The Pressure Ulcer Scale for Healing (PUSH) is a commonly used tool that monitors a wound through the healing process. It is an easy, quick and effective scale that can differentiate between a healing and nonhealing wound. However, there are some limitations to the PUSH scale. Below is a review of the literature both supporting and refuting the PUSH scale.
Supporting PUSH
The study, “A Prospective Study of the PUSH Tool in Diabetic Foot Ulcers,” by Sue Gardner, Stephen Hillis, and Rita Frantz aimed to determine how scores of the PUSH tool change over time, whether the tool could predict healing time, and which categories of the tool were able to most accurately predict healing time in individuals with neuropathic foot ulcers. Patients studied had a neuropathic foot ulcer on the plantar surface of their foot and did not have peripheral arterial disease. The patients all received moist dressing and debridement of heir ulcers and were assessed using the tool 7 times over a 13 week period. The results of the study found that PUSH scores decreased over time, the PUSH was able to predict healing time, and length X width measurement may be the best predictor of healing time.
In the article by Gardner et.al., a prospective study of residents of three nursing homes in two states with pressure ulcers was completed to determine effectiveness of the PUSH scale. In order to be included in the study, the subjects had to have a stage two or greater pressure ulcer during a six month time period. The pressure ulcers were examined each week using the PUSH, the ressure Sore Status Tool (PSST), and acetate tracings. These assessments continued each week until the ulcer healed, the resident died or transferred, or the 6 months was completed. At the conclusion of the study, it was found that PUSH scores decreased among healed ulcers but did not decrease among the unhealed ulcers. “Comparison of PUSH total scores for healed and unhealed ulcers approached closure, confirming the ability of PUSH to differentiate healing from non-healing ulcers.” It was noted that the PUSH gives a valid measure of healing over time and distinguishes healing from non-healing ulcers. It is also clinically practical for tracking change. The study stated that while it was effective, mostly stage 2 ulcers were examined and more data would need to be gathered on other ulcer stages.
The study, “A prospective study evaluating the Pressure Ulcer Scale for Healing (PUSH Tool) to assess stage II, stage III, and stage IV pressure ulcers," was conducted to evaluate the use of the Pressure Ulcer Scale for Healing (PUSH tool) in patients with one or more pressure ulcers. The main aims of the study were to determine if the total PUSH score would change significantly over time and if the PUSH total scores were significantly different for healed and unhealed pressure ulcers. The study included 72 patients with 86 pressure ulcers total (49% Stage II, 47% Stage III, 4% Stage IV). For those with multiple ulcers, the PUSH scores were added together. The results of the study showed that the PUSH total scores decreased significantly during the 8-week study. Differences were noted each week for healed ulcers, whereas scores in unhealed ulcers only showed significant differences between the first and eighth week. These findings show that the PUSH scores were consistent with healing outcomes and validate the tools ability to differentiate between healing and nonhealing pressure ulcers in multiple stages.
This study, Use of the PUSH tool to measure venous ulcer healing, demonstrates the effectiveness of the PUSH tool to measure venous wounds rather than pressure ulcers. It has a relatively small sample size in 27 patients. Ulcers were measured on each patient. If a patient had multiple ulcers, the largest one was used for measurement. These patients were seen 3 times with 1 month between each visit. Of the 23 ulcers that healed, all had a decrease in PUSH score. Additionally, the PUSH score increased in the ulcers that were not healing. The authors concluded that the PUSH is good to use to assess healing over time, but may not be best for onitoring effect of a specific intervention. The PUSH should be used as a global assessment of healing in venous ulcers.
Refuting PUSH
The article, “The PUSH Tool: A Survey to Determine Its Perceived Usefulness,” aimed to determine the positive and negative aspects of the PUSH tool through a survey completed by users of the tool. The areas of interest included: experience with the instrument, perceived ease of use, and perceived weakness. A 5 point Likert scale was used to answer statements about the PUSH tool and open ended questions were included for more detailed answers. The results of the survey found that most agreed the PUSH was quick and easy to use and that PUSH scores encourage reassessment and treatment. Many respondents agreed that improvements could be
made in the tool in the areas of the size, tissue type, and exudate amount subscales. In the open ended section suggestions were made about adding wound depth. Comments were also made suggesting that for large wounds, the tool does not portray healing appropriately.
