Pressure Ulcer Risk Assessment Tools Research Articles

Development and validation of a pressure ulcer risk assessment tool for acute hospital patients

The purpose of this study was to develop and validate a pressure ulcer risk assessment for acute hospitals. This tool was developed in a cohort of 342 patients with a mean age 63 years (SD 19.82) and validated in a second cohort of 165 patients with a mean age 68 years (SD 18.40). Risk factors for inclusion on The Northern Hospital Pressure Ulcer Prevention Plan (TNH-PUPP) were identified from the literature then examined and weighted using logistic regression. Risk factors included on the TNH-PUPP were requires assistance to move in bed (odds ratio [OR] 5.15; 95% confidence interval [CI]: 2.49-10.65), admission to intensive care during current admission (OR 2.98; 95% CI: 1.33-6.67), aged ≥ 65 years (OR 2.81; 95% CI: 1.24-6.36), reduced sensation (OR 2.29; 95% CI: 1.19-4.42), and cognitive impairment (OR 2.26; 95% CI: 1.09-4.67). The TNH-PUPP was validated in a prospective sample. The new tool had high diagnostic validity (area under the receiver operating curve=0.86), consistent in the validation sample (area under the receiver operating curve=0.90). The TNH-PUPP has a moderate positive predictive value (development=0.50; validation=0.13), and a high negative predictive value (development=0.94; validation=0.99) enabling low-risk patients to be screened out, as noncandidates for pressure ulcer prevention interventions. An accurate pressure ulcer risk assessment has been developed and validated, which identifies a high-risk group to whom limited pressure ulcer prevention resources should be directed. The TNH-PUPP facilitates effective resource allocation and is likely to reduce unnecessary patient harm and costs from pressure ulcers in acute hospitals.

Factors Associated With Pressure Ulcers in Patients in a Surgical Intensive Care Unit

We sought to describe the occurrence of pressure ulcers in patients managed in a surgical intensive care unit (ICU) and report preliminary work toward development of a pressure ulcer risk assessment tool for use in this population that incorporates comorbidities and other factors not addressed in previous instruments. Three hundred sixty-nine patients managed in the surgical ICU at Yale-New Haven Hospital comprised the sample. Demographic and clinical data, including Braden Scale scores, were collected in this prospective, 2-phase study. The principal investigator (G.C.S.) performed skin assessments on all patients. We used chi-square analysis and t tests to determine variables to include in a stepwise logistic regression analysis to determine factors independently associated with the development of pressure ulcers. We collected data, using a form we developed that contained demographic and clinical factors found in previous research and in our clinical practice to be associated with pressure ulcers. Eighty-eight out of 369 patients (23.9%) experienced a hospital-acquired pressure ulcer. Braden Scale scores ranged from 6 to 21, with a mean score of 11.9 ± 2.2. A lower Braden Scale score, the presence of diabetes mellitus, and patient age 70 years or older independently predicted the development of a pressure ulcer. These factors have been incorporated into the preliminary Surgical ICU Pressure Ulcer Risk Assessment scale. Findings from this study suggest that, in addition to a low Braden Scale score, age >70 years and a diagnosis of diabetes may represent clinically relevant pressure ulcer risk factors in the surgical intensive care population and that patients with these factors may benefit from more aggressive preventive care. In addition, the Surgical ICU Pressure Ulcer Risk Assessment scale requires additional psychometric testing before its use can be recommended for the research or practice settings.

Using the Braden Q Scale to Predict Pressure Ulcer Risk in Pediatric Patients

The Braden Q Scale for Predicting Pediatric Pressure Ulcer Risk (Braden Q Scale) is a widely used, valid, and reliable pediatric-specific pressure ulcer risk assessment tool. Since its original publication, requests for clarification on how best to use the tool across the wide spectrum of pediatric patients commonly cared for in health care systems have been received. Common clarifications focus on using the Braden Q Scale as originally designed; specifically, not using untested derivations of the tool, and not using the Braden Q Scale to predict medical device-related pressure damage. The purpose of this article is to provide practical information on how best to use the Braden Q Scale and how to score a pediatric patient's risk for pressure ulcers. Accurate assessment of patient risk for pressure ulcers is the first step in guiding appropriate nursing interventions that prevent pressure ulcers. Patient assessment, scoring, and common clinical scenarios are presented.

