Braden Scale risk assessments and pressure ulcer prevention planning: what's the connection?

OBJECTIVE: To investigate the relationship between risk assessment scores on Braden subscales and nurses' selection of 10 commonly used best-practice pressure ulcer (PU) preventive interventions. DESIGN: Exploratory secondary data analysis, using a descriptive correlational design. SETTING AND SUBJECTS: A total of 377 Braden Scale PU risk assessments were made on 102 patients at different levels of risk. Assessments were made by RNs working at 3 different acute care hospitals. RNs making risk assessments also used an intervention checklist to select from 10 commonly used preventive interventions that should be implemented based on patient level of risk on each Braden subscale. INSTRUMENTS: The Braden Scale for Predicting Pressure Sore Risk was used to guide risk assessments. The Registered Nurses Intervention Checklist was used to identify PU preventive interventions that should be implemented. RESULTS: Braden subscale ratings influenced nurses' endorsement of preventive interventions in 2 distinct ways. First, endorsement of most (9 out of 10) preventive interventions was influenced by risk information embedded in unique combinations of Braden subscale assessments. Second, there appears to be a predictable pattern of increase in the likelihood of endorsing an intervention as Braden subscale scores decreased and the level of risk increased. CONCLUSION: Variability in Braden subscale ratings differentially predicts nurses' endorsements of selected PU-prevention interventions. Also, there is a predictable pattern of increase in the likelihood of endorsing a preventive intervention as PU risk levels increase, a pattern that may be related to the timing of risk assessment and PU-prevention planning activities.

A quasi-experimental study to assess the effect of technology-assisted training on correct endorsement of pressure ulcer preventive interventions.

The two-fold purpose of the Detroit Medical Center (DMC) Braden Scale Training Module is to teach nurses to use the Braden Scale to correctly assess pressure ulcer risk and to effectively plan risk-based prevention interventions. A pre-test, post-test, two-group, quasi-experimental study was conducted to evaluate the effect of web-based DMC Braden Scale Training on staff nurses' ability to correctly endorse the use or non-use of 10 commonly-used risk-based pressure ulcer preventive interventions for patients at different levels of risk for pressure ulceration. "Regular" or "new" users of the Braden Scale from three hospitals assessed 102 patients. On eight out of 10 preventive interventions, the percentages of correct endorsements were higher for patients at extreme levels of risk (generally not at risk or high/very high risk) than they were for patients at midlevels of risk. Correct endorsement of prevention interventions was unaffected by group membership. Training substantially improved ability to correctly endorse interventions, but for new user only. Importantly, patients at midlevels of risk may be more vulnerable to pressure ulceration than their risk assessments indicate simply because nurses have great difficulty determining which preventive interventions should be implemented for this group of patients. Alternative approaches to training are needed to ensure that regular users of the Braden Scale are adequately prepared to use risk-based information to effectively plan pressure ulcer prevention.

The nursing process and pressure ulcer prevention: making the connection.

PURPOSE: To provide the wound care practitioner with an understanding of how use of the nursing process enhances pressure ulcer prevention. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After reading this article and taking this test, the reader should be able to: 1. Describe the use of the nursing process for planning, implementing, and evaluating the outcomes of a pressure ulcer prevention program. 2. Explain how to use the Braden Scale for Predicting Pressure Sore Risk to develop "at risk" nursing diagnoses and to guide intervention.

The effect of Web-based Braden Scale training on the reliability of Braden subscale ratings.

