Acute Tertiary Hospital Research Articles

Unplanned 3-day re-attendance rate at Emergency Department (ED) and hospital's bed occupancy rate (BOR).

BackgroundUnplanned re-attendance at the Emergency Department (ED) is often monitored as a quality indicator of the care accorded to patients during their index ED visit. High bed occupancy rate (BOR) has been considered as a matter of reduced patient comfort and privacy. Most hospitals in Singapore operate under BORs above 85 %. This study aims to explore factors associated with the unplanned 3-day ED re-attendance rate and, in particular, if higher BOR is associated with higher 3-day unplanned ED re-attendance rate.MethodsThis was a multicenter retrospective study using time series data. Three acute tertiary hospitals were selected from all six adult public hospitals in Singapore based on data availability. Daily data from year 2008 to 2013 were collected from the study hospitals’ information systems. These included: ED visit date, day of week, month, year, public holiday, daily hospital BOR, daily bed waiting time (BWT) at ED (both median and 95th percentile), daily ED admission rate, and 3-day ED re-attendance rate. The primary outcome of the study was unplanned 3-day ED re-attendance rate from all reasons. Both univariate analysis and generalized linear regression were respectively applied to study the crude and adjusted association between the unplanned 3-day ED re-attendance rate and its potential associated factors. All analyses were conducted using SPSS 18 (PASW 18, IBM).ResultsThe average age of patients who visited ED was 35 years old (SD = 2), 37 years old (SD = 2), and 40 years old (SD = 2) in hospitals A, B, and C respectively. The average 3-day unplanned ED re-attendance rate was 4.9 % (SE = 0.47 %) in hospital A, 3.9 % (SE = 0.35 %) in hospital B, and 4.4 % (SE = 0.30 %) in hospital C. After controlling for other covariates, the unplanned 3-day ED re-attendance rates were significantly associated with hospital, time trend, day of week, daily average BOR, and ED admission rate. Strong day-of-week effect on early ED re-attendance rate was first explored in this study. Thursday had the lowest re-attendance rate, while Sunday has the highest re-attendance rate. The patients who visited at ED on the dates with higher BOR were more likely to re-attend the ED within 3 days for hospitals A and B. There was no significant association between BOR and ED re-attendance rate in hospital C.ConclusionsA study using time series data has been conducted to explore the factors associated with the unplanned 3-day ED re-attendance rate. Strong day-of-week effect was first reported. The association between BOR and the ED re-attendance rate varied with hospital.

Nurses' knowledge, attitudes, and current practice of daily oral hygiene care to patients on acute aged care wards in two Australian hospitals.

This study aimed to identify nurses' knowledge, attitudes, and current practice in relation to oral hygiene (OH) by means of a questionnaire. It was conducted on the aged care wards of two acute tertiary referral hospitals in New South Wales, Australia. We found that 74% of nurses have a set OH practice. Fifty-four percent of nurses learn their OH practice at university or TAFE. The main nurse qualification is a registered nurse (72%). Denture cleaning, toothbrushing, and swabbing the mouth with a toothette are the main OH practices. Nurses (99%) considered OH to be important. The main barriers to conducting OH practices were patient behaviors, lack of time and staff, and patient physical difficulties. Nurses considered OH important however patient behaviors impact on their ability to undertake the task. Education institutions and hospitals should consider the joint development of a formal OH procedure and training package that can be used on acute geriatric care wards.

Risk factors for acquisition of carbapenem resistant Enterobacteriaceae in an acute tertiary care hospital in Singapore.

