National Pressure Ulcer Advisory Panel (NPUAP) Announces a Change in Terminology From Pressure Ulcer to Pressure Injury and Updates the Stages of Pressure Injury Protection Status
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Washington, DC – April 13, 2016 – The term "pressure injury" replaces "pressure ulcer" in the National Pressure Ulcer Advisory Panel Pressure Injury Staging System according to the NPUAP. The change in terminology more accurately describes pressure injuries to both intact and ulcerated skin. In the previous staging system Stage 1 and Deep Tissue Injury described injured intact skin, while the other stages described open ulcers. This led to confusion because the definitions for each of the stages referred to the injuries as "pressure ulcers".

In addition to the change in terminology, Arabic numbers are now used in the names of the stages instead of Roman numerals. The term "suspected" has been removed from the Deep Tissue Injury diagnostic label. Additional pressure injury definitions agreed upon at the meeting included Medical Device Related Pressure Injury and Mucosal Membrane Pressure Injury.

The updated staging definitions were presented at a meeting of over 400 professionals held in Chicago on April 8-9, 2016. Using a consensus format, Dr. Mikel Gray from the University of Virginia adeptly guided the Staging Task Force and meeting participants to consensus on the updated definitions through an interactive discussion and voting process. During the meeting, the participants also validated the new terminology using photographs.

Dr. Laura Edsberg from Daemen College in Buffalo, NY and Dr. Joyce Black from the University of Nebraska Medical Center in Omaha served as co-chairs of the Staging Task Force appointed by the NPUAP Board of Directors. Task force members included Margaret Goldberg, MSN, RN, CWOCN from Delray Wound Center, Florida, Laurie McNichol, MSN, RN, CWOCN, CWON-AP, from Cone Health in Greensboro, NC, Lynn Moore, RDN, from Nutrition Systems, Mississippi and Mary Sieggreen, MSN, CNS, NP, CVN, from Detroit Medical Center.

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 will be available for use at no cost through the NPUAP website (

The updated staging system includes the following definitions:

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.

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 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 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).

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.

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.

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.

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 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.

Additional pressure injury definitions:

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.

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.

More information will be forthcoming on teaching points for the new stages and the rationale for some of the changes in the staging system.

About the National Pressure Ulcer Advisory Panel
The National Pressure Ulcer Advisory Panel is a multidisciplinary group of experts in pressure injury. The NPUAP serves as the authoritative voice for improved patient outcomes in pressure injury prevention and treatment through public policy, education and research. Contact NPUAP at


Recently I attended the 2016 NPUAP Consensus Conference and am distressed with the process and outcome of the conference. In my opinion this was not a consensus conference. The new changes are not worth the thousands of dollars and man hours required for implementation. The staging system is broken and needs a major overhaul. I implore the NPUAP to put their proposed staging system on hold and bring together experts in each field to create a valid system.

The NPUAP staging system certainly needs an overhaul since it does not reflect the current understanding of the pathophysiology of the way in which ulcers form. However, changing the name is not going to fix the fundamental flaws which underlie the system. Numbering these categories (no matter how you do it) and calling them "stages" implies progression between the stages, regardless of your efforts state otherwise, and the drawings of the stages on the website are used in court to demonstrate that all pressure ulcers form from the outside-in and progress from Stage 1 to 4. Numbering them allows attorneys to successfully make the case that a stage 4 (which occurred from the inside-out, for example, in a nursing home) actually began with the "stage 2" documented in the hospital, and then progressed "through the numbers". It is nearly impossible to convince jurors otherwise. Hospitals are paying large sums of money in damages as a direct result of the NPUAP "staging" system. Worse, plaintiffs have linked pressure ulcers to elder abuse in order to avoid the cap on punitive damages passed with tort reform in some states. The result is the criminal prosecution of caregivers and clinicians when patients develop pressure ulcers. Now that you have termed all of these "injuries", you have handed a gift to the plaintiffs that will keep on giving for years to come. I can summarize my concerns as follows:

