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Jill Cox
Am J Crit Care 2011;20:364-375 doi: 10.4037/ajcc2011934
2011 American Association of Critical-Care Nurses
Published online http://www.ajcconline.org
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AJCC, the American Journal of Critical Care, is the official peer-reviewed research
journal of the American Association of Critical-Care Nurses (AACN), published
bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049.
Copyright 2011 by AACN. All rights reserved.
REDICTORS OF
PRESSURE ULCERS IN
ADULT CRITICAL CARE
PATIENTS
By Jill Cox, RN, PhD, APN, CWOCN
C E 1.0 Hour
Notice to CE enrollees:
A closed-book, multiple-choice examination
following this article tests your understanding of
the following objectives:
1. Identify the stages of pressure ulcers as defined
by the National Pressure Ulcer Advisory Panel.
2. Describe the components of the Braden Scale
for assessing risk for pressure ulcers.
3. Discuss potential factors not included in the
Braden Scale that can be predictors for pressure ulcers in critical care populations.
To read this article and take the CE test online,
visit www.ajcconline.org and click CE Articles
in This Issue. No CE test fee for AACN members.
364
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Pressure ulcers
are one of the
most underrated
medical problems
in critical care
patients.
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365
Table 1
Pressure ulcer staging system of the
National Pressure Ulcer Advisory Panela
Stage
Description
II
III
IV
Unstageable
Braden subscales
of activity and nutrition have not been
useful as risk predictors in intensive
care patients.
Methods
366
medical-surgical ICU (MSICU) in Englewood Hospital and Medical Center, a suburban Magnet teaching hospital in Englewood, New Jersey.
Sample
All adult patients admitted to the MSICU from
October 2008 through May 2009 who met the
inclusion criteria were included in this convenience
sample. Patients were included if they were 18 years
or older and had an MSICU stay of 24 hours or greater.
Patients were excluded if they had an MSICU stay
of less than 24 hours or had a pressure ulcer at the
time of admission to the MSICU. A power analysis
was conducted for regression analysis to determine
an appropriate sample size.32 In order to achieve a
power of 80%, a minimum sample size of 163 was
needed for a moderate effect size, a significance level
of = .05, and 22 predictor variables.
Data Collection
Data were abstracted from the hospitals existing computerized documentation systems and
included the following study variables: pressure
ulcer (recorded as present or absent at discharge
from the MSICU); score on Braden Scale at the
time of admission to the MSICU; scores on
Braden subscales at admission to the unit; age;
arteriolar pressure (defined as the total number
of hours in the first 48 hours that the patient had
mean arterial pressure <60 mm Hg, and/or systolic blood pressure <90 mm Hg, and/or diastolic
blood pressure <60 mm Hg); length of MSICU
stay; total number of hours of administration of
any of the following vasopressor agents during
the MSICU stay: norepinephrine, epinephrine,
vasopressin, dopamine, and phenylephrine; severity of illness according to the APACHE II score;
and presence or absence of any of the following
comorbid conditions: diabetes mellitus, cardiovascular disease, peripheral vascular disease, and
concomitant infection/sepsis. During the study
period, routine protocols for prevention of pressure ulcers were in place in the MSICU. The protocols were based on the clinical practice
guidelines33,34 current at that time.
Demographic data and patient characteristics
included ethnicity, sex, and admitting MSICU
diagnosis. In addition, for patients in whom a
pressure ulcer developed, the number of hours
into the admission the pressure ulcer occurred and
the anatomical location and stage of the pressure
ulcer according to the 2007 National Pressure
Ulcer Advisory Panel staging system35 (Table 1)
were recorded.
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Data Analysis
SPSS, version 16.0 for Windows, software (SPSS
Inc, Chicago Illinois) was used for data analysis.
Descriptive statistics included frequency distributions for study variables and demographic data. The
Pearson product moment correlation was used for
correlational analyses of the study variables. Direct
logistic regression was used to create the best model
for predicting the development of pressure ulcers in
ICU patients. For comparison of study variables
between patients with and without pressure ulcers,
t tests and 2 analysis were used.
Results
Description of the Sample
Of the 579 patients admitted to the MSICU
during the study period, 347 met the inclusion criteria and were included in the final sample. The
patients were 20 to 97 years old (mean, 69; SD, 17).
The top 3 admitting diagnoses were respiratory failure or distress (20.7%), sepsis or septic shock (17.3%),
and neurological problems (15%). Demographic
characteristics of the sample are summarized in
Table 2.
Descriptive Statistics of the Study Variables
Descriptive statistics of the study variables are
summarized in Table 3. Among the 347 patients in
the sample, a pressure ulcer developed in 65 (18.7%).
