Wound assessment remains an integral part of wound care as it provides useful parameters for differentiating wounds that are responding to treatment from those that are not.
However, suboptimal assessment, coupled with inconsistent documentation, can prevent timely treatment and result in delayed wound healing, increased risks for infection, and complications (Gillespie et al, 2014). Therefore, it is important for a clinician to perform wound assessment and documentation in an accurate, consistent, and timely manner (Ding et al, 2016).
Presently, the wound assessment and documentation practices remain inconsistent among different clinicians, institutions, and countries (Coleman et al, 2017). Ding et al (2016) conducted an integrative review of nurses' surgical wound assessment and documentation practices and reported inadequate documentation and inconsistent wound practices despite having national clinical guidelines. They cautioned that this could hamper the quality and monitoring of wound healing progression and treatment.
There are several well-established wound assessment tools (WATs) to facilitate standardisation in wound assessment and documentation, such as TIME-CDST (Tissue, Infection/Inflammation, Moisture, and Edge—Clinical Decision Support Tool)(Blackburn et al, 2019), Pressure Ulcer Scale for Healing (PUSH) Tool (Stotts et al, 2001), Triangle of Wound Assessment (TWA) (Dowsett and von Hallern, 2017), Wound Healing Assessment and Monitoring (WHAM) (Shepherd and Nixon, 2013), and Wound Bed Preparation (WBP) (Dowsett and Newton, 2005). Most healthcare organisations have adapted and modified these tools by deciding the amount and types of wound information required for meaningful and efficient evaluation based on expert opinion and organisational needs. However, these modifications could lead to variations in WATs and inconsistent wound practices rather than standardisation (Greatrex-White and Moxey, 2015). In England, Coleman et al (2017) conducted a literature review and consensus study to develop a generic Wound Care Assessment Minimum Data Set (WCA-MDS) with the aim of facilitating a consistent approach to wound assessment across the country and improving clinical decision making for wound care. The MDS also allows the clinicians to review their existing WATs against a set of evidence-based criteria.
In Singapore, the most commonly-used WATs are the TIME-CDST and PUSH Tool (Low, 2015). In the authors' experience most hospitals have adapted them with modifications to include or exclude certain wound parameters based on their clinical and operational requirements. However, whether these modified WATs have been beneficial for clinicians here remains unclear. This study, therefore, sought to evaluate the local WATs to determine whether they meet the WCA-MDS criteria and clinicians' needs in Singapore.
Methods
This study aimed to evaluate how well the existing WATs used in Singapore and seven other well-established WATs benchmark against evidence-based criteria. The study adopted an action evaluation methodology, a praxis-oriented research, involving a community of practitioners who interactively develop clear goals and design methods to solve a practical problem using consensus-based decision making (Silverman, 2020). The WCA-MDS developed in England was used as the benchmark for evaluating the different WATs in Singapore. It consisted of 34 items, which covered the following subdomains: general health information, baseline wound information, wound assessment parameters, wound symptoms, and specialists (Coleman et al, 2017). An audit form was developed to assess the quality of the WATs against the 34 criteria, which required reviewers to indicate whether the criteria have been met or not.
The evaluation was conducted on eight WATs used by various institutions in Singapore (four acute hospitals (A, B, C, D), one community hospital (E), two nursing homes, and a charitable home care agency). Seven well-established WATs were also included in the evaluation: the TIME-CDST (Blackburn et al, 2019), PUSH Tool (Stotts et al, 2001), Applied Wound Management (AWM) tool (Gray et al, 2010), National Wound Assessment Form (NWAF) (Fletcher, 2010), Bates-Jensen Wound Assessment Tool (BWAT) (Bates-Jensen et al, 2019), Leg Ulcer Measurement Tool (LUMT) (Woodbury et al, 2004), and MEASURE (Measure, Exudate, Appearance, Suffering, Undermining, Re-evaluate, and Edge) assessment framework (Keast et al, 2004). This study was conducted over 2 months from June to July 2020, involving two expert clinicians who evaluated the WATs against the WCA-MDS criteria. Any discrepancy or disagreement on the criteria was referred to the rest of the clinicians for resolution. As this study did not involve data collection from human subjects, it was determined by the institutional management that no formal ethical approval was required. Nevertheless, permission was obtained from the authors' institutions to publish and share the findings on the WATs under anonymity.
