Dear Dr. Olshansky,

Thank you for your letter concerning our article "All At-Risk Patients Are Not Created Equal: Analysis of Braden Pressure Ulcer Risk Scores to Identify Specific Risks." As we noted, this study was a retrospective chart review of 12,566 patients who were assessed to be at risk of pressure ulcer (PU) development, using the Braden Scale. Our aim for this study did not include correlating specific nursing interventions with patient outcomes. Furthermore, we acknowledge as a limitation of the study that clinicians in our institution were using many interventions to reduce risk during the timeframe of analysis and that the effectiveness of these interventions might have influenced our results.

We agree that the Braden Scale is used to assess the presence and severity of factors known to increase risk of PU development. Since the Braden Scale has demonstrated the best overall sensitivity and specificity of risk assessment scales, our point is that a low Braden Scale score is an indicator for those at risk for developing a PU, especially if risk factors are not eliminated or controlled. The term prediction is used in terms of being able to forecast who has the most chance of developing a PU. Similar to a weather forecast, there is always a certain amount of error in any prediction, and clinical judgment must be used along with the Braden Scale score. Clinicians should understand that in general, a single factor or intervention is not totally responsible for PU prevention. The use of specialty beds does not preclude the need for repositioning, nor does turning eliminate the effects of moisture or shear.

The genesis for this study came from 3 clinical questions: How well does the admission Braden Scale score predict PU development for patients at the time of admission? Are there any other clinical factors that could indicate that a patient is at additional risk? Are any individual subscales more important than others in contributing to risk and thus could be a focus of intervention? Our idea was that if bedside clinicians could better focus their interventions and resources on those factors that had the greatest impact on risk, there would be more efficient use of time and money in prevention efforts.

In regard to the 60% of patients with a score of 6 to 9 developing a PU, thank you for pointing out this typographical error on our part. We apologize for this oversight. The corrected statement should read "Approximately 30% of patients with a baseline Braden Scale score of 6 to 9 (very high risk) developed a PU during their hospitalization, whereas only 9% of patients with scores of 10 to 12 (high risk) developed a PU (Figure 1)."

By no means are we suggesting that a PU is a fait accompli in the very high-risk patient. However, we do know that not every risk factor can be eliminated, and that other factors beyond those captured by the Braden Scale have been associated with PU development as has been recently demonstrated by Cox1 and Alderden and colleagues.2 As we look to the future of PU prevention, we must not ignore the basic interventions, while also being open to analyzing our current practices with new eyes in order to make progress in the future.

Ann N. Tescher, RN, PhD, CCRN, CCNS, CWCN, FCCM

Megan E. Branda, MS

T. J. O Byrne

James M. Naessens, ScD

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