Cath Lab Digest

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  In addition, the reliability of the items on the CSSC compare favorably with other studies that have examined inter-clinician agreement with respect to wound infection status. Wirthlin et al⁶ found that agreement between surgeons with respect to wound cellulitis/infection and the presence of erythema were -0.04 and 0.22, respectively. Cutting⁷ found that agreement between nurses with respect to the infection status of granulating wounds was only 47.5%. Neither of these studies employed a structured tool from which to identify the specific signs and symptoms of infection.

  Consistent with the findings from the initial study,¹ the signs of heat, discoloration of granulation tissue, and foul odor had only moderate or fair agreement. These signs require more subjective judgment than other signs and symptoms because they include the characteristics of touch, color, and smell. The newly included sign (sanguineous drainage) also had only fair agreement, which may indicate the descriptor of this item needs to be revised.

  It is important to note that the majority of ulcers in this study were dressed with gauze dressings, which are more conducive to assessing type of wound exudate/drainage than other dressing types such as hydrocolloids.¹ Hydrocolloids interact with the wound fluid, producing a creamy substance that is difficult to distinguish from purulent exudate. Gauze dressings allow more direct observations of exudate/drainage color and consistency. In clinical settings that use non-gauze dressings for wound care, wound exudate/drainage can best be assessed by cleansing the ulcer, dressing the ulcer with a dry gauze dressing for an hour, and then completing the assessment of the wound for type of wound exudate.¹

  In addition, the findings of this study are based on the assessments of nurses trained in chronic wound assessment and the use of the CSSC. Other clinicians, such as physical therapists, physicians, or podiatrists trained in wound assessment and the use of the CSSC, should be able to achieve similar results.

  Finally, the fact that most ulcers were plantar neuropathic diabetic foot ulcers may have resulted in all having similar signs and symptoms. This similarity may have inflated the inter-rater reliability findings reported here. Nevertheless, the findings on inter-rater reliability reported here are similar to the findings reported on the CSSC in a mixed sample of chronic wounds. Also, the fact that most of the subjects were Caucasian may have made erythema easier to identify than it may be in persons of color. This may have inflated the inter-rater reliability for erythema. The findings from our first study¹ also were based on a primarily Caucasian sample.

Implications for Practice

  The early identification of infection in diabetic foot ulcers is essential to preventing infection-related complications, such as amputation. The Infectious Disease Society of America (IDSA) recently published guidelines⁸ specific to identifying and managing diabetic foot infections. The IDSA states that “wound infections must be diagnosed clinically on the basis of local (and occasionally systemic) signs and symptoms of inflammation.”⁸ Specifically, the guidelines regarding a diabetic foot ulcer note the presence of purulent exudate or the presence of two or more signs of inflammation, such as redness, warmth, swelling or induration, and pain or tenderness. The items on the CSSC relevant to these signs include purulent exudate, increasing pain, erythema, heat, and edema. The identification of purulent exudate had substantial inter-rater reliability using the CSSC, as did increasing pain, erythema, and edema.