No PrI were observed on trochanters so these locations are not reported here. Visual skin assessment training, definitions of blanchable and nonblanchable erythema and deep tissue injury DTI , details of the protocol, and reliability have been previously reported Skin that demonstrated no erythema or PrI damage was considered normal skin.
The details of the protocol and reliability of the instrument have been previously reported Briefly, subepidermal moisture reflects water below the epidermis to the depth of 2.
Over 8 seconds electromagnetic waves of MHz are transmitted via a coaxial line terminating in an open-ended coaxial wand on the skin.
The induced electrical field interacts with water molecules closest to the wand while the portion of the electromagnetic energy that is not absorbed by tissue water is reflected, measured, and displayed in the measuring unit. Subepidermal moisture is displayed as the tissue dielectric constant TDC and is directly proportional to the hydration of the tissue. Thus, subepidermal moisture increases with increasing water content and edema range 0—79 TDC.
Normal sacral and ischial skin is approximately 37 TDC Research staff training was carried out by a certified wound care nurse BBJ using photographs that depicted each BWAT characteristic and choice. Initial training required an hour. Additional minute training sessions occurred at the beginning of each new cohort of NHs generally every five months throughout the five-year study period. Independent PrI assessments were obtained by two research staff five to 10 minutes apart, at randomly selected observation visits.
Critically important to the study was identifying unique, separate PrIs on the same anatomic location as this was necessary for determining PrI history and incidence. Using a Q-sort method, the summaries of the visual assessments over 16 weeks of each anatomic location for each participant were evaluated independently by 3 blinded raters chosen from research staff.
Each rater categorized each summary into one of four history patterns observed during the study: 1 PrI all weeks, 2 PrI less than three weeks, 3 PrI three or more weeks but not all weeks, and 4 PrI resolved, no damage for two weeks. For those with PrI resolved, subsequent damage was considered a new PrI.
The nested nature of the study design required data to be summarized or selected at the level appropriate for the analysis e. Descriptive statistics illustrate the demographic characteristics of the study participants. To standardize analyses used to examine BWAT score and individual characteristics by PrI stage and location, the BWAT assessment of the first observed PrI at an anatomic location either at study start or developed during the study was used.
In total, 36 subsequent PrIs were excluded from these analyses as they occurred on anatomic sites with prior PrIs. To examine total and individual item score reliability, BWAT data collected during any weekly PrI assessment for which there was data from two independent observers was used. Multiple approaches were used to examine reliability: correlation coefficients, measures of agreement. Spearman rho correlation coefficients were used to provide a measure of general association between observers across a variety of participant e.
Three measures of agreement were calculated. First, simple exact percent agreement was examined. Next, we calculated a moderate estimate of percent agreement for scores plus or minus 1 point. The moderate estimate of percent agreement may more accurately reflect clinically meaningful agreement as a 1-point difference in score may not be differentially actionable. Finally, Weighted Fleiss Kappa statistics were used to calculate agreement, correcting for chance agreements. This is a more stringent evaluation and may also be a better reflection of agreement in clinical use.
To formally assess reliability, intraclass correlation coefficients ICC were used. The ICC allows examination of reliability estimates from more than 2 observers. Both the single rating and the mean rating agreement statistic to summarize the pattern of reliability across the various combinations of raters are presented.
The 2-way random-effects model was used because not all raters assessed all PrIs, thus a sample of raters is reported. Observation level data were analyzed with generalized multinomial logistic modeling 40 — 43 using Stata version Effects for participant and measurement period were included in all models to account for the correlated nature of the data Multinomial logistic regression models were conducted to examine ability of BWAT initial assessment to predict PrI history pattern using covariates of size surface area and stage.
Only PrI history pattern four-level categorical outcome on the trunk and heels were analyzed due to inadequate numbers of PrI on other locations. Longitudinal skin health and PrI measures were obtained from participants with PrIs Figure 1. PrIs ranged in size from 0. While not significant, subepidermal moisture values at the PrI edge were highest for stage 4 PrIs Note: Mixed models used to account for multiple PrIs by participant on different anatomic locations.
For PrIs that developed during the study, significant differences existed between initial BWAT score across anatomic locations with higher BWAT scores at the sacrum compared to heels BWAT scores were significantly lower for persons with light skin tones compared to those with medium and dark skin tones light skin tones Initial BWAT scores were significantly higher for PrIs that persisted and were present all weeks of the study compared to PrIs present less than 3 weeks Subepidermal moisture values were associated with BWAT characteristics of wound edges, skin color surrounding the wound, and exudate type.
Exudate types of bloody and serous demonstrated higher subepidermal moisture values BWAT characteristics of peripheral tissue induration and edema, necrotic tissue type, and undermining did not show sufficient numbers across all characteristic choices making analyses not possible. The average time to complete a BWAT assessment was 1. Two characteristics generated weighted Kappas above 0. Agreement was higher for all characteristics when examined with moderate agreement plus or minus one point Table 4.
