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The PUSH Tool: A Survey to Determine Its Perceived Usefulness

Berlowitz, Dan R. MD, MPH; Ratliff, Catherine PhD, APRN-BC, CWOCN; Cuddigan, Janet PhD, RN, CWCN, CCCN; Rodeheaver, George T. PhDNational Pressure Ulcer Advisory Panel

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Pressure ulcer (PrU) management is a challenge faced by many clinicians. Identifying and implementing a standardized monitoring tool that accurately describes the wound and any progress in healing are central to PrU management.1 Monitoring instruments are used for various purposes, including documenting medical records, assisting in care planning, facilitating communication among providers, predicting likely outcomes, and setting benchmarks for assessing quality of care.1,2

For many years, PrU healing was predominantly described by reverse staging. With this method, healing ulcers are described by progressively lower staging, using systems originally developed for describing the depth of pressure-induced injury.3,4 This practice, however, does not realistically reflect PrU healing, in which ulcers progress through a process of wound contracture and scar tissue formation, rather than replacement of lost muscle, subcutaneous fat, and dermis. Stage IV PrUs, therefore, cannot progress through the healing process to ulcer Stages III, II, and I.

In 1995, the National Pressure Ulcer Advisory Panel (NPUAP) published a position statement against reverse staging.5 In 1997, the topic for the NPUAP's fifth national conference was "Monitoring Pressure Ulcer Healing: An Alternative to Reverse Staging."6 One component of the conference was presentation of PrU monitoring tools,7-10 including a version of NPUAP's Pressure Ulcer Scale for Healing (PUSH).11,12

PUSH has subsequently been modified, with research suggesting the instrument's validity13,14 and describing healing rates based on the PUSH tool.2 Moreover, experience has increased as clinicians incorporate PUSH into routine practice. Use will likely expand as the Center for Medicare & Medicaid Services (CMS) considers PUSH for inclusion in Resident Assessment Protocols that accompany the nursing home Minimum Data Set (MDS).

Little information exists, however, regarding a critical component of instrument performance: PUSH must not only be reliable, valid, and sensitive to change, but also clinically practical.15 Users must find PUSH simple, easy to use, efficient, and credible. To address this issue, the NPUAP recently conducted a survey of PUSH users. This article presents the results of that survey.


The NPUAP PUSH task force was responsible for survey development, data collection, and analyses. Beginning in 2003, task force members identified key domains of interest, including experience with the instrument, ease of use, and perceived utility and weakness. The group then developed specific items related to each domain, consisting mostly of declarative statements about the PUSH tool with which respondents could agree or disagree. Responses were given on a 5-point Likert scale, ranging from "strongly agree" to "strongly disagree." Open-ended questions were also included to allow for more detailed information regarding a respondent's experience with PUSH. After reviewing and modifying the draft document, the NPUAP board approved a final, 25-item survey, which became available on the NPUAP Web site in December 2003.

The convenience sample of PUSH users included (1) visitors to the NPUAP Web site who chose to complete the survey online, and (2) 312 registered users of PUSH who received an invitation from the NPUAP president to respond to the survey online.

Following a 4-month collection period, survey data were downloaded to a database (Access; Microsoft, Redmond, WA), allowing simple descriptive analyses and aggregating comments to open-ended questions. All data were reviewed by the NPUAP at a semiannual meeting. For the purposes of this article, questions receiving no response are combined with "neither agree nor disagree."


Of 103 people responding to the survey, 35% had responded to the letter of invitation; the remaining respondents had visited the NPUAP Web site and had chosen to respond. The majority of respondents were nurses (80%), with the remaining respondents including physicians, physical therapists, and other health professionals. In relationship to PrUs, the primary roles were clinicians (43%), clinical care administrators (27%), and educators (10%).

Most respondents (65%) continued to use PUSH, 19% reported that they had stopped using it, and 15% reported that they had never used it. Among those not currently using PUSH, 24 did not provide additional information beyond the descriptive data or include reasons for discontinuation. Subsequent results, therefore, relate predominantly to the remaining 79 respondents, with about 50% using PUSH for less than 6 months and 15% using it for longer than 2 years.

