Long-Term Care Survey Alert

A scoring system can be worth a thousand words to show ulcer healing.

Saying a pressure ulcer is healing is one thing. Proving it is another matter entirely--especially to surveyors armed with revised F314 survey guidance designed to ding facilities that don't change care plans for a nonhealing wound.

The key to ensuring adequate wound healing and outcomes is knowing when to change direction with a wound, says Roberta Reed, RN, MSN, NHA, a survey expert in Cleveland, OH.

Solution: Using the PUSH tool (Pressure Ulcer Scale for Healing), you can score a wound's status over time to show surveyors that a wound is indeed improving. "The PUSH tool gives you a better idea of healing by measuring the amount of necrotic versus granulating tissue in a wound bed," says Sarah Sunleaf, director of nursing for Aurora Life Care Center in Denver.

The tool can also provide an early warning system that a wound's healing trajectory has stalled, which could be due to infection or care-related issues (see "Wound Not Healing? Pull Out The 'Three-Legged Stool' To Take A Closer Look," later in this issue).

The National Pressure Ulcer Advisory Panel developed the PUSH tool as an alternative to downstaging wounds as required by Medicare, says Joyce Black, PhD, RN, associate professor of nursing at the University of Nebraska in Omaha.

Key point: The PUSH assessment scheme works best on chronic wounds. "The tool was validated in research studies evaluating healing in chronic wounds and is thus most reliable in assessing that type of wound," says Black. "So it doesn't work as well in assessing the speed at which one sees changes in an acute wound," she adds. "Wounds in long-term care tend to be more stable and heal over six months."

Here's How It Works

Clinicians use the PUSH tool to assess a wound weekly. "The directions [for using the instrument] are fairly clear," she notes. The first parameter for measuring the wound is its size, which is the best independent predictor of wound healing, says Black.

"Measure the wound from 12 to 6 o'clock or head to toe (length) and width from 3 to 9 o'clock," Black directs. To determine a score for size, multiply the length by the width (in centimeters) and come up with an estimate of the wound's size in square centimeters (see the tool, later in this issue).

Tip: An oddly shaped wound can pose a challenge to accurate measurements--an issue that the NPUAP, which developed the tool, is looking into, Black adds.

The tool also measures wound exudate (drainage) and the type of tissue in the wound bed. The tool directions call for providers to estimate the wound's exudate after removing the wound dressing and before applying any topical ointments or other medication to the wound. Estimates range from none to light, medium or heavy.

The type of tissue present in the wound includes necrotic, slough, granulation tissue or epithelial tissue (for descriptions and scoring, see the PUSH tool instrument later in this issue).

Augment Your Assessment

The PUSH instrument doesn't measure odor, pain and bleeding. "But you can supplement the tool by assessing those variables," says Black. For example, if a chronic wound is red and has an odor, you'd suspect an infection. "If a wound has an infection, its [healing] trajectory will stall or decline," she says.

Wound pain signals infection  or ischemia. For example, the person may have been putting too much pressure on the area resulting in new ischemia, says Black. "A new wound hurts," she adds, "but as the wound heals and closes, pain should decrease."

Pain can also reflect ischemia due to a thrombotic (clotting) process. "You see that in ulcers affecting the extremities, but if you had embolization of the iliac artery, the person's leg wouldn't have a pulse," says Black.