Pressure sore staging challenged
In December 2011, a panel of experts rocked the pressure ulcer world by attacking some of the underpinnings of the current pressure ulcer classification systems (Staging, Grading, Categories). They said that some of the language creates problems from clinical, regulatory, legal and economic perspectives. The advisory panel is proposing the new Superficial Changes & Deep Pressure Ulcer Theory©. Here is one piece of what they asserted:
Current numerical pressure ulcer classification systems (staging, grading, or categories) are problematic and misleading because they imply that pressure ulcers progress through defined stages (from I to IV).
The current numerical pressure ulcer classification systems are intended to describe the anatomic depth of tissue damage. Stage 1 is characterized by non-blanchable erythema of intact skin that may be coupled with alterations in skin temperature and tissue consistency. Stage 2 is a superficial lesion involving the erosion of epidermis with epidermal base or an ulcer with loss of epidermis and a dermal base. Full thickness tissue damage may extend to subcutaneous tissue as in stage 3 pressure ulcers and to deeper supporting structures such as muscle, fascia, joint capsule and bone that are classified as stage 4 pressure ulcers. Evolution of pressure ulcers does not necessarily follow a predictable linear pattern from superficial to deep; from Stage 1 ulcers to Stage 2, then to Stage 3 and finally Stage 4 ulcers.
Deep tissue injury
Accumulating evidence suggests that a number of pressure ulcers (most Stage 3 and 4 ulcers) may initially originate in the deep tissue compartment and progress outward to the dermis and epidermis (inside out theory). Deep tissue injury may not be visible to naked eyes but may take hours to days before any clinical signs are evident. Once observed, deep tissue injury can deteriorate rapidly into deep craters despite stringent and optimal treatment that meets the standard of care. Deep tissue injury has the appearance of a purple or maroon bruise under intact skin that resembles and is often mistaken for a stage 1 pressure ulcer. Donnelly documented that 10% of pressure ulcers were initially diagnosed as stage 1 by visual inspection and evolved to stage 3/4 within days. It is possible that a proportion of the stage 1 ulcers in this study were misclassified and that they were really deep tissue injuries given how quickly these ulcers evolved over time. Other skin lesions with color change may reflect different dermatological diagnoses including; moisture associated dermatitis, fungal or yeast intertrigo or other dermatological conditions.
By eliminating the current numerical classification system and documenting the partial thickness and full thickness depth along with the appropriate physical findings (location, size, base, exudate, and margins), healthcare providers may prevent misleading communication.
Modified with permission from Dr. Diane Krasner, one of the authors of the Shifting the Original Paradigm article published in Advances in Skin and Wound Care December 2011.
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