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Rehabilitation Measures

Pressure Ulcer Scale for Healing

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Purpose

The PUSH assesses change in pressure ulcer status over time, including size, exudate amount, and tissue type.

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Instrument Details

Acronym PUSH

Assessment Type

Observer

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

  • Arthritis + Joint Conditions
  • Brain Injury Recovery
  • Cardiac Dysfunction
  • Cerebral Palsy
  • Parkinson's Disease & Neurologic Rehabilitation
  • Spinal Cord Injury
  • Stroke Recovery

Key Descriptions

  • The PUSH is composed of three parameters:
    1) Surface area of the wound - the greatest length of wound from head to toe and greatest width from side to side measured in square centimeters.
    2) Exudate amount in the wound visually assessed after the dressing has been removed - classified as none, light, moderate and heavy.
    3) Tissue type of the wound bed (see instructions manual for complete criteria)
  • Total scores range from 0 to 17, with higher scores indicating worse ulcers.
  • Scores are also plotted on a graph to show change over time.

Number of Items

3

Time to Administer

20-30 minutes

Required Training

No Training

Age Ranges

Adolescent

13 - 17

years

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Created by Jason Raad, PhD in 7/2011; Updated by Jill Smiley, MPH in 12/2013.

Body Part

Head
Neck
Back
Upper Extremity
Lower Extremity

ICF Domain

Body Structure

Measurement Domain

General Health

Considerations

  • In at least some studies, PUSH scores did not strongly correlate with the observations made by nursing staff (George-Saintilus, 2009)

  • The PUSH categorizes ulcers with an area greater than 24 cm2 as "very large", thus a decrease in wound area may occur without being recognized as such by subsequent PUSH scores (Lynn-West, 2007).

  • The PUSH is not intended to be a comprehensive assessment tool (Stotts, 2001)

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Mixed Populations

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Normative Data

Various Diagnosis:

(Gardner, 2005; n = 23: dementia = 9, diabetes = 6; mean age = 79.5 (15.60) years)

Week 1 Measures of Healing for all Ulcers  and by Healing Outcome

 

 

 

 

All Ulcers

(N = 32)

Healed

(n = 21)

Unhealed

(n = 11)

Mean total PUSH score

8.6 (3.06)

7.6 (2.99)

10.5 (2.30)

Length X width item*

5.6 (2.33)

4.9 (2.37)

7.0 (1.48)

Exudate amount item

0.4 (0.49)

0.3 (0.48

0.5 (0.52)

Tissue type item

2.6 (0.91)

2.4 (0.87)

3.0 (0.90)

Notes: *p < 0.05
PUSH = Pressure Ulcer Scale for Healing; PSST = Pressure Sore Status Tool

 

 

 

Construct Validity

Various Diagnosis:

(Gardner, 2005; = 23, dementia = 9, diabetes = 6; mean age = 79.5 (15.60) years)

Correlations of PUSH Scores with the PSST:

 

 

 

 

Week

n

Strength

Pearson r

p value

1

32

Excellent

0.72

0.000

2

32

Excellent

0.76

0.000

3

26

Excellent

0.89

0.000

4

24

Excellent

0.90

0.000

5

20

Excellent

0.95

0.000

PUSH = Pressure Ulcer Scale for Healing
PSST = Pressure Sore Status Tool

 

 

 

 

Non-Specific Patient Population

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Interrater/Intrarater Reliability

Chronic Leg Ulcers:

(de Gouveia Santos, 2007; n = 41 patients with chronic leg ulcers; 49% right leg; 36% venous ulcers)

  • Interrater reliability was calculated by comparison between the observations of clinical nurses and stomal therapists (ST) for sub-scores and total score
  • Excellent interrater reliability for sub-scores of the length X width variable
    • kappa ST x Nurse 1 = 1.00 (< 0.001)
    • kappa ST x Nurse 2 = 0.97 (< 0.001)
  • Excellent interrater reliability for sub-scores of tissue type
    • kappa ST x Nurse 1 = 1.00 (< 0.001)
    • kappa ST x Nurse 2 = 1.00 (< 0.001)
  • Excellent interrater reliability for total score
    • kappa ST x Nurse 1 = 1.00 (< 0.001)
    • kappa ST x Nurse 2 = 0.97 (< 0.001)

 

Long Term Care Facility Residence:

(Stotts et al, 2001, n = 1274 over a 12 week period; mean age = 80 (range = 18 - 102); at baseline stage II ulcers were most common, n = 1196)

  • Excellent agreement among trained study personnel (> 95%)
  • Information regarding rater characteristics or type of agreement not reported

Criterion Validity (Predictive/Concurrent)

Diabetic Foot Ulcers (DFUs):

(Gardner et al, 2011; n = 18 subjects with Wagner 2 or greater neuropathic, non-ischemic ulcers on the plantar surface of the foot, which healed completely over a 13-week follow-up period; mean age = 54.1 (11.1) years; 12 males; all Caucasion)

  • PUSH tool can predict how long it should take a specific DFU to heal (R= 0.76)
  • Sub-items exudates and tissue type are not valuable at predicting healing time for DFUs:
    • Rfor exudate = 0.36
    • Rfor tissue type = 0.42
    • Rfor sum of exudate and tissue type = 0.46
  • Performance of length x width as a predictor of time-to-heal (R= 0.81) is comparable to that of total PUSH score (R= 0.76)

 

Nursing Home Residence:

(George-Saintilus et al, 2009, n = 48 residence aged 65 years or older)

  • Agreement between clinical observation and PUSH scores was found to be weak. Specifically, Of 370 observations, there was agreement in only 159 (43%) of cases.

