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Critical care is designed for managing the sickest patients within our healthcare system. Multiple factors associated with an increased likelihood of pressure ulcer development have been investigated in the critical care population. Nevertheless, there is a lack of consensus regarding which of these factors poses the greatest risk for pressure ulceration. While the Braden Scale for Pressure Sore Risk is the most commonly used tool for measuring pressure ulcer risk in the United States, research focusing on the cumulative Braden Scale score and subscale scores is lacking in the critical care population. This author conducted a literature review on pressure ulcer risk assessment in the critical care population, to include the predictive value of both the total score and the subscale scores. In this review, the subscales Sensory Perception, Mobility, Moisture, and Friction/Shear were found to be associated with an increased likelihood of pressure ulcer development; in contrast, the Activity and Nutrition subscales were not found to predict pressure ulcer development in this population. In order to more precisely quantify risk in the critically ill population, modification of the Braden Scale or development of a critical care specific risk assessment tool may be indicated.
Pressure ulcers (PUs) are encountered in all care settings, including the intensive care unit (ICU), and are described as perhaps the most underrated condition within this care setting.1 Despite implementation of evidence-based preventive interventions, hospital-acquired PUs continue to be a major healthcare concern. In 2008, the Health Care Cost and Utilization Project cited an 80% increase in PU occurrence between the years 1993 and 2006 in hospitalized adult patients, with total associated costs estimated at $11 billion (US dollars).2 From 2008 to 2009, there was a slight decrease in the overall prevalence of hospital-acquired PUs. Nevertheless, prevalence rates in the ICU remained the highest among hospitalized patients, ranging from 9% to 42%.3-5 In 2009, 3.3% of critical care patients developed deep tissue injuries or stage III, IV, or unstageable ulcers.5
Pressure ulcer prevention has long been a major focus of patient care. Recent changes enacted by the US Centers for Medicare & Medicaid Services restricting reimbursement for hospital-acquired stage III and IV (full-thickness) PUs have heightened awareness and inspired a renewed sense of urgency for successful PU-prevention programs in the acute and critical care settings.6 Despite quality care and best practices, PUs continue to develop in hospitalized patients and the risk is highest among those admitted to an ICU.7-9
The first step in preventing PUs is accurate identification of patients at risk. Traditionally, PU risk measurement has been accomplished through the use of validated PU risk assessment tools such as the Braden Scale for Pressure Sore Risk.10 In the United States, the Braden Scale is the most widely used risk assessment tool across all care settings, and it is recommended for use in multiple current clinical practice guidelines.11,12 While limited evidence suggests that the cumulative Braden Scale score predicts PU risk in critically ill patients, evidence concerning the contribution of the instrument's 6 subscales is especially sparse; only 4 studies were identified that examined the relationship of subscale scores to PU risk in this population.13-16
In addition to the factors assessed via the Braden Scale, a number of other factors prevalent in critically patients have been found to be associated with PU development. They include advanced age,1,4,13,14,17-19 lengths of stay in the ICU of greater than 5 days,1,13,14,18,20 emergent admission to the ICU,18,21 severity of illness measured via the APACHE II scale,1,14,22 and various comorbid conditions including diabetes mellitus, infection, and cardiovascular/vascular disease.13,14,17,19,23 Researchers have also evaluated the influence of iatrogenic factors on PU risk such as the use of vasopressor agents.1,14,23 At present, there is insufficient data to determine the level of risk associated with these factors.
In order to gain a better understanding of the predictive power of the Braden Scale for Pressure Sore Risk in the ICU population, a comprehensive review of the literature was undertaken focusing on the predictive value of the overall Braden Scale score and the individual subscale scores in determining PU risk in the critical care population. The computerized databases of EBSCO-CINAHL and EBSCO-MEDLINE were searched using the terms pressure ulcer, Braden Scale, critical care, intensive care and risk factors. Journal hand searching and ancestry searching were also used as search techniques.
Inclusion criteria established for this review included (1) peer reviewed and published reports on PU risk factors in adult critical care patients that included the Braden Scale and/or subscales as variables and (2) studies conducted from 1995 to present. Exclusion criteria were (1) studies in languages other than English and (2) studies in which interventions for PU prevention in ICU patients were the primary focus.
