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.

Validation test for climate control on air-loss supports.

OBJECTIVE: To develop a simple, reproducible validation test protocol for classification of air-loss support systems. DESIGN: Simultaneous experimental measurement of moisture loss and temperature reduction at the air-loss support surface-human body equivalent interface from a sweating human skin analogue. SETTING: A hospital department of physical medicine and rehabilitation. OTHER PARTICIPANTS: These 3 manufacturers contributed 14 support surfaces. INTERVENTIONS: Test support surfaces and a standard foam mattress were placed on a hospital bed. Water was circulated to a loading gauge, placed on a dry moisture reservoir, and connected to a water bath to keep the interface at 37 degrees +/- 0.5 degrees C. The loading gauge and support surface was adjusted 23cm below the water bath level and the air flow through the interface initiated. After the dry moisture reservoir came to temperature equilibrium for 30 minutes, it was replaced with a wet one that was saturated with 36g of saline. The temperature change and evaporation rate were recorded throughout a 90-minute test period. MAIN OUTCOME MEASURES: Temperature of support surface interface and evaporation rate. RESULTS: Clustered data from temperature reduction and standardized rate of moisture loss yielded 3 groups of support surfaces in categories of no air loss (control), low air loss (LAL), and high air loss. The mean values of the characteristic temperature reduction and rate of moisture loss differed significantly between the groups. By multiple comparisons with Bonferroni's adjustment, the group means differed significantly for average temperature reduction (p <.017) and for standardized rate of moisture loss (p =.0001). The measured temperature change at any instant of time reflected the effect of evaporation and the opposing effect of thermal conductivity. CONCLUSION: Measurements of support interface climate change allowed for selective grouping of LAL surfaces according to rate of moisture evaporation and the resulting temperature reduction. Neither temperature change nor evaporation rate alone was sufficient to determine the microclimate characteristics of the support surface. Combined, these characteristics can effectively describe the performance of any LAL support system and may be used to define standards of performance.

Treating pressure ulcers in the home.

A large proportion of home care patients have pressure ulcers as the primary diagnosis or secondary to other conditions. In the April 1999 issue of this journal, the author presented current research and discussed how environmental factors can be manipulated to prevent pressure ulcers in home care patients. This companion article focuses on treatment strategies and clinical approaches in caring for patients who present with pressure ulcers.

Interrupting the pressure ulcer cycle.

Pressure ulcers represent a significant health care problem for older adults and patients with chronic disease. The National Pressure Ulcer Advisory Panel (NPUAP) estimates that over 1 million people in America suffer from pressure ulcers. Reported pressure ulcer prevalence varies widely and pressure ulcer incidence is difficult and labor-intensive to track; however, nursing has both a responsibility and an opportunity to help decrease the number of individuals who suffer from pressure ulcers. This article suggests ways that nurses can assist with improving care for patients at risk for pressure ulceration.

Preventing pressure ulcers in home care patients.

A large proportion of home care patients present with pressure ulcers, and many more patients are at risk. Home care nurses have an opportunity to manipulate favorably certain environmental factors that can prevent pressure ulcers from forming and to develop effective treatment plans for ulcers once they occur. This article discusses the current practice for pressure ulcer prevention. Next month, a companion article will explore treatment strategies for these wounds.

An update on horizontal patient support surfaces.

Horizontal patient support surfaces play an important role in the prevention and development of pressure ulcers. This article reviews the literature published on these support surfaces since the release of the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline Number 15: Treatment of Pressure Ulcers. The purpose of this review is twofold: One, to see if any new evidence is available to assist the clinician in making scientifically based decisions in the use of support surfaces, and two, to determine if new knowledge about support surfaces would change the AHCPR recommendation.

Policy implications of using reverse staging to monitor pressure ulcer status.

