1	"Caroline E" Caroline E. Fife, MD Associate Professor Department of Anesthesiology University of Texas Health Science Center, Houston Memorial Hermann Center for Wound Healing
2	Pressure Ulcers in the U.S. In 2006 there were 322,946 reported cases of Medicare patients with a pressure ulcer as a secondary diagnosis. It is estimated 2.5 million patients are treated each year in U.S. acute care facilities for pressure ulcers.
3	National focus on PUs… Healthy People 2010 Goal significantly reduce pressure ulcer incidence during this decade. BUT WE ALREADY KNOW IT IS GOING TO FAIL This seems like a simple problem, why can’t we fix it?
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5	Stage I Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones.
6	Is it blanching or non-blanching?
7	Detecting Stage I “Deep tissue injury may be difficult to detect in individuals with dark skin tones.” (NPUAP) “The skin should be assessed for alterations in pain or feeling (note that this requires a responsive patient). “. . . a change of skin color should be noted by knowing the range of skin pigmentation that is normal for your particular patient.” “The correct lighting source is important to accurately perform this assessment. Use natural or halogen light.” “Florescent light should be avoided as it casts a bluish hue to the skin.”
8	Reliability of Stage I pressure Assessment Stage I pressure ulcers are not “ulcers” in the strict definition of the term since there is no break in the epithelium The ability to identify Stage I pressure ulcers is reduced among patients with pigmented skin. “A reliable system to accurately identify Stage I pressure ulcers in individuals with darkly pigmented skin should be developed.” It is not known with what accuracy and reliability Stage I pressure ulcers can be reliably assessed in patients of any ethnicity.
9	What are Stage I “ulcers?” These skin changes are defined as “pressure ulcers” even though they are not “ulcers” in the correct sense of the word. Data confirm that patient skin color, and the need for an interactive effort (blanching) which is subjective and requires training and skill, makes it almost impossible to reliably diagnose them. To date there is no evidence that stage I pressure “ulcers” develop into other pressure ulcers.
10	Stage I vs. DTI: Potential Pitfall “Bruise like” areas which may actually represent deep tissue injury may be mistaken for Stage I pressure ulcers. It seems likely that only highly trained individuals will be able to detect Stage I pressure sores at all, or distinguish them from DTI, particularly in darkly pigmented individuals. Furthermore, the NPUAP has provided guidance for the MDS forms to mark “stage I” for skin changes likely to represent deep tissue injury since no other classification exists.
11	Stage II Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. * This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
12	7 y.o. girl with spina bifida who gets wounds on her knees from crawling without her knee pads
13	NOT Stage II Not supposed to be used to classify skin tears and other superficial injuries. However, this is common practice in skin assessments. Furthermore, in some high risk areas of the body, it may be difficult to differentiate injury due to friction and sheer or pressure from other types if injury. At this time, most hospitals have no alternative system for documenting the presence or severity of these wounds. Likely they will continue to be documented as “Stage II ulcers.”
14	How would you document this? Discoloration of a heel in a child after a cast is removed. Not really a blister (yet). Not a Stage I because it is not “non blanching erythema.” Might be called a II if it turns into a blister since the NPUAP classified blisters as Stage II.
15	Blisters as Stage II NPUAP classifies this closed heel blister as a Stage II. However, as long as the blister is in tact, the full extent of tissue injury in this case cannot be known. This is a serious problem with classifying closed blisters as Stage II.
16	Statistically, what are the risk factors for Stage II “Pressure Ulcers?” Moisture Friction Sheer Incontinence
17	Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. May include undermining and tunneling. The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
18	Stage IV Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.
19	Stage III and IV confusion The old definition of Stage III was an ulcer which did not extend through the fascia, but not all areas have fascia. Anatomical location determines how much soft tissue is present over the bone. The definition of a Stage III is full thickness tissue loss but no “directly palpable” bone. The bone is palpable at the elbow here. Is it a III or a IV? Similar areas are the head and nose.
20	What are the risk factors for Stage III and IV pressure ulcers? Immobility Decreased level of consciousness Decreased sensation Poor nutrition Acute severe illness
21	84 y.o. woman with dementia who developed bilateral ischial sores after a change in mattress
22	Are these wounds caused by the same process?
23	Pressure Ulcer Pathophysiology Tissue near bone experiences the most pressure which dissipates and spreads as superficial layers are approached. Confirmed by seated MRI images of paraplegics. While superficial layers experience the least amount of pressure, they have the largest AREA affected (an upside down triangle).
24	Stage III and IV PUs form from the INSIDE OUT Despite low skin surface pressures, deep tissues have higher pressures which causes the formation of a cavity below the dermis. The epidermis does not show signs of necrosis until LATE.
25	Forming from the Inside Figure 3 shows the sacrum of a patient on admission demonstrating subcutaneous tissue damage when skin changes were not apparent. Figure 4 shows improvement over time. Suggests early intervention might halt progression to the skin, but that once damage has become apparent at the level of the skin, irreversible deep tissue damage has already occurred.
26	Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.
27	Unstageable? The NPUAP definition of a Stage II ulcer says that it is without slough. Therefore, any wound which DOES have slough or necrotic material by definition MUST be a stage III or stage IV. The only reason an ulcer would be called “unstageable” is because one cannot determine whether muscle or bone is involved, but the presence of eschar or slough means that it MUST be a stage III or IV. However, the new present on admission policy does not assign the MC-CM code to “unstagable” ulcers, even though they MUST be either stage III or IV! Furthermore, we simply cannot have a “staging system” in which one of the official stages is “unknown.”
