The National Pressure Ulcer Advisory Panel (NPUAP) recently met in Chicago for the 2016 Staging Consensus Conference. In the days following the meeting, the organization announced it will, effective immediately, use “pressure injury” to replace “pressure ulcer” for purposes of its staging system. According to the NPUAP, the change more accurately describes pressure injuries to intact and ulcerated skin. It was always inaccurate to call a stage I pressure ulcer an “ulcer” since there was no break in the skin. However, changing the name of all so-called stages to “injuries” does not solve the numerous foundational problems with the staging system — the biggest being it’s not a staging system at all. However, calling an area of intact skin an “ulcer” was no more bizarre than having a stage called “I can’t tell what the stage is.” Here are a few major points to consider: 1) ICD-10-CM diagnosis codes for pressure ulcers haven’t changed. Therefore, it’s ill-advised for clinicians to change the wording used in relation to pressure ulcers since this is likely to confuse coding and billing processes. 2) The current NPUAP staging system is not a true staging system because the word “stage” implies progression or gradation along a continuum. It should be possible to use stages to direct treatment and predict outcome. If some stages have the same outcome, they aren’t really different stages. 3) The NPUAP staging system is inconsistent with what we now know about the pathophysiology of how pressure ulcers form, specifically from the inside out with deep tissue injury/stages III and IV, and from the outside in — in stage II. I’m not sure anyone really knows what a “stage I” is. 4) The NPUAP staging system is directly responsible for a high percentage of medical malpractice lawsuits because: Plaintiff’s attorneys are able to argue successfully that stage IV ulcers happen from stage II because “any fool can count to four”; “poor care” caused these ulcers to worsen from a stage II to a stage IV (Note: the National Quality Forum claims pressure ulcers are always the result of a failure of care.); stage IV ulcers “should have been able to be identified at an earlier stage”; and pressure ulcers are popular targets for malpractice because plaintiffs’ attorneys link them to elder abuse, thus removing the cap on punitive damages. 5) Calling pressure ulcers “injuries” will continue to criminalize pressure ulcers. In addition to increasing the success plaintiffs have had in linking pressure ulcers to elder abuse to avoid the cap on punitive damages, saying we “injured” a patient takes this from neglect to intentional harm. That makes pressure ulcers “willful abuse” and criminal. Malpractice insurance doesn’t cover a clinician for criminal charges of battery or manslaughter. 6) Sunshine Laws require disclosure of financial relationships between clinicians and manufacturers, and courses offering continuing education mandate additional disclosures (eg, company stock, consulting, advisory board work, etc.). However, clinicians aren’t required to disclose activities in the area of medical malpractice work that can be lucrative enough to provide full-time employment. Calling pressure ulcers “injuries” has profound medicolegal implications. Given the number of NPUAP board members who serve as experts in malpractice cases, the legal implications of this change should have been a major point of discussion at this meeting since there’s no mechanism by which expert-opinion activities had to be disclosed by the participants. Whether this was really a consensus meeting, I can’t say. I can say the changes were ill-conceived, they might have unintended negative consequences for providers, and aren’t likely to benefit patients. It’s time for rational minds to create a real staging system. I caution wound care providers not to use the word “injury” in their notes related to events previously referred to as a pressure ulcer. For those compelled by their hospitals to make this change, I urge you to notify the risk-management department each time the word “pressure injury” is used so that these individuals can assist in mitigating the legal implications of the term for healthcare staff.
Caroline E. Fife, MD, FAAFP, CWS, FUHM, is chief medical officer at Intellicure Inc.; executive director of US Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands, TX; and co-chair of the Alliance of Wound Care Stakeholders.