1) Because the terminology of the pressure ulcer ICD-10 diagnosis codes remain unchanged, Using the term “injury” in referring to pressure ulcers in a patient’s medical record will confound billing and coding functions.
2) Even though pressure ulcers are NOT classified by CMS as “never events”, plaintiff’s attorneys have successfully argued that these often unpreventable hospital acquired conditions (HACs) are ALWAYS evidence of substandard care-- certainly this is what is currently on the National Quality Forum website. Using the term “injury” will almost certainly advance the specious argument that pressure ulcers result from poor care.
3) Plaintiffs are anxious to link the development of pressure ulcers to elder abuse in order to avoid the cap on punitive damages. It seems highly likely that using the term “injury” will advance the agenda of plaintiffs to equate pressure ulcers with elder abuse.
4) Most concerning is a trend toward the criminalization of pressure ulcers. We know of instances in which individuals have been successfully prosecuted for manslaughter in relation to patients who died with pressure ulcers. Because the term “injury” has overtones of intentional harm, using the term “injury” may increase the possibility that pressure ulcer cases could be litigated in the criminal court system.
Given the fact that several of the current and past NPUAP board members are frequent plaintiffs' experts in malpractice cases, the NPUAP cannot simply shrug off the serious legal implications of this change. Because of the high regard in which I hold several members of the NPUAP, I know that this ill-conceived decision was not made with the intent to worsen the malpractice climate in the USA> However, this is yet another in a series of such badly done meetings that it will soon be difficult to defend the NPUAP as a well-intentioned academic group that simply fails to understand the implications of its actions. At some point, the rest of us begin to shake our heads and wonder if you have completely lost yours.

I agree with the comments made by Ms. Shank and Dr. Fife on the new staging system. While some "new terminology" does help with descriptions of certain " stages", it certainly does not address the issues clinicians deal with every day. Pressure related wounds/injuries/ulcers are about more than "pressure" and the NPUAP cannot ignore the ramifications of their positions and products on the clinical, legal, and regulatory environment in the country. The Panel needs to step "outside the box" on this important issue if they are to remain relevant and respected in the wound care community.

I feel the need to add my comment to Joyce's and Carolyn's. I too attended the conference and participated in feedback. I have to agree that the staging system is broken, knowing what we know pathyphysiologically how they occur. There was no disagreement at the conference about the fact that pressure ulcers usually (if not always?) are a bottom up phenomenon versus the top down phenomenon that the staging system implies and that is so ubiquitous in belief. Yet the conference forged ahead without discussion about this most important fact. I had hoped for more discussion about this elephant in the room and consideration of restructuring of the whole system. Alas, rather than provide a fix for a broken system, the NPUAP has only added to the problem. Members of the task force were strong in their opposition to considering the legal implications of the changes, but we cannot divorce ourselves from the legal issues surrounding pressure ulcers. Billboard lawyers are everywhere, and I cannot help but feel that they have been handed a gift.

First of all, I was hoping to attend this consensus conference, but was unable to do so due to scheduling conflicts. While at the SAWC in Atlanta, I was informed of these new changes and nearly threw up, then I got very frustrated because NPUAP has failed us again. I fully agree with the comments of Joy Schank, Carolyn Fife and others and will not repeat what they have said so succinctly. Indeed, NPUAP has given a gift to the plaintiff's side, but this should come as no surprise since several past and current NPUAP members (past presidents no less!!) work the for the side against clinicians. I find it hard to believe how some of these members can get up in front of an audience of their peers, do presentations designed to help educate and then essentially say, "oh, by the way, if you are named in a lawsuit, I will be on the other side to bury you, not defend you." Indeed, I have read depositions from these plaintiff friendly members and they completely misrepresent the NPUAP guidelines to favor their side at the detriment to the clinicians and institutions that did nothing wrong.
I am at the point that frankly, though there are some fine members who I know that is on NPUAP, the time is coming and perhaps soon, that this organization can no longer be considered a reputable institution that we should support or listen to anymore. If they continue to ignore the problems with the staging system, then perhaps the rest of us who see this as a real issue should write a new, more sensible "assessment system", stop calling it staging since indeed it does suggest progression, and go to one of other wound care societies (AAWC, WOCN, WHS, etc) and have institutions start adopting a more sensible and helpful clinical tool and give up on the NPUAP if they refuse to be fair and balanced.

