and dietitans, will be addressed by the NPUAP in future panel work. The next NPUAP conference is scheduled for February 2007.

    Ostomy/Wound Management is grateful to Mary Ellen Posthauer, RD, CD, LD, President, NPUAP; and Karen Zulkowski, DNS, RN, CWS, for providing the information for this article.