Intervention Review

You have free access to this content

Risk assessment tools for the prevention of pressure ulcers

  1. Zena EH Moore1,*,
  2. Seamus Cowman2

Editorial Group: Cochrane Wounds Group

Published Online: 5 FEB 2014

Assessed as up-to-date: 19 DEC 2013

DOI: 10.1002/14651858.CD006471.pub3


How to Cite

Moore ZEH, Cowman S. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD006471. DOI: 10.1002/14651858.CD006471.pub3.

Author Information

  1. 1

    Royal College of Surgeons in Ireland, School of Nursing, Dublin, Ireland

  2. 2

    Royal College of Surgeons in Ireland, Faculty of Nursing and Midwifery, Dublin, Ireland

*Zena EH Moore, School of Nursing, Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin, D2, Ireland. zmoore@rcsi.ie.

Publication History

  1. Publication Status: New search for studies and content updated (conclusions changed)
  2. Published Online: 5 FEB 2014

SEARCH

 
Characteristics of included studies [ordered by study ID]
Saleh 2009

MethodsRCT, allocation by ward (cluster). No details provided regarding the randomisation process.


ParticipantsPatients in a military hospital with a Braden score of less than or equal to 18. For the Braden group, 74 patients post-test. For the training group, 76 patients post-test. For the clinical judgement group, 106 patients post-test.


InterventionsGroup A: Braden risk assessment and training n = 74
Group B: training alone n = 76
Group C: clinical judgement alone n = 106


OutcomesPressure ulcers developed
Group A: Braden risk assessment and training n = 16
Group B: training alone n = 17
Group C: clinical judgement alone n = 16


NotesThe groups were not comparable at baseline for medical diagnoses, pressure ulcer prevention practices, use of barrier creams and use of vitamin supplementary therapy.
The type of mattress the patients lay on was not the same for all participants.
The repositioning schedules for each participant was not the same


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "for pragmatism, this study randomly allocated nine wards into three groups"

Allocation concealment (selection bias)Unclear riskQuote: "for pragmatism, this study randomly allocated nine wards into three groups"

Blinding (performance bias and detection bias)
All outcomes
High riskThe authors report that the data were collected by one of the authors, who was the Tissue Viability Nurse Specialist at the hospital, and 2 staff nurses. The two staff nurses were recruited to the wound care team and each had medical–surgical nursing experience of six to eight years. There is no mention of blinding of the patient, the staff, the data collector or the data analyst within the text.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskPressure ulcer incidence is reported for all patients in the post-test groups, however a number of patients were excluded and it is unclear if these patients were excluded before the start of the study, i.e. that they did not meet inclusion criteria. This is not specifically stated by the authors.

Selective reporting (reporting bias)Low riskThe study protocol was not available but the important outcome measures stated in the methods section are reported in the results.

Other biasHigh riskUse of cluster-randomisation, i.e. wards were the unit of randomisation not patients. No allowance for this is made in the sample size calculation and the data analysis.
The groups were not comparable at baseline for medical diagnoses, pressure ulcer prevention practices, use of barrier creams and use of vitamin supplementary therapy.
The type of mattress used was not the same for all participants. The repositioning schedules for each participant was not the same.

Webster 2011

MethodsA single blind randomised controlled trial.


Participants1231 patients admitted to internal medicine or oncology wards


InterventionsParticipants allocated to either:

A. Waterlow (n=410)

B. Ramstadius (n=411) screening tool group

C. Clinical judgement group (n=410) where no formal risk screening instrument was used.


OutcomesIncidence of hospital acquired pressure ulcers.

The incidence of hospital-acquired pressure ulcers was similar between the groups:

A. Waterlow 31/411 (7.5%)

B. Ramstadius 22/410 (5.4%),

C. Clinical judgement 28/410 (6.8%)

p=0.4


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "A computer-generated randomised list was used"

Allocation concealment (selection bias)Low riskQuote: "A phone randomisation method was used"

Blinding (performance bias and detection bias)
All outcomes
Low riskQuote: "The patient and the outcome assessor were blinded to group assignment"

Incomplete outcome data (attrition bias)
All outcomes
Low riskThe number of participants allocated to each group were analysed for the primary outcome

Selective reporting (reporting bias)Low riskThe authors report all outcomes alluded to in the paper

Other biasLow riskThe study was funded by research grants from the Queensland Nursing Council, the Royal Brisbane and Women’s Hospital Private Practice Fund, the Royal Brisbane and Women’s Hospital Research Foundation and a Queensland Health Nursing Research Grant.

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Anthony 1998Did not look at the effect of risk assessment on pressure ulcer development, as some patients already had pressure ulcers

Bale 1995Not a RCT

Bergstrom 1998Not a RCT: random allocation to Braden, but no control group. The authors are focusing on sensitivity and specificity.

Chan 1997Not a RCT, descriptive statistics only

Defloor 2005Clinical trial, random allocation to turning group, but not to risk assessment tool, patients assessed using Braden and Norton. Looked at the sensitivity and specificity of Braden and Norton among the 2 groups: turning and no turning.

Gunningberg 1999Clinical trial but no random allocation

Gunningberg 2001This was an audit of nursing records and not a RCT

Hodge 1990Quasi-experimental

Lyne 1999This was a retrospective chart analysis and was not a RCT

Salvadena 1992Only looked at sensitivity and specificity

 
Comparison 1. Comparison between Braden pressure ulcer risk assessment and training vs. unstructured pressure ulcer risk assessment following training alone

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pressure ulcer incidence - Braden risk assessment and training vs. unstructured risk assessment following training alone1150Risk Ratio (M-H, Fixed, 95% CI)0.97 [0.53, 1.77]

 
Comparison 2. Comparison between Braden pressure ulcer risk assessment and training vs. unstructured pressure ulcer risk assessment alone

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pressure ulcer incidence - Braden risk assessment and training vs. unstructured risk assessment alone1180Risk Ratio (M-H, Fixed, 95% CI)1.43 [0.77, 2.68]

 
Comparison 3. Comparison between Waterlow and no formal risk assessment

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pressure Ulcer incidence: Waterlow versus no formal risk assessment1821Risk Ratio (M-H, Fixed, 95% CI)1.10 [0.68, 1.81]

 
Comparison 4. Comparison between Ramstadius and no formal risk assessment

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pressure Ulcer incidence: Ramstadius versus no formal risk assessment1820Risk Ratio (M-H, Fixed, 95% CI)0.79 [0.46, 1.35]

 
Comparison 5. Comparison between Waterlow and Ramstadius

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pressure Ulcer Incidence: Waterlow versus Ramstadius1831Risk Ratio (M-H, Fixed, 95% CI)1.44 [0.85, 2.44]