Wound Classification Systems: Are They Significantly Utilized In Practice?
The variety of classification systems for lower extremity wounds is stunning. There is the popular Wagner Ulcer Classification System, the University of Texas (UT) Diabetic Wound Classification System, the National Pressure Ulcer System, the PEDIS classification from the International Working Group for the Diabetic Foot and diabetic foot infection guidelines from the Infectious Diseases Society of America (IDSA) among other classification schemes. In a guest column for our “Diabetes Watch” column (see page 20), Kathleen Satterfield, DPM, discusses some of these classification systems and raises some provocative questions. Perhaps one of the more intriguing questions centers on whether practitioners will use these systems in a private practice setting. Just as there are a variety of classification systems to choose from, there appears to be a variety of clinician approaches to using these systems. For general wounds, one clinician doesn’t “really reference (a wound classification system) in (his) charting.” He says he prefers a more “practical approach” that incorporates broad wound categories (venous, ischemic, neuropathic, vasculitic, etc.). The podiatrist notes these categories overlap but says his decision-making is based upon these broad classifications from his clinical examination. Another DPM at an academic institution concedes that “we do not place significant emphasis on general wound classifications.” He also adds that some of the classification systems are not conducive to use in the average podiatric practice. “A variety of the classification mechanisms are extremely complex and difficult for many to employ in the daily practices,” notes the DPM. There also seems to be various opinions when it comes to using diabetic foot ulcer classifications. A podiatrist notes that while the UT classification for diabetic foot wounds is probably very useful from an academic standpoint, he doesn’t “see much need to use this system … from a practical standpoint in a clinical setting.” Yet another DPM “frequently” employs the UT classification for diabetic foot ulcers. There is a general consensus that the Wagner classification is the most widely used scheme by DPMs. However, as Dr. Satterfield points out in her guest column, this classification does not account for the size of the lesion or neuropathy. “Indeed, these factors can have a pronounced effect on the treatment and potential outcome,” says Dr. Satterfield. While another podiatrist likes the fact that the UT classification factors in ischemia and infection, he admits he “can’t get used to using (the UT scheme) routinely in practice.” The DPM says he has used a combination of the Wagner system and wound measurements to document ulcer care for the last two decades. More recently, two new classification systems have emerged for diabetic foot infections. The aforementioned PEDIS classification (see www.iwgdf.org) and the IDSA guidelines (published last year in the Journal of the American Podiatric Medical Association) were discussed in “Treating Diabetic Foot Infections,” a previous supplement to the December 2005 issue of Podiatry Today. Benjamin Lipsky, MD, noted in the supplement that both “ … provide reasonably useful, easy to remember classifications that facilitate easy clinical application.” In terms of an ideal classification system, many agree that a simple yet validated scheme is needed to facilitate understanding across different specialties. One podiatrist favors a scheme that documents whether a wound is partial- or full-thickness, infected or not infected, and with or without bone involvement. He says this is easy to understand and “avoids confusion.” Perhaps the ultimate challenge is finding that elusive line between avoiding confusion and avoiding a system that may be too simplistic to facilitate an accurate clinical assessment.