BackgroundCarbapenem resistant Enterobacteriaceae (CRE) is increasingly reported worldwide. A similar increase is seen in Singapore since identification of its first case in 2008. The aim of this study was to identify local risk factors for carriage of CRE in patients from an acute tertiary care hospital in Singapore.MethodA matched case-control study was conducted on inpatients treated from January 1, 2011 till December 31, 2013. Two hundred and three cases of CRE infection or colonization were matched with 203 controls. CRE types were identified by PCR. Statistical analysis of data including a multivariate logistic regression analysis was done using SPSS 21.0.ResultsCREs were commonly seen in Klebsiella pneumoniae (42.2 %), Escherichia coli (24.3 %) and Enterobacter cloacae complex (17.2 %) in the 268 isolates. NDM-1 was the commonest CRE type seen (44.4 %), followed by KPC (39.9 %) whilst OXA-48 only constituted (7.8 %). Univariate analysis identified key risk factors associated with CRE as history of previous overseas hospitalization (OR: 33.667; 95 % CI: 4.539-259.700), admission to ICU (OR: 11.899; 95 % CI: 4.986-28.399) and HD/ICA (OR: 6.557; 95 % CI: 4.057-10.596); whilst a multivariate analysis revealed exposure to antibiotics penicillin (OR: 4.640; 95 % CI: 1.529-14.079] and glycopeptide (OR: 5.162; 95 % CI: 1.377-19.346) and presence of central line device (OR: 3.117; 95 % CI: 1.167-8.330) as significant independent predictors.ConclusionsThe identification of risk factors amongst our local population helped to refine the criteria used for target active surveillance screening for CRE amongst inpatients at time of hospital admission.

Ensuring healthcare workers’ safety in the management of Ebola virus disease: a novel competency assessment checklist for proper PPE use

In response to EVD outbreak in Africa, Malta like many other countries in Europe, stepped up efforts to prepare and train in correct procedures for safe identification and management of potential EVD patients in the main acute tertiary hospital.

Effectiveness of electronic learning on urinary catheter care in an acute tertiary hospital

Effectiveness of electronic learning on urinary catheter care in an acute tertiary hospital

Assessment of dyspnoea in the emergency department by numeric and visual scales: A pilot study

Objective(s)Dyspnoea is a common and often debilitating symptom that affects up to 50% of patients admitted to acute tertiary care hospitals. The primary purpose of this study was to compare the numeric rating scale (NRS) and the visual analogue scale (VAS) for dyspnoea evaluation in the ED setting. Study design and patientsThis was a cohort study of patients admitted to the ED in a university hospital, with dyspnoea as the chief complaint. MethodsThe agreement of the two dyspnoea scales was assessed using the intraclass correlation coefficient (ICC). ResultsOne hundred and seventeen patients were included in this analysis. The median age for the whole study population was 67 years and 42% of patients were male. The aetiology of dyspnoea was acute heart failure (AHF) in 35% of patients. There was good agreement between the two scores (ICC=0.795; 95% CI=0.717–0.853; P<0.001). ConclusionsThis pilot study demonstrated that numerical rating and visual analogue scales agree well when assessing the severity of dyspnoea in the ED. Further studies with larger cohorts of patients are needed to confirm these preliminary results.

Patterns of health care use in a high-cost inpatient population in Ottawa, Ontario: a retrospective observational study.

A small proportion of patients account for the majority of health care spending. We used detailed clinical and administrative data to explore clinical characteristics, patterns of health care use and changes in cost profiles over time among high-cost inpatients in an acute tertiary care hospital in Ottawa, Ontario. We identified all people who had 1 or more inpatient admissions to The Ottawa Hospital between Apr. 1, 2009, and Mar. 31, 2012. We calculated the direct inpatient costs using case-costing information to categorize patients into persistently high-cost, episodic high-cost and non-high-cost groups. Within each group, we used discharge abstracts to measure encounter-level characteristics and patterns of inpatient health care use over time. We also developed transition matrices to explore how inpatient costing states changed over time. During the study period, 100178patients had 132996hospital admissions. Hospital spending was often limited to a single year for most of the patients (90.2%), with only a small proportion (7.4%) of patients remaining in the high-cost group in the subsequent year. Patients in the persistently (n = 236) and episodic (n = 5062) high-cost groups were often older, had medically complex conditions and generated most of the costs from nursing care and intensive care. Compared with patients in the other cost groups, those in the persistently high-cost group were more likely to have multiple readmissions (43.4%) and multiple placements in an alternate level of care (19.0%) and were high users of health care services outside of the hospital setting. Hospital spending was often limited to a single year for most patients, and only a small proportion of patients remained in the high-cost group in the subsequent year. These persistently high-cost patients had medically complex conditions and often required expensive care. A greater understanding of the circumstances that result in persistent hospital spending remains an area for future work, including an exploration of the potential barriers impeding efficient transition out of acute care for high-risk patients.

Incidence and predictors of new-onset constipation during acute hospitalisation after stroke.

