Braden量表预测压疮诊断界值及危险因素的研究

目的探讨Braden量表不同分界值的灵敏度、特异度、阳性预测值以及压疮发生的相关危险因素。方法将2011年4月至2013年6月住院的65 926例患者中发生压疮的380例患者应用Braden量表进行压疮风险评估。结果①当Braden量表分界值为14分时,其灵敏度、特异度具有最好的平衡性。②神志、白蛋白、中重度水肿、休克(应用血管活性药物)与压疮发生有关。结论应用Braden量表对住院患者的压疮危险因素进行评估时结合压疮发生的相关危险因素,可以使Braden量表有更好的灵敏性、特异性,从而采取相应措施,有效降低住院患者的压疮发生率。     

Pressure ulcers: validation of two risk assessment scales

Aims and objectives. To compare the predictive value of two pressure ulcer risk assessment scales (Braden and Norton) and of clinical judgement. To evaluate the impact of effective preventive measures on the predictive validity of the two risk assessment scales. Methods. Of the 1772 participating older patients, 314 were randomly selected and assigned to the ‘turning’ group; 1458 patients were assigned to the ‘non‐turning’ group. Using the Braden and the Norton scale the pressure ulcer risk was scored twice weekly during a four‐week period. Clinical assessment was monitored daily. The patients at risk in the ‘turning’ group (Braden score <17 or Norton score <12) were randomly assigned to a two‐hour turning schedule or to a four‐hour turning schedule in combination with a pressure‐reducing mattress. The ‘non‐turning’ group received preventive care based on the clinical judgement of the nurses. Results. The diagnostic accuracy was similar for both scales. If nurses act according to risk assessment scales, 80% of the patients would unnecessarily receive preventive measures. The use of effective preventive measures decreased the predictive value of the risk assessment scales. Nurses predicted pressure ulcer development less well than the Braden and the Norton scale. Only activity, sensory perception, skin condition and existence of old pressure ulcers were significant predictors of pressure ulcer lesions. Relevance to clinical practice. The effectiveness of the Norton and Braden scales is very low. Much needless work is done and expensive material is wrongly allocated. The use of effective preventive measures decreases the predictive value of the risk assessment scales. Although the performance of the risk assessment scales is poor, using a risk assessment tool seems to be a better alternative than relying on the clinical judgement of the nurses.     

Pressure ulcer risk in long-term units: prevalence and associated factors

AIM: This paper is a report of a study to assess pressure ulcer prevalence in a group of long-term units and to describe the main factors associated both with risk for and presence of a pressure ulcer. BACKGROUND: Despite being potentially preventable, pressure ulcers are highly frequent among institutionalized patients and are associated with increased morbidity and mortality. METHOD: A cross-sectional study was carried out, involving 571 patients from 10 long-term units in Rome, Italy. Healthcare staff in each unit evaluated pressure ulcer risk and collected clinical data while a single Registered Nurse assessed all patients to identify pressure ulcers. Univariate and multivariate analyses were performed for the two outcomes: condition at risk for pressure ulcers (Braden score < or = 16) and pressure ulcer presence. The data were collected in February-March 2005. FINDINGS: The overall prevalence of pressure ulcers was 27%. Multivariate analysis showed a statistically significant positive association between high-risk condition of pressure ulcer and previous stroke (OR = 1.96; 95% CI 1.30-2.96), previous trauma (OR = 1.83; 95% CI 1.12-2.99) and cognitive decline (OR associated with a 1 point Short Portable Mental State Questionnaire increase = 1.26; 95% CI 1.05-1.50). The model for pressure ulcer presence confirmed a statistically significant excess in patients with cardiovascular diseases (OR = 1.79; 95% CI 1.13-2.85), with high Activity of Daily Living scores (OR associated with a 1 point increase 1.38; 95% CI 1.03-1.84) and low Braden Scale scores (OR associated with a 1 point increase = 0.80; 95% CI 0.70-0.87). The risk of pressure ulcers according to number of full-time nurses and auxiliary staff per 10 beds lower than five was marginally statistically significant (OR = 1.60; 95% CI 0.98-2.61). CONCLUSION: Further research is needed to validate our findings and further prospective research is needed to identify ways of preventing pressure ulcers. Our data on staffing suggest that organizational factors should be taken into account when exploring determinants of pressure ulcers.     

