Opinion: The Misplaced Debate on Pressure Injury vs. Ulcer When Defining Skin Damage
By Cheryl Carver, LPN, WCC, CWCA, FACCWS, DAPWCA, CLTC
It is 2018, and health care professionals around the world are still debating what to call skin damage. I totally immersed myself in wound care because of losing my 47-year-old mother to what was then called "decubitus ulcers." I was young when my mother died, and I wanted to know why and how this could happen. My perspective is different from that of most clinicians because of my personal experience.
My purpose in writing this blog is not only to share my opinion but also to shed a different light on this controversy. There have been many debates at conferences, in the workplace, and on social media forums. After all of these discussions, there doesn't seem to be an easy answer. Based on this dissension, we need not only to establish the correct term but also to make revisions to the staging system itself. Some argue that if you change the term, the definitions automatically change. There have been some revisions, but are they enough?
Health care professionals perform a multitude of roles, and they share the same goal. They want to be "skin savers." Changing the term for skin damage is not going to help prevent and manage the ulcer/injury. There must be a goal to justify the terminology change. Changing the term, including the debate of terminology changes, not only has caused a distraction, but also has increased legalities and created an extra expense to change the name. The most recent changes announced by the Centers for Medicare & Medicaid Services, on October 1, 2018, added the term "injury." You will now see "ulcer/injury" changed throughout the CMS's RAI Version 3.0 Manual in Section M.1 This change will help some of the confusion I am going to mention, but it doesn't resolve the issue at hand.
The confusion of using "ulcer" versus "injury" in the long-term care arena has been a significant distraction, to say the least, because of wound providers and/or wound healing centers now documenting "injury" and not "ulcer." I have heard many nurses ask, "Why do they say injury and we say ulcer?" I have also helped write a plan of corrections for nursing homes with pressure ulcer/injury F-Tag citations, and the director of nursing has asked what term should be used. This leads us into a gray area within documentation. The most widely used electronic medical records (EMRs) in long-term care continue to use the term "ulcer" within the wound evaluation templates, and frequently the wound care nurse enters the wound assessment from the provider's progress notes directly into the EMR.2 Nursing homes are already under a microscope, so to speak, and the use of the term "injury" implies that their staff has harmed a person, which makes nursing homes an easier target for lawsuits. I have seen Facebook ads pop up periodically titled, "Has Your Family Member Developed Bedsores While in a Hospital, Nursing Home, or Assisted Living Facility? CLICK HERE."3 The term "injury" is the focus, implying bodily harm.
There has also been acquired expense as facility EMRs, protocols, policies and procedures, and educational resources make changes to the terminology and definitions along the way. A common question is, "Will the National Pressure Ulcer Advisory Panel (NPUAP) change their name to the National Pressure Injury Advisory Panel (NPIAP)?"
This is an international debate. Another question is, "Should these changes be worldwide?" There are also different opinions on terminology, definition, and classification. Is the staging system consistent with "how" a pressure ulcer develops and its true level of tissue destruction? And let's not forget about the confusion for MDS nurses, coders, and billers. There is no entry in the alphabetic index for pressure injury. If you ask a wound care clinician, a bioengineer, and a wound biologist what a pressure injury is, you are going to get three different answers. There needs to be clarity. There has been an array of terms used throughout the years to describe skin damage: pressure ulcer, pressure sore, decubitus, bedsore, bed ulcer, decubitus ominosus, ulcerations.4 Why so many? And why are we still deciding on this?
Working as a wound educator for years, I have witnessed the confusion out in the field and during training. This confusion applies not only to clinicians, but to providers as well. Determining the level of tissue destruction is frequently misunderstood. The staging system is confusing to clinicians and providers. It needs to be simplified, or we are missing something? What is the underlying pathophysiology? What is the true cause of the ulcer/injury? There are so many questions unanswered. With the increase in legal implications, it is critical for health care professionals to have a clear understanding of the staging system.
Term and Definition Changes for Pressure Ulcers
The NPUAP, European Pressure Ulcer Advisory Panel (EPUAP), and Pan Pacific Pressure Injury Alliance (PPPIA) recommended the term "ulcer" in 2014. The Australian Wound Management Association (AWMA) continues to use the term "injury."5 Then, in 2016, the NPUAP made the term change to "injury."6
The 2014 the definition stated: "A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear."5
The updated NPUAP (2016) definition states: "A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device [...] The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear."5
What Was Wrong with the Term "Ulcer?"