We investigated new-onset constipation in patients with stroke compared with orthopaedic conditions and explored the predictors associated with constipation during acute hospitalisation. This was a prospective matched cohort study of 110 patients comparing stroke patients (n = 55) with orthopaedic patients (n = 55) admitted to a large tertiary acute hospital. Both cohorts were matched by age and sex. The incidence of new-onset constipation which occurred during a patient's acute hospitalisation was determined. Demographics, comorbidity, clinical factors, laboratory parameters and medications were evaluated as possible predictors of constipation. The incidence of new-onset constipation was high for both stroke (33%) and orthopaedic patients (27%; p = 0.66). Seven stroke patients (39%) and four orthopaedic patients (27%) developed their first onset of constipation on day 2 of admission. Mobility gains (RR 0.741, p < 0.001) and the use of prophylactic laxatives (RR 0.331, p < 0.01) had a protective effect against constipation. Bedpan use (RR 2.058, p < 0.05) and longer length of stay (RR 1.032, p < 0.05) increased the risk of developing new-onset constipation. New-onset constipation is common among patients admitted for stroke and orthopaedic conditions during acute hospitalisation. The early occurrence, on day 2 of admission, calls for prompt preventive intervention for constipation.

Designing and evaluating an interactive multimedia Web-based simulation for developing nurses' competencies in acute nursing care: randomized controlled trial.

BackgroundWeb-based learning is becoming an increasingly important instructional tool in nursing education. Multimedia advancements offer the potential for creating authentic nursing activities for developing nursing competency in clinical practice.ObjectiveThis study aims to describe the design, development, and evaluation of an interactive multimedia Web-based simulation for developing nurses’ competencies in acute nursing care.MethodsAuthentic nursing activities were developed in a Web-based simulation using a variety of instructional strategies including animation video, multimedia instructional material, virtual patients, and online quizzes. A randomized controlled study was conducted on 67 registered nurses who were recruited from the general ward units of an acute care tertiary hospital. Following a baseline evaluation of all participants’ clinical performance in a simulated clinical setting, the experimental group received 3 hours of Web-based simulation and completed a survey to evaluate their perceptions of the program. All participants were re-tested for their clinical performances using a validated tool.ResultsThe clinical performance posttest scores of the experimental group improved significantly (P<.001) from the pretest scores after the Web-based simulation. In addition, compared to the control group, the experimental group had significantly higher clinical performance posttest scores (P<.001) after controlling the pretest scores. The participants from the experimental group were satisfied with their learning experience and gave positive ratings for the quality of the Web-based simulation. Themes emerging from the comments about the most valuable aspects of the Web-based simulation include relevance to practice, instructional strategies, and fostering problem solving.ConclusionsEngaging in authentic nursing activities using interactive multimedia Web-based simulation can enhance nurses’ competencies in acute care. Web-based simulations provide a promising educational tool in institutions where large groups of nurses need to be trained in acute nursing care and accessibility to repetitive training is essential for achieving long-term retention of clinical competency.

Human Factor and Operating Considerations for Door Lockset Design for Patient Bathrooms in a Tertiary Acute Hospital

130 patient bathroom and toilet door locksets in an acute hospital was surveyed to evaluate the design features that would satisfy the criteria of universal design, patient human factors, operating requirement of healthcare workers, and ease of emergency rescue.The data collected was categorized according to door handle type; latch and lock bolts; “in-use’ indicator; and external lock release mechanism.The results were used by Workplace Safety, Nursing and Facilities Maintenance departments to develop a priority schedule for improvement on the patient bathroom door locksets.

