Evaluating pressure sores: a new computerized tool.

A research-based instrument is available for assessing and monitoring wounds and tracking and analyzing outcomes data. One of the developers explains...

Because of the chronic, often difficult-to-treat nature of pressure ulcers, a long-term care facility's nursing staff can easily begin to feel that their best efforts are having no positive impact. One reason for this frustration is the lack of an effective tool for assessing - and therefore choosing the best treatment for - these wounds. As I discussed in the October/November issue of Nursing Homes Magazine (p. 47), attempting to select appropriate therapies is a hit-or-miss proposition without a thorough evaluation of wound characteristics.

The Pressure Sore Status Tool (PSST), a pen-and-paper assessment instrument that I developed in 1990, is designed to be an easy-to-use, reliable way to perform such an assessment. Since that time, I have collaborated with Dr. Patrick McNees of Seattle in developing a computerized instrument-the Wound and Skin Intelligence System (WSIS), which includes the PSST and other wound management features. Although the PSST is copyrighted, permission for its use is freely given; it remains a viable option for use by long-term care personnel.

Whether a facility chooses the pen-and-paper PSST or its computer-age sibling is not important: Either tool will do the job. What is important is that nursing staff do not apply a single dressing to a single pressure sore until they have performed an adequate, detailed wound assessment. This is the only way they - or physicians - will have more to base treatment choices upon than hunches, personal preferences or the "that's what we always use" mentality that often prevails.

The PSST - both in its original form and as the major component of the WSIS - includes 13 indices of the clinical manifestations of pressure ulcers. This research-based instrument is intended to provide more precise measurements of wound status than can typically be achieved by staging wound severity, since the stages used do not express a continuum of healing - either from one stage to the next or even within stages.

Merely measuring the wound is inadequate, as well; this is subject to bias and inaccuracy because of the varied topography of the wound bed. Furthermore, when viewed alone, measurements can be misleading since wounds often become larger as they heal - for example after debridement. Therefore, the PSST calls for additional information about the wound's characteristics, including appearance of wound edges, presence and extent of undermining/tunneling, necrosis, type of exudate, condition of surrounding tissue, granulation and epithelialization.

All these characteristics are rated and the scores recorded on the PSST (paper or software version) along with the date, so that it can be determined over time whether the wound is healing or degenerating. The PSST includes detailed instructions on how to obtain all the needed measurements and make the necessary observations for scoring. After the initial evaluation, the assessment should be repeated at least weekly - or whenever there is a noticeable change in the wound - throughout the course of treatment.

Facilities wishing to institute a thorough wound assessment plan using this methodology might benefit by starting with the pen-and-paper version of the PSST and using it for six months or so, until staff are comfortable with it. Then they can switch to the computerized version with ease, because they've become familiar with and are confident in using the basic assessment instrument. In fact, some organizations won't need or want to move on to the computerized version at all.

Those facilities that do choose to go with the WSIS software package should experience a number of major advantages in addition to the obvious one (paperwork reduction). These include:

* Increased capabilities for monitoring/reporting wound care data;

* Standardization of policies and procedures throughout an organization;

* Ability to produce graphic representations of data;

* Data/outcomes analysis available with the push of a button.

To amplify on these:

Monitoring/reporting: Software has a much greater capacity for monitoring wound data and compiling reports - whether for individual residents, groups of residents or the entire facility - than is possible manually. Of course, inputting the data into a computer system takes roughly the same amount of time as recording them on paper, but great time savings are realized when it's time to get those data back out of the computer. Rather than searching through charts and other paperwork and manually calculating statistics, one can obtain data and print out reports and analyses quickly.

These printouts might include daily incidence and prevalence reports, showing which residents have pressure ulcers, who is at risk to develop them and the severity of the wounds. The software allows users to print a document that can be placed directly into the medical record. Reports can be obtained in standard, narrative form or in other formats as needed.

Policies and procedures: Computerization allows standardization of specific policies and procedures throughout all the organization's sites or facilities. Our program includes AHCPR guidelines for pressure ulcer prediction, prevention and treatment to provide the current standard of care for any given patient. In fact, these guidelines are printed out in the form of a standard physician order sheet; this printout includes a space requesting physicians to explain any variations from the AHCPR guidelines.

Graphic capability: Most people understand data more readily when they are presented in graphic form. With the WSIS, I call the graph a "wound EKG." Graphs can also be prepared showing outcomes trends and other pertinent data analysis.

Outcomes analysis: Not only can data for individual patients be analyzed, but the program can be a powerful tool for tracking outcomes facility-wide. Our approach will also use benchmarking; each facility's data will be shared with those of all other users and analyzed on an aggregate basis. Each will receive a report that includes geographic information and compares outcomes among same-size facilities. This is, in fact, the main thrust of the system.

In addition to the PSST, the WSIS includes the Braden scale for predicting pressure sore risk; the software can integrate resident information with risk assessment standards and recommend specific, individualized preventive interventions. Also, the system's capacity to collect patient background and demographic information, such as ICD-9 codes, allows the wound assessment system to be tied in to the billing system.

We are in the process of integrating the WSIS software into the MediTech computerized billing system. However, although there are more than 200 such billing systems, as well as numerous programs for inventory tracking, compatibility between our system and those programs should not be a problem. The capacity of WSIS to export and import data permits the smooth transfer of wound care and other data between it and most other programs. The same is true of statistical analysis. If a user wishes to perform more extensive analyses than WSIS itself supports, he or she can quickly export data into a statistical analysis program.

We have been questioned as to whether WSIS is "compatible" with MDS 2.0 software. I don't believe it really needs to be. There is no reason why a facility could not use this instrument and be compliant with the MDS 2.0 standards because, in terms of wound care, the PSST goes well beyond MDS requirements. The former is a detailed weekly assessment of pressure ulcers, while the latter only requires minimal information, and then only on a quarterly basis.

This program is available and is already in use at long-term care facilities in both Canada and Australia, as well as approximately 15 acute care and home care organizations in the United States, and feedback has been positive.

We have entered into a partnership with ConvaTec, the wound care division of Bristol-Myers Squibb, which has assumed responsibility for marketing the software in the U.S.; they are specifically targeting large healthcare and managed care organizations.

Although we consider the system to be suitable for any long-term care facility, we believe that it is best adopted from the administration downward, rather than to expect a wound care nurse to assume primary responsibility for running and maintaining it. As many healthcare organizations have discovered, unfortunately, the "bottom-up" approach to computerization leads all too often to staff dissatisfaction with the product.

The long-term care industry has had some difficulty getting up to speed with computers and automation. To keep up with the many changes looming on the healthcare horizon, long-term care administrators and their staffs will need to "step up to the plate" and start using computers and automation to ease their workload and begin producing the measurable outcomes that so many payers are calling for these days.

Meanwhile, as an adequate number of facilities implement the WSIS system and begin to contribute data to a wound care outcomes database, we anticipate the ultimate benefit of being able to answer questions in wound care that, up until now, we haven't even been able to ask.

Barbara-Bates Jensen, MN, RN, CETN, is assistant professor of clinical nursing and director of the Enterostomal Therapy Nursing Education Program, University of California, Los Angeles. To request permission to use the PSST (paper version) or to obtain a copy, call her at [phone]; fax: [phone]. For more information on the Wound and Skin Intelligence System, contact Applied Health Science in Seattle-phone: [phone]; fax: [phone]; e-mail: [e-mail].