Braden Subscales Research Articles

An Integrated System of Braden Scale and Random Forest Using Real-Time Diagnoses to Predict When Hospital-Acquired Pressure Injuries (Bedsores) Occur

Bedsores/Pressure Injuries (PIs) are the second most common diagnosis in healthcare system billing records in the United States and account for 60,000 deaths annually. Hospital-Acquired Pressure Injuries (HAPIs) are one classification of PIs and indicate injuries that occurred while the patient was cared for within the hospital. Until now, all studies have predicted who will develop HAPI using classic machine algorithms, which provides incomplete information for the clinical team. Knowing who will develop HAPI does not help differentiate at which point those predicted patients will develop HAPIs; no studies have investigated when HAPI develops for predicted at-risk patients. This research aims to develop a hybrid system of Random Forest (RF) and Braden Scale to predict HAPI time by considering the changes in patients' diagnoses from admission until HAPI occurrence. Real-time diagnoses and risk factors were collected daily for 485 patients from admission until HAPI occurrence, which resulted in 4619 records. Then for each record, HAPI time was calculated from the day of diagnosis until HAPI occurrence. Recursive Feature Elimination (RFE) selected the best factors among the 60 factors. The dataset was separated into 80% training (10-fold cross-validation) and 20% testing. Grid Search (GS) with RF (GS-RF) was adopted to predict HAPI time using collected risk factors, including Braden Scale. Then, the proposed model was compared with the seven most common algorithms used to predict HAPI; each was replicated for 50 different experiments. GS-RF achieved the best Area Under the Curve (AUC) (91.20 ± 0.26) and Geometric Mean (G-mean) (91.17 ± 0.26) compared to the seven algorithms. RFE selected 43 factors. The most dominant interactable risk factors in predicting HAPI time were visiting ICU during hospitalization, Braden subscales, BMI, Stimuli Anesthesia, patient refusal to change position, and another lab diagnosis. Identifying when the patient is likely to develop HAPI can target early intervention when it is needed most and reduces unnecessary burden on patients and care teams when patients are at lower risk, which further individualizes the plan of care.

Pressure Injury Risk Assessment and Associations in an Adult Inpatient Rehabilitation Sample- Retrospective Cohort Study

<h3>Research Objectives</h3> To identify risk factors for the development of Hospital Acquired Pressure Injury (HAPI) over 6 months in an Inpatient Rehabilitation Facility (IRF) using the Braden Scale for Pressure Injury Prevention (Braden) and other variables. <h3>Design</h3> Observational Retrospective Cohort Study. <h3>Setting</h3> 262 bed free-standing IRF at an urban academic medical center. <h3>Participants</h3> Adults 18 years and older admitted to IRF from July through December 2020 were included. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> Logistic regression is used to assess HAPI occurrence during episode of care, against possible predictors including the Braden total score, Braden subscales, demographics, lab albumen, pain, diagnosis-related impairment group, external medical/orthopedic devices, expression of ideas/wants and understanding of verbal content. <h3>Results</h3> Of 1342 unique patients with 1494 episode of care, 54 (3.6%) HAPI events occurred. Before adjustment, Braden total score of 15 (14.69, SD 1.92) and below was associated with increased HAPI occurrence (p< 0.001). Univariate analyses identified the following significant risk factors for HAPI: age, impairment group, gastrointestinal tube, urinary catheter, expression of ideas/wants and understanding of verbal content. After adjusting for these variables, each one-point increase was associated with a 23% reduced odds of HAPI occurrence (95% CI, 0.65-0.90; p< 0.001). Three variables were still strongly associated with increased HAPI occurrence: Braden subscale "Friction/Shear" (OR 0.47; 95%CI, 0.27-0.81; p< 0.007), presence of a gastrointestinal tube (OR 2.51 higher odds; 95%CI, 1.03-5.66; p< 0.001), and rarely/never expresses ideas/wants (OR 9.16 higher odds; 95%CI, 0.94-70.05; p< 0.04) compared to no difficulty. Impairment group modified the effects: People with Spinal Cord Injury (SCI) had a greater odds of HAPI occurrence compared to those with Brain (OR 0.28; 95% CI, 0.11-0.66; p< 0.001) and Medically Complex (OR 0.31; 95% CI, 0.15-0.63; p< 0.001) impairments. <h3>Conclusions</h3> This study builds on prior SCI-related Braden research by including all patients admitted to IRF. Clinicians should consider adult IRF patients at risk for HAPI with Braden total scores of 15 and below, worse problems of "Friction/Shear", presence of a gastrointestinal tube, and patient's inability to express ideas/wants. <h3>Author(s) Disclosures</h3> N/A.

