Assessing the subjective method of nursing observation to monitor pressure ulcer healing through the use of quantitative measurements (PUSH) in nursing home residents

Background: The development of pressure ulcers may lead to morbidity/mortality. In 1997 the National Pressure Ulcer Advisory Panel (to improve/standardize treatment) recommended the Pressure Ulcer Scale for Healing (PUSH) to document ulcers/monitor healing using exudate, size, and depth. Regardless of these recommendations, traditional nursing observation remains standard practice. This study compares subjective nursing observation with the recommended standardized assessment (PUSH).

Methods: A retrospective chart review of 48 residents (2004-2006) with stage II-IV decubiti was implemented at a large skilled nursing facility. Based on this review, a PUSH score was calculated. Nursing observations for these residents were compared to PUSH scores for agreement/correlation (N=298). Agreement was assessed using Kappa statistics between the nurse's impression and the change in PUSH score.

Results: The nurses documented improvement in 170 cases (57%), of which there were only 74 concordant PUSH scores. Of the 92 (30.9%) clinically unchanged ulcers, 42 matched PUSH scores. For the 36 (12.1%) documented deteriorating ulcers, half were in agreement with the PUSH scores. Overall, there was a statistically insignificant low level of agreement between traditional clinical assessment and the PUSH Tool. Less than half of clinical assessments (44.9%) were in agreement with the PUSH tool.

Conclusion: In this study, the subjective nursing observation of the pressure ulcer healing process did not correlate with objective measurements (i.e., PUSH tool). Therefore, we suggest that the interdisciplinary clinical team should be educated as to the scientific benefits of the PUSH tool, leading to decreased morbidity and mortality and overall improvement in quality outcomes.