Pressure Ulcer Risk Assessment Research Articles

Predictive validity and reliability of the Braden scale for risk assessment of pressure ulcers in an intensive care unit

ObjectiveContribution to validation of the Braden scale in patients admitted to the ICU, based on an analysis of its reliability and predictive validity. DesignAn analytical, observational, longitudinal prospective study was carried out. SettingIntensive Care Unit, Hospital Virgen del Rocío, Seville (Spain). PatientsPatients aged 18years or older and admitted for over 24h to the ICU were included. Patients with pressure ulcers upon admission were excluded. A total of 335 patients were enrolled in two study periods of one month each. InterventionsNone. Variables of interestThe presence of grade I–IV pressure ulcers was regarded as the main or dependent variable. Three categories were considered (demographic, clinical and prognostic) for the remaining variables. ResultsThe incidence of patients who developed pressure ulcers was 8.1%. The proportion of grade I and II pressure ulcer was 40.6% and 59.4% respectively, highlighting the sacrum as the most frequently affected location. Cronbach's alpha coefficient in the assessments considered indicated good to moderate reliability. In the three evaluations made, a cutoff point of 12 was presented as optimal in the assessment of the first and second days of admission. In relation to the assessment of the day with minimum score, the optimal cutoff point was 10. ConclusionsThe Braden scale shows insufficient predictive validity and poor precision for cutoff points of both 18 and 16, which are those accepted in the different clinical scenarios.

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.

Modified Delphi Technique: Content validity of the Pressure ulcer risk assessment tool

A study was undertaken to develop the risk assessment tool for prediction of pressure ulcer. Content validity of the tool was done through modified Delphi technique. The Delphi is an interactive process designed to combine expert’s opinion into group consensus. Panel of experts was selected and three rounds of Delphi were completed for content validation. The I-CVI was ranged from 0.86 to 1. The content validity index of risk assessment tool (S-CVI) came out to be 0.92.

Efficacy and Cost-Effectiveness Analysis of Evidence-Based Nursing Interventions to Maintain Tissue Integrity to Prevent Pressure Ulcers and Incontinence-Associated Dermatitis.

A reduction in tissue tolerance promotes the development of pressure ulcers (PUs) and incontinence-associated dermatitis (IAD). To determine the cost-effectiveness and efficacy of evidence-based (EB) nursing interventions on increasing tissue tolerance by maintaining tissue integrity. The study involved 154 patients in two intensive care units (77 patients, control group; 77 patients, intervention group). Data were collected using the following: patient characteristics form, Braden PU risk assessment scale, tissue integrity monitoring form, PU identification form, IAD and severity scale, and a cost table of the interventions. Patients in the intervention group were cared for by nurses trained in the use of the data collection tools and in EB practices to improve tissue tolerance. Routine nursing care was given to the patients in the control group. The researcher observed all patients in terms of tissue integrity and recorded the care-related costs. Deterioration of tissue integrity was observed in 18.2% patients in the intervention group compared to 54.5% in the control group (p < .05). The average cost to increase tissue tolerance prevention in the intervention and control groups was X¯ = $204.34 ± 41.07 and X¯ = $138.90 ± 1.70, respectively. It is recommended that EB policies and procedures are developed to improve tissue tolerance by maintaining tissue integrity. Although the cost of EB preventive initiatives is relatively high compared to those that are not EB, the former provide a significant reduction in the prevalence of tissue integrity deterioration.

Prevalence of pressure ulcer and associated risk factors in middle- and older-aged medical inpatients in Norway.

To describe the prevalence of pressure ulcers among middle- and older-aged patients in a general medical hospital in Norway and to describe the associations between pressure ulcers and potential risk factors additional to the Braden risk score. Degrees of mobility, activity, perfusion and skin status are risk factors for development of pressure ulcer. Nurses' clinical judgements combined with risk assessment tools are effective to detect pressure ulcer risk. Cross-sectional study. The study was performed as part of a research project conducted between September 2012-May 2014 in a general hospital in the capital of Norway. Registered nurses and nursing students collected data from all eligible patients on 10days during the students' clinical practice studies. The Braden scale was used to measure pressure ulcer risk, and skin examinations were performed to classify the skin area as normal or as indicative of pressure ulcer according to the definitions by the National Pressure Ulcer Advisory Panel. Comorbidities were collected by patient's self-report. This analysis focused on the 255 inpatients at the medical wards ≥52years of age, most of whom had more than one comorbidity. The prevalence of pressure ulcers was 14.9% in this sample. Higher age, underweight, diabetes and worse Braden scores were factors associated with pressure ulcer, and pressure ulcer was most frequently sited at the sacrum or heel. Adding age, weight and diabetes status to pressure ulcer risk assessment scales may improve identification of patients at risk for pressure ulcers. Knowledge about strengths and limitations of risk assessment tools is important for clinical practice. Age, weight and diabetes status should be considered for inclusion in risk assessment tools for pressure ulcers in medical wards.