Nine studies were identified that satisfied inclusion/exclusion criteria.4,13-16,19,24-26 Critical care settings represented in these studies included medical, surgical, medical/surgical, and neurologic ICUs. A summary of the studies included in this review can be found in Table 1.
The Braden Scale for Predicting Pressure Sore Risk10 measures cumulative risk for PU development based on 7 risk factors measured on 6 subscales (Sensory Perception, Activity, Mobility, Moisture, Nutrition, and Friction/Shear) and is based on the conceptual schema developed by Braden and Bergstrom.27 Subscale scores range from 1 to 4 with the exception of the Friction/Shear subscale, which ranges from 1 to 3. Each subscale score is clearly defined by narrative descriptors that assist the clinician to accurately "match" the patient's status to the correct subscale level. Pressure ulcer risk is based on a summated score of 6 to 23, with lower scores indicating greater risk. Currently, a cutoff score of 18 has been found to demonstrate the best balance between sensitivity and specificity; thus, clinically this score represents risk for PU development.28 Some clinicians propose stratification of PU risk, with scores of 15 to 18 indicating mild risk, scores of 13 to 14 indicating moderate risk, scores of 10 to 12 indicating high risk, and scores of 9 or less indicating very high risk.29
The Braden Scale has been subject to the most extensive psychometric testing of all the PU risk tools.30 Initial reliability studies, conducted in skilled nursing facilities, yielded interrater reliability coefficients ranging from r = 0.83 to r = 0.99 (P < .001). In the critical care population, Bergstrom and colleagues31 reported an interrater reliability of r = 0.89 (P < .001).
The predictive validity of a PU risk assessment tool can be assessed using 4 measurements: sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) (Figure 1). Sensitivity refers to the tool's ability to accurately identify patients at risk, and specificity refers to the tool's ability to correctly identify patients not at risk, while PPV and NPV describe the scale's ability to accurately predict patients who will and will not develop PUs.30 In the critical care population, predictive validity was first established by Bergstrom and colleagues,31 who reported 83% sensitivity and 64% specificity, with a NPV of 85% and a PPV of 61%, based on a cutoff score of 16. The Braden Scale has been reported to have performed similarly or better than other risk assessment instruments in various care settings on measures of predictive validity.30,32
A number of studies have used multivariate analyses to evaluate the Braden Scale in the critical care setting. Total Braden Scale score was a significant predictor of PU development in critical care patients in 5 of the 9 studies reviewed.4,13,15,19,24 In 1 study of 347 medical-surgical ICU patients,14 statistically significant lower Braden Scale scores were found between patients who developed a PU and patients who did not develop a PU (Braden Scale score 13 vs 15, respectively). In another study of 85 medical-surgical ICU patients,16 the investigators reported a statistically significant difference in Braden Scale scores between patients who did and did not develop PUs; however, specific scores were not reported. Wolverton and colleagues26 found lower Braden Scale scores in their sample of 422 critical care patients who developed PUs; however, their analysis was limited to descriptive statistics. In contrast, a study of 40 medical ICU patients25 found no significant difference in Braden Scale scores between patients who did and did not develop PUs.
Cumulative scores on the Braden Scale in critically ill patients varied from 9.8 to 15, indicating moderate to high risk.13,14,15,19,25 The timing of the Braden Scale assessment varied across the studies. In 3 studies, the Braden Scale score was obtained at the time of admission to the ICU.14,16,24 The timing of the scores in other studies included cross-sectional measurements at the time of data collection,4,13 mean Braden Scale scores recorded multiple times,15 and lowest Braden Scale score recorded during the ICU admission.25 One study did not report when the Braden Scale score was calculated.19
In the studies reviewed, only 1 group of investigators provided data regarding interrater reliability. Jiricka and coworkers16 reported IRR measurements ranging from 88% to 92%; their study involved 85 medical-surgical ICU patients. Unfortunately, they provided neither any explanation for the range in IRR nor any description as to how these data were obtained. No other studies reported measures of reliability in the published reports.
