Devising alternatives to reverse staging rule

Change won't come quickly

In 1995, Diane Krasner, PhD, RN, CETN, CWS, then a doctoral student at the University of Maryland School of Nursing, testified before a panel of the Health Care Financing Administration (HCFA). The panel had asked her to explain why the National Pressure Ulcer Advisory Panel (NPUAP) had begun openly criticizing HCFA's policy of reverse staging in the Minimum Data Set - 2 (MDS-2). Krasner, a member of the NPUAP advisory panel, explained the medical inappropriateness of downstaging wounds as they heal.

The exercise fascinated Krasner from an intellectual standpoint. Then she started considering the practical implication of reverse staging of wounds, and soon found herself at the apex of a campaign to amend Section M of the MDS, which pertains to skin conditions. Krasner currently is a postdoctoral nurse fellow at the Center for Nursing Research of Johns Hopkins University School of Nursing in Baltimore.

The problem with Section M, according to Krasner and other wound care authorities, is that it requires evaluators to use reverse staging (also referred to as downstaging) of wounds as they heal. The practice rankles clinicians for a number of reasons:

· Wounds do not revert physiologically to previous stage descriptions as they heal.

· The pressure ulcer staging system was intended for use in assessing wounds, not for describing improvement of an ulcer.

· HCFA requires the scale, which was formulated for pressure ulcers, to be applied to venous ulcers.

"It became clear that not only HCFA, but the wound care community at large, had been making the mistake of conflating and confusing the assessment of wounding and the assessments of healing," Krasner says. Now, she adds, it's time for a change. Krasner and other wound care professionals are hoping that HCFA's next version of the Minimum Data Set, the MDS-3, will include an updated model for skin assessment.

Krasner and Dot Weir, RN, CETN, regional wound healing manager for Ortho-McNeil Pharmaceutical in Windermere, FL, developed and copyrighted an alternative they titled the Wound Healing Scale, an early version of which was presented to the NPUAP in early 1996.

The scale includes 12 descriptive modifiers for the assessment of healing in acute and chronic wounds. These modifiers are designed to be used in conjunction with assessment of wounding systems, such as the pressure ulcer staging system.

"We saw our scale as a way that HCFA could consider a fix within the data set system they had already developed," Krasner explains. "We also wanted to keep it simple, because I knew that the folks in the field who would be filling out the MDS were, in the best cases, LPNs, and in some cases were nursing assistants."

But development of the MDS-3 is still several years off, according to HCFA, and Krasner notes that making changes to an entrenched data collection system that has been used to compile an enormous database is tricky. "They have a large, ongoing data set with thousands of cases in it. It's not like they can turn it around and change it quickly, and they can't scrap it and start over."

When Krasner and Weir presented a revised version of their Wound Healing Scale to HCFA in August 1997, the agency expressed a great deal of interest. (For a copy of the scale, see p. 53.) The scale has since been sent to experts for comments. Krasner says she is now looking for funding to conduct reliability and validity testing of the tool, and that further revisions are under way. "We hope to field-test the scale sometime this year," she says, adding that she welcomes outside comments on the scale.

Postacute MDS under development

Sue Nonemaker, a technical adviser in HCFA's office of clinical standards and quality in Baltimore, which is responsible for the MDS, says the agency is reviewing a number of proposals for wound evaluation systems or scales that could be used in future versions of the MDS, including Krasner's Wound Healing System and an initiative from the NPUAP called the Pressure Ulcer Scale for Healing (PUSH) tool. "We're talking with both groups, but we've made absolutely no decisions, and it's premature to speculate on what might happen," she says.

Nonemaker adds that the MDS-3 should be developed over the next two to three years, and that an MDS specifically for postacute care is currently in the works. "It's hard for me to say whether we'd be able to put something [regarding skin evaluation] into [the post-acute care MDS] or not, because we're involved in field-testing that right now. It depends on where things stand in terms of research and substantiation of these scales," she says.

The PUSH tool is based in part on a model of healing in which surface area, exudate amount, and surface appearance figure prominently. The final instrument, says the PUSH task force, "meets the requirement of simplicity, validity, and sensitivity to change. By measuring only three variables, the instrument can be used to obtain an ulcer score. Both the magnitude and direction of this score can be used to describe ulcer status."1

Wound Care will examine the PUSH tool in greater depth in an upcoming issue.


1. Thomas D, Rodeheaver GT, Bartolucci AA, et al. Pressure ulcer scale for healing: Derivation and validation of the PUSH tool. Advances in Wound Care 1997; 10:96-101.