An instrument to measure healing in pressure ulcers: development and validation of the pressure ulcer scale for healing (PUSH).

BACKGROUND: Currently, there is no instrument that provides an accurate and simple method of monitoring pressure ulcer healing in clinical practice. This article reports the two studies that were conducted to assess the validity of the Pressure Ulcer Scale for Healing (PUSH) as a tool to monitor healing of stage II-IV pressure ulcers. METHODS: Subjects in both studies (N = 103 and N = 269) were elderly (mean Study 1, 75 years, mean Study 2, 80 years), and the majority were women (Study 1, 51%, Study 2, 70%). Study data were extracted from patients' permanent records. RESULTS: Principal components analysis confirmed that the PUSH tool accounted for 58% to 74% of the wound healing variance over a 10-week period in Study 1 and 40% to 57% of the wound healing variance over a 12-week period in Study 2. In addition, multiple regression analysis, used to measure the sensitivity of the model to total healing, showed PUSH accounted for 39% of the variance in 6 weeks and 31% of the variance over 12 weeks (p <.001; Studies 1 and 2, respectively). CONCLUSIONS: Data from these two studies confirmed that the PUSH tool, with the components of length times width, exudate amount, and tissue type, is a valid and sensitive measure of pressure ulcer healing. It is a practical approach that provides clinically valid data regarding pressure ulcer healing. Further testing is needed to confirm these findings.

The validity of the clinical signs and symptoms used to identify localized chronic wound infection.

It is uncertain how accurately classic signs of acute infection identify infection in chronic wounds, or if the signs of infection specific to secondary wounds are better indicators of infection in these wounds. The purpose of this study was to examine the validity of the "classic" signs (i.e., pain, erythema, edema, heat, and purulence) and the signs specific to secondary wounds (i.e., serous exudate, delayed healing, discoloration of granulation tissue, friable granulation tissue, pocketing at the base of the wound, foul odor, and wound breakdown). Thirty-six chronic wounds were assessed for these signs and symptoms of infection with interobserver reliability ranging from 0.53 to 1.00. The wounds were then quantitatively cultured, and 11 (31%) were found to be infected. Increasing pain, friable granulation tissue, foul odor, and wound breakdown showed validity based on sensitivity, specificity, discriminatory power, and positive predictive values. The signs specific to secondary wounds were better indicators of chronic wound infection than the classic signs with a mean sensitivity of 0.62 and 0.38, respectively. None of the signs or symptoms was a necessary indicator of infection, but increasing pain and wound breakdown were both sufficient indicators with specificity of 100%.

Integration of pressure ulcer treatment protocol into practice: clinical outcomes and care environment attributes.

The purpose of this study was to determine if a research-based protocol for pressure ulcer treatment that had been successfully implemented in a long-term care facility was sustained over time. A secondary aim was to describe the attributes of the care environment that may have contributed to or impeded the maintenance of this protocol. A retrospective chart review was conducted of all patients who developed incident stage II, III, or IV pressure ulcers in the facility over a one-year period five years after initial implementation of a pressure ulcer treatment protocol. Data regarding ulcer characteristics and type, frequency, and duration of treatments were collected. Subjects were followed until the ulcer healed, the subject died or was discharged, or the 1-year study period ended. Care environment attributes, including patient care hours, turnover and stability rates, salaries, decision-making structures, and facility mission were obtained from the facility's Human Resource Department and existing databases in the Nursing Services Department. Outcomes of protocol implementation were defined as ulcer healing and costs associated with treatment. Costs were calculated from the provider perspective and included cost of supplies and labor consumed in providing direct pressure ulcer care. Of the 46 incident ulcers treated during the one-year study period, 40 (87%) healed and five (11%) were unhealed when the subject died. One ulcer remained unhealed at the end of the study. The total cost for treatment of these incident ulcers was $18,688, with nursing labor comprising 80% of the total expenditures. Adherence to the protocol, which contained predominantly inexpensive moist wound healing treatment options, resulted in complete healing of most pressure ulcers at a relatively low cost to the facility. The organizational environment of the facility, which maintains staffing levels and salaries at higher than national averages and promotes staff nurse accountability and decision making, may have provided the necessary climate to overcome barriers to clinical integration and sustain the desired care practices.

A tool to assess clinical signs and symptoms of localized infection in chronic wounds: development and reliability.