PURPOSE: The primary purpose of this study was to evaluate the effect of Web-based Braden Scale training on the reliability of Braden Scale subscale ratings made by nurses working in acute care hospitals. A secondary purpose was to describe the distribution of reliable Braden subscale ratings before and after Web-based Braden Scale training. DESIGN: Secondary analysis of data from a recently completed quasi-experimental, pretest-posttest, interrater reliability study. SUBJECTS AND SETTING: A convenience sample of RNs working at 3 Michigan medical centers voluntarily participated in the study. RN participants included nurses who used the Braden Scale regularly at their place of employment ("regular users") as well as nurses who did not use the Braden Scale at their place of employment ("new users"). METHODS: Using a pretest-posttest, quasi-experimental design, pretest interrater reliability data were collected to identify the percentage of nurses making reliable Braden subscale assessments. Nurses then completed a Web-based Braden Scale training module after which posttest interrater reliability data were collected. The reliability of nurses' Braden subscale ratings was determined by examining the level of agreement/disagreement between ratings made by an RN and an "expert" rating the same patient. In total, 381 RN-to-expert dyads were available for analysis. RESULTS: During both the pretest and posttest periods, the percentage of reliable subscale ratings was highest for the activity subscale, lowest for the moisture subscale, and second lowest for the nutrition subscale. With Web-based Braden Scale training, the percentage of reliable Braden subscale ratings made by new users increased for all 6 subscales with statistically significant improvements in the percentage of reliable assessments made on 3 subscales: sensory-perception, moisture, and mobility. Training had virtually no effect on the percentage of reliable subscale ratings made by regular users of the Braden Scale. CONCLUSION: With Web-based Braden Scale training the percentage of nurses making reliable ratings increased for all 6 subscales, but this was true for new users only. Additional research is needed to identify educational approaches that effectively improve and sustain the reliability of subscale ratings among regular users of the Braden Scale. Moreover, special attention needs to be given to ensuring that all nurses working with the Braden Scale have a clear understanding of the intended meanings and correct approaches to rating moisture and nutrition subscales.

Multisite Web-based training in using the Braden Scale to predict pressure sore risk.

OBJECTIVE: To evaluate the effect of a Web-based Braden Scale training module on nurses' knowledge of pressure-ulcer risk assessment and prevention. DESIGN: Pre-experimental, posttest-only design. SETTING: Web-based learning environment. PARTICIPANTS: Registered nurses (N=1391) working at 3 medical centers in the Midwest. MAIN OUTCOME MEASURES: Primary outcomes of interest were reliability and competence associated with using the Braden Scale for pressure-ulcer risk assessment. Secondary outcomes of interest focused on program evaluation, specifically nurses' perceptions of program adequacy and ease of use. MAIN RESULTS: After training, nurses correctly rated Braden Scale level of risk 82.6% of the time. Numeric ratings for Braden subscales were generally more reliable when case-study data indicated extreme risk levels (generally not at-risk level, high-risk level, and very high level) than when data indicated midlevels of risk (mild-risk level and moderate-risk level). Nurses' knowledge of appropriate risk-based preventive interventions was high, but correlated poorly with the ability to correctly assign numeric ratings to Braden subscales. CONCLUSION: Web-based training alone may not ensure reliable, competent estimates of pressure-ulcer risk for patients at all risk levels. Other strategies, such as clinical practice with expert supervision, should be considered. Further research is needed to clarify the links between scoring Braden subscales correctly and selecting appropriate risk-based preventive interventions.

The effect of Web-based Braden Scale training on the reliability and precision of Braden Scale pressure ulcer risk assessments.

OBJECTIVE: To evaluate the effect of Web-based Braden Scale training on the reliability and precision of pressure ulcer risk assessments made by registered nurses (RN) working in acute care settings. DESIGN: Pretest-posttest, 2-group, quasi-experimental design. SETTING AND SUBJECTS: Five hundred Braden Scale risk assessments were made on 102 acute care patients deemed to be at various levels of risk for pressure ulceration. Assessments were made by RNs working in acute care hospitals at 3 different medical centers where the Braden Scale was in regular daily use (2 medical centers) or new to the setting (1 medical center). INSTRUMENT: The Braden Scale for Predicting Pressure Sore Risk was used to guide pressure ulcer risk assessments. A Web-based version of the Detroit Medical Center Braden Scale Computerized Training Module was used to teach nurses correct use of the Braden Scale and selection of risk-based pressure ulcer prevention interventions. RESULTS: In the aggregate, RN generated reliable Braden Scale pressure ulcer risk assessments 65% of the time after training. The effect of Web-based Braden Scale training on reliability and precision of assessments varied according to familiarity with the scale. With training, new users of the scale made reliable assessments 84% of the time and significantly improved precision of their assessments. The reliability and precision of Braden Scale risk assessments made by its regular users was unaffected by training. CONCLUSION: Technology-assisted Braden Scale training improved both reliability and precision of risk assessments made by new users of the scale, but had virtually no effect on the reliability or precision of risk assessments made by regular users of the instrument. Further research is needed to determine best approaches for improving reliability and precision of Braden Scale assessments made by its regular users.

