Guest Editorial: Pressure Injury Brexit?

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Catherine T. Milne, APRN, MSN, CWOCN-AP Connecticut Clinical Nursing Associates Bristol, Connecticut

Christopher Columbus initially was scorned because he believed an alternative trade route to the East existed. Like most groundbreaking exploration, Columbus’ came with unintended consequences. His serendipitous findings: a new land. The consequence? Transmitting devastating illnesses with massive population loss to indigenous people. 

Metaphors regarding unintended consequences can be drawn to the recent National Pressure Ulcer Advisory Panel (NPUAP) 2016 Staging Consensus meeting held in April of this year. The Panel members are all distinguished leaders in pressure ulcer research, practice, management, and academia. They analyzed more than 3000 articles to determine what the latest literature has added to our knowledge of pressure-induced tissue injury since the last update in 2014. Revising the current staging system was a labor-intensive, thorough, and time-consuming endeavor. 

It takes courage and leadership to put in Herculean efforts and then have others call your baby ugly. The NPUAP responded on their website (NPUAP.org) to numerous concerns with the recent update. Resistance to the updated staging system is being voiced for a variety of reasons and may boil down to Lewin’s Change Theory1 (ie, only babies with wet diapers like change). Simply put, successful change requires a process of unfreezing behavior, implementing the change, and refreezing the new behaviors. However, specific content and implementation issues with the document need addressing: 

  • Pressure ulcer litigation concerns eloquently expressed in detail by Dr. Caroline Fife2;
  • No recognition of the descriptor pressure injury in the ICD 10 coding system. Coders and auditors have been advised that additional queries will be made to the provider when pressure injury is used3;
  • How different health care settings must “ignore” new evidence recommended by the experts until the Center for Medicare and Medicaid Services mandates legally change the MDS 3.0 in long-term care and the OASIS-C in home health and Acute Rehab use of the Inpatient Rehab Facility-Patient Assessment Form;
  • Pathophysiology of pressure-induced tissue damage2,4;
  • Histology that suggests granulation tissue presents in dermal wounds, contrary to the updated Stage 2 definition. Our burn colleagues recognize the difference between superficial papillary dermal and deep reticular dermal burns. Dermatological texts and our own wound literature5 already have recognized granulation tissue can be generated from deep partial-thickness wounds; and
  • Difficulty in interpreting research and comparing outcomes related to medical device-related pressure injuries in different care settings.6

Should the consensus meeting have taken place? Absolutely. Knowing the sheer volume of literature reviewed for this project and having participated in content validation studies, I can say with some assurance that while some consensus meeting participants were intimately familiar with the research leading up to the decisions, that likely is not true for all in the voting audience. Dissemination of material before the meeting would have allowed many attendees to better prepare. 

The unfreezing aspect of the change process might have been better handled by working with the partners with whom the NPUAP has done so well in the past — namely, the European Pressure Ulcer Advisory Panel (EPUAP) and the Pan Pacific Pressure Injury Alliance (PPPIA). Although the Academy of Nutrition and Dietetics and the Wound, Ostomy, Continence Nurses Society7 (WOCN) support the changes, the WOCN8 was forthright in identifying at least one of the unintended consequences the consensus meeting has now brought to the table: ICD 10 coding. 

Other “missing” organizations (the Association for Advancement of Wound Care [AAWC], American Professional Wound Care Association [APWCA], World Council of Enterostomal Therapists [WCET], and the Wound Healing Society [WHS]) officially have remained silent, although many prominent members, including Dr. Gregory Bohn,4 the current AAWC president, have made their personal concerns about the recent changes known. We are such a small wound care world; what was to be gained by not obtaining consensus from these organizations? 

More concerning to me is the absence of wholehearted agreement among the NPUAP partners who developed the 2014 International Pressure Ulcer Guidelines. The EPUAP has the issue under discussion.9 An arm of the PPPIA, the Australian Wound Management Association10 (AWMA) “strongly recommend[s] that members continue to use the definitions for pressure injury staging as outlined in the Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury (2011) and the joint NPUAP, EPUAP, and PPPIA Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline (referred to as the International Guideline) (2014), until the revised joint International Guideline is published in 2019. This review will commence in 2017 and will afford an opportunity to examine the proposed NPUAP definition changes in line with the evidence in the literature and expanded consensus development.” 

The NPUAP has reiterated it is in discussions with a variety of agencies regarding the impact of the changes. But how many of these unintended consequences had been anticipated before the Consensus meeting? Practicing clinicians, industry partners, and regulators all look to the NPUAP to translate the evidence base for the everyday user. Many of the issues are related to how the change process has been managed. 

A “pressure injury Brexit” has occurred, and the global wound community has been profoundly affected. Why didn’t the NPUAP wait for its partners? At the very least, floating a trial balloon about their findings to those affected — bedside clinicians, regulators, and industry — would have allowed people to begin to prepare. Incredible amounts of financial and personnel resources will be spent translating evidence into practice. The fault of the NPUAP is one of implementation. As Benjamin Franklin said, “Failure to plan is a plan to fail.” 

We can applaud the NPUAP, the conference attendees, and those who have taken time to professionally convey the challenges and opportunities to improve the pressure-induced tissue staging system. But a true consensus involves working together to foresee/address unintended consequences. 

References

1. Sunderland K. Applying Lewin’s Change Management Theory to the Implementation of Bar-Coded Medication Administration. Can J Nurs Informatics. 2013;8(1&2). Available at: http://cjni.net/journal/.  Accessed June 15, 2016.

2. Fife C. 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. Available at: www.woundsource.com/blog-category/industry-news. Accessed June 12, 2016.

3. Medicare Compliance Watch. May 20, 2016. Available at: www.medicarecompliancewatch.com/news-analysis/npuap-updates-pressure-ulc.... Accessed: June 6, 2016.

4. 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.

5. Brown-Etris M. Measuring healing in wounds. Adv Wound Care.1995;8(4 suppl):53–58.

6. Saleh MYN. The hidden risk of medical-device related pressure ulcers. Wounds Middle East. 2016;3(1):5–7.

7. National Pressure Ulcer Advisory Panel. News/Hot Topics. WOCN Society and Academy of Nutrition and Dietetics Support New Staging System and Terminology. Available at: www.npuap.org/wocn-society-supports-new-staging-system-and-terminology. Accessed June 25, 2016.

8. Wound, Ostomy, Continence Nurses Society. NPUAP Terminology Update. Available at: www.wocn.org/news/294222/Pressure-Injuries-New-Guidelines--More.htm.  Accessed June 24, 2016.

9. European Pressure Ulcer Advisory Panel. EPUAP Position on ‘Pressure Injury’ Terminology Change. Available at: www.epuap.org/news/epuap-position-on-npuap-change-in-terminology/#comments. Accessed June 21, 2016.

10. Australian Wound Management Association. NPUAP Revised Pressure Injury Definitions Released on 14 May, 2016. Available at: www.awma.com.au/news/news121.php.  Accessed June 23, 2016.

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