Results
Figure 1 reports the number of criteria indicators met by each WAT, in descending order from left to right. The results show that only five WATs met at least 50% of the 34 criteria indicators, with the MEASURE assessment framework achieving the most criteria at 68%, followed by TIME-CDST at 65%, Hospital C WAT at 56%, NWAF at 53%, and AWM form at 50%. On the other hand, the PUSH Tool met the lowest percentage of criteria at 21%. Although Figure 1 provides information on how well the individual WAT meets the criteria for an optimal WAT based on the UK WCA-MDS, it does not indicate how well each individual criterion was met. For example, for the criterion on exudate amount, some WATs require clinicians to document the amount as ‘(+) to (+++)’. In contrast, the better-designed ones would provide descriptors on how to quantify the amount, eg ‘(+)—slight amount, some part of gauze is soaked’.
Figure 2 pools together the data from all WATs and calculates the percentage of WATs that met the individual criteria indicators to determine the most frequently assessed/included criteria indicators across these WATs. The criteria indicators were organised based on the WCA-MDS criteria under five subdomains: ‘patient information’, ‘wound baseline information’, ‘wound assessment parameters’, ‘wound symptoms’, and ‘specialist's referral’. Based on Figure 2, the five most common criteria indicators are wound type/classification, date and time of wound, wound size, wound bed tissue type, and exudate information. On the other hand, most of the criteria indicators under the ‘patient information’ and ‘specialist's referral’ subdomains were unmet in the WATs, reflecting the lack of documentation in these areas. Under the ‘wound baseline information’ subdomain, the most commonly omitted criteria indicators were treatment aims and planned re-assessment date. Under the ‘wound assessment parameters’ subdomain, the most frequently omitted criteria indicators included information about undermining/tunnelling wounds, wound margins description, and quantification of wound bed tissue amount after wound cleansing. Finally, under the ‘wound symptoms’ subdomain, the most commonly omitted criteria indicators were information about wound pain, signs of local or systemic infection, and wound swab.
Discussion
The study findings have provided a good gauge of how well the existing WATs performed against the WCA-MDS criteria. The only local WAT that performed comparatively well against the seven well-established tools was Hospital C WAT, which achieved 56% of the WCA-MDS criteria. Hospital C is a tertiary-level hospital in Singapore with a strong emphasis on clinical, research, and innovation excellence and the presence of a well-established wound care team. Several key observations were made about the local WAT designs. First, there were marked variations across the local WATs, reflecting the perilous state of wound assessment and documentation adherence to the best practice standards. The results here concur with a chart review study by Gartlan et al (2010), who observed disparity in charting wound parameters among different clinicians within an Australian regional hospital. They attributed these findings to a lack of a standardised framework for wound assessment and documentation, staff attitudes, and the inconsistent use of validated WATs within the organisations. Second, most local WATs include additional information on prescribed treatment options, such as cleansing solutions and wound products. This element, which has not been included in the WCA-MDS criteria, is viewed as an important factor in determining the effectiveness of wound treatment. A study by Moore et al (2019) reported a proliferation of wound products, making it challenging for clinicians to determine their effectiveness and cost-efficiency. They expanded the TIME framework by including a clinical decision support tool to assist clinicians in determining the appropriateness of the treatment options (Moore et al, 2019). Finally, one local WAT (the home care agency tool) has incorporated serial photography to track wound healing progression and conduct planimetric wound measurement. This wound measurement method effectively provides a more accurate baseline measurement than the ruler-based method in terms of area calculation and the percentage of area reduction, which are useful parameters for differentiating wounds responding to treatment from those that are not (Little et al, 2009).