PUSH was used in various settings, including nursing homes (44%), subacute care/rehabilitation (18%), acute care (14%), and home health care (7%). Although used for various purposes, including monitoring aggregate data on PrU outcomes for groups of patients (27%) and collecting research data (19%), PUSH is most commonly used to monitor PrU healing in individual patients (75%). Those monitoring individual wound healing also use PUSH for other wound assessments (75%). Certain respondents (27%) use PUSH to monitor healing of PrUs and other wound types. In addition, 25% of respondents reported prior use of other instruments, most commonly the Pressure Sore Status Tool (PSST) or internally developed instruments.

The survey shows that most respondents "agree" or "strongly agree" that PUSH: (1) is easy to use and teach to others; (2) requires an appropriate amount of time to complete; and (3) results in similar scores when completed by different users Table 1. Respondents were not as positive, however, regarding the instrument's usefulness, with 75% agreeing that an increased PUSH score prompts patient reassessment and treatment (Table 2).

Table 1
Table 1:
Table 2
Table 2:

Despite generally favorable views, PUSH survey respondents "agree" or "strongly agree" that improvements are possible in the size subscale (59%), the tissue type subscale (49%), and the exudate amount subscale (32%).

Twenty-six respondents specifically commented on perceived areas for improvement; most commonly, they indicated that wound depth information should be added. One respondent expressed a common theme, "[One] could have a very small wound with depth and the severity of the wound is not reflected in the score." Another respondent stated, "The absence of depth/tunneling forces us to use tools in addition to PUSH." Respondents also frequently suggested that the size subscale does not adequately capture improvements in large wounds. For example, one respondent stated, "Size needs to be expanded so it can reflect some healing in large wounds. One wound I used it on decreased in size by several centimeters, but there has been no movement in the PUSH score."

Reasons cited for stopping use of PUSH (15 respondents) include availability of computer-based monitoring systems (4 respondents), reliability when PUSH is performed by staff (2 respondents), irrelevance to practice setting (2 respondents), amount of work involved (2 respondents), and MDS not adopting PUSH (2 respondents). Another respondent commented, "The staff had too much difficulty with the area/size calculation. We are in the process of purchasing a better computer software program, so that these calculations would be done automatically."


Survey results add to the growing body of evidence supporting the usefulness of the PUSH tool for evaluating PrU healing.

Ease of use was an important concern in PUSH development. This feature distinguishes PUSH from other instruments (eg, the Pressure Sore Status Tool) that have more items and, consequently, may require additional time and effort to complete.7 Respondents overwhelmingly confirmed that PUSH is easy to use and can be completed in an appropriate amount of time. This is important because busy clinicians maybe reluctant to complete additional documentation describing patient status if it is unwieldy or not useful. In addition, respondents often requested that additional assessments be included in the tool.

To justify ongoing use, clinicians must also find PUSH helpful for PrU management. Results should prompt meaningful changes in therapy. Because increased PUSH scores prompt patient and treatment reassessment, most respondents agreed that PUSH was helpful.

At the same time, concern was expressed that clinically important wound changes may not be detected by score changes. For example, although large wounds could show considerable improvement, PUSH scores may remain unchanged. Earlier versions of PUSH also identified the issue with the size subscale.12 In the present version, the upper limit of the size subscale was increased from >5 cm2 to >24 cm2, together with an increase in possible size categories (from 5 to 10). Despite past changes, however, some users still have concerns.

The PUSH tool's usefulness is further supported because its use is not limited to one isolated aspect of clinical practice. Various types of clinicians currently use PUSH for various purposes and in various settings.

Reasons respondents gave for stopping use of the PUSH tool are diverse. Interestingly, the most frequently cited reason was adoption of computer-based wound monitoring systems. The role of PUSH in these systems needs clarification. Those discontinuing PUSH may likely view the instrument as being of limited value. Their perceptions were not captured on the scaled items; instead, they described reasons for discontinuing PUSH on open-ended questions.

The use of supplemental instruments and concern regarding absence of depth information raise some question as to the face validity of the PUSH tool, even if depth is not independently associated with healing. Additionally, because different users may not get the same PUSH score, many feel the tool is unreliable. Prior studies only evaluated reliability as it pertains to research protocols and not general practice. Further research on PUSH is needed to help alleviate any concerns.


Although respondents indicate room for improvement, survey results reassuringly demonstrate that many users find the instrument not only useful, but also easy to use. To determine if further modifications to the PUSH tool are warranted, the NPUAP must consider all input gathered from survey respondents.

It is important for NPUAP to continue encouraging broad use of PUSH and improving it so that the tool is more useful to clinicians. Indeed, this task should result in further improvements in PrU care-an important goal of NPUAP and health care providers throughout the country.


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