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Reducing Pressure Ulcer Incidence through Braden Scale Risk Assessment and Support Surface Use

Edward H. Comfort, PhD

The past several years have seen an accumulation of evidence

that pressure ulcer incidence in hospitals can be reduced

markedly—in a number of cases nearly to zero—using risk

assessment based on the Braden Scale. Several hospitals, cited

in this article, have published results of internal studies

demonstrating the benefits, including cost savings, of placing

high-risk patients on specialized support surfaces upon

admission, without waiting for Stage I or II pressure ulcers to

develop. This study analyzes these results to arrive at a valid

statistical measure of the incidence reduction to be expected by

hospitals undertaking to implement such a policy.

INTRODUCTION Pressure ulcers are a significant cause of death in hospitals,1

although the recorded cause of death often disguises this fact.

Redelings et al1 conclude, ‘‘pressure ulcers are associated with

fatal septic infections and are reported as a cause of thousands

of deaths each year in the United States.’’ However, these

figures are likely to be very low because, even in those cases

where pressure ulcers were an important contributing factor,

they are often unlikely to be listed as a cause of death.1

Despite the efforts of many people and organizations, the

prevalence of pressure ulcers in hospitals remained unchanged

at about 16% over a 6-year period from 1999 through 2004.2

The incidence of pressure ulcers in acute care facilities has

varied between 7% and 9% over the same period.2 During that

6-year period, about 70% of individuals older than 65 years

with pressure ulcers also developed new pressure ulcers.2

The Braden Scale3 was developed in 1988 as a means of

assessing the degree of risk of pressure ulcer development any

individual patient faces. Six factors are considered: sensory

ADVANCES IN SKIN & WOUND CARE & VOL. 21 NO. 7 330 WWW.WOUNDCAREJOURNAL.COM

ORIGINAL INVESTIGATION

Edward H. Comfort, PhD, is Executive Director at the National Decubitus Foundation, Aurora, CO. Submitted on July 5, 2006; accepted in revised form on April 17, 2007.

ABSTRACT

OBJECTIVE: To collect available evidence showing that some

hospitals have been able to markedly reduce pressure ulcer

incidence despite broad surveys in previous recent years that

demonstrated little or no progress and to provide guidance to

hospitals through analysis of the evidence showing incidence

reduction to be expected by taking the measures indicated.

APPROACH: At the time of the article’s writing, a review of the

literature was conducted using PubMed. References were sought

that cited hospitals using the Braden Scale to identify at-risk

patients and providing pressure-reducing surfaces to those found

to be at risk. Nine hospitals were so identified. Each hospital

had reduced pressure ulcer incidence through risk assessment

followed by intervention that included support surface provision.

Statistical measures were used to establish confidence limits for

the noted improvements.

INTERVENTIONS: Each of the hospitals reviewed had imple-

mented a policy of risk assessment of all admitted patients using

the Braden Scale followed by implementation of best practices,

generally including assignment of patients judged to be at risk to

a pressure-reducing support surface.

MAIN OUTCOME MEASURES: Each hospital reported in the

literature a rate of nosocomial prevalence, both before and

after program implementation. All hospitals demonstrated

improvement, although the amount of improvement varied widely.

MAIN RESULTS: Realizing that each of the hospitals reviewed

started from different baselines, used different at-risk criteria,

did not utilize the same support surface, and may have

implemented a variety of additional interventions, it is perhaps not

surprising that the 95% confidence interval for incidence odds

ratio is broad, from 0.220 to 0.508 (meta-analysis), yet clearly

significant. Cost savings due to reduced need for rental of

expensive low-air-loss- or fluidized-bed therapy were reported.

CONCLUSIONS: Risk assessment of all admitted patients followed

by provision of specialized support surfaces to all deemed to be

at risk offers real hope of reducing the present very high rate of

hospital-caused pressure ulcers. With the growing understanding

that some pressure ulcers have their origin in deep tissue, it no

longer makes sense to wait for the appearance of Stage I or II

ulcers before taking action.

ADV SKIN WOUND CARE 2008;21:330 – 4

perception, moisture, activity, mobility, nutrition, and friction/

shear. A score is assigned for each factor; factor scores can be

added to arrive at a total score.

