Development of Granulation Tissue in Stage 2 Pressure Ulcers: The Evidence

Background: In June 2016 the Wound Ostomy Continence Nurses (WOCN) Society and the Canadian Association for Enterostomal Therapy (CAET) held a joint conference in Montreal Canada.  The National Pressure Ulcer Advisory Panel’s (NPUAP) revised staging system was presented at this conference.  Stage 2 continued to be defined as a partial thickness loss of skin with exposed dermis.  But now included in this revised definition is the statement that granulation tissue is not present.  Hence, according to the NPUAP, if granulation tissue is present then this pressure ulcer is to be categorized as stage 3.

Purpose: The purpose of this presentation is to clarify an error that exists in the NPUAP’s revised definition of a stage 2 pressure ulcer.  Stage 2 pressure ulcers do indeed form granulation tissue.  

Methods: A literature search produced numerous scientific publications and presentations to support this fact.  

Results: At SAWC Fall 2018 one laboratory research poster discussed granulation tissue in deep partial thickness wounds, what would be a stage 2 pressure ulcer.  Based on the NPUAP revised definition, a stage 2 pressure ulcer would erroneously be categorized as a stage 3 pressure ulcer.  This has significant and far-reaching implications for clinicians, health care organizations, the interpretation of research findings, as well as the legal, financial and regulatory implications. For example, it will result in erroneous reporting nosocomial stage 2 pressure ulcers as stage 3 pressure ulcers to the State Department of Health; there may be implications on Magnet status; there will be impact on Medicare payments to facilities as well as monetary penalties.  

Conclusion: The anatomy and physiology of skin and the biology of wound repair will be discussed with dermatopathology slides presented to support these facts.  Our intent is to provide the audience with the evidence based facts to support evidenced based practice.