Clinical evaluation of a new pressure ulcer risk assessment instrument, the Pressure Ulcer Risk Primary or Secondary Evaluation Tool (PURPOSE T).

AimTo test the psychometric properties and clinical usability of a new Pressure Ulcer Risk Assessment Instrument including inter‐rater and test–retest reliability, convergent validity and data completeness.BackgroundMethodological and practical limitations associated with traditional Pressure Ulcer Risk Assessment Instruments, prompted a programme to work to develop a new instrument, as part of the National Institute for Health Research funded, Pressure UlceR Programme Of reSEarch (RP‐PG‐0407‐10056).DesignObservational field test.MethodFor this clinical evaluation 230 patients were purposefully sampled across four broad levels of pressure ulcer risk with representation from four secondary care and four community NHS Trusts in England. Blinded and simultaneous paired (ward/community nurse and expert nurse) PURPOSE‐T assessments were undertaken. Follow‐up retest was undertaken by the expert nurse. Field notes of PURPOSE‐T use were collected. Data were collected October 2012–January 2013.ResultsThe clinical evaluation demonstrated “very good” (kappa) inter‐rater and test–retest agreement for PURPOSE‐T assessment decision overall. The percentage agreement for “problem/no problem” was over 75% for the main risk factors. Convergent validity demonstrated moderate to high associations with other measures of similar constructs.ConclusionThe PURPOSE‐T evaluation facilitated the initial validation and clinical usability of the instrument and demonstrated that PURPOSE‐T is suitable of use in clinical practice. Further study is needed to evaluate the impact of using the instrument on care processes and outcomes.

The introduction and evaluation of a pressure ulcer risk assessment tool for photopheresis outpatients.

Chronic graft-versus-host disease (cGVHD) patients are at high risk of compromised skin integrity, and of developing pressure ulcers, which may bleed and/or become infected. The Rotherham Outpatient Screening Tool (ROST) was adapted from the Waterlow score and the Malnutrition Universial Screening Tool (MUST) to suit patients attending an outpatient unit for photopheresis. A review of the screening tool highlighted patients at a higher risk of developing pressure damage during treatment and therefore the unit was able to reduce this risk by the provision of a pressure-relieving cushion (Repose).

Perioperative registered nurses knowledge, attitudes, behaviors, and barriers regarding pressure ulcer prevention in perioperative patients

BackgroundHospital acquired pressure ulcers have a detrimental effect on patient quality of life, morbidity, mortality, and cost to the healthcare industry. Little is known about pressure ulcer prevention in perioperative services. ObjectivesThe objectives of this study were to describe perioperative registered nurses (RNs) knowledge, attitudes, behaviors, and barriers about pressure ulcer prevention and to determine if knowledge and the availability of a pressure ulcer staging tool are predictors of pressure ulcer prevention behavior. MethodsA cross-sectional descriptive pilot study was conducted. Sixty-two perioperative RNs from 10 acute care hospitals participated. ResultsPerioperative nurses believed carrying out pressure ulcer prevention strategies is essential to nursing practice but only two-thirds reported conducting pressure ulcer risk assessment on all patients and daily assessment on at risk patients. Results indicated a knowledge deficit regarding assessment and prevention of pressure ulcers as performance on the PUKT (72%) fell below the recommended score of 90%. Results of binary logistic regression indicated that knowledge as measured by the PUKT and availability of a pressure ulcer staging tool were statistically significant (p=0.03) predictors of pressure ulcer prevention behavior. The initial model without the predictor variables, indicated an overall success rate of correct predictions of 64% which increase to 73% when the predictor variables were added to the initial model. ConclusionsAlthough perioperative nurses believe that pressure ulcer prevention is important, a knowledge deficit exists and there is a need for pressure ulcer prevention education.