DEVELOPMENT OF AN INTEGRATED SCREENER FOR UNDERNUTRITION WITHIN A COMPREHENSIVE GERIATRIC ASSESSMENT SYSTEM

Objective: To develop a screener for the presence of undernutrition in older adults in acute care utilizing items within a comprehensive geriatric assessment (CGA) instrument (the interRAI Acute Care). Design: Prospective cohort study and retrospective medical record review of nutritional assessment data. Setting: Acute care tertiary teaching hospital in Brisbane, Australia. Participants: Five hundred fifty-seven general medical patients aged 70 and older admitted to the hospital. Measurements: Prevalence of geriatric syndromes at admission; measures of functional status (activities of daily living), cognition, behavioural symptoms, social support, community assistance services, health conditions, medications and other medical treatments, weight, body mass index (BMI), mode of nutritional intake; demographic variables and Subjective Global Assessment (SGA) of nutritional status. These measures were tested for their prediction of undernutrition using a logistic regression model and decision tree analysis. Results: The following variables were significant independent predictors of undernutrition on admission, after adjustment for age and gender: (i) feeling sad/depressed (OR: 3.494 [1.124-10.864]; p&lt;0.05); (ii) short term memory recalling ability (OR: 3.325 [1.152-9.594]; p&lt;0.05); (iii) weight loss of 5% or more in the last 30 days or 10% or more in the last 180 days (OR: 2.877 [0.983-8.416]; p=0.05); (iv) fatigue (OR: 3.494 [1.414-43.205]; p&lt;0.05). Decision tree analysis revealed two models most predictive of undernutrition: (i) short term memory recalling ability and depression (AUC 72.8% [95% CI: 65%-80.6%]); (ii) short term memory recalling ability and recent weight loss (5% or more in the last 30 days or 10% or more in the last 180 days) (AUC: 74.8% [95% CI: 65.9% - 83.6%]). Conclusion: Several measures within the interRAI-AC may be used as part of a screener for undernutrition in acute hospital patients aged 70 years or older. The combination of short term memory recalling ability and percentage weight loss provides the most statistically robust screener for undernutrition within the interRAI-AC.

Serum procalcitonin is a marker for prediction of readmission from an intermediate care to an acute care hospital in neurosurgical patients.

Background:Readmission of patients to acute hospitals contributes significantly toward inefficient utilization of healthcare resources, with studies quoting up to 90% being preventable. We aim to report and analyze the factors involved in the readmission of neurosurgical patients who had been previously transferred to an intermediate step-down care facility, and explore possible predictive markers for such readmissions.Methods:We conducted a retrospective analysis of all 129 neurosurgical patients who were transferred from out acute tertiary hospital to an intermediate care facility. The cases were segregated into those who were readmitted and those who were not readmitted back to our acute center. The demographic data, clinical features, diagnoses, treatment modalities, pretransfer laboratory findings, and inpatient complications were compared with readmission rate.Results:There were 23 patients (17.8%) who were readmitted to our acute hospital. The most common causes of readmission was infection (n = 12, 52.2%). We found a statistically significant correlation between the higher pretransfer procalcitonin levels with the readmission of our patients (P = 0.037). There was also a significant difference noted between ethnic groups (P = 0.026) and having no complications of disease or treatment (P = 0.008), with readmission.Conclusion:Procalcitonin is a pro-hormone known to correlate with infection and poor neurological status. We have found that its serum values correlate significantly with the readmission rates of neurosurgical patients in our study. We postulate that by ensuring normality in procalcitonin levels prior to transfer to an intermediate care facility, potentially half of neurosurgical readmissions can be prevented.

Caregiving across the lifespan: comparing caregiver burden, mental health, and quality of life.

Care can be considered a lifelong process, but caring for a child is different from caring for an older adult. The present study aims to compare the caregiving process from infancy through old age by evaluating differences in caregiver burden, mental health, and quality of life and to describe the factors that could impact these outcomes. To compare different groups of caregivers, we included 300 caregivers recruited from admissions to a tertiary acute hospital: 100 caregivers of children, 100 caregivers of adults, and 100 caregivers of older adults. A self-administered questionnaire was used that covered the following: sociodemographics, depression (Beck Depression Inventory), anxiety (Beck Anxiety Inventory), quality of life (Short Form Health Survey (SF-36)), religiosity (Duke Religion Index) and caregiver burden (Zarit Caregiver Burden Interview). A comparison between groups was performed (through χ2 and anova), and a linear regression analysis was used to assess the related factors. We found that children's caregivers had more depressive symptoms (higher Beck Depression Inventory scores), better physical health (SF-36: physical functioning and SF-36: Physical Component Summary), and lower pain (SF-36: bodily pain) than other caregivers. We found that caregivers of adults had better mental health (SF-36: mental health and SF-36: Mental Component Summary) than other caregivers and that caregivers of older adult had a higher caregiver burden (Zarit Caregiver Burden Interview scores) than other caregivers. After we controlled for baseline characteristics, only depressive symptoms and caregiver burden remained statistically significant. In conclusion, there are important differences between caregiving across the lifespan. Caregiving for children was associated with more depressive symptoms, and caregiving for older adults was associated with higher caregiver burden. Further studies are needed to replicate these findings in other settings.

