Thomas P. Stewart, PhD, SUNY at Buffalo; Lisa Corbett, DNP, APRN, CWOCN, Hartford Healthcare, Hartford, CT; and Nancy Overstreet, DNP, GNP-BC, CWOCN, CDP, Lynchburg College, Lynchburg, VA and AMDA
Through the years, the National Pressure Ulcer Advisory Panel (NPUAP) has periodically updated staging systems for PrU based on the best evidence and consensus development. Beginning in 1987, this process began with the usage of Shea’s classic 4-stage system; subsequently, NPUAP’s leadership provided numerous updates to staging, such as landmark guidance on deep tissue injury (DTI), unstageable PrU, and unavoidable PrU. Various stakeholders affected by the present guidelines include patients, caregivers, hospitals, long-term care (LTC) facilities, legal entities, payers, regulatory professionals and politicians.
The staging systems are generally believed to follow the etiology and pathophysiology of PrU. However, the 4-stage PrU system has always implied a “top-down” progression in the pathophysiology of PrU. Research concerning etiology and pathophysiology also has unveiled substantial evidence to challenge this progression; there is discord between scientific data and what is currently promoted and reinforced for clinical care. Thus, evidence should be examined to determine if the present staging system, pathophysiological models, and assessment tools are still valid.
At a staging consensus conference in 2016, the NPUAP proposed changing the nomenclature from pressure ulcerto pressure injury(PrI). However, the Society for Post-Acute and Long-Term Care Medicine (AMDA/PALTC), while acknowledging the nomenclature changes in their 2017 Revised Clinical Practice Guideline on Pressure Ulcers, continued to support the use of pressure ulcer. The society also passed a resolution opposing nomenclature changes and supporting the term pressure ulcerin the 10th Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) and other diagnostic catalogues and classification systems.
Longstanding inconsistencies exist in PrU risk assessment, staging definitions, classifications for adverse event reporting, and definitions for quality metrics across health care settings. These contradictions place a daily burden on clinical resources in health care organizations and have not significantly advanced the mission of improved patient safety. How recent changes in pressure ulcer staging will cascade to provide clarity, and what alternative approaches can improve this gap, are unclear.
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Discussion points. Although the development of PrU staging systems is driven primarily by science, PrU staging in clinical practice tends to be driven more by regulatory and legal forces. For example, slough is an indication of inflammation, which is an internal process, and the established definition for Stage 2 PrU has no slough. However, clinicians tend to classify PrU with slough as Stage 2 because of concerns about regulatory or legal consequences. There is also some debate as to whether wounds containing slough at the base could be classified scientifically as Stage 2 PrU.
Definitions and reporting tend to differ across stakeholders. For example, PrU might be defined differently among an oncologic population than among a long-term care population, or different consensus panels can develop different definitions based on the same or similar information. In addition, several organizations tend to track PrU incidence, but regulatory agencies such as the Centers for Medicare and Medicaid Services (CMS) emphasize prevalence. How to change the paradigm toward an emphasis on incidence is not clear.
The environment for reporting PrU is highly punitive. For example, even when clinicians and staff undergo training and implement prevention practices, they still must report PrU occurrences. An estimated 35% of PrU are caused by medical devices. Separating these ulcers from overall reporting could aid researchers and clinicians in working with manufacturers to innovate in interventions.