Evaluating the effects of using the mobility assessment sub-scale within the Braden Scale on pressure ulcer incidence and preventive interventions in adult acute care settings: A systematic review.

Abstract

Background Pressure ulcers remain a serious problem in healthcare. For example, the incidence of hospital acquired pressure ulcers in the United States has been reported to be between 7% to 9%.1 This number could be higher given that the data on pressure ulcer incidence reported in the national survey was based on a point prevalence study of observed hospital acquired pressure ulcers over a period of only five days. When a pressure ulcer develops, the damage to the skin can inflict undue pain on a person.2 Other complications associated with pressure ulcers include severe infections requiring intensive treatment and surgery, long hospital stay and risk of death.3-4 Prolonged hospitalisation to attempt to reverse the effects of the injury adds to the financial burden to the patient and hospital. Although the highest incidence is seen in long term care, most newly developed pressure ulcers are in the acute care settings.5 In view of the grave consequences that pressure ulcers may have on patients, identifying persons at risk for developing pressure ulcers becomes imperative so that preventive interventions can be instituted. Originally developed for use in nursing homes (residential care facilities), the Braden scale is a risk assessment scale for identifying patients at risk for developing pressure ulcers.6 The Braden scale is highly recommended for use in healthcare settings.7-8 It consists of six subscales; sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Each subscale has four ratings scored from 1 to 4 with increasing levels of severity, except for friction and shear which has three ratings. The summative score of the subscale scores determines the pressure ulcer risk for that individual. The lower the score, the higher the risk for developing pressure ulcers. An individual is considered as being at risk for developing pressure ulcer if the total score is 18 and below.9 The recommendation for using the Braden scale over other risk assessment scales was based on the findings of a systematic review in which the Braden scale presents the best balance of sensitivity (57.1%) and specificity (67.5%).10 In this review, 22 of the 30 included studies were focussed on validating the Braden scale. Based on this review, the Braden scale seems to be a reliable risk assessment scale for identifying patient's risk for developing pressure ulcers. However, the value of an assessment tool in being able to predict possible pressure ulcer development is of limited value to the patient if health professionals are not able to use assessment findings to reduce the incidence of pressure ulcer. Two systematic reviews10 11 attempted to ascertain the effect of using risk assessment scales on incidence of pressure ulcers. One systematic review found no randomised controlled trials that linked risk assessment tools and pressure ulcer incidence.11 The second systematic review found two studies that assessed the effect of risk assessment scale on pressure ulcer incidence.10 Although there is widespread use of and multiple studies on the Braden risk assessment scale, the two studies reported in the systematic review utilised the Norton risk assessment scale only. The Norton scale consists of five subscales; physical condition, mental condition, activity, mobility, and incontinence.12 Similar to the Braden scale, the Norton scale uses a scoring system to identify patient's risk for developing pressure ulcers. Both scales include a subscale for assessing mobility and activity. However, the Norton scale has five subscales compared to the Braden scale which has six. For the Norton scale, higher scores predict greater risk for developing pressure ulcers, which is the reverse of the Braden scoring system where a lower score predicts higher risk. The two studies reported in the systematic review compared the use of the Norton risk assessment scale versus usual assessment by nurses. Both studies showed an increase in nursing interventions as a result of the implementation of the Norton risk assessment scale. However, there was no significant difference in the pressure ulcer incidence. The review concluded that there is not enough evidence that the use of risk assessment scales reduce the incidence of pressure ulcers. A more recent study by Saleh13 affirms the findings of the systematic review by Pancarbo-Hidalgo10 that the use of a structured risk assessment tool may not be effective in reducing the incidence of pressure ulcers. Saleh13 conducted a before and after study to assess the effect of Braden risk assessment scale on the incidence of hospital acquired pressure ulcers. In this study, nine wards were divided into three study arms. The nurses in all wards attended a wound care management study day. Additional training on pressure ulcer prevention was provided to the nurses in the other two study arms but only one study arm implemented the Braden risk assessment scale. The study found the control arm, where nurses used their clinical judgment only with no additional training on pressure ulcer prevention, showed a statistically significant reduction in pressure ulcer incidences comparable to the