Optimizing Pressure Ulcer Risk Assessment Tools to Increase the Patient Safety

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Table of Contents

Introduction
Problem statement
Need assessment and description of the project
The significance of the study
Goals and Measurable Outcomes
Problem background
Evaluation criteria for the successful implementation of the project
Literature review, desired solution, and its justification
References

Introduction

Pressure ulcers (PU) in patients of all ages are an extremely urgent problem for medical institutions worldwide. As a rule, a timely risk assessment can prevent pressure ulcers by taking timely preventive measures. Trends in developing pressure ulcers are usually considered as a nursing quality indicator in patient safety. According to scientists, pressure ulcers are a significant health care issue – according to scientists, the overall global prevalence is 6.3%. (1) Other scientists cite an 8.9% prevalence of PU among intensive care units in Iranian medical institutions. (2) Notably, PU is one of the seven most common and costly diseases. (3)

A pressure ulcer is usually determined as “localized damage to the skin and underlying tissue, usually over the protrusion of the bones, as a result of pressure, including shear pressure.” (3) A significant risk factor for PU development is impaired mobility, even in the absence of sensory sensitivity; PU has a severe psychological and physiological effect on the patient. (3) PU is also a factor of increased pain and risk of infection; it raises morbidity and mortality and lowers the quality of patients’ lives, being a source of discomfort and depression.

No less significant is the burden of pressure ulcers on the health system due to patients’ prolonged staying in hospitals and expensive treatment costs. In this way, PU is a national adverse health factor demanding substantial financial costs of medical care and reflecting the decline in the population’s working capacity. According to scientific evidence, the average cost of PU treatment is “from the US $ 12 for Grade I PU to the US $ 66,834 for Grade IV PU.” (2) Considering the facts stated above, it is imperative that 95% of PU can be prevented. The most important preventive measure is assessing the risk of developing PU in patients, which is carried out using various risk assessment scales. Different assessment tools have advantages and disadvantages, but their common goal is to identify a person at risk. (3)

Problem statement

Today, there is a lack of standardized risk assessment tools in the clinical area to help nurses early predict the risk of pressure ulcers. In particular, experts disagree regarding the efficiency of the existing assessment tools, including the Braden scale, Braden scale (ALB), Braden Q scale, Waterlow scale, Ramstadius scale, CALCULATE scale, and COMHON index. Although some scientists recognize the Braden scale’s effectiveness, it is widely believed that the scale requires the introduction of additional assessment factors and must be combined with clinical assessment. Simultaneously, some scientists consider the Braden (ALB) scale to be more effective than the Braden scale, while others say that these scales generally give equivalent results.

Need assessment and description of the project

The gaps in PU assessment were identified based on the literature review and using brainstorming. Besides, the structured questions for nurses were developed by the project team members (Appendix A). Moreover, the project carriers were reviewing the Pressure Ulcer policy and guidelines regarding Pressure Ulcer Prevention. The patient risk factors that may disrupt the needed effect of pressure ulcer risk assessment were considered.

The significance of the study

This Quality Assurance Project is important due to several aspects. Firstly, the prevalence of pressure ulcers among patients can only be eliminated through prevention policy based on using the risk assessment tools. Since various aspects of these tools’ efficiency are widely discussed and criticized by scientists, there is an urgent need to improve the existing risk assessment tools or to develop the new ones. The Braden scale needs particular improvements based on reconsidering the determinants used to make healthcare decisions. The new approach to the Braden scale should be based on more individualized assessment.

In particular, the nurses should ask patients about the list of symptoms that are currently not considered by the scale. Particular attention should be paid to patients with decreased sensitivity and patients with burn injuries. Besides, the Braden scale should be reconsidered in term of pediatric treatment.

Goals and Measurable Outcomes

The general goal is to prevent PUs in the new opening hospital by early prediction of risk patients. Major goals should be reached to narrow down the established gaps, including introducing and implementing an evidence-based Skin Assessment Tool and refining the use of the Braden scale in the facility. Another goal is increasing staff awareness regarding the Braden scale. Two primary goals are defined and should be achieved by the end of this project. The approximate duration of the improvement project is three to six months. The goals will be achieved by developing a new Skin Assessment Tool; the scientific suggestions and evidence will also be used to refine the Braden scale’s use; the handout materials will be developed to increase the staff awareness regarding the Braden scale.

