Bluebelle Wound Healing Questionnaire (WHQ)

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The Bluebelle WHQ is an 18 item questionnaire for the assessment of surgical site infection (SSI) in closed primary wounds.

The Bluebelle WHQ is an 18 item questionnaire for the assessment of surgical site infection (SSI) in closed primary wounds. It is a single measure designed for completion by patients (using the PRO version) or healthcare professionals (using the ClinRO version) during a period of up to 30 days after discharge from hospital. The questionnaire includes items to assess signs, symptoms and wound care interventions indicative of SSI. Response categories include an ordinal scale to capture symptom severity. Development of the measure involved patients and professionals using robust methodology.

The questionnaire is available in two different versions.

Patient reported (PRO) version of the Bluebelle.

To be completed by the patient themselves after leaving hospital following surgery.

Clinician reported (ClinRO) version of the Bluebelle.

To be completed by any healthcare professional involved in wound assessment.


Surgical site infections (SSIs) are the third most common hospital-associated infection and can lead to significant patient morbidity and healthcare costs. Identification of SSIs is key to surveillance and research but reliable assessment is challenging, particularly after hospital discharge when most SSIs present.

Design and development

A three-phase mixed methods study was undertaken to inform the development and design of this questionnaire: Phase 1, an analysis of existing tools and semi-structured interviews with patients and professionals to establish the concepts to be measured and content of the measure; Phase 2, development of questionnaire items suitable for patients and professionals; Phase 3, pre-testing the single measure to assess acceptability and understanding to both stakeholder groups. Interviews and pre-testing took place over a 12 month period with patients and professionals from five specialities recruited from two UK hospital Trusts.

Subsequent to the above study, the WHQ was field-tested for completion by patients (self-assessment) and healthcare professionals (observer-assessment) in a large study following abdominal surgery. An 18 item WHQ was adopted as the final version. The WHQ has demonstrated strong internal consistency and good reliability between test-retest and self- versus observer assessment.

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Scoring system

The WHQ consists of a single scale. An overall score is calculated by simply summing the scores for each item. When summed, possible overall scores range from 0 to 41 with a lower score representing a better wound healing outcome. There are no pre-defined recommendations from the developers for dealing with missing values, with the exception of an optional component for Item 6 (Item 6b)

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Further research

Research into the further application and validation of the WHQ in other types of wound and surgical specialties is underway. Cut-off scores for SSI diagnosis will be explored further.

In addition, members of the research group are exploring the feasibility of collecting digital images of the wound taken by patients as a tool to use in conjunction with the WHQ for improving remote and blinded SSI assessment.

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The development and validation of the WHQ was embedded within the Bluebelle feasibility study. The Bluebelle study was funded by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme (project number 12/200/04). The WHQ development and validation was supported by the by the Medical Research Council (MRC) ConDuCT-II (Collaboration and innovation in Difficult and Complex randomised controlled Trials In Invasive procedures) Hub (MR/K025643/1) for Trials Methodology Research and the NIHR Biomedical Research Centre (BRC) at University Hospitals Bristol NHS Foundation Trust and the University of Bristol.

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Administration Methods

The Bluebelle WHQ is to date validated for pen and paper completion. Careful migration to a digital delivery format (for example screen based device) can be authorised. Please contact us for advice.

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