自制神经外科压疮危险因素评估量表与Braden量表信度与效度的比较研究

目的 更准确地评估神经外科患者发生压疮的危险性,降低压疮发生率.方法 采用两个评估量表(即自制神经外科压疮危险因素评估量表和Braden量表)评估500例神经外科患者的压疮危险因素,并进行信度和效度的比较.结果 自制神经外科压疮危险因素评估量表的Cronbach's α为0.941,Braden量表的Cronbach's α为0.743.因子分析结果显示,两个量表的结构效度与原设想的基本一致.预测效度显示,当自制神经外科压疮危险因素评估量表的诊断界值取16分时,灵敏度和特异度分别为89%和78%;当Braden量表取18分时,灵敏度和特异度分别为78%和58%.结论 两种量表均具有较好的内部一致性信度、结构效度和预测效度,但自制神经外科压疮危险因素评估量表优于Braden量表,是适合神经外科患者人群的压疮危险评估工具.     

Development of a new risk assessment scale for predicting pressure ulcers in an intensive care unit

Aims and objectives: The study aimed to evaluate the predictive validity and accuracy of a new pressure ulcer risk assessment scale in two Indonesia intensive care units (ICUs). Background: Several risk assessment scales have been designed to identify patients at risk of developing pressure ulcers in ICU. However, the relative weight of each variable that contributes to pressure ulcer development in these scales is not described to enable designing of a risk assessment scale. Currently, the risk factors contributing to pressure ulcer development include interface pressure, body temperature and cigarette smoking. Design: A prospective cohort study was conducted in two ICUs in Pontianak, Indonesia. Methods: A total of 253 patients were recruited to the study from both hospitals. Data collection included new risk assessment scale [i.e. the Suriadi and Sanada (S.S.) scale] scoring, demographic, pressure ulcer severity scores (based on the National Pressure Ulcer Advisory Panel) and skin condition measures. Using the S.S. scale, trained data collectors scored patients once and assessed the body temperature daily until patients were discharged. Additionally, daily data were also collected in relation to the patient‘s skin condition and stage of pressure ulcer. Results: Out of the 253 patients, 72 (28·4%) developed pressure ulcers. In ICU A, the incidence was 27%; pressure ulcers developed into stage I (41·7%), stage II (45·8%), stage III (10·4%) and stage IV (2·1%). In ICU B, the incidence was 31·6%; the development of pressure ulcers was 48% in stage I and 52% in stage II. Using the predictive validity test, the S.S. scale balanced sensitivity (81%) and specificity (83%) at a cut‐off score of 4. The area under the receiver‐operating characteristic curve was 0·888 (confidence interval: 0·84–0·93). Conclusion: The S.S. scale was found to be a valid risk assessment tool to identify the patients at risk of developing pressure ulcers in Indonesia ICU.     

根因分析法在降低Braden评分不超过16分的老年患者压疮发生率中的应用研究

目的探讨根因分析法对降低Braden评分不超过16分的老年患者压疮发生率的效果。方法成立根因分析小组,运用根因分析法对2015年4-5月发生在老年科的12例压疮患者逐一进行追踪,调查导致患者发生压疮的原因,寻找近端原因、剖析出根本原因,进而制订改进措施并实施于2015年7-9月的228例次Braden评分不超过16分的老年患者。比较实施前后患者压疮发生率。结果通过护理干预,Braden评分不超过16分的老年患者压疮发生率从开展前的6.06%降到开展后的2.19%,差异有统计学意义(P0.01)。结论采用根因分析法可以有效对Braden评分不超过16分的老年患者的皮肤进行安全管理,从而降低老年患者压疮发生率,提升护理质量。     