  • Poor agreement between clinical observations and PUSH scores:

    • Stage II ulcers; Kappa = 0.132 (= 0.029)

    • Stage III ulcers; Kappa = 0.129 (p = 0.04)

    • Stage IV ulcers; Kappa = 0.111 (p = 0.029)

 

Pressure, Venous, and Diabetic Foot Ulcers:

(Hon et al, 2010; n = 98 people, 47 with pressure (PU), 23 with venous leg (VLU), and 28 with diabetic foot (DFU) ulcers; mean wound size at baseline (cm2) = 71.1 (10.1); mean wound size at follow-up (cm2) = 4.7 (9.1); mean age = 60 (20-89) years)

Baseline Wound Size and Baseline Total PUSH Score Correlation

 

 

 

 

 

Total Group

Pressure Ulcer (all)

Venous Leg Ulcer

Diabetic Foot Ulcer

Pearson’s r

0.66 Excellent

0.63 Excellent

0.74 Excellent

0.71 Excellent

P value

0.01

0.01

0.01

0.01

 

Baseline Wound Size and Individual PUSH Score Components Correlation

 

 

 

 

Size (l x w) Range 0 – 10

Exudate Range 0 - 3

Tissue Type Range 0 - 4

Spearman’s rho

0.83 Excellent

0.54 Adequate

0.41 Adequate

P value

0.01

0.01

0.01

Content Validity

  • Registered users of the PUSH tool generally found it easy to use and helpful in pressure ulcer management (Berlowitz et al, 2005)

Responsiveness

Pressure, Venous, and Diabetic Foot Ulcers:

(Hon et al, 2010)

Responsiveness of Individual PUSH Score Components

 

 

 

 

Score Components (normal range)

 

 

 

Size (l x w)a(range 0 – 10)

Exudate Amount (range 0 – 3)

Tissue Type (range 0 – 4)

Mean (SD) baseline score

6.5 (2.3)

2.0 (0.7)

2.6 (0.7)

Mean (SD) follow-up score

4.8 (2.3)

1.5 (0.9)

1.7 (0.7)

Mean (SD) score change

1.7 (2.4)

0.5 (0.9)

0.9 (0.9)

P value

0.0001b

0.0001b

0.0001b

Effect size

0.74 (large change)

0.71 (large change)

1.29 (large change)

Standardized response mean

0.71

0.56

1.00

a obtained using a disposable ruler

b statistically significant difference (alpha = 0.05) between baseline and follow-up assessments (31.7 +/- 20.1 days later)

 

 

 

Older Adults and Geriatric Care

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Normative Data

Elderly:

(Stotts et al, 2001; n = 103 across 10 sites; mean age = 74.6 (15.0) years, baseline stage III ulcers = 4704, Stage II = 34.9%, stage IV = 11% and 6.6% could not be staged; sample drawn from clinics, nursing homes, research study sites, and home care settings)

  • Mean ulcer area = 7.3 (11.8) cm2
  • Mean ulcer volume = 5.5 (14.8) cm3

Responsiveness

Elderly:

(Stotts et al, 2001)

  • Changes over time (suggestive of healing), were evaluated with pairwise comparisons across each of the 10 weeks participants were assessed.

  • PUSH total scores were significantly different from baseline to each time the patient was assessed (weeks 1 to 10; p < 0.05)

Bibliography

Berlowitz, D. R., Ratliff, C., et al. (2005). "The PUSH tool: a survey to determine its perceived usefulness." Adv Skin Wound Care 18(9): 480-483. Find it on PubMed

de Gouveia Santos, V. L., Sellmer, D., et al. (2007). "Inter rater reliability of Pressure Ulcer Scale for Healing (PUSH) in patients with chronic leg ulcers." Rev Lat Am Enfermagem 15(3): 391-396. Find it on PubMed

Gardner, S. E., Frantz, R. A., et al. (2005). "A prospective study of the pressure ulcer scale for healing (PUSH)." Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 60(1): 93-97. Find it on PubMed

Gardner, S. E., Hillis, S. L., et al. (2011). "A prospective study of the PUSH tool in diabetic foot ulcers." J Wound Ostomy Continence Nurs 38(4): 385-393. Find it on PubMed

George-Saintilus, E., Tommasulo, B., et al. (2009). "Pressure Ulcer PUSH Score and Traditional Nursing Assessment in Nursing Home Residents: Do They Correlate?" Journal of the American Medical Directors Association 10(2): 141-144.

Hon, J., Lagden, K., et al. (2010). "A Prospective, Multicenter Study to Validate Use of the Pressure Ulcer Scale for Healing (PUSH©) in Patients with Diabetic, Venous, and Pressure Ulcers." Ostomy wound management 56(2).

Lynn, J., West, J., et al. (2007). "Collaborative clinical quality improvement for pressure ulcers in nursing homes." Journal of the American Geriatrics Society 55(10): 1663-1669. Find it on PubMed

Stotts, N. A., Rodeheaver, G. T., et al. (2001). "An instrument to measure healing in pressure ulcers: development and validation of the pressure ulcer scale for healing (PUSH)." Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 56(12): M795-799. Find it on PubMed