Pressure ulcer PUSH score and traditional nursing assessment in nursing home residents: do they correlate?

Background: Over a decade ago, the National Pressure Ulcer Advisory Panel (NPUAP, 1997) recommended a new tool, the Pressure Ulcer Scale for Healing (PUSH) tool to document ulcers and monitor the healing process. Yet, traditional nursing observation remains standard practice in chronic care, thus prompting this correlational study between PUSH and traditional documentation of pressure ulcers.

Methods: Data were cross-tabulated through a retrospective chart review of all residents with stage II-IV decubiti at a 672-bed skilled nursing facility, between January 1, 2004, and December 31, 2006. A correlation analysis was performed between the clinical nursing observation, which was based primarily on ulcer size and documented on the weekly decubiti flow sheets, and the weekly PUSH score over a period of at least 2 months. Agreement was assessed using kappa statistics for a 3 x 3 table between the nurse's impression (improved, unchanged, deteriorating) and the change in PUSH score (+1, 0, or -1).

Results: In the 370 observations compiled for the 48 residents, the nurses documented improvement in 212 observations (57%). However, of these 212 traditionally assessed "improved" ulcers, there were only 89 (42%) concordant "better" PUSH scores and 99 (47%) received a "no change" PUSH score. Twenty-four (11%) of the 212 actually received a deterioration of the ulcer rate using the PUSH tool. Of the 110 (30%) traditionally assessed as "unchanged" ulcers, only 45 (42%) matched "unchanged" PUSH scores. Finally, for the 48 (13%) traditionally documented "deteriorating" ulcers, there were only 25 (52%) observations in agreement with the "deteriorating" PUSH scores. Overall, in this longitudinal study, the symmetric measures reports indicated very little agreement between the 2 assessment methods (kappa range: 0.007-0.298).

Conclusion: Although the NPUAP has formally recommended the PUSH tool as the pressure ulcer assessment method of choice, our data indicate that the PUSH does not highly correlate with traditional nursing observation. Further study is required to determine the most accurate assessment method. The adoption of a universally accepted tool, together with rigorous documentation methods, will improve the overall clinical care of chronic patients with pressure ulcers.