Pressure Ulcer PUSH Score and Traditional Nursing Assessment in Nursing Home Residents: Do They Correlate?
Article Outline
Background
Over a decade ago, the National Pressure Ulcer Advisory Panel (NPUAP, 1997) recommended a new tool, the Pressure Ulcer Scale for Healing (PUSH) tool to document ulcers and monitor the healing process. Yet, traditional nursing observation remains standard practice in chronic care, thus prompting this correlational study between PUSH and traditional documentation of pressure ulcers.
Methods
Data were cross-tabulated through a retrospective chart review of all residents with stage II–IV decubiti at a 672-bed skilled nursing facility, between January 1, 2004, and December 31, 2006. A correlation analysis was performed between the clinical nursing observation, which was based primarily on ulcer size and documented on the weekly decubiti flow sheets, and the weekly PUSH score over a period of at least 2 months. Agreement was assessed using kappa statistics for a 3 × 3 table between the nurse's impression (improved, unchanged, deteriorating) and the change in PUSH score (+1, 0, or –1).
Results
In the 370 observations compiled for the 48 residents, the nurses documented improvement in 212 observations (57%). However, of these 212 traditionally assessed “improved” ulcers, there were only 89 (42%) concordant “better” PUSH scores and 99 (47%) received a “no change” PUSH score. Twenty-four (11%) of the 212 actually received a deterioration of the ulcer rate using the PUSH tool. Of the 110 (30%) traditionally assessed as “unchanged” ulcers, only 45 (42%) matched “unchanged” PUSH scores. Finally, for the 48 (13%) traditionally documented “deteriorating” ulcers, there were only 25 (52%) observations in agreement with the “deteriorating” PUSH scores. Overall, in this longitudinal study, the symmetric measures reports indicated very little agreement between the 2 assessment methods (kappa range: 0.007–0.298).
Conclusion
Although the NPUAP has formally recommended the PUSH tool as the pressure ulcer assessment method of choice, our data indicate that the PUSH does not highly correlate with traditional nursing observation. Further study is required to determine the most accurate assessment method. The adoption of a universally accepted tool, together with rigorous documentation methods, will improve the overall clinical care of chronic patients with pressure ulcers.
Keywords: Pressure ulcer, PUSH, wound care
Despite new technologies and increased awareness, pressure ulcers (PU) remain a common problem in the long-term care setting, where as many as 50% of elderly nursing home patients have decubiti.1, 2 It estimated that 1.3 to 3.0 million institutionalized adults have pressure ulcers, and the cost of healing any individual pressure ulcer ranges between $500 and $45,000.3, 4, 5 Pressure ulcers are associated with pain, suffering, and decreased quality of life.6, 7 In addition, the health care industry today faces an increasing amount of oversight as they comply with new guidelines from federal, state, and local governments and agencies to document in a timely manner the occurrence of pressure ulcers for clinical care.8 On August 1, 2007, the Centers for Medicare and Medicaid Services (CMS) selected 8 preventable conditions that would impact inpatient prospective payment.8 Of these 8 conditions, pressure ulcers are a critical issue for both long-term care nursing facilities and hospitals, because appropriate documentation of skin condition at time of transfers to and from nursing facilities may impact overall patient health care and reimbursement. As of October 2008, CMS will no longer reimburse hospitals for the additional diagnosis related group (DRG) cost of facility-acquired pressure ulcers. The addition of the new indicator Present on Admission (POA) has considerable financial implications for adequate reimbursement of pressure ulcer treatment, which is labor intensive and often requires costly topical applications.8 These new regulations are triggering an urgent need to reevaluate pressure ulcer monitoring and documentation, not only in nursing facilities, but also in acute care settings.