Braden group. The author attributed the similar effect in pressure ulcer reduction in all arms to Hawthorne effect and training on pressure ulcer interventions. Further analysis of the effect of the study that was not reported in the article, found the relative risk of the control group (RR=0.478, 95% CI; 0.279 to 0.82, p=0.009) had a significant effect compared to the Braden (RR=0.657, 95% CI; 0.384 to 1.123, p=0.167) or the non-Braden group (RR=0.754, 95% CI; 0.446 to 1.274, p=0.373) which showed no effect. The author questioned the routine use of a risk assessment tool when clinical judgment was as effective in preventing the development of pressure ulcer. In addition, not having to unnecessarily perform the structured risk assessment scale would save time and manpower costs in a busy acute care setting or time that could be optimised. Thus the findings from this study raised a question of the viability of using risk assessment scales in pressure ulcer prevention. Clinical judgment therefore seems to be a viable alternative for assessing pressure ulcer risk. However, clinical judgment lacks structure, which makes repeatability of its performance difficult; this may manifest in inconsistent assessments and interventions. Some form of structure is still warranted to ensure standardisation and consistent assessment of pressure ulcer risk. Impaired mobility had emerged as a strong risk factor for pressure ulcer development. It was reported that nurses had initiated preventive interventions for pressure ulcer based on assessment of patient's impaired mobility.14 In addition, impaired mobility was found to be significantly associated with pressure ulcer development.15 Incidentally, the majority of participants who did not developed pressure ulcers were found to have no mobility impairment. The link between pressure ulcer preventive interventions and mobility impairment was affirmed in a descriptive study which found that the Braden subscale mobility assessment had the highest number of interventions (7 out of 10 interventions).16 The Braden subscale mobility assessment consists of four levels of severity; (1) completely immobile, (2) very limited, (3) slightly limited, and (4) no limitations.6, 9 The Braden mobility subscale assessment seems to be a simple yet feasible alternative for assessing pressure ulcer risk. However, based on the studies by Magnan16 and Lindgren15, would assessment of impaired mobility alone suffice in initiating the appropriate interventions to prevent pressure ulcer? Is the subscale mobility assessment comparable to the Braden risk assessment scale overall score in predicting pressure ulcer risk? Can the level of severity of the mobility impairment be used to determine the use of special mattresses or other pressure ulcer preventive interventions? A systematic review found 51 randomised trials on the effect of interventions targeting impaired mobility on pressure ulcer development in a variety of settings.17 The review recommended the use of appropriate support surfaces such as mattresses and overlays for individuals with impaired mobility. Studies conducted in acute care settings that showed a reduction in pressure ulcer incidence were mostly comparing two different types of dynamic mattresses. Only one study, out of four studies, showed statistical significance in the reduction of pressure ulcer incidence. The review identified that findings were inconsistent and studies had methodological flaws. Pooled results of the findings would have provided a better picture of the overall effect of the interventions. However, no empirical results were reported in the review other than whether there is a reduction or no reduction in pressure ulcer incidence. The review also explored positioning as an intervention for impaired mobility. Only one study was found evaluating the effect of positioning and the findings were inconclusive. One limitation of the systematic review was that there was no information on the tool or method used to assess mobility. In addition, the studies included in the review were from inception of the databases searched up to 2006. In view of recent advances in pressure ulcer preventive management, inclusion of findings from the earlier studies may not be reflective of current practices in the clinical setting. The Braden risk assessment scale is a validated risk assessment scale, reliable for predicting pressure ulcer risk.10 Saleh13 found that using Braden risk assessment scale did not have a direct effect on pressure ulcer development. Two studies on the Norton risk assessment scale had similar findings.10 Based on the available evidence so far, the use of validated structured risk assessment tools, such as the Braden Scale, had not provided the expected leverage to aid nurses in determining preventive nursing interventions by reducing pressure ulcer incidence compared to clinical judgment. Clinical judgment seems to be a more viable alternative as it is less cumbersome and takes less time than the conventional structured risk assessment scales in a busy clinical setting. However, the use of clinical judgment may result in inconsistency in the risk assessment and interventions provided as it is based on the discretion of the individual nurse. A simple alternative to clinical judgment with some form of structure is required. Mobility