Home / Staging & Records

Staging / Classification Systems Quick Reference

IWGDF 2023 principle: choose the classification system by clinical purpose — SINBAD for communication and audit, IWGDF/IDSA for infection, WIfI for the threatened limb.

1. SINBAD (Diabetic Foot)

Six items scored 0–1 each, total 0–6; a score ≥3 indicates a poorer prognosis.

Item	0 points	1 point
Site	Forefoot	Midfoot/hindfoot
Ischemia	Pedal blood flow intact (at least one palpable pulse)	Clinical evidence of ischemia
Neuropathy	Protective sensation intact	Loss of protective sensation
Bacterial infection	None	Present
Area	<1 cm²	≥1 cm²
Depth	Skin/subcutaneous tissue	Reaching muscle/tendon/bone

Monteiro-Soares 2023, IWGDF classification update. DOI:10.1002/dmrr.3648

2. IWGDF/IDSA Infection Grading (Diabetic Foot)

Grade	Definition (summary)
Uninfected	No signs of infection — do not use antibiotics
Mild	Local infection, erythema ≤2 cm, limited to skin/subcutaneous tissue
Moderate	Erythema >2 cm or deeper structures involved, no systemic response
Severe	Accompanied by systemic inflammatory response syndrome (SIRS)

Osteomyelitis is designated separately (O). Deep tissue specimens are preferred over surface swabs.

Senneville 2023, IWGDF/IDSA. Clin Infect Dis. DOI:10.1093/cid/ciad527

3. WIfI (SVS Threatened Limb Classification)

Wound (0–3) × Ischemia (0–3) × foot Infection (0–3) → clinical limb-threat Stage 1–4, guiding amputation risk and benefit of revascularization.

	0	1	2	3
W Wound	No ulcer	Small/shallow ulcer	Deep ulcer exposing bone/joint/tendon	Extensive deep ulcer or gangrene
I Ischemia	ABI ≥0.80	0.60–0.79	0.40–0.59	<0.40
fI Infection	None	Mild	Moderate	Severe (SIRS)

Mills 2014, J Vasc Surg. DOI:10.1016/j.jvs.2013.08.003

4. Wagner and University of Texas (Historical Systems)

Wagner: Grade 0 (at-risk foot) → 1 (superficial ulcer) → 2 (deep to tendon) → 3 (osteomyelitis/deep abscess) → 4 (forefoot gangrene) → 5 (whole-foot gangrene).

University of Texas Classification System (1996)

Core concept: a 4×4 matrix that cross-evaluates wound depth (Grades) with complications (Stages).
Depth (Grades 0–3):
- Grade 0: pre- or post-ulcerative lesion (intact skin).
- Grade 1: superficial wound not involving tendon, capsule, or bone.
- Grade 2: wound penetrating to tendon or joint capsule.
- Grade 3: wound penetrating to bone or joint.
Stages (A–D) — infection and ischemia:
- Stage A: no infection or ischemia.
- Stage B: with infection.
- Stage C: with ischemia.
- Stage D: with both infection and ischemia.

UT matrix	Grade 0 Intact skin	Grade 1 Superficial	Grade 2 Tendon/capsule	Grade 3 Bone/joint
A No infection or ischemia	0A	1A	2A	3A
B Infection	0B	1B	2B	3B
C Ischemia	0C	1C	2C	3C
D Infection + ischemia	0D	1D	2D	3D

Deeper wounds (higher Grade) with infection/ischemia (Stage toward D) carry higher amputation risk; Stage D is the highest-risk group.

Current IWGDF guidance recommends selecting a system by purpose; these two are historical foundations but remain common in clinical communication.

