The Facts about Reverse Staging in 2000
The
NPUAP Position Statement
What is Staging? Staging is an assessment
system that classifies pressure ulcers based
on anatomic depth of soft tissue damage.1-2 This assessment system only describes the
anatomic status of the ulcer at time of assessment.
Staging of pressure ulcers can only occur
after necrotic tissue has been removed allowing
complete visualization of the ulcer bed.
Pressure ulcer staging is only appropriate
for defining the maximum anatomic depth of
tissue damage.
What is Reverse Staging? In 1989, due to
a lack of research validated tools to measure
pressure ulcer healing, clinicians resorted
to using pressure ulcer staging systems in
reverse order to describe improvement in
an ulcer.
Why not Reverse Stage? Pressure ulcers heal
to progressively more shallow depth, they
do not replace lost muscle, subcutaneous
fat, or dermis before they re-epithelialize.3
Instead, the ulcer is filled with granulation
(scar) tissue composed primarily of endothelial
cells, fibroblasts, collagen and extracellular
matrix. A Stage IV pressure ulcer cannot
become a Stage III, Stage II, and/or subsequently
Stage I. When a Stage IV ulcer has healed
it should be classified as a healed Stage
IV pressure ulcer not a Stage 0 pressure
ulcer. Therefore, reverse staging does not
accurately characterize what is physiologically
occurring in the ulcer. The progress of a
healing pressure ulcer can only be documented
using ulcer characteristics or by improvement
in wound characteristics using a validated
pressure ulcer healing tool.3
How Should You Document a Healing Pressure
Ulcer? The NPUAP does recognize that federal
regulations require long term care facilities
to reverse stage at the present time; however,
long term care facilities are encouraged
to also document in the medical record appropriate
healing using either descriptive characteristics
of the wound (i.e., depth, width, presence
of granulation tissue) or using a validated
pressure ulcer healing tool. If a pressure
ulcer re-opens in the same anatomical site,
the ulcer resumes the previous staging diagnosis
(i.e once a Stage IV always a Stage IV).
What is the NPUAP Doing to Replace Reverse
Staging? Since 1996, the NPUAP has developed
and validated the Pressure Ulcer Scale for
Healing tool (PUSH Tool).4 This tool documents
pressure ulcer healing (see next page for
a full description of PUSH Tool). Presently,
this tool is being pilot tested for adoption
by the U.S. Health Care Financing Administration
MDS Post Acute Care system.
References
1. Maklebust J. Policy implications of using
reverse staging to monitor pressure ulcer
status. Adv Wound Care 1997;10(5)32-35.
2. Maklebust J. Perplexing questions about
pressure ulcers. Decubitus 1992;5(4) 15.
3. Xakellis G, Frantz RA. Pressure ulcer
healing: What is it? What influences it?
How is it measured? Adv Wound Care 1997;10(5)20-26.
4. Thomas DR, Rodeheaver GT, Bartolucci AA.
et al. Pressure ulcer scale for healing:
Derivation and validation of the PUSH tool.
Adv Wound Care 1997;10(5)96-101.
Source: www.npuap.org
