Table 2.
Components of the BWAT total score and BWAT-CUA
| BWAT item/scores | BWAT total | BWAT- CUA |
|---|---|---|
| Necrotic tissue type | Yes | Yes |
| 1 = None visible | – | – |
| 2 = White/grey non-viable tissue and/or non-adherent yellow slough | – | – |
| 3 = Loosely adherent yellow slough | – | – |
| 4 = Adherent, soft, black eschar | – | – |
| 5 = Firmly adherent, hard, black eschar | – | – |
| Necrotic tissue amount | Yes | Yes |
| 1 = None visible | – | – |
| 2 = <25% of wound bed covered | – | – |
| 3 = 25–50% of wound covered | – | – |
| 4 = >50% and <75% of wound covered | – | – |
| 5 = 75–100% of wound covered | – | – |
| Exudate type | Yes | Yes |
| 1 = Non | – | – |
| 2 = Bloody | – | – |
| 3 = Serosanguineous: thin, watery, pale red/pink | – | – |
| 4 = Serous: thin, watery, clear | – | – |
| 5 = Purulent: thin or thick, opaque, tan/yellow, with or without odour | – | – |
| Exudate amount | Yes | Yes |
| 1 = None, dry wound | – | – |
| 2 = Scant, wound moist but no observable exudate | – | – |
| 3 = Small | – | – |
| 4 = Moderate | – | – |
| 5 = Large | – | – |
| Skin colour surrounding wound | Yes | Yes |
| 1 = Pink or normal for ethnic group | – | – |
| 2 = Bright red and/or blanches to touch | – | – |
| 3 = White or grey pallor or hypopigmented | – | – |
| 4 = Dark red or purple and/or non-blanchable | – | – |
| 5 = Black or hyperpigmented | – | – |
| Peripheral tissue oedema | Yes | Yes |
| 1 = No swelling or oedema | – | – |
| 2 = Non-pitting oedema extends <4 cm around wound | – | – |
| 3 = Non-pitting oedema extends >4 cm around wound | – | – |
| 4 = Pitting oedema extends <4 cm around wound | – | – |
| 5 = Crepitus and/or pitting oedema extends >4 cm around wound | – | – |
| Peripheral tissue induration | Yes | Yes |
| 1 = None present | – | – |
| 2 = Induration <2 cm around wound | – | – |
| 3 = Induration 2–4 cm extending <50% around wound | – | – |
| 4 = Induration 2–4 cm extending >50% around wound | – | – |
| 5 = Induration >4 cm in any area around wound | – | – |
| Granulation tissue | Yes | Yes |
| 1 = Skin intact or partial thickness wound | – | – |
| 2 = Bright, beefy red; 75–100% of wound filled and/or tissue overgrowth | – | – |
| 3 = Bright, beefy red; <75% and >25% of wound filled | – | – |
| 4 = Pink, and/or dull, dusky red and/or fills ≤25% of wound | – | – |
| 5 = No granulation tissue present | – | – |
| Undermining | Yes | No |
| 0 = Healed, resolved wound | – | – |
| 1 = None | – | – |
| 2 = Undermining <2 cm in any area | – | – |
| 3 = Undermining 2–4 cm involving <50% wound margins | – | – |
| 4 = Undermining 2–4 cm involving >50% wound margins | – | – |
| 5 = Undermining >4 cm or tunnelling in any area | – | – |
| Size | Yes | No |
| 0 = Healed, resolved wound | – | – |
| 1 = Length × width <4 cm2 | – | – |
| 2 = Length × width 4 to <16 cm2 | – | – |
| 3 = Length × width 16.1 to <36 cm2 | – | – |
| 4 = Length × width 36.1 to <80 cm2 | – | – |
| 5 = Length × width >80 cm2 | – | – |
| Depth | Yes | No |
| 0 = Healed, resolved wound | – | – |
| 1 = Non-blanchable erythema on intact skin | – | – |
| 2 = Partial thickness skin loss involving epidermis and/or dermis | – | – |
| 3 = Full thickness skin loss involving damage or necrosis of subcutaneous tissue; may extend down to but not through underlying fascia; and/or mixed partial and full thickness and/or tissue layers obscured by granulation tissue | – | – |
| 4 = Obscured by necrosis | – | – |
| 5 = Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures | – | – |
| Edges | Yes | No |
| 0 = Healed, resolved wound | – | – |
| 1 = Indistinct, diffuse, none clearly visible | – | – |
| 2 = Distinct, outline clearly visible, attached, even with wound base | – | – |
| 3 = Well-defined, not attached to wound base | – | – |
| 4 = Well-defined, not attached to base, rolled under, thickened | – | – |
| 5 = Well-defined, fibrotic, scarred or hyperkeratotic | – | – |
| Epithelialization | Yes | No |
| 1 = 100% wound covered, surface intact | – | – |
| 2 = 75% to <100% wound covered and/or epithelial tissue extends >0.5 cm into wound bed | – | – |
| 3 = 50% to <75% wound covered and/or epithelial tissue extends to <0.5 cm into wound bed | – | – |
| 4 = 25% to <50% wound covered | – | – |
| 5 = <25% wound covered | – | – |