Risk assessment tools for the prevention of pressure ulcers

Abstract

Background: Use of pressure ulcer risk assessment tools or scales is a component of the assessment process used to identify individuals at risk of developing a pressure ulcer. Use of a risk assessment tool is recommended by many international pressure ulcer prevention guidelines, however it is not known whether using a risk assessment tool makes a difference to patient outcomes. We conducted a review to provide a summary of the evidence pertaining to pressure ulcer risk assessment in clinical practice, and this is the third update of this review.

Objectives: To assess whether using structured and systematic pressure ulcer risk assessment tools, in any healthcare setting, reduces the incidence of pressure ulcers.

Search methods: In February 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

Selection criteria: Randomised controlled trials (RCTs) comparing the use of structured and systematic pressure ulcer risk assessment tools with no structured pressure ulcer risk assessment, or with unaided clinical judgement, or RCTs comparing the use of different structured pressure ulcer risk assessment tools.

Data collection and analysis: Two review authors independently performed study selection, data extraction, 'Risk of bias' assessment and GRADE assessment of the certainty of evidence.

Main results: We included two studies in this review (1,487 participants). We identified no new trials for this latest update.Both studies were undertaken in acute-care hospitals. In one study, patients were eligible if they had a Braden score of 18 or less. In the second study all admitted patients were eligible for inclusion, once they were expected to have a hospital stay of more than three days and they had been in hospital for no more than 24 hours before baseline assessment took place. In the first study, most of the participants were medical patients; no information on age or gender distribution was provided. In the second study, 50.3% (619) of the participants were male, with a mean age of 62.6 years (standard deviation (SD): 19.3), and 15.4% (190) were admitted to oncology wards.The two included studies were three-armed studies. In the first study the three groups were: Braden risk assessment tool and training (n = 74), clinical judgement and training (n = 76) and clinical judgement alone (n = 106); follow-up was eight weeks. In the second study the three groups were: Waterlow risk assessment tool (n = 411), clinical judgement (n = 410) and Ramstadius risk assessment tool (n = 410); follow-up was four days. Both studies reported the primary outcome of pressure ulcer incidence and one study also reported the secondary outcome, severity of new pressure ulcers.We are uncertain whether use of the Braden risk assessment tool and training makes any difference to pressure ulcer incidence, compared to risk assessment using clinical judgement and training (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.53 to 1.77; 150 participants), or compared to risk assessment using clinical judgement alone (RR 1.43, 95% CI 0.77 to 2.68; 180 participants). We assessed the certainty of the evidence as very low (downgraded twice for study limitations and twice for imprecision).Risk assessment using the Waterlow tool may make little or no difference to pressure ulcer incidence, or to pressure ulcer severity, when compared to risk assessment using clinical judgement (pressure ulcers of all stages: RR 1.10, 95% CI 0.68 to 1.81; 821 participants; stage 1 pressure ulcers: RR 1.05, 95% CI 0.58 to 1.90; 821 participants; stage 2 pressure ulcers: RR 1.25, 95% CI 0.50 to 3.13; 821 participants), or risk assessment using the Ramstadius tool (pressure ulcers of all stages: RR 1.41, 95% CI 0.83 to 2.39; 821 participants; stage 1 pressure ulcers: RR 1.16, 95% CI 0.63 to 2.15; 821 participants; stage 2 pressure ulcers: RR 2.49, 95% CI 0.79 to 7.89; 821 participants). Similarily, risk assessment using the Ramstadius tool may make little or no difference to pressure ulcer incidence, or to pressure ulcer severity, when compared to risk assessment using clinical judgement (pressure ulcers of all stages: RR 0.79, 95% CI 0.46 to 1.35; 820 participants; stage 1 pressure ulcers: RR 0.90, 95% CI 0.48 to 1.68; 820 participants; stage 2 pressure ulcers: RR 0.50, 95% CI 0.15 to 1.65; 820 participants). We assessed the certainty of the evidence as low (downgraded once for study limitations and once for imprecision).The studies did not report the secondary outcomes of time to ulcer development, or pressure ulcer prevalence.

Authors' conclusions: We identified two studies which evaluated the effect of risk assessment on pressure ulcer incidence. Based on evidence from one study, we are uncertain whether risk assessment using the Braden tool makes any difference to pressure ulcer incidence, compared with training and risk assessment using clinical judgement, or risk assessment using clinical judgement alone. Risk assessment using the Waterlow tool, or the Ramstadius tool may make little or no difference to pressure ulcer incidence, or severity, compared with clinical judgement. The low, or very low certainty of evidence available from the included studies is not reliable enough to suggest that the use of structured and systematic pressure ulcer risk assessment tools reduces the incidence, or severity of pressure ulcers.

Conflict of interest statement

Zena Moore: has received an honorarium for speaking at professional meetings for Smith & Nephew and Molnlycke.

Declan Patton: none known.

Joan Webster (peer reviewer) is an author of one of the included studies in this review.

Figures

1

Study flow diagram.

2

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

References

References to studies included in this review Saleh 2009 {published data only}

Webster 2011 {published data only} References to studies excluded from this review Anthony 1998 {published data only} Bale 1995 {published data only} Bergstrom 1998 {published data only} Chan 1997 {published data only} Defloor 2005 {published data only} Gunningberg 1999 {published data only} Gunningberg 2001 {published data only} Hodge 1990 {published data only} Lyne 1999 {published data only} Salvadena 1992 {published data only} Additional references Ackroyd‐Stolarz 2014 AHCPR 1992 Anthony 2008 Baris 2015 Bauer 2016 Black 2007 Braden 1987 Chou 2013 Cullum 1995 Defloor 2004 Demarre 2015 Donner 2004 Elley 2004 Fox 2002 Friedman 1996 Gallagher 2008 Gould 2002 GRADEpro GDT 2015 [Computer program] Haalboom 1999 Hahn 2005 Halfens 2000 He 2012 Henoch 2003 Higgins 2003 Higgins 2011 Hollis 1999 Hopkins 2006 Jacobson 2016 Khor 2014 Lefebvre 2011 Liberati 2009 Manzano 2014 McGough 1999 Medical Research Council 2002 Moher 2001 Montori 2001 Moore 2011 Moore 2012 Moore 2013 NICE 2001 Norton 1975 NPUAP 1998 NPUAP/EPUAP/PPPIA 2014 Pancorbo‐Hidalgo 2006 Puffer 2005 Ramstadius 2000 Reeves 2011 Review Manager 2014 [Computer program] Rycroft‐Malone 2000 Schoonhoven 2002 Schünemann 2011 Scott 2006 SIGN 2018 Spilsbury 2007 Sterne 2011 US Census Bureau 2018 Waterlow 1985 References to other published versions of this review Moore 2007 Moore 2008 Moore 2014