Over a decade ago, in 1997, the National Pressure Ulcer Advisory Panel (NPUAP) developed the Pressure Ulcer Scale for Healing (PUSH) tool, an objective instrument to improve the monitoring of pressure ulcer healing.9, 10, 11 This tool is a quantitative method used to monitor the healing of pressure ulcers. In February 2007, the NPUAP included 2 additional stages, namely “unstageable” and “suspected deep tissue injury” (DTI).12 Current clinical practice guidelines recommend the use of the PUSH tool on a weekly basis throughout the long-term care industry.13
The PUSH tool consists of 3 parameters to be assessed once a week: length times width, exudate amount (none, light, moderate, and heavy), and tissue type (necrotic tissue, slough, granulation tissue, epithelial tissue, or closed). Each parameter is scored and the sum of the 3 yields a total wound status score to determine healing. The score ranges from 0 to 17, 0 scored as healed and 17 scored as the worse possible score. Observation of the changes in the direction and magnitude of the score over time indicates whether wound healing is occurring. The main purpose of the authors' research is to compare the PUSH tool method to the traditional method of nursing observation of pressure ulcers in the nursing home setting to determine the correlation between the 2 methods.
Methods and Design
The study consisted of a retrospective chart review of 100 charts of long-term care residents living at a 672-bed skilled nursing facility located in the New York metropolitan area with stage II to IV pressure ulcers, chronologically arranged by discharge date during the 2-year study period. Inclusion criteria were as follows:
The data were collected from weekly nursing pressure ulcer flow sheets from open and closed records of nursing documentation over a 2-month period in 2007. All 3 parameters used in the PUSH tool, namely, length by width, exudate amount, and tissue type, were tabulated. In residents with multiple pressure ulcers, one single pressure ulcer was selected for ongoing monitoring, using a table of randomization. Therefore, only one ulcer was monitored per resident for the purpose of this study.
The clinical observations were performed by the nurses assigned to the unit, as usual care. As per nursing home protocol, the observations from the nurses' assessments were charted (improved, deteriorating, unchanged) based on their clinical impression. The PUSH score, however, was calculated by the principal investigator, via the clinical observation documentation obtained in the chart, based on the PUSH score parameters, namely, surface area, tissue type, and exudate amount. We compared the level of agreement between the PUSH score (0 to 17) and the nurse's clinical observation (deteriorating, unchanged, improved) with regard to healing, compared to the change in the direction and magnitude of the PUSH score over time. An agreement analysis was performed between the traditional, clinical observation and the difference in the PUSH score. Agreement was assessed using kappa statistics for a 3 × 3 table between nurses' impressions (improved, unchanged, deteriorating) and the change in PUSH tool score (improved: –1 or less; unchanged: 0; deteriorating: +1 or more). The observation from the nurses' assessments (better, same, worse) were compared to the change in the direction and magnitude of the PUSH scores over time, using the information documented on the Weekly Pressure Ulcer Flow Sheet.
Results
Of these 100 residents, 52 were excluded from the analysis: 22 were found to have documented stage I ulcers, 21 were found to have completely healed ulcers, and 9 had incomplete documentation, rendering the calculation of the PUSH score impossible. In the 370 remaining total weekly observations for the 48 residents who conformed to study criteria, the nurses' clinical impressions were compared with tabulated longitudinal PUSH scores. In terms of overall agreement between clinical observation and PUSH measurements, only 159 (43%) of the 370 ulcers observed showed agreement between the traditional assessment and PUSH scores (Table 1).
Table 1. Within Group Concordance of Clinical Observation and PUSH Measurements for 48 Residents (N = 370)
| Total Assessment | + | 0 | − | Total |
|---|---|---|---|---|
| + | 89 (42%) | 99(47%) | 24(11%) | 212 |
| 0 | 27(25%) | 45(42%) | 38(35%) | 110 |
| − | 9(19%) | 14(29%) | 25(52%) | 48 |
| Total | 125 | 158 | 87 | 370 |
In those 370 weekly observations, the nurses documented improvement in 212 (57%). However, of these improved ulcers, there were only 89 (42%) concordant “improved” PUSH scores with 99 (47%) unchanged and 24 (11%) deteriorating PUSH scores.
Of the 110 (30%) clinically unchanged ulcers, only 45 (41%) had matching “unchanged” PUSH scores. There were 27 (25%) improving and 38 (35%) deteriorating pressure ulcers according to PUSH scores.
Finally, for the 48 (13%) documented deteriorating ulcers, there were 25 (52%) scores in agreement with the “deteriorating” PUSH tool, 9 (19%) improving, and 14 (29%) unchanged ulcers according to PUSH scores (Table 1a).