Braden评估表在神经内科卧床患者压疮预防中的应用

目的 评价Braden评估表对神经内科卧床患者压疮的预测效果,探讨压疮分组预防措施效果.方法 选取400例新人院、首次评估无压疮的神经内科卧床患者,应用Braden评估表动态评估发生压疮的危险性,将400例患者按评分分为高危、中危、低危及无危组4组各100例,并分别将高危、中危、低危组随机分为实验组和对照组各50例;对照组采取常规干预措施,高危实验组使用气垫床,中危实验组使用海绵床垫,低危实验组每4 h翻身1次,其他预防措施同对照组,无危险组不采取任何干预措施.结果 Braden评估表在首次和末次评分时ROC曲线下面积分别为0.771和0.828,诊断界值取17分时其对应灵敏度、特异度、阳性预测值、阴性预测值等指标均能达到较高水平.在分组干预中,高、中、低危实验组分别与对照组比较,各组压疮发生率均无显著差异.结论 Braden评估表对神经内科卧床患者压疮发生有较好的预测效果,17分是较理想的诊断界值.对神经内科压疮高危者采用气挚床、中度危险者采用海绵垫,压疮发生率降低不显著.低危者可采取每4 h翻身1次的方法以减少资源的消耗.     

Braden评估表在神经内科卧床患者压疮预防中的应用

目的评价Braden评估表对神经内科卧床患者压疮的预测效果,探讨压疮分组预防措施效果。方法选取400例新人院、首次评估无压疮的神经内科卧床患者,应用Braden评估表动态评估发生压疮的危险性,将400例患者按评分分为高危、中危、低危及无危组4组各100例,并分别将高危、中危、低危组随机分为实验组和对照组各50例;对照组采取常规干预措施,高危实验组使用气垫床,中危实验组使用海绵床垫,低危实验组每4h翻身1次,其他预防措施同对照组,无危险组不采取任何干预措施。结果Braden评估表在首次和末次评分时ROC曲线下面积分别为0．771和0．828,诊断界值取17分时其对应灵敏度、特异度、阳性预测值、阴性预测值等指标均能达到较高水平。在分组干预中,高、中、低危实验组分别与对照组比较,各组压疮发生率均无显著差异。结论Braden评估表对神经内科卧床患者压疮发生有较好的预测效果,17分是较理想的诊断界值。对神经内科压疮高危者采用气垫床、中度危险者采用海绵垫,压疮发生率降低不显著。低危者可采取每4h翻身1次的方法以减少资源的消耗。     

Relation between pressure, friction and pressure ulcer categories: a secondary data analysis of hospital patients using CHAID methods

Background

According to the latest pressure ulcer definition provided by the EPUAP and NPUAP pressure and shear are named as factors causing pressure ulcers. Empirical evidence suggests that pressure forces in combination with shear seem to be primarily responsible for deeper tissue injuries leading to category III or IV pressure ulcers. Superficial frictional forces seem to cause skin lesion resembling category II pressure ulcers.

Objectives

The objective of this study was to explore the empirical relationships between friction forces and category II pressure ulcers and between pressure forces and categories III and IV pressure ulcers.

Design

A secondary analysis of data from six German annual hospital pressure point prevalence studies.

Settings

161 Hospitals of all specialties and categories throughout Germany.

Participants

28,299 Adult hospital patients. The average age was 65.4 (SD 17.0) years. Female participation was 55.0%.

Methods

For the classification of the sample regarding pressure ulcers as a dependent variable and the Braden scale items as predictor variables, Chi-square Automatic Interaction Detection (CHAID) for modelling classification trees, controlled for age, has been used. CHAID analysis was performed for category II pressure ulcers and categories III/IV pressure ulcers separately.