The US Department of Health and Human Services

published the first edition of the Agency for Healthcare

Research and Quality (AHRQ [formerly the Agency for Health

Care Policy and Research, AHCPR]) Clinical Practice Guideline

Number 3 in 1992.4 This guideline, developed by the Panel for

the Prediction and Prevention of Pressure Ulcers in Adults,

states that ‘‘individuals should be assessed on admission to

acute care. . .using a validated risk assessment tool such as the

Braden Scale. . . .’’4 The guideline further states, ’’Anyone

assessed to be at risk should be placed on a pressure-reducing

device when lying in bed. . ..’’4 Although relatively few

hospitals have fully implemented these guidelines, this article

describes the results obtained by those hospitals that have

done so and have reported their results in the literature.

In addition to reducing pressure ulcer incidence, many

facilities in the study were able to reduce costs because the

support surfaces capable of preventing ulcers are far less

expensive than those required5 to facilitate healing once a

Stage IV pressure ulcer has been allowed to develop.

Prevention is always the best approach.

METHODS An online literature search was conducted on PubMed, using

keywords such as ‘‘Braden’’ and ‘‘support surface.’’ Those

studies describing trials at acute care facilities that included

factors of risk assessment and support surface assignment were

selected. The outcomes achieved by the facilities identified

during the literature search were reviewed. The summaries of

results that follow do not, of course, include detailed data,

analysis, or costs for each reported trial; cited references should

be consulted for further information. Although some facilities

presented results both including and excluding Stage I pressure

ulcers, the data inclusive of all pressure ulcers have been used

here. Each of the studies included here reported on the effect of

actions taken on the occurrence of hospital-caused pressure

ulcers. Terminology differed among institutions, but the most

common nomenclature used was nosocomial prevalence,

referring to the number of ulcers found upon survey at a point

in time that had not been present at admission. Nosocomial

prevalence rate (incidence) refers to nosocomial ulcers divided

by beds surveyed.

A 500-bed acute care facility in California6 placed all admitted

patients in its 44-bed AIDS/oncology unit on the ZoneAire7

support surface (Hill-Rom Inc, Batesville, IN) during a 6-month

trial in 1995. This was an initial trial to confirm the efficacy of

the support surface. Monthly surveys on 9 occasions before the

trial showed a total of 12 nosocomial ulcers. The incidence of

ulcers during the trial period, which consisted of 7 monthly

surveys from April 1995 through November 1995, and another

unannounced survey in May 1996, was zero. Risk assessment

tools were not used during the period of the study, but since

mid-1996, the Braden Scale evaluation has been used in the

500-bed hospital to determine which admitted patients are

placed on the new beds. Purchase of the ZoneAire beds allowed

an 83% reduction in rental costs for low-air-loss therapy.

A major university medical center8 replaced its hospital beds

at the end of 1995 and in early 1996. A newly available interface

pressure-reducing support surface was chosen. In September

1996, after all of the new beds were in place, a survey of 262

patients found the rate of nosocomial ulcers to be 6%. This

compares with rates of 19% and 21% in 2 preprotocol surveys

(February 1992 and February 1995).

Another university hospital9 conducted 1-day surveys of its

750-bed hospital in 1993, 1995, and 1997. The prevalence rate

of nosocomial ulcers was 14% in 1993, 8% in 1995, and 6%

(3% excluding Stage I) in 1997. Risk assessment based on the

Braden Scale was introduced during the 1997 study for every

hospitalized patient. Improved survey results were thought to

be, at least in part, because ‘‘support surface selection criteria

were developed and consistently applied, and the hospital

purchased several pressure-relieving beds in order to reduce

cost and ‘‘waiting times for rental beds.’’9

An acute care hospital in Hawaii implemented a program of

risk assessment followed by support surface assignment in

1996.10 The nosocomial pressure ulcer prevalence rate in this

159-bed acute care facility was found to be 31.4% (25.7%

excluding Stage I) during a 1995 survey. During the first quarter

of 1996, the Braden Scale was implemented as the risk

assessment tool of choice at the hospital. New ZoneAire

pressure-reducing support surfaces were purchased. Those

admitted patients who were judged to be at risk were placed on

the beds. The nosocomial prevalence rate was reduced to

14.9% (5.9% excluding Stage I) in October 1996 and to 4.7%

(1.5% excluding Stage I) in September 1997.10

A Texas hospital11 conducted the first in an annual series of

pressure ulcer–prevalence surveys during 1996. This survey

found the prevalence rate of hospital-acquired ulcers to be

18%, or 158 patients. Nosocomial prevalence rates dropped to

10%, or 183 patients, in 1997 and to 9%, or 157 patients, in

1998. Although the authors stated that risk assessment using

the Braden Scale and a ‘‘specialty mattress/bed protocol’’ were

in place before the 1996 survey, they speculated in this article

that the designation of unit skin care resource nurses following

that survey led to greater care and emphasis in the

implementation of these practices.