In the article by George-Saintilus, et.al., data was gathered through retrospective chart review of patients with stage 2-4 pressure ulcers in a skilled nursing facility during a two year period. The point of this study was to determine if the PUSH correlated with nursing assessment of pressure ulcers. Analysis was then performed looking at the PUSH score, clinical nursing observation (based mainly on ulcer size), and weekly flow sheets. A kappa statistic for a 3 x 3 table was used comparing nursing observation (improved, unchanged, deteriorating) and PUSH score difference (+1, 0, -1). It was determined that although the PUSH is usually recommended, it “does not highly correlate with traditional nursing observation.” It was determined that further study would be needed to figure out what assessment tool would be most accurate and have the strongest correlation with nursing observation.
This article makes an important point that although this scale seems to work, it does not match up with the observation of health care professionals which may create confusion in prognosis as well as treatment plans.
In the article, A prospective study evaluating the Pressure Ulcer Scale for Healing (PUSH Tool) to assess stage II, stage III, and stage IV pressure ulcers, the author describes some of the limitations for the PUSH scale. He explains that the tool incorporates three different categories (size: length x width, exudate amount and tissue type) each of which has its own weighted score. “Size is weighted about 3.33 times more heavily than exudate amount and 2.5 times more heavily than tissue type.” That means the status of the wound is mostly affected by changes in wound size over exudate amount or tissue type. This can be a problem because the dressings applied to the wound will affect the amount of exudate. Wound dressings are not all standardized when it comes to wound management, so the exudate analysis may not be as accurate. Another major limitation to the PUSH tool is that it does not assess the depth of the wound. If the tool is used to assess the healing process, the PUSH scale would not be able to determine significant improvements when depth has changed. More studies are needed to assess these limitations to determine the accuracy of the PUSH tool for wound healing assessment.
In the article, Use of the push tool to measure venous ulcer healing, the authors describe some of the limitations to the PUSH scale. One of them was that it can’t be used to measure specific
treatment effects. The scale is best used for long-term, global assessments of wound healing. They also explained that the PUSH can’t be used on every type of wound. Further studies need to be conducted to assess these limitations.
References:
Gardner, S. E., Hillis, S. L., & Frantz, R. a. (2011). A prospective study of the PUSH tool in diabetic foot ulcers. Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society / WOCN, 38(4), 385-93. doi:10.1097/WON.0b013e31821e4dbd
Gardner, Sue, Rita Frantz, Sandra Bergquist, and Chingwei Shin. "A Prospective Study of the Pressure Ulcer Scale for Healing (PUSH)." Journal of Gerontology. 60A.1 (2005): 93-97. Web. 10 Apr. 2012.
Günes UY. “A prospective study evaluating the Pressure Ulcer Scale for Healing (PUSH Tool) to assess stage II, stage III, and stage IV pressure ulcers.” Ostomy Wound Management. 2009 May
1;55(5):48-52. Web 18 Apr. 2012.
Ratliff, C. R., & Rodeheaver, G. T. (2008). Use of the push tool to measure venous ulcer healing. Ostomy Wound Management, 51(5), 58. Retrieved from http://www.o-wm.com/article/4082?
Berlowitz, D. R., Ratliff, C., Cuddigan, J., & Rodeheaver, G. T. (2005). The PUSH tool: a survey to determine its perceived usefulness. Advances in skin & wound care, 18(9), 480-3. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16365545
George-Saintilus, Erica, Barbara Tommasulo, et al. "Pressure Ulcer PUSH Score and Traditional Nursing Assessment in Nursing Home Residents: Do They Correlate?." Clinical Practice in Long-Term Care-JAMDA. (2009): 141-144. Web. 10 Apr. 2012.
At this time, there is no evidence to negate what is stated above. However, I did find additional evidence on how the PUSH tool should be used, along with another limitation.