Of these ulcers, most (35%) were stage II, and the
sacrum was the most common anatomical location
(58%). Mean time until development of a pressure
ulcer was 133.61 hours (median 90.0; range, 5-573;
SD, 120.13). The distribution of pressure ulcers by
stage and hours to development is summarized in
Table 4.
Mean Braden Scale scores were 14.28 (SD, 2.68;
range, 6-23) for the entire patient sample, 12.73
(SD, 2.65) for patients in whom pressure ulcers
developed, and 14.63 (SD, 2.65) for patients who
remained ulcer-free. Of the 65 patients in whom a
pressure ulcer developed, 28% (n = 18) were classified as at risk, 28% (n = 18) as at moderate risk,
35% (n = 23) as at high risk, and 9% (n = 6) as at
very high risk. Predictive validity of the Braden Scale
was measured by using sensitivity and specificity
values in addition to negative and positive predictive values36 (Table 5). At a cut-off score of 18, the
sensitivity was 100%, specificity was 7%, positive
predictive value was 20%, and negative predictive
value was 100%. According to the scores on the
Braden Scale, 94% of the sample was predicted to
be at risk for pressure ulcers; the actual occurrence
rate was 18.7%.
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Table 2
Demographic characteristics
of the study sample (n = 347)
Valuea
Characteristic
Age, mean (SD), range, y
69 (17.0), 20-97
Sex
Male
Female
171 (49.3)
176 (50.7)
Race
White
Black/African American
Asian/Pacic Islander
Hispanic
Other
255 (73.5)
48 (13.8)
26 (7.5)
17 (4.9)
1 (0.3)
72
60
52
44
24
24
23
17
13
12
6
(20.7)
(17.3)
(15.0)
(12.7)
(6.9)
(6.9)
(6.6)
(4.9)
(3.7)
(3.5)
(1.7)
Values are number (%) unless otherwise indicated. Because of rounding, not all
percentages total 100.
A pressure
ulcer developed
in 18.7% of the
sample; most
were stage II
sacral ulcers.
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367
Table 3
Descriptive statistics of study variables and comparison of patients
with acquired pressure ulcers and patients without pressure ulcers
Valuea
Independent variables
All patients
(n = 347)
14.28 (2.68)
2.85 (0.936)
3.40 (0.756)
1.08 (0.442)
2.53 (0.829)
2.29 (0.655)
2.10 (0.473)
Statistic
12.73 (2.65)
2.40 (0.884)
1.75 (0.729)
1.00 (0.000)
2.06 (0.788)
2.06 (0.555)
1.90 (0.491)
14.63 (2.65)
2.94 (0.928)
1.55 (0.758)
1.09 (0.489)
2.64 (0.801)
2.35 (0.665)
2.14 (0.458)
t = 5.9b
t = 3.95b
t = -1.93
t = 1.63
t = 5.31b
t = 6.38b
t = 3.71b
73 (15)
68 (18)
t = -2.72b
2.41 (4.96)
3.65 (6.74)
23.12 (15.39)
3.67 (5.83)
5.61 (7.72)
30.43 (15.26)
2.12 (4.71)
3.20 (6.42)
21.43 (14.95)
t = -2.00c
t = 2.33c
t = -4.35b
118.84 (155.58)
Arteriolar pressure, h
Mean arterial pressure <60 mm Hg
Systolic <90 mm Hg
Diastolic <60 mm Hg
No pressure ulcer
(n = 282)
69 (18)
Age, y
Pressure ulcer
(n = 65)
281.21 (256.14)
81.41 (85.78)
t = -6.20b
14.63 (2.65)
t = -5.58b
17.268 (7.72)
21.89 (6.71)
Vasopressor administration, h
Norepinephrine
Epinephrine
Phenylephrine
Dopamine
Vasopressin
13.87 (50.05)
0.29 (3.69)
1.29 (8.80)
1.70 (9.44)
3.76 (22.24)
54.98 (101.50)
0.892 (0.700)
2.05 (7.83)
3.41 (12.16)
16.15 (47.59)
4.39 (16.05)
0.152 (2.34)
1.12 (9.02)
1.30 (8.67)
0.909 (7.09)
t = -4.00b
t = -1.45
t = -0.770
t = -1.627
t = -2.57c
30
Yes, 4 (6)
No, 61 (94)
Yes, 26 (9)
No, 256 (91)
2 = 0.6d
145
Yes, 37 (57)
No, 28 (43)
2 = 7.5b
Diabetes
97
Yes, 19 (29)
No, 46 (71)
Yes, 78 (28)
No, 204 (72)
2 < 0.1
Infection
120
Yes, 36 (55)
No, 29 (45)
Yes, 84 (30)
No, 198 (70)
2 = 15.3b
Cardiovascular disease
Discussion
In this study sample, a Braden Scale score of 18
was not predictive of the development of a pressure
ulcer. In fact, 75% (n = 261) of the patients were
classified as at risk for pressure ulcers (Braden Scale
score 18) but remained ulcer-free (see Figure).