Neuromuscular blocking agents and opioids are major risk factors for developing pressure injuries in patients in the intensive care unit.

Patients in the intensive care unit (ICU) are at high risk for developing pressure injuries, which can cause severe complications and even increase the mortality risk. Therefore, prevention of pressure injuries is most important. In this study, we investigated the risk factors of pressure injury development in patients admitted to the ICU. We retrospectively analyzed patients ages &gt; 18 years admitted to the medical ICU in a tertiary hospital between January and December 2019. We collected patient baseline characteristics, medications received, mechanical ventilation or hemodialysis use, laboratory findings, and date of pressure injury onset and characteristics. We analyzed 666 patients who did not have pressure injuries at ICU admission. Pressure injuries developed in 102 patients (15%). The risk of pressure injury development increased as the administration days for neuromuscular blocking agents (NMBAs; odds ratio [OR], 1.138; p = 0.019) and opioids (OR, 1.084; p = 0.028) increased, and if the patient had problem with friction and shear (OR, 2.203; p = 0.011). The prolonged use of NMBAs and opioids can increase the risk of pressure injury development. Because these medications are associated with immobilization, using both should be minimized and patient early mobilization should be promoted. Among the Braden subscales, "friction and shear" was associated with the development of pressure injuries in ICU patients.

Pressure ulcer risk profiles of hospitalized patients based on the Braden Scale: A cluster analysis

The aim of this work is to identify the pressure ulcer risk profiles of hospitalized patients with reference to Braden Scale subscales. A total of 2996 hospitalized Portuguese participants were screened using the Braden Scale. A hierarchical and nonhierarchical cluster analysis was conducted, with ethical approval. Five risk profiles (clusters) based on the first risk assessments were identified. Regarding the Braden Scale total score, two profiles with high risk and three profiles with low risk of pressure ulcer development were identified. All clusters were statistically significantly different in terms of sociodemographic and clinical variables. When the first and the last risk assessments were compared, all the clusters improved the Braden Scale total score on the last risk assessment, except Cluster 4 (low-risk category). Clusters 3, 4 and 5, which were classified as low risk, decreased in several Braden subscales at the last risk assessment. The classification of low risk may misguide the early identification of patients with individual risk factors. Increasing the awareness of health care professionals for the importance of risk assessment of each Braden subscale is necessary for pressure ulcer prevention. We recommend the implementation of strategies for early identification of patients at risk at local and national levels.

Reducing Hospital-Acquired Pressure Injuries through Measure-vention.

Evidence has shown that Braden subscale scores are independent predictors of the development of pressure injuries. However, current practice is to implement preventive measures for pressure injuries based on the total Braden Scale score. Applying evidence from the literature on Braden subscales and using "Measure-vention," a quality improvement project using Braden subscales, was implemented in a 30-bed ICU in a Northern California level II trauma acute care hospital. The pilot study's purpose was to test whether tailoring interventions specific to the patient's subscale risk would decrease the incidence of hospital-acquired pressure injuries (HAPIs). A 6-month pilot was launched for all patients in the ICU, regardless of Braden total score. Frontline staff collected data in real time, measuring adherence to the "Interventions by Braden Subscale" protocol, and event reports were aggregated to measure the incidence of HAPIs before and after the pilot. At the end of the pilot, the ICU noted a decrease in HAPIs by 63.5%. The results demonstrated the efficacy of using the Braden subscales to guide preventive HAPI care, preventing both HAPIs and the overutilization of resources.

Patient-specific factors associated with pressure injuries revealed by electronic health record analyses.

Hospital-acquired pressure injuries (HAPIs) are a major source of unintended patient harm and unnecessary costs. The Braden Scale is widely used for risk assessment, yet it lacks specificity and clinical applications. This study used the electronic health record to examine associations between patient-specific factors and pressure injury. Adult patients (age >18) with 3-day length of stay from April 2011 to December 2016 were included. Pressure injuries were identified by ICD-9/ICD-10 codes. Longitudinal multivariate logistic regression was used to evaluate the association between patient-specific factors and HAPIs. This included 57,227 hospital encounters and 241 HAPIs. We observed 2-3 times increased likelihood of acquiring a pressure injury among patients who were malnourished or who had increased intraoperative time. The Braden subscales of nutrition, mobility, and friction showed significant predictive value. Future work is needed to assess the clinical applicability of this work.