ReplyDeleteThe characteristics evaluated on the PUSH scale have associated weights, but these weights are not clinically related to outcome. Clinical meaning of a one-point change of score has not been clarified for the PUSH tool, because the weights were derived based on expert opinions. The PUSH scale is a good tool to evaluate the severity at a given time and monitor the progress of a pressure ulcer. However, this tool does not have the ability to predict subsequent healing, based on the degree of score change. A tool that is better suited to capture this predictive aspect is the Design-R, which uses weights that were statistically calculated to depict pressure ulcer healing rates. With this tool, a one-point improvement over any one-week timeframe is positively associated with healing within the next thirty days, for both superficial and deep pressure ulcers.
The Scientific Education Committee of the Japanese Society of Pressure Ulcers (JSPU) recently developed Design-R, and it has been widely used throughout Japan since. The purpose of this prospective cohort study was to explore the predictive ability of pressure ulcer monitoring and determine the optimal cutoff criteria for improvement and deterioration of pressure ulcer status, while using the Design-R tool. A major advantage to the use of the Design-R over the PUSH tool is that depth is included as a measure, classifying wounds as superficial or deep, which is one of the limitations to the PUSH tool. Wound monitoring, using the cutoffs established in the Design-R tool, helps clinicians accurately evaluate prognosis, detect abnormal healing, and reassess the suitability of the treatment interventions. Whereas, the PUSH tool is really only capable of evaluating severity at a given point in time and tracking the progress of the wound.
Reference:
Lizaka S, Sanada H, Matsui Y, et al. Predictive validity of weekly monitoring of wound status using DESIGN-R score change for pressure ulcer healing: a multicenter prospective cohort study. Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society. 20(4):473–81. doi:10.1111/j.1524-475X.2012.00778.x.
It seems there is a common theme that although the PUSH tool is helpful & convenient,quick & encourages reassessment,it lacks in correspondence with the opinion of the experienced wound care specialists.It seems that everyone just keeps using it because it is an established way to document wound care progression even though no one really underst&s how reliable or valid it is.I found an article that addressed this dilemma & after assessing the reliability & validity of the PUSH scale & 3 other wound healing assessment tools,researchers decided to create a new improved tool.
ReplyDeleteIn a systematic review article by Juan Carlos Restrepo-Medrano & José Verdú Soriano the reliability & validity of different wound healing assessment tools were analyzed.The object was to research the tools & decide if there was one tool with high enough reliability & validity to be named the “Gold st&ard” of tools. They began their systematic review in data bases of health science.Their searches initially lead them to 20 articles based on 8 different wound healing assessment tools.A literature review was done & found that 4 of the articles had reliability & validity test measures: PUSH,PSST,CODED & DESIGN.The PUSH scale was found to be the only scale validated for venous insufficiency wounds & was the most widely used by clinicians.It was found to be the quickest & most reliable way to measure the status & progress of wounds through time,however the evidence behind how it was developed was not clear in the literature which lead to questioning of reliability & validity.The PUSH test has also been translated to be used in Spanish speaking countries,but no evidence exists on the reliability & validity of the adaptation.
Based on their findings,the researchers concluded that there were no reliable & valid wound healing assessment tools,so they decided to create a “de novo” scale that could be trusted to be reliable & valid for all types of chronic wounds.They created the RESVECH V1.0 tool.Below is their explanation of how the tool is used as well as a sample measure:
“It [RESVECH V1.0] contains nine items: wound dimensions,depth/tissues involved,edges,perilesional maceration,tunneling,type of tissue in the wound bed,exudate,infection/inflammation (biofilm signs),& pain frequency (in the past 10 days).The scale is scored numerically between 0 (wound healed) & 40 points (worst possible condition).Additionally,operational definitions are provided for each item,as well as the way of assessing them.”--- (Carlos & Soriano,2012)
“RESVECH SCALE V1.0: Scale of results from assessment & progress of wound healing. Operational definitions of variables & instructions for use: Indicate the score for each item in the box corresponding to the time of measurement (e.g.,Measurement 0,Date ___________)."
"1.Ulcer dimensions 1.1. Dimensions: Indicate the measurements as length x width,as follows: n Length: Cephalocaudal measurement (from head to feet),n Width: Perpendicular to length.Express both measurements in cm.Then multiply length x width to obtain the area in cm2.Assign a score from 0 to 6 according to the area.For example,an area of 44 cm2 would be scored as 4.” (Carlos & Soriano,2012)
This new tool was then analyzed & found to have a CVI (context validity index) of 98%.It was also proven that this is the first wound measurement tool that is applicable to all types of wounds from any etiology that can be used from the time the wound is obtained until complete healing has occurred.
