To the Editor:

I know that this letter may ruffle some feathers (no pun intended), but I do feel sometimes as healthcare providers we have our heads in the sand. The May/June issue [2012;39(3)] of the Journal of Wound, Ostomy and Continence Nursing included several articles that I feel are worthy of discussion.

Tescher AN, Branda ME, Byrne TJO, Naessens JM. All at-risk patients are not created equal: analysis of Braden pressure ulcer risk scores to identify specific risks. J Wound Ostomy Continence Nurs. 2012;39(3):282-291.

In the introduction of the article, the authors state, "The use of the Braden Scale as a component of a generalized assessment is intended to identify specific factors known to contribute to skin breakdown and to direct the nurse to preventative and restorative interventions." I totally support this definition. The authors then specify research questions for this study including the following: "1) Given patients equally at risk by total Braden Scale score, what is the difference between those patients who do and do not develop a pressure ulcer? 2) Are there specific factors that place the patients at higher risk for pressure ulcer development?"

A retrospective chart review of 12,566 patients was performed. Regular Braden Scale score assessments were recorded. Analyses were performed on all potential risk factors. Results showed that more than 60% of patients with a baseline Braden Scale score of 6 to 9 developed pressure ulcers during their admission. In other words, every 6 out of 10 very high-risk patients developed pressure ulcers. The article then goes on to say that "the Braden Scale score in isolation was found to be highly predictive of pressure ulcer development."

So let me understand. If the Braden Scale score is highly predictive of pressure ulcer development, does that mean it is predicting that 60% of patients with a Braden Scale score of 6 to 9 will get a pressure ulcer? In fact, that's what occurred. Are we to accept a 60% pressure ulcer rate as a fait accompli? Does this mean we have no influence whether the patient develops a pressure ulcer? In my opinion, the word "predict" has no relationship to the Braden Scale and I do not believe that was ever its intention. In my opinion, the Braden Scale cannot predict. A prediction is what one believes will happen. The Braden Scale can only "assess" risk and, in fact, does so extremely well, but even then it has one major flaw and that is failure to assess the skills of the nursing staff. In my opinion, the level of care delivered has as much or more to do with developing a pressure ulcer as the patient's risk factors. I could not find in the article whether or not each patient's record documented appropriate turning and positioning in the pressure ulcer patients. The article did say, "We did not perform a natural history study without interventions. Our data was based on an active clinical practice where clinicians are incorporating many interventions to reduce risk of pressure ulcer development. The effectiveness of these interventions may have influenced our results." Unless we know exactly what care was given, how can one determine what factors influenced pressure ulcer development. Was it the patient, the caregivers, or both?

Gadd MM. Preventing hospital-acquired pressure ulcers: improving quality of outcomes by placing emphasis on the Braden subscale scores. J Wound Ostomy Continence Nurs. 2012;39(3):292-294.

The first paragraph in the article states, "The aim of the Braden Risk Assessment tool is to predict which patients might develop pressure ulcers with the intention of planning successful preventative patient care." In my opinion, the operative word is "assess." A better measure of predicting the development of a pressure ulcer would be if the patient is being turned and repositioned appropriately based on their risk. The article goes on to say, "Assessment as part of the nursing process should identify patients with nursing problems and guide the nurse to carry out appropriate nursing actions. Implementing evidence-based care is likely to be frustrating for nurses when they do not have the knowledge or resources to support them in a timely manner." I totally agree and this is where the "ostrich syndrome" occurs. We all have to honestly look at what role our care plays in preventing pressure ulcers.

Our patients are sick and very challenging, but are we delivering the best care possible? If all institutions would perform a root cause analysis on every hospital-acquired pressure ulcer, I would suggest that in a very high percentage of cases there were lapses in our care. Let me make it very clear that I work with our hospitals' pressure ulcer prevention collaborative on a regular basis and I appreciate the difficulties nurses face every day. However, in my experience, we still have a lot of work to do in leadership, education, and accountability. The literature proves this point. Almost every journal article that reports on the implementation of a pressure ulcer prevention program shows that the incidence of pressure ulcers decreases. It was not the patients who changed!!!

Kenneth Olshansky, MD

Clinical Professor Plastic Surgery (Ret)

Virginia Commonwealth University

Physician Champion Pressure Ulcer Prevention Collaborative (current)

Bon Secours Hospital, Richmond, Virginia