Presently, none of the WATs met all of the WCA-MDS criteria, including the seven well-established tools. The criteria indicators under three subdomains (patient information, wound symptoms, and specialist's referral) were more commonly omitted than the other two subdomains. These results echo the observations by Gartlan et al (2010), who found that only 50% of the chart review cases documented sufficient information about vital wound parameters, such as wound margins, periwound area, pain, and signs of infection. There are several reasons why the local healthcare organisations have excluded certain wound parameters from their WATs. First, some of these criteria indicators or wound information can be easily retrieved from other data sources within the clinical documentation system. Second, most organisations intentionally limit the number of items within their WAT design to keep it simple and easy to use. A lengthy form would otherwise lead to excessive duplicate information, work inefficiency and reduced staff compliance with completing documentation (Ousey et al, 2018; Do et al, 2021). Third, most patients' average length of stay at the hospital ranges from 1 to 2 weeks, making it difficult for clinicians to monitor wound healing progression beyond hospital stay, especially hard-to-heal (chronic) wounds (Do et al, 2021). Finally, the selection of wound parameters could be attributed to the arbitrary judgment of expert clinicians to meet their clinical and operational needs (Greatrex-White and Moxey, 2015). Despite these reasons, it is essential to note that wound healing is a complex process influenced by multiple factors, including patient condition and specialist intervention (Moore et al, 2019). Without integrating these parameters within the WAT, clinicians would find it challenging to evaluate wound care holistically and meaningfully.
This is the first known study to evaluate the performance of the local WATs against the England WCA-MDS as the clinical benchmark. The study has highlighted the marked variations in the WATs used by different healthcare organisations in Singapore and demonstrated the need to revise them based on a set of evidence-based criteria. There is also an urgent need to establish a national wound care assessment and documentation standard similar to the WCA-MDS for the local context. In addition, the results from the evaluation of each WAT can help the clinicians from these organisations determine which aspects of the form require enhancement to meet their clinical needs in wound assessment better. Although wound care remains a challenge for many clinicians, this study has demonstrated the value of WAT in supporting a structured and consistent wound assessment and documentation approach, particularly for inexperienced clinicians (Greatrex-White and Moxey, 2015).
This study has several limitations. First, the study only evaluated the WATs from eight local healthcare organisations, which might not represent other healthcare organisations in Singapore. The eight organisations were included in this study based on their organisational size, researchers' access, and perceived representation for the care sector. Second, the study did not include other well-established international WATs as these tools were not commonly used in Singapore. Finally, the WCA-MDS was designed as a national benchmark for wound assessment and documentation in the NHS in England, which might limit its global application. Nevertheless, the WCA-MDS has provided a well-established, evidence-based benchmarking criteria for the present study due to a lack of such standards in Singapore.
The study reveals a lack of emphasis on wound care education in undergraduate medical and nursing programmes. Most clinicians would only acquire these skills in the workplace through mentorship, peer learning, and in-house training programmes (Welsh, 2018; Goh et al, 2019). Welsh (2018) conducted a systematic review of wound education and reported that nurses' competence in wound assessment and management significantly improved after training intervention for pre-registration and post-registration participants. Such training interventions should include wound assessment and documentation standardisation, clinical decision making, and wound product-specific training. A comprehensive wound education for nurses would significantly improve their ability to perform competent and effective wound care for their clients.
Conclusion
Accurate and optimal wound assessment remains an integral part of effective wound management and serves as a means for monitoring wound healing progression. However, despite the advances in WAT development within the literature, the current state of wound assessment and documentation across healthcare institutions remains inconsistent and perilous. This study has found marked variations in wound assessment and documentation practices across different healthcare organisations. Many locally designed or adapted WATs did not meet the benchmark required for an optimal tool. The current state could be attributed to a lack of national standards and contextualisation of WAT design to the specific care setting without being subjected to validation testing. Future research into the redesign and psychometric testing of local WATs and training programmes to improve clinicians' competence in wound practices are needed.
KEY POINTS
- Many wound assessment tools (WATs) have been developed to standardise wound assessment and documentation
- Even though they are adapted from validated WATs, there are marked variations in wound assessment practices across institutions as they include selected wound parameters based on organisational and clinical requirements.
- The study highlights the need for a national wound care assessment and documentation standards framework in Singapore
- The Wound Care Assessment Minimum Data Set can serve as a useful framework for clinicians to develop a nationally validated WAT for institutions and educators to standardise nurses' training in wound assessment and monitoring.
CPD reflective questions
- How confident are you to conduct a wound assessment independently without a wound assessment tool (WAT)?
- Consider your institutional WAT. Are there any wound parameters or information that is not included that could hamper your assessment or monitoring of your clients' wounds?
- Is there any area where you can improve the WAT to suit your assessment needs better?