1. Zulkowski, Karen DNS, RN, CWS
  2. Langemo, Diane PhD, RN, FAAN
  3. Posthauer, Mary Ellen RD, CD, LD
  4. the National Pressure Ulcer Advisory Panel

Article Content

Pressure ulcers (PrUs) are problematic for patients and their health care providers in terms of both treatment and cost. In addition, litigation has become more commonplace after a patient develops a PrU. This trend toward increasing litigation has focused attention on the need for commonality in staging, treatment, and documentation of PrUs across the continuum of care. This article will focus on issues related to staging and documentation. First, a look at the scope of the PrU problem.


Prevalence and Incidence

The confusion over how to document PrUs is particularly alarming when one considers that approximately 2.5 million hospitalized patients receive treatment for a PrU in the acute care setting each year.1 Because the methods to determine PrU prevalence have varied widely, an accurate figure is difficult to determine. A large, international, multisite study supported by Hill-Rom estimated the prevalence rate in facilities of all types to be 15.5%.2 Novation/KCI supported a similar study that found a PrU prevalence rate of 16% and an incidence rate of 7% in the acute care setting.3 Other researchers have reported prevalence rates ranging from 10% to 18% in acute care and from 13.6% to 26.8% in long-term care.4


Pressure ulcer incidence has remained relatively stable over the last 10 to 15 years. This is viewed as a positive trend, as today's patients are older and sicker than their predecessors. Over the past decade, PrU incidence in the United States has been reported to be between 0.4% and 38% in acute care and 2.2% and 23.9% in long-term-care facilities.4


The total cost of caring for hospital-acquired PrUs has been estimated to be between $2.2 and $3.6 billion dollars per year,1 with the estimated cost of caring for a hospitalized individual with a PrU ranging from $5000 to $40,000 per PrU.5-7 These figures are somewhat dated, however. Using a yearly inflation rate of 10%, it is estimated that the cost to treat PrUs in 2004 dollars is $9.1 to $11.6 billion per year, with the cost per PrU ranging from $20,900 to $151,700.


Documentation Dilemma

Despite the large number of patients with PrUs, however, consensus of documentation does not always occur. This leads to wide variation in how ulcer location, characteristics, and staging are documented, even between members of the same health care team. Because achieving positive wound outcomes is a team effort, inconsistent documentation may create confusion, lead to inappropriate treatment recommendations, and stall healing.


Certain mandatory reporting forms, such as the Minimum Data Set (MDS) in long-term care and the Outcomes and Assessment Information Set (OASIS) in home care, can contribute to this problem because they necessitate the use of reverse staging. Reverse staging suggests that ulcers heal from the bottom up, anatomically regaining the missing tissues. Such healing does not occur biologically: Full-thickness wounds heal by scar and contraction and never regain more than 70% of their original tensile strength. Scar tissue is adynamic and relatively ischemic, making it more prone to future ulceration.


Consider the example of a Stage II PrU. This stage implies that underlying tissue, such as muscle and fascia, are intact. Now suppose a healing, but not epithelialized, Stage III PrU-which involves full-thickness skin loss-were reverse-staged as a Stage II PrU as it healed. Health care providers unfamiliar with the history of the wound would rarely prescribe the needed level of preventive care to protect this fragile tissue, thereby increasing the chance of future breakdown of the same area.


This lack of consistency between what is needed for medical record documentation and Medicare reporting has increased staff confusion and reduced the accuracy of information communicated.


Arriving at a Consensus

When 'qcommunicating about any health problem, a unified, or consensual, approach is important. Consensus is widely regarded as a collective opinion or general agreement.8 To achieve consensus, experts in the field come together (usually at a conference) to share ideas and establish agreement for definitions and terminology. The National Institutes of Health defines a consensus conference as "a technique developed with the aim of providing help to clinical decision making and health planning through a clear definition of the indicators by which a given process can be considered appropriate, inappropriate or deserving of a further close examination."9 In essence, this method is useful in identifying valid, timely, and useable responses on a particular aspect of health care where definitions, use, effectiveness, and methods of application are scientifically debated in the literature and/or among individuals.


The National Pressure Ulcer Advisory Panel (NPUAP) has a history of using the consensus conference format to debate questions about PrUs, having facilitated consensus of definition, appropriate documentation, and development of treatment guidelines for PrUs. At the end of February, the NPUAP will take on yet another area where consensus is needed: staging and documentation of deep tissue injury (DTI). An NPUAP task force began studying DTI in 2001. The task force concluded that although several staging systems are widely cited and used in clinical practice, "none defines pressure-related deep tissue injury under intact skin."10


As a result, some of these wounds are being staged and documented as Stage I PrUs when, in fact, they are extensive full-thickness wounds. Without consensus on what DTI is and how it should be documented, the clinician is unable to accurately diagnose and prescribe individualized treatment. In today's litigious climate, the legal implications of underdiagnosis or misdiagnosis can be enormous.


The NPUAP currently recommends that clinicians use the terminology "pressure-related deep tissue injury under intact skin" or "deep tissue injury under intact skin" to describe these lesions.10 Exactly how deep tissue injury under intact skin fits into the NPUAP's current PrU staging system must be further evaluated. Any change to the current staging system would have a far-reaching impact. In particular, it would affect federal regulations (including MDS and OASIS), which would subsequently influence reimbursement for health care providers. However, not having a clear way of fitting DTI into the current PrU staging system does a disservice to patients, who may not get the care they need.


The goal of the NPUAP's 9th consensus conference, to be held February 25 to 26, 2005, in Tampa, FL, is to reach consensus on clinical, research, and regulatory issues related to DTI. In preparation for the debate, practitioners are invited to participate in a discussion of definitions and characteristics of Stage I PrUs, Stage II PrUs, and DTI before the start of the conference. Visit for more information.




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