The Inter-rater Reliability of the Clinical Signs and Symptoms Checklist in Diabetic Foot Ulcers

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Sue E. Gardner, PhD, RN; Rita A. Frantz, PhD, RN; Heeok Park, MSN, RN; and Melody Scherubel, BSN

However, the routine assessment of diabetic foot ulcers often does not include a systematic approach to identifying these specific signs and symptoms of infection. Incorporating the CSSC into wound assessment may improve clinician skill and accuracy in identifying the specific signs and symptoms (eg, purulent exudate and signs of inflammation) delineated as most important by the IDSA.

  Although the findings from this study suggest that the CSSC may improve the ability to consistently identify signs and symptoms of diabetic foot ulcer infection, the findings reported here do not address the validity of these signs and symptoms as accurate indicators of infection in diabetic foot ulcers. A study9 designed to examine the validity of clinical signs as indicators of diabetic foot ulcer infection revealed that the IDSA definition (purulent exudate or two or more signs of inflammation) is a better indicator of infection status among diabetic foot ulcers than any one sign or symptom alone. Moreover, the signs specific to secondary wounds were better indicators of infection in diabetic foot ulcers than the classical signs of infection. More study is needed to identify which signs and symptoms, or combinations of signs and symptoms, are most indicative of diabetic foot ulcer infection.


  A study to examine the inter-rater reliability of the revised CSSC in diabetic foot ulcers found that inter-rater reliability was lower but still substantial regarding the more subjective signs and symptoms of infection (eg, heat, discoloration of granulation tissue, and foul odor) than the inter-rater reliability regarding secondary signs and symptoms such as wound breakdown, pocketing, and increasing pain. A systematic approach to wound infection assessment potentially can improve diagnosis and subsequent treatment, making instruments such as the CSSC important tools in the management of diabetic foot wounds specifically and chronic wounds in general.

This study was funded in part by the Nursing Research Initiative, Health Services Research and Development, Department of Veteran’s Affairs (NRI 01-005-1) and with support from the Gerontological Nursing Interventions Research Center NIH #P30 NR03979 (PI: Toni Tripp-Reimer, The University of Iowa College of Nursing) and the Hartford Center for Geriatric Nursing Excellence, The John A. Hartford Foundation (PI: Kathleen Buckwalter, The University of Iowa College of Nursing). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Department of Veteran’s Affairs or the National Institute of Nursing Research.


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