Teaming Together to Understand Pressure Injuries / (Ulcers): NPUAP Terminology and Staging Clarification
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1 Teaming Together to Understand Pressure Injuries / (Ulcers): NPUAP Terminology and Staging Clarification
2 We encourage you to share this information with your staff and colleagues by facilitating clinician education, it is our mission to make evidence based wound care available to more patients. Sue Kennedy, RN, BS, CWOCN, FACCWS (386) Debbie Ritter, RN, BSN, CWOCN, FACCWS (985)
3 Disclosure Commercial Interest or Conflict of Interest: No commercial or conflict of interest to report.
4 Skin Facts Largest organ of the body : 10-15% of body weight Naturally acidic ph ( ) Composed of 2 layers: epidermis and dermis Functions include protection, sensation, thermoregulation, metabolism, body image and immune processing Receives one third of the body s circulating blood volume Thickness varies from 0.5mm (tympanic membrane area) to 6mm (soles of feet and palms of hands)
5 Skin Integrity Facts
6 Extent of Tissue Damage: Partial Thickness vs. Full Thickness Partial thickness tissue damage involves epidermis and may extend to dermis but not through the dermis layer Full thickness tissue damage includes epidermis, dermis and extends into subcutaneous layer (and possibly into the muscle or bone
7 Partial Thickness Tissue Loss Heals by epidermal resurfacing of epithelial cells (epithelialization). There will be no granulation or necrotic tissue present.
8 Healing Process: Partial Thickness vs. Full Thickness Partial thickness heals by reepithelialization (regeneration of the epidermis across a wound surface) Full thickness- granulation, contraction of wound edges, epithelialization. Granulation tissue is composed of new blood vessels, connective tissue, fibroblasts, and inflammatory cells which fills an open wound when it starts to heal; typically appears deep pink or red with an irregular, berry-like surface (WOCN Guidance On OASIS C-1 Integumentary Items Glossary)
9 Full Thickness Tissue Loss: Granulation / Necrotic Tissue granulation slough eschar
10 Scar Tissue and Tensile Strength Presence of scar tissue indicates full thickness skin tissue involvement (no matter what type of wound etiology) Scar tissue is only 80% as strong (tensile strength) as original skin status prior to the full thickness tissue injury. Scar tissue will break down more quickly than undamaged skin Include education to avoid unrelieved pressure to any scarred area is an important intervention.
11 The National Pressure Ulcer Advisory Panel (NPUAP) Revised Guidelines 2016
12 Why The Revision by NPUAP? Pressure injuries are staged to indicate the extent of tissue damage. The stages were revised based on questions received by NPUAP from clinicians attempting to diagnose and identify the stage of pressure injuries. Schematic artwork for each of the stages of pressure injury was also revised and available for use (may be downloaded at the NPUAP website).* *NPUAP Pressure Injury Staging Press Release April 13, 2016
13 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 issue for pressure and shear may be affected by microclimate, nutrition, perfusion, comorbidities and condition of the soft tissue.
14 Healthy Skin - Caucasian Healthy Skin Non-Caucasian
15 Stage 1 Pressure Injury: Nonblanchable erythema of intact skin 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.
16 Stage 1 Pressure Injury Caucasian Non-Caucasian
17 Stage 1 Pressure Injury - Edema
18 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).
19 Stage 2 Pressure Injury
20 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.
21 Stage 3 Pressure Injury
22 Stage 3 Pressure Injury With Epibole
23 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 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.
24 Stage 4 Pressure Injury
25 Unstageable 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 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.
26 Unstageable Pressure Injury Dark Eschar Slough and Eschar
27 Unstageable Pressure Injury Eschar Slough
28 Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration The word Suspected has been eliminated. Intact or non-intact skin with localized area of persistent nonblanchable deep red, 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.
29 Deep Tissue Pressure Injury (continued) 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).
30 Deep Tissue Pressure Injury (continued) Do not use Deep Tissue Pressure Injury to describe vascular, traumatic, neuropathic, or dermatologic conditions.
31 Deep Tissue Injury
32 Additional Pressure Injury Definitions
33 Medical Device Related Pressure Injury This is the 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.
34 Medical Device Related Pressure Injury
35 Check for Pressure from Objects and Tubes
36 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.
37 What Has Not Changed The cause of the pressure ulcer/tissue damage continues to be an injury related to unrelieved pressure secondary to immobility. The actual stage of the wound that has evolved due to the pressure injury has not changed. (The staging definitions include additional descriptors to assist with identifying the extent of tissue layer damage). ICD-10 Coding is following CMS guidelines to adhere to the 2014 NPUAP Guidelines and will not have code adjustments based on the 2016 NPUAP staging update clarifications.
38 What Has Changed Although CMS had planned to continue to adhere to the NPUAP 2014 Pressure Ulcer (Injury Guidelines) in 2017, they did proceed with: Incorporating some of the specifics into the patient assessment documentation in the health care settings The labeling of Pressure Injuries (Ulcers) has changed from Roman numerals to Arabic numerals.