When the Braden Scale was used, the risk for pressure ulcers was overpredicted, as indicated by the
low specificity and low positive predictive value.
Because of the overprediction, drawing any important conclusions about the capability of the scale in
predicting development of pressure ulcers in the
patients in the study is difficult. Either use of the
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Table 4
Analysis of patients with pressure ulcers
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Characteristic
No. (%)a
Pressure ulcer
65 (18.7)
20 (31)
23 (35)
1 (2)
1 (2)
15 (23)
5 (7)
38
22
3
2
21 (32)
7 (11)
15 (23)
22 (34)
(58)
(34)
(5)
(3)
Hours to
detection Stage I Stage II Stage III Stage IV
Deep
tissue
injury
Unstageable
Total
1-48
21
49-72
73-144
15
145
22
Table 5
Predictive validity criteria of a pressure
ulcer risk assessment scalea
Criterion
Description
Sensitivity
Specicity
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369
Table 6
Bivariate correlations: independent variables and
dependent variable (pressure ulcer development)
Independent variable
-0.276a
-0.275a
-0.088
-0.208a
0.104
0.196a
-0.175a
0.130b
0.122b
0.140a
0.228a
Independent variable
Severity of illness
(APACHE II score)
0.288a
Vasopressor administration
Norepinephrine
Phenylephrine
Epinephrine
Dopamine
Vasopressin
0.395a
0.041
0.078
0.087
0.268a
Comorbid conditions
Cardiovascular disease
0.147a
Peripheral vascular disease -0.043
Diabetes mellitus
0.014
Infection
0.210a
0.502a
Hours in intensive
care unit
at P .01.
at P .05.
Table 7
Logistic regression analyses
Logistic regression (n = 347)
Variable
Standard
error
Wald
4.725
Exp (B)
95%
Condence
interval
.03
1.033
1.003 to 1.064
1.008
1.005 to 1.011
Age
0.033
0.015
Hours in
intensive care
unit
0.008
0.002
Cardiovascular
disease
1.082
0.401
7.288
.007
2.952
1.3 to 6.4
Mobility
-0.823
0.398
4.262
.04
0.439
0.210 to 0.95
Constant
-7.049
2.857
6.087
.01
0.001
21.996 <.001
Nagelkerke R2 = 0.512.
Hosmer and Lemeshow test: 2 = 6.993, df = 8, P = .54.
Variable
Standard
error
Wald
Exp (B)
95%
Condence
interval
1.008
1.004 to 1.012
0.008
0.002
Cardiovascular
disease
1.218
0.519
5.510
.02
3.380
1.223 to 9.347
Friction/shear
1.743
0.709
6.039
.01
5.715
1.423 to 22.95
Norepinephrine
0.017
0.008
4.223
.04
1.017
1.001 to 1.033
-10.512
3.779
7.737
.005
0.000
Constant
18.063 <.001
Nagelkerke R2 = 0.569.
Hosmer and Lemeshow test: 2 = 5.836, df = 8, P = .67.
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125
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100
75
No. of patients
50
25
19-23
15-18
13-14
10-12
Score on Braden Scale
6-9
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371
Limitations
The retrospective nature of this study is a limitation. However, most of the data abstracted represent objective clinical data that would not vary on
the basis of the study design. Using only the Braden
Scale measurements recorded in the first 24 hours
of the ICU stay may also be a limitation; however,
determining risk early during a
patients stay is crucial because
the determination may result in
earlier implementation of prevention strategies. The inability
to assess and stage developing
pressure ulcers is also a limitation of a retrospective design.
Pressure ulcers were staged and
recorded in the patients record
by staff nurses who are educated annually on assessment and staging of pressure ulcers and use of the
Braden Scale. Use of a single study site also diminishes the generalizability of the study findings.
A model for
assessing pressure
ulcer risk in intensive care patients
is needed.
Conclusions
Critical care patients are a unique subset of hospitalized patients and are the sickest patients in the
health care system. ICU patients are repeatedly confronted with multiple, concomitant risk factors for
372
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8.
9.
10.
11.
12.
13.
14.
FINANCIAL DISCLOSURES
None reported.
15.
eLetters
Now that youve read the article, create or contribute to an
online discussion on this topic. Visit www.ajcconline.org
and click Respond to This Article in either the full-text or
PDF view of the article.
16.
17.
SEE ALSO
For more about preventing pressure ulcers, visit the
Critical Care Nurse Web site, www.ccnonline.org, and
read the article by Jankowski, Tips for Protecting
Critically Ill Patients From Pressure Ulcers (April
2010).
REFERENCES
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2. Russo C, Steiner C, Spector W. Hospitalizations related to
pressure ulcers among adults 18 years and older, 2006.
Healthcare Cost and Utilization Project, Statistical Brief 64.