Results

7.5% (95% CI 7.2–7.8) of the hospital patients had “Friction & Shear” problems according to the respective Braden sale item. 5.4% (95% CI 5.1–5.6) were “Completely immobile” according to the Braden scale item “Mobility”. The category “Problem” of the item “Friction & Shear” was the strongest predictor for category II pressure ulcers. Categories III/IV prevalence was 1.9%. Compared to all other Braden scale items there was the strongest association between being completely immobile and deeper categories III/IV pressure ulcers.

Conclusions

Based on a large sample of patients from multiple centres throughout Germany results indicate, that there is a strong relationship between friction forces and superficial skin lesions and between pressure forces and deeper categories III and IV PUs. This indicates that there might be different aetiologies causing different wounds. Given, that both superficial and deep ulcers have different aetiologies the validity of the current PU definition and classification is questionable, because ulcers due to maceration and excoriation are excluded from this classification system.     

2种压疮评估量表在患儿中的应用研究

目的 评价并比较Braden Q和Braden 2种压疮评估量表在儿科重症患者中的应用效果,探索区分患儿发生压疮风险的临界值.方法 采用多中心前瞻性队列研究设计,研究地点为3家儿童医院的重症监护室,派遣2名临床护士充当数据收集员,分别负责量表评分和皮肤评估,两者分别独立进行.结果 本次研究收集样本145例,实际发生压疮9例,发生率为6.2%.Braden Q量表和Braden量表的预测临界值分别是17分和14分;而两者的ROC曲线(受试者工作特征曲线)下面积分别为0.481和0.398.结论 Braden Q量表更加适用于儿科患者,且需要进一步研究改进量表.     

Skin Integrity in the Pediatric Population: Preventing and Managing Pressure Ulcers

purpose . To summarize clinical and empirical knowledge about pressure ulcers in infants and children and to describe an approach developed at Children's Hospital, Boston, to prevent and manage pressure ulcers
population . Acutely ill children with potential or actual alteration in skin integrity due to pressure ulcers
conclusions . The three-pronged approach for pressure ulcer prevention and management developed by the Skin Care Task Force at the Children's Hospital, Boston, decreases unnecessary variation in practice surrounding the prevention and care of pressure ulcers in acutely ill children.
practice implications . The Skin Care Task Force recommends use of the Braden Q for pediatric risk assessment, a skin care algorithm for prevention of pressure ulcers, and a pressure ulcer algorithm for staging and managing pressure ulcers.     

Incidence of pressure ulcers in a neurologic intensive care unit

OBJECTIVES: To determine the risk factors for pressure ulceration in an intensive care setting, to evaluate the Braden scale as a predictor of pressure ulcer risk in critically ill patients, and to determine whether pressure ulcers are likely to occur early in the hospital stay. DESIGN: Cohort study of patients with no preexisting ulcers with a 3-month enrollment period. SETTING: The neurologic intensive care unit and the neurologic intermediate unit at a primary care/referral hospital with a level I trauma center. PATIENTS: A total of 186 patients entered the study. INTERVENTION: Within 12 hrs of admittance, initial assessment, photographs, and Braden score were completed. Patients were re-examined every 4 days or at discharge from the unit, whichever came first. MAIN OUTCOME MEASURES: Determining risk factors for pressure ulcers, performing detailed statistical analyses, and testing the usefulness of the Braden score as a predictor of pressure ulcer risk. RESULTS: Twenty-three of 186 patients developed at least one pressure ulcer (incidence = 12.4%) after an average stay of 6.4 days. The Braden scale, which measures six characteristics of skin condition and patient status, proved to be a primary predictor of ulcer development. No ulcers developed in the 69 patients whose Braden score was 16 or higher. The likelihood of developing a pressure sore was predicted mathematically from the Braden score. However, being underweight was a significant and distinct factor in pressure ulcer development. CONCLUSIONS: Pressure ulcers may develop within the first week of hospitalization in the intensive care unit. Patients at risk have Braden scores of < or = 16 and are more likely to be underweight. These results suggest that aggressive preventive care should be focused on those patients with Braden scores of < or = 13 and/or a low body mass index at admission.     

