Comparison of four pressure ulcer risk assessment tools in critically ill patients

Abstract

Background Critically ill patients are at a higher risk of developing pressure ulcers (PUs) than non‐critically ill patients. Tools that aid in the early identification of those who are most at risk of PUs could help health care providers deliver early interventions and reduce unfavourable outcomes. Aims To compare the validity of four PU risk tools (the Braden scale, the Braden [ALB] scale, the CALCULATE, and the COMHON index) and to demonstrate the optimal cut‐off points for each tool in critically ill patients. Design This was a prospective descriptive study. Method This study was conducted in the intensive care units (ICUs) of a tertiary care hospital in Thailand from January to April 2019. Baseline characteristics were collected at admission to the ICUs. Skin assessment was evaluated every 24 hours. PU assessment scores were collected every 72 hours. Receiver operating characteristic curves were used to compare the performance of the tests in predicting PUs. Results A total of 288 patients were recruited. The incidence of PUs was 11.1%. The Braden (ALB) scale performed the best based on the area under the receiver operating characteristic curves (area under curve 0.74), followed by the CALCULATE (area under curve 0.71), the Braden (area under curve 0.67) scale, and the COMHON (area under curve 0.61) index. At the optimal cut‐off point, the Braden (ALB) scale (≤13)) and the CALCULATE (≥3) were similar in terms of performance with an area under the curve of 0.69. Conclusion The Braden (ALB) performed the best at predicting PU development in ICU patients. Relevance to clinical practice The validity of all four PU risk tools was limited in Thai patients. The scales should thus be used in conjunction with clinical judgement to provide optimal outcomes. The development of better assessment tools for the prediction of PUs is required.

Development and validation of CAVE score in predicting presence of pressure ulcer in intensive care patients

“…According to the primary study entitled of “Factors predicting development of pressure injury in critically ill patients” [ 20 ], there were 4 clinical risk factors associated with development of PUs after using logistic regression model which included 1) Patients with mechanical ventilation, 2) Presence of cardiovascular disease, 3) serum albumin <3.3 mg/dl, and 4) Presence of edema. Table 2 shows the results of logistic regression analysis with their coefficients and risk scores.…”

“… Note: the risk factors in the final model development were derived from the primary study [ 20 ], OR; odds ratio, CI; confidence interval, comorbid cardiovascular disease included coronary artery disease, stroke and TIA, peripheral vascular disease and systemic scleroderma. …”

“…Patients with a positive CAVE score (a score of 2.5 or over) indicated at high risk in developing of PUs. In comparison with existing risk score predictor in ICU setting in recently published report in Thailand, at the optimal cut-off points, the AUC of ROC curves of the Braden scale, Braden (ALB), COMHON index and CALCULATE were 0.65, 0.69, 0.61 and 0.69, respectively [ 20 ] whereas the areas under the ROC curve of the CAVE score at the optimal cut-off points in the model development and the model validation were 0.74 and 0.67, respectively.…”

“…Baseline data variables were summarized using descriptive statistics and presented as percentage, mean, and standard deviation, but if the data distribution was not normal, median and inter-quartile ranges were used instead. For Model development, an area under a Receiving Operating Characteristic (ROC) curve of the final model to predict development of pressure ulcers derived from the result of the primary study which using regression analysis was reported [ 20 ]. The coefficient from each significant factor derived from multivariate logistic regression analysis were used to create a risk score for development of pressure ulcers.…”

“…Another study with direct comparison of Braden scale, Braden (ALB) scale (a modified version of the Braden scale, in which the nutritional subscale is based on serum albumin) [ 19 ], COMHON index and CALCULATE in ICU setting of Thailand reported that the sensitivity and specificity of the Braden scale was 50% and 80.15%, the Braden (ALB) scale was 65.2% and 73.04%, the COMHON index was 37.5% and 83.98%, and the CALCULATE was 68.75% and 68.75%. This study concluded that the Braden (ALB) and the CALCULATE showed the greatest and comparable performance at their optimal cut-off points with the area under curve of 0.69 [ 20 ].…”