Validating Wound Care Algorithms* For Use By

Registered Nurses: Results of a Cross-Sectional Study

Janice M. Beitz PhD, RN, CS, CNOR, CWOCN, CRNP1; Lia Van Rijswijk, MSN, RN, CWCN2

School of Nursing and Health Sciences, La Salle University, Philadelphia, PA;

1

2
La Salle University, Philadelphia, PA; Clinical Editor, Ostomy/Wound Management

Abstract Methods
Research shows that providing quality wound care affects outcomes Design
and costs. Heuristic devices, such as clinical guidelines and algorithms • Cross sectional, mixed methods, quantitative survey design.
to facilitate this process, are widely available. Unfortunately, few have
been validated for clinical use by wound care experts or the non-expert Ethical Considerations
professionals for whom they were designed. The content validity of • IRB approval was obtained and all participants were provided written
one general wound care algorithm has been established.¹ However the informed consent.
construct validity (usage of the wound care algorithms by non-expert
Sample
registered nurses) was lacking and potential areas for improvement
were not yet identified. A cross-sectional, mixed methods quantitative • Researchers contacted practicing RNs associated with a School of
survey design was conducted to validate usage of these algorithms Nursing and Health Sciences in the Northeastern United States (total
with non-expert registered nurses (RNs). Following a brief introduction, sample size 375).
204 RNs associated with an urban university were asked to rate the 11 • Of those, 204 (response rate 54%) participated.
components pervading the algorithms, apply them to a variety of acute
• Most were women (n = 180; 88% - average age 34.8 yrs. ± 11.95) who
and chronic wounds (N = 15), and comment on the research process, and
had a bachelor’s degree (n=148; 73%) and practiced in the acute care
algorithm structure and processes. The majority of the participants (n =
setting (N = 146; 72%).
180) were women practicing in acute care settings (n = 146). Participant
average age was 34.8 years (SD 11.95). The Content Validity Index was Instrumentation/Data Collection
high (CVI * 0.96) and 71 to 98% of nurses selected the correct (primary) A spiral-bound paper copy of all 8 wound care algorithms was available
or appropriate but not entirely correct (secondary) algorithm. Correct for each participant.
dressing selection occurred for 75 to 91% of the 15 wounds displayed.
The proportion of correct algorithm and dressing selection was lower for Users considered wound moisture and amount of necrotic tissue in
wounds with necrotic tissue. Intra-rater reliability (two sets of wounds) wound bed (Figure 1). A paper-pencil data collection instrument was
was modest but unexpectedly higher for necrotic wounds. Participant designed with three segments:
wound assessment insecurity was a common qualitative theme. The study 1) demographic data;
results support that these algorithms have face and content validity and 2) content validation of algorithm components in all algorithms;
facilitate the provision of optimal care with diverse wound types (construct
validity) and confirm that wound education improvements for registered 3) photographic application activity.
nurses are critically needed.
Figure 1. Algorithm example
Introduction
1. Dry, < 25% Necrotic Tissue
• Research has shown that providing quality wound care affects patient
outcomes and costs. Heuristic devices such as guidelines and Medical Diagnosis: Acute or Chronic Wound
Nursing Diagnosis: Skin Integrity Impaired or Tissue Integrity Impaired
algorithms, to facilitate this process are widely available but most Goals of
Reduce risk factors for ulcer development and delayed healing. Prevent wound complications and promote wound healing.
have not been validated for use by experts or the non-expert health Patient Care

Wound Assessments Observed

professionals for whom they were designed. Wound bed/exudate Dry-minimal moisture

Wound bed/tissue
< 25% necrotic tissue/fibrin slough

• The validity of one set of wound care algorithms has been established
Assess for Clinical Signs and Symptoms of Infection (Purulent exudate and/or elevated temperature and/or peripheral induration or edema)
by expert wound clinicians and excellent preliminary clinical usage Depth

outcomes were reported,1,2 but their validity to expedite the clinical Surrounding skin
Superficial or partial thickness Full-thickness

decision-making process when used by non-expert RNs has not been Healthy/reddened Healthy/reddened

evaluated.
Wound edges
Healthy Healthy Undermined

Goals of

Study Purpose
Wound Care

Obtain clean wound bed Provide moist environment Provide moist environment/
prevent premature wound closure

• The purpose of this study was to validate usage of the wound care
Wound Care Plan
Cleanse Cleanse Wound

algorithms by non-expert RNs. Primary Dressing

Moisture Retentive Dressing Wound Hydration

Secondary Dressing
N/A Moisture Retentive Dressing

Research Questions Patient

Care Plan
Reduce risk factors
RISK FACTORS
Arterial ulcers: Smoking, hypertension, hyperlipidemia and inactivity. Review surgical/medical management options to improve arterial circulation.
Diabetic ulcers: Smoking, hypertension, obesity, hyperlipidemia and high blood glucose. Review surgical/medical management options and use appropriate off-loading
techniques.
for developing chronic
1) How do registered nurses (RNs) rate the appropriateness/validity of the
Pressure ulcers: Pressure, shear, friction, nutritional deficiencies, dehydration and dry skin conditions, skin exposure to moisture or wound contamination secondary to
ulcers and delayed incontinence, perspiration or other fluids, e.g. skin protection.
healing, e.g.: Venous ulcers: Edema with leg elevation, ambulation and compression. If patient is not ambulatory, assure frequent ankle flexes. Review
surgical/medical management options to improve arterial circulation and compression bandages if appropriate.

components and processes inherent in the algorithms? Mixed arterial-venous ulcers: Smoking, hypertension, inactivity, hyperlipidemia. Review surgical/medical management options to improve arterial circulation and
compression bandages if appropriate.
All patients: Provide patient and/or caregiver teaching and support. Confirm and treat infection if needed. Assess and manage wound pain and odor if present.

