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This letter is being sent to you to clarify the reporting mandates established by Senate Bill 1301, Chapter 647, Statutes of 2007 with regard to reporting of pressure ulcers (Section 1279.1 (b)(4)(F) of the Health and Safety Code). Per statute, hospitals are mandated to report all Stage 3 and 4 pressure ulcers acquired after admission to the health facility excluding progressive ulcers from Stage 2 to Stage 3 if Stage 2 ulcer was recognized upon admission. The California Department of Public Health, Licensing and Certification will be conducting investigations of complaints and reports of adverse events related to pressure ulcers pursuant to Section 1279.1 of the Health & Safety Code.

We are recommending review of the guidelines established by the nationally recognized authority on staging of pressure ulcers, the National Pressure Ulcer Advisory Panel (NPUAP), last modified in February 2007 with respect to determining whether to report a pressure ulcer and in diagnosing pressure ulcers for purposes of reporting as mandated by SB 1301.

According to the February 2007 NPUAP guidelines, an unstageable ulcer is defined as a 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. It is further described as: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.

Stage 2 ulcers are defined as a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Stage 2 ulcers may also present as an intact or open/ruptured serum-filled blister.

Both Stage 3 and Stage 4 ulcers are full thickness ulcers. Unstageable ulcers are either Stage 3 or Stage 4 ulcers that cannot be definitively placed in either category because of the eschar that is obstructing the clear observation of the wound. Unstageable ulcers are not stage 2 or stage 1. Thus all unstageable ulcers are reportable by hospitals as adverse events if acquired after admission, excluding progression from Stage 2 to Stage 3 if Stage 2 was recognized and noted upon admission. 

The following websites provide the most up-to-date information and history of staging:

Medscape

http://www.medscape.com/viewarticle/556483_2 

Current staging:

The National Pressure Ulcer Advisory Panel (NPUAP)

Current staging: NPUAP educational and clinical resources (PDF)  http://www.npuap.org/pr2.htm

Sincerely,

Original Signed by Kathleen Billingsley, R.N.

Kathleen Billingsley, R.N.
Deputy Director