Measurable Outcomes

At the end of this project, the following measurable outcomes will be achieved:

The Braden Scale will be introduced, implemented, and regularly applied to all patients with limited mobility; their status will be shown through a color-coding system.
Level of knowledge among nurses on using the Braden scale will be increased.

Problem background

Scientists acknowledge different instruments for assessing pressure ulcers, and all of these instruments have distinct advantages and limitations. The scientists analyzed the use of various assessment tools, including the Waterlow scale, Braden scale, Braden (ALB) scale, CALCULATE scale, and COMHON index, and found that all these tools must be used with an additional clinical assessment to ensure reliability.

The Braden Scale is commonly used to predict the risk of pressure ulcers, helping health care providers assess the risk of developing pressure ulcers based on six criteria: sensory perception, moisture, activity, mobility, nutrition, friction, and shear. Scientists note that the current application of these categories is insufficient to be the basis for developing effective preventive interventions and suggest use the Braden scale only together with an additional clinical assessment. According to the scientists, this assessment may include a more individualized approach and analysis of patients’ symptoms.

Evaluation criteria for the successful implementation of the project

The project carriers will use the following measurable outcomes:

The refined Braden Scale will be evaluated based on improved patient outcomes.
The new evidence-based Skin Assessment Tool will be evaluated based on improved patient outcomes.

Literature review, desired solution, and its justification

Scientists evaluated the validity and effectiveness of the Waterlow scale and concluded that the scale should be used in conjunction with clinical judgment for maximum effect. (3) Changes were also proposed for implementation in the Waterlow scale, which was previously revised in 2005. According to the new data, additional risk factors were presented, including physique/weight for growth, BMI, skin score, gender, age, urinary retention, mobility, nutrition, medications, tissue malnutrition and neurological deficits, and major surgery or injury. (3)

Other scientists have evaluated the Waterlow scale and Ramstadius scale and concluded that they are of marginal efficacy compared to clinical judgment. (4) Some 1487 people at risk of developing pressure ulcers took part in the studies of 2009 and 2011, analyzed by scientists. (4) It is also noted that part of the risk assessment tools apply to broad groups of patients, while the other part is designed for specific subgroups. (5)

Given this observation, it is possible to add additional assessment factors to the refined Braden scale to apply it to individual subgroups so that all patients are developed into subgroups according to the additional factors outlined above. Then, the researchers concluded that “clinical assessment should always be a key element in patient risk assessment,” and the project adheres to this advice. (5) Scientists also propose an alternative way of developing rating scales to identify risk areas, which may inspire further related projects. (5)

Next, four standard PU risk assessment tools – Braden scale, Braden scale (ALB), CALCULATE scale, and COMHON index – were analyzed and compared in terms of reliability. (6) The study was conducted in Thailand in 2019 and involved 288 people. The Braden scale (ABL) showed the best results, and other scales were placed in descending order of efficiency: CALCULATE scale, Braden scale, and COMHON index. (6)

As with other studies, the researchers concluded that all scales’ effectiveness was limited and should only be used in conjunction with clinical assessment. The Braden Q scale has also been studied in pediatric practice. The researchers concluded that the Braden Q scale “has moderate predictive power with moderate sensitivity and low specificity for pressure ulcers in hospitalized children” and requires further development and modification. (7)

Notably, another study examined the importance of the contribution of symptoms reported by patients in risk assessment. Additional risk factors included age over 80 years, vomiting, severe pain at rest, urinary problems, shortness of breathing, and low albumin levels. The researchers concluded that the additional “use of patient-reported symptoms and standard laboratory results” could improve the risk assessment quality.