Pressure ulcer prevention as an indicator of nursing care quality: A comment on Jull and Griffiths (2010)

In their editorial Jull and Griffiths (2010) discuss pressure ulcer prevention as an indicator of nursing care quality. The cautionary note includes remarks on pressure ulcer risk assessment tools, pressure ulcer prevention strategies and the application of pressure ulcer rates as a quality indicator. The authorsmake a number of important remarks. However we would like to add our view on these issues which is based on our experience in developing, collecting, reporting and conducting research with nursing quality data – including pressure ulcers – for the National Database of Nursing Quality Indicators (NDNQI) in the US.

Inter-rater reliability of the Glamorgan Paediatric Pressure Ulcer Risk Assessment Scale

Children who are at risk of pressure ulcers need to be identified so that preventative measures can be taken. Most paediatric pressure ulcer risk assessment scales were developed using clinical experience, or by modifying adult scales. The Glamorgan Paediatric Pressure Ulcer Risk Assessment Scale was developed using detailed paediatric inpatient data. To establish whether the inter-rater reliability of the Glamorgan scale was adequate for use in clinical practice. Fifteen qualified nurses randomly selected from staff working on seven paediatric wards or units in a large tertiary referral hospital have participated in the study to date. Nurses asked permission from the children and parents in their care to collect anonymous data in the risk assessment section of the Glamorgan scale. The nurse and the researcher independently assessed the child's risk. Paired risk assessments were later compared and analysed using SPSS. The total risk scores ranged from 15 to 34 (high to very high risk). There was 100 per cent agreement on all items except for 'inadequate nutrition'. These preliminary data indicate that the risk assessment scale is reliable. More research on the reliability and validity of this tool with specific paediatric patient groups should be carried out, ideally comparing the performance of this tool with other published paediatric pressure ulcer risk assessment tools.

Risk Assessment for Pressure Ulcer

To identify patients at risk for developing pressure ulcer among hospitalized patients and the prevalence of pressure ulcer in this group. A prospective study included 100 patients from medical and surgical wards. Data were collected on admission, and subjects were followed up at regular intervals. The Waterlow pressure ulcer risk assessment tool was completed and patients were stratified "as not at risk," "at risk", "high risk", and "very high risk". Subjects were then monitored for 2 weeks and the actual incidence of pressure ulcer formation was analyzed in the various risk groups. Of 100 patients studied, 20% were at risk, 10% were assessed at high risk, and 7% were classified as at very high risk for developing a pressure ulcer. Necessary preventive measures were taken (posture change, specialized beds/mattresses, nursing care, nutritional input, etc) for those patients at risk of development of pressure ulcer. Four of 7 patients (57.1%) who were at very high-risk developed pressure ulcer as compared with 2 of 10 patients (20%) categorized in the high-risk category within a period of 2 weeks. No patient who was classified as not at risk on the Waterlow pressure ulcer risk assessment tool developed a pressure ulcer within the observation period. Pressure ulcers developed in identified risk groups despite adequate available preventive measure being taken to prevent their development. It is of extreme importance to identify patients at risk for the development of pressure ulcers so that preventive measures can be instituted to reduce the incidence of hospital-acquired pressure ulcers.

Predictive validity of pressure ulcer risk assessment tools in intensive care patients

Predictive validity of pressure ulcer risk assessment tools in intensive care patients

Waterlow assessment: not a predictor

The article in BJN by Deidre Thompson,‘An evaluation of the Waterlow pressure ulcer risk assessment tool’ (Vol 14(8): 455–9),was well written, full of facts, figures and references.