2) How well do RNs use the algorithms to select appropriate wound Expected
Outcomes
Wound is not infected and is healing as evidenced by a reduction in size
after 2 to 4 weeks of care. No evidence of new skin breakdown.

dressings with a variety of wounds? Delayed Healing Re-evaluate plan of care or address underlying etiology if ulcer has not reduced in size during 2 to 4 weeks of care

3) What themes of positive responses or concerns about appropriateness

do RN users describe when assessing content validity and using the
algorithms for wound care therapy selection? ®/TM indicates trademarks of ConvaTec Inc. © 2010 ConvaTec Inc. AP-XXXXXX-US

4) What insights into wound care decision making processes can be obtained
from users’ comments about algorithm usage?
Content and Photographic “Construct” Validation
• Algorithm Content validity was assessed using a 4-point scale3 to rate
the 11 components pervading all 8 algorithms. The proportion of items
rated 3 or 4 (CVI) was calculated for the 11 components.
• Fifteen (15) “test item” chronic and acute wounds with varying moisture
levels (identified for the participant) and amounts of necrotic tissue
in the wound bed were presented. Participants had to assess all
algorithm variables and determine appropriate therapy. Two photos
were repeats to test selection reliability.
• Question 3: Eight themes of positive response or concerns were
identified (Table 2).
• Question 4: Participants noted personal deficits in following areas:
Wound terminology, wound assessment, knowledge of wound
products, and differentiating necrotic from healthy tissue; notably
found it hard to assess wounds without using “staging” (even for non-
pressure wounds).
Table 2. Qualitative Themes

Data Analysis
• Quantitative data were coded, entered into Excel 2003 and uploaded Algorithms helpful
into SPSS Version 16.0 (SPSS, Chicago, IL). Algorithms educational and instructive
• Summary statistics for demographic data, mean scores for algorithm
Research process interesting
components, and individual component and total instrument Content
Validity Index (CVI) were calculated. Algorithms use required education, time, practice
• For each wound photograph % correct primary / secondary algorithm Confusion about wound terminology
and dressing type were calculated.
Influence of wound staging
• Qualitative comments were transcribed and themes derived using
qualitative narrative data reduction techniques. Algorithm limitations

Results Suggestions for improvement

• Research Question 1: On scale of 1 to 4, 11 algorithmic components

rated 3.63 to 3.81; content validity index (CVI) for 11 components rated
Discussion
* 0.96 and 0.98 for total algorithms. (Table 1) • The overall ratings and Content Validity Index (CVI) were strong and
qualitative statements made by participants supported the quantitative
Table 1. Algorithm Component Ratings and analysis.
Content Validity Index (CVI) Results • Participants noted difficulty identifying necrotic tissue.
Algorithm Component Mean Rating (1-4) CVI (0-1) • Results confirm wound assessment limitations of non-expert clinicians
and need for more education.4,5,6
Amount of exudate 3.79 0.98
• Exudate amount could not be tested (simulated) which is a limitation in
Amount of necrotic tissue 3.76 0.98 the study.
Signs/symptoms of infection 3.80 0.99 • Wound assessment skills affect nurses’ and other caregivers’ ability to
select optimal treatment.
Wound depth 3.80 0.98
• Algorithm usage guided non-expert users to a high level of safe wound
Surrounding skin status 3.81 0.99 care decisions but user assessment skill limitations could affect the
Wound edges 3.75 0.98 quality of decision making.

Goals of wound care 3.66 0.97 Conclusion

Appropriate wound care plan 3.72 0.98 • Multiple factors affect optimal algorithm use. Most critically, as in other
Appropriate patient care plan 3.64 0.96 studies, non-expert users were found to have limited wound assess-
ment education and knowledge.
Expected outcomes identified 3.63 0.97
• Despite these limitations, the algorithms expedited the clinical decision
Evaluation for delayed healing 3.70 0.97 making process for non-expert users.
• Algorithm content validity was high and construct validation demon-
• Research Question 2: Algorithms help non-expert RNs make strated high percent correct in wound care choices; in other words, this
appropriate wound care decisions: study provides evidence that the wound care algorithms promote safe,
- Percent correct algorithm selection: 39-93% (primary) and 71-98% effective patient care.
primary and secondary;
- Percent correct dressing selection (primary and secondary): 75- References
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Percent Correct Primary and Secondary Algorithm Nurs. 2005;32(5):307-316; 6. Ayello E, Baranoski S, Salati DS. Nursing 2005 wound care survey
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90%
80%
70%
60%
Financial Disclosure
50% Supported by a research grant from ConvaTec Inc. The study was conducted and the data
40% analyzed by the authors who are solely responsible for the design and content of this study and
30% the analysis and presentation of the data. The authors do not have a financial interest in any of
20% the products discussed in this poster.
10%
* Solutions® Wound Care Algorithms, ConvaTec Inc. Solutions is a registered trademark of
0%
Photo Photo Photo Photo Photo Photo Photo Photo ConvaTec Inc.
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