Pushing for Results

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June 2004

By Carrie Sussman, PT

The best available evidence-based method to measure pressure ulcer healing outcomes is being overlooked. The Pressure Ulcer Scale for Healing (PUSH) Tool was developed by the National Pressure Ulcer Advisory Panel (NPUAP) to quantitatively measure the healing of pressure ulcers and to replace an inappropriate reporting system called "reverse staging of pressure ulcers."¹

PUSH is the correct tool for replacing reverse staging, as it is very useful in monitoring pressure ulcer healing, senescence, or deterioration over time. PUSH provides a consistent, evidence-based methodology that enhances communication between health care professionals, providers, medical reviewers, caregivers, and patients regarding changing wound status.

Consequences of improper reporting of pressure ulcer healing include discounting the severity of the tissue injury, inappropriate or shortened treatment, failure of the pressure ulcer to heal, delayed reporting of ulcer deterioration, increased risk that the pressure ulcer may reoccur, and loss of reimbursement for services rendered. Furthermore, improper reporting of healing indirectly compromises the quality of life of patients with pressure ulcers.²

PUSH AND DOCUMENTATION
PUSH is an appropriate tool to be used for documentation to objectively quantify changes in wound status required by the Centers for Medicare and Medicaid Services (CMS) to qualify for reimbursement under the coverage policy for electrical stimulation for wound healing. Under CMS policy, it is necessary to show that the wound has not had measurable improvement in 30 days of standard care, and then to show measurable improvement in the next 30 days after introduction of the electrical stimulation intervention.

"Measurable" is defined by CMS as: decreased area or volume, decreased exudate amounts, or decreased amount of necrotic tissue-the same parameters used in PUSH. Consistent measurements using the same valid instrument would meet the CMS policy requirements.

Pressure ulcers are commonly classified using a four-stage system developed by the NPUAP and by the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality )³ (see Figure 1).

Figure 1. NPUAP Staging System.

The four-stage system is based on the depth of tissue lost and is appropriate for classifying the pressure ulcer initially or after debridement, but is not an appropriate system to measure pressure ulcer healing over time. Reverse staging assumed that a deep pressure ulcer, stage IV, would fill in and become a stage III, II, and finally a stage I when it closed. Reverse staging is not biologically correct because the replaced tissue for stages III and IV pressure ulcers is scar tissue and does not mimic the original tissue that has been lost. Healing of this type is referred to as secondary intention or tissue repair healing. Repaired tissue strength never returns to prior injury level. Stage II pressure ulcers close by regeneration, no scar is left, and the tissue strength returns to original levels. A closed stage III or IV pressure ulcer is always referred to as a healed stage III or IV and should not be called a stage I.

PUSH PERCEPTIONS
NPUAP recognized that there was a need for a simple valid instrument that would be sensitive to pressure ulcer healing and be biologically correct to monitor the efficacy of methods used to heal pressure ulcers. The job specifications for such an instrument were that it be valid for measuring pressure ulcer healing, and that it is reliable and sensitive enough to detect important clinical changes over time. The tool would provide a single score that would be tracked over time to show progress, stagnation, or deterioration. The result was the PUSH tool. Total PUSH scores range from 0, closed, to 17, the highest number representing wound deterioration.

Figure 2. Reporting and evaluating amounts of wound drainage.

Since its introduction in 1997, clinical use of PUSH has been limited even though the methodology used is thought to be the best available at this time for objectively measuring healing. A prospective study by Pompeo using a modified form of PUSH for tracking nearly 1,000 pressure ulcers in a clinical practice setting was recently published.⁴ Pompeo considered the reasons why use of PUSH in clinics is not widespread. Findings indicated that there appears to be a perception that the PUSH tool is time-consuming to use, that it has limited value and limited research support, that it requires interpretation by skilled clinicians, and that it is best used in settings where care is provided over a several-week period.

These perceptions are not based on the facts. Completing the PUSH assessment takes at most a couple of minutes; the PUSH tool has been validated and is evidence based; and the single score that may be decreasing, unchanging, or increasing is easy to understand, even by nonexpert clinicians, caregivers, and patients. One of the most important concerns of everyone involved is to know what is happening with the wound. A number removes uncertainty about healing, when to change interventions, and expected outcomes.

Perhaps some of the resistance to adopting PUSH is that clinicians are already so overburdened with data collection tasks that they do well to just collect data about wound size on a consistent basis without the additional burden of recording additional parameters and manipulating the findings into a wound score. Such attitudes overlook the significant benefits of having a more complete picture of clinical outcomes. There is good inter-rater reliability for the PUSH tool. If it is used across the continuum of care, as was done in the Pompeo study, it provides an opportunity to track wound healing over time that meets quality assurance standards and provides historical benchmarks for the facility or health care system. If use of PUSH were to become widespread and the score published, it would be a step toward development of national benchmarks.⁴

SCORE PARAMETERS
PUSH scores three parameters: size (greatest length by greatest width, perpendicular to the length), exudate (drainage) amount (none, light, moderate, heavy) (see Figure 2), and predominant tissue type that appears in the wound bed (necrotic, slough, granulation, epithelial, and closed). Other parameters have been suggested as markers for healing, but statistical analysis has not demonstrated that they contribute to the tool's validity in measuring healing. Brevity and accuracy make the use of PUSH time efficient and ideal for clinical use.