Inter-rater reliability and waterlow’s pressure ulcer risk assessment tool

Inter-rater reliability and waterlow’s pressure ulcer risk assessment tool

Inter-rater reliability and Waterlow’s pressure ulcer risk assessment tool

To ascertain whether a lack of inter-rater reliability with the original Waterlow (1996) pressure ulcer risk assessment scale is due to different perceptions of patients by nurses or different interpretations of Waterlow as a tool. A sample of 110 qualified nurses, who used the Waterlow pressure ulcer risk assessment scale in their daily work and were delegates at five study days, were given a case study and an uncompleted copy of the tool. They were asked to complete a risk assessment for the patient. The risk assessment score obtained by delegates was analysed using the Wilcoxon Signed Rank Test to measure the null hypothesis that there is no significant difference between the median of the nurses' scores and the patient's actual or 'gold standard' score. Nurses tend to over-rate (n=72, 65 per cent) rather than under-rate (n=25, 23 per cent) the patient's risk of developing a pressure ulcer. Only 13 of the 110 nurses (12 per cent) accurately rated the patient's score as 18. The Wilcoxon Test rejected the null hypothesis that there was no difference in the risk scores arrived at by individual nurses and the patient's actual score, that is, there is a significant difference between the scores obtained by the nurses in the study and the gold standard score. The results show poor inter-rater reliability when using the Waterlow pressure ulcer risk assessment scale. Part of the problem is that nurses are not using the tool in the way it was intended.

An evaluation of the Waterlow pressure ulcer risk-assessment tool

The National Institute for Clinical Excellence (NICE, 2001) stated that in order to achieve clinical governance strategies, risk management in the form of pressure ulcer risk assessment will contribute to improved quality of patient care. Risk-assessment tools must display high-predictive values, be highly sensitive and specific, reliable, and easy and convenient to use. Despite their extensively documented poor performance, pressure ulcer risk-assessment scales play a primary role in the prevention and management of pressure ulcers. The tools attempt to determine patients' risk status by quantifying a range of the most commonly recognized risk factors. Although there are over 40 different assessment tools, the Waterlow pressure ulcer risk-assessment tool is the tool that is most widely used in the UK. This article aims to review studies relating to the reliability, content validity, predictive validity, concurrent validity and the construct validity of the Waterlow pressure ulcer risk-assessment tool.

Predicting Pressure Ulcer Risk

To compare the predictive validity of 4 pressure ulcer risk assessment tools. Prospective clinical design in which 230 subjects free of pressure ulceration on admission were assessed using the Braden, Gosnell, Norton, and Waterlow scales within 48 hours of admission. Subjects' skin condition was assessed once every 24 hours for a minimum of 14 days to identify any skin breakdown. Based on Youden's index, the Gosnell Scale had better predictive validity in identifying patients at risk for pressure ulcer development (J = 68%). The other scales did not predict individuals at risk with high accuracy, despite having high sensitivity and specificity. Numerous pressure ulcer risk assessment tools have been developed, but sufficient evidence for using one tool over another does not exist. In this study, the Gosnell Scale was found to be more appropriate for application in patients with neurologic and orthopedic conditions. Being able to predict which patients are at risk for pressure ulcers can assist practitioners in tailoring care to prevent unnecessary complications and suffering, as well as reduce costs.

Free paper: A comparison of pressure ulcer risk assessment tools in palliative care

Aim: To investigate which of three pressure ulcer risk assessment tools is most suitable for assessing the risk of patients admitted to a palliative care unit. Method: A prospective cross-sectional study with data collected at admission and discharge or death on all consenting patients admitted over a 12-week period. Data included the risk assessment score of the currently used Waterlow tool, the Walsall tool used by the community nurses, the Hunters Hill palliative care tool!, skin condition and mattress in use. Results: A total of 74 patients took part, of whom 38 had pressure damage on admission, although for 68% this was grade 1. The Walsall tool had the highest sensitivity (89%), compared to the Waterlow (34%) and Hunters Hill (18%). The Hunters Hill tool had the higher specificity at 83%, compared to the Waterlow tool (67%) currently in use. The Kappa test indicated substantial agreement between the assessed risk and the nurses' clinical judgment of risk in relation to the Walsall tool (Kappa = 0.75) and the Hunters Hill tool (Kappa = 0.73), but only fair agreement for the Waterlow tool (Kappa = 0.38).

Pressure ulcer grading tools: how reliable are they?

Use of grading tools has become routine, yet their reliability and validity have not been rigorously researched and they should not be used to monitor healing. Also, many require a level of expertise that is beyond the capability of general nurses.

Malnutrition and pressure ulcers: nutritional assessment tools

Good nutrition is essential throughout life and often patients have a poor understanding of what a balanced diet comprises. Nurses need to have a good comprehension of malnutrition. Where malnutrition is evident it can be resolved by working with the patient to encourage a healthy diet. One way to improve patient nutrition is by a nutrition audit of patient food. Numerous nutritional assessment tools exist which help to identify a patient's nutritional status. No nationally standardized nutritional assessment tool exists and there is a danger of assessment methods becoming as proliferate as pressure ulcer risk assessment tools. A solution to this problem may be to use a pressure ulcer risk assessment tool with a nutritional risk assessment tool such as the Burton Score. Pressure ulcers and malnutrition have been demonstrated to be strongly correlated with each other. Malnutrition is not just present in hospitals but also in nursing homes. A solution to this problem is to use nutritional tools to highlight nutritional deficiency in a patient's diet not only in hospitals but also in the community and in nursing homes.

