Table 1.
Qualitative wound drainage tools
| Qualitative tools | ||||||
|---|---|---|---|---|---|---|
| Name | Scale | Measurement of drainage | Other variables measured | Assessed by patient, caregiver, or HCP | Validated? | Example of study utilizing the scale |
| Drainage severity, assessed by patient | ||||||
| Malignant Wound Assessment Tool—Clinical (MWAT) [3] |
Dry Minimal Moderate Heavy |
Clinical wound features, physical effects and emotional and social impacts of the wound | Patient | Yes | Breast wound [29] | |
| Toronto Symptom Assessment System for Wounds (TSAS-W) [4] | 0–100 |
0 = No drainage or exudation 10 = Most severe and/or continuous drainage or exudation |
Odor, itching, bleeding, cosmetic concern, swelling/edema, bulk/mass effect from wound, bulk/mass effect from dressings | Patient or caregiver | No | Breast wound [30] |
| Wound Symptoms Self-Assessment Chart (WoSSAC) [5] | 0–10 |
How often has fluid been leaking from your dressing over the last week? 0 = No fluid leaking 10 = Constantly leaking |
Pain from wound, pain related to dressing changes, fluid leakage from dressing, bleeding, smell, itching | Patient | No | Acute and chronic wounds in a wound cleansing trial [31] |
| Wound Management Questionnaire (Elliott et al.) [6] |
In the past 24 h, has fluid leaked through the dressing? Not at all, A little, Quite a bit, A lot |
Dressing replacement in the last 24 h | Patient | No | Surgical sites [32] | |
| Drainage severity, assessed by provider | ||||||
| National Wound Assessment Form [7] |
Wound moisture level Dry, Moist, Wet, Saturated, Leaking |
HCP | No | NA | ||
| World Union of Wound Healing Societies’ Initiative Exudate Assessment (WUWHS) [8] |
Dry Wound bed is dry; no visible moisture and primary dressing is unmarked; dressing may be adherent to wound Moist Small amounts of fluid are visible when the dressing is removed; primary dressing may be lightly marked; dressing change frequency appropriate for dressing type Wet Small amounts of fluid are visible when the dressing is removed; the primary dressing is extensively marked, but strikethrough is not occurring; dressing change frequency is appropriate for dressing type Saturated Primary dressing is wet, and strikethrough is occurring; dressing change is required more frequently than usual for the dressing type; peri-wound skin may be macerated Leaking Dressings are saturated and exudate is escaping from primary and secondary dressings onto clothes or beyond; dressing change is required much more frequently than usual for dressing type |
Exudate color, consistency, odor (see “Drainage appearance” below) | HCP | No | NA; referenced in treatment consensus for epidermolysis bulla [33] and chronic wound management [34] | |
| New Wound Bed Score (WBS) [9] | 0–2 |
0 = Severe 1 = Moderate 2 = None/Mild |
Edges, eschar, depth and granulation tissue, edema, dermatitis, peri-wound callus/fibrosis, wound bed | HCP | Yes | Lower extremity wounds [9] |
| Modified tissue, inflammation/infection, moisture, edge/epithelialization (TIME) [10] | 0–2 |
0 = No exudate 1 = Exudate 2 = Smelly exudate |
Age, mental state, self-sufficiency, nutrition, predisposing disease | HCP | Yes | NA |
| Pressure Ulcer Scale for Healing (PUSH tool) [11] | 0–17 |
0 = None 1 = Light 2 = Moderate 3 = Heavy |
Area (cm2), tissue type | HCP | Yes | Pressure ulcers [35] |
| Leg ulcer measurement tool [12] | 0–56 |
0 = None 1 = Scant 2 = Small 3 = Moderate 4 = Copious |
Type, size, undermining, necrotic tissue type, necrotic tissue, granulation tissue, skin viability, leg edema, assessment of bioburden | HCP | Yes | Lower extremity ulcers [36] |
| Drainage appearance | ||||||
| Bates–Jenson Wound Assessment Tool (BWAT) [14] | 1–60 |
Exudate type: 1 = Bloody (thin, bright red) 2 = Serosanguineous (thin, watery pale red to pink) 3 = Serous (thin, watery, clear) 4 = Purulent (thin or thick, opaque tan to yellow) 5 = Foul purulent (thick, opaque yellow to green with offensive odor) |
Size, edges, undermining, necrotic tissue, skin color, peripheral tissue edema, induration, granulation, epithelialization, drainage amount (see Table 2) | HCP | Yes | Post-surgical healing [37] |
| World Union of Wound Healing Societies’ Initiative Exudate Assessment (WUWHS) [8] |
Color: clear, amber; cloudy, milky or creamy; pink or red; green; yellow or brown; gray or blue Viscosity: high viscosity, low viscosity |
Drainage volume (see “Drainage amount, assessed by provider” in Table 1) | HCP | No | See above | |
| Change in drainage | ||||||
| NCT03249909 |
Exudate status: Dry, Moist, Wet, Saturated, Leaking Change in exudate status: decrease, equal/unchanged, increase |
HCP | No | NA | ||
HCP Health care provider