The Development and Preliminary Validity Testing of the Healing Progression Rate Tool
Accurate assessment and clear documentation are important aspects of wound care; they provide a basis for appropriate patient care decisions and reimbursement. A descriptive, qualitative study was conducted to develop and provide preliminary evidence of the validity of a new tool to measure wound healing (the Healing Progression Rate [HPR]), a modified version of the Pressure Ulcer Scale for Healing (PUSH).
Three (3) groups of current and future practitioners participated in the instrument development and evaluation process: 1) 3 wound care experts/authors (2 physical therapists, 1 nurse) with a minimum of 15 years of experience, 2) 6 additional wound care experts (4 nurses and 2 physical therapists) with a minimum of 10 years experience, and 3) 120 participants (77 [64.2%] RNs, 2 [1.7%] nursing students, 12 [10%] physical therapists [PTs], and 29 [24.2%] PT students). After the instrument was developed, the first group of 3 wound care experts used 2 photos of the same pressure injury at different points in time for 30 different wound cases to determine wound status (improved, worse, or the same) using the HPR and PUSH tools. The 6 experts from group 2 completed a similar exercise and, after completing a demographic questionnaire, the nonexpert participants scored 20 randomly selected cases (10 with the PUSH and 10 with the HPR) followed by a 4-question survey about the instruments. All data were collected on spreadsheets. Descriptive statistics were generated and mean HPR and PUSH scores for each image were compared to expert scores using a paired t-test. If the mean of participants’ image scores was significantly higher or lower than that of the experts, it was placed in the “higher” or “lower” group. If the difference was not statistically significant, the image was placed in the “same” group. Chi-squared tests (χ2) were used to compare the frequency distribution within each of these 3 groups for the HPR and PUSH tools. Due to violations of normality, the nonparametric Friedman’s analysis of variance and Wilcoxon signed rank test were used to compare the experts’ votes on which tool they thought captured the difference between the pre- and post-wound pictures and to perform post hoc testing, respectively. Qualitative data from the exit survey were reviewed and grouped into common themes. In 8 cases, a statistically significant difference was found among the number of votes (from the 6 experts) for which tool best reflected the change in wound status (χ2 (2) = 11.20; P = .004). Post hoc comparison revealed experts believed the change in HPR score better reflected the change in wound status compared to the PUSH tool (P = .026). Almost 75% of nonexpert participants preferred the HPR, rating it as more objective (73%). The results of this preliminary validation study suggest that further validation and reliability testing is warranted.
Chronic wounds, including pressure injuries (PI) or pressure ulcers (PU), vascular ulcers, and diabetic wounds, are a health care problem affecting 6.5 million people in the United States each year.1,2 The costs associated with caring for these wounds likely add $25 billion every year to the American health care system.3 Annual expenditure on wound care products, only 1 component of care costs for these wounds, is approximately $15.3 billion.4
In a 2007 review paper,5 researchers agreed that accurate assessment and clear documentation are important aspects of wound care. According to reviews and overviews,6–10 documentation provides the basis for appropriate patient care decisions and for payment from third-party payers; studies5,6 also have noted how difficult it is to monitor progress in a wound, set goals for healing, design a comprehensive care plan, and select the correct dressings when assessment is not properly performed or incomplete and not clearly documented. Interestingly, standards for assessment and documentation of wounds are still being debated despite or maybe because of the availability of so many tools for this task.11–14
A 1999 critical appraisal of the literature15 considered 5 wound assessment instruments specific to PUs and concluded that although assessment instruments could be completed in <15 minutes, training and wound care experience were needed in order for the tools to provide reliable results. One recent evaluation study14 used an author-developed audit tool to evaluate 14 selected wound assessment instruments on how closely their scores matched those of an “optimal wound assessment tool” as defined by the authors based on literature review. The authors concluded none of the wound assessment tools they evaluated fulfilled criteria for an optimal wound assessment tool, and most did not provide a score that allowed for quick comparison of wound status over time. The 2 tools the authors believed best fulfilled their criteria were the Applied Wound Management tool and the National Wound Assessment Form.
