A New Pressure Ulcer Risk Assessment Scale for Individuals With Spinal Cord Injury1

Abstract

Each year, one-fourth of the 200,000 individuals with spinal cord injury in the United States develop pressure ulcers. No method currently exists, however, to accurately identify which of these individuals are at increased risk for development of pressure ulcers. We studied 219 spinal cord-injured patients, seen at a Veterans Affairs Medical Center, during a 6-yr period. Our goal was to develop a pressure ulcer risk assessment scale, specifically for persons with SCI. Each risk factor had to meet four criteria: (1) statistical association with pressure ulcer development; (2) biologically plausible mechanism; (3) literature support; (4) improved prediction. Among the 219 spinal cord-injured patients evaluated, 176 (80.4 percent) had a history of one or more pressure ulcers. Fifteen risk factors met the four criteria for inclusion into the risk assessment scale. They were as follows: restricted activity level, degree of immobility, complete spinal cord injury, urinary disease, impaired cognitive function, diabetes, cigarette smoking, residence in a nursing home or hospital, hypoalbuminemia, and anemia. Compared with the more general scales available, for quantifying the risk of pressure ulcer development, preliminary results suggest that this new scale is a significant improvement for the spinal cord-disabled.

A review of scales for assessing the risk of developing a pressure ulcer in individuals with SCI

“…All of these studies used retrospective data extracted from medical records to determine each subject's risk assessment scale score and presence of pressure ulcers. The measures in these studies included the Abruzzese, 27 Braden, 28 Gosnell, 29 Norton, 30 SCIPUS, 14 SCIPUS-A 15 and Waterlow. 31 A brief overview of each instrument is provided in Table 2.…”

“…The SCIPUS and SCIPUS-A were developed exclusively for individuals with SCI using regression analysis to identify variables, collected via retrospective chart review that predicted pressure-ulcer development. 14,15 Although the risk factors considered for inclusion were not described for the SCIPUS, 14 over 50 potential pressure-ulcer risk factors were evaluated for the SCIPUS-A of which 21 were explicitly described. 15 Those factors included age, tobacco use, alcohol history, nutritional support, level of activity, mobility, mental status, urinary continence, nutritional status, moisture, 'friction and shear', and 10 laboratory blood work variables.…”

“…15 For the SCIPUS and SCIPUS-A, the same data were used to generate the scale and to test their validity. 14,15 For all scales, items are scored using item-specific descriptive criteria, but the amount of detail provided varies considerably across measures. The Norton and Waterlow provide the least detailed scoring instructions.…”

“…These included (1) three of the most commonly used and validated scales for pressure-ulcer prediction in the general population (the Braden, Norton and Waterlow); 10,32 (2) two measures designed specifically for individuals with SCI during acute hospitalization (SCI-PUS-A) 15 and rehabilitation (SCIPUS) 14 and (3) two lesser known and validated scales (the Abruzzese and the Gosnell).…”

“…12 A large number of risk and protective factors for the development of pressure ulcers have been described for individuals with SCI. Some of the risk factors that have been identified include: being underweight, 13 smoking, 13,14 lower level of activity, 14,15 incontinence, 14,15 pulmonary disease, 14,15 decreased albumin, 14,15 decreased mobility, 14,15 extent of paralysis, 14,15 increasing age, 14 use of medications for sleep, 16 impaired cognitive function, 14 diabetes, 14 living in a hospital or nursing home, 14 spasticity, 14 renal disease, 14 and low hematocrit. 14 Protective factors identified include completing a college degree, 13 being married, 13 being employed, 13 exercise 16 and healthy diet.…”