The 2016 NPUAP Pressure Injury Update

New Staging Definitions

April 13, 2016 NPUAP Announces

National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages

of pressure injury.

http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/

Updates Timeline

• April 13, 2016 NPUAP - Announcement

• May 31, 2016 NPUAP - Consensus/Staging FAQs

• June 16, 2016 WOCN - Expresses support for NPUAP update

Updates Timeline

• August 12, 2016 WOCN - Guideline for Prevention and Management of Pressure Ulcers (Injuries) - Now Available!

• August 30, 2016 NPUAP - Governmental Agencies and Professional Organizations Support NPUAP’s Pressure Injury Staging System

• January 24, 2017 NPUAP - Position Statement on Staging – 2017 Clarifications

Updates Timeline

• January 30, 2017 NPUAP - National Pressure Ulcer Advisory Panel Meets with CMS to Discuss Identification and Treatment of Pressure Injuries

• February 2, 2017 NPUAP - Attorneys Agree: NPUAP’s New Staging System Does Not “Wound” Providers

• April 14, 2017 NPUAP - Free webinar/CE “Considerations for Bariatric Patients in Pressure Injuries & Wound Care”

NPUAP Changes

• Updated staging definitions

• Roman Numerals (i.e. I, II) to Arabic numerals (i.e. 1, 2) for staging

• Removed “Suspected” from Deep Tissue Injury

• Refined definitions for Mucosal and Medical Device pressure injury

http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/

NEW Pressure Injury Definition

Pressure Injury:

A 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 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.

http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/

NEW Stage 1 Pressure Injury Definition

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

http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/

Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented 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 Pressure Injury Non-blanchable erythema of intact skin

NEW Stage 2 Pressure Injury Definition

Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis

Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as 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).

http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/

New Illustration Stage 2 Pressure Injury Partial-thickness skin loss with exposed dermis

"The use of NPUAP material does not imply endorsement of products or programs associated with the use of the material."

Stage 2 Pressure Injury Partial-thickness skin loss with exposed dermis

NEW Stage 3 Pressure Injury Definition

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 anatomical 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.

http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/

New Illustration Stage 3 Pressure Injury Full-thickness skin loss

"The use of NPUAP material does not imply endorsement of products or programs associated with the use of the material."

New Illustration Stage 3 Pressure Injury with Epibole Full-thickness skin loss

"The use of NPUAP material does not imply endorsement of products or programs associated with the use of the material."

Stage 3 Pressure Injury Full-thickness skin loss

NEW Stage 4 Pressure Injury Definition

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or 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.

http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/

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

NEW Illustration Stage 4 Pressure Injury Full-thickness skin and tissue loss

"The use of NPUAP material does not imply endorsement of products or programs associated with the use of the material."

Stage 4 Pressure Injury Full-thickness skin and tissue loss

NEW Unstageable Pressure Injury Definition

Full-thickness skin and tissue loss in which the extent of tissue damage 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 removed.

http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/

Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss

NEW Illustrations Unstageable Pressure InjuryObscured full-thickness skin and tissue loss

Unstageable Pressure Injury Dark Eschar

"The use of NPUAP material does not imply endorsement of products or programs associated with the use of the material."

Unstageable Pressure Injury Slough & Eschar

Unstageable Pressure InjuryObscured full-thickness skin and tissue loss

NEW Deep Tissue Pressure Injury DefinitionDeep 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 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.

http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/

New Illustration Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration

"The use of NPUAP material does not imply endorsement of products or programs associated with the use of the material."

Deep Tissue Pressure InjuryPersistent non-blanchable deep red, maroon or purple discoloration

NEW Medical Device Related Pressure Injury

Medical Device Related Pressure Injury: This describes an etiology. Use the staging system to stage

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

http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/

Medical Device Related Pressure Injury This describes an etiology. Use the staging system to stage

NEW Mucosal Membrane Pressure Injury

Mucosal Membrane Pressure Injury: Mucosal membrane pressure 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.

http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/

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Staging Quiz

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Thank you!

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Updates Timeline Expanded

May 31, 2016 NPUAP Consensus/Staging FAQs

1. Why was there no consensus on some aspects of the new definitions? 2. Does the word injury increase the likelihood of being sued over a pressure injury? 3. Did the consensus conference attendees make any significant changes in the proposed definitions? 4. Why did we remove the term “Suspected” from Deep Tissue Pressure Injury?

http://www.npuap.org/wp-content/uploads/2016/05/NPUAP-Consensus-Staging-FAQs-May-2016.pdf

May 31, 2016 NPUAP Consensus/Staging FAQs

5. This will be an expensive change in our system. When do we need to make these changes? 6. How soon will the Federal documents, MDS, OASIS, Acute Rehab IRF –PAI reporting regulations for skin conditions, change to the new staging terms? 7. How will we be paid for pressure injury since it is not in the ICD-10 codes? 8. Does NPUAP have any training material on the new staging system?

http://www.npuap.org/wp-content/uploads/2016/05/NPUAP-Consensus-Staging-FAQs-May-2016.pdf

June 16, 2016 WOCN Support NPUAP Update

Expresses support for NPUAP update

“WOCN supports universally recognized terminology and descriptors in the staging of pressure injuries and the importance

of staging in the management of acute and chronic pressure injuries.”

