Can We Talk?: Implementing the NPUAP pressure injury changes

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Joan McInerney, MSN, RN-BC, CWOCN; and Theresa Morrison, PhD, CNS-BC NCH Healthcare System, Naples, FL

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”.

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) guidelines2-5 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: 

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 



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