Pressure Injury Definition and Stages fS · 10/13/2016 4 Staging System Consensus Conference •...

10/13/2016

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Pressure Injury f S

©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

Definition and StagesChanges to the Staging System in 2016

Laurie McNichol, MSN, RN, GNP, CNS, CWOCN, CWON-AP, FAAN

Disclosures

• Ms. McNichol has no relevant disclosures

©2016 National Pressure Ulcer Advisory Panel | www.npuap.org2

Program Objective

• Identify the changes to the 2016 NPUAP staging system


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NPUAP Formed the Staging Task Force in January 2015

Co-Chairs• Laura Edsberg, PhD

• Joyce Black, PhD, RN, CWCN, FAAN

Margaret Goldberg, MSN, RN, CWOCN

Laurie McNichol, MSN, RN, GNP, CNS, CWOCN, CWON-AP

Lynn Moore, RD, LD

Mary Seiggreen, MSN, RN, CNS, NP, CVN


Charge to Task Force

• Review the current Staging system and relevant literature

• Revise the Staging definitions and artwork toRevise the Staging definitions and artwork to clarify and refine the system


New Understanding of Etiology

Global Guidelines• Pressure

• Shear

• Microclimate

- Temperature, humidity

airflow

• Tissue Tolerance

• Nutrition, Age, Mobility


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The Process

Literature Review• Reference Librarian

• Over 3000 references

identified

• 242 addressed topic

directly


The Process (continued)

Review questions NPUAP receives about Staging


Draft Definitions

• Draft proposed definitions

- Send to NPUAP Board of

Directors Alumni and

• Edit/revise definitions

- Repeat

• Create new artworkPanel members

• Elicit opinions/

comments

- Organizations,

Stakeholders, General

Public

Create new artwork


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Staging System Consensus Conference

• April 2016

• Moderator

-Mikel Gray, PhD, APRN,

FNP-BC, PNP-BC, CUNP,FNP BC, PNP BC, CUNP,

CCCN, FAANP, FAAN


Proposed Definitions

• Proposed changes were based on science and expert opinion

• Regulatory compliance, documentation and legal issues were considered

NPUAP history of consensus conferences to draft• NPUAP history of consensus conferences to draft staging definitions in 1989 and 2007

• Facilitate discussion of the parts of the definitions that needed clarification or revision, based on stakeholder and public comments


Ideal Definition

• Concise and clear

• Teaching points vs. Definition

Glossary-Glossary


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Pre-conference Decisions

• Roman to Arabic Numerals

• Injury

• Updated and improved artwork

• Drafted revised definitions for each• Drafted revised definitions for each

Stage


Prior to Staging a Wound

• Clean the wound

• Determine etiology

-Presence of pressure

and/or shearand/or shear


Ulcer to Injury

Pressure Injuries present as both intact and open wounds


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Ulcer

• A break in skin or mucous membrane with loss of surface tissue, disintegration and necrosis of epithelial tissue and often pusepithelial tissue, and often pus

-Merriam Webster


Injury

Injury = Bodily damage caused by transfers of energy and also the absence of energy

• Drowning, asphyxia, hypothermia

Low energy exposure injuries

• Carpal tunnel

• Pressure injury

J Langley and R Brenner, Injury Prevention, 2004


Pressure Ulcer Injury

• Ulcer does not accurately describe the physical presentation of Stage 1 or Deep Tissue Pressure Injuries

-Can have an injury without an ulcerj y

-Cannot have an ulcer without an injury


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Pressure Injury Comments

• Overwhelming support for the term injury

• Medical device related pressure injuries

-Proposed adding to the definition

Define microclimate• Define microclimate

-Glossary vs. Definition


New Artwork: Healthy Skin


Definition

Old Pressure Ulcer Definition

A Pressure ulcer is localized injury to the skin and/or underlying tissue usually over a b i lt f

New Pressure Injury DefinitionA pressure injury is 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

bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing factors or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.

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, co-morbidities and condition of the soft tissue.