Agency for Healthcare Quality and Research Web site.
http://www.hcup-us.ahrq.gov/reports/statbriefs/sb64.pdf.
Published December 2008. Accessed June 3, 2011.
3. Keller P Wille J, van Ramshorst B, van der Werken C. Pres,
sure ulcers in intensive care patients: a review of risks and
prevention. Intensive Care Med. 2002;28(10):1379-1388.
4. Shahin ES, Dassen T, Halfens RJ. Pressure ulcer prevalence
in intensive care patients: a cross-sectional study. J Eval
Clin Prac. 2008;14:563-568.
5. VanGilder C, Amlung S, Harrison P Meyer S. Results of the
,
2008-2009 International Pressure Ulcer Prevalence Survey
and a 3-year acute care, unit-specific analysis. Ostomy
Wound Manage. 2009;55(11):39-45.
6. Centers for Medicare and Medicaid Services. Eliminating
serious, preventable and costly medical errorsnever
events. Centers for Medicare and Medicaid Services Web
site. http://www.cms.hhs.gov/apps/media/press/release
.asp?Counter=1863. Published May 18, 2006. Accessed
June 3, 2011.
7. Centers for Medicare and Medicaid Services. CMS proposes
additions to hospital-acquired conditions for fiscal year
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53.
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Bergstrom N, Braden B, Kemp M, Champagne M, Ruby E.
Multi-site study of incidence of pressure ulcers and the
relationship between risk level, demographic characteristics,
diagnoses and prescription of preventive interventions.
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Lindgren M, Unosson M, Fredrickson M, Ek A. Immobility
a major risk factor for development of pressure ulcers
among adult hospitalized patients: a prospective study.
Scand J Caring Sci. 2004;18(1):57-64.
Lewicki L, Mion L, Splane K, Samstag D, Secic M. Patient
risk factors for pressure ulcers during cardiac surgery.
AORN J. 1997;65(5):933-942.
Pokorny M, Koldjeski D, Swanson M. Skin care interventions for patients having cardiac surgery. Am J Crit Care.
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Spinal Cord Injury Rehabilitation Evidence. Outcome Measures. Spinal cord injury pressure ulcer risk scale. Spinal
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CE Test Test ID A112005: Predictors of Pressure Ulcers in Adult Critical Care Patients. Learning objectives: 1. Identify the stages of pressure ulcers as
defined by the National Pressure Ulcer Advisory Panel. 2. Describe the components of the Braden Scale for assessing risk for pressure ulcers. 3. Discuss potential factors not included in the Braden Scale that can be predictors for pressure ulcers in critical care populations.
1. Which of the following is the estimated percentage of hospital
acquired pressure ulcers in intensive care patients?
a. 13% to 35%
c. 16% to 63%
b. 14% to 42%
d. 17% to 71%
2. Which of the following explains the reasoning for the Centers
for Medicare and Medicaid Services limited reimbursement
for never events?
a. They can be prevented by implementing evidence-based preventive measures
b. They are grounds for malpractice against the nursing staff
c. They are unavoidable consequences of properly organized care
d. They are inexpensive to treat
3. Which of the following Braden scores belongs to the patient
with a high risk for developing a pressure ulcer?
a. 16
c. 11
b. 13
d. 8
4. Which of the following pressure ulcer risk factors was not
included as part of the Braden Scale?
a. Sensory perception
c. Low arteriolar pressure
b. Mobility
d. Nutrition
5. Which of the following was included in the def inition of
low arteriolar pressure in the study?
a. Number of hypotensive hours during intensive care unit (ICU) stay
b. Mean arterial pressure <60
c. Systolic blood pressure <100
d. Diastolic blood pressure <70
6. In this study, which of the following were the most common
anatomical location and stage of pressure ulcers?
a. Buttocks; stage II
b. Sacrum; stage I
c. Sacrum; stage II
d. Buttocks; stage I
Test ID: A112005 Contact hours: 1.0 Form expires: September 1, 2013. Test Answers: Mark only one box for your answer to each question. You may photocopy this form.
1. a
b
c
d
2. a
b
c
d
3. a
b
c
d
4. a
b
c
d
5. a
b
c
d
6. a
b
c
d
7. a
b
c
d
8. a
b
c
d
9. a
b
c
d
10. a
b
c
d
11. a
b
c
d
12. a
b
c
d
Fee: AACN members, $0; nonmembers, $10 Passing score: 10 correct (77%) Category: A, Synergy CERP A Test writer: Marylee Bressie, MSN, RN, CCRN, CCNS, CEN.
Program evaluation
Name
Yes
No
Member #
Address
City
Country
State
Phone
ZIP
E-mail address
RN License #1
State
RN License #2
State
Payment by:
Visa
M/C
AMEX
Card #
Check
Expiration Date
Signature
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