Research progress and prospect of the pressure ulcer risk assessment scale

The pressure ulcer risk assessment scale has been widely used in clinical practice because it helps nurses to access the risk of patients' pressure ulcer with accuracy in a short time. This literature review aims to discuss the research progress, diagnosis cutoff, target population, evaluation results, limitations, and further development of the scale, and to provide evidence for its improvement in clinical practice. Key words: Review; Pressure ulcer; Risk assessment; Scale; Diagnosis cutoff

Can Braden Score Predict Outcomes for Hospitalized Heart Failure Patients?

Braden score is a routine assessment of pressure ulcer risk hypothesized to identify the frail phenotype. To investigate the predictive utility of the Braden score on outcomes of inpatients with heart failure (HF). Retrospective cohort study. An academic medical center between January 1, 2012 and June 30, 2013. 642 inpatients with a primary diagnosis of HF (ICD-9 428). The primary predictor was Braden score. Primary outcome was 30-day mortality. Additional outcomes included 30-day readmission, length of stay (LOS), and discharge destination. Multivariable methods were used to determine the association between the primary predictor and each outcome adjusted for patient demographics and clinical variables. Mean admission and discharge Braden scores were 19.5 ± 2.3 (SD) (range = 9-23) and 20.0 ± 1.9 (range = 11-23), respectively (P < .0001). Mean age was 61.8 ± 16.2 years (range = 19-101). The 30-day mortality rate was 4.4%, 30-day readmission rate was 16.2%, mean LOS was 7.0 ± 8.7 days, and 78.2% were discharged home. After adjustment, higher (better) Braden score was significantly associated with decreased 30-day mortality (discharge Braden AOR 0.81 (95% CI 0.66-0.996)), and decreased average LOS (admission Braden β -0.52 days (P = .0002)). Higher discharge Braden score was significantly associated with discharge to home (AOR 1.66 (95% CI 1.42-1.95)). Braden score was not significantly associated with 30-day readmission. Braden score is an independent predictor of mortality, LOS, and discharge destination among inpatients with HF. Further exploration of the use of Braden scores to identify inpatients who might benefit from specialized intervention is warranted.

Management of intraoperative pressure ulcer prevention in patients with ankylosing spondylitis

Objective To explore the methods and effects of pressure ulcer prevention and management for patients receiving ankylosing spondylitis surgery. Methods Totally 51 patients who received ankylosing spondylitis surgery in our hospital from January 2015 to May 2016 were selected by purposive sampling method, excluding those who had skin damage before operation. Patients′ preoperative and postoperative skin conditions were evaluated by Waterlow pressure ulcer risk assessment scale, and corresponding prevention measures were taken based on the risk factors of pressure ulcer that they had, including targeted interview, use of TG-A arched frame, intensive wake-up tests before operation, the reduction of pressure on pressed parts with protective pad such as gel pad and foam materials, close coordination and synchronized movement between doctors and nurses in reposition during operation, and condition evaluation of pressed skin according to the staging criteria recommended by the National Pressure Ulcer Advisory Panel of America, closer attention and pressure prevention after operation. Results Among 51 patients, 35 had high risk of pressure ulcer (15-19 points) , and 16 cases had extremely high risk (≥20 points) . After pressure ulcer prevention and management, there was only one case of stage II pressure ulcer whose preoperative pressure ulcer assessment was 25, and belongs to extremely high risk, and the incidence of pressure ulcer was 1.96%. Conclusions Ankylosing spondylitis patients have high risk of pressure ulcer during the perioperative period, and targeted preventative measures can help to reduce the incidence of intraoperative pressure ulcer effectively. Key words: Spondylitis, ankylosing; Perioperative nursing; Comprehensive prevention; Pressure ulcer; Skin protection; Waterlow pressure ulcer risk assessment scale

Factors Affecting Nurses’ Compliance in Preventing Pressure Ulcer Among Hospitalized Patients at King Abdulaziz University Hospital

Prevention of pressure ulcers is an indicator of quality of care. Nursing care has a major effect on pressure ulcer development and prevention. Hence, many people believe that most pressure ulcers are preventable if the appropriate interventions are implemented. The study aimed to assess factors affecting nursing compliance in preventing pressure ulcer. Descriptive correlation design was used which is a type of non-experimental design to collect data from medical, surgical units and the critical cardiac unit at King Abdulaziz University Hospital in Jeddah city. Purposive sampling technique was carried out to select 113 nurses and 113 patients. Data were collected by three tools, tool 1 is a structured questionnaire divided into 2 parts, included demographic data and list of barriers facing nurses in preventing pressure ulcer, tool 2 is an observational checklist and tool 3 is the Waterlow pressure ulcer risk assessment tool. The study concluded that there is significant correlation between barriers and nursing compliance in prevention pressure ulcer. Heavy workload/staff shortage is considered as the most barriers facing nurses’ compliance regarding prevention pressure ulcer. The study recommended that the managers should review nurses’ workload which the findings of this study have shown to be a major barrier in the priority given to the prevention of pressure ulcers.