Two (2) assessment tools specific to PUs are commonly used in the United States: the Bates-Jensen Wound Assessment Tool (BWAT; formerly the Pressure Sore Status Tool) and the Pressure Ulcer Scale for Healing (PUSH). The BWAT has 13 separate items to complete for a total score from 13–65; it was originally designed as a tool for researchers.16–18 The PUSH assesses 3 items (wound size, exudate amount, and tissue type); individual item scores are summed to provide a total score that can be used to track wound changes over time.19,20 The validity of these items was reported by Thomas et al19 and Stotts et al21 using statistical analysis of existing wound data. Both studies found the PUSH tool accounted for somewhere between 31% and 74% of the variability in wound healing, but it is insensitive to changes in large wounds due to an inherent ceiling on size of 24 cm2.18 The reliability of the PUSH tool has been tested for inter-rater agreement and found to be between 90% and 95%.21,22
Despite the utility of the PUSH tool for quantification of wound status and healing, this instrument was designed only for PUs.15 The current authors have observed its use to assess other wound types and this is evidenced in the literature,23 but its validity for other wounds is unknown. In addition to utility for a single wound type, the PUSH tool has other limitations. It was developed before the National Pressure Ulcer Advisory Panel (NPUAP) defined deep tissue pressure injury (DTPI) and unstageable PIs and has not been updated to reflect new staging.15,24 In addition, a serum-filled blister, common over a new or evolving PI, also does not appear on the PUSH tool, making scoring difficult and leading to potential variation in the score.
Thus, the current wound care environment has few valid and reliable instruments to assess and quantify wound healing objectively, aside from documenting simple measurements and calculating percent healing. Without an objective assessment and score to compare over time, change in wound status may be based only on what a provider documented in a series of narrative observations and his/her memory of the wound’s appearance. Although wound size is the primary quantifiable measure of healing, it is a measurement primarily based on the wound border.15 However, clinical trials25,26 have reported the border denoting the beginning of intact skin can be difficult to identify precisely, resulting in greater interrater variability. Additionally, nonexperts asked to assess wounds may require the help of experts who may use photographs of the wounds to aid in their assessment.17,27
These limitations are compounded when language from the PUSH tool is used in other reports. For example, skilled nursing reporting forms (eg, Minimum Data Set – MDS 3.0) use PUSH language for staging but do not include important components that facilitate comparison of wound status between assessments (ie, comparisons of wound size or surface area changes over time), tissue types visible in the wound bed, and differentiation between an open or closed wound.28–30 This creates a temptation to use stage numbers to indicate healing; however, the NPUAP specifically clarified this is not a correct use of the staging system.31
Although commonly used, the authors believe the PUSH tool’s 3 components have inherent limitations. First, the PUSH gives the same size score for all wounds larger than 24 cm2. Second, they believe the amount of exudate is difficult to assess objectively because the amount visible may depend on the absorptive capacity of the dressing being used and that exudate is difficult to discern in a picture. Third, with regard to tissue type, maroon or purple/deep tissue injury cannot be included in the score, no option exists to score wounds that are not yet open to the air (such as a blood- or serum-filled blister), and full-thickness wounds with red granulation tissue are scored the same as partial-thickness wounds that have smooth red dermal tissue. Finally, no scoring option is available for superficial nonblanchable or blanchable erythema with intact tissue.21 Therefore, the purpose of this study was to describe the initial development of an alternative instrument — the Healing Progression Rate (HPR) tool — for measuring wound healing and to provide preliminary evidence of its construct validity.
Developing the new tool. The HPR was developed by 3 wound care experts — 1 nurse and 2 physical therapists — each with more than 15 years of experience in wound assessment) using the PUSH tool as a template. Over the course of ~1 year, 1 of the experts began to outline the HPR and to casually experiment with it in practice to see if different items and scoring structures could indicate numerically whether wounds were the same, better, or worse compared to expert opinion. The use of the PUSH score at the expert’s hospital facilitated comparison with HPR scores. These efforts were fueled by wound care team members at the hospital expressing frustration with the limited tissue type choices in the PUSH and the fact that PUSH scores showed no change in larger wounds that were healing. For example, the PUSH tool has no option for purple as the tissue type (as is seen in DTPI), so clinicians would have to decide to call it black (a score of 4) or red (a score of 1). Thus, a purple wound bed could go from a score of 4 on admission to a score of 1 on discharge without any change in wound status.
Table 1 presents the new tool. It comprises 3 sections: worst tissue type observed, surface area, and whether skin is intact. Items in each section are assigned a point value and tallied for a total score. Based on the casual experimentation done during clinical care, the same scoring and score weights used in the PUSH tool were used and expanded to include a larger surface area scale and a larger, more detailed tissue type scale. The other 2 experts reviewed item order and point values for face validity. The PUSH tool exudate section and its subscore were eliminated in the HPR because of the expert’s concern over the subjectivity of this metric. The 3 experts all believed exudate was important but could not be objectively verified in photo-documentation when nonexpert clinicians performed assessments.