Pressure ulcer incidence and Braden subscales: Retrospective cohort analysis in general wards of a Portuguese hospital

AimTo study the influence of Braden subscales scores (at the first pressure ulcer risk assessment) on pressure ulcer incidence using a univariate and a multivariate time to event analysis. Materials and methodsRetrospective cohort analysis of electronic health record database from adult patients admitted without pressure ulcer(s) to medical and surgical wards of a Portuguese hospital during 2012. The hazard ratio of developing a pressure ulcer during the length of inpatient stay was calculated by univariate Cox regression for each variable of interest and by multivariate Cox regression for the Braden subscales that were statistically significant. ResultsThis study included a sample of 6552 participants. During the length of stay, 153 participants developed (at least) one pressure ulcer, giving a pressure ulcer incidence of 2.3%. The univariate time to event analysis showed that all Braden subscales, except “nutrition”, were associated with the development of pressure ulcer. By multivariate analysis the scores for “mobility” and “activity” were independently predictive of the development of pressure ulcer(s) for all participants. Conclusion(Im)“mobility” (the lack of ability to change and control body position) and (in)“activity” (the limited degree of physical activity) were the major risk factors assessed by Braden Scale for pressure ulcer development during the length of inpatient stay. Thus, the greatest efforts in managing pressure ulcer risk should be on “mobility” and “activity”, independently of the total Braden Scale score.

Using the Braden Scale to predict patient's risk of developing pressure ulcers in the acute care setting

Background: It is well-recognized that pressure ulcers are a significant cause of morbidity and lead to lower quality of life for both the patients and their carers. The first measure in prevention is risk assessment. In Singapore General Hospital, the Braden Scale is used to assess patients’ risk, given that it has the strongest published reliability and acceptable sensitivity and reliability. Objective: This study aimed to evaluate the predictive validity of the Braden Scale in a local acute care tertiary hospital. Methods: A methodological study was conducted, using the database from a study evaluating the effectiveness of a liaison nurse and care algorithm on the prevention and management of pressure ulcers. In the original study, data was collected over a 6 months period after implementation of the liaison nurse and care algorithm (July–Dec 2012); in 6 acute wards in SGH. All patients were assessed using the Braden Scale upon admission and followed up till discharge to evaluate any development of nosocomial pressure ulcers. Results: Data from 1024 patients were available for analysis. 48 patients developed ulcers (incidence rate of 4.7%). The mean total Braden score was 17.4. The mean total score in patients with pressure ulcer was significantly different from those whom did not have pressure ulcers (14.3 vs. 17.6, p < 0.001). All 6 Braden sub-scales were significant predictors of pressure ulcers. Compared with patients who were ulcer-free, patients who developed ulcers had lower scores for all the subscales. The ‘activity’ sub-scale demonstrated the largest difference in mean score of 0.88. For our cohort, a cut-off of 13.5 resulted in sensitivity of 0.8 and specificity of 0.6, with an AUC of 0.7. Conclusion: Study demonstrated that the Braden Scale is valid for our local patients. However, the recommended score of 13–14 to be at moderate risk might be too high for our patients.

The Relationship Between Pressure Ulcer Prevalence, Body Mass Index, and Braden Scales and Subscales

The purpose of this study was to evaluate whether any of the Braden subscales were more strongly related to pressure ulcer occurrence than the Braden total score in obese and nonobese hospitalized patients. The authors investigated whether defining high risk for the total Braden score of 16 or less was associated with pressure ulcer occurrence.

Braden Subscales and Their Relationship to the Prevalence of Pressure Ulcers in Hospitalized Obese Patients

Abstract Pressure ulcer development is a significant problem for any hospitalized patient, but the obese patient may be at higher risk for ulcer development. The purpose of this study was to examine the relationship of the individual Braden subscales to pressure-ulcer occurrence in the obese and non-obese hospitalized patient. Pressure-ulcer prevalence was slightly higher in the obese (17%) compared to the non-obese (14%). However, mean total Braden and Braden subscale scores were similar between the obese and non-obese. Although high-risk total Braden and Braden subscales, except for moisture, were significantly related to the occurrence of ulcer occurrence in both groups, high-risk total Braden score and mobility and friction/shear subscale scores were much more strongly related to ulcer occurrence in obese patients. Additionally, the prevalence of ulcers in obese patients with both high-risk mobility and friction/shear scores (79%) was much higher than in non-obese patients with both high-risk mobility...