Braden scale (ALB) for assessing pressure ulcer risk in hospital patients: A validity and reliability study

PurposeThe inter-rater reliability of Braden Scale is not so good. We modified the Braden(ALB) scale by defining nutrition subscale based on serum albumin, then assessed it's the validity and reliability in hospital patients. MethodsWe designed a retrospective study for validity analysis, and a prospective study for reliability analysis. Receiver operating curve (ROC) and area under the curve (AUC) were used to evaluate the predictive validity. Intra-class correlation coefficient (ICC) was used to investigate the inter-rater reliability. ResultsTwo thousand five hundred twenty-five patients were included for validity analysis, 76 patients (3.0%) developed pressure ulcer. Positive correlation was found between serum albumin and nutrition score in Braden scale (Spearman's coefficient 0.2203, P<0.0001). The AUCs for Braden scale and Braden(ALB) scale predicting pressure ulcer risk were 0.813 (95% CI 0.797–0.828; P<0.0001), and 0.859 (95% CI 0.845–0.872; P<0.0001), respectively. The Braden(ALB) scale was even more valid than the Braden scale (z=1.860, P=0.0628). In different age subgroups, the Braden(ALB) scale seems also more valid than the original Braden scale, but no statistically significant differences were found (P>0.05). The inter-rater reliability study showed the ICC-value for nutrition increased 45.9%, and increased 4.3% for total score. ConclusionThe Braden(ALB) scale has similar validity compared with the original Braden scale for in hospital patients. However, the inter-rater reliability was significantly increased.

Predictive validity of the Braden Scale, Norton Scale, and Waterlow Scale in the Czech Republic.

The aim of this study was to determine the predictive validity of the Braden, Norton, and Waterlow scales in 2 long-term care departments in the Czech Republic. Assessing the risk for developing pressure ulcers is the first step in their prevention. At present, many scales are used in clinical practice, but most of them have not been properly validated yet (for example, the Modified Norton Scale in the Czech Republic). In the Czech Republic, only the Braden Scale has been validated so far. This is a prospective comparative instrument testing study. A random sample of 123 patients was recruited. The predictive validity of the pressure ulcer risk assessment scales was evaluated based on sensitivity, specificity, positive and negative predictive values, and the area under the receiver operating characteristic curve. The data were collected from April to August 2014. In the present study, the best predictive validity values were observed for the Norton Scale, followed by the Braden Scale and the Waterlow Scale, in that order. We recommended that the above 3 pressure ulcer risk assessment scales continue to be evaluated in the Czech clinical setting.

Establishment and application of pressure ulcer risk assessment module based on the nursing information system

Objective To develop an electronic information system, and make the pressure ulcer risk management more standardized. Methods The information module of pressure ulcer assessment was based on the Norton assessment. This technology relied on the hospital′s nursing information platform, mobile nursing workstation, PDA and other hardware facilities. With this innovation, many intelligent features could be achieved, which included automatically data grabbing and results calculating. In addition, it could help in risk warning, bitmap management of skin problems and the selection and record of nursing measures. Meanwhile, a before-after controlled trial was compared in the advantage of time and satisfaction between the pressure ulcer risk assessment module and traditional assessment. Results The time of pressure ulcer risk assessment and nursing measure was significantly different between the pressure ulcer risk assessment module (4.4±0.3), (12.3±0.8)min and traditional assessment (9.2±0.8), (23.7±1.1)min (P<0.05). The time of pressure ulcer risk assessment module on pressure ulcer nursing management and nursing measures were (12.3±0.8) min, which was less than that of traditional paper pressure ulcer management (23.7±1.1) min (t=36.941, P<0.05). Pressure ulcer risk assessment module improved the satisfaction of nursing staff towards pressure ulcer assessment and it increased by 45% (χ2=8.025, P<0.05). Conclusions The establishment of this information module makes the risk management of pressure ulcer more effective, and the application of nursing information more extensive. Key words: Nursing information system; Pressure ulcer; Risk assessment

Using cognitive pre-testing methods in the development of a new evidenced-based pressure ulcer risk assessment instrument.