Tissue types that have been identified by the NPUAP as essential markers for PI stages were added and include maroon or purple, blood- or serum-filled blister, and red granulation tissue separate from smooth red dermal tissue.24 Additional size categories were added to raise the ceiling on surface area to 225 cm2. Scores for the new tissue types and size categories were ordered based on NPUAP stage association or size and given the next whole number as their respective value; for example, a serum-filled blister would be scored 2 while a blood-filled blister would be scored 5. A new objective subscore for surface skin layers (intact or not intact) was added to represent a healed wound, a DTPI, Stage 1, intact blister, or intact eschar; this intact skin score was given a value of 0.5. The tissue type and size scores are in whole numbers and together could range from 0 (best — ie, less severe wound) to 27 (worst, most severe wound). The 0.5 addition for intact skin would clearly communicate the presence of an open wound versus a wound with intact surface layers because the tissue type and size scores are in whole numbers.
Once the new tool was developed, Institutional Review Board approval was obtained from the hospital where data collection would occur as well as from the university where data would be analyzed.
Photographs. The hospital obtained consent from all patients for deidentified pictures to be used in research. Photographs from hospital medical records were utilized and did not include any personally identifiable patient information. The pictures were selected by the research team to represent a variety of PIs and patient types to compare PUSH and HPR scores for different wounds. This was a nonrandom sample of wound images without specific inclusion or exclusion criteria beyond the requirement that the pictures be of the same PI taken at 2 clearly identified points in time. If the wounds were not clearly PIs with date and time marked, they were not considered for inclusion. Photographs of the wounds were needed at 2 different time points to compare wound change for each wound using both PUSH and HPR. With these goals in mind, 30 cases were selected and 2 photographs of the same wound were selected from 2 different points in time. Wound types and locations are shown in Table 2.
All wound photographs at this hospital are taken with the NE1 Wound Assessment Tool (NE1 WAT, originally called the NE One Can Stage “NEOCS”, N.E. Solutionz, Las Vegas, NV) framing the wound.32,33 The NE1 WAT is an “L” shaped ruler with a slightly adhesive backing designed to aid in the assessment of PI. The tool has representative pictures of PI for the various NPUAP stages with descriptions of those stages. It also contains room for documentation of the patient, provider, date, and time of assessment. In 2011, the development and psychometric testing of the NE1 WAT was described and its reliability and validity were established.32 In the first of these tool psychometric studies, 101 clinical wound care providers (registered nurses, physical therapists, physicians, and nursing and physical therapy students) staged pictures of wounds with and without the NE1 WAT.32 In the second, 94 registered nurses staged pictures of wounds with and without the NE1 WAT.33 In both studies, reliability coefficients were high (ICCs = 0.6–0.9) and accuracy of clinician wound staging improved by as much as 61% when they used the NE1 WAT compared to when they did not.32,33 However, it does not provide a score indicative of wound healing or worsening.
Scoring by experts. Using print photographs and paper-and-pencil instruments, the 3 expert participants that initially developed the HPR viewed each of the 60 images (30 cases) and scored the wounds using the PUSH and HPR tools, yielding 3 scores for each case. Because the measurement instructions are different between the tools, experts were cautioned to strictly follow the directions of each tool for each element of scoring. For example, the PUSH tool requires measurements to be taken from the wound edge and the HPR directs that involved periwound should be included in the size measurement. Additionally, the instructions for obtaining length and width measurements are worded slightly differently. The HPR directs that measurements for length should be from 12 o’clock to 6 o’clock and width from 3 o’clock to 9 o’clock at the widest and longest portion of the wound, and the PUSH tool measurements are obtained using greatest length (head to toe) and the greatest width (side to side). The wound images were all taken with the NE1 WAT on the patient framing the wound, and the ruled border of the NE1 WAT was used for measurement in this assessment. These 3 experts then met to discuss their scores and came to consensus so each picture had 1 score from PUSH and 1 score from HPR. The HPR and PUSH scores for each case then were compared to determine if they were lower, higher, or the same in terms of change between the 2 photographs.
