Letter to the Editor: Can we (still) talk about the implications of the NPUAP changes?

Login toDownload PDF version
Mary Litchford, PhD, RDN, LDN

The National Pressure Ulcer Advisory Panel (NPUAP) is attentive to the comments made by wound care professionals about the changes in staging definitions and nomenclature published following the 2016 Staging Consensus Conference.1 In the last few months, we have been encouraged to hear many supportive statements by speakers and participants at numerous wound care conferences regarding implementation of these changes. The new staging definitions and nomenclature have been integrated into numerous health care systems and database coding structures. As the nation’s leading scientific experts on pressure injury prevention and treatment, it is our mission to improve health through advances in public policy, education, and research. The NPUAP is actively working toward strengthening our collaborative relationships with all wound care organizations. 

However, we feel profound dismay that selected publications have presented editorial that paints a different picture of the NPUAP, its directors, and its alumni. Can We Talk? by Schank and Fife2 is a recent example. As colleagues committed to improving health outcomes and reducing pain and suffering in patients with pressure injuries, we invite the authors to join me in realigning your priorities to areas of mutual agreement and disband the path of destructive rhetoric that impugns the reputation of the NPUAP and to extinguish inflammatory criticism in the public forum. We continue to welcome scholarly discourse and reasoned discussions on the prevention and treatment of pressure injuries. 

Mary Litchford, PhD, RDN, LDN 
President, National Pressure Ulcer Advisory Panel 


1. National Pressure Ulcer Advisory Panel. 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-ulcer-advisory-panel-npuap-announces-a-c.... Accessed May 22, 2018.

2. Schank J, Fife C. Editorial: Can We Talk? The National Plaintiff’s Advisory Panel: Pressure Ulcers, Litigation, and the NPUAP’s New Staging System. Available at: www.o-wm.com/article/can-we-talk-national-plaintiffs-advisory-panel-pres.... Accessed May 22, 2018.


It has become common practice for medical professional associations to set standards for the performance and disclosure of expert witness testimony. Given the visibility of the NPUAP and the importance of its staging system, we are confused as to why the NPUAP would find it inflammatory to suggest they develop similar standards. However, we are grateful for the opportunity to explain further. 

Many individuals and organizations, including hospital risk managers, insurance associations, and malpractice defense attorneys, have expressed grave concern regarding the NPUAP’s new terminology and definition changes. Unfortunately, the process followed by the NPUAP did not allow sufficient opportunity for dialogue prior to its decision to change terminology and staging verbiage; it was rendered in a less-than-public venue and offered no opportunity for an informed response. Because the NPUAP’s decision is final, individuals and groups with serious concerns have only the public forum in which to raise these issues.  

The pressure-ulcer-versus-pressure-injury debate is not merely a semantic argument, and we are not provocateurs. First, there is the science to consider. Dr. Laura Bolton1 made a compelling argument for the NPUAP’s manipulation of the science involved in the recent changes. She pointed out the NPUAP consensus conference statements regarding the formation of granulation tissue and epidermal blisters run contrary to evidence on partial-thickness wound healing and slough/eschar. According to Bolton, “the revised [staging] verbiage is not in sync with biological, histopathological, dermatological, and surgical definitions of wound healing.”

Then there are the legal aspects. Pressure ulcers are the number one reason for litigation against nursing homes in the state of Texas and the second most common malpractice claim across the United States.2,3 Even if the case is non-suited (meaning, dropped), a health care practitioner will carry a suit with him/her for the rest of his/her professional career. The clinician is required to provide the details of the case and its disposition in writing every time application for hospital privileges is tendered. If the terminology and definition changes by the NPUAP increase the filing of malpractice cases by only 10%, the impact on practitioners will be enormous, regardless of whether it changes in the likelihood of a judgment for the plaintiff. Such cases represent hundreds of hours of lost work, time spent on paperwork away from patient care, and most probably an increase in malpractice insurance rates for those individuals. 