两种压疮危险评估表预测效果的比较研究

[目的]测量并比较Waterlow压疮危险评估表和Braden修订版压疮危险评估表的预测效果。[方法]分别用两种评估表对332例病人进行评分,分析不同临界值时敏感性、特异性、阳性预测价值、阴性预测价值。[结果]Braden修订版压疮危险评估表以19分为临界值、Waterlow压疮危险评估表以15分为临界值时敏感性、特异性、阳性预测价值、阴性预测价值等指标间能达到较好的平衡,且Braden修订版压疮危险评估表各指标均大于Waterlow压疮危险评估表;Braden修订版压疮危险评估表的ROC曲线下面积略高于Waterlow压疮危险评估表。[结论]Braden修订版压疮危险评估表和Waterlow压疮危险评估表都有较好的预测效果,尤其以Braden修订版效果更优。     

两种压疮评估表在外科长期卧床患者中的应用效果比较

目的:比较我院自行研制的压疮危险评估量表(SPURAS)与Braden评估量表在外科长期卧床住院患者压疮评估中的应用效果。方法:将我院457例外科住院、丧失下肢行动能力患者随机分为A,B两组,A组(228例)采用外科住院患者SPURAS量表进行评估,B组(229例)采用Braden量表评估,根据评估结果分别给予相应的护理措施。结果:A组实际发生压疮7例,发生率为3.10%;B组实际发生压疮17例,发生率为7.42%,两组比较有统计学意义(P0.05)。结论:SPURAS量表预测外科长期卧床住院患者压疮的效果与Braden压疮评估表比较,SPURAS量表更加直观,易于操作,节省时间,提高效率。     

Using the Braden Q Scale to Predict Pressure Ulcer Risk in pediatric patients

The Braden Q Scale for Predicting Pediatric Pressure Ulcer Risk (Braden Q Scale) is a widely used, valid, and reliable pediatric-specific pressure ulcer risk assessment tool. Since its original publication, requests for clarification on how best to use the tool across the wide spectrum of pediatric patients commonly cared for in health care systems have been received. Common clarifications focus on using the Braden Q Scale as originally designed; specifically, not using untested derivations of the tool, and not using the Braden Q Scale to predict medical device-related pressure damage. The purpose of this article is to provide practical information on how best to use the Braden Q Scale and how to score a pediatric patient's risk for pressure ulcers. Accurate assessment of patient risk for pressure ulcers is the first step in guiding appropriate nursing interventions that prevent pressure ulcers. Patient assessment, scoring, and common clinical scenarios are presented.     

Braden评分联合微循环评价指标构建创伤重症患者压力性损伤风险可视化预后模型

目的:基于Braden评分,联合局部皮肤温度和局部组织氧饱和度作为局部微循环指标,构建创伤重症患者压力性损伤风险预后模型,并开发可视化列线图。方法:选取浙江省某三甲医院2020年06月1日至2020年08月31日期间所有进入急诊重症监护室（EICU）的创伤患者,采取Braden量表评估患者压力性损伤发生风险,测量患者骶尾部受压部位皮肤温度与血氧饱和度,作为微循环评价指标。采用多因素Logistic回归构建基于Braden评分联合微循环评价指标的创伤重症患者压力性损伤预后模型及可视化列线图,并与单纯Braden量表构建的预测模型比较。通过计算受试者操作特征曲线下面积判断预测模型区分度。C指数对最佳模型进行内部验证、H-L拟合优度检验、整体鉴别指数观察预测模型效果。结果:本研究共纳入152例患者,其中33例发生压力性损伤,占21.71%。Braden量表联合局部皮肤温度与局部组织氧饱和度后曲线下面积为0.866,模型内部验证C指数为0.847。H-L拟合优度检验结果为8.37, P=0.051,即模型具有良好区分度与一致性。模型整体鉴别指数=0.144, P=0.023。 结论:Braden量表联合局部微循环指标构建创伤重症患者压力性损伤预后模型具有良好区分度与一致性,较单纯Braden量表预测效力提高14.4%,据此构建列线图,能够为临床提供快捷、方便可靠的预测工具。     

