Reporting outcomes for stage IV pressure ulcer healing: A proposal

Advances in Skin & Wound Care,  Nov/Dec 2000  by Brown, Gregory S

• E-mail
• Print
• Link

ABSTRACT

OBJECTIVES: To calculate the average daily healing rate for Stage IV pressure ulcers. To create and analyze wound healing curves.

DESIGN: Retrospective analysis of healing rates of Stage IV pressure ulcers.

SETTING: Veterans Affairs Transitional Care Unit at the VA North Texas Health Care System.

PARTICIPANTS: Nine residents with pelvic Stage IV pressure ulcers that were fully healed.

INTERVENTIONS: A sodium chloride-impregnated gauze or calcium alginate was the primary dressing, followed by a hydrocolloid or foam dressing. Eschar was removed by sharp, mechanical debridement, and fibrous necrotic tissue was removed with wet-to-dry dressings.

MAIN OUTCOME MEASURES: Wounds were measured weekly using linear length and width in centimeters; measurements were multiplied to obtain wound area. The end of treatment was considered to be full epithelialization of the wound.

RESULTS: Wound area reduction in square centimeters per day generally increased as initial wound area increased. However, the reduction in pressure ulcer area did not occur at a strict linear rate.The wound healing curves demonstrated the granulation, contraction, and epithelialization phases of wound healing.

CONCLUSIONS: Calculation of an average daily healing rate is a useful method for determining pressure ulcer healing outcomes. Averaging together wound healing curves would enable health care providers to more accurately predict future healing times and quickly assess delays in healing. A standardized method for reporting healing rates would also help establish a baseline rate of pressure ulcer healing.

ADV SKIN WOUND CARE 2000;13:277-83

Health care professionals and researchers need a simple method for determining wound healing rates in order to evaluate past performance and current progress of therapies. Currently, there is no standardized method for collecting, analyzing, and reporting pressure ulcer (PU) healing rates. Although a number of multidimensional scales to track progress of PUs exist, none are widely used. This lack of standardization significantly impacts the ability to compare healing rates in published research or among health care professionals. In addition, no research studies are available to provide baseline data on the length of time for PUs to fully heal. This article presents 2 methods for reporting PU healing rates that can be used in clinical practice and in research.

Previous studies that have examined PU healing have analyzed the percentage of healed versus nonhealed wounds at certain intervals.1-2 These studies followed the wounds for only a few weeks and not to full healing. Also, these studies have reported that wounds "improved" or"significantly improved" over a certain number of weeks using a particular therapy. These terms are open to interpretation and, therefore, have little clinical value. Only Ferrell et all present wound area reduction rates in square millimeters per day from initial treatment to final healing. However, it was unclear whether the reduction in wound size was the result of specific therapies or simply due to the natural process of healing because no baseline rate with which to compare the outcomes was given.

Because of the variability in published data on PU healing, the National Pressure Ulcer Advisory Panel (NPUAP) has recommended general guidelines to standardize reporting of PU research.4,5 The recommendations include making use of large sample sizes and multiple settings and following subjects to full healing. Additionally, the NPUAP recommends reporting the mean and standard deviation for baseline size, length of follow-up for each treatment group, and percentage of healing per week stratified across wound size.

METHODS

Wound care rounds were performed in a Veterans Affairs transitional care unit over the past 3 years. During an 18month period, measurements of 10 PUs on 9 patients were obtained and entered into a computer spreadsheet (example for 1 patient shown in Table 1). The demographics of this patient population are presented in Table 2. Wounds included in the study were fully healed Stage TV PUs in the pelvic area.

Wound measurement

Measurements were obtained weekly by 1 of 2 certified wound, ostomy, and continence nurses to reduce the chance of interrater error. Daily measurements were not practical and monthly measurements would have been too infrequent.

In this study, linear measurements-in which length=vertical axis of patient; width=horizontal axis; and depth=straight depth measurement in the deepest area of the wound-were used because they are simple to obtain and are used by a variety of practitioners. Linear length and width were multiplied to determine overall wound area. Reporting wound volume instead of area was rejected for 2 reasons: (1) volume can change significantly with only a small change in depth; and (2) wounds with no depth or with hypergranulation would have no volume but could still have a significant open area. Depth measurements of the 10 wounds were graphed; no consistent pattern of depth reduction was noted.