Measurements of predictive validity, including sensitivity, specificity, and NPVs and PPVs, were reported in 2 of the 9 studies in this review.14,16Table 2 provides a summary of studies reporting the predictive validity of the Braden Scale in adult critical care patients and contains the 2 studies included in this review,14,16 the initial study on the predictive validity of the Braden Scale in the ICU population by Bergstrom and colleagues,31 and 2 additional studies33,34 that focused exclusively on psychometric testing of PU risk assessment scales in the critical care population.
While the majority of patients across all study samples fell below the established level of 18 and were, therefore, considered "at risk," the vast majority of patients remained PU free. In one study of 369 surgical ICU patients,19 99.5% of the sample fell into the at-risk range (Braden Scale score # 18), with 60% of the sample reporting as high risk or very high risk. However, the incidence of PU development was only 24%. In a second study of 347 medical/surgical ICU patients,14 94% of the patients were classified at risk, with 44% of the sample found to be at high risk or very high risk, but the reported incidence was 18.7%. Wolverton and associates26 evaluated 422 patients in a medical/surgical ICU; they identified 92% as being at risk for PU, including 41% at high or very high risk, but the reported incidence of PU was 14%. This "overprediction" may represent a flaw in the risk assessment tool or it may reflect the positive effects of PU-prevention measures; this issue will be addressed in greater detail.
Four studies13-16 evaluated Braden subscales (Table 1). Sensory perception is defined as the ability of the individual to perceive and respond to discomfort as a result of exposure to pressure.10 Examination of evidence reveals variability in reported influence of this subscale on PU development. Two studies15,16 reported that the Sensory Perception subscale was a significant predictor of PU development. In a third study,14 the Sensory Perception subscale was significantly associated with PU development in a bivariate analysis; however, this subscale did not emerge as a significant predictor in a multivariate analysis. In contrast, a fourth study found no statistically significant relationship between the Sensory Perception subscale and PU development.13
Braden and Bergstrom27 define altered mobility as a diminished ability to change and control body position, which increases the potential for exposure to prolonged and intense pressure. Two studies found the Mobility subscale score to be predictive of PU development.13,14 Conversely, 2 studies did not find this subscale to be significantly associated with PU development in either bivariate or multivariate analyses.15,16
Diminished levels of activity (bed-bound or chair-bound status) influence the duration and intensity of pressure experienced by patients and can contribute to pressure ulceration.27 None of the 4 studies reporting Braden subscale scores found the Activity subscale to be associated with PU development.
Braden and Bergstrom10 state that increased maceration of the skin due to exposure to urine, stool, wound, or fistula drainage increases its susceptibility to pressure ulceration. Two studies13,16 found the Moisture subscale to be predictive of PU development, and 2 studies14,15 found no association between the Moisture subscale and PU development.
The Nutrition subscale is intended to reflect the individual's nutritional intake.27 Nutritional deficiencies lead to hypoproteinemic states and protein-calorie malnutrition, which can alter the ability of the skin to tolerate prolonged exposure to pressure and increase the risk for pressure ulceration. Cox14 evaluated the contributions of the Braden Scale and subscales in a study of PU risk factors in 347 medical-surgical ICU patients. While the Nutrition subscale was found to be significantly associated with PU development in a bivariate analysis, this subscale was not a significant predictor of PU development in a multivariate analysis in this sample of ICU patients. While this is the only ICU study to find a significant bivariate relationship between the Nutrition subscale and PU development, no studies examining the Braden subscales found this subscale to be a significant predictor of PU development in this population.
The Friction/Shear subscale measures 2 conceptually distinct yet interrelated risk factors. Braden and Bergstrom27 define friction as the force that results when 2 surfaces move across each other such as occurs from dragging a patient to change position. Shear is defined as a force created by the interplay of gravity and friction, resulting in damage at the deeper fascial levels.35 While Jiricka and colleagues16 found a significant association between the friction/shear subscale and PU development, Cox14 found this subscale to be a significant predictor of PU development in this population.