A convenience sample of 6 additional wound care experts (4 nurses and 2 physical therapists with a minimum of 10 years of clinical wound experience) were recruited via email. When the invitation was accepted, the criteria and further instructions were emailed to them and they were asked to review the same cases and existing expert scores and provide feedback comparing the HPR to PUSH along with suggestions on how to improve the HPR. In cases where the PUSH and HPR scores disagreed regarding direction of wound healing (same, better, worse), the 6 experts were asked to indicate if they thought the wound had improved, deteriorated, or remained the same. Once the test packets were sent out, a time frame of 2 weeks was given for completion.
Nonexpert testing. A convenience sample of 120 participants was recruited from a university and a community hospital. Participants were approached in person by members of the research team in the course of their work as students or clinicians in the university or hospital over a period of 2 months. If persons recruited met the inclusion criteria (ie, educated on PI management and assessment and expected to perform these skills in their professional roles now or in the future), they provided written informed consent and completed a demographic profile on paper and were assigned a subject number. The demographic profile included years of experience in wound care, specialty certifications related to wound care, a single question on self-perceived skill level in wound care (Likert-style scale with 5 choices from expert to none), and prior experience with either of the tools being tested (yes or no) (see Figure 1 and Table 3).
The participants used a computer in a hospital training room to view 30 cases (60 images) and score the photographs according to the HPR and the PUSH tools. The computer program was a training version of the clinical documentation interface used by the hospital for wound care documentation. Screenshots of the interface are provided in Figures 2–4. Participants were asked to read the scoring directions for the PUSH tool and then use the tool to score a semi-random selection of 10 of the 60 pictures. The study was designed so that each picture would be shown to at least 3 participants. Participants then were asked to read the scoring directions for the HPR and score a different semi-random selection of 10 pictures using the HPR. No other training was provided during the study. The computer program used a digital box, the size and placement of which was controlled by the participant, to measure wound size. Scoring was completed automatically by the computer program based on the participants’ selections.
Following the computer-based wound scoring exercise, all participants completed an exit survey on paper (see Figure 1) to provide feedback on the 2 tools that included 3 questions with Likert-scale responses and 1 free-response item. The first 2 questions asked the participants about their preference for HPR or PUSH and the Likert scales had “0 1 2 3 2 1 0” options with PUSH on the left and HPR on the right. The third question had a traditional 7-point Likert scale with 1 = not important and 7 = very important. All testing and survey completion was completed in a single session which lasted approximately 1 hour for each participant. The testing room had 10 computers and groups of participants were tested simultaneously whenever possible without allowing them to discuss the cases or their answers during testing.
Data collection and analysis. Nonexpert scores for each item of the PUSH and HPR were exported directly into a spreadsheet file; data from paper forms were manually entered into the same spreadsheet. Following data collection spreadsheets were imported and analyzed in SPSS Version 24 (SPSS Statistics for Windows, IBM Corp, Armonk, NY).
Descriptive statistics were generated and a paired t-test was performed to compare the mean score (HPR and PUSH) of nonexpert participants on each image to the expert score for each image. Images then were placed into 3 groups based on the result of the t-tests. If the mean of the participants’ score was significantly higher or lower than that of the expert for an image, that image was placed into the respective (“higher” or “lower”) group. If no statistical difference was noted between the participant mean and expert score, that image was placed in the “same” group. Chi-squared tests (χ2) were used to determine whether the frequency distribution within each of the above-mentioned 3 groups was significantly different between the 2 types of tools used (HPR and PUSH). Due to violations of normality, the nonparametric Friedman’s analysis of variance (ANOVA) and Wilcoxon signed rank test were used to compare the experts’ votes on which tool they thought captured the difference between the pre- and post-wound picture and to perform post hoc testing, respectively. Free-response comments to question 4 of the exit survey were grouped into common themes by the authors in a group setting.
In 8 cases (5, 7, 15, 16, 21, 24, 28, 30), the single consensus scores for the PUSH and the HPR (from the first 3 experts wound assessment) did not agree concerning the change in wound condition between pre and post pictures of that case (see Table 2 for type of wound). The 6 additional experts then reviewed those cases and consensus scores and indicated which tool they thought better captured the difference in wound status (better, worse, same) between the pre- and post-pictures. A statistically significant difference was noted among the number of votes on these 8 cases for HPR, PUSH, or neither (χ2  =11.20, P = .004). Post hoc comparison showed experts believed the change in HPR score better reflected the change in wound status compared to the PUSH tool (P = .026) (see Figure 5).