28	When a stage is not a stage
29	The Stages were meant to be used independently of one another “This assessment system only describes the anatomic status of the ulcer at the time of assessment.” (NPUAP) It is based on the anatomic depth of soft tissue damage. There is no implication in the staging system that the stages progress through the numbers. However, THIS MEANS THAT THE SYSTEM DOES NOT MEET THE DEFINITION OF A “STAGING” SYSTEM.
30	Requirements of a Staging System In cancer, stages PROGRESS from one stage to another. Example: carcinoma in situ, invasive cancer, metastatic cancer Staging can be used to PREDICT OUTCOME Staging can be used to DIRECT TREATMENT
31	Do Pressure ulcers “Progress” Are there any data to support the idea that pressure ulcers “Progress” from one stage to another? Tissue (biopsy) data from pressure ulcers is VERY limited (this needs to be corrected). However, to date, the evidence is overwhelming that stage III/IV pressure ulcers form from the inside out and do not progress from stage II ulcers. The reason they might be perceived to have progressed from “stage I” ulcers is that deep tissue injuries were MISCLASSIFIED as stage I ulcers.
32	Stage IV Pressure ulcers do not progress but evolve
33	Stage IV Pressure ulcers do not progress but evolve
34	A Heel Pressure Sore Evolves
35	A Heel Pressure Sore Evolves
36	Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
37	Silent stage IV lesion… DTI-Deep Tissue Injury Purple non-blanchable area of intact skin Demarcation in 24-48 hours Deep underlying tissue destruction Damage has occurred at bone-tissue interface
38	So what is DTI in clinical practice Since Stage III and IV ulcers are forming from the inside out, what do they look like as they form? It seems likely that Stage III and IV pressure ulcers are examples of deep tissue injury after their evolution has completed.
39	Are All Pressure Ulcers the Result of Deep Tissue Injury? Dan R. Berlowitz, MD, MPH; and David M. Brienza, PhD A growing body of evidence suggests that all stage III and IV pressure ulcers are the result of deep tissue injury.
40	What does Staging mean in Pressure Ulcers? In cancer staging, the stage of the cancer either predicts outcome or directs treatment. Stage III and IV pressure ulcers have a statistically equal likelihood of requiring surgical intervention and are thus not different from each other. Stage II pressure ulcers have a high likelihood of healing. Stage I pressure ulcers may resolve or result in deep ulcerations.
41	Healing in Relation to Stage
42	Treatment of Stage II
43	Healing of Pressure Sores Stage III and IV often will heal with deep tracts. 39.9% healing stage III in nursing home, 45.2% in hospital 34.1% healing for stage IV in nursing home, 30.6% in hospital There is no statistical difference in the surgical closure rate between Stage III and Stage IV ulcers.
44	No reverse staging
45	Federal Tag 314 and Reverse Staging The Resident Assessment Instrument (RAI) includes directions to describe the healing ulcer. “Although CMS understands that pressure ulcers do not heal from a Stage IV to a Stage III (eg, reverse staging) until the Minimum Data Set (MDS) is changed, reverse staging ulcer should continue.”
46	Position Statement on Reverse Staging NPUAP recommends the following: 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. 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.
47	How would you reverse stage these?
48	How do you stage a healed ulcer? CMS requires these to be classified as Stage I.
49	Pressure vs. Non-pressure “The treatment of pressure ulcers is predicated on the fact that clinical staff can properly assess ulcer characteristics.” (1) differentiate the type of ulcer (pressure versus non-pressure-related ulcer . . . . . . The LTCF should have staff members who are proficient in their ability to delineate between a pressure ulcer and the more common chronic ulcers . . .arterial insufficiency ulcers.
50	What are these?
51	Is this a pressure sore? “The LTCF should have staff members who are proficient in their ability to delineate between a pressure ulcer and. . .arterial insufficiency ulcers.”
52	Summary The NPUAP staging system refers only to the depth of tissue apparent base of the wound at the time it is assessed. The numeric nature of the staging system does not imply that ulcers “progress” through the stages. Stage I pressure ulcers are extremely difficult correctly identify regardless of skin type and may be mistaken for deep tissue injury. Stage II pressure ulcers are more likely related to friction and sheer and are often confused with skin tears, tape burns and other types of trauma. There is no evidence that Stage III and IV pressure ulcers are preceded by earlier stage pressure ulcers. Stage III and IV pressure ulcers seem to form from a similar pathological process (deep tissue necrosis) and may be hard to distinguish from each other depending on the anatomical location.
53	Summary Deep tissue injury may be the early presentation of Stage III and IV pressure ulcers. Unstageable pressure ulcers will be staged as Stage III or IV after debridement. Arterial ulcerations are often confused with pressure ulcerations and pressure can be the inciting event for arterial ulcers.
54	Summary The current NPUAP staging system does not meet the critera for a staging system since stage I and DTI can be confused with each other, stage III and IV are likely the same thing (with the same outcome, ie, surgery) and stage II ulcers do not become deeper ulcers.
55	Data collection disaster As long as IN TACT skin is classified as an ULCER in any way, there will continue to be confusion. Any system which uses letters or numbers will imply PROGRESSION.
56	Superficial vs. Deep
57	The real challenge The real challenge will be finding a way to describe pressure ulcers as they are forming, BEFORE the skin breaks down. In tact skin changes should not be called ulcers. What will we call them?