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Pressure ulcers: coping with the "reverse staging" dilemma.

An Interview with Cathy Thomas Hess, RN, BSN, CETN

Since the 1989 Consensus Development Conference, most clinicians have looked to the National Pressure Ulcer Advisory Panel (NPUAP) staging system to document the severity of skin breakdown, determine the most appropriate treatment and ensure reimbursement for treatment. The staging system (stage I through IV, with IV being the most severe) was adopted by the AHCPR Pressure Ulcer Guideline Panels and published in both sets (1992 and 1994) of Pressure Ulcer Clinical Practice Guidelines.

What has not yet been developed or published, however, is a standardized tool to describe pressure ulcer healing. Out of necessity, both LTC providers and HCFA have relied upon the use of reverse staging (stage IV, to III, to II, etc.) to describe the healing process for both therapeutic and reimbursement purposes. Sounds logical, right?

Wrong! says NPUAP, along with a number of wound and skin care experts. In a recent position paper, NPUAP states that reverse staging is based on erroneous assumptions about the healing process, and goes on to caution that the use of reverse staging has a number of negative clinical, regulatory and reimbursement consequences.

As a result, NPUAP is calling for HCFA to work with the Panel and other related organizations to "rectify procedures, policies and reimbursement criteria that encourage or require reverse staging as a means to assess pressure ulcer healing." To help sort all this out, Nursing Homes Managing Editor Laura Bruck asked for clarification of these issues from Cathy Thomas Hess, RN, BSN, CETN, President of Wound Care Strategies, Inc., a Harrisburg, PA-based clinical consulting corporation which assists providers and payers in developing, implementing, marketing and supporting wound care systems.

Bruck: Why is it erroneous to use reverse staging to describe a healing pressure ulcer?

Hess: The staging system developed by NPUAP is an anatomical description of tissue destruction or wound depth designed for use only with pressure ulcers or wounds created by pressure. While it is essential to have this information, it is also very important to document other wound characteristics such as size, drainage and granulation tissue, to make the wound assessment complete.

Reverse staging is based on the misconception that a stage IV pressure ulcer, for example, becomes a stage III, then a stage II wound as it heals. But as wound healing progresses, original tissue types (skin, subcutaneous tissue, muscle) are replaced with granulation tissue and new epithelium.

So, the philosophy of healing is such that bone and muscle destroyed by a stage IV pressure ulcer are not replaced as the pressure ulcer heals; rather, the area is filled with a new kind of tissue. Therefore, it is inaccurate to describe a healing stage IV ulcer as a stage III, stage II, and so on.

Bruck: How did the practice of reverse staging come about?

Hess: The answer is really two-fold. From a clinical standpoint, reverse staging came about as an attempt to find a tool to describe pressure ulcer healing - a tool that simply is not out there.

There have been attempts to define such a tool, such as the red-yellow-black method, proposed by a pharmaceutical company, in which assessments and treatments were based on wound color - an easy-to-follow but overly simplistic approach. Another attempt, the practice of determining the percentage of granulation or reepithelialization throughout the healing process, is highly subjective and has room for quite a bit of error. Reverse staging is simply another attempt to define such a tool, and while we now know this isn't the best way to go, credit should at least be given for making this kind of effort in the absence of research to develop a sound system.

From a reimbursement standpoint, the use of reverse or downstaging in long-term care stems from wound care coverage criteria - the providers' use of the resident assessment instrument (RAI) for clinical protocol. The fiscal intermediaries also use the RAI for coverage criteria. In other words, by using the MDS as the data gathering tool that may drive Medicare and Medicaid payment, as well as quality indicators, providers are essentially required to use reverse staging for reimbursement purposes.

This is not to say that HCFA is to blame for the problem. It is simply that no one has taken the time or resources to conduct the research needed to come up with a reliable, clinically accurate system.

Bruck: What kinds of problems can result from the use of reverse staging?

Hess: From a clinical standpoint, it can result in less than optimal wound care. The topical treatment choices for any type of wound should not be based solely on stage. It is important to include other wound characteristics as well so your formulary is not reflective only of the wound stage or degree of thickness. If, for example, all I know about a pressure ulcer is the stage, and I base my treatment decision to use an alginate on that information alone, I could possibly dessicate the wound bed by dehydrating it if there is no drainage.

Bruck: And the problems from a reimbursement standpoint?

Hess: First, it is important to understand that Medicare Part A reimbursement is restricted to pressure ulcers documented as stage III and above. The most obvious case is the patient with a stage IV pressure ulcer on the turning surface who is placed on a specialty bed to reduce pressure. When the wound fills in and objectively appears to be a stage II, that patient no longer qualifies for that bed. If you, as the provider, don't downstage, and the fiscal intermediary sees from your documentation of size, depth and drainage, that the wound is something less than a stage III, it is conceivable that you could end up owing the payer.

Bruck: What is the wound care clinician's perspective on all this?