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ORIGINAL INVESTIGATION

A 500-bed hospital in Illinois12 implemented the AHCPR

Guidelines in 1998. Risk assessment through use of the Braden

Scale was instituted. A measure of incidence was chosen as the

preferred indicator of the effectiveness of prevention strategies

to reduce nosocomial pressure ulcers. Data collection was

initiated through participation in the 1998 KCI/Novation

National Prevalence and Incidence Study.13 Because the

average length of stay at this hospital was 4.8 days, a second

survey was taken after 5 days to obtain the data needed to

calculate incidence. After 1 year, pressure ulcer incidence

decreased from 14% to 9%.

A teaching hospital in Georgia reported14 the success of its

wound care program in 1999. Prevention protocols, including

the use of the ZoneAire support surfaces throughout the

hospital, resulted in the reduction of the nosocomial prevalence

rate from 16.5% to 3.5%. The reduction was from 9.5% to 1.2%

excluding Stage I ulcers.

Young et al15 described a successful attempt to reduce

nosocomial pressure ulcer incidence at an 877-bed tertiary

teaching hospital in Florida. The prevention program was

initiated in January 2000. ‘‘The first and primary responsibility

was to identify high-risk patients without pressure ulcers. At-

risk individuals were identified by the Braden Score.’’ During

the 2000–2001 period, 97% of patients received an initial skin

assessment within 24 hours of admission. This project was

successful in reducing the incidence of nosocomial ulcers

between 1999 and 2001 by 55% including Stage I ulcers and by

50% when Stage I ulcers were excluded.

A 243-bed acute care medical center in Pennsylvania16

replaced traditional foam mattresses throughout the hospital

with a new support surface, Isoflex (Gaymar Industries Inc,

Orchard Park, NY), designed to reduce pressure and shear. The

hospital has a policy of assessing patient risk of developing

pressure ulcers using the Braden Scale upon admission. In

1999, an audit of 108 patients found the prevalence rate of

nosocomial ulcers to be 5.5%. A similar audit of 128 patients in

October 2000, 3 months after implementing the new support

surfaces, found the prevalence rate of hospital-acquired

pressure ulcers to be 3.1%. The number of ulcers Stage II and

above decreased dramatically from 8% to 2%.16

RESULTS Each of the aforementioned hospitals undertook a program of

risk assessment followed by action directed at all admitted

patients as of a definite time. Although the key action

undertaken was not exactly the same in all cases, for the most

part, provision of a specialized support surface was involved.

Table 1 illustrates the nosocomial prevalence rate reported at

each hospital before and after instituting such a program.

Each of the studies identified by the initial literature review

reported on a procedure whereby risk assessment of all

admitted patients based on the Braden Scale was implemented

at a point in time. Analysis of these results involves combining

studies with much in common, but involving a wide range of

patient populations. Meta-analysis is the statistical procedure

that allows conclusions to be drawn by combining several

similar studies. A weighted procedure gives more importance

to the results of large studies than to small ones.

Table 2 presents the results of meta-analysis of the 9 studies

considered in this investigation. Columns designated ‘‘control’’

present survey results at each hospital before implementing risk

assessment, whereas ‘‘treated’’ columns show nosocomial

prevalence after risk assessment was in place. The key statistic

presented is the odds ratio. The odds are the number of

patients developing pressure ulcers divided by the number who

did not. The odds ratio is then the odds ‘‘after’’ (treated)

divided by the odds ‘‘before’’ (control). If the procedure being

tested made no difference, the odds ratio would be 1.

The analysis was performed using the random-effects

model, rather than the fixed-effects model, thus avoiding the

restrictive assumption that if all studies considered were

sufficiently large, then they would give the same results. The

upper and lower limits on the odds ratio are presented at

a confidence level of 95%. These limits do include the null

value of 1 for 2 of the included studies, but the combined

results give the odds ratio as falling between 0.220 and 0.508.

Because these limits do not include the null value of 1, the

procedure being tested is statistically significant at the 95%

confidence level.