Table 1a. Between Group Concordance of Clinical Observation and PUSH Measurements for 48 Residents (N=370)
| N=370 | Push Improved | Push Unchanged | Push Worse | Total |
|---|---|---|---|---|
| Clinically improved | 89(24%) | 99(27%) | 24(6%) | 212(57%) |
| Clinically same | 27(7%) | 45(12%) | 38(10%) | 110(30%) |
| Clinically worse | 9(2%) | 14(4%) | 25(7%) | 48(13%) |
The data were further stratified by staging (in the event a resident had multiple staging, the maximum stage was selected). The kappa statistic for concordance between clinical impression and PUSH score was calculated. There was low level of agreement for each stage. For stage II ulcers, the kappa statistic was 0.132 (P = .029). For stage III ulcers, the kappa statistic was 0.129 (P = .04). For stage IV ulcers, the kappa statistic was 0.111 (P = .029). In regards to a longitudinal study, the symmetric measures reports indicated very little agreement between the 2 assessment methods at each staging level. Overall in this retrospective study, the symmetric measures reports indicated very little (statistically insignificant) agreement between the 2 assessment methods (kappa range: 0.007 to 0.298) (Fig.1).
Fig. 1.
Performance matrix illustrating overall level of agreement between PUSH and traditional assessment method. Note: The size of the bubble corresponds to the number of observations falling in each cluster.
Discussion
The goal of the study was not to determine the superiority of either method of wound assessment. We sought to explore the relationship between these 2 common approaches to monitoring pressure ulcers, since the NPUAP recommended implementation of the PUSH tool and descriptive information such as the length, width, and depth of the wound.
This study showed a striking lack of agreement between traditional nursing assessment and the PUSH tool. Nurses routinely documented the size of the ulcers as a parameter for healing (or nonhealing), rather than integrating the 2 parameters of tissue type and exudate amount. Pressure ulcer monitoring is a time-consuming nursing task, regardless of method of assessment. There is no evidence that the 3 elements of the PUSH tool would be more time consuming to administer than complex nursing observations, which may include site, stage, size, tunneling, depth, undermining, drainage, (amount, type, odor) wound base, necrosis treatment, pain, rating, progress, and signature. On the other hand, PUSH tool implementation does require staff training, which can also be time consuming for nursing and medical staff. Given the current and imminent changes in CMS regulations, pressure ulcers are certainly proving to be a multidisciplinary problem rather than strictly a nursing concern. In long-term care facilities, CMS has established a definition for “unavoidable pressure ulcers,” that may prevent unwarranted penalties.14, 15 CMS clearly defines the term “unavoidable” in relation to long-term care facilities as follows: “The resident developed a pressure ulcer even though the facility had evaluated the resident's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of interventions; and revised the approaches as appropriate.”17 Failure of nursing homes to properly assess residents' skin integrity on admission, to identify pressure ulcer risks when appropriate, and not update care plans to document the progress of monitoring are all at risk for a citation under Federal Tag F314.
Conclusion
This study showed little correlation between the PUSH tool and traditional nursing assessments. The monitoring of pressure ulcers is a time-consuming challenge for the geriatric team and a critical issue for health care administrators, requiring objective and sensitive tools to document and monitor pressure ulcers. Preventive strategies must be developed in the areas of clinical training for health care personnel. Research efforts must be encouraged through studies such as the National Pressure Ulcer Long-Term Care Study, to identify risk factors and facility characteristics associated with pressure ulcer development in long-term care residents.16 This problem, which is a frequent comorbidity seen in elderly patients in hospital and long-term care settings and in their own homes, is now becoming the focus on new CMS guidelines.
The management of pressure ulcers is a premier example of the importance of an interdisciplinary team communicating effectively and assisting each other for the ultimate benefit of their patients. Choosing the most appropriate clinical assessment tool is critical to maximize communication. Although the NPUAP has formally recommended the PUSH tool as the tool of choice, our data indicate that the PUSH does not highly correlate with traditional nursing observation. Further study is required to determine the most accurate assessment method. The adoption of a universally accepted tool, together with rigorous documentation methods, will improve the overall clinical care of chronic patients with pressure ulcers.
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None of the authors have any financial interest in the study, nor do they have any conflict of interest.
PII: S1525-8610(08)00416-7
doi:10.1016/j.jamda.2008.10.014
© 2009 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.