assessment has been linked to most of the pressure ulcer preventive interventions16 however, it has yet to be determined whether mobility assessment alone is a viable alternative in predicting pressure ulcer risk or at initiating appropriate preventive pressure ulcer interventions in an acute care setting. Thus, the systematic review will aim to address this gap in the literature. Review objective The objective of this review is to establish whether using the Braden subscale mobility assessment is comparable to using the full Braden assessment scale. The specific review questions to be addressed are: What preventive pressure ulcer nursing interventions are initiated based on assessment of mobility impairment alone or in comparison with the full Braden risk assessment scale? What is the effect of using mobility assessment alone on incidence of hospital acquired pressure ulcers? Inclusion criteria Types of participants This review will consider studies that include adult patients, 18 years and older, in acute care setting who are at risk of developing pressure ulcers. At risk patients are those identified using Braden risk assessment scale as ‘at risk’, ‘moderate risk’, ‘high risk;, and ‘very high risk’ for developing pressure ulcer6, 9 or the sub scale for impaired mobility as ‘completely immobile’, ‘very limited’ and ‘slightly limited’9. Studies involving children only and studies conducted in the emergency department only or in the operating room only will be excluded from the review as they are not consistent with the review objective. Types of intervention(s)/Phenomena of interest This review will consider studies that include pressure ulcer risk identified using assessment of the subscale mobility impairment compared with full Braden scale assessment where available. Types of outcomes This review will consider the following primary outcome measures: Whether patients in either study arm are more or less likely to receive appropriate preventative interventions, including, but not limited to protective mattresses, creams and skin barriers, vitamin supplements, patient positioning etc Incidence of hospital acquired pressure ulcers Secondary outcome measures: Reliability of mobility assessment ± Braden assessment Frequency of assessment Types of studies The review will consider any randomised controlled trials; in the absence of RCTs other research designs, such as non-randomised controlled trials, before and after studies, and descriptive studies will be considered for inclusion in a narrative summary to enable the identification of current best evidence regarding pressure ulcer preventive interventions for impaired mobility. Search strategy The search strategy aims to find both published and unpublished studies in English language only. A three-step search strategy will be utilised in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. In view of recent advances in pressure ulcer management, studies spanning over the last ten years from 2000 to 2010 will be included in the review. Where systematic reviews on interventions for mobility are found, the primary studies that are within the period of the review will be retrieved. The databases to be searched include: CINAHL MEDLINE Academic Search Complete Health Source: Nursing/ Academic Edition Global Health Current Contents EMBASE Science Citation Index Expanded (SCI-EXPANDED) Cochrane Central Register of Controlled Trials (CENTRAL) Digital Dissertations Science Direct Springer Journals Online The search for unpublished studies will include: Conference proceedings Conference Proceedings Citation Index (CPCI-S) Science Direct (Include articles in press) Scopus Google Scholar Further search for primary papers will be traced from the reference list of the selected studies/articles. Manual search for articles in relevant journals will be undertaken. The relevant nursing groups, experts, and authors will be contacted to elucidate for additional information. Initial keywords to be used will be: Pressure ulcer, pressure sore, decubitus ulcer Risk assessment Prevention, intervention, preventive measures, preventive interventions Hospital, acute care, inpatients Braden Keyword search of databases in the article abstract and text will be generated. Boolean search of the primary concepts will be combined to generate a focussed list of articles. Assessment of methodological quality Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (AppendixII). The data extracted will include specific details about the author, year, populations, study methods, risk assessments and level of severity/risk, interventions, pressure ulcer incidence, stage(s) of pressure ulcer, preventive measures instituted frequency of assessments, and any other outcomes of significance to the review question and specific objectives. Data synthesis Information on preventive interventions for pressure ulcer will be reported. Statistical information such as relative risk, odds ratio, and mean difference will be collated and/or pooled. Where statistical information is not available, narrative synthesis of information will be reported. Quantitative papers will, where possible be pooled in statistical meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form. Conflicts of interest The primary, secondary and associate reviewers have no conflicts of interest in the review.