Wagner 1981 (DOI:10.1177/107110078100200202); Lavery 1996 (DOI:10.1016/s1067-2516(96)80125-6); Meggitt 1976

5. NPIAP Pressure Injury Staging

Stage	Definition (summary)
Stage 1	Intact skin with non-blanchable erythema
Stage 2	Partial-thickness skin loss with exposed dermis; wound bed pink and moist
Stage 3	Full-thickness skin loss with visible adipose tissue; undermining/tunneling may be present
Stage 4	Full-thickness loss with exposed fascia/muscle/tendon/bone
Unstageable	Obscured by slough/eschar; depth cannot be determined
DTPI Deep Tissue Pressure Injury	Intact or non-intact skin with deep purple/maroon discoloration or blood-filled blister

Also: medical device-related pressure injury (staged as above); mucosal membrane pressure injury cannot be staged.

EPUAP/NPIAP/PPPIA 2019 International Guideline; NPIAP staging definitions

6. CEAP 2020 (Chronic Venous Disease)

C class	Clinical presentation
C0	No visible signs of venous disease
C1	Telangiectasias/reticular veins
C2	Varicose veins
C3	Edema
C4	Skin changes (pigmentation/eczema/lipodermatosclerosis/atrophie blanche)
C5	Healed venous ulcer
C6	Active venous ulcer (C6r = recurrent)

Lurie 2020, J Vasc Surg Venous Lymphat Disord. DOI:10.1016/j.jvsv.2019.12.075

7. ISTAP Skin Tear Classification

Type 1: skin flap intact and can be repositioned | Type 2: partial flap loss | Type 3: complete flap loss (see Wound Classification for details).

LeBlanc 2018 ISTAP; Van Tiggelen 2020 (DOI:10.1111/bjd.18604)

8. Burn Depth Classification

Superficial (epidermal) | Partial-thickness (dermal, subdivided into superficial/deep) | Full-thickness (into subcutaneous tissue); area estimated by the Rule of 9s or Lund-Browder chart.

ISBI 2016/2018 Practice Guidelines

9. Gustilo–Anderson Open Fracture Classification

Type I (<1 cm) | II (1–10 cm) | IIIA (adequate soft-tissue coverage) | IIIB (requires flap coverage) | IIIC (vascular injury) — see full table in Wound Classification.

Gustilo 1976; Gustilo 1984

10. CDC Surgical Wound Contamination Classes

Clean | Clean-contaminated | Contaminated | Dirty/Infected — a contamination classification, not a depth staging. See full table in Wound Classification.

CDC NHSN SSI Event Manual

11. Wound Assessment & Documentation Systems (TIME / TIMERS / MEASURE)

Key conclusion: There is no single universal wound documentation system. TIME/TIMERS organize clinical reasoning, MEASURE structures documentation, and PUSH, BWAT and DESIGN-R quantify healing trends; pressure injuries, diabetic foot, venous and arterial ulcers still require etiology-specific classifications (sections 1–6 above). Recommended approach: "TIMERS as the clinical-reasoning framework + MEASURE as standard documentation fields + standardized photos and area trends for tracking."

11.1 Why standardize wound documentation?

Wound appearance changes with time, dressing changes, position, lighting and camera angle. Standardized documentation lets the same wound be compared across dates, caregivers and care settings, and triggers timely reassessment or referral:

Describe current status: location, etiology, size, depth, tissue, exudate, pain, edge and periwound skin.
Compare trends: area, tissue proportions, exudate volume, pain and infection signs.
Support decisions: debridement, dressing adjustment, offloading, compression, perfusion assessment or anti-infective care.
Team communication: physicians, nurses, case managers, patients and caregivers share the same information.
Data quality: consistent fields for quality management, research, referral and digital wound tracking.

⚠️ No documentation tool replaces etiologic diagnosis, perfusion assessment, neurologic and pressure evaluation, infection judgment, or whole-person assessment.

11.2 Three categories of systems

Category	Representative systems	Main use	Should NOT be misused as
Assessment & management frameworks	TIME, TIMERS, MEASURE, Wound Triangle, WBP, DIME, MOIST	Sequence assessment, identify barriers to healing, plan management	A single diagnosis or a complete quantitative score
Quantitative tracking tools	PUSH, BWAT, DESIGN-R	Convert wound status into repeatable, comparable scores/trends	A universal treatment guideline for all etiologies
Etiology-specific classifications	NPIAP staging, SINBAD, WIfI, IWGDF/IDSA, CEAP, etc.	Describe severity, infection, ischemia or etiologic features	A general wound documentation form

In practice you usually need "one generic documentation backbone + one etiology-specific module": e.g. record a diabetic foot ulcer with MEASURE, then add SINBAD or WIfI; pressure injuries also need stage, pressure source and offloading measures.

