Departments: Guest Editorial
Beginning with the inaugural conference in 1989, the National Pressure Ulcer Advisory Panel (NPUAP) has addressed the importance of terminology and its clarification. The roots of the NPUAP staging classification system were presented in 1989 for a consensus agreement prior to a call for validation research.1 In keeping with its historical emphasis, the NPUAP held a session on “Untangling the Terminology: Unavoidable Pressure Injuries, Terminal Ulcers & Skin Failure” at its recent 2017 conference.2 The literature has featured 4 terms to describe unavoidable skin changes, including terminal pressure injuries: Kennedy Terminal Ulcer,3 Trombley-Brennan Terminal Tissue Injury,4,5 Skin Changes at Life’s End,6,7 and Skin Failure .8–10
The presenters were Karen Kennedy-Evans, RN, FNP, APRN-BC (Kennedy Terminal Ulcer); R. Gary Sibbald, MD, DSc (Hons), MEd, BSc, FRCPC (Med)(Derm), FAAD, MAPWCA (Skin Changes at Life’s End); Mary Brennan, MBA, RN, CWON (Trombley-Brennan Terminal Tissue Injury); Diane Langemo, PhD, RN, FAAN (Skin Failure); and Jeffrey Levine, MD, AGSF, CMD, CWSP (Skin Failure). Stella Mandl, BSN, BSW, RN, PHN, the deputy division director from the Centers for Medicare & Medicaid Services (CMS), provided the CMS’s perspective. Dr Levine (NPUAP board member) chaired this session and has provided a commentary with his continuing thoughts on skin failure on page 200 of this issue. The session moderator, Elizabeth A. Ayello, PhD, RN, ACNS-BC, CWON, ETN, MAPWCA, FAAN, was charged with identifying the commonalities and differences of these 4 concepts as presented by the faculty. See Association News on page 204 for more info on this session.
Uniformity and clarification of key taxonomies and definitions are vital for several reasons. A unified conceptual framework facilitates keyword and literature searches and evaluation of published concepts, along with future evidence-based scientific studies. Consistency of terminology is important for communication among the interprofessional team and constituents in various healthcare settings. Standardization of terms may assist regulatory bodies, including CMS, to locate appropriate evidence-based research for decision-making.
We applaud the NPUAP’s efforts to codify and unify overlapping terms and to begin dialogue about this complex issue. This panel presentation was not designed as a consensus session; however, it is an important step in raising the awareness of skin and wound care professionals and other stakeholders about the need to clarify the terminology.
Wound care professionals are in the best position to recognize and educate constituents about the clinical evidence that some pressure injuries are unavoidable.11–14 This does not mitigate the importance of pressure injuries as a quality indicator, but rather underscores the need to educate the 5 P’s (patients and their circle of caregivers, healthcare professionals, providers, policy makers, and politicians) that when pressure injuries are unavoidable it is not the fault of the healthcare team. There are certain medical conditions that contribute to pressure injuries despite implementation of accepted standards of care.
In summary, we need to improve pressure injury care for the avoidable and especially the unavoidable pressure injuries, even if healing is not the primary goal. Improved terminology can serve as the catalyst for research and improved patient outcomes.
1. Wittkowski JA. Pressure ulcers prevalence, cost and risk assessment consensus development conference statement. Decubitus 1989;2(2):24–9.
2. NPUAP Conference Brochure. March 10-11, 2017, New Orleans, Louisiana. http://www.npuap.org
/wp-content/uploads/2015/07/2017-Biennial-Conference-Reg-Brochure.pdf. Last accessed March 20, 2017.
3. Kennedy KL. The prevalence of pressure ulcers in an intermediate care facility. Decubitus 1989;2(2):44–7.
4. Sibbald RG, Krasner DL, Lutz JB, et al. Skin Changes at Life’s End (SCALE): a preliminary consensus statement. World Council Enterostomal Ther J 2008;28(4):15–22.
5. Sibbald RG, Krasner DL, Lutz J. SCALE: Skin Changes at Life’s End: final consensus statement: October 1, 2009. Adv Skin Wound Care 2010;23:225–36.
6. Brennan MB, Trombley K. Kennedy Terminal Ulcers—a palliative care unit’s experience over a 12-month period of time. World Council Enterostomal Ther J 2010;30(3):20–2.
7. Trombley K, Brennan MR, Thomas L, Kline M. Prelude to death or practice failure? Trombley-Brennan Terminal Tissue Injuries. Am J Hosp Palliat Care 2012;29:541–5.
8. Langemo DK, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care 2006;19:206–11.
9. Levine JM. Skin Failure: an emerging concept. J Am Med Dir Assoc 2016;17:666–9.
10. Levine JM. Unavoidable pressure injuries, terminal ulceration and skin failure; in search of a unifying classification system. Adv Skin Wound Care 2017;30:200–2.
11. Centers for Medicare & Medicaid Services. Guidance to surveyors in long term care. Tag F314. Pressure Ulcers. http://www.cms.gov
/Regulations-and-Guidance/Guidance/Transmittals/downloads/R5SOM.pdf. Last accessed March 20, 2017.
13. Black JM, Edsberg LE, Baharestani MM, et al. Pressure ulcers: avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound Manage 2011;57(2):24–37.
14. Wound Ostomy and Continence Nurses Society. WOCN Society Position Paper: Avoidable Versus Unavoidable Pressure Ulcers (Injuries). Mt Laurel, NJ: Wound Ostomy and Continence Nurses Society; 2017.