robeastwood-agency
commented
3 years ago Analysis of available terminologies
LOINC
| LOINC contains on the an answer list in this space. See below, this represents the answers to the question of what is the pressure injury staging (LL5203-6): | Answer | Answer ID |
|---|---|---|
| Stage 1 Pressure Injury: Non-blanchable erythema of intact skin | LA29668-3 | |
| Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis | LA29669-1 | |
| Stage 3 Pressure Injury: Full-thickness skin loss | LA29670-9 | |
| Stage 4 Pressure Injury: Full-thickness skin and tissue loss | LA29671-7 | |
| Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss | LA29672-5 | |
| Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration | LA29673-3 |
Analysis:
- the concepts in the answer list are equivalent to the PPPIA promoted concepts
Conclusion: Notwithstanding that the concepts are analogous to the PPPIA promoted concepts, SNOMED-CT remains as the preference in Australia to represent clinical concepts. Therefore, these LOINC codes are not recommended for use in this value set. No requirement nor benefit is identified at this time for a concept map with these LOINC codes. However, should a future need be raised, it would be straight forwards to add one/more later.
Wound Grade Concepts code system
Wound Grade Concepts code system is implemented in the HL7 International Wound Assessment FHIR Implementation Guide, with the PI-specific constrained National Pressure Ulcer Advisory Panel Pressure Injury Classification System value set.
The implementation guide notes that this use of concepts is temporary and will be replaced by 'Solor Extension' SNOMED CT terms when available.
Analysis:
- the concepts in the National Pressure Ulcer Advisory Panel Pressure Injury Classification System value set are equivalent to the PPPIA promoted concepts
Conclusion: There is no identified value in adopting or mapping to this terminology in an Australian context.
The International Classification of Diseases (ICD)
The ICD is hosted by the World Health Organization (WHO), used worldwide, and is promoted as the "global standard for diagnostic health information". The WHO have released the ICD-11 version as of Jan 2021.
The following codes are available within ICD-10 (International):
| Code | Description | Suitability |
|---|---|---|
| L89.0 | Stage I decubitus ulcer and pressure area | Not fully equivalent to the preferred concept of pressure injury |
| L89.1 | Stage II decubitus ulcer | Not fully equivalent to the preferred concept of pressure injury |
| L89.2 | Stage III decubitus ulcer | Not fully equivalent to the preferred concept of pressure injury |
| L89.3 | Stage IV decubitus ulcer | Not fully equivalent to the preferred concept of pressure injury |
| L89.9 | Decubitus ulcer and pressure area, unspecified | Not fully equivalent to the preferred concept of pressure injury |
The following codes are available within ICD-10-AM (Australian Modification), sourced from the Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline The International Guideline.
| Code | Description | Suitability |
|---|---|---|
| L89.0 | Pressure injury, stage I | Equivalent and suitable for the preferred concept of pressure injury |
| L89.1 | Pressure injury, stage II | Equivalent and suitable for the preferred concept of pressure injury |
| L89.2 | Pressure injury, stage III | Equivalent and suitable for the preferred concept of pressure injury |
| L89.3 | Pressure injury, stage IV | Equivalent and suitable for the preferred concept of pressure injury |
| L89.4 | Pressure injury, unstageable, so stated | Equivalent and suitable for the preferred concept of pressure injury |
| L89.5 | Suspected deep tissue injury, depth unknown, so stated | Equivalent and suitable for the preferred concept of pressure injury |
The following codes are available within ICD-11:
| Code | Description | Inclusion |
|---|---|---|
| EH90.0 | Pressure ulceration grade 1 | pressure injury stage 1 |
| EH90.1 | Pressure ulceration grade 2 | pressure injury stage 2 |
| EH90.2 | Pressure ulceration grade 3 | pressure injury stage 3 |
| EH90.3 | Pressure ulceration grade 4 | pressure injury stage 4 |
| EH90.4 | Suspected deep pressure-induced tissue damage, depth unknown | |
| EH90.5 | Pressure ulceration, ungradable | pressure injury with depth unknown |
| EH90.Z | Pressure ulcer of unspecified grade | pressure injury |
Analysis:
- ICD-10-AM coding is used throughout Australia to classify episodes of admitted patient care across hospital services. ICD-11 has not yet been implemented.
- In the 2020 ADHA presentation "Terminologies and classifications: SNOMED CT-AU and ICD-10-AM use in Australia", ICD is described as a classification system, rather than a clinical terminology (such as SNOMED-CT). As such it supports the specific use case of secondary analysis of data, such as statistical aggregating and reporting (rather than supporting direct clinical care as does SNOMED-CT).