Considered collectively, findings from these studies provide evidence that the cumulative Braden Scale score is a significant predictor of PU risk in the critical care setting. The Braden Scale is associated with lower specificity and PPV scores, indicating a tendency to overpredict PU development. Analysis of critically ill subjects reveals that virtually all had a Braden Scale score of 18 or less, but the majority did not develop a PU. Overprediction of PU incidence is often criticized as a limitation shared by all of the validated PU risk assessment instruments.30
There are 2 potential explanations of the comparatively low positive predictive scores reported in the studies under review. Administration of the Braden Scale may have accurately identified patients at risk for PU, resulting in the aggressive implementation of preventive strategies. Alternatively, it might be that the Braden Scale failed to adequately differentiate risk magnitude, resulting in the implementation of unnecessary and potentially costly preventive interventions. Based on current evidence, it is not possible to determine which of these explanations is most accurate. Thus, caution is recommended when considering a risk assessment scale's predictive ability, because the prevention strategies triggered by identification of a patient "at risk" can substantially reduce the risk of PU development.36
Another factor that may have influenced the predictive validity of the Braden Scale is the timing of assessments within the individual studies. Some studies based findings on a Braden Scale score obtained at admission, while others based findings on a single measurement or multiple measurements obtained over time. The Braden Scale score obtained on admission is critical from a clinical perspective, because it enables prompt identification of risk and early implementation of prevention strategies. Basing statistical analysis on a Braden Scale score obtained at admission provides a consistent point in time of measurement for all subjects in a given study; however, it reflects only 1 risk assessment during the ICU admission and does not capture variability in patient and risk status throughout the ICU stay. Basing results on a cross-sectional approach reflects risk scores obtained at various points during patients' ICU admission and results in a single measurement obtained at different points during subjects' ICU course. Analysis based on a single score measured on admission or in a cross-sectional analysis does not take into account the variability in the acuity of illness experienced by critically ill patients during an ICU admission, which can impact PU risk. Using multiple measurements over time for a statistical analysis has the potential advantage of capturing fluctuations and trends in patients' clinical condition and subsequent changes in PU risk status. This approach minimizes the potential for use of a single aberrant risk score in data analysis that may occur with other study designs. Due to the variability in approach to Braden Scale measurement in these studies, the ability to translate the findings into the clinical arena is hampered. Perhaps future investigators could use a multiple measurement approach; such an approach may enhance our ability to determine the true predictive validity of the Braden Scale. Consistent application of this approach may also provide clinicians with empirical evidence regarding the optimal point or points in time for PU risk assessment in the ICU population.
Evidence regarding the contributions of the individual subscales to PU incidence in the critical care population is especially sparse and study findings are mixed. In the studies retrieved in this review, 4 subscales (Sensory Perception, Mobility, Moisture, and Friction/Shear) demonstrated varying degrees of predictive value based on a multivariate analysis, and 2 (activity and nutrition) did not prove predictive in any study. Determining the relative contributions of each of the subscales to overall risk is significant because it helps identify which preventive interventions are most appropriate for an individual patient. In the current era of heightened fiscal accountability, implementation of risk-appropriate preventive measures is indicated in order to ensure the best possible clinical and economic outcomes.
The Braden Scale Sensory Perception subscale was found to be a significant risk factor in 2 of the 4 studies that examined the predictive validity of this subscale.15,16 These findings are consistent with current clinical practice guidelines,12 which emphasize the significance of sensory impairment and recommend that clinicians implement preventive measures for patients who score low on the Sensory subscale, even if the total score does not indicate significant risk.
The Activity subscale did not emerge as a significant risk factor in any of the 4 studies that evaluated subscales, but 2 studies13,14 reported that the Mobility subscale was a significant predictor of PU development. Though clearly associated with mobility, activity is defined as the patient's overall level of physical activity and ranges from bed-bound to ambulatory.10 Since most critical care patients are bed-bound, this subscale has limited discriminating value when applied to a critically ill population. Mobility takes into account the patient's ability to move independently while confined to bed. Therefore, it may provide a more accurate representation of the critically ill patient's ability to adjust his or her position to redistribute pressure and prevent ischemia and ulceration. The Braden subscales of Mobility, Activity, and Sensory Perception represent related yet conceptually distinct risk factors.10,12 In the clinical setting, especially in the ICU population, these 3 risk factors (altered mobility, diminished activity, and impaired sensory perception) frequently coexist; thus, it can be difficult to determine the degree to which each individual factor contributes to overall PU risk.
