title: The Wound Trend Scale: A Retrospective Review of Utility and Predictive Value in the Assessment and Documentation of Lower Leg Ulcers.
abstract: Wound assessment is essential to manage wound care. The Wound Trend Scale (WTS) is a paper-and-pen instrument comprised of 14 parameters designed to guide assessment of findings relevant to lower leg ulcer management and includes an infection screen and cues for physician consultation. To determine its clinical utility, predictive value, and reliability, data were retrospectively analyzed from a random sampling of medical records of patients seen at a Foot and Leg Clinic between January 1, 2007 and December 31, 2008. Patients had 1 leg or foot ulcer, 3 consecutive assessments scheduled according to wound status (twice weekly if at high risk for nonhealing or amputation, weekly for moderate risk, or 1 to 2 months if stable), known outcomes, and a maximum treatment period of 3 months. Patient demographics included ulcer etiology, comorbid conditions (diabetes, neuropathy, peripheral arterial disease), and wound outcomes (closed, infection, amputation and surgery). Predictive values, inter- and intrarater reliability (assessed among the authors and 5 additional nurses with expertise using the study instrument), and the impact of WTS education on the wound assessment process were determined using 5 representative cases. Parameters were compared using the t-test. Seventy (70) patient records were examined and subdivided by ulcer site: foot (below ankle, 37) and leg (ankle and above, 33). Of the 13 etiologies, the foot group had 4 and the leg group 10; the foot group had more diabetes (92%), neuropathy (76%), and peripheral arterial disease (95%) than the leg group (52%, 5%, and 70%, respectively). Ulcer duration before referral averaged 16.42 (range 4-144) months. Wound outcomes included closed (57), infection (21), amputation (13), and surgery (3). Healing predictive values were sensitivity (99%), specificity (87%), and positive and negative predictive values and test efficiency (all 96%). Inter- and intrarater reliability were .85 (range .16-.96) and .86 (range .50-1.00), respectively. On admission, leg ulcers had larger surface area (P <0.05), more edema (P <0.01), more granulation (P <0.05), and higher total WTS scores (P <0.05) than foot ulcers, which had more infections (P <0.05). Foot ulcers at the third assessment had decreased tissue depth (P <0.05), increased epithelial tissue (P <0.01), and lower total WTS score (P <0.05). Significant third assessment parameters for leg ulcers were reduced depth (P <0.001), less necrotic tissue (P <0.001), less exudate (P <0.01), improved periwound condition (P <0.05), reduced edema (P <0.001), and increased epithelialization (P <0.01). After exposure to the WTS experience, the number of parameters assessed increased from 2.6 (registered nurses) and 1.5 (student nurses) to both using 15 (P <0.001). Nurses complied 100% with physician consultation for cued risks. Patient outcomes were 81% closure, and 70% had physician consultation for the risks identified. WTS predictive performance was excellent and improved nursing assessment practices. Future research to identify parameter criteria validity is warranted.
authors.affiliation: Foot and Leg Ulcer Clinic, Van- couver Island Health Authority, British Columbia, Canada.
authors.forename: Noreen A
authors.initials: NA
authors.lastname: Campbell
authors.affiliation: Foot and Leg Ulcer Clinic, Van- couver Island Health Authority, British Columbia, Canada.
authors.forename: Donna L
authors.initials: DL
authors.lastname: Campbell
authors.affiliation: Foot and Leg Ulcer Clinic, Van- couver Island Health Authority, British Columbia, Canada.
authors.forename: Andrea
authors.initials: A
authors.lastname: Turner
mesh_terms: D000368:Aged; D002983:Clinical Competence / Q000592:standards*; D004282:Documentation / Q000592:standards; D005260:Female; D006801:Humans; D007871:Leg Ulcer / Q000145:classification*; D008297:Male; D008875:Middle Aged; D009726:Nurses / Q000592:standards; D009730:Nursing Assessment / Q000592:standards*; D063868:Patient Outcome Assessment; D010820:Physicians / Q000592:standards; D015203:Reproducibility of Results; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D014945:Wound Healing