39 Cost of Pressure Injuries/Ulcers Pressure Injury /Ulcer cost is $9.1- $11.6 billion per year in the United States. According to the Agency for Healthcare Research and Quality (AHRQ), more than 2.5 million patients in United States acute care facilities suffer from pressure ulcers, and 60,000 die from pressure ulcer complications each year. * *The Remington Report Volume 25 Issue 1 January/February 2017, page 11
40 Predicted Incidence of Pressure Injuries/Ulcers Occur most commonly in elderly patients (the fastest growing segment of the population )* U.S. Life Expectancy at Birth 1900 to 2009 The number of patients at risk for developing pressure injuries/ulcers is expected to increase as life expectancy increases *The Remington Report Volume 25 Issue 1 January/February 2017, page 11
41 Common Reasons for Hospitalizations During which Pressure Ulcers Were Also Present* In order of most frequent admission diagnoses: Septicemia Pneumonia Urinary Tract Infections Rehabilitation care, fitting of prostheses, and adjustment of devices Respiratory failure, insufficiency, arrest Congestive Heart Failure (Non-hypertensive) Complication of device, implant or graft Aspiration Pneumonitis Acute and Unspecified Renal Failure Fluid and Electrolyte Disorders *The Remington Report Volume 25 Issue 1 January/February 2017, page 12-13
42 Utilization of the NPUAP 2016 Pressure Injury Guidelines to: Promote Standardized Documentation:
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46 Consider Utilization of the NPUAP 2016 Pressure Injury Guidelines to: Provide education to clinicians re: assessing the extent of skin and tissue layer involvement /destruction to promote accurate documentation and coding. Discuss wound etiology wounds caused by unrelieved pressure due to immobility (vs. wounds caused by neuropathy, vascular disease, incontinence, etc).
47 Pressure Injuries/Ulcers: Stage 3 and 4 Are full thickness wounds they close by granulation, contraction and epithelialization Are never reverse staged Are considered at their worst stage if they reopen superficially they are staged at their worst Are negated only if replaced by a muscle flap (not a skin graft) at which point it is a surgical wound A failed graft would be documented as non-healing surgical wound, and coded as a failed graft.
48 Closed / Healed Stage 3 and 4 Pressure Ulcers and Coding As of , although a closed / healed stage 3 or 4 pressure injury will not be counted in CMS data collection tools on the initial patient assessment. Closed stage 3 and stage 4 pressure injuries will continue to require assessment and interventions to prevent re-opening of the ulcer sites.. Depending on the health care setting, consider inclusion of the closed stage 3 and stage 4 pressure injury in the coding sequence (since assessment and interventions is required to prevent breakdown of the closed sites).
49 Consider Utilization of the NPUAP 2016 Pressure Injury Guidelines to Assist With Clinician Education: Assure that the patient is assessed for Risk of Developing Pressure Ulcers using a standardized validated tool (such as the Braden Scale or Norton Scale) Implement interventions to promote skin integrity and prevent skin breakdown.
50 Consider Utilization of the NPUAP 2016 Pressure Injury Guidelines to Assist with Documentation: Accurate documentation of pressure injury (ulcer) wound status is very important. Commonly seen errors: Documenting full thickness tissue loss wounds as partial thickness tissue loss wounds. Example: statement made: It s a stage 2 pressure injury as it is not very deep and there is just a little bit of slough.the presence of slough indicates full thickness tissue damage indicating that if this wound is due to unrelieved pressure, it would be a stage 3 pressure injury or unstageable if the depth of tissue damage is not able to be assessed.
51 Commonly Seen Documentation Errors: Wound Etiology Not Properly Identified Examples: Neuropathic Ulcers being referred to as pressure injury wounds Arterial Ulcers being referred to as pressure injury wounds Incontinence Associated Skin Damage (IASD) being referred to as pressure injury areas when skin breakdown is actually due to damage caused by maceration related to incontinence
52 Promoting Accurate Wound Etiology Ensure accurate communication of wound characteristics to assist the physician with accurate etiology / coding Ensure accurate documentation regarding the extent of tissue layer destruction in addition to accurate etiology. Accurate assessment will support the need for skilled care to promote healing.
53 Ways to Avoid Commonly Seen Errors Assess the overall patient status Review patient history Assess co-morbidities Review medications Consider location of wound Review recent patient events Interview patient - include length of time wound has been present
54 Questions?
55 Resources Bryant, Ruth A., Nix, Denise P., Acute & Chronic Wounds Current Management Concepts 4 th Edition CWOCN Guidance On OASIS C-2 Integumentary Items Hess, RN, BSN,CWOCN, Cathy Thomas, Clinical Guide to Skin & Wound Care 7 th Edition Wound, Ostomy and Continence Nurses Society. (2007). The WOCN image library [Image database]. Retrieved from Kennedy - Evans, Karen Lou; Lisa Selman-Holman OASIS C2 updates Eli s Home Care Week Newsletter, Volume XXV, Number 36, The Remington Report Volume 25 Issue 1 January/February 2017, Lisa Remington Organizational Readiness to Manage Pressure Ulcers and Readmissions, Getting Ready for the IMPACT Act, page Wound, Ostomy and Continence Nurses Society Core Curriculum, Wound Management 2016
56 Debbie Ritter, RN, BSN, CWOCN, FACCWS, COS-C Sue Kennedy, RN, BS, CWOCN,FACCWS, COS-C
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