Mean observer agreement ICCs were in the good to excellent range 0. Single observer agreement ICCs were mostly 0. Three characteristics had single observer agreement ICCs below 0. These values must be interpreted with caution as minimal heterogeneity in presentation of these wound characteristics existed across the PrIs in this study. In this report, two goals are accomplished.
First, updated reliability estimates for the BWAT that demonstrate acceptability when used by non-health care research staff to monitor PrI status are provided. The reporting of reliability estimates across these categories is the first of such reports. Specifically, lower reliability estimates for persons with medium and dark skin tones suggest the need for education targeted at identification of wound characteristics among persons of color The slightly lower reliability estimates for heel PrI may indicate a need for refining descriptors of macroscopic wound characteristics for PrI on heels 46 — The less than optimal reliability estimates for stage 2 PrIs and DTIs may be related to difficulty in assessing skin discoloration reflective of DTIs and problems differentiating moisture associated skin damage from stage 2 PrI 49 , The ICC values must be interpreted cautiously for some wound characteristics as there was minimal heterogeneity across the PrIs notably peripheral tissue edema, necrotic tissue type and amount.
When ICCs are applied to homogenous populations as in these cases the ICC will be low as it is strongly influenced by the variance of the trait in the sample in which it is assessed Chan and Lai 51 used the BWAT to examine wound healing in clean open wounds excluding wounds with edema and induration and their sample of wounds also showed minimal heterogeneity across necrotic tissue type and undermining. Jesada and colleagues 32 also found lower reliability estimates for the wound characteristic of necrotic tissue type kappa range 0.
Reliability of wound assessment tools, and the BWAT in particular, has not been reported when used by non-health care workers and those with limited wound care experience.
We demonstrate that adequate to good reliability can be obtained when persons with limited to no experience with wounds such as non-health care research staff or beginning nursing students use the BWAT with adequate training.
The average time to complete the BWAT was only 1. The use by persons with limited to no experience in wound care and the quick assessment times suggest the tool is practical for clinical use. The reliability estimates reported in this study may be higher when the BWAT is used by experienced wound care nurses and providers. Higher scores would be expected because as skin and tissue damage increases, visual observation of more severe wound characteristics is available.
BWAT scores differed by anatomic location, a somewhat surprising finding. This may be related to differences in anatomic structure of the heel 46 , The anatomy of the heel may not allow for development and visualization of all the macroscopic wound characteristics evaluated by the BWAT characteristics.
The higher scores may be due to difficulty in observing some of the macroscopic wound characteristics on persons with dark skin tones. Subepidermal moisture was higher for stage 2, 3 and 4 PrIs approximately 41 TDC , compared to subepidermal moisture at normal sacral skin 37 TDC 33 suggesting some level of edema at the wound edge.
This was not true for all heel PrI subepidermal moisture values. Subepidermal moisture values for Stage 3, DTI, and unstageable heel PrIs 21, 27, and 28 TDC, respectively were all lower than subepidermal moisture at normal heel skin. Again, these differences may be related to the anatomic structure of the heel 46 , Subepidermal moisture varied as would be expected across several characteritics on the BWAT. Subepidermal moisture values increased as wound edge increased in severity and with exudate types of bloody and serous.
As skin color surrounding the wound increased in severity typically demonstrating more tissue destruction below the skin surface , subepidermal moisture values also decreased. This is similar to findings using subepidermal moisture values to detect PrI where values have been reported as lower for deep tissue injury. In addition, BWAT score predicted PrI duration of greater than three weeks compared to those less than three weeks at the trunk and predicted resolved versus persistent heel PrIs.
Others have shown that wound assessment instruments can be useful as predictors of wound healing 52 , These findings with the BWAT should be evaluated in a larger population with sufficient time to allow for PrI healing.
The calculation and reporting of multiple measures of reliability provides a realistic and robust examination of the BWAT when used by non-health care providers and non-wound care experts. The findings confirm the utility of the BWAT for reliably assessing PrI progress and healing progress and suggest several areas for improved training and education in wound assessment.
The photographs needed to be of high resolution and good quality for eventual publication and validated by the original BWAT author as being representative of the intended characteristic. In phase 2, a face-to-face validation exercise was completed to include, edit, or exclude these photographs. Corrections were made; additional photographs were obtained for the remaining characteristics and to replace those not validated.
Phase 3 involved an electronic survey that achieved validation online. Participants: Phase 2 participants consisted of 15 WOC nurses with a mean of Phase 3 had 8 WOC nurses and 1 master's prepared wound care specialist, with approximately 10 years of experience.
Now published in a pocket guide format, it is a standardized way to teach BWAT wound assessment skills in a consistent format. Tags Type your tag names separated by a space and hit enter. J Wound Ostomy Continence Nurs. Links Publisher Full Text. Aggregator Full Text. Bates-Jensen B. Parslow N. Raizman R. Singh M. Ketchen R. Citation Harris, Connie, et al. Bates-Jensen wound assessment tool: pictorial guide validation project.
Harris, C.
0コメント