The Association of BMI and Braden Total Score on the Occurrence of Pressure Ulcers

We compared pressure ulcer (PU) prevalence patients with a body mass index (BMI) of 40 or more, and Braden Scale scores of 16 or more to patients with lower BMI. A cross-sectional study by using existing data was conducted combining patient skin status with BMI. Subjects underwent skin assessment for evidence of skin breakdown by nurses trained in PU assessment. Data from this assessment were combined with historic data gathered from review of medical records and BMI. The study was carried out in a tertiary medical center in Eastern North Carolina. Three hundred sixty-two patients were included in the prevalence study. Fourteen percent of all patients had at least 1 PU. The prevalence among patients with a BMI of less than 40 was 12.5% as compared to 26% in patients with a BMI of more than 40 (P 5 .01). When controlling for the effects of BMI, patients with a Braden Scale score of 16 or less were almost 6 times more likely to have a PU as compared to those with Braden Scale scores of more than 16 (P, .001). Body mass index had an independent association with the probability of PU occurrence. Patients with BMIs of more than 40 were almost 3 times more likely to have a PU compared to those with BMIs of 40 or less, after controlling for Braden risk (P 5 .01). A BMI of more than 40 and Braden Scale score of 16 or less were found to have an independent and statistically significant association with PU occurrence. Future studies should investigate the predictive validity of BMI along with individual Braden subscales.

Braden Scale Risk Assessments and Pressure Ulcer Prevention Planning

To investigate the relationship between risk assessment scores on Braden subscales and nurses' selection of 10 commonly used best-practice pressure ulcer (PU) preventive interventions. Exploratory secondary data analysis, using a descriptive correlational design. A total of 377 Braden Scale PU risk assessments were made on 102 patients at different levels of risk. Assessments were made by RNs working at 3 different acute care hospitals. RNs making risk assessments also used an intervention checklist to select from 10 commonly used preventive interventions that should be implemented based on patient level of risk on each Braden subscale. The Braden Scale for Predicting Pressure Sore Risk was used to guide risk assessments. The Registered Nurses Intervention Checklist was used to identify PU preventive interventions that should be implemented. Braden subscale ratings influenced nurses' endorsement of preventive interventions in 2 distinct ways. First, endorsement of most (9 out of 10) preventive interventions was influenced by risk information embedded in unique combinations of Braden subscale assessments. Second, there appears to be a predictable pattern of increase in the likelihood of endorsing an intervention as Braden subscale scores decreased and the level of risk increased. Variability in Braden subscale ratings differentially predicts nurses' endorsements of selected PU-prevention interventions. Also, there is a predictable pattern of increase in the likelihood of endorsing a preventive intervention as PU risk levels increase, a pattern that may be related to the timing of risk assessment and PU-prevention planning activities.

Assessing predictive validity of the modified Braden scale for prediction of pressure ulcer risk of orthopaedic patients in an acute care setting

To assess and compare the predictive validity of the modified Braden and Braden scales and to identify which of the modified Braden subscales are predictive in assessing pressure ulcer risk among orthopaedic patients in an acute care setting. Although the Braden scale has better predictive validity, literature has suggested that it can be used in conjunction with other pressure ulcer risk calculators or that some other subscales be added. To increase the predictive power of the Braden scale, a modified Braden scale by adding body build for height and skin type and excluding nutrition was developed. A prospective cohort study. A total of 197 subjects in a 106-bed orthopaedic department of an acute care hospital in Hong Kong were assessed for their risk for pressure ulcer development by the modified Braden and Braden scales. Subsequently, daily skin assessment was performed to detect pressure ulcers. Cases were closed when pressure ulcers were detected. Out of 197 subjects, 18 patients (9.1%) developed pressure ulcers. The area under the receiver operating characteristic curve for the modified Braden scale was 0.736 and for the Braden scale was 0.648. The modified Braden cut-off score of 19 showed the best balance of sensitivity (89%) and specificity (62%). Sensory perception (Beta = -1.544, OR=0.214, p = 0.016), body build for height (Beta = -0.755, OR = 0.470, p = 0.030) and skin type (Beta = -1.527, OR = 0.217, p = 0.002) were significantly predictive of pressure ulcer development. The modified Braden scale is more predictive of pressure ulcer development than the Braden scale. The modified Braden scale can be adopted for predicting pressure ulcer development among orthopaedic patients in an acute care setting. Specific nursing interventions should be provided, with special attention paid to orthopaedic patients with impaired sensory perception, poor skin type and abnormal body build for height.