In addition, payments made on behalf of physicians/health care providers in connection with medical liability settlements and judgments are maintained in an electronic depository, the National Practitioners Data Bank (NPDB).4 Federal law requires that information on medical liability payments and certain adverse actions be reported to the NPDB, and the NPDB is required by law to make this information available to hospitals, state licensure boards, and other health care entities. If a health care provider is involved in a malpractice case and the carrier wants to settle, even if the case has no merit, payment of a settlement can generate a NPDB report. If the judgment awarded the plaintiff exceeds the limits of the practitioner’s policy, the result may be personal bankruptcy. Although malpractice litigation has destroyed lives and ended professional careers, we find ourselves longing to return to the days when professional or financial ruin were the worst possible outcomes of litigation. In order to avoid statutory caps on punitive damages, plaintiffs have successfully linked the development of pressure ulcers to elder abuse, the result of which has been the criminalization of pressure ulcers. The successful prosecution of a Hawaiian nursing home operator for manslaughter after the death of a resident with pressure ulcers was touted as, “a new weapon against poor nursing care.”5 Pressure ulcer quality measures that are classified as “Hospital Harms,”6 “getting to zero” campaigns in relation to pressure ulcers,7 and the National Quality Forum position that Stage 3 and Stage 4 pressure ulcers occurring after hospital admission are serious reportable events that result from poor care8 send an unambiguous message. Pressure ulcers, now termed pressure injuries, are always sins of either caregiver omission or commission. While the NPUAP may have intended the term injury to be understood by health care professionals in the histopathological sense, it is more likely to be understood by jurors in the common English vernacular sense. 

The NPUAP staging system has profound implications that may affect both the number of cases filed and their outcomes. Every case involving pressure ulcers relies, at least in part, on documentation utilizing the NPUAP staging system to support either the plaintiff’s assertion of negligence or the defendant’s argument to the contrary. According to the NPUAP website,9 its mission is to serve as the authoritative voice in pressure injury prevention and treatment through public policy, education, and research. The NPUAP actively works to maintain its influence and authority. Given the weight of this responsibility and the influence it wields, we are surprised that some NPUAP members regularly provide expert testimony and that, as of a 2014 testifying search, NPUAP member paid testimony had resulted in an estimated $10 million (minimum) in judgments against clinicians and health care organizations. 

In our opinion, the optics of these substantiated facts are not good. Given the vital importance of the NPUAP staging system and, by extension, the power and influence of its members, it seems only reasonable that the NPUAP establish a policy regarding member expert testimony that includes public transparency regarding these activities. 

We understand this suggestion and the attention we are drawing to the implications of the NPUAP terminology change are unwelcome. But as Bolton1 noted, “All of the consensus in the world cannot change the biology of healing,” nor the perception of bias. We raise these concerns because we fear the NPUAP membership may not fully comprehend what is at stake.

NPUAP members who are not clinical advanced practitioners may count themselves fortunate that they are unlikely to ever personally face a charge of medical malpractice. The rest of us are very familiar with inflammatory language, thanks to examples provided in a typical plaintiff’s complaint accusing us of professional negligence because a patient developed a “pressure injury.” Armchair generals who do not have to suffer the consequences of their decisions might at least acknowledge the concerns of those who do. We also urge the NPUAP to consider that support for the terminology and definition changes may vary depending on whether the clinician had to hire an attorney or was hired by one.  

Caroline E. Fife, MD, FAAFP, CWS, FUHM
Joy E. Schank, RN, MSN, ANP, CWOCN


1. Bolton L. Letter to the Editor: Partial-thickness pressure injuries and epidermal blisters: concerning definitions. Ostomy Wound Manage. 2016;62(6):8. 

2. Cunningham N. Litigation: How to Prevent and Survive. Presented at the Symposium on Advanced Wound Care. Charlotte, NC. April 25–29, 2018. 

3. Leaf Healthcare. The Financial Impact of Pressure Ulcers. 2014. Available at: www.leafhealthcare.com/pdfs/LH_WP_FinancialOverview_1563AB_101316.pdf. Accessed May 22, 2018. 

4. The National Practitioner Databank. Available at: www.npdb.hrsa.gov/. Accessed May 18, 2018.

5. Wolters Kluwer Health. Homicide by Decubitus Ulcers in Nursing Home Patient. Available at: www.newswise.com/articles/homicide-by-decubitus-ulcers-in-nursing-home-p.... Accessed May 22, 2018.

6. List of Closed Public Comments: Hospital Harms; Hospital-Acquired Pressure Injury. Available at: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/.... Accessed May 22, 2018.

7. Duncan KD. Preventing pressure ulcers: the goal is zero. Jt Comm J Qual Patient Saf. 2007;33:605-610.

8. National Quality Forum. Serious Reportable Events in Healthcare. 2006 Update, a consensus report. Available at: file:///C:/Users/cfife/Downloads/SRE%202006_full.pdf. Accessed May 22, 2018.

9. The National Pressure Ulcer Advisory Panel. Mission. Available at: www.npuap.org/about-us/mission. Access May 30, 2018.

The opinions and statements included herein are specifi c to the respective authors and not necessarily those of OWM or HMP. This article was not subject to the Ostomy Wound Management peer-review process.