The 120 nonexpert participants included registered nurses (77), nursing students (2), physical therapists (12), and physical therapy students (29) (see Table 3). More than 79% of participants were new graduates or students with <1 year of wound care experience; however, more than 50% of participants said their wound care skill level was better than fair.
Each of the 30 cases was scored with the PUSH and HPR by 21 nonexperts each; rarely did the same nonexpert score the same image with both PUSH and HPR due to the semi-random assignment of the images by the computer system. The mean nonexpert score was compared to the expert score with a t-test for each image. When wounds were scored by nonexperts using the PUSH tool and compared to expert scores, 27 were higher, 20 were lower, and 13 were the same. When wounds were scored by nonexperts using the HPR, 13 were higher, 29 were lower, and 18 were the same when compared to the expert score (see Figure 6).
A significant difference was found between the number of cases in the groups for the tool used (HPR or PUSH) and the higher, lower, same groups (χ2  = 7.4; P = .03). Post-hoc testing with a Bonferroni correction to the α-value (0.05/3 = 0.017) revealed nonexperts scored a wound higher more often than the experts when using the PUSH tool compared to when they used the HPR tool (27 PUSH, 13 HPR; P <.01). No differences were noted in the number of images with scores the same (13 PUSH, 18 HPR; P = .30) or lower than the expert score (20 PUSH, 29 HPR; P = .10) (see Figure 6).
Among nonexperts, answers to the first 2 questions of the exit survey revealed a strong preference for the HPR tool (see Table 4). The first question, which asked about preference for the HPR or PUSH, revealed 74% of participants preferred the HPR, 17% preferred the PUSH, and 10% had no preference. In response to the second question, which asked which tool they felt was more objective, 73% of participants preferred the HPR tool, 15% preferred the PUSH, and 11% thought they were equally objective. For the third question, How important are pictures in wound care, 100% of participants felt they were important; on a scale where 1 = not important and 7 = very important, 81% marked 7, 14% marked 6, and 5% marked 5 (see Table 4).
Among nonexperts, comments on the exit survey referencing the PUSH tool were grouped into 5 main themes by the authors: 1) Frustrated that a purple or DTPI option was not offered, 2) Difficult to score exudate amount; 3) Vague directions for measurement; 4) Poor selection of tissue types; and 5) Hard to score with just a picture. Comments from nonexperts on the exit survey referencing the HPR tool were grouped into 7 main themes by the authors: 1) Hard to score with just a picture; 2) Difficult to determine boundaries for measurement; 3) Better tissue type choices; 4) Picture scale for tissue types was helpful; 5) Liked having a purple or DTPI option; 6) Instructions for measurement more clear; and 7) Intact value score is confusing. As shown in Table 5, the comments for the PUSH were all negative and the HPR had both negative and positive comments.
This study described the initial development of the HPR tool for measuring wound healing and provided preliminary evidence for its face and construct validity. This study highlighted that the PUSH tool may not reflect actual change in all PIs and that the HPR may help improve wound status assessment.
With the exception of 1 case, expert participants agreed the HPR score change best reflected their opinion about the change in wound status. In that 1 case, the photos showed a heel wound presenting as a DTPI in picture 1 and a serum-filled blister in picture 2. When examined by the experts, 3 agreed with the HPR score that the wound had improved from photo 1 to photo 2, 1 agreed with the PUSH score that no change in wound severity had occurred, and 2 did not agree with either the HPR or PUSH score, indicating they believed the wound status had worsened from photo 1 to photo 2. This was most likely due to difficulty identifying the DTPI in picture 1 and then comparing it to a more obvious serum- filled blister in picture 2, underscoring the importance of palpating the actual wound.34
Wound care novices using the PUSH tool gave wounds a higher score than the experts significantly more often than they did when using the HPR. The reason the PUSH score provided by the nonexperts often was significantly higher than an expert score was not examined. The scale of the HPR allowed for large wounds to have a higher score overall than the same wound with the PUSH; however, that does not explain why an expert using the PUSH would score a wound lower than a novice scoring that same wound with the PUSH. It is possible the novices perceived exudate amount as greater than the expert, given their limited experience in seeing wound exudate, which would lead to a higher score. The authors propose this may highlight the difficulty of scoring exudate from a picture, something previous studies have noted12; however, this difference may simply be a spurious finding.