Computer-based testing of the Braden Scale for Predicting Pressure Sore Risk.

The Detroit Medical Center nursing documentation system requires all staff nurses to complete the Braden Scale for Predicting Pressure Sore Risk on an Acute Care Flow Record or Critical Care Flow Sheet on every patient, every day. An audit of these records raised concern as to whether staff nurses accurately used the Braden Scale to calculate pressure sore risk. Advanced Practice and ET Nurses noted that staff nurses were rating patients at lower levels of pressure sore risk than was warranted by the patient condition. In response, a computer-based learning module with case study examples was developed and tested to teach nursing staff to accurately evaluate pressure ulcer risk by using the Braden Scale and its subscales and to identify preventive interventions based on the patient's Braden subscale scores. Following revisions of those case study example narratives that were found to be problematic, the learning/assessment module was instituted in 2002. More than 2,500 nurses at the facility were tested regarding their knowledge of pressure ulcer risk assessment and prevention using this program. On average, nurses correctly rated the Braden Scale level of risk 75.6% of the time. The percentage of correct responses was highest for very high (92%) and very low (78%) levels of risk. This finding is consistent with the observation that most nosocomial pressure ulcers in this facility occur in patients who are rated in the "mild risk" level on the Braden scale. Subscales with the lowest percentage of correct answers were moisture and sensory perception. Correct clinical identification of a Stage I pressure ulcer as it was described in writing occurred only 53% of the time. These results indicate that training and practice are needed to use an assessment scale accurately. The Detroit Medical Center plans to include the Braden Scale in annual nursing education and competency testing.

Pressure ulcers: the great insult.

Pressure ulcers are a common and frustrating problem. Pressure ulcers increase demands on health care resources and are sometimes a source of malpractice litigation. Skin breakdown, often an iatrogenic complication of hospitalization, increases the length of stay and contributes to mortality and morbidity. Long-term care facilities are under increasing regulatory pressure to reduce rates of pressure ulcer occurrence. The process-outcome link continues to escape us. Processes of care seem disjointed. Numerous studies show a failure to implement what we know. When pressure ulcer risk is identified, preventive measures often are not implemented. The literature is replete with reports of quality improvement activities that enumerate multiple opportunities to improve care related to pressure ulcers. Various quality improvement strategies for pressure ulcer prevention and management have been produced, but recommendations are not always applied to practice. When studies compared various outcomes before and after implementation of guidelines, most of the evidence was clinical audit data. Overall, active strategies were associated with better outcomes and passive strategies with poorer ones. Baier et al reported improvement in processes of care after using a structured quality improvement approach in the long-term care setting. Targeted education sessions were common to all studies reporting successful outcomes. Multidisciplinary wound care teams that conduct rounds at the bedside are highly recommended to enhance patient outcomes.Functioning interdisciplinary teams clearly represent an important approach to error reduction. To close the gap between risk identification and pressure ulcer prevention, we should develop active multidisciplinary wound care teams and "Strive for Six Sigma in Pressure Ulcer Care".

Choosing the right support surface.

PURPOSE: To provide the clinician with an overview of support surfaces used to manage tissue integrity as well as a review of how pressure ulcers develop. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in understanding how available support surfaces can impact the development and treatment of pressure ulcers. OBJECTIVES: After reading the article and taking the test, the participant should be able to:

Take the load off by choosing the right support surface.

Bewildered by the plethora of choices in pressure-reducing surfaces? Find out how they work so you can choose wisely and appropriately.