1. Salcido, Richard MD

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If a patient admitted to a long-term-care (LTC) facility develops a new problem or an exacerbation of a preexisting comorbidity, such as pneumonia, and has to be transferred to a hospital for treatment, how likely is it that the LTC facility will face a financial penalty? Not very; although we strive to achieve the best outcomes, it is accepted that many individuals requiring hospitalization or care in the postacute continuum are at risk of developing complications related to their concurrent illnesses.


Now, what if that same LTC patient develops a pressure ulcer instead of pneumonia? Apparently, a different standard would apply: In the current regulatory environment, it is common for LTC facilities to be assessed accreditation and licensing sanctions and to be subject to malpractice and civil lawsuits. Criminal charges are also a possibility: In Hawaii, an individual was convicted of manslaughter when a patient at an adult residential care home died from a pressure ulcer. The state said that the individual had permitted the pressure ulcer to progress and had not sought medical treatment for the resident.1


This does not make sense. Just as we recognize that certain patients in LTC facilities are at increased risk for pneumonia and other medical complications due to their complex comorbidities (eg, diabetes or urinary tract infections), we know that patients who are admitted to a medical facility or who are otherwise bed, chair, or wheelchair mobile are at risk for development of pressure ulcers. I realize that malpractice does occasionally play a role in untoward outcomes such as pressure ulcers. However, it appears that those of us who are wound care specialists are being asked to look into a "crystal ball" and predict which of our patients will develop a pressure ulcer, then take steps to prevent every one of them-or suffer the consequences, financial or otherwise.


Unrealistic Expectations

This is not realistic. True, it is our responsibility to assess the overall health of our patients and determine risk. Unfortunately, our current tools are not infallible; they are not the magic crystal balls that regulatory bodies seem to want us to gaze into with clarity to find the answers.


That is because risk assessment scales were never intended to be the final word in pressure ulcer prediction or to be used as regulatory or punitive measures. Instead, they were formulated to predict the probability-not the certainty-of pressure ulcer development.


The most commonly used clinical judgment tools are the Norton2 and the Braden scales.3 More recently, a simple clinical prediction tool-the Prevention and Pressure Ulcer Risk Score Evaluation (prePURSE)-was developed by Schoonhoven et al.4


The Norton Scale rates patients in 5 subscales: physical condition, mental condition, activity, mobility, and incontinence.2 The Braden Scale uses a scoring system to rate patients in 6 subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.3 The new prePURSE is a clinical scale based on 5 patient characteristics: age, weight at admission, abnormal appearance of the skin, friction and shear, and planned surgery in the coming week.4


The Norton and Braden scales have a reported sensitivity ranging from 70% to 90% and a reported specificity ranging from 60% to 80%.5,6 The Braden Scale shows optimal validation and the best balance of sensitivity and specificity (57.1% and 67.5%, respectively).7 Its score is considered to be a good predictor of pressure ulcer risk (odds ratio = 4.08, 95% CI = 2.56-6.48). The Norton Scale has reasonable scores for sensitivity (46.8%), specificity (61.8%), and risk prediction (OR = 2.16, 95% CI = 1.03-4.54).7


The ideal concept or tool for prediction of pressure ulcers probably can be achieved with a scale based on prospectively (dynamically) gathered data. The recently developed prePURSE scale is based on regression modeling, thus accounting for the mutual associations between predictors.4 Furthermore, the weights assigned to each of the predictors were based on the regression coefficients. Even though the prediction rule has an Area Under the Curve (AUC) of 0.70 (current AUC for other scales varies between 0.55 and 0.61),8 the final proof of its validity should be obtained in a separate group of comparable hospitalized patients.


All of these scales meet the standard of care, are used in common practice in the clinical setting, and have been confirmed as independent predictors for pressure ulcers. Their main purpose is to identify patients at risk; they are not meant to be absolute measures of the health care act.


Limitations, but[horizontal ellipsis]

In fact, risk assessment scales have major limitations for pressure ulcer prediction. For example, most of the studies that involved the scales were performed for scale validation; only a few have tested their clinical effectiveness. The evidence behind the effectiveness of risk assessment scales for decreasing the incidence of pressure ulcers is also very weak.7 In addition, these scales have low interrater reliability, unless the assessment is performed by trained staff.7,9


Despite the limitations, risk assessment scales play an important role in patient care. They augment the intensity and effectiveness of preventive measures and allow the wound care team to generally observe, evaluate, and prevent as many pressure ulcers as humanly possible.


No system or tool-including pressure ulcer risk assessment scales-is infallible. We cannot predict the future when dealing with complex and dynamic human beings with preexisting diseases and comorbid conditions. We do not have the crystal ball that some seem to think we have.




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7. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, Alvarez-Nieto C. Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs 2006;54:94-110. [Context Link]


8. Schoonhoven L, Haalboom JR, Bousema MT, et al. Prospective cohort study of routine use of risk assessment scales for prediction of pressure ulcers. BMJ 2002;325:797. [Context Link]


9. Salvadalena GD, Snyder ML, Brogdon KE. Clinical trial of the Braden Scale on an acute care medical unit. J ET Nurs 1992;19:160-5. [Context Link]