11.3 TIME: the classic wound bed preparation framework

TIME grew out of Wound Bed Preparation. It works well as a checklist and reasoning framework, but does not cover size, etiology, perfusion, pain, patient goals or outcome trends.

Letter	Focus	What to observe	Possible management direction
T｜Tissue	Tissue viability	Granulation, epithelium, slough, eschar, foreign body, exposed tendon/bone	Debridement per perfusion and goals, protect new tissue, or refer
I｜Infection/Inflammation	Infection or abnormal inflammation	Redness, swelling, heat, pain, pus, odor, increased exudate, friable granulation, stalled healing, systemic signs	Full infection assessment; drainage/culture/anti-infectives when indicated; exclude non-infectious inflammation
M｜Moisture balance	Moisture balance	Exudate volume, color, viscosity, dressing saturation, maceration, dryness or leakage	Adjust dressing absorbency, change frequency and periwound protection
E｜Edge	Edge advancement	Epithelial advance, rolled edge, keratosis, maceration, undermining, tunneling, detachment from wound bed	Reassess etiology, pressure, ischemia, infection, debridement and advanced therapy needs

TIME answers "what local wound-bed barriers exist?" — it does not fully answer "what is the etiology, is it healable, how much has it improved, can the patient carry out care?" (Schultz 2003, DOI: 10.1046/j.1524-475X.11.s2.1.x; Schultz 2004, DOI: 10.1111/j.1742-481x.2004.00014b.x)

11.4 TIMERS: adding repair and patient context

TIMERS adds two items to TIME, better suited to hard-to-heal wounds and interdisciplinary teams:

Added item	Content	Simplified message
R｜Repair/Regeneration	Assess need for NPWT, skin substitutes, biologic materials, grafting, reconstruction or other advanced repair strategies	If stalled despite standard care, reassess etiology and advanced therapy
S｜Social/patient factors	Pain, nutrition, smoking, activity, cognition, finances, living environment, caregiver support and self-care capacity	The care plan must be one the patient and caregiver can actually carry out

TIMERS is still not a scoring scale — present it as a "six-item clinical reasoning framework"; do not convert checkboxes into prescriptions.

Atkin L, et al. J Wound Care 2019;28(Sup3a):S1-S50. DOI: 10.12968/jowc.2019.28.Sup3a.S1

11.5 MEASURE: closest to a standardized record form

MEASURE maps to electronic fields better than TIME. Use it as the backbone of a consistent record format, then add etiology, perfusion, systemic status, management and safety alerts.

Letter	Item	Suggested fields
M｜Measure	Measurement	Site, length, width, depth, area; method and scale reference
E｜Exudate	Exudate	Volume, color, viscosity, odor, dressing saturation and leakage
A｜Appearance	Appearance	Epithelium, granulation, slough, eschar, foreign body, exposed structures
S｜Suffering	Pain	0–10 score, character, timing, at rest/activity/dressing change
U｜Undermining	Undermining/tunneling	Direction, deepest extent, dead space, communication with deep structures
R｜Re-evaluate	Regular re-evaluation	Compare size, tissue, exudate, pain, infection and treatment response
E｜Edge	Edge & periwound skin	Rolled edge, maceration, erythema, keratosis, scaling, edema, induration

Keast DH, et al. Wound Repair Regen 2004;12(3 Suppl):S1-S17. PMID: 15230830

11.6 Other useful frameworks

System	Core concept	Best use	Main limitation
Wound Triangle	Wound bed, wound edge, periwound skin	Dressing choice, exudate management, periwound protection; visual education	Etiology, perfusion, systemic issues under-covered
WBP 2021	Treat cause and patient factors first; classify healable / maintenance / non-healable	Overall treatment goals and debridement intensity for chronic wounds	For professionals; not a simple form
DIME	Debridement, Infection/Inflammation, Moisture, Edge	Wound bed preparation and local care	Overlaps TIME; terminology varies
MOIST	Moisture, Oxygen, Infection, Support, Tissue management	Local and supportive therapy planning for chronic wounds	Includes advanced therapies; less widely adopted

⚠️ Key safety principle: WBP 2021 stresses judging healability first. Dry gangrene with severe non-revascularizable ischemia should not be aggressively debrided before perfusion assessment.

