According to researchers at The Ohio State University Wexner Medical Center who reviewed the electronic health records of 7,709 ICU patients, the Braden scale, which has reportedly been used by nurses for 30 years to assign patients an ulcer risk factor score, may not be accurate in evaluating ICU patients.
In a recent news release, Brenda Vermillion, DNP, RN, explains, “The scale told us that every single patient in the ICU was at high risk for pressure ulcer. But we knew that not every single patient went on to get a pressure ulcer. Going by the score means that most ICU patients would either be under—or over treated for ulcer prevention—neither is optimal.”
The release notes that the study represents the culmination of years of cross-discipline clinical and biomedical informatics research. Vermillion and a team of ICU nurses say that in 2008, following a review of ICU patients’ electronic records that suggested the Braden scale was not helping, they decided to pinpoint alternative tools.
Vermillion began searching nursing and medical research literature for articles that might reflect the data she was observing in patient charts. Vermillion, the release states, found a promising study in Korean, written by Sookyung Hyun, a nurse with a specialty in biomedical informatics at Ohio State’s College of Nursing.
Huyn had worked on the paper in Korea, which suggested the Braden was not effective in an ICU population. The release also notes that Huyn recently received a pilot grant from The Ohio State University for Clinical and Translational Science to research the validity of the Braden scale in ICU patients.
Both nurses coordinated with Susan Moffatt-Bruce, MD, PhD, Ohio State Wexner Medical Center’s Chief Quality and Patient Safety Officer. The release reports that Hyun’s research then progressed with the support of a multi-disciplinary team that decoded EMR acronyms, meshed massive amounts of patient data, and fundamentally, understood how ICU nurses used EMRs and the Braden scale.
Their study, which appears in the American Journal of Critical Care, suggests that a score of 16 on the Braden scale, the current high risk indicator for ICU patients, would have better predictive validity and accuracy if it was moved closer to a score of 13. Yet, the researchers say, even when shifting the risk score lower, they hypothesize that the scale does not sufficiently reflect the characteristics of ICU patients who may have a range of comorbid conditions and medications that put them at a higher risk of ulcers. The data pool also indicated that the medical center’s ongoing pressure ulcer initiatives were able to reduce the incidence of ulcers across the system by 40% during the 4-year study.
“…While the study and our improvement efforts were running in parallel, it made us all more sensitive to the fact that ICU patients need more scrutiny, and that there are probably other clinical signs we need to find that could help us prevent ulcers in those patients,” Moffatt-Bruce says.
The release says the Vermillion and her team aim to find these clinical signs, adding, “Before, we had experience telling us that the Braden didn’t fully meet our needs. Now we have the data confirming that. Armed with this information and by continuing to use the EMR, we’re beginning to identify factors unique to ICU patients, such as ventilator status, that can help us better predict which patients are really at risk.”
Vermillion emphasizes that the Braden is still very useful in other clinical settings and in nursing homes, and says ICU nurses will continue to use the scale as a starting point.
The researchers also acknowledge the limitations of their study in the release, which include an overall lower rate of pressure ulcers than similar studies, as a result of potential coding errors in the EMR or inconsistencies among nurses using the Braden scale. The researchers add that they also did not examine whether the admission Braden scores made a difference in the level of care patients received.
Source: The Ohio State University Center for Clinical and Translational Science