The NPUAP is attentive to the comments made by wound care professionals about the 2016 Staging Consensus Conference. As the authoritative voice for pressure injury prevention and treatment, we feel compelled to clarify some misinformation regarding the 2016 Staging Consensus Conference.
Let’s consider the facts:.
1. The conference was conducted using a Delphi process, which was previously used by the organization and supported by expert moderator Mikel Gray.
2. The term "injury", replacing "ulcer" was overwhelmingly supported in both the stakeholder organizational and individual open comment periods for the staging definitions that were held months prior to the conference.
3. The role of consensus is to come to agreement on specific aspects of a topic that are not yet reported in the scientific literature or understood. For that reason, not every word of each definition was discussed at the conference. Our process was explained in detail at the beginning of the conference.
4. The NPUAP followed this process and the revised staging system is based on the scientific literature as well as the results of the consensus achieved at the conference.
5. Answers to questions which have been frequently asked about the new definitions are posted at our website,
6. Further information will be included in a forthcoming published manuscript based on the conference and a teaching slide set will be available on our website

Mary Sieggreen, President, NPUAP

As a conference attendee, we gave consensus only on pre-selected words/sentences. It was not clear to me we would not be allowed to give consensus on entire definitions. It makes no sense we did not have this opportunity. Participants had no input regarding the term “injury” or the development of 2 new pressure categories. In my opinion we did not include significant scientific literature. Also I am distressed because CMS and legal experts should have been consulted prior to announcing any revisions. My concerns were dismissed as I was told the conference was about clinical matters and not legal matters. I implore the NPUAP to put these revisions on hold and bring experts together for a true consensus conference.


The National Pressure Ulcer Advisory Panel, of which I am a board member, recently revised the pressure ulcer staging system. Clearly this has been met with mixed responses. There are some who have applauded the change as more closely reflecting what is seen in the clinical setting. Others are disappointed that it went too far.

For those who have not had a chance to fully review the original sourced material or attend I would like to provide these highlights.

1. The new system changes the term ulcer to injury. This was done to more accurately describe what is seen histologically and to acknowledge that not all pressure related changes are open wounds and therefore injury may be a more accurate term.

2. The numbering system was changed from Roman numeral to Arabic numeral. This was done for logistical reasons; data collection, communication and electronic health record input. The number system in no way implies a sequential progression of ulcers. This was not intended and is clearly stated.

3. The descriptive terminology and images associated with different pressure injury stages was modified for clarity, precision and an attempt to limit ambiguity.

I would like to thank the taskforce members who undertook this endeavor. None of them did it for personal gain or personal agenda. They understood, as we all did, that any change would result in confusion and active discourse. Frankly, I am happy these changes have resulted in a lively discourse in the public space. I am however disappointed that much of the discussion has focused on litigation, need for updated paperwork, financial gain for consultants and inconvenience for many those who were entrenched in the previous system. I can tell you that everyone involved in the cross-setting consensus process was focused keenly on how this would impact patient care. None of this was taken lightly.

Change is difficult. In the future even this revision will be outdated. However until that happens this revised system is the best most expedient manner in which clinicians, researchers, regulators, caregivers and patients can communicate regarding pressure injury.

I applaud those who are looking for a “moon shot” for the problem of pressure injury for our patients. If that happens I am sure NPUAP will endorse such an endeavor. Until then we must continue to use our resources and do the best we can for our patients.

Aamir Siddiqui MD

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