Hess: The perspective is basically one of frustration. There probably isn't a great deal of difference between the four-part staging systems developed by HCFA and NPUAP, other than the NPUAP system being more clinically descriptive. Our frustration, as clinicians in long-term care, has more to do with diagnostic issues.

A patient diagnosed with stage II cervical cancer will always have stage II as a diagnosis, whether the cancer is active or in remission. What perplexes us as clinicians is why, once a patient is diagnosed with a stage IV pressure ulcer, that diagnosis should not remain a stage IV pressure ulcer. We know it can take anywhere from 24 days to two years for wounds to actually heal. It is very frustrating to have to take a patient, such as the one described earlier, off a specialty bed just because the appearance of the wound is different this week than it was last week. We know that patient is still at very high risk for breakdown: the wound may look different, but it is still a stage IV, and the same risk factors are still present.

Bruck: What is the appropriate way to describe healing pressure ulcers?

Hess: Clinically, the wound in the above scenario would be most accurately described as a healing stage IV pressure ulcer (which, of course, Medicare won't accept as documentation). While most long-term care providers are, at this point, downstaging, there are some who are adopting a "once a stage IV, always a stage IV" stance.

We work with these providers to develop and customize their wound care policies and procedures based on the AHCPR guidelines, which incorporate the NPUAP staging system. Their weekly documentation includes not only the wound stage, but other descriptive characteristics such as size, depth of granulation tissue, drainage, and even, whenever possible, the wound depth prior to admission. On paper, the weekly documentation indicates the wound stage, followed by the objective description of the wound that week.

These providers are trying to stay on the cutting edge of wound care and are the ones who will probably have the easiest transition when other alternatives to create a workable system are identified.

Bruck: How are these "cutting edge" facilities making sure that their documentation meets all the outcomes-based criteria of third-party payers, particularly managed care?

Hess: What we're looking at with respect to managed care right now is the ability to determine treatment cost for each stage of pressure ulcer. In the meantime, when providers set up the fields in their databases, it's important for them to make sure to include the type of wound care product used, by both generic category and trade name, and the number of days it took for the wound to close or get smaller. We're also looking at the adjunctive therapies used with topical treatment - nutritional supplements, support surfaces, rehab involvement such as electrical stimulation or ultrasound - all of which drive up the cost of wound care.

Bruck: What should LTC wound care nurses and DONs be doing until all this is rectified?

Hess: The most important thing is to make sure your policies and procedures are updated to reflect the AHCPR prevention and treatment guidelines. The information incorporated into the guidelines is invaluable and provides you with a blueprint from which you can customize your program in order to develop a holistic wound care system. My hope is that this is the direction most facilities are taking, because it will put them a step ahead when, hopefully, the changes occur.

There are four points that should be incorporated into any wound healing system, to make it effective: 1) education, to make certain that everyone across the continuum is speaking the same language with respect to wound assessment, intervention and healing, 2) consistent care, through the use of a standardized system, 3) a consistent documentation system for outcomes of each stage, and 4) validation of clinical competency, meaning we shouldn't assume caregivers understand how to assess and treat wounds until we actually see them perform the required tasks.

I also think we need to continue to educate HCFA and the state surveyors - and many organizations are doing so - on the proper use of the staging system. Of course, we still have to remember that the survey process is directed by HCFA's guidelines, and that can create some difficulties during annual state survey time. If, for example, you have a surveyor who believes you should not be downstaging, yet HCFA mandates that you do so, you may end up with deficiencies that are not warranted under the guidelines.

Of course, it is also important to stay abreast of any changes, clinically and with respect to regulations and reimbursement, and to maintain an appropriate education level for all staff involved in wound care. Nurses are expected to assess, treat and document on these wounds, sometimes without the benefit of sufficient wound care training. It is very difficult at times to assess a wound simply by observation. For example, it is very clear when you are seeing bone, but what you think to be muscle could, in fact, be a stage III wound with granulation tissue.

Based on this example, I see the need to establish educational criteria and documentation standards, both of which are paramount for quality care and reimbursement for providers and payers. These are the first steps needed to promote quality through a seamless system.

Bruck: Are you optimistic that that day of change will come?

Hess: Absolutely. I think eventually HCFA's position will change on some level, albeit not as quickly as some of us would like. These things don't happen overnight - it may take a few years.

In the meantime, some of the more forward-thinking LTC providers are headed in the right direction. All the manuals I've developed for my clients during the past year are incorporating the AHCPR guidelines and customizing them for long-term care to create what I like to call a wound care system. By doing this, providers are positioning themselves to make a statement on reverse staging within their manuals. While that, in and of itself, won't change the present state of affairs, what it will do is put those facilities a step ahead of the game when the changes finally do occur.
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Title Annotation:interview with Pres. Cathy Thomas Hess of Wound Care Strategies, Inc.
Author:Bruck, Laura
Publication:Nursing Homes
Article Type:Interview
Date:Sep 1, 1996
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