Insult after Injury

Nonexperimental-Descriptive. The inclusion criteria were trauma patients, ages 15 and older, who were hospitalized for > 2 days, and who did not have preexisting skin breakdown. A total of 148 consecutive trauma patients admitted to the study institution meeting the inclusion criteria were prospectively enrolled. Patients were assessed every 3 days for skin breakdown. Information on the patient's bed type, therapies, medical devices, and nutrition was collected. The Braden Scale for predicting pressure ulcer risk was completed at each assessment. Of the 148 patients enrolled, 30 developed at least one area of skin breakdown for a prevalence of 20.3% in patients hospitalized more than 2 days. The most common cause of breakdown was positional pressure (47.4%). Cervical collars were the second leading cause at 23.7%, followed by tracheostomy/endotracheal tubes at 10.5%. The mobility subscale of the Braden Pressure Ulcer Risk Assessment tool was significantly predictive of skin breakdown (p < .001). Skin breakdown is a significant problem in trauma patients who are hospitalized for more than 2 days. Aggressive protocols on positioning, cervical collar use, and airway adjuncts, as well as additional active nursing interventions for immobile patients, may be ways to decrease the skin breakdown prevalence in this population.

Selection and use of pressure ulcer risk-assessment tools and treatment protocols in extended-care facilities in the southwest

Purpose: The purpose of this study was to investigate pressure ulcer treatment protocol selection and use by care providers in extended health care facilities. Design: Descriptive survey. Setting and Subjects: The target population was directors of extended health care facilities in the southwestern border region of Arizona, New Mexico, and west Texas. Methods: Questionnaires were mailed to 427 directors of extended-care facilities, who were asked to self-report treatment selection methods. The results from 96 returned and usable questionnaires were analyzed. Main Outcome Measures: Descriptive statistics were used to analyze the returned data. Results: Most (56.25%) of the respondents reported using a facility-developed assessment tool, 15.63% used no assessment tool at all, and less than 50% of the responding institutions reported using established protocols for pressure ulcer treatment. Although selection methods differed, most (61.46%) pressure ulcer treatments were reported to be determined by collaboration among nurses, physicians, and other health care providers. Conclusion: Selection and use of pressure ulcer risk-assessment tools and treatment protocols showed a wide range of variation by extended-care facilities. A high percentage of institutions did not report the use of established, research-based protocols for pressure ulcer treatment, although interdisciplinary collaboration for treatment selection was reported.

Selection and Use of Pressure Ulcer Risk-Assessment Tools and Treatment Protocols in Extended-Care Facilities in the Southwest

In Brief Purpose The purpose of this study was to investigate pressure ulcer treatment protocol selection and use by care providers in extended health care facilities. Design Descriptive survey. Setting and Subjects The target population was directors of extended health care facilities in the southwestern border region of Arizona, New Mexico, and west Texas. Methods Questionnaires were mailed to 427 directors of extended-care facilities, who were asked to self-report treatment selection methods. The results from 96 returned and usable questionnaires were analyzed. Main Outcome Measures Descriptive statistics were used to analyze the returned data. Results Most (56.25%) of the respondents reported using a facility-developed assessment tool, 15.63% used no assessment tool at all, and less than 50% of the responding institutions reported using established protocols for pressure ulcer treatment. Although selection methods differed, most (61.46%) pressure ulcer treatments were reported to be determined by collaboration among nurses, physicians, and other health care providers. Conclusion Selection and use of pressure ulcer risk-assessment tools and treatment protocols showed a wide range of variation by extended-care facilities. A high percentage of institutions did not report the use of established, research-based protocols for pressure ulcer treatment, although interdisciplinary collaboration for treatment selection was reported. An investigation of the reported use of pressure ulcer prevention guidelines among a group of long-term care facilities in the American southwest.