According to this article,the PUSH tool should be abandoned & the RESVECH tool implemented.However,I am not sure how easily accessible this tool is yet,it might take time for this to make its way to mainstream PT & wound management practice.
Reference: Carlos,J.,& Soriano,J.V.(n.d.).Development of a wound healing index for chronic wounds.(2012).EWMA Journal,12(2),39-46
Submission by Amy Watchous Renfro
My reviews are not specifically for the PUSH scale, but for other methods used in wound bed assessment. The first article is a review of specialized nurse education for wound bed assessment.
ReplyDeleteHospital acquired pressure ulcers (HAPUs) are costly to both hospitals and patients. HAPUs have been reported to cost approximately $129,248 for a single admission and $124,327 over four admissions. These costs are becoming increasingly difficult for the hospitals to get reimbursed, as the Centers for Medicare and Medicaid Services are tightly regulating non-payment for hospital-acquired conditions and pressure ulcers. The costs of HAPUs are increasingly high for patients also, as they lead to longer hospital stays, increased pain and discomfort, and increased morbidity and mortality rates.
In 2008, the Winthrop University Hospital in Mineola, NY began implementing strategies in its Neuroscience Unit to reduce HAPUs and tracked the results of these implementations over several years. The initial interventions included: repositioning patients every 1-2 hours, using specialty beds with higher risk patients, and developing a SWAT team (skin and wound assessment team) to check all patients in the unit at least once a week. The SWAT team consisted of two nurses and two nursing assistants who were already members of the hospital staff. The SWAT members’ monitored patients’ status from head to toe, measured ulcers, documented, and educated other nursing staff on how to perform these tasks. In 2009, the end of the first year of the program’s implementation, the incidence of HAPUs in the Neuroscience ICU was reduced from 23 to 12 (48% reduction) and was reduced in the Neuroscience floor from 17 to 7 (59% reduction).
In 2010, further strategies were added to the program including the addition of: eight Stryker beds for high risk patients, heel lifting boots for vented and immobilized patients, and education for all new hospital staff. In a previous study by Black et al., “low air loss weight-based pressure redistribution-microclimate management system beds” were shown to be superior to “integrated powered air pressure redistribution beds” in reducing the frequency of pressure ulcers to the buttocks, sacrum, and coccyx (presence of ulcers with specialty beds: 0/31 – 0% for the former and 4/21 – 18% for the latter.) Education of the nursing staff continued to improve as the National Database of Nursing Quality Indicators (NDNQI) was added to the curriculum of all existing and entering nursing staff. A checklist with skin care reference guides was also given to new nursing employees to aid in predicting pressure sore risk, staging pressure ulcers, and determining the best skin care and positioning devices. These implementations helped the nursing staff become “experts” in skin care and further decreased the incidence of HAPUs in the Neuroscience Unit. By 2010, HAPUs were reduced down to 10 (a 57% overall reduction) in the ICU and down to 6 (a 65% reduction) in the floor.
In 2010, the SWAT team also gained hospital-wide usage. By the end of the study in 2011, the Neuroscience ICU had decreased the occurrence of HAPUs by 61%, the Neuroscience floor as a whole had decreased HAPUs by 82%, and all nurses in the hospital units had completed the NDNQI and HAPU prevention training. The implementations by the Winthrop University Hospital Neuroscience Unit proved to be successful in reducing the prevalence the HAPUs. The SWAT team was able to significantly impact the occurrence of HAPUs; which saves money and time, decreases potential length-of-stay for patients, and improves patient overall outcomes.
