Dear Editor,
After reading Development of a Risk Assessment Tool for Intraoperative Pressure Ulcers, (JWOCN, January/February 2005), I was moved to share a few reflections. The Braden Scale was developed to determine who is/is not at risk for pressure ulcers for the purpose of planning preventive strategies. To the degree that prevention is successful, pressure ulcers are prevented. The Braden Scale differs from other methods of risk assessment that enumerate a list of risk factors, in that it takes a conceptual approach, linking conceptually all risk factors that contributed to one conceptual risk. For instance, mobility may be influenced by medical problems such as fractured hip, stroke, Parkinson's disease, or other phenomenon, such as anesthesia-induced unconsciousness. The purpose of conceptual classification is to identify and to rank or grade the level of immobility. Once this is known, interventions can be planned. In total, the Braden Scale never purported to assess risk during the operative period. It was always assumed that during the operative period, all patients are at highest risk. There are other factors that influence the level of risk as well. Kemp showed years ago that support surface and extracorporeal circulation were important factors during the period when the person is most vulnerable. My perception has always been that the length of time the person has bradycardia, has diastolic blood pressure below 60 mmHg, or is on a cooling blank is very important due to reduction in peripheral perfusion. Inability to move exposes the patient to pressure and requires pressure relief. Manufacturers are providing us with better support surfaces to achieve this goal. Decreased perfusion reduces the ability to tolerate the pressure that requires greater pressure relief and other support measures. There are other interventions, such as a careful eye to protection of the skin when exposed to cold, maintaining oxygen saturation and blood pressure. Because these factors are monitored closely by the anesthesiologist, we undoubtedly have fewer pressure ulcers.
The Braden Scale for Predicting Pressure Sore Risk, a copyrighted instrument, was presented in an abridged version in this article. The editors of this journal graciously agreed to print the Braden Scale as originally copyrighted (Figure 1). Barbara Braden and I have a long history of granting permission for any clinical agency to use this tool for patient care, free of charge. There are 4 things we ask in exchange: the wording of the tool must not be changed, the scoring must remain as written, the correct title shall be used and copyright recognition included (Copyright, Barbara Braden and Nancy Bergstrom, 1988. Reprinted with permission. All rights reserved.). The Braden Scale is widely used in the US with more than 450 new letters of permission granted in the second half of 2004, and it is used to some extent on each continent. We maintain the strong standards above because it is very easy for a tool such as this to develop drift. If even one or two facilities would decide to adopt an abridged version, a disservice would be done to the persons who were assessed. The tool has been carefully designed and tested. Abridged formatting tends to add to the subjectivity of the tool and reduce the reliability and validity.
If you want to use the Braden Scale, please contact us at http://www.bradenscale.com. If you are improving patient care, we will quickly make this tool available to you at no charge. You can download an official version. If you would like to use the tool in your research, we will gladly discuss that with you as well.
When the AHCPR guidelines were written, they were considered in the public domain with the exception of two copyrighted inclusions. This may have created some misunderstandings among users. We are pleased with the great support that you, the WOCNs, have given us over the years, and we aim to help you in any way we can. We thank the editors for printing the entire version and wish the authors of the manuscript well in their work.
Sincerely,
Nancy Bergstrom, PhD, RN, FAAN
Theodore J. and Mary E. Trumble Professor of Aging Research and Director, Center on Aging University of Texas Health Science Center