The 11th National NPUAP Biennial Conference was held February 27 - 28, 2009 in Arlington, VA. They featured two concurrent conference tracks:
International Guideline: Consensus on Implementation
Current Best Practice in Pressure Ulcer Management
The President of NPUAP, Laura Edsberg, Ph.D. welcomed the participants in the Plenary Session on Day one, and we then spent a full morning listening to the NPUAP - EPUAP Guideline Initiative, Overview of the Guideline Methodology, Prevention and Treatment of Pressure Ulcer Guidelines. After lunch we continued with: Understanding the reasons for adjusting for risk in measures of quality as it relates to pressure ulcer formation, Present on Admission Rule in Acute Care, The Impact of CMS Rulings on Hospital Practice, Measuring Pressure Ulcer Rates, and ended with The Braden Scale: From Reliable Assessment to Effective Intervention.
Then on Day two we split into the two concurrent conference tracks. The first track was the International Guideline Consensus on Implementation and the second track was Current Best Practice in Pressure Ulcer Management. I followed the Best Practice Track that covered the following lectures: How does pressure, shear, friction and microclimate lead to ulceration ?, How can Risk Assessments be Matched to Interventions ?, How do you know if this is a pressure ulcer ?, How can Incontinence Associated Dermatitis skin lesions be reduced ?, How can Pressure Ulcers on the Heels be prevented and treated ?. We then listened to presentations on Topical Treatments and Nutritional iinterventions. After lunch the presentations turned to the following presentations: How Biofilm retards wound healing, The role support surfaces serve in pressure ulcer prevention and treatment and finally: When and how should pressure ulcers be debrided.
The new position by NPUAP on Pressure Ulcers on Mucous Membranes was presented by Joyce Black, PhD, RN and that was a lively discussion. The day ended with Adjuvant therapies to promote pressure ulcer healing, How documentation improves the care of patients with pressure ulcers, and What should be the standard of care when healing is not the goal ?.
This was a very interesting and information packed conference. The ushering in of new international guidelines for pressure ulcer prevention and treatment:
Public policy and clinical practice will be revealed in May, 2009 about the same time that NDNQI will be releasing their new guidelines.
The New NPUAP Pressure Ulcer Classification System
NPUAP - Unable to Categorize
In 2008, the NPUAP and EPUAP developed a common international definition and classification system for pressure ulcers. Over the past several years, members of the two organizations have had ongoing discussions about the many similarities between the NPUAP and EPUAP pressure ulcer grading/staging systems. As the NPUAP-EPUAP release an international pressure ulcer prevention and treatment guideline, they considered this the ideal time to develop a common classification system which could be used by the international community. There are several underlying assumptions.
Staging/Grading implies a progression from I to III or IV, when that is not always the case. The NPUAP-EPUAP attempted to find a common word to describe the stage or grade and could not do so. The NPUAP-EPUAP recognizes that there is a familiarity to the words "stage" and "grade" and therefore they are proposing to use whatever word (e.g., stage, grade or category) is most clear and understood.
However, the NPUAP-EPUAP see that the most significant benefit from this collaboration is that the actual definitions of pressure ulcers and the levels of skin-tissue injury are the same, even though one group may label the pressure ulcer as a "stage" or "grade".
"Category" was suggested as a neutral term to replace "stage" or "grade". Although, foreign to those accustomed to other terms, "category" has the advantage of being a non hierarchical designation, allowing us to free ourselves from the mistaken notion of "progressing from I to IV" and "healing from IV to I".
The NPUAP-EPUAP has agreed upon four levels of injury. Recognizing that the terms "unclassified/unstageable' and 'deep tissue injury' are generally graded as "IV" in Europe, NPUAP has agreed to put them separately in the text in the guideline. This difference will remain an issue when comparing cross country data.
NEW PRESSURE ULCER CLASSIFICATION DEFINITIONS
Category I: Non-blanchable redness of intact skin Intact skin with non-blanchable erythema of a localized area usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness or pain may also be present. Darkly pigmented skin may not have visible blanching. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons.
Category II: Partial thickness skin loss or blister Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation.
Category III: Full thickness skin loss (fat visible) Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough may be present. May include undermining and tunneling. Further description: The depth of a Category III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category III pressure ulcers. Bone/tendon is not visible or directly palpable.
Category IV: Full thickness tissue loss (muscle/bone visible) Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. Further description: The depth of a Category IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.
Unclassified: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category III or Category IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the "body's natural (biological) cover" and should not be removed.
Suspected Deep Tissue Injury Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Further description: The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with treatment.
Last Update 10/14/2009 Mideast Region of the Wound Ostomy Continence Nurses Society
