QUESTION

Does the use of a structured, systematic pressure ulcer risk assessment tool reduce the incidence of pressure ulcers, compared with a nonstructured risk assessment tool or unaided clinical judgement?

RELEVANCE TO NURSING CARE

Pressure ulcers occur in people who do not have the ability to reposition themselves to relieve pressure on bony prominences. They occur more often in the elderly population, and with greater severity. Pressure ulcers negatively affect the patient's quality of life, as patients frequently experience pain, combined with fear, isolation, and anxiety related to wound healing. They are also associated with an increased risk of death.

Pressure ulcer risk assessment tools are components of the risk assessment process used by nurses to identify individuals who are at risk for developing pressure ulcers. Several tools are well known and have been used for an extended period; however, there are currently approximately 40 risk assessment scales in use. There is a lack of consensus regarding whether conducting a formal risk assessment impacts on patient outcomes; therefore, a systematic review was warranted.1

STUDY CHARACTERISTICS

Randomized controlled trials were the only studies of interest to the review authors. Studies had to compare the use of a structured, systematic, risk assessment tool either with an assessment tool that was not structured or with an unaided clinical judgement. Randomized controlled trials could also compare different structured assessment tools. Participants, of any age, in any healthcare setting, who did not have any pressure ulcers at the time of the start of the study, were included.

The primary outcome of interest was the proportion of participants developing new pressure ulcers. Secondary outcomes included the severity of new pressure ulcers, the time to ulcer development, and pressure ulcer prevalence.

A total of two studies were included in the review. Meta-analysis could not be undertaken owing to heterogeneity of interventions, so a narrative summary was provided. In terms of methodological quality, one study was considered at high risk for bias and the other at low risk for bias.

The first study consisted of three arms [Group A, the Braden assessment tool and training (n = 74); Group B, unstructured risk assessment and training (n = 76); and Group C, unstructured risk assessment alone (n = 106)] and was undertaken in a Saudi military hospital. Results indicated there were no significant differences between Group A and Group B in pressure ulcer incidence as well as between Group A and Group C.

The second study contained 1231 patients admitted to an internal medicine or oncology ward in a tertiary teaching hospital in Australia. Individual participants were allocated to one of three arms [Group A, Waterlow Risk Assessment Scale (n = 410); Group B, Ramstadius (n = 411) Screening Tool; or Group C, clinical judgement (n = 410)]. Results indicated no significant differences in incidence of pressure ulcers when Group A was compared with Group C, when Group A was compared with Group B and when Group B was compared with Group C.

IMPLICATIONS FOR NURSING CARE

There is little empirical evidence available concerning the reliability and validity of existing tools, leading to some nurses using their clinical judgement when assessing pressure ulcer risk. The review currently indicates that undertaking a structured pressure ulcer risk assessment may not make any difference to pressure ulcer incidence; however, methodological limitations prevent firm conclusions.

IMPLICATIONS FOR RESEARCH

There is a need to conduct further research aimed at establishing whether the conduct of risk assessment makes any difference to pressure ulcer incidence. Further studies should ensure that the following are incorporated: true randomization, adequate allocation concealment, blinded outcome assessment, intention-to-treat analysis, baseline comparability of groups, adequate sample size, and reporting of studies in accordance with the CONSORT guidelines.

Acknowledgements

The author reports no conflicts of interest.

Reference