In this study, all participants evaluated wounds using pictures. Using live tissue when evaluating a wound has clear advantages; however, it has been shown in reliability studies17,27,35–37 of PU staging that pictures can be used with confidence in this type of study and, when combined with clinical information, also used in clinical wound care. The current authors believe pictures are an essential component of wound care practice. Although the variability of color reproduction and lighting can make comparison difficult, the authors believe standardized reference taken in the picture against the skin around the wound, such as the NE1 WAT, allows for comparison.23 Having a picture also allows an expert to review the assessment of a bedside clinician and make appropriate adjustments to the plan of care or a wound care report. With a picture, measurements can be made at 2 different points in time by the same or different clinicians, underscoring the need for photographs to become standard of care for patients with wounds.7
In this study, PUSH and HPR scores tended to agree in terms of wound status. Of the 30 cases studied, 22 (73%) showed agreement between the HPR and PUSH scores regarding the change in wound status. Of the 8 wounds (27%) on which the HPR and PUSH scores did not agree regarding change in wound status, the 6 experts agreed with the HPR score 88% of the time and with the PUSH 8% of the time. Only 2 experts, on a single case, found neither the PUSH tool nor the HPR captured the change in wound condition correctly. This provides preliminary evidence for the face and construct validity of the HPR and captures information in its score that the PUSH tool does not. However, the PUSH tool was developed using principal component analysis of several possible variables to predict healing19,21 and the elimination of exudate in HPR development was not similarly tested. Additionally, the reliability of the HPR was not tested.
Despite having more specific measuring directions for what should and should not be included in wound measurements, clinicians were inconsistent with using the measuring points for total surface area, a problem highlighted by other laboratory studies of wound measurement.25,38 This finding would underscore the importance of having wound measurements validated by an expert using an image-based record, such that similar data points could be used when comparing wound size status at 2 different points in time.7 Additionally, length x width surface area measurements used by both PUSH and HPR include all skin/wound surface areas (damaged and some not damaged areas) that fall in the 12–6 and 3–9 o’clock square area. Therefore, wounds not shaped like a square or rectangle would have surface area measurements larger than their actual size. Rather than resorting to expensive or difficult measurement tools, the solution is to combine photo documentation with the bedside assessment.
Although this study leaves several questions unanswered including the reliability and sensitivity to change of the HPR, it provides valuable evidence for the face and construct validity of the HPR and gives direction to future research needed for the new instrument. Some important considerations for future research on the HPR include changing the instructions for the HPR to include hyperemic wound edges and hyperemic periwound in the measurements; making the green wound measuring box lines thinner (in the present version, the thick lines blocked some of the visual field); for the HPR itself, changing the words Intact Value to something more understandable by the novice clinician like, Are there any open areas?; adding open scar, fat, epibole, fascia, scab, and dried skin edge as tissue types that can be scored; assigning participants the same pictures to score for both PUSH and HPR to capture data for testing reliability; and serially measuring wounds over time to allow for sensitivity to change calculations.
One goal for HPR development was to determine its ability to measure any wound, not just PIs. The design of this study did not include other wound types or assessment tools, so it was not possible to provide empirical evidence for the performance of the HPR on other wound types. Because the participants in this study did not score the same wounds with both the HPR and PUSH, reliability statistics cannot be calculated. This was done to minimize the chance that participants would use the same wound measurement points for both tools despite the different healing direction or the inclusion (or not) of periwound skin for the HPR. In hindsight, other study methods, such as a time delay of some days between assessments, may have better accomplished this goal and allowed for reliability calculations.
This study describes the initial development of the HPR tool for measuring wound healing and provides preliminary evidence of its face and construct validity. The HPR was initially created by 3 wound care experts, compared to the PUSH by another 6 experts, and used by a cohort of nonexperts. The reliability of the HPR was not tested, but evidence for the validity of the tool was presented. Specifically, experts and novice clinicians thought the HPR provided a better set of metrics for measuring wound status and change over time, compared to the PUSH tool. Testing the reliability of this new instrument is warranted. n
The authors recognize Sunrise Hospital and Medical Center, Las Vegas, Nevada, as well as its parent corporation, HCA, Nashville, Tennessee, for providing time and resources to conduct this study. They also are grateful to Shelby Estocado and Amber Bennett for assisting with data organization and Healthlines Information Systems Corporation, Charlotte, North Carolina for providing the testing program software.