Each of the three parameters is scored, creating subscores. Then the subscores for the three parameters are summed together to yield a total score. The NPUAP version 3.0 PUSH contains a grid for scoring of each ulcer on a separate form. NPUAP has suggested graphing the ulcer scores so clinicians can visually track the healing trajectory. If the ulcer is on a healing trajectory, the scores should be decreasing. Trajectories of healing are reported in the literature as an appropriate way to evaluate and predict the results of care (see Figure 2⁵ ).

PUSH tool development included a multiphased process with peer review at a national consensus conference in 1997 and has been subjected to two national retrospective validation studies on nearly 3,000 cases. Results of the two studies showed that there are significant and measurable differences in healing over the first 6 weeks but that there was a loss of sensitivity in the last weeks of healing.⁶

PUSH is designed as a tool for ongoing assessment and not initial comprehensive assessments of patient or ulcer. Since PUSH is a "research validated tool," NPUAP, which holds the copyright, stresses that the content of the tool should not be altered or modified by individual users without crediting the original work of NPUAP. NPUAP permits use of PUSH by clinicians and educators as long as they use it for educational, research, and practice purposes. Other uses require written permission and possibly royalty fees. Pompeo and his group developed a revised data collection form that lists multiple ulcers for a single patient on one sheet using essentially the same grid as Version 3.0 of PUSH. The revised form shows only an initial and discharge or monthly summed PUSH score for all wounds on that patient. The suggestion is to use the summed PUSH scores for all wounds as an indicator of the total wound burden for the patient. The initial and discharge PUSH scores can also be used to determine the healing rate per ulcer per day (PUSH score/patient days). Slow wound healing may be the consequence of a heavy bioburden from multiple wounds. By summarizing all the wounds with PUSH scores, it is possible to document changes that may otherwise not be reported.

USING PUSH IN THE CLINIC
PUSH should be introduced into the clinical setting as a staff education offering to assure that it is used appropriately. PUSH is not a comprehensive examination instrument for either the patient or the ulcer. The education offering should include use of the tool on actual patient wounds and conducting inter-rater reliability checks to compare the outcomes between new and experienced users.

Can PUSH be used for measuring healing of wounds of other etiologies besides pressure? The CMS guidelines to document healing are not etiology specific. CMS calls for documentation of any or all of the three parameters listed in PUSH as acceptable for measuring wound healing. Use of one tool to report results of care simplifies clinical evaluation, and PUSH is being used in this way clinically. Interdisciplinary use of PUSH is recommended to assure that the same variables are tracked consistently by the health care team.⁷ Pompeo reported that the clinical wound program was able to use PUSH to track, objectively, the efficacy of wound interventions and outcomes of the program,4 which make it an ideal tool to use for quality assurance and marketing. Given the move toward evidence-based practice, it is time to take the PUSH tool out of senescence and expand its use in clinical practice.

Carrie Sussman, PT, is president of Sussman Physical Therapy Inc and Wound Care Management Services, Torrance, Calif.

REFERENCES

Thomas DR, Rodeheaver GT, Bartolucci AA, et al. Pressure ulcer scale for healing: derivation and validation of the PUSH tool. The PUSH Task Force. Adv Wound Care. 1997;10:96-101.
Sussman C, Cuddigan J, Ayello E, Lyder C, Langemo DK. Measuring pressure ulcer healing is critical to quality of life. Paper presented at: Partnership for Health in the New Millennium: Launching Healthy People 2010; January 2000; Washington, DC.
Bergstrom N, Allman RM, Alvarez OM, Bennet MA, Carlson CE, Frantz R. Clinical Practice Guideline: Treatment of Pressure Ulcers. Rockville, Md: US Department of Health and Human Services, Public Health Service Agency for Health Care Policy and Research; 1994.
Pompeo M. Implementing the PUSH tool in clinical practice: revisions and results. Ostomy/Wound Management. 2003;49:32-46.
Robson MC, Hill D, Woodske M, Steed D. Wound healing trajectories as predictors of effectiveness of therapeutic agents. Arch Surg. 2000;135:773-7.
Stotts NA, Rodeheaver GT, Thomas DR, et al. An instrument to measure healing in pressure ulcers: development and validation of the pressure ulcer scale for healing (PUSH). J Gerontol A Biol Sci Med Sci. 2001;56:M795-9.
Sussman C, Myer A. Clinical decision trees for pressure ulcer prevention and treatment. Paper presented at: Symposium for Advanced Wound Care; April 29, 2003; Las Vegas.

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June 2004