What is the purpose and application of the Pressure Ulcer Scale for Healing (PUSH) score in wound care?

PUSH Score: Purpose and Clinical Application

The Pressure Ulcer Scale for Healing (PUSH) is a validated monitoring tool that tracks wound healing progress by scoring three parameters—surface area (length × width), exudate amount, and tissue type—with scores ranging from 0 (healed) to 17 (worst possible), and should be used to objectively document treatment effectiveness in pressure ulcers, diabetic foot ulcers, and venous leg ulcers. 1

Core Components and Scoring System

The PUSH tool measures three specific wound characteristics that account for 40-74% of wound healing variance:

• Surface area calculated as length × width in cm² 1
• Exudate amount (none, light, moderate, or heavy) 1
• Tissue type (closed, epithelial tissue, granulation tissue, slough, or necrotic tissue) 1

The total score decreases as wounds heal, with 0 indicating complete healing and 17 representing the most severe wound state 2.

Primary Clinical Applications

Treatment Effectiveness Monitoring

Use the PUSH score to evaluate whether your interventions are working by obtaining serial measurements at consistent intervals (weekly or biweekly). 2

• The American College of Nutrition specifically recommends using PUSH scores to assess nutritional intervention effectiveness in pressure ulcers, particularly in polymorbid malnourished older adults 3
• Significant score decreases between assessments indicate healing progression, while stable or increasing scores signal treatment failure requiring intervention changes 2
• The tool accurately differentiates between healing and non-healing wounds as early as week 1 of monitoring 2

Validated Wound Types

The PUSH tool has demonstrated validity beyond its original pressure ulcer indication:

• Pressure ulcers (Stages II-IV): Original validated indication with strong correlation to healing outcomes 1
• Diabetic foot ulcers: Validated in multicenter studies showing significant score decreases correlating with healing 4
• Venous leg ulcers: Effective monitoring tool with mean scores decreasing from 12 to 8 over 2 months in healing ulcers 5

Practical Implementation Protocol

Assessment Frequency

• Obtain baseline PUSH score at initial wound evaluation 2
• Reassess weekly for acute care settings or biweekly for long-term care facilities 6
• Continue monitoring until complete healing, patient transfer, or death 2

Interpreting Score Changes

A decreasing PUSH score indicates healing progression, while stable or increasing scores after 1-2 weeks warrant immediate treatment modification. 2

• Mean score changes are significantly different between healing versus non-healing wounds (P = 0.000) 4
• The length × width component alone can accurately differentiate healed from non-healed ulcers 2
• After 8 weeks of effective treatment, expect PUSH score reductions of approximately 50% from baseline 6

Clinical Pitfalls and Limitations

Common Measurement Errors

• Ensure consistent measurement technique between assessments—the same clinician should measure when possible to reduce inter-rater variability 2
• The tool lacks a dedicated wound depth subscale, which limits assessment of undermining or tunneling 2
• Most validation occurred in sacral pressure ulcers (77% of study wounds), so applicability to other anatomic locations requires clinical judgment 2

When PUSH May Be Insufficient

• For wounds with significant depth, undermining, or tunneling, supplement PUSH with additional depth measurements 2
• The tool was validated primarily in elderly patients (mean age 66-80 years), so performance in younger populations is less established 2, 1
• Consider that surface area measurements alone may suffice for basic healing monitoring in resource-limited settings 2

Documentation and Quality Improvement

Use PUSH scores to create objective, quantifiable documentation that supports clinical decision-making and demonstrates treatment outcomes. 3

• The tool provides clinically valid data suitable for quality improvement initiatives and outcome tracking 1
• Serial PUSH scores create an objective record that justifies continuing or changing treatment approaches 3
• The Clinical Nutrition guideline endorses PUSH for evaluating nutritional intervention effectiveness specifically 3