The Moisture subscale was found to be a significant predictor of PU development in 2 studies that enrolled critical care patients,13,16 although a third study found no association.14 Two studies conducted in the critical care setting found that fecal incontinence was an independent predictor of PU development.1,4 Exposure of the skin to urine and stool is linked to an increased risk for incontinence-associated dermatitis,37 and both may be managed by indwelling devices in the ICU. Indwelling urinary catheters are common among critically ill patients, especially since they are also used to provide an accurate measurement of urine output. Indwelling fecal containment devices were introduced in 2004 and have gained popularity in clinical practice among critically ill patients, although they are less widely used than urinary catheters. Preliminary evidence suggests that selective use of these devices, combined with an evidence-based PU-prevention program, may decrease PU incidence among ICU patients exposed to high levels of moisture from liquid stool.38
The Nutrition subscale was not predictive of PU development in any study retrieved for this review. The Nutrition subscale measures the patient's usual food intake. Because of the acuity of their illness, most ICU patients are unable to provide a dietary history, which limits the predictive value of this subscale in this population. Sparse evidence suggests that alternative techniques for measuring the nutritional status of critically ill patients may prove more predictive. For example, body mass index and the number of days without nutrition have been reported as significant predictors of PU incidence in the ICU population.18,24 At this point, we need more data in order to identify the best physiologic indicator of nutritional status in the critically ill patient.39 Commonly used biomarkers such as body weight, albumin, prealbumin, and lymphocyte counts are of limited value due to the intravascular fluid shifts that are common in critical care patients and that significantly influence both weight and laboratory values. In addition, evidence linking nutritional status to PU risk is mixed, and additional research is needed to more precisely define the nature of this relationship.12,40
The Friction/Shear subscale is included in the Braden Scale because each of these forces can cause significant damage to the skin and soft tissue. Friction damages the epidermal and dermal layers of the skin, while shearing forces cause angulation and deformation of the blood vessels at the fascia level. Shear forces have been hypothesized to cause much of the damage associated with full-thickness pressure ulceration.35 The Friction/Shear subscale emerged as a significant predictor of PU development in 1 study.14 Many ICU patients require prolonged head-of-bed elevation for prevention of ventilator-associated pneumonia and/or to prevent aspiration in patients receiving enteral feedings; head-of-bed elevation predisposes the patient to significant shearing forces. Research evaluating the effects of prolonged head-of-bed elevation on PU incidence is warranted in an effort to better understand the effects of shear forces on skin and tissue integrity.41
The results of these studies suggest that the clinical utility of the Braden Scale may be limited. Most critically ill patients are deemed at risk for PU development when assessed using the Braden Scale, and it is not yet known whether the comparatively low predictive values represent the success of preventive interventions or failure of the tool to accurately differentiate between patients who are at risk and those who are not at risk. In addition, there are factors unique to the critical care population that may increase their risk for PU development, such as the use of vasopressor agents, prolonged ICU admissions, and comorbid conditions; further investigation is needed to determine their contribution to PU risk. If these factors are found to be predictive of PU development in this population, they should be incorporated into a setting-specific, validated risk assessment tool.1,13,14,17-20,23 Other factors such as advancing age and low arterial pressure were hypothesized to be related to PU development by Braden and Bergstrom, even though they ultimately were not included in the Braden Scale for Pressure Sore Risk.27 A growing body of evidence suggests that advancing age increases the likelihood of PU development in the critical care population,1,4,13,14,17-19 whereas studies to date have not shown low arterial pressure to be a risk factor for PU development in this population.14,19,23,25,42
The findings of this review reveal multiple opportunities for additional research including development and testing of a PU risk assessment tool specific to the critical care population, either a modified Braden Sale or a newly developed tool. There is precedence for development of a modified Braden Scale; the Braden Q Risk Assessment Tool is a modified and validated version of the Braden Scale that includes the 6 Braden subscales and an additional subscale measuring tissue perfusion and oxygenation; it is designed for use in the pediatric population.43,44
Modification of the current Braden Scale may help to more accurately identify critical care patients who are at significant risk for PU development. Redefining the various levels within the subscale definitions so that they are relevant to the critical care population may be one potential option. The inclusion of other empirically supported critical care risk factors such as advanced age, prolonged ICU length of stay, comorbid conditions, or vasopressor use should undergo further investigation to determine whether their inclusion might enhance the predictive power of such an instrument in the critical care setting.