Reference: McGuinness, J., Persaud-Roberts, S., Marra, S., Ramos, J., Toscano, D., Policastro, L., & Epstein, N. E. (2012, January). How to reduce hospital-acquired pressure ulcers on a neuroscience unit with a skin and wound assessment team. Surgical neurology international. doi:10.4103/2152-7806.103645
Wound bed preparation:
ReplyDeleteWound bed preparation (WBP) is a process that aids in wound healing, especially difficult healing chronic wounds. Dr. Vincent Falanga and Dr. Gary Sibbald introduced WBP in 2000 with the goal to create the most optimal environment in the wound to promote wound vascularization, a stable wound bed, and little or no exudate. In 2003, International Wound Bed Preparation Advisory Board advanced WBP by developing “T.I.M.E” to guide preparation and optimize healing. T.I.M.E. stands for tissue management, inflammation and infection control, moisture balance, and epithelial (edge) advancement. T.I.M.E. process can be used in all wound types to help prevent acute wounds from becoming chronic wounds, and to jumpstart chronic wound healing.
Tissue management. Removal of necrotic tissue is one of the first steps in WBP. Necrotic tissue can interfere with proper wound healing. If necrotic tissue remains in the wound bed, accurate assessment of the wounds’ depth, size, and shape may be impeded. Necrotic tissue is a host for bacterial growth; removal helps prevent infection. Bacterial prevention keeps the small supply of nutrients and oxygen surrounding the wound available for regeneration of viable tissue. With necrotic tissue removed, a more viable wound base remains with a more functional extracellular matrix to promote tissue growth.
Tissue debridement can be accomplished through different techniques. Surgical method is considered the fastest and most accurate for assessing wound severity, but has downfalls as healthy tissue can be removed with necrotic tissue, surgical skill must be available, and treatment may be limited by patient tolerance. One advancement made in surgical debridement is introduction of Versajet hydrosurgery (Smith and Nephew, Tampa, FL). With Versajet, energy from a saline beam removes the wound surface with little damage to healthy tissue. This process has been documented as effective as pulse lavage in removing bacteria from the wound, and reducing the number of surgeries needed for WBP.
Inflammation and Infection control. Uncontrolled bacteria can cause critical colonization and delay wound healing. Microorganisms begin replicating and causing local tissue damage in critical colonization. Host defenses cannot maintain a bacterial balance and, if untreated, infection can develop. Signs of critical colonization include changes in wound bed color, unhealthy granulation tissue, abnormal odor, increased serous exudate, and pain. Chronic wound infection can be identified by an increased ulcer size. Critical colonization should be treated with antimicrobial dressings like sustained-release silver dressings with widespread antimicrobial actions. The wound should be debrided to remove replicating bacteria and reduce bacterial burden at the wound bed.
Moisture balance. Moisture balance is important in providing an optimal healing environment. A moist environment accelerates re-epithelialization in the wound bed by stimulating components that can increase wound healing like growth factors. Growth factors and cytokines help cells proliferate. Excessive fluids contain matrix metalloproteinases and serine proteases that can damage the extracellular matrix. Balancing the moisture in the wound bed is a delicate process requiring continuous examination. Advancement in this area is use of negative pressure on wounds, used to manage heavily draining wounds by providing the necessary moisture in the wound bed while draining the excess exudate. Negative pressure reduces edema, improves tissue perfusion, and reduces size and complexity of wounds by promoting contraction (macro-deformation). The properties of negative pressure alter the cytoskeleton around the wound, stimulate angiogenesis, reduce bacterial loads, and increase granulation tissue formation.
ReplyDeleteEpithelial (edge) advancement. Edge advancement is a key indicator of a healing wound. With delay in edge advancement, factors in T.I.M.E. WBP should be revisited. Once the element causing the delay is identified, treatment should begin to jumpstart the wound healing process.
Wound bed preparation continues to evolve. T.I.M.E. method of WBP has helped guide treatment of all wound types to promote the best environment for proper healing. Research has further advanced wound bed preparation, shifting toward holistic wound healing treatment. In the complex process of wound healing, systemic factors can impede the healing process. Systemic factors, including glycemic control in diabetes mellitus, medications like steroids and immunosuppressants, anemia, and smoking, are addressed as part of the wound patient treatment due to their affect on the regenerative capability of tissue and their tendency to delay wound healing.
Reference: Halim, a S., Khoo, T. L., & Saad, a Z. M. (2012, May). Wound bed preparation from a clinical perspective. Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India. doi:10.4103/0970-0358.101277
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