In 1995, the National Pressure Ulcer Advisory Panel held its Fourth National Conference, "Pressure Ulcer Healing: Controversy to Consensus, Assessment Methods and Outcomes." At that time, agreement was reached on uses and misuses of the current pressure ulcer staging system. Participants agreed that pressure ulcer staging definitions should not be used in reverse order to measure improvement in an ulcer. Negative outcomes of reverse staging were seen as (1) denial of acute or skilled care after Stage IV ulcers were restaged as Stage II ulcers; (2) withdrawal of pressure-reducing support surfaces when ulcers "healed" from Stage III or Stage IV to Stage II; and (3) lower fees paid to extended-care facilities for care of patients with healing Stage III and Stage IV ulcers that were reclassified as Stage II or Stage I pressure ulcers.

Pressure ulcer scale for healing: derivation and validation of the PUSH tool. The PUSH Task Force.

Measuring progress toward healing is fundamental to the management of pressure ulcers. A method to assess progress of an individual ulcer over time is lacking. Given the limitations of currently available instruments and the need for a precise and practical method of monitoring healing in clinical practice, the National Pressure Ulcer Advisory Panel initiated the development of a new tool for measuring pressure ulcer healing. The key elements in developing an instrument include simplicity of use in clinical settings, validity for measuring whether ulcers are improving or worsening, and sensitivity to changes in the ulcer between observations. A new tool incorporating surface area, exudate amount, and surface appearance is proposed. Content validity, correlation validity, prospective validity, and sensitivity to change can be met by the proposed Pressure Ulcer Scale for Healing instrument.

PUSH Tool reality check: audience response. Pressure Ulcer Scale for Healing.

Following presentation of the Pressure Ulcer Scale for Healing (PUSH), conference participants broke into small discussion groups according to their practice settings: acute care, long-term care, and home care/outpatient care. Questions were posed to participants regarding the reality of using the PUSH Tool in their practice settings. These questions were structured to elicit comments about: (1) the characteristics of the PUSH Tool; (2) the validity, reliability, and practicality of the PUSH Tool; and (3) education and implementation requirements prior to use of the PUSH Tool. This article summarizes their comments, which will be used in refining the PUSH Tool.

Pressure ulcer assessment.

Pressure ulcer assessment requires quantification of multiple parameters of the ulcer and periulcer tissue. Clinical assessment should include ulcer history (including etiology, duration, and prior treatment), anatomic location, stage, size (including length, width, and depth measured in centimeters), sinus tracts, undermining, tunneling, exudate or drainage, necrotic tissue (slough and eschar), presence or absence of granulation tissue, and epithelialization. In addition, the ulcer borders can provide clues to healing potential. Intact skin surrounding the ulcer should be assessed for redness, warmth, induration or hardness, swelling, and any obvious signs of clinical infection. Pressure ulcer associated pain should be assessed prior to examination of the ulcer.

Debridement: choices and challenges.

Debridement of nonviable tissue is crucial to optimal wound healing, which can be impaired unless all necrotic tissue, exudate, and metabolic wastes have been removed from the wound. Debridement methods are classified as sharp, mechanical, chemical, and autolytic. This article describes methods of debridement and their outcomes.

Pressure ulcers: decreasing the risk for older adults.

Pressure ulcers are common among the frail elderly. Reducing the incidence of pressure ulcers requires vigilance on the part of an entire interdisciplinary team; however, gerontology nurses in particular must know how to intervene and assist in maintaining tissue integrity for older adults who are at risk. This article discusses various factors that place individuals at risk for pressure ulceration. Ways to address factors that place patients at particularly high risk for pressure damage are also suggested.

Using wound care products to promote a healing environment.

Healing is characterized by the synthesis of new tissue and scar formation. Despite the complexity of healing with full-thickness injury, the repair process occurs in a predictable manner. There are four basic principles of wound care: (1) debride necrotic tissue and cleanse the wound to remove debris, (2) provide a moist wound healing environment through the use of proper dressings, (3) protect the wound from further injury, and (4) provide nutritional substrates essential to the healing process. Most importantly, any underlying pathophysiology must be treated or the wound will not heal. Products selected to create a healing environment must be chosen thoughtfully and scientific rationale must support their use. Intensive care nurses have the opportunity to get the patient off to the right start by attending to the basic principles elucidated in this article. Accurate wound assessment and appropriate product choices can promote a healing environment. Intensive care of patients includes differentiating wound types and making appropriate wound care product decisions that ultimately affect patient outcomes.