Factors associated with in-hospital death by site of consultation among elderly inpatients receiving pain and palliative care consultations.

Despite palliative care implementation, most deaths still occur in hospitals. To identify factors associated with in-hospital death among elderly patients receiving palliative care, by site of consultation. Prospective observational study. All inpatients aged 65 years and older receiving pain and palliative care consultations in a 533-bed acute tertiary care hospital in Honolulu, Hawaii, from January 2005 through December 2009. During consultation, demographics, diagnoses, consultation site (intensive care unit [ICU], non-ICU medical, non-ICU surgical, and rehabilitation floors), consultation indication (assistance with establishing goals of care versus pain and/or symptom management), Karnofsky scores, length of stay (LOS), discharge disposition, and in-hospital death were collected. Multiple logistic regression analyses examined factors associated with in-hospital death. Of 1630 elderly inpatients receiving palliative care, 305 (19%) died in-hospital. In-hospital death among non-ICU medical patients was associated with needing consultation to assist with plan of care (odds ratio [OR]=1.89, 95% confidence interval [CI]=1.27-2.80). Likelihood of in-hospital death increased 2% for each additional hospital day before consultation (OR=1.02, 95% CI=1.01-1.03). Among elderly ICU patients, likelihood of in-hospital death increased 8% for each additional hospital day before consultation (OR=1.08, 95% CI=1.01-1.16). Among elderly non-ICU medical patients receiving palliative care consultations, the need for a consultation to assist with plan of care was associated with in-hospital death, while length of stay prior to consultation was important among both elderly ICU and non-ICU medical patients. Elderly hospitalized patients may benefit from earlier identification and palliative care consultation for assistance with plan of care to avoid in-hospital death.

Prognostic validity of 3-Minute Nutrition Screening (3-MinNS) in predicting length of hospital stay, readmission, cost of hospitalisation and mortality: a cohort study.

It is important to identify patients who are at risk of malnutrition upon hospital admission as malnutrition results in poor outcomes such as longer length of hospital stay, readmission, hospitalisation cost and mortality. The aim of this study was to determine the prognostic validity of 3-Minute Nutrition Screening (3-MinNS) in predicting hospital outcomes in patients admitted to an acute tertiary hospital through a list of diagnosis-related groups (DRG). In this study, 818 adult patients were screened for risk of malnutrition using 3-MinNS within 24 hours of admission. Mortality data was collected from the National Registry with other hospitalisation outcomes retrieved from electronic hospital records. The results were adjusted for age, gender and ethnicity, and matched for DRG. Patients identified to be at risk of malnutrition (37%) using 3-MinNS had significant positive association with longer length of hospital stay (6.6 ± 7.1 days vs 4.5 ± 5.5 days, p<0.001), higher hospitalisation cost (S$4540 ± 7190 vs S$3630 ± 4961, p<0.001) and increased mortality rate at 1 year (27.8% vs 3.9%), 2 years (33.8% vs 7.2%) and 3 years (39.1% vs 10.5%); p<0.001 for all. The 3-MinNS is able to predict clinical outcomes and can be used to screen newly admitted patients for nutrition risk so that appropriate nutrition assessment and early nutritional intervention can be initiated.

The Acute-Care Nurse Practitioner – A Transformational Journey

The Acute-Care Nurse Practitioner – A Transformational Journey is an insightful and in-depth examination of nurse practitioners (NPs) working in acute tertiary care hospitals across Canada. The book is based on face-to-face interviews with 26 experienced NPs who aimed to answer the question, "What is the experience of being an acute-care NP?".

