I have a drawer in my desk into which I throw things that are not of much practical value but do not merit disposal. As the years go by this drawer has gotten filled with clutter. The same thing seems to be happening to the pressure ulcer staging system.

Jeff Levine, Jeffrey Levine MD geriatrician physician artist photographerIn 1989 the National Pressure Ulcer Advisory Panel (NPUAP) did the healthcare community a great service by formulating a standardized 4 stage system for classifying pressure ulcers. This was a significant contribution because previously there were several classification schemes with no universally accepted set of criteria. Since the initial NPUAP system was implemented, limitations became apparent and additional classifications of “unstageable” and “deep tissue injury” were added.

These modifications were useful, particularly as the importance of pressure ulcers grew from a regulatory, coding, and reimbursement standpoint. NPUAP recommendations have led the way toward recognizing the complexity of this disease and clarifying the natural history of this costly and often preventable disease.

NPUAP has recently added new terminology to the staging scheme, which in my opinion is a step in the wrong direction. They have recommended the term “category” in addition to “stage,” and modified their website accordingly. The rationale is that the term “stage” infers an orderly progression of wound evolution which may not reflect actual pathophysiology.

Certainly this is a good teaching point and definitely worth a footnote, but does this semantic issue merit revision of teaching materials and documentation forms in healthcare facilities across the country? NPUAP is considered an authoritative source, and they must be aware of the revisions that will ensue when terminology is modified.

There is a huge need for pressure ulcer education across all disciplines.  Patients require timely and accurate skin assessment, and documentation needs to be consistent.  Nurses, administrators, physicians and surgeons of all specialties need to be aware of proper staging criteria.  It is more important to recognize the presence of an ulcer and describe it correctly than to quibble whether this is a “stage” or a “category.”  As someone involved with wound care education I can say that the task is challenging, and unnecessary terminology will divert discussion from more salient issues.

Like my desk drawer, the staging system is getting filled with clutter. There are many important regulatory, reimbursement, treatment, and risk-management issues concerning pressure ulcers, and efforts of NPUAP can be better directed to more practical and useful matters than redefining currently accepted and perfectly reasonable terminology. So let’s get back to basics and apply adages such as “Keep it simple,” and “If it ain’t broke don’t fix it.” Cluttering up the staging system risks unnecessary confusion where clarity, consistency, and ease of use should be  the goal.

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Related posts:

Pressure Ulcer Staging: Should I get my Raincoat?
New Pocket guide to Pressure Ulcers.
How Much do Medical Residents Know about Pressure Ulcers?
Straight Talk on Reverse Staging of Pressure Ulcers

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