1. Singer AJ, Clark RA. Cutaneous wound healing. N Engl J Med. 1999;341(10):738-746. doi:10.1056/NEJM199909023411006.
2. Pieper B. Pressure Ulcers: Prevalence, Incidence and Implications for the Future. 2nd ed. Washington, DC: National Pressure Ulcer Advisory Panel; 2012.
3. Spetz J, Brown DS, Aydin C, Donaldson N. The value of reducing hospital-acquired pressure ulcer prevalence: an illustrative analysis. J Nurs Adm. 2013;43(4):235-241. doi:10.1097/NNA.0b013e3182895a3c.
4. Sen CK, Gordillo GM, Roy S, et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen. 2009;17(6):763-771. doi:10.1111/j.1524-475X.2009.00543.x.
5. Fletcher J. Wound assessment and the TIME framework. Br J Nurs. 2007;16(8):462-466. doi:10.12968/bjon.2007.16.8.23415.
6. Collier M. The elements of wound assessment. Nurs Times. 2003;99(13):48-49.
7. Fife CE, Yankowsky KW, Ayello EA, et al. Legal issues in the care of pressure ulcer patients: key concepts for healthcare providers — a consensus paper from the International Expert Wound Care Advisory Panel©. Adv Skin Wound Care. 2010;23(11):493-507. doi:10.1097/01.ASW.0000390494.20964.a5.
8. Vargo DM. Make sense of wound care billing: turn your cents into reimbursement dollars. J Wound Ostomy Continence Nurs. 2008;35(2):186-198. doi:10.1097/01.WON.0000313641.14376.fd.
9. Lyder CH, Ayello EA. Annual checkup: the CMS pressure ulcer present-on-admission indicator. Adv Skin Wound Care. 2009;22(10):476-484.
10. Young DL, Shen JJ, Estocado N, Landers MR. Financial impact of improved pressure ulcer staging in the acute hospital with use of a new tool, the NE1 Wound Assessment Tool. Adv Skin Wound Care. 2012;25(4):158-166. doi:10.1097/01.ASW.0000413597.20438.d2.
11. Gartlan J, Smith A, Clennett S, et al. An audit of the adequacy of acute wound care documentation of surgical inpatients. J Clin Nurs. 2010;19(15-16):2207-2214. doi:10.1111/j.1365-2702.2010.03265.x.
12. Maylor ME. Establishing nurses’ preferences in wound assessment: a concept evaluation. J Clin Nurs. 2006;15(4):444-450. doi:10.1111/j.1365-2702.2006.01310.x.
13. Hess CT. The art of skin and wound care documentation. Adv Skin Wound Care. 2005;18(1):43-53.
14. Greatrex-White S, Moxey H. Wound assessment tools and nurses’ needs: an evaluation study. Int Wound J. 2015;12(3):293-301. doi:10.1111/iwj.12100.
15. Woodbury MG, Houghton PE, Campbell KE, Keast DH. Pressure ulcer assessment instruments: a critical appraisal. Ostomy Wound Manage. 1999;45(5):42–55.
16. Bates-Jensen BM. The Pressure Sore Status Tool a few thousand assessments later. Adv Wound Care. 1997;10(5):65-73.
17. Jesada EC, Warren JI, Goodman D, et al. Staging and defining characteristics of pressure ulcers using photographs by staff nurses in acute care settings. J Wound Ostomy Continence Nurs. 2013;40(2):150-156. doi:10.1097/WON.0b013e31828093a4.
18. Mullins M, Thomason SS, Legro M. Monitoring pressure ulcer healing in persons with disabilities. Rehabil Nurs. 2005;30(3):92-99.
19. 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(5):96-101.
20. Thomas DR. Existing tools: are they meeting the challenges of pressure ulcer healing? Adv Wound Care. 1997;10(5):86-90.
21. 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(12):M795-M799.
22. Gardner SE, Frantz RA, Bergquist S, Shin CD. A prospective study of the pressure ulcer scale for healing (PUSH). J Gerontol A Biol Sci Med Sci. 2005;60(1):93-97.
23. de Gouveia Santos VL, Sellmer D, Massulo MM. Inter rater reliability of Pressure Ulcer Scale for Healing (PUSH) in patients with chronic leg ulcers. Rev Lat Am Enfermagem. 2007;15(3):391-396.
24. Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised pressure injury staging system. National Pressure Ulcer Advisory Panel Pressure Injury Staging System. J Wound, Ostomy Continence Nurs. 2016;43(6):585-597. doi:10.1097/WON.0000000000000281.