The programs put in place by the hospitals discussed above

were not precisely the same. Some placed more emphasis on

providing specialized support surfaces to at-risk patients than

Table 1.

NOSOCOMIAL PRESSURE ULCER PREVALENCE RATE BEFORE AND AFTER PROGRAM IMPLEMENTATION

Study Name Year Action Taken Before After % Reduction

Santa Clara 1996 Support Surface 3.6 0.0 100 Stanford 1996 Support Surface 20 7 65 Allegheny 1997 Various, incl. Bed 8 6 25 Straub 1996 Support Surface 31.4 4.7 85 Scott & White 1997 Support Surface 18 9 50 Trinity 1998 Guideline No. 3

4 14 9 36

Robert Packer 1999 Support Surface 5.5 3.1 44 Augusta 1998 Support Surface 16.5 3.5 79 Tampa 2000 Best Practices * * 55

*Data not provided.

ADVANCES IN SKIN & WOUND CARE & VOL. 21 NO. 7 332 WWW.WOUNDCAREJOURNAL.COM

ORIGINAL INVESTIGATION

did others, and some had more elements of a risk assessment

program already in place when they conducted the ‘‘before’’

surveys than did others. These results indicate that hospitals

that put in place a similar program can expect to reduce the

odds that a patient will develop a pressure ulcer by somewhere

between a factor of 2 and 5.

DISCUSSION Clearly, all hospitals should be performing risk assessment on

all admitted patients at the time of admission, and all patients

found to be at risk should be immediately placed on a support

surface that has been demonstrated to significantly reduce

pressure ulcer incidence when an ulcer is not already present

(eg, ZoneAire). However, on an even more fundamental level,

the results of such a risk assessment must be shared with the

patient and the patient’s family. The risk of pressure ulcer de-

velopment in hospitals is very high, especially for older adults.

The federal Centers for Medicare and Medicaid Services

announced in August 2007 that as of October 2008 it will no

longer reimburse hospitals for treating 8 ‘‘reasonably prevent-

able’’ conditions if absent at admission. Pressure ulcers are

among the most prevalent on the list. Hospitals therefore have

significant financial incentive to take every possible step to

prevent pressure ulcers.

At-risk patients and their families must be advised of the im-

portance of frequent repositioning, good nutrition, and avoidance

of friction and shear before any sign of a pressure ulcer develops.

The support surface may not need to be an expensive high-

technology design to achieve promising results. Xakellis et al,17

working at a 77-bed long-term care facility to implement the

AHRQ guidelines,4 provided inexpensive 2- and 4-in foam

overlays to those patients determined to be at risk based on

Braden Scale assessment. They used a staged approach

providing overlay alone, turning schedule alone (none had

been in place before protocol implementation), or both turning

schedule and overlay, depending on the level of risk identified.

This approach was successful in reducing the 6-month

incidence rate from 23% preprotocol (16 of 69) to 5%

postprotocol (3 of 63).

The National Pressure Ulcer Advisory Panel (NPUAP) con-

vened a consensus conference in 2005 to deal with the issue of

deep tissue injury.18 One stated conclusion was that ‘‘deep tissue

injury due to pressure exists as a form of pressure ulcer and is

not well captured by current staging.’’ Following this conference,

in February 2007 the NPUAP added 2 stages to the original 4.

One of these is labeled, ‘‘Suspected Deep Tissue Injury.’’

An engineering text,19 based on analysis of stress distribu-

tion in the vicinity of a bony prominence, concludes, ‘‘There-

fore, pressure sores likely begin in the deep tissue.’’

CONCLUSION Realization that most, if not all, pressure wounds have their

origin in deep tissue explains why the practice followed by

most hospitals of providing a specialty support surface only

after the appearance of Stage I or II indicators has so often met

with failure. Clearly, the only policy with any hope for success

must include the provision of pressure-reducing support

surfaces to all at-risk patients at admission, before the

appearance of any pressure wound indicator. This article has

demonstrated that such a policy significantly reduces pressure

ulcer incidence in hospitals.& REFERENCES 1. Redelings M, Lee N, Sorvillo F. Pressure ulcers: more lethal than we thought? Adv Skin

Wound Care 2005;18:367-72.

2. Whittington K, Briones R. National prevalence and incidence study: 6-year sequential

acute care data. Adv Skin Wound Care 2004;17:490-4.

3. Braden BJ, Bergstrom N. Clinical utility of the Braden Scale for predicting pressure sore

risk. Decubitus 1989;2:44-51.