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Pressure Injury Teaching Points

• Prior to Staging as a pressure injury

- Clean the wound

- Determine the etiology

(Note: the presence of pressure and/or shear)(Note: the presence of pressure and/or shear)

• Define microclimate

- Determine whether microclimate is adverse


FAQ: Injury and Potential Litigation

• Discussed in detail by NPUAP prior to the conference

• Plaintiff and defense attorneys were consulted

- Professionals need to develop the science; attorney look at

the facts in the case to determine if it was unavoidable.

• The word “injury” occurs in other clinical diagnostic labels that may or may not be litigated

- Acute kidney injury, spinal cord injury, traumatic brain injury


Stage 1 Pressure Injury

Lightly Pigmented Darkly Pigmented


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Stage 1 Pressure Injury: Erythema

Blanchable Non-Blanchable



Without Edema With Edema


Blanch Response

Pale or whitish areas on the skin as blood flow to the region is prevented by a finger or plastic disc (diascopy).


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Old Stage I Pressure Ulcer Definition:Non-blanchable erythema

Intact skin with non-blanchable redness of a localized area usually over a boney prominence. Darkly

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin

Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly over a boney prominence. Darkly

pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons.

y y ypigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.


Stage 1 Teaching Points

• First visible change in the skin

-Heralding sign

-Blanch response

• Stage 1 is NotStage 1 is Not-Scar tissue

-Deep tissue pressure injury




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Stage 2 Comment Themes and New Literature

• Partial thickness loss of skin with exposed viable

dermis

• Addition of MASD, IAD, ITD, and MARSI as being different form a Stage 2

-Well documented in the literature (Doughty, Mahoney, others)

• Add even more conditions that are not Stage 2

-Examples: mucosal pressure injuries, surgical wounds, friction

injuries


Old Stage II Pressure Ulcer Definition

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. Thisor dry shallow ulcer without slough or bruising . This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation.*Bruising indicated deep tissue injury.



Stage 2 Pressure Injury: Partial thickness skin loss with exposed dermisPartial thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist and may also present ass an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD), including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).


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• Heals by reepithelialization, not granulation

• Define MASD, MARSI, IAD, ITD




Stage 3 Pressure Injury with Epibole


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Old Stage III Pressure Ulcer: Full thickness skin loss

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and

Stage 3 Pressure Injury: Full thickness skin loss

Full-thickness loss of skin, in which adipose(fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by y g

tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

p g yanatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.



• Anatomy differences in body areas can result in very different depths of injury

-Extent of damage and visible tissue layer

• Slough is in inflammatory exudate comprised of proteinaceous tissue fibrin neutrophils andproteinaceous tissue, fibrin, neutrophils and bacteria, rather than nonviable tissue

-Often produced in response to biofilm

• Epibole (rolled wound edges) are often present

• If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury




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Old Stage IV Pressure Ulcer: Full thickness skin loss

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer

Stage 4 Pressure Injury: Full thickness skin and tissue loss.

Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or escharg y g p

varies by anatomical location. The bridge of the nose, tear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow.

Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.

bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.



• Clinicians should assess for osteomyelitis


Unstageable Dark Eschar


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Unstageable Focus on Slough


Old Unstageable Pressure Ulcer: Full thickness skin or tissue loss-depth unknown

Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan,

Unstageable Full-Thickness Pressure Injury: Obscured Full-thickness skin and tissue loss

Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmedg ) (

brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the “body’s natural (biological) cover” and should not be removed.

within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury

will be revealed. Stable eschar (i.e., dry adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be softened or removed.


Unstageable Teaching Points

• Describe the role of eschar as the body's natural (biological) cover.

-Removing stable eschar in the poorly perfused area results in

an open wound that may expose the limb to infection and tax

the ability to heal.

• Treat the stable eschar as dry gangrene; do not moisten or soften it.

• Most important intervention is pressure redistribution rather than eschar removal.

• As eschar loosens from the wound bed, trim the edges to avoid inadvertent removal.


