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
1Maklebust J. Policy implications of using reverse staging to monitor pressure ulcer status. Adv Wound Care 1997;10(5)32-35.
2Maklebust J. Perplexing questions about pressure ulcers. Decubitus 1992;5(4) 15.
3Xakellis G, Frantz RA. Pressure ulcer healing: What is it? What influences it? How is it measured? Adv Wound Care 1997;10(5)20-26.
4Thomas 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.