BackgroundVariation in development methods of Pressure Ulcer Risk Assessment Instruments has led to inconsistent inclusion of risk factors and concerns about content validity. A new evidenced-based Risk Assessment Instrument, the Pressure Ulcer Risk Primary Or Secondary Evaluation Tool - PURPOSE-T was developed as part of a National Institute for Health Research (NIHR) funded Pressure Ulcer Research Programme (PURPOSE: RP-PG-0407-10056). This paper reports the pre-test phase to assess and improve PURPOSE-T acceptability, usability and confirm content validity.MethodsA descriptive study incorporating cognitive pre-testing methods and integration of service user views was undertaken over 3 cycles comprising PURPOSE-T training, a focus group and one-to-one think-aloud interviews. Clinical nurses from 2 acute and 2 community NHS Trusts, were grouped according to job role. Focus group participants used 3 vignettes to complete PURPOSE-T assessments and then participated in the focus group. Think-aloud participants were interviewed during their completion of PURPOSE-T.After each pre-test cycle analysis was undertaken and adjustment/improvements made to PURPOSE-T in an iterative process. This incorporated the use of descriptive statistics for data completeness and decision rule compliance and directed content analysis for interview and focus group data. Data were collected April 2012-June 2012.ResultsThirty-four nurses participated in 3 pre-test cycles. Data from 3 focus groups, 12 think-aloud interviews incorporating 101 PURPOSE-T assessments led to changes to improve instrument content and design, flow and format, decision support and item-specific wording. Acceptability and usability were demonstrated by improved data completion and appropriate risk pathway allocation. The pre-test also confirmed content validity with clinical nurses.ConclusionsThe pre-test was an important step in the development of the preliminary PURPOSE-T and the methods used may have wider instrument development application. PURPOSE-T proposes a new approach to pressure ulcer risk assessment, incorporating a screening stage, the inclusion of skin status to distinguish between those who require primary prevention and those who require secondary prevention/treatment and the use of colour to support pathway allocation and decision making. Further clinical evaluation is planned to assess the reliability and validity of PURPOSE-T and it’s impact on care processes and patient outcomes.

Prophylactic use of dressings for pressure ulcer prevention in the critical care unit.

Multiple comorbidities and intensive therapy increase the risk of pressure ulcer (PU) development in critical care unit (CCU) patients. Given the high number of risk factors that CCU patients present with, it is important to acknowledge that not all PUs are entirely preventable, and incidence is thought to be between 14% and 42%. The consequences of acquiring a PU in critical care include increased mortality, morbidity and longer length of stay. Implementing prevention strategies as soon as the patient enters the unit can significantly reduce incidence. By adopting a proactive versus reactive mind-set, one CCU abandoned traditional PU risk assessment and implemented a number of intensive interventions, including the use of a prophylactic sacral dressing as an adjunct. As a result, PU incidence fell from 19.9 per 1000 patient population to 0.84 per 1000 patient population in 2014. In addition, 310 PU-free days were achieved.

Pressure Ulcer Risk in the Incontinent Patient: Analysis of Incontinence and Hospital-Acquired Pressure Ulcers From the International Pressure Ulcer Prevalence™ Survey.

