NPUAP Statement on Reverse Staging of Pressure Ulcers

In 1975, Darrell Shea, an orthopaedic surgeon at the University of Miami, published a landmark paper describing a method of classifying pressure ulcers. Each pressure ulcer stage was defined by the anatomic depth of soft tissue damage. Over the intervening years, Shea's original work has been modified. In the current literature, the National Pressure Ulcer Advisory Panel (NPUAP) staging system from the 1989 Consensus Development Conference is cited more frequently than others. This staging system has been adopted by the AHCPR Pressure Ulcer Guideline Panels and is published in both sets of Pressure Ulcer Clinical Practice Guidelines (1992, 1994). A new Stage I definition was adopted by the NPUAP in 1998 that is more inclusive of the range of skin pigmentation. For more information about the development of this new revised Stage I definition, please see the article in th September 1997 issue of Advances in Wound Care  The NPUAP Pressure Ulcer Staging System is now described as follows:

Stage I: A Stage I pressure ulcer is an observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.

• Stage II: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.
• Stage III: Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
• Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers.

Pressure ulcer staging is only appropriate for defining the maximum depth of tissue involvement. Unfortunately, pressure ulcer staging definitions appear to have erroneously been used in reverse order, for example to describe improvement in an ulcer.

Using pressure ulcer staging systems to describe healing must assume that full thickness pressure ulcers heal by replacing the same structural layers of body tissue that were lost. Clinical studies indicate that as Stage IV pressure ulcers heal to progressively more shallow depth, they do not replace lost muscle, subcutaneous fat, and dermis before they re-epithelialize. Instead, the defect is filled with granulation tissue composed primarily of endothelial cells, fibroblasts, collagen, and an extracellular matrix. Therefore, Stage IV pressure ulcers cannot become Stage III, Stage II, and/or subsequently Stage I ulcers as defined by anatomical and structural layers of epidermis, dermis, subcutaneous fat, muscle, and bone. The progress of a healing Stage IV pressure ulcer can only be appropriately documented by improvement in wound characteristics (size, depth, amount of necrotic tissue, amount of exudate, etc.).

The use of reverse staging to indicate healing is inappropriate and can lead to problems such as, but not limited to:

1. inappropriate wound care that is directed by protocols solely based on the stage of the pressure ulcer;
2. third-party payers using pressure ulcer stage status as a primary reimbursement criterion;
3. extended care facilities being paid lower fees for patients with healing Stage III and IV pressure ulcers that are inappropriately classified during healing assessment as Stage II or I ulcers;
4. regulatory bodies and surveyors determining fines for licensed health care facilities based on the number of certain stage pressure ulcers;
5. nursing home personnel being inappropriately rewarded for documenting that pressure ulcers are progressing to a "lesser" stage;
6. Medicare beneficiaries being denied acute or skilled care after Stage IV ulcers are "backstaged" to Stage II ulcers;
7. medical policy for Medicare beneficiaries denying patients particular pressure relieving or reducing mattresses or beds when an ulcer "heals" from a Stage III to a Stage II ulcer.

It is not logical that reimbursement agencies require health care practitioners to periodically "restage" pressure ulcers to show improvement. It is incorrect to indicate that pressure ulcers heal by moving from Stage IV to Stage I. Therefore, the NPUAP recommends the following:

• Reverse staging should never be used to describe the healing of a pressure ulcer.
• Pressure ulcer staging systems should only be used to document the maximum anatomic depth of tissue involved in the ulcer after necrotic tissue has been removed.
• Healing of pressure ulcers should be documented by objective parameters such as: size, depth, amount of necrotic tissue, amount of exudate, presence of granulation tissue, etc.
• Health Care Financing Administration should work with NPUAP and other interested health care organizations to rectify procedures, policies and reimbursement criteria that encourage or require reverse staging as a means to assess pressure ulcer healing.

Taken from the NPUAP Report, a newsletter from the National Pressure Ulcer Advisory Panel, Vol. 4, No. 2, September, 1995

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