• Task force - develop formal position statement

• Awaiting updates from CMS and ICD-10 coding group

August 12, 2016 WOCN New Pressure Injury Guideline

Guideline for Prevention and Management of Pressure Ulcers (Injuries) - Now Available!

“Within the appendices are the National Pressure Ulcer Advisory Panel's (NPUAP) new pressure injury stages and illustrations (in

color)”

• Task force - two year operation to update 2010 guideline

• Includes medical device-related pressure ulcers

August 30, 2016 NPUAP Press Release

Governmental Agencies and Professional Organizations Support NPUAP’s Pressure Injury Staging System

• Joint Commission

• CMS

• National Database of Nursing Quality Indicators (NDQI)

• Wound Ostomy Continence Nurses Society (WOCN)

http://www.npuap.org/governmental-agencies-and-professional-organizations-support-npuaps-pressure-injury-staging-system/

January 24, 2017 NPUAP Position Statement

NPUAP Position Statement on Staging – 2017 Clarifications

•Position Statement 1: The diagnosis of a “pressure injury” does not mean that the health care provider(s) “caused” the injury.

•Position Statement 2: Some pressure injuries are unavoidable despite provision of evidence- based care by the health care team.

•Position Statement 3: The numerical staging system does NOT imply linear progression of pressure injuries from Stage 1 through Stage 4, nor does it imply healing from Stage 4 through Stage 1.

•Position Statement 4: The NPUAP Staging System classifies pressure injuries based on the type of tissue loss that can be visualized or directly palpated.

http://www.npuap.org/wp-content/uploads/2012/01/NPUAP-Position-Statement-on-Staging-Jan-2017.pdf

January 24, 2017 NPUAP Position Statement

NPUAP Position Statement on Staging – 2017 Clarifications

• Position Statement 5: The pressure injury may be more extensive than initially apparent. The wound base and surrounding tissue should be assessed for variations in sensation, temperature, firmness, color and any expression of drainage from surrounding tissues when palpated.

• Position Statement 6: Deep Tissue Pressure Injury (DTPI) may evolve into a full thickness wound despite optimal care.

• Position Statement 7: Any pressure injury should be treated in accordance with current evidence-based practices and monitored closely for changes that require re-evaluation of treatment strategies.

http://www.npuap.org/wp-content/uploads/2012/01/NPUAP-Position-Statement-on-Staging-Jan-2017.pdf

January 24, 2017 NPUAP Position Statement

In Process

• There have been ongoing discussions between NPUAP and CMS to facilitate implementation for documentation, quality monitoring and reimbursement.

• Coding systems such as LOINC and SNOMED CT are being analyzed for congruence with the new staging system.

• Pressure injury is listed as a synonym for pressure ulcer in the beta draft of the ICD-11.2

• The Veterans Affairs is revising teaching materials to align with these changes. • The Partnership for Patients - Hospital Engagement Network (HEN) is dually listing • pressure injury/ulcer in its materials. • The Joint Commission has posted the new staging system on its website as a point of

information.

http://www.npuap.org/wp-content/uploads/2012/01/NPUAP-Position-Statement-on-Staging-Jan-2017.pdf

January 24, 2017 NPUAP Position Statement

In Process

• The International Guideline Group will examine the new NPUAP Staging System as well as new evidence as they revise the international pressure ulcer guideline for 2019.

• The NPUAP recognizes that change is difficult and significant efforts are being made to implement these changes in databases, instructional materials, and electronic health records. The NPUAP is very appreciative of the nation-wide efforts being undertaken to improve pressure injury identification, documentation and monitoring. As implementation has spread, the NPUAP has had several requests for clarification. The statements noted below are designed to respond to those requests and further clarify the position of the NPUAP.

http://www.npuap.org/wp-content/uploads/2012/01/NPUAP-Position-Statement-on-Staging-Jan-2017.pdf

January 30, 2017 NPUAP Press Release

National Pressure Ulcer Advisory Panel Meets with CMS to Discuss Identification and Treatment of Pressure Injuries

• NPUAP and CMS will continue to collaborate and share scientific expertise

• CMS representative presenting at NPUAP’s Biennial Conference

• Conference focus include implementation of the 2016 Staging System and quality measures

http://www.npuap.org/national-pressure-ulcer-advisory-panel-meets-with-cms-to-discuss-identification-and-treatment-of-pressure-injuries/

February 2, 2017 NPUAP Press Release

Attorneys Agree: NPUAP’s New Staging System Does Not “Wound” Providers

• Recent article in The National Law Review by Denning and Klaus

• Important to use new staging system

• Promote accurate/early identification

• Promote appropriate care

http://www.npuap.org/attorneys-agree-npuaps-new-staging-system-does-not-wound-providers/

April 14, 2017 NPUAP Latest News

FREE NPUAP Live Webinar! Considerations for Bariatric Patients in Pressure Injuries & Wound Care

• Free webinar by Susan Morello CWOCN

• Examine the factors which have an impact on skin issues of the bariatric patient

• Prevention and treatment of skin injuries when caring for a bariatric patient

• Describe factors to be considered when selecting a support surface. seat cushion and/or specialty equipment for the bariatric patient

http://www.npuap.org/free-npuap-live-webinar-considerations-for-bariatric-patients-in-pressure-injuries-wound-care/