SALT LAKE CITY The Pressure Ulcer Scale for Healing proved superior to assessment by experienced nurses in determining status and progression of long-term care residents' wounds, researchers reported at the annual symposium of the American Medical Directors Association.
"It was surprising because we thought the clinical way was the better way," said Dr. Erica George-Saintilus with Long Island Jewish Medical Center, who presented a poster on her study at the center-affiliated Cold Spring Hills Center for Nursing and Rehabilitation in Woodbury, N.Y.
Whereas nurses assessed the wounds primarily by subjective impressions and wound size, the Pressure Ulcer Scale for Healing (PUSH) tool tallied three parameters:
▸ Wound size in scores representing skin area from none (0) to more than 24 cm
▸ Amount of exudate from none (0) to heavy (3).
▸ Tissue type from closed/resurfaced (0) to necrotic tissue/eschar (4).
The team reviewed records of all residents with stage II-IV ulcers in the 627-bed skilled nursing facility from 2004 through 2006. Weekly reports on the wounds included data sufficient to calculate a PUSH score as well as nurse assessments such as "improved," "deteriorated," or "unchanged." In patients with multiple wounds, the study tracked only one ulcer.
"There's no indication [from statistical analyses] that nurses' observations agree at all with the PUSH," said Dr. George-Saintilus.
Looking specifically at 2 months of data for 30 residents, the researchers determined that PUSH scores were better than the nurses' assessments at indicating the direction that a wound was taking. Dr. George-Saintilus pointed out instances in which a pressure ulcer that a nurse had recorded as "healed" returned and got worse. In contrast, PUSH scores were more likely to indicate the true progression of a wound.
Further, Dr. George-Saintilus and her colleagues discovered that the nurses' assessments were idiosyncratic. "Each nurse has her own way of giving her impression," the researcher said.
PUSH was introduced 11 years ago by the National Pressure Ulcer Advisory Panel, a coalition of corporate and professional organizations that sets care standards. AMDA's "Pressure Ulcers in the Long-Term Care Setting" clinical practice guideline cites PUSH as a "validated tool for characterizing and monitoring pressure ulcers." The guideline includes directions and a blank scoring sheet, and the advisory panel offers the same at http://www.npuap.org/PDF/push3.pdf
Dr. George-Saintilus said that her observations of nurses at the Cold Spring Hills facility, which now uses the PUSH tool, show that PUSH is actually quicker to use than the subjective system. The old record keeping included nurses' assessments and several wound parameters but didn't combine those data into a score that could be tracked as easily as the PUSH score. She said that PUSH "saves time and money."