OASIS Alert

Published on Mon Jan 28, 2008 PDF

Here's your early warning system for pressure ulcer deterioration.

With two new wound care measure on Home Health Compare, it will be even more important to show improvement in the OASIS items assessing changes in wound status. Here's one way to improve assessment and wound care.

When patients have chronic wounds that take a long time to heal, clinicians may have trouble demonstrating progress in wound status. And poor documentation may make it hard to determine when progress stalls and the wound requires a new treatment approach.

Solution: Use the PUSH tool (Pressure Ulcer Scale for Healing) developed by the National Pressure Ulcer Advisory Panel.

"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 PUSH tool was developed and validated using research studies evaluating healing in chronic wounds, and is "most reliable in assessing that type of wound," says Joyce Black, associate professor of nursing at the University of Nebraska in Omaha.

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

Clinicians use the PUSH tool to assess a wound weekly. The directions [for using the instrument] are fairly clear, Black notes:

• Measure size. The first parameter for measuring the wound is its size, which is the best independent predictor of wound healing, she says.

"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 (for tool, see p. 7).

Watch for: 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.

• Estimate drainage. 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.

• Determine tissue type. The type of tissue present in the wound includes necrotic, slough, granulation tissue or epithelial tissue.

The PUSH tool doesn't stage the ulcer, but it does support the clinician's judgment about the ulcer's stage. NPUAP has added an unstageable category for a pressure ulcer that needs to be debrided before you can stage it. "Almost always, a wound bed covered by necrotic tissue is a stage 4," says Dorothy Doughty, director of the Wound Ostomy Continence Nursing Edu-cation Center at Emory University. Even so, "you cannot technically stage the wound until you can visualize the wound bed," she says.

The PUSH instrument doesn't measure odor, pain and bleeding. "But you can supplement the tool by assessing those variables," says Black.

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.