PUSH Tool adds option to avoid violating reverse-staging rule
Helps monitor healing over time
[Editor's note: The May issue of Wound Care featured coverage of the controversy over Medicare regulations requiring wounds to be reverse-staged as they heal for reimbursement purposes. The story described the development of one system, called the Wound Healing Scale, which is intended to accurately describe a healing wound while meeting the Health Care Financing Administration (HCFA) requirements for completing quarterly Minimum Data Set reports. HCFA insists that these include evaluations based on the commonly applied four-stage Pressure Ulcer Staging System, which was never intended to describe wounds as they heal.
The National Pressure Ulcer Advisory Panel is developing another tool to satisfy HCFA's demands, called the Pressure Ulcer Healing Scale or the PUSH Tool. Wound Care asked Janet Cuddigan, PhC, RN, a nurse specialist at the University of Nebraska Medical Center in Omaha and a co-developer of the PUSH Tool, to explain the project.]
Wound Care: What are the reasons for undertaking the PUSH initiative?
Cuddigan: Pressure ulcers are commonly classified using the four-stage system developed by the NPUAP and adopted by the Agency for Health Care Policy and Research (AHCPR) guideline panels on pressure ulcer prediction, prevention, and treatment. Although this system is appropriate for classifying the initial depth of tissue damage after debridement, it is not an appropriate system for monitoring pressure ulcer healing over time. In fact, the NPUAP issued a policy statement in 1995 advising clinicians not to downstage healing pressure ulcers and calling for further research on appropriate methods to monitor healing.
WC: What do you hope to accomplish with the PUSH initiative?
Cuddigan: The goal of the PUSH initiative is to develop an easy, quick, and reliable method to monitor pressure ulcer healing over time. An effective tool should have four characteristics:
1. It should be valid. Does the tool really measure pressure ulcer healing?
2. It should be reliable. Does the same rater get the same score on the same ulcer, and do two different raters get the same score on the same ulcer?
3. It should be responsive, or sensitive, to change. Can the tool detect clinically important changes in the ulcer over time?
4. It should be clinically practical. Is the tool practical to apply in a clinical setting while still providing valid, reliable, and responsive data?
WC: At what stage of development is the PUSH tool?
Cuddigan: The tool was initially developed based on an analysis of research literature to identify critical parameters commonly used to monitor pressure ulcer healing, and a statistical analysis of existing research data based on pressure ulcer monitoring. PUSH has been subsequently validated in a large multisite retrospective chart review study. The tool was presented to HCFA in March 1998, and the agency is currently conducting clinical tests of the tool to determine its usability in long-term care settings.
WC: Why focus just on pressure ulcers? Why not expand the tool to include other types of wounds?
Cuddigan: The goal of the PUSH initiative was to develop a tool to monitor pressure ulcer healing. At this time, the NPUAP has sufficient data to support use of PUSH on pressure ulcers. Although there are some data from the retrospective study on other types of wounds, these data are not sufficient to support a recommendation that PUSH be used to monitor any wounds other than pressure ulcers. Future studies may provide the data to support such a recommendation.
The NPUAP invites suggestions for refining and improving the PUSH Tool. Send comments to the NPUAP, 515 Kimball Tower, Buffalo, NY 14214. Fax: (716) 829-3517. E-mail: [email protected].
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