25. Langemo D, Spahn J, Spahn T, Pinnamaneni VC. Comparison of standardized clinical evaluation of wounds using ruler length by width and Scout length by width measure and Scout perimeter trace. Adv Skin Wound Care. 2015;28(3):116-121. doi:10.1097/01.ASW.0000461117.90346.0d.
26. Langemo D, Spahn J, Snodgrass L. Accuracy and reproducibility of the Wound Shape Measuring and Monitoring System. Adv Skin Wound Care. 2015;28(7):317-323. doi:10.1097/01.ASW.0000465900.04721.18.
27. Bergquist-Beringer S, Davidson J, Agosto C, et al. Evaluation of the National Database of Nursing Quality Indicators (NDNQI) Training Program on pressure ulcers. J Continence Educ Nurs. 2009;40(6):252-260, 279.
28. Roberson S, Ayello EA, Levine J. Clarification of pressure ulcer staging in long-term care under MDS 2.0. Adv Skin Wound Care. 2010;23(5):206-210.
29. Levine JM, Roberson S, Ayello EA. Essentials of MDS 3.0 section M: skin conditions. Adv Skin Wound Care. 2010;23(6):273-284.
30. Ayello EA, Levine JM, Roberson S. CMS updates on MDS 3.0 section M: skin conditions-change in coding of blister pressure ulcers. Adv Skin Wound Care. 2010;23(9):394-397.
31. The Facts about Reverse Staging in 2000. The NPUAP Position Statement. 2000. Washington, DC: National Pressure Ulcer Advisory Panel;2000.
32. Young DL, Estocado N, Landers MR, Black J. A pilot study providing evidence for the validity of a new tool to improve assignment of national pressure ulcer advisory panel stage to pressure ulcers. Adv Skin Wound Care. 2011;24(4):168-175. doi:10.1097/01.ASW.0000396304.90710.ea.
33. Lilly D, Estocado N, Spencer-Smith JB, Englebright J. Validation of the NE1 wound assessment tool to improve staging of pressure ulcers on admission by registered nurses. J Nurs Meas. 2014;22(3):438-450.
34. Pedley GE. Comparison of pressure ulcer grading scales: A study of clinical utility and inter-rater reliability. Int J Nurs Stud. 2004;41(2):129-140.
35. Stausberg J, Lehmann N, Kröger K, Maier I, Niebel W.; Interdiscioplinary Decubitus Project. Reliability and validity of pressure ulcer diagnosis and grading: an image-based survey. Int J Nurs Stud. 2007;44(8):1316-1323. doi:10.1016/j.ijnurstu.2006.06.006.
36. Defloor T, Schoonhoven L. Inter-rater reliability of the EPUAP pressure ulcer classification system using photographs. J Clin Nurs. 2004;13(8):952-959.
37. Buckley KM, Tran BQ, Adelson LK, Agazio JG, Halstead L. The use of digital images in evaluating homecare nurses’ knowledge of wound assessment. J Wound, Ostomy Continence Nurs. 2005;32(5):307-316.
38. Lucas C, Classen J, Harrison D, De H. Pressure ulcer surface area measurement using instant full-scale photography and transparency tracings. Adv Skin Wound Care. 2002;15(1):17-23.
Potential Conflicts of Interest: Nancy Estocado is the president of N.E. Solutionz, LLC, Las Vegas, NV, which owns the NE1 Wound Assessment Tool. Sunrise Hospital and Medical Center in Las Vegas, NV, is part of the HCA Hospital Corporation in Nashville, TN.
Dr. Young is an Associate Professor, Department of Physical Therapy, School of Allied Health Sciences, University of Nevada, Las Vegas, NV. Ms. Estocado is a Program Supervisor/Rehab Therapy, Sunrise Hospital and Medical Center, Las Vegas. Dr. Feng is a Professor, School of Nursing, University of Nevada, Las Vegas. Dr. Black is an Associate Professor, College of Nursing - Omaha Division, University of Nebraska Medical Center, Omaha, NE. Please address correspondence to: Daniel L. Young, PT, DPT, PhD, Associate Professor, Department of Physical Therapy, School of Allied Health Sciences, University of Nevada, Las Vegas, 4505 S. Maryland Parkway, Box 453029, Las Vegas, NV 89154-3029; email: email@example.com.