Multisite Web-Based Training in Using the Braden Scale to Predict Pressure Sore Risk

To evaluate the effect of a Web-based Braden Scale training module on nurses' knowledge of pressure-ulcer risk assessment and prevention. Pre-experimental, posttest-only design. Web-based learning environment. Registered nurses (N=1391) working at 3 medical centers in the Midwest. Primary outcomes of interest were reliability and competence associated with using the Braden Scale for pressure-ulcer risk assessment. Secondary outcomes of interest focused on program evaluation, specifically nurses' perceptions of program adequacy and ease of use. After training, nurses correctly rated Braden Scale level of risk 82.6% of the time. Numeric ratings for Braden subscales were generally more reliable when case-study data indicated extreme risk levels (generally not at-risk level, high-risk level, and very high level) than when data indicated midlevels of risk (mild-risk level and moderate-risk level). Nurses' knowledge of appropriate risk-based preventive interventions was high, but correlated poorly with the ability to correctly assign numeric ratings to Braden subscales. Web-based training alone may not ensure reliable, competent estimates of pressure-ulcer risk for patients at all risk levels. Other strategies, such as clinical practice with expert supervision, should be considered. Further research is needed to clarify the links between scoring Braden subscales correctly and selecting appropriate risk-based preventive interventions.

Nosocomial Pressure Ulcer Rates in Critical Care

Assessment, monitoring, and prevention of pressure ulcers in the hospitalized patient are required standards of care. The annual nosocomial pressure ulcer (NPU) rates for the adult intensive care units at our facility had trended up to 33% from 14% over a 13-month period. Our performance improvement team decided to track 5 variables that may have contributed to the increased incidence of NPU. Weekly skin care rounds were conducted to collect data, educate staff, and reinforce skin care policy and standards of care. Data analysis revealed 3 areas that required further emphasis with nursing staff: daily assessment with the Braden Scale, prevention of NPU beginning on the day of hospital admission, and the effect of sedation on patient mobility. Implementation of appropriate interventions targeted to specific Braden subscales needs to be included in the plan of care.

Subscales, Subscores, or Summative Score: Evaluating the Contribution of Braden Scale Items for Predicting Pressure Ulcer Risk in Older Adults Receiving Home Health Care

The purpose of this study was to determine whether certain Braden subscales or subscores were more important than others or the summative score in predicting stage I to IV pressure ulcers among older adults receiving home health care. A retrospective cohort study (secondary analysis) was used. The cohort sample included 1684 nonhospice patients who were not receiving intravenous therapy and who were admitted to the Intermittent Skilled Nursing Division of a large midwestern home health care agency between January 1995 and March 1996. The patients were > or =60 years and free of pressure ulcers. Demographic data and data on the Braden Scale were extracted from admission information. Patient records were followed forward chronologically to 1 of 2 outcomes: development or absence of pressure ulcers (ie, free of pressure ulcers upon discharge, institutionalization, death, or the end of the study period). Following admission, a stage I to IV pressure ulcer developed in 107 subjects (incidence = 6.3%). Cox regression analysis revealed that activity and moisture subscale scores predicted pressure ulcer development. Regression modeling of individual Braden Scale subscores (response categories) revealed that problems with friction/shear, being very limited in mobility, and being constantly moist, very moist, or occasionally moist predicted pressure ulcer development. When the overall level of risk was added to each of these models, the Braden Scale summative score was most strongly related to pressure ulcer development. No simplified scale improved risk prediction. When the Braden Scale was used, the summative score rather than any subscale or subscore best predicted pressure ulcer risk among the older adults receiving home health care.

Predicting the risk of pressure ulcers in critically ill patients

Critically ill patients are at high risk for pressure ulcers. To determine the contributions of the Braden subscales in predicting pressure ulcers in critically ill patients and to investigate how often the Braden scale should be completed to assess the risk for pressure ulcers in critically ill patients. The Braden scale was used to assess repeatedly 136 adult patients without pressure ulcers in a medical intensive care unit, a surgical intensive care unit, and a noninvasive respiratory care unit, and the patients' skin was inspected routinely for pressure ulcers. A total of 36 pressure ulcers, most commonly on the sacrum or coccyx and the heels (15 stage 1, 20 stage 2, 1 stage 3), developed in 17 patients (12%). In 14 (82%) of the 17, the ulcers developed within 72 hours of admission to the intensive care unit. The risk for pressure ulcers increased as the mean sensory perception (P = .01) and the mean total Braden (P = .046) scores decreased. The mean sensory perception scores obtained at 12 and 36 hours after admission also had a significant relationship to the risk for pressure ulcers (P = .03). Patients in intensive care units have an increased risk for pressure ulcers. Although waiting until 12 hours after a patient's admission to the intensive care unit to obtain the initial Braden rating may be reasonable (with the second rating obtained 36 hours after admission), additional research is needed before this practice can be recommended.