Sibbald RG, et al. Adv Skin Wound Care 2021;34(4):183-195. DOI: 10.1097/01.ASW.0000733724.87630.d6

11.7 Quantitative healing tools

Quantitative tools convert serial observations into comparable trends — but total scores never replace clinical judgment, and scores must not be compared across different tools.

Tool	Content	Strengths	Limitations / licensing
PUSH Tool	Area, exudate amount, tissue type	Fast; good for serial charting of pressure injuries	Few fields; NPIAP explicitly requires licensing for external programs, commercial products or websites
BWAT	13 items: size, depth, edges, undermining, necrosis, exudate, periwound skin, edema, induration, granulation, epithelialization	Comprehensive; suits professional use and research	Training required; inter-rater variability; BWAT is copyright-protected
DESIGN-R	Depth, exudate, size, inflammation/infection, granulation, necrosis, pocket/undermining	Suits pressure injury severity and healing trends	Use per Japanese Society of Pressure Ulcers manual with attribution; do not modify the scoring

A safer product strategy: define your own "standard wound record module" (fields + operational definitions), and integrate formal scales only as separately licensed modules — do not copy scale tables, instructions or scoring rules.

NPIAP PUSH Tool (licensing terms at npiap.com); Bates-Jensen BM, et al. Wound Repair Regen 2019. DOI: 10.1111/wrr.12714; JSPU DESIGN-R manual

11.8 Etiology-specific classifications must be added

Wound type	Common systems	Documentation focus
Pressure injury	NPIAP/EPUAP/PPPIA staging, PUSH, DESIGN-R; Braden for risk prediction	Stage, site, pressure/shear, offloading, incontinence, nutrition; Braden is not a healing score
Diabetic foot ulcer	SINBAD, WIfI, IWGDF/IDSA infection grading, Wagner, UT, PEDIS	Infection, ischemia, neuropathy, depth, area, site, offloading; IWGDF 2023 prefers SINBAD for professional communication
Venous ulcer	CEAP, VCSS	Edema, pigmentation, lipodermatosclerosis, exudate, suitability and adherence of compression
Arterial ulcer	WIfI, Rutherford, Fontaine; ABI, TBI, toe pressure, TcPO₂	Objective perfusion data, ischemic pain, gangrene, revascularization need
Wound infection	IWGDF/IDSA (diabetic foot), TILI; NERDS/STONEES as clinical prompts	Infection is a clinical diagnosis; scales only assist — never judge by odor, culture or imaging alone

Details of each system: sections 1–6 above.

11.9 Recommended documentation workflow (website/app)

Baseline: etiology, site, onset date, comorbidities, perfusion, standardized photo.
Each follow-up: same-method recording of size, exudate, appearance, pain, periwound skin and today's care.
Trends: compare area, pain and exudate; keep raw data — never show only a single score.
Alerts: spreading redness, pus, fever, increasing pain, ischemic signs or deep-tissue exposure → prompt urgent care.
Regular reassessment: without reasonable improvement, recheck etiology, perfusion, infection, pressure/edema, adherence and referral need.

Area reduction rate = (baseline area − current area) ÷ baseline area × 100%. Length × width is only an approximation; irregular wounds need a consistent, validated measurement method.

⚠️ This section supports education and documentation standardization only — no diagnosis, infection interpretation or individual prescriptions. Photos never replace palpation, depth, undermining, perfusion, neurologic and systemic assessment. Confirm licensing, translation and commercial terms before formally adopting PUSH, BWAT, DESIGN-R or other protected tools.

Last updated: 2026-08-29