This paper reports on the development and testing of a tool designed to assess chronic wounds for the clinical signs and symptoms of localized infection. Thirty-one wounds were assessed by two independent nurse observers for the signs and symptoms of infection using the Clinical Signs and Symptoms Checklist. The Clinical Signs and Symptoms Checklist delineates 12 signs and symptoms of infection (i.e., pain, erythema, edema, heat, purulent exudate, serous exudate with concurrent inflammation, delayed healing, discoloration of granulation tissue, friable granulation tissue, pocketing at the base of the wound, foul odor, and wound breakdown) and their definitions. The reliability of each sign or symptom on the checklist was calculated using percent agreement and the Kappa statistic. Percent agreement ranged from 65% to 100%, and Kappa statistics ranged from 0.53 to 1.00, excluding pocketing of the wound base. The reliability estimates obtained for signs and symptoms on the Clinical Signs and Symptoms Checklist compare favorably with other data regarding interclinician agreement on wound assessment. Incorporating a structured approach to assess and monitor for wound infection, such as the Clinical Signs and Symptoms Checklist, may improve clinician skill and accuracy in identifying this condition.

Translating pressure ulcer guidelines into practice: it's harder than it sounds.

OBJECTIVE: To determine the cost-effectiveness of a guideline-based pressure ulcer prevention protocol over time. DESIGN: Retrospective and prospective quasi-experimental longitudinal design. Costs are presented from the long-term-care facility perspective. Data collection occurred for 3 periods: the first 6 months of 1994 (prior to protocol implementation), the first 6 months of 1995 (immediately following implementation) and the first 6 months of 1997 (2 years following implementation). SETTING: 77-bed long-term-care facility PATIENTS/PARTICIPANTS: Subjects were ulcer-free facility residents at the start of each data collection period. There were 69 subjects in the 1994 sample, 63 in the 1995 sample, and 71 in the 1997 sample. INTERVENTIONS: A guideline-based pressure ulcer prevention protocol was implemented during the last 3 months of 1994. The protocol consisted of specific policies for pressure ulcer prevention and treatment, intensive staff education on pressure ulcer care, and monitoring with regular performance feedback to staff. MEASUREMENTS AND MAIN RESULTS: Time to ulcer development varied among the 3 groups (log rank = 8.81, P = .01), with longer time to ulcer development in 1995 compared with 1994; no difference was seen between 1997 and 1994. The time for ulcers to heal decreased over the 3 years (log rank = 9.49, P <.01), with ulcer healing time being shorter in 1995 and 1997 compared with 1994. Total costs were unchanged during the 3 years (F = 0.2, P =.81). Costs of treatment declined significantly from 1994 to 1995 and 1997 (F = 5.5, P <.01) and costs of prevention increased significantly from 1994 to 1995 and 1997(F = 15, P <.01). From 1994 to 1997, the cost for 1 day of ulcer-free life was $3.50. CONCLUSIONS: Implementation of a pressure ulcer prevention protocol showed mixed results. Initial reductions in pressure ulcer incidence were lost over time. Clinical results of ulcer treatment, however, improved and treatment costs fell during the 3 years. Implementation of preventive programs poses a major leadership challenge.

How accurate are chronic wound assessments using interactive video technology?

This project examined the accuracy of chronic wound assessments made using an interactive, video telecommunications system (Teledoc 5000, NEC America, Inc., Irving, TX) by comparing a nurse expert's in-person wound assessments with wound assessments made from taped Teledoc sessions. Wound assessments determined the absence or presence of nine wound characteristics instrumental in guiding treatment (e.g., tunneling, undermining, granulation tissue, necrotic tissue, epithelial tissue, purulent exudate, erythema, edema, induration). A sample of 13 paired wound observations was analyzed. The accuracy of the Teledoc technology was examined by calculating the amount of agreement between the in-person assessments and the taped Teledoc assessments for each of the nine characteristics. Agreement for eight of the nine wound characteristic exceeded 75%, suggesting this telehealth medium does not alter wound assessment data, which are essential in guiding treatment decisions. In addition to connecting the remotely based nurse with nursing expertise to improve patient care, telehealth technology seemed to increase the remotely-based nurses' knowledge of wound assessment and treatment as well.

A nursing application of telecommunications. Measurement of satisfaction for patients and providers.

