To the Editor:

I have observed that authors discuss the predictive capacity of pressure ulcer risk assessment scales throughout the wound care literature. It is my contention that it is almost impossible to predict risk or development of pressure ulcers. We need to eliminate the word "predict" from our pressure ulcer lexicon.

An article in the January/February 2014 issue of Journal of Wound, Ostomy and Continence Nursing titled "Predictive Capacity of Risk Assessment Scales and Clinical Judgment for Pressure Ulcers: A Meta-Analysis" studies the "capacity of pressure ulcer risk assessment scales and nurses' judgment to predict PU development." I would like to propose that we eliminate the word "predict" from our pressure ulcer lexicon.

It would be nice if we could predict pressure ulcer risk and/or development with accuracy, but I believe that it is an impossible task. In order to validate a prediction, one has to compare the prediction with what actually occurred. For example, if we say that pressure ulcer risk assessment scales (PURAS) have the capacity to predict the development of a pressure ulcer, then that implies that any given risk assessment score would be statistically expected to develop a pressure ulcer at some frequency. Can any healthcare provider actually evaluate a patient and predict whether they will develop a pressure ulcer based on the patient's Braden, Norton, or Waterlow scores? I would love to be able to do that. The only way I could predict with reasonable certainty that a patient will develop a pressure ulcer would be leaving a 400-pound bariatric patient lying on a hard mattress without being turned for 3 days. Even then there are so many variables that predicting PU development is impossible.

We then come to predicting PU risk. Is it appropriate to say that PURAS are predicting risk? I again say that the word "predict" is inappropriate. What the PURAS do are list findings in the patient's assessment that makes them more or less vulnerable to developing a pressure ulcer. Where does predictability come into the equation? Again, in order for there to be predictions, one has to have an expectation that something will occur. If one assumes that no care will be given, then I would suspect that the risk assessment score would be reasonably predictive. We all know that whether or not a patient develops a pressure ulcer is more dependent on the care given than any of the factors evaluated in a PURAS.

The article also states that "the clinical judgment of nurses was found to achieve inadequate predictive capacity when used alone and should be used in combination with a validated scale." Again the premise of expecting nurses/physicians to predict who will develop a pressure ulcer is fallacious. Under everyday scenarios, it would be a travesty if a nurse or a physician predicted that a patient would develop a pressure ulcer and in fact they did. What would that say about our care?

In closing, I believe that we must get away from using "predictability" in the context of pressure ulcer risk or development or when using PURAS. Having said all this, I would like to make a prediction. The better we all educate ourselves and the better we care for our patients, the fewer pressure ulcers we will see.

Kenneth Olshansky, MD

Physician Champion

Pressure Ulcer Collaborative Bon Secours

Hospital System

12000 Club Commons Dr

Glen Allen, VA 23059

[email protected]