This proposal should be considered in the implementation of this project. (8) Next. Several scholars have criticized the validity of the current Braden scale. A study that featured over 1058 patients with PU discovered that “the Braden score has moderate predictive value with good sensitivity and low specificity in critically ill adult patients” and requires further modification. (9) Scientists also note that the Braden scale has mediocre results for risk assessments for burn injury patients and may not be a useful tool for this population. (10)

The Braden scale received positive reviews from scientists who concluded that the Braden (ALB) scale and Braden scale have similar reliability, although the Braden (ALB) scale is slightly more reliable. (11) Other scientists have found that the Braden scale is not valid enough for particular section points based on a study in Spain with 335 patients. (12) It was also noted that the Braden scale is the best predictive tool for intensive care patients with physical impairment. (13) Finally, it was said that the Brayden scale “lacks sufficient constructive validity” for patients in emergency care. (14) Scientists have proposed developing new rating scales based on intelligent data analysis.

Thus, the scientists express contradictory views regarding the effectiveness of the Braden scale risk assessment tool. The most common view is that this scale should be used together with the clinical assessment. Besides, scientists suggest the implementation of more individualized risk assessment that considers symptoms and health conditions. New categories proposed by scholars include physique/weight for growth, BMI, skin score, gender, age, urinary retention, mobility, nutrition, medications, tissue malnutrition and neurological deficits, and major surgery or injury.

References

Al Mutairi, K. B., & Hendrie, D. (2018). Global incidence and prevalence of pressure injuries in public hospitals: a systematic review. Wound Medicine, 22, 23-31.
Zarei, E., Madarshahian, E., Nikkhah, A., & Khodakarim, S. (2019). Incidence of pressure ulcers in intensive care units and direct costs of treatment: Evidence from Iran. Journal of Tissue Viability, 28(2), 70-74.
Charalambous, C., Koulori, A., Vasilopoulos, A., & Roupa, Z. (2018). Evaluation of the validity and reliability of the Waterlow pressure ulcer risk assessment scale. Medical Archives, 72(2), 141.
Moore, Z. E., & Patton, D. (2019). Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews, (1).
Fletcher, J. (2017). An overview of pressure ulcer risk assessment tools. Wounds UK, 13(1).
Theeranut, A., Ninbanphot, S., & Limpawattana, P. (2021). Comparison of four pressure ulcer risk assessment tools in critically ill patients. Nursing in Critical Care, 26(1), 48-54.
Liao, Y., Gao, G., & Mo, L. (2018). Predictive accuracy of the Braden Q Scale in risk assessment for pediatric pressure ulcer: A meta-analysis. International Journal of Nursing Sciences, 5(4), 419-426.
Skogestad, I. J., Martinsen, L., Børsting, T. E., Granheim, T. I., Ludvigsen, E. S., Gay, C. L., & Lerdal, A. (2017). Supplementing the Braden scale for pressure ulcer risk among medical inpatients: The contribution of self‐reported symptoms and standard laboratory tests. Journal of Clinical Nursing, 26(1-2), 202-214.
Wei, M., Wu, L., Chen, Y., Fu, Q., Chen, W., & Yang, D. (2020). Predictive validity of the Braden scale for pressure ulcer risk in critical care: A meta‐analysis. Nursing in Critical Care, 25(3), 165-170.
Griswold, L. H., Griffin, R. L., Swain, T., & Kerby, J. D. (2017). Validity of the Braden scale in grading pressure ulcers in trauma and burn patients. Journal of Surgical Research, 219, 151-157.
Chen, H. L., Cao, Y. J., Zhang, W., Wang, J., & Huai, B. S. (2017). Braden scale (ALB) for assessing pressure ulcer risk in hospital patients: A validity and reliability study. Applied Nursing Research, 33, 169-174.
Lima-Serrano, M., González-Méndez, M. I., Martín-Castaño, C., Alonso-Araujo, I., & Lima-Rodríguez, J. S. (2018). Predictive validity and reliability of the Braden scale for risk assessment of pressure ulcers in an intensive care unit. Medicina Intensiva (English Edition), 42(2), 82-91.
Jansen, R. C. S., Silva, K. B. D. A., & Moura, M. E. S. (2020). Braden Scale in pressure ulcer risk assessment. Revista Brasileira de Enfermagem, 73(6).
Chen, H. L., Cao, Y. J., Shen, W. Q., & Zhu, B. (2017). Construct validity of the Braden scale for pressure ulcer assessment in acute care: A structural equation modeling approach. Ostomy/Wound Management, 63(2), 38-41.

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