Consumer and provider satisfaction is key to the continued use and expansion of telehealth technology. This pilot study compared satisfaction of providers and patients with wound consultations done in person with those done via real-time interactive video technology. Eleven telehealth consultations with a nurse expert were immediately followed by an in-person consultation with a second nurse expert. Satisfaction questionnaires were administered to patients, referring nurses, and the consultant nurse expert following both the in-person consultation and the telehealth consultation. The referring nurses (100%) were satisfied with both the telehealth and in-person consultations, noting the ability to provide better care for their patients. The patients (55%) were "very satisfied" with the telehealth consultations versus 40% satisfied with the in-person consultations. Difficulty in hearing for the patients was equal in both groups, which resulted in changes in the consultation process. The patients' difficulty in seeing the telehealth consultant was addressed through larger screens and strategic positioning to provide easier viewing for the patient and providers. The telehealth nurse consultant was satisfied overall but had some difficulty communicating. This pilot study helped provide useful information for both the telehealth and in-person consultations.

Do oxygen-enriched atmospheres exist beneath surgical drapes and contribute to fire hazard potential in the operating room?

The purposes of this study were to (1) describe the microenvironment in terms of oxygen concentration beneath the drapes of healthy subjects who were simulating patients undergoing minor surgical procedures with supplemental oxygen and to (2) evaluate the efficacy of using a scavenger system beneath the drapes. A convenience sample of 12 healthy volunteer subjects was studied in an ambulatory surgery center operating room, which was ventilated with 25 air exchanges per hour. The study was carried out in 2 parts. Each subject was supine, and oxygen was applied by a standard nondivided nasal cannula. The subjects were draped as routinely done for ophthalmic procedures. Oxygen concentrations were measured by using an Ohmeda Rascal II gas analyzer beneath the drapes and at the hypothetical surgical site with oxygen flow rates of 0, 1, 2, 3, and 4 L/min, allowing 5 minutes to elapse after a change in flow rate was made. Following a 10-minute break, the subjects were redraped, and the procedure was repeated using a scavenger system consisting of a suctioning system connected to wall suction at 170 to 190 mm Hg. Although the mean +/- SD oxygen saturation never fell below 95% (97.75% +/- 1.54%), mean +/- SD oxygen concentrations beneath the drapes were lower than normal room air concentrations (19.08% +/- 0.51%) when no oxygen was delivered to the patient. With supplemental oxygen and no scavenger system, oxygen concentrations beneath the drapes were consistently elevated (as high as 45% with 4 L/min) compared with normal ambient concentrations (21%) or with concentrations obtained at the surgical site (as high as 23.4%). With the scavenger system in place, mean +/- SD oxygen concentrations reached 34.08% +/- 5.52% beneath the drapes. Statistical analyses revealed that significantly higher oxygen concentrations occurred beneath the drapes with each incremental change in oxygen flow rate, and regardless of the oxygen flow rate used, oxygen concentrations beneath the drapes were significantly reduced with the use of the scavenger system.

Effect of electrical stimulation on chronic wound healing: a meta-analysis.

The purpose of this meta-analysis was to quantify the effect of electrical stimulation on chronic wound healing. Fifteen studies, which included 24 electrical stimulation samples and 15 control samples, were analyzed. The average rate of healing per week was calculated for the electrical stimulation and control samples. Ninety-five percentage confidence intervals were also calculated. The samples were then grouped by type of electrical stimulation device and chronic wound and reanalyzed. Rate of healing per week was 22% for electrical stimulation samples and 9% for control samples. The net effect of electrical stimulation was 13% per week, an increase of 144% over the control rate. The 95% confidence intervals of the electrical stimulation (18-26%) and control samples (3.8-14%) did not overlap. Electrical stimulation was most effective on pressure ulcers (net effect = 13%). Findings regarding the relative effectiveness of different types of electrical stimulation device were inconclusive. Although electrical stimulation produces a substantial improvement in the healing of chronic wounds, further research is needed to identify which electrical stimulation devices are most effective and which wounds respond best to this treatment.

Cost-effectiveness of an intensive pressure ulcer prevention protocol in long-term care.

