UHMS Member Wound Scoring System Is Receiving Coverage
Long Beach Memorial Medical Center, Hyperbaric Medical Program, Long Beach, California U.S.
Our paper “Clinical applications and validation of an innovative wound score” was recently published in the journal Wounds: A compendium of clinical research and practice (Wounds 2018; 30(6):154-159; Epub 2018 March 21). To the best of our knowledge this article describes the only wound scoring system – the Long Beach Wound Scores (LBWS) – that has both reliability and validation data in a peer-reviewed journal.
We feel our LBWS has the potential for wound scoring that the Apgar score has for neonatology. With its implementation, wound management becomes obvious. For example, the “healthy” category (LBWS 7-1/2 to 10 points) dictates simple, inexpensive dressing agents be used (possibly biologics if epithelialization is not observed within four to six weeks). For the “problem” wound category (LBWS 3-1/2 to 7 points), the primary problem(s) such as deformity, deep infection, and/or ischemia-hypoxia need to be addressed.
The obvious niche for hyperbaric oxygen treatment is the “problem” wound with ischemia-hypoxia . The “endstage” wound (LBWS 0 to 3 points) justifies amputation, if revascularization is not possible or it is insufficient to improve the LBWS to the “problem” category.
For research purposes, especially for effectiveness of wound dressing agents, the LBWS is ideal for comparing “like for like” wounds, i.e. Comparative Effectiveness Research (CER), since objective criteria are used to grade from (2 to 0 points) each of the five assessments. They are:
- appearance (of the wound including base and
- size (including recesses and/or undermining);
- depth (to wound base or end of tract);
- infection; and
Finally, the LBWS is a useful tool for establishing Minimally Clinically Important Improvement (MCII), since objective scoring criteria can be used with a simplified scoring system (as we used in our paper).
- Healed Wounds were scored 2 points;
- Improved Wounds scored 1-1/2 points (e.g., smaller size, shallower depth, simplified wound care, elimination of pain, clearing of sepsis and/or resumption of mobility);
- No Improvement wounds scored 1 point;
- Worsening Wounds scored 1/2 point; and
- Major Amputation and/or Death scored 0 points.
I respectfully recommend that whenever the Wagner scoring system is done to grade a diabetic foot ulcer, a concomitant LBWS be added and the categories described above be used to guide treatment.
In addition to the paper itself, a short descriptive article can be found in Pressure, the open-access member newsletter of the UHMS at: https://www.uhms.org/publications/pressure/2018-pressure/third-quarter-pressure-2018.html
- Wagner Grades: Analogues with LBWS Wagner Grade 0 = deformity confounder in problem wound type; Wagner Grades 1 & 2 = healthy wound type; Wagner Grade 3 = localized sepsis grade in infection assessment; Wagner Grade 4 & 5 = black grade on wound appearance
- Niches for HBO: Primary: Problem wound type with ischemia-hypoxia cofounder (when revascularization not feasible or not effective); Other indications: a) localized sepsis in infection assessment (with improvement not occurring after 30 days of conventional management); b) deep infection cofounder with >200 mmHg juxta-wound transcutaneous oxygen measurement with HBO; c) Wagner Grade 4, 5 diabetic foot ulcers; d) facilitating auto amputation of the end-stage wound type
- CER: Objectivity and ability to compare “like for like” wounds became possible by studying the effectiveness of interventions on similar wound types (i.e. healthy, problem, or end-stage + transitional) and/or similar LBWSs
- Outcome Measures for Reliability and Validation to quantify MCII/R: A five permutation scale was used as follows: Healed = 2 points; Improved (smaller wound size, decrease wound care needs, resumptino of activities, absence of pain, and/or elimination of exudate and odor) = 1 ½ points; No Change = 1 point; Worsening = ½ point; and Death/Major Amputation = 0 points