Why the change to the term pressure "ulcer" to "injury"? Per the NPUAP, the reason was to clarify the staging system further. Stage 1 and deep tissue injury described intact skin that was injured. The other stages described non-intact or open ulcers. This was misleading.
To make matters a bit more confusing, the term "ulcer," when defined, doesn't really fit either. It is a break in the skin or mucous membrane, has loss of surface tissue, and/or festers like an open sore.7 Is this definition consistent with a stage 1? No.
It only takes one word to change the meaning. If we look at the term "injury," it can be interpreted as trauma, or an act that damages or hurts, depending on what dictionary you use.8 If you look at the time it takes for an injury to occur, it can happen in as little as one second. Also, the mechanism of an "injury" is much different from that of an "ulcer." As you can imagine, this sort of sets the stage for legal implications that the health care provider injured the patient.
Skin Damage Terminology Suggestions Around the Globe
There have been suggestions to use the description, "force-related tissue damage." This term stresses that deformations of and other related changes in tissue can be the result of forces acting on and in the body. This is a wider concept than pressure and shear alone. Not only may forces cause cells and tissues to be harmed and even die, but also peak forces can cause ruptures, leading to traumatic lesions, especially in harmed tissue. Forces and the effects thereof trigger the body in a series of events to prevent further damage; the first response is behavioral, reducing peak forces and/or restoring perfusion by repositioning. However, responses at the cellular and/or molecular level aimed at resolving the situation may cause additional harm in the process.9
My opinion is...Clinicians need to know not only how to remove the cause of the damage, but also how to identify and differentiate the cause. There also needs to be a better understanding of shear, pressure, stress, damage, force, perfusion, and tissue response. Agreeing on a term will not solve the problem, nor will it help health care clinicians or caregivers prevent and manage skin damage. Evidence demonstrates that there can be numerous causes of skin damage. We need more studies to blueprint practice about prevention and treatment of pressure ulcer/injury.
1. Centers for Medicare and Medicaid Services. Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual. October 2018. Page M-1. https://downloads.cms.gov/files/3-MDS-30-RAI-Manual-v1-16-Replacement-Ma.... Accessed on October 28, 2018.
2. PointClickCare. https://www4.pointclickcare.com/care/chart/assess/stagedefinitions.jsp.
3. DiCello Levitt & Casey. We are the bedsores firm. https://www.ohiobedsores.com/. Accessed on October 28, 2018.
4. Ousey K, Schoonhoven L, Moore Z, Fletcher J, Smit H. Debate: should the EPUAP and NPUAP adopt the new pressure ulcer terms and definitions?
5. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. https://www.npuap.org/wp-content/uploads/2014/08/Updated-10-16-14-Quick-....
6. National Pressure Ulcer Advisory Panel. National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury. 2016. http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announ.... Accessed on October 28, 2018.
7. Merriam Webster. Definition of ulcer. https://www.merriam-webster.com/dictionary/ulcer. Accessed on October 28, 2018.
8. Merriam Webster. Definition of injury. https://www.merriam-webster.com/dictionary/injury. Accessed on October 28, 2018.
9. Strong P, Smit HJ. Force related tissue damage white paper: March 2018.
About the Author
Cheryl Carver's experience includes over a decade of hospital wound care and hyperbaric medicine. She currently works as a Clinical Specialist for a leading independent provider of wound care solutions for long term care facilities in the United States, American Medical Technologies a d/b/a of Gordian Medical, Inc. Carver is not only known for her knowledge and expertise, but for enjoying her vocation as much as anyone possibly could. Her strong passion is driven from a life long list of personal experiences as a caregiver. Her mother passed away in in her arms at the young age of 47, due to complications from diabetes, amputation, and pressure ulcers. She now has dedicated her professional career to wound care education in hopes to bolster quality of care and strengthen pressure ulcer prevention. She has received many high reviews from her fellow physician and nurse students from across the country, including but not limited to: plastic surgeons, cardio-thoracic surgeons, general surgeons with wound care experience. Ms. Carver single-handedly developed a comprehensive educational training manual for onboarding physicians and is the star of disease specific educational video sessions accessible to employee providers and colleagues.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.