- its stated scope is specifically for classifying episodes of admitted patient care - this is much more narrow that the intended application of the PICS, where it would be in use in residential aged care facilities and even home-based care
Conclusion: given its scope, ICD (in any flavour) is not recommended for use as the basis of the PICS. However, given the widespread use in Australian hospital reporting, it is recommended to develop concept maps to the ICD-10-AM equivalents.
SNOMED CT
SNOMED-CT is the most comprehensive multilingual health terminology in the world, with the primary purpose of directly supporting clinical data entry in a patient record. It is the preferred national solution for clinical terminology, endorsed by the Australian Health Ministers’ Advisory Council (AHMAC).
| The following codes are currently available (as at October 2021) in SNOMED CT to support grading of pressure ulcers: | Code | Preferred term | Suitability |
|---|---|---|---|
| 421076008 | Pressure ulcer stage 1 (disorder) | Not fully equivalent to the preferred concept of pressure injury | |
| 420324007 | Pressure ulcer stage 2 (disorder) | Not fully equivalent to the preferred concept of pressure injury | |
| 421927004 | Pressure ulcer stage 3 (disorder) | Not fully equivalent to the preferred concept of pressure injury | |
| 420597008 | Pressure ulcer stage 4 (disorder) | Not fully equivalent to the preferred concept of pressure injury | |
| 421594008 | Nonstageable pressure ulcer (disorder) | Not fully equivalent to the preferred concept of pressure injury | |
| 723071003 | Pressure injury of deep tissue (disorder) | Not fully equivalent to the preferred concept of pressure injury |
These above concepts that are not fully equivalent will be replaced with Pressure Injury concepts for the January 2022 release. The SNOMED CT concepts for Pressure Injury will provide the concepts for mapping to the six Pan Pacific Pressure Injury Alliance (PPPIA) Pressure Injury concepts.
Analysis:
- in widespread usage across the Australian healthcare system
- there is no known reference set supporting these concepts
- SNOMED-CT will provide support (in Jan 2022) for the above requirements, to directly support the stated usage scenarios, these are suitable for adoption.
Conclusion: clear front-runner to base the PICS terminology on SNOMED-CT. If and when concept maps are needed, SNOMED-CT would be the front-runner to be used as the ConceptMap source.
(updated following review comments below)
dtr-agency
StephenC-ADHA
LB-Agency
Prerequisites
The feature
Value set(s) to representing pressure injury classification is needed to support exchange of wound management information (see GitHub #119) between healthcare providers, and between healthcare providers and the My Health Record system.
The values are to cover the concepts in the Pressure Injury Classification System (PICS), and are expected to be drawn from SNOMED CT as the preferred national solution for clinical terminology.
The value set(s) will be referenced directly in FHIR and CDA specifications that support the exchange of wound management information in forthcoming aged care specifications, and is intended to be considered for inclusion in other continuity of care specifications such as Discharge Summary, Referral or care planning.
The usage scenario is the electronic exchange of current, valid, pressure injury information documented as part of an assessment by a healthcare provider.
Concept definitions
A pressure injury (PI), is a type of wound that has localised damage to the skin and/or underlying tissue as a result of pressure or pressure in combination with shear, usually occurring over a bony prominence but may also be related to a medical device or other objects[^1].
[^1]: European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 3rd edition 2019
What it actually enables people to do
Provide a publicly accessible FHIR representation of the internationally agreed set of values in a governed manner that is reusable in an Australian context.
How awesome would it be?
Pretty awesome - a small but significant step into the representation of broader concepts, to support exchange of wound management clinical concepts.
The Australian Commission on Safety and Quality in Health Care have declared PI as a leading hospital acquired complication and is specifically called out in the National Safety and Quality Health Service (NSQHS) Standard: Comprehensive Care Standard, 2020. The 3 related actions require that healthcare organisations establish systems and processes for pressure injury prevention and wound management that are consistent with best-practice guidelines. This includes the documentation of the level of tissue loss using an agreed international classification system.
An international collaboration between the European Pressure Ulcer Advisory Panel (EPUAP), the US National Pressure Injury Advisory Panel (NPIAP) and the Pan Pacific Pressure Injury Alliance (PPPIA) resulted in the publication of the Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline The International Guideline (3rd edition 2019), which includes the recommended PI classification system.
Additional context
Some materials commenting on clinical terms for interest - not directly related to the value set definition.