National Pressure Ulcer Advisory Panel (NPUAP) FAQs Protection Status
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Washington, DC – June 6, 2016 – The National Pressure Ulcer Advisory Panel (NPUAP) recently announced a change in terminology in the National Pressure Ulcer Advisory Panel Pressure Injury Staging System. According to the new System, the term “pressure injury” replaces “pressure ulcer”. The updated System also includes changes in the staging definitions, and uses Arabic instead of Roman numerals in the names of the stages.

The updated staging definitions were presented at the 2016 Staging Consensus Conference held in Chicago on April 8-9, 2016, which was attending by over 400 professionals. 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.

The NPUAP is attentive to the comments made by wound care professionals about the 2016 Staging Consensus Conference. Following are responses to frequently asked questions resulting from the meeting:

Why was there no consensus on some aspects of the new definitions?
Consensus is a process to develop a common understanding in areas where science cannot provide guidance, or such science is not yet available. In this process, NPUAP chose to develop new labels for pressure damaged soft tissue as "pressure injury" replacing pressure ulcer. The term "injury" was more inclusive of all 6 stages. Stage 1 is present as intact skin, as is Deep Tissue Pressure Injury, which has always used "injury" in the nomenclature.

The words "prolonged" and "intense" as the aspects of pressure that lead to ulceration have been described since Kosiak in 1961. The physics of pressure cannot be changed. Kosiak's work allowed understanding of Deep Tissue Pressure Injuries because they were initially seen in people who were subjected to intense pressure when they were found lying down on concrete, a kitchen floor etc., for a prolonged period of time. These are the same phenomena in cases of pressure injuries developing in the operating room. The work on pressure ulcer etiology and tissue mechanics has been extended by Oomen's laboratory in the Netherlands and Gefen's research group in Israel. Consensus was not required in this area. A specific time or specific pressure was not identified because the aspect of pressure injury development that must be factored into the equation is the individual tolerance for pressure.

Does the word injury increase the likelihood of being sued over a pressure injury?
This issue was discussed in detail by NPUAP prior to the conference. Plaintiff and defense attorneys who work in the pressure injury arenas were consulted. Their summarized responses were that professionals need to develop the science; attorneys look at the facts in the case to determine if it was unavoidable. For further information about unavoidable pressure injuries, please see the NPUAP's previously published work in this area ( While the word "injury" may be used in jury instructions, the definition would need to be explained within the clinical context. 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…to name a few.

Did the consensus conference attendees make any significant changes in the proposed definitions?
Yes, numerous changes were made in the proposed definitions, e.g., the inclusion of nonmedical devices as a cause of exposure to pressure and the idea that some DTPI s can resolve. The manuscript from the conference will include all changes to each definition.

Why did we remove the term "Suspected" from Deep Tissue Pressure Injury?
The original definition was written over 10 years ago and little was known about the problem of DTI at that time. Today more is known and we are able to diagnose with more accuracy. Clinicians can add the word "suspected" to the documentation about any definition or condition. For example, a patient could have a suspected pressure injury or a suspected Stage 2 pressure injury.

This will be an expensive change in our system. When do we need to make these changes?
There were no changes to the stages of pressure injury; what you know today as a Stage II is still a Stage 2. Therefore, NPUAP recommends that your system be changed to include pressure injury when you are making other changes. Many organizations are incorporating the term "injury" into their documentation. It is likely that you made similar decisions a few years ago when acute renal failure became acute kidney injury or when changes to myocardial infarction over the past years led to Unstable Angina/STEMI/NonSTEMI as part of Acute Coronary Syndromes.

How soon will the Federal documents, MDS, OASIS, Acute Rehab IRF –PAI reporting regulations for skin conditions, change to the new staging terms?
The NPUAP is responsible for using science to make needed changes combined with consensus to clarify or amplify the wording. The NPUAP has shared the changes with CMS and looks forward to working with them on an implementation plan. All the changes are aimed at improving assessment and documentation precision.

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 into the new system. The changes should go into effect in 2017.

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".

Does NPUAP have any training material on the new staging system?
Yes, a slide set is available on the NPUAP website. Artwork that accompanies the new staging system is available for free at

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


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.

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