To measure the prevalence of incontinence in the 2013-2014 International Pressure Ulcer Prevalence (IPUP) surveys and determine the relative risk of developing a facility-acquired pressure ulcers (FAPUs) by stage and by Braden Scale score groupings. The IPUP survey is an observational, cross-sectional cohort database designed to determine the frequency and severity of pressure ulcers in various populations. The survey includes acute care (91.4%), long-term acute care (1.7%), rehabilitation patients (1.7%) and long-term care residents (5.2%). Geographic distribution included 182,832 patients in the United States, 22,282 patients in Canada, and the rest of the world, primarily in Europe and the Middle East. We analyzed data from the 2013 and 2014 IPUP surveys to better understand the relationship between incontinence and the frequency and severity of FAPUs. The IPUP survey is an annual voluntary survey of patients who are hospitalized or who reside in long-term care facilities. Data were collected over a 24-hour period within each participating facility. Data collection included limited demographics, presence and stage of pressure ulcers, and pressure ulcer risk assessment score (Braden Scale for Pressure Sore Risk, Braden Q, Norton, Waterlow, and others). In addition, data were collected on pertinent pressure ulcer risk factors including the number of linen layers, use of a pressure redistributing surface, adherence to repositioning schedule, and whether moisture management was provided in the last 24 hours. We aggregated data by urinary, urinary catheter, fecal, fecal management system, double (urinary and fecal), and ostomy incontinence category. If patients were managed by indwelling urinary catheter or fecal management systems, they were considered incontinent in this analysis. In order to analyze ulcers likely to be affected by incontinence, we defined a subset of ulcers as Relevant Pressure Ulcers, which are ulcers that are facility-acquired, non-device-related, and located in the pelvic region. We analyzed 176,689 patients based on data collected between 2013 and 2014. Slightly less than half (n = 83,800; 47%) of patients did not have incontinence, and 92,889 (53%) were deemed to be incontinent. The prevalence of pressure ulcers was 4.1% for continent patients and 16.3% for incontinent patients; the prevalence of FAPUs was 1.6% and 6.0%, respectively. The relative risk for PU development in incontinent patients was higher than predicted by the Braden Scale risk score. As wound severity increased, the odds ratios for pressure ulcer development for incontinent patients versus continent patients also increased, especially in patients with fecal incontinence. Incontinent patients had higher Braden Scale scores and higher overall and FAPU prevalence. Incontinence was associated with an increased risk for all pressure ulcers, but especially full-thickness injuries.

Identifying Patterns in Implementation of Hospital Pressure Ulcer Prevention Programs: A Multisite Qualitative Study.

To describe the presence or absence of key components of hospital pressure ulcer (PU) prevention programs in 6 acute care hospitals. Multisite comparative case study. Using purposeful selection based on PU rates (high vs low) and hospital size, 6 hospitals within the Veterans Health Administration health care system were invited to participate. Key informant interviews (n = 48) were conducted in each of the 6 participating hospitals among individuals playing key roles in PU prevention: senior nursing leadership (n = 9), nurse manager (n = 7), wound care specialist (n = 6), frontline RNs (n = 26). Qualitative data were collected during face-to-face, semistructured interviews. Interview protocols were tailored to each interviewee's role with a core set of common questions covering 3 major content areas: (1) practice environment (eg, policies and wound care specialists), (2) current prevention practices (eg, conduct of PU risk assessment and skin inspection), and (3) barriers to PU prevention. We conducted structured coding of 5 key components of PU prevention programs and cross-case analysis to identify patterns in operationalization and implementation of program components across hospitals based on facility size and PU rates (low vs high). All hospitals had implemented all PU prevention program components. Component operationalization varied considerably across hospitals. Wound care specialists were integral to the operationalization of the 4 other program components examined; however, staffing levels and work assignments of wound care specialists varied widely. Patterns emerged among hospitals with low and high PU rates with respect to wound care specialist staffing, data monitoring, and staff education. We found hospital-level variations in PU prevention programs. Wound care specialist staffing may represent a potential point of leverage in achieving other PU program components, particularly performance monitoring and staff education.

Use of Munsell color charts to measure skin tone objectively in nursing home residents at risk for pressure ulcer development.

To assess the feasibility of classifying skin tone using Munsell color chart values and to compare Munsell-based skin tone categories to ethnicity/race to predict pressure ulcer risk. Pressure ulcer classification uses level of visible tissue damage, including skin discoloration over bony prominences. Prevention begins with early detection of damage. Skin discoloration in those with dark skin tones can be difficult to observe, hindering early detection. Observational cohort of 417 nursing home residents from 19 nursing homes collected between 2009-2014, with weekly skin assessments for up to 16weeks. Assessment included forearm and buttocks skin tone based on Munsell values (Dark, Medium, Light) at three time points, ethnicity/race medical record documentation, and weekly skin assessment on trunk and heels. Inter-rater reliability was high for forearm and buttock values and skin tone. Mean Munsell buttocks values differed significantly by ethnicity/race. Across ethnicity/race, Munsell value ranges overlapped, with the greatest range among African Americans. Trunk pressure ulcer incidence varied by skin tone, regardless of ethnicity/race. In multinomial regression, skin tone was more predictive of skin damage than ethnicity/race for trunk locations but ethnicity/race was more predictive for heels. Given the overlap of Munsell values across ethnicity/race, color charts provide more objective measurement of skin tone than demographic categories. An objective measure of skin tone can improve pressure ulcer risk assessment among patients for whom current clinical guidelines are less effective.