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Deep Tissue Pressure Injury (DTPI)


Old Suspected Deep Tissue Injury: Depth Unknown

• Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Deep Tissue Pressure injury: Persistent non-blanchable deep red, maroon or purple discoloration

Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration

• Deep tissue injury may be difficult to detect in individuals with dark skin tones.

• Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar.

• Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full-thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.


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DTPI Teaching Points

• Confirm purple skin (appearing as ecchymosis or bruising) is due to pressure or shear and not medication or trauma

• Attempt to identify the timing and setting of the pressure/shear that led to DTPI for root cause analysis

• Document the evolution damage

• of the DTPI following discovery

- Sloughing of epidermis to reveal deeper tissue

damage

-If injury becomes full-thickness, the Stage of the resultant

injury


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Medical Devices


Old Medical Device Related Pressure Ulcer:

Medical device related pressure ulcers are pressure ulcers that result from the use of devices

Medical Device Related Pressure Injury:

This describes an etiology. Medical device related pressure injuries result from the use of devices

designed and applied for diagnostic or therapeutic purposes. The resultant pressure ulcer generally closely conforms to the pattern or shape of the device.

designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the Staging system.


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Mucosal Tissues


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Old Mucosal Pressure Ulcer

Mucosal Pressure Ulcers are pressure ulcers found on

b ith

Mucosal Membrane Pressure Injury

Mucosal membrane pressurei j i f dmucous membranes with a

history of a medical device in use at the location of the ulcer.

injury is found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue these injuries cannot be Staged.


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Since April

• “The WOCN Society Board of Directors is in full support of NPUAP’ updated Staging definitions and illustrations presented during the consensus conference.”

• JWOCN is changing all references to PrU to PrI• JWOCN is changing all references to PrU to PrI

• “Academy of Nutrition and Dietetics Board of Directors is in support of NPUAP’s updated Staging definitions and illustrations”


The Joint Commission

• Preventing Pressure Injuries

-Quick Safety Issue 25 July 2016

• Includes the new terms and definitions introduced in April by the NPUAP

• Replaces the term “Pressure Ulcer” with “Pressure Injury”

https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_25_

July_20161.PDF


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Coding Systems

• Completed initial analysis of changes needed in SNOMED CT, LOINC (Logical Observation Identifiers Names and Codes)

• Will analyze changes needed in UMLS (Unified Medical Language System) and the pressure injury-related VSACs (Value Set Authority Center)

NPUAP i f i T k F t l k t h i i th• NPUAP is forming a Task Force to look at harmonizing the new NPUAP Definitions with universal coding systems and taxonomies.


Frequently Asked Questions Since April


How will we be paid for pressure injury since it is not in the ICD-10 codes?• The current ICD-10 coding system lists “pressure ulcer” and

coders are supplied with synonyms for the condition including bed sore, decubitus ulcer, plaster ulcer, pressure area and pressure sore.

• The NPUAP is working with International Wound

Organizations on the ICD-11 to incorporate the term

“pressure injury”


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Will NDNQI change their reporting systems to pressure injury?

• Yes, the National Database of Nursing Quality Indicators is changing their reporting documents and training modules intochanging their reporting documents and training modules into the new system. The changes should go into effect in 2017.


How soon will the Federal documents, MDS, OASIS, Acute Rehab IRF-PAI reporting regulations for skin conditions, change to the new Staging system?

• The NPUAP has met with CMS and is working• The NPUAP has met with CMS and is working toward an implementation plan.

• All changes are aimed at improving assessment and document precision.


When do we need to make these changes?

• There were no changes to the Stages of Pressure Injury; what you know today as Stage II is still a Stage 2

• Your system can be changed to include pressure injury whenYour system can be changed to include pressure injury when you are making other changes

• Many organizations are incorporating the term “injury” into their documentation

• Similar decisions were made when acute renal failure became acute kidney injury


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What’s next?

• Manuscript will appear in the Jan/Feb issue of the JWOCN

• NPUAP is issuing a Teaching Slide Set

• www.NPUAP.orgwww.NPUAP.org


Thank you for your attention


attention.

Enjoy the rest of your conference!

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