Comparison of two skin examination methods for grade 1 pressure ulcers

Aims and objectives. The purpose of this study was to find out whether the application of a transparent device for diagnosing grade 1 pressure ulcers influences grade 1 pressure ulcer prevalence rates and the total number of observed grade 1 pressure ulcers. Background. It is assumed that the accuracy of visual grade 1 pressure ulcer diagnosis is enhanced if a transparent device is used. Design. Quasi‐experimental. Method. Within a pressure ulcer prevalence study participating institutions were divided into groups at random. Data collecting nurses of the intervention group (n = 4667) applied a transparent disc. Data collecting nurses of the control group (n = 5095) conducted skin inspection using the ‘finger‐method’. Group comparisons were conducted. Relations between skin assessment methods and grade 1 pressure ulcer prevalence was analysed by logistic regressions. Results. Both groups were comparable regarding demographic characteristics. Grade 1 pressure ulcer prevalence in the intervention group was 3·9% and 7·1% in the control group (p<0·001). The total number of observed grade 1 pressure ulcers was 282 (intervention group) and 555 (control group). The chance to identify at least one grade 1 pressure ulcer increased when the ‘finger method’ was used (p<0·001). Conclusions. The use of a transparent disc influences the grade 1 pressure ulcer prevalence rates and the total number of observed grade 1 pressure ulcers. Relevance to clinical practice. Accurate identification of grade 1 pressure ulcers is important, because the development of those skin alterations indicate an urgent need for preventive measures. As the diagnosis of grade 1 pressure ulcers seems to be affected by the observation method, it is unknown which method is the more accurate. A study of diagnostic accuracy is needed to answer this question. It is recommended to report pressure ulcer prevalence rates including and excluding grade 1.     

Non-blanchable erythema as an indicator for the need for pressure ulcer prevention: a randomized-controlled trial

Aims and objectives. To evaluate whether postponing preventive measures until non‐blanchable erythema appears will actually lead to an increase in incidence of pressure ulcers (grades 2–4) when compared with the standard risk assessment method. Background. To distinguish patients at risk for pressure ulcers from those not at risk, risk assessment scales are recommended. These scales have limited predictive validity. The prevention of further deterioration of non‐blanchable erythema (grade 1 pressure ulcer) instead of the standard way of assigning prevention could be a possible new approach. Design. Randomized‐controlled trial. Methods. Patients admitted to surgical, internal or geriatric wards (n = 1617) were included. They were randomly assigned to an experimental and a control group. In the experimental group (n = 826), prevention was started when non‐blanchable erythema appeared, in the control group (n = 791) when the Braden score was <17 or when non‐blanchable erythema appeared. In both groups, patients received identical prevention, either by using a polyethylene–urethane mattress in combination with turning every four hours or by using an alternating pressure air mattress. Pressure points were observed daily and classified according to the four grades of the European Pressure Ulcer Advisory Panel. The Braden scale was scored every three days. Results. In the experimental group, 16% of patients received preventive measures, in the control group 32%. The pressure ulcer incidence (grades 2–4) was not significantly different between the experimental (6·8%) and control group (6·7%). Conclusion. Significantly fewer patients need preventive measures when prevention is postponed until non‐blanchable erythema appears and those patients did not develop more pressure ulcers than patients who received prevention based on the standard risk assessment method. Relevance to clinical practice. Using the appearance of non‐blanchable erythema to allocate preventive measures leads to a considerable reduction of patients in need of prevention without resulting in an increase in pressure ulcers.