Pressure ulcer risk assessment scales, including the Braden Scale, tend to overpredict risk; as noted, this may be due to an inherent weakness in the tool itself or may reflect the effectiveness of currently used prevention protocols.30 The majority of ICU patients in this review were found to be at risk for PU development based on the Braden Scale score but did not develop a PU; it is unknown whether this represents true overprediction or is the result of preventive care. In the first scenario, overprediction may be the result of an intrinsic weakness of the scale and results in the unnecessary implementation of prevention protocols, which could impact healthcare costs. In this case, the refinement or development of a scale that better measures PU risk in the population would be warranted. In the second scenario, the apparent overprediction may reflect the successful implementation of PU-prevention protocols; identification of the patient as being "at risk" triggered preventive care that actually prevented PU occurrence. Clinically, the second scenario validates the benefits of a comprehensive PU-prevention program. Since withholding PU-prevention strategies would be unethical, it is impossible to conduct a study to definitively determine whether the apparent overprediction is true overprediction or the result of effective care. In clinical practice, the consequences of underprediction would far outweigh the costs of overprediction.30
An in-depth analysis of "at-risk" critical care patients who develop a PU despite prevention strategies compared to "at-risk" critical care patients who do not develop a PU may be of benefit. Such an analysis might provide insight into the risk factors that contribute to PU development in this population that are not measured by the Braden Scale and could provide empirical evidence for the development of a critical care risk assessment scale or a modified Braden Scale. Such a study might also provide valuable clinical information regarding the effectiveness of the PU-prevention program. Development of a PU in a patient who has been identified as "at risk" and placed on a prevention protocol may represent some failure or gap in the PU-prevention protocol or may represent an unavoidable ulcer.
The purpose of all PU risk assessment scales is to predict PU risk and subsequently mobilize clinicians to implement prevention strategies that will impede PU occurrence. Thus, the determination of the predictive validity of a PU risk assessment scale cannot be made in isolation from the prevention strategies that are implemented. However, it is possible that a risk assessment tool designed specifically for the critical care population could help eliminate true overprediction and to more accurately identify patients who need preventive care; thus, further research in this area is warranted.
Research indicates that critically ill patients who develop PUs are classified as at risk by the Braden Scale, and that most of the critical care patients who did not develop PUs were also classified as at risk. At present, we do not know whether this discrepancy reflects the success of preventive interventions or inadequate discrimination of risk. While the subscales Sensory Perception, Mobility, Friction/Shear, and Moisture have demonstrated predictive ability in critical care patients, the paucity of empirical investigations precludes our ability to draw definitive conclusions regarding the relative contributions of each of these subscales to PU risk detection and PU development. Modification of the Braden Scale or development of a critical care PU risk assessment scale might improve our ability to accurately identify at-risk patients in this population and should be addressed in future studies.
* Limited clinical evidence suggests that the cumulative Braden Scale score is a predictor of PU development in adult critical care patients.
* Evidence concerning the contribution of Braden Scale subscales is sparse, and findings are mixed in the critical care population.
* Limited evidence suggests that the Sensory Perception, Mobility, Moisture, and Friction/Shear subscales are predictors of PU development in the critical care population.
* Modification of the Braden Scale or development of a critical care specific risk assessment tool might improve our ability to accurately identify "at-risk" patients in the critical care setting.
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