Nurse practitioners versus doctors diagnostic reasoning in a complex case presentation to an acute tertiary hospital: A comparative study

BackgroundNurse practitioners perform a diagnostic role previously delivered by doctors. Multiple studies demonstrate nurse practitioners are as effective as doctors when managing chronic conditions and minor illnesses and injuries. No studies have focused on how nurse practitioners compare to doctors in their management of complex cases presenting for the first time. ObjectiveThis study assessed how nurse practitioners’ diagnostic reasoning abilities when managing a complex case compared to those of doctors’? DesignA comparative research design. ParticipantsPurposeful sampling recruited 30 nurse practitioners and 16 doctors working in multiple specialties in New Zealand. All doctors were completing postgraduate specialist training programmes. Specialties included older adults, emergency care, primary health care/general practice, cardiology, respiratory and palliative care. MethodsA complex case scenario assessed by an expert panel and think aloud protocol was used to assess diagnostic reasoning abilities. The ability of 30 nurse practitioners to determine diagnoses, identify the problem, and propose actions was compared to that of 16 doctors. Correct responses were determined by an expert panel. Data gained from the case scenario using think aloud protocol were quantified for analysis. Results61.9% of doctors identified the correct diagnoses, 56.3% the problem and 34.4% the actions as determined by the expert panel. This compares to 54.7% of nurse practitioners identifying the correct diagnoses, 53.3% the problem and 35.8% the actions. Analysis revealed no difference between these groups (diagnoses 95% CI: −1.76 to −0.32, p=0.17, problem χ2=0.00, p=1.0, or actions 95% CI: −1.23 to 1.58, p=0.80). ConclusionNurse practitioners’ diagnostic reasoning abilities compared favourably to those of doctors in terms of diagnoses made, problems identified and action plans proposed from a complex case scenario. In times of global economic restraints this adds further support to alternative models of care.

Rapid response team implementation and in-hospital mortality*.

To determine the relationship between implementation of rapid response teams and improved mortality rate using a large, uniform dataset from one state in the United States. This observational cohort study included 471,062 adult patients hospitalized between 2001 and 2009. Ten acute tertiary care hospitals in Washington State. Hospital abstract records on adult patients (18 years old or older) were examined (n = 471,062). Patients most likely to benefit from rapid response team interventions were included and other prognostic factors of severity of illness and comorbidities were controlled. Each participating hospital provided the implementation date of their rapid response team intervention. Mortality rates in 31 months before rapid response team implementation (pre-rapid response team time period) were compared with mortality rates in 31 months following rapid response team implementation (post-rapid response team time period). Implementation of a rapid response team within each acute tertiary care hospital. In-hospital mortality. Relative risk for in-hospital mortality improved in the post-rapid response team time period compared with the pre-rapid response team time period (relative risk = 0.76; 95% CI = 0.72-0.80; p < 0.001). In-hospital mortality improved in six of 10 acute tertiary care hospitals in the post-rapid response team time period when compared with the pre-rapid response team time period. Because of a long-term trend of decline in hospital mortality, these decreases could not be unambiguously attributed to rapid response team implementation. Further research should examine additional objective outcomes and optimal configuration of rapid response teams to maximize intervention effectiveness.

To what extent are we engaging the best practices for assisting acute hematology-oncology patients during their meal times?

Background: Maintaining adequate nutritional intake for cancer patients is important to improve their fitness for cancer treatment and strengthen their immune system. Clinical practices are already in place for nurses to provide meal time assistance to patients to maintain/improve their nutritional status. However, direct observation and patients’ feedback revealed that this basic fundamental aspect of care was neglected. Objective: The aim was to improve the clinical practice in rendering adequate assistance to patients during their meal time through the utilization of best practice evidences. Methods: This project used pre and post implementation audit strategies from Joanna Briggs Institute Practical Application of Clinical Evidence System and a validated Patients’ Satisfaction Survey to collect data. Getting Research into Practice programme was also used to analyse the potential barriers and design the final action plan. This project was conducted in three different phases over a 5-month period at a 24-bed oncology ward located in an acute tertiary hospital in Singapore. Results: All 4 criteria had achieved at least an 80% compliance. There was a significant improvement in Criterion 1, from 10% to 86% during the post implementation audit. With Criterion 2 achieving 100% post implementation, this was a significant improvement as compared to 0% in the baseline audit. Criterion 3 achieved 100% compliance, a sustained compliance with a 15% increase. Criterion 4 showed a significant improvement from 14% to 94%. Discussion: This project has led to improvements in clinical based practices related to current evidences. It has resulted in an increased awareness and knowledge on the importance of protected meal times and the rendering of adequate assistance for adult patients with cancer. Conclusion: Utilization of best practices, to ensure adequate nutritional intake for patient, is feasible in an acute setting. Providing mealtime assistance to patients also strengthens the nurse-patient relationship and leads to a more satisfied inpatient experience.

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.