Conducted in a 77-bed long-term-care facility, this study compared the costs of implementing an intensive pressure ulcer prevention protocol plus the calculated costs of treatment before and after implementing the protocol. A total of 69 patients comprised the preprotocol sample; 16 of them developed 26 ulcers. The postprotocol sample consisted of 63 patient, 3 of whom developed 5 ulcers. The 6-month pressure ulcer incidence was 23% in the preprotocol sample and 5% in the postprotocol sample. Mean cost for prevention and treatment of pressure ulcers was $113 +/- $345 per subject for the preprotocol sample and $100 +/- $157 per subject for the postprotocol sample (t = 0.27, df = 130, p = .79). Mean time to ulcer development was 146 +/- 61 days for the preprotocol subjects and 158 +/- 53 days for the postprotocol subjects (log rank = 8.63, p = .003 Implementation of a protocol that emphasized pressure ulcer prevention significantly reduced the incidence of pressure ulcers and cost per day of ulcer-free life.

Nursing assessment: impact on type and cost of interventions to prevent pressure ulcers.

OBJECTIVE: To describe pressure ulcer preventive interventions and their cost, and to compare the preventive intervention use and cost with level of risk. DESIGN: Comparative, descriptive design. SETTING AND SUBJECTS: A large midwestern Veteran's Affairs Medical Center with 260 long-term care beds. Thirty-one chair- or bed-bound residents from 1 long-term care unit comprised the study sample. MAIN OUTCOME MEASURES: The outcome variables included demographic information (patient record), Braden Risk Assessment score, institutional risk assessment score (Pressure Ulcer Risk Tool), type and frequency of preventive interventions, and the related costs. METHODS: Subjects were assessed on a weekly basis for type and frequency of preventive intervention and for the development of a pressure ulcer. Each subject was observed until death, discharge, pressure ulcer formation, or the end of the 3-month study period. RESULTS: The 3-month pressure ulcer incidence rate was 13%. All subjects were at risk for pressure ulcer development according to Braden scores; whereas only 74% were assessed at risk with use of the facility's risk assessment tool. Preventive measures included regular repositioning (87%); 67% were placed on mattress support surfaces. There was no relationship between level of risk (facility risk tool score) and type of prevention used. The total cost of pressure ulcer prevention to the nursing unit was $14,926, representing a mean of $497 per subject, and $5.55 per subject per day. CONCLUSION: As compared with previous studies, the higher cost of prevention described in this study may be attributed to inadequate linkage of preventive interventions to risk level.

Pressure ulcer research: pressure ulcer treatment. A monograph from the National Pressure Ulcer Advisory Panel.

The AHCPR guideline on Treatment of Pressure Ulcers was released in December 1994. This guideline was based on the best available scientific evidence published between 1966 and May 1, 1993. Over 45,000 abstracts were reviewed in the literature analysis. Yet only 63.2% of the guideline recommendations were based on research of any type, and only 4.5% of the recommendations were supported by two or more randomized clinical trials. A more recent literature review (covering articles on pressure ulcers listed in the MEDLINE database between May 1, 1993, and December 1, 1996), revealed minimal advances in the scientific body of knowledge on pressure ulcer treatment. Advances have been made in the knowledge of electrical therapy and growth factors, and efforts are under way to enhance tools for monitoring healing. In an era of limited research funding, we need to carefully target our research efforts to maximize the advancement of our knowledge of pressure ulcer treatment. It is the hope of the NPUAP that this monograph will guide the research needed to ensure the most efficient utilization of funds to improve patient outcomes.

Pressure ulcer healing: what is it? What influences it? How is it measured?

Defining healing requires a set of measurements that quantify the physical factors that change during healing. Such a list of measures gives a de facto definition of what constitutes pressure ulcer healing and what influences it. This paper attempts to answer a more specific question: Which measurements are strong candidates for inclusion in a tool for monitoring pressure ulcer healing? Three sets of clinical measurements are analyzed--the assessment proposed by the Agency for Health Care Policy and Research Guideline Development Panel for the Treatment of Pressure Ulcers; the recommendations of the Wound Healing Society; and the Pressure Sore Status Tool. The validity of the 11 clinical measures common across these assessment methods is examined using empiric evidence from studies of wound healing.

Adjuvant therapy for ulcer care.

Adjuvant therapies, specifically electrotherapy, hyperbaric oxygen, ultrasound, and hydrotherapy, are considered increasingly for use with conventional local wound care to support healing of pressure ulcers. This article describes the characteristics of these modalities, their physiologic effects on the healing process, and the research to evaluate their efficacy.

Measuring prevalence and incidence of pressure ulcers.

