Risk assessment scales poorly predict pressure ulceration

Editor—Several fundamental issues around the use of pressure risk scales are highlighted by the article by Schoonhoven et al.¹

These scales are poor predictors of pressure ulcer development, but nurses are encouraged to use them to meet the clinical governance agenda. The guidelines from the National Institute for Clinical Excellence recommend their use as an aide-mémoire, which should not replace clinical judgment.² Nurses should not rely on these scales, but they do at least offer a framework for assessment, unlike clinical judgment. The evidence from the study by Schoonhoven et al is that these tools may have some value in detecting patients who will develop pressure ulcers, but with a high number of false positive responses.

This has resource implications in providing prevention strategies for patients who will not develop pressure ulceration. Using the Braden scale, we calculate that 728 of the 2190 patient weeks (33%) would require measures to prevent 59 ulcers (assuming 100% success in those identified). This would also fail to identify 76 patients who would receive no prevention but who would develop pressure ulceration.

Although identifying patients at high risk is important, having firm evidence on the value of different pressure relieving strategies is equally essential. Few quality trials on the use of pressure relief have been reported in the literature. A trial of a pressure relieving mattress in high risk patients reduced the one week incidence from 65% to 25%, but these trials are rare, and even with optimum care one quarter of patients still developed ulceration.³

With changes in demography, earlier discharge from hospital, the threat of litigation, and an ever higher reliance on community services, nurses and clinicians will need more potent evidence to support their management of patients at risk of pressure ulcer development.