4. Panel on the Prediction and Prevention of Pressure Ulcers in Adults. Pressure Ulcers

in Adults: Prediction and Prevention. Clinical Practice Guideline, No. 3. AHCPR

Publication No. 92-0047. Rockville, MD: Agency for Health Care Policy and Research;

May 1992.

5. Comfort EH. Support surfaces for bedsore healing: correlation of engineering analysis

with clinical results. Presented at the 14th Annual Clinical Symposium on Wound Care;

September 30 to October 4, 1999; Denver CO. Poster 73.

6. Jacksich BB. Pressure ulcer prevalence and prevention of nosocomial development: one

hospital’s experience. Ostomy Wound Manage 1997;43:32-40.

7. Hill-Rom Corp. ZoneAire sleep surface: system performance evaluation. Batesville, IN;

Hill-Rom Corp. 1997.

8. Gamboa B, Moore SM. Hospital and Industry Collaborate to Share Risk and Improve

Patient Outcomes. Stanford University Medical Center; 1997.

9. O’Brien SP, Wind S, van Rijswijk L, et al. Sequential biannual prevalence studies of

pressure ulcers at Allegheny-Hahnemann University Hospital. Ostomy Wound Manage

1998;44:78s-88s.

Table 2.

META-ANALYSIS OF PRESSURE ULCER STUDIES

Study Name Control Total N

Control PrU

Treated Total N

Treated PrU

Odds Ratio

Lower Limit

Upper Limit

Santa Clara 334 12 291 0 0.044 0.003 0.751 Stanford 311 62 262 18 0.252 0.156 0.407 Allegheny 331 25 315 19 0.753 0.408 1.390 Straub 34 12 127 6 0.091 0.031 0.268 Scott & White 158 28 157 14 0.455 0.229 0.901 Trinity* 330 46 330 30 0.617 0.379 1.006 Robert Packer 108 15 128 7 0.359 0.141 0.915 Augusta* 404 67 404 14 0.181 0.100 0.327 Tampa* 579 52

y 579 23 0.419 0.253 0.695

Combined (Random- Effects Model)

0.335 0.220 0.508

*Population (N) calculated based on capacity and average occupancy rates. yCalculated based on average incidence of 9%.2

ADVANCES IN SKIN & WOUND CARE & JULY 2008333WWW.WOUNDCAREJOURNAL.COM

ORIGINAL INVESTIGATION

10. Kaalakea G, Jackson D. Preventing nosocomial pressure ulcers: a ZoneAire sleep surface

success story. Batesville, IN: Hill-Rom CLS004. 1998.

11. Hopkins B, Hanlon M, Yauk S, et al. Reducing nosocomial pressure ulcers in an acute

care facility. J Nurs Care Qual 2000;14:28-36.

12. Robinson C, Gloeckner M, Bush S, et al. Determining the efficacy of a pressure ulcer

prevention program by collecting prevalence and incidence data: a unit-based effort.

Ostomy Wound Manage 2003;49:44-51.

13. Whittington K, Patrick M, Roberts JL. A national study of pressure ulcer prevalence

and incidence in acute care hospitals. J Wound Ostomy Continence Nurs

2000;27:209-15.

14. Butts PM, Wiggins WC, Blackburn RH, et al. Wounds that heal: a compre-

hensive interdisciplinary wound care program. Presented at the 14th Annual Clini-

cal Symposium on Wound Care; September 30 to October 4, 1999; Denver, CO.

Poster 17.

15. Young ZF, Evans A, Davis J. Nosocomial pressure ulcer prevention: a successful project.

J Nurs Adm 2003;33:380-3.

16. Stewart S, Box-Panksepp JS. Preventing hospital-acquired pressure ulcers: a point

prevalence study. Ostomy Wound Manage 2004;50:46-51.

17. Xakellis GC Jr, Frantz RA, Lewis A, et al. Cost-effectiveness of an intensive pressure

ulcer prevention protocol in long-term care. Adv Wound Care 1998;11:22-9.

18. Black JM, NPUAP. Moving toward consensus on deep tissue injury and pressure ulcer

staging. Adv Skin Wound Care 2005;18:415-21.

19. Webster, JG. Prevention of Pressure Sores—Engineering and Clinical Aspects. New York,

NY: Adam Hilger; 1991:32.

ORIGINAL INVESTIGATION

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