The current competitive health care environment has intensified the need for data that provide a snapshot of the realities of clinical practice. As decision making moves from a clinically based perspective to one grounded in scientific data, health care providers are increasingly being challenged to document the extent of a problem and the effectiveness of its management. This is especially true with pressure ulcers, which are viewed as high-volume, high-risk problems in most health care settings. Moreover, in long-term care facilities, regulatory agencies have designated the development of pressure ulcers as an indicator of quality of care provided to patients. Thus, it is essential that data related to the scope and severity of pressure ulcers in a facility be gathered accurately. The aim of this article is to describe a methodology for determining prevalence and incidence of pressure ulcers that accurately measures the effectiveness of preventive intervention. The importance of risk assessment and of clear operational definitions of the population and a case will be addressed.

The cost-effectiveness of interventions for preventing pressure ulcers.

BACKGROUND: While there is scientific evidence to support the efficacy of preventive interventions for pressure ulcers, few empirical data are available on their cost-effectiveness. The aim of this study was to determine the cost-effectiveness of interventions to prevent pressure ulcers. METHODS: Cost of preventive interventions and days of ulcer-free survival were compared for two groups of patients. One group consisted of 250 patients from a geriatric unit of a British hospital (Norton sample). At the time of the study, no preventive measures were used. Data from the original report of the study were used to determine patients' attainment of one of three end points--ulcer formation, death, or discharge--from which a disease-free survival table was constructed. The second cohort of 420 patients consisted of residents of a long-term care facility in Iowa, where aggressive preventive measures were used (Iowa sample). Data were collected at the study onset and 3 months later. The types of preventive interventions used on each patient were assessed and their costs calculated. Cost of treatment for pressure ulcers was estimated from previous research performed at the Iowa facility. The cost-effectiveness of the preventive intervention was calculated by dividing the mean difference in cost between the two groups by mean difference in ulcer-free days. RESULTS: Survival analysis of days to ulcer development showed the Norton (no prevention) sample had a significantly shorter time to ulcer development than did Iowa sample (patients receiving preventive measures) (P < 0.0001). The mean cost for prevention and treatment of an ulcer was $167 +/- $307 for the Norton sample and $245 +/- $379 for the Iowa sample. The mean number of ulcer-free days was 21.0 -/+ 17.4 for the Norton sample and 78.5 +/- 11.0 for the Iowa sample. The cost per day of ulcer-free life gained was $1.36. CONCLUSION: The use of aggressive preventive measures in the long-term care setting is effective in reducing pressure ulcers and requires a relatively low level of institutional expenditures.

Adoption of a research-based practice for treatment of pressure ulcers.

Evaluation of a skin care protocol for the treatment of pressure ulcers in this institution showed that practitioners did adopt research-based practice. This change in practice was associated with a corresponding decrease in costs for treatment. More pressure ulcers received treatment after implementation of the protocol. Furthermore, the majority of pressure ulcers were being treated with wound care modalities identified by research as supportive of healing. Use of antiseptic agents harmful to the healing process declined as did use of topical agents with little research base to support their efficacy. The shift to practice patterns that were more consistent with research findings was associated with a corresponding decrease in costs for pressure ulcer treatment. Factors in this situation that lead to the positive outcome of knowledge utilization were an organizational model that promoted accountability of individual practitioners, staff participation in decision making, agency regard for research, and consultation with a nurse expert. Informal individual utilization of knowledge related to the treatment of pressure ulcers reinforced use of the research-based practice and expedited formal implementation of a policy/procedure related to their treatment. The process of knowledge utilization that occurred in this institution provides a prototype of how research can be translated into practice. Although limited to one specific clinical problem, the results of this process can be applied to any clinical condition where there are sufficient research findings to support development of recommendations for practice.

The cost of treating pressure ulcers following implementation of a research-based skin care protocol in a long-term care facility.

Although concern for the costs associated with pressure ulcer treatments persists, studies that precisely quantify costs are limited. A retrospective research design was used to describe the costs incurred by an 830-bed, long-term care facility to treat 81 pressure ulcers over a one-year period following implementation of a research-based, skin care protocol. The total cost for the study period was $30,079 with 73% of these expenditures attributable to nursing care. Mean cost of treatment was $3.74/pressure ulcer/day, which was a reduction from the $5.35/pressure ulcer/day cost prior to implementation of the skin care protocol. These findings suggest that implementing a research-based, skin care protocol can promote a reduction in treatment costs.