Pressure Ulcer Prevalence and Incidence and a Modification of the Braden Scale for a Rehabilitation Unit

In Brief Purpose We examined pressure ulcer incidence and prevalence, the cutoff score for risk for skin breakdown, and the contribution of each of the subscale risk factors of the Braden pressure ulcer risk-assessment tool in an inpatient rehabilitation unit. Subjects and Setting One hundred seventy adult men hospitalized on a rehabilitation unit during 1 calendar year were included in the research. Subject ages ranged from 35 to 99 years (M = 69). Instruments Pressure ulcer risk was assessed using the Braden Scale. Methods A retrospective chart review of a continuous series of 170 adult male patients hospitalized during a 1-year period on a 50-bed rehabilitation unit was conducted. Data were documented on a standardized researcher-designed form. Results A total of 46 pressure ulcers occurred, with the sacrum the most common location (46%), followed closely by the heel–ankle area (44%, n = 20). Most pressure ulcers (57%) were stage II, 24% were stage I, 15% stage III, and 4% stage IV. When using a cutoff score of 16, the Braden Scale demonstrated limited usefulness in predicting pressure ulcer development on our inpatient rehabilitation unit. Further calculations were completed, and a cutoff score of 18 or higher was found to provide better predictive value. With use of multiple logistic regression analysis, three of the six risk factors from the Braden Scale were found to significantly contribute to risk for pressure ulcer development in this sample: moisture, nutrition, and friction and shear. Therefore a modified Braden Scale was developed, with a possible range of scores from 3 to 11; the cutoff score was 8, sensitivity was 52%, and specificity 66%. Conclusions The mean prevalence rate of 12% was comparable, and the incidence rate of 6% for this unit was lower, compared with other skilled care and rehabilitation settings reported in the literature. The proactive, interdisciplinary approach to skin integrity on this unit likely contributed to the lower incidence rate. Risk factors most predictive of pressure ulcer development in this sample were moisture, nutrition, and friction and shear. Predicting risk for skin breakdown with use of a consistent risk-assessment tool is essential for all rehabilitation patients. Assessing risk with the Braden Scale merits further research. An investigation of the epidemiology of pressure ulcers on an inpatient rehabilitation unit and the positive and negative predictive value of the Braden scale when used in this clinical setting.

Pressure ulcer prevalence and incidence and a modification of the braden scale for a rehabilitation unit

Purpose: We examined pressure ulcer incidence and prevalence, the cutoff score for risk for skin breakdown, and the contribution of each of the subscale risk factors of the Braden pressure ulcer risk-assessment tool in an inpatient rehabilitation unit. Subjects and Setting: One hundred seventy adult men hospitalized on a rehabilitation unit during 1 calendar year were included in the research. Subject ages ranged from 35 to 99 years (M = 69). Instruments: Pressure ulcer risk was assessed using the Braden Scale. Methods: A retrospective chart review of a continuous series of 170 adult male patients hospitalized during a 1-year period on a 50-bed rehabilitation unit was conducted. Data were documented on a standardized researcher-designed form. Results: A total of 46 pressure ulcers occurred, with the sacrum the most common location (46%), followed closely by the heel-ankle area (44%, n = 20). Most pressure ulcers (57%) were stage II, 24% were stage I, 15% stage III, and 4% stage IV. When using a cutoff score of 16, the Braden Scale demonstrated limited usefulness in predicting pressure ulcer development on our inpatient rehabilitation unit. Further calculations were completed, and a cutoff score of 18 or higher was found to provide better predictive value. With use of multiple logistic regression analysis, three of the six risk factors from the Braden Scale were found to significantly contribute to risk for pressure ulcer development in this sample: moisture, nutrition, and friction and shear. Therefore a modified Braden Scale was developed, with a possible range of scores from 3 to 11; the cutoff score was 8, sensitivity was 52%, and specificity 66%. Conclusions: The mean prevalence rate of 12% was comparable, and the incidence rate of 6% for this unit was lower, compared with other skilled care and rehabilitation settings reported in the literature. The proactive, interdisciplinary approach to skin integrity on this unit likely contributed to the lower incidence rate. Risk factors most predictive of pressure ulcer development in this sample were moisture, nutrition, and friction and shear. Predicting risk for skin breakdown with use of a consistent risk-assessment tool is essential for all rehabilitation patients. Assessing risk with the Braden Scale merits further research.