To the Editor

In the July/August 2007 Journal of WOCN, there was a special focus on pressure ulcer risk assessment scales (PURAS). The articles studied many of the excellent PURAS available to us including the Braden, Norton, and Waterloo Scales. Some of the articles, however, seemed to suggest that some of the PURAS may have a "predictive value" as to who might develop a pressure ulcer. It is my opinion that these scales, which only assess the patient, are not able in any accurate and consistent way to predict who might develop a pressure ulcer. The importance of this discussion is to differentiate risk assessment from predicting who might develop a pressure ulcer.

A PURAS is a tool to help clinicians determine which patients are at risk for developing a pressure ulcer. For example, let's take the highest risk patient with a Braden score of 6. We can all agree that this patient is at an extremely high risk for developing a pressure ulcer. Once the patient is identified as being high risk, it is the responsibility of the staff to implement pressure ulcer prevention.

Now to the prediction aspect of developing a pressure ulcer. Let's take the same high-risk Braden score 6 patient. We can all make the prediction that if the staff taking care of that patient is conscientious, places the patient on an air-fluidized bed, and turns the patient every two hours, the chance of developing a pressure ulcer will be low. If that same patient was being taken care of by a poor staff, was placed on a hard mattress, and was not turned, we can predict that the likelihood of developing a pressure ulcer would be high. It is important to note that despite the Braden scores being the same, the outcomes would be markedly different. The principle is that the best way for nurses to initially assess risk is to use one of the PURAS. However, if one wants to predict whether a patient will develop a pressure ulcer, one has to assess the staff. When reviewing the literature, whenever an institution lowered its incidence of nosocomial pressure ulcers, it was always an improvement in staff performance as opposed to a less risky patient population.

In summary, PURAS are a vital tool in assessing a patient's risk and are critical for alerting the staff of the need to implement preventive measures. However, the other part of the equation is knowing our staff and ourselves well enough to predict whether we are up to the task of preventing pressure ulcers from happening. This is one of the great quality issues in hospital care.

Kenneth Olshansky, MD

Clinical Professor, Plastic Surgery, Virginia Commonwealth University-Medical College of Virginia, Richmond, Virginia