Background
Pressure ulcers are a frequent occurrence in healthcare worldwide and should be considered an adverse event (events that result in avoidable patient harm, WHO, 2023). As far back as 1859, Nightingale highlighted that the responsibility to prevent ‘bedsores’ was in the domain of a nurse, and this remains a hot topic today and is evident by the number of systematic reviews and journal articles looking at risk assessment and interventions to prevent pressure ulcers (Hultin et al, 2021. Kottner et al, 2024). The complications associated with pressure ulcers are multiple and include pain, depression, poor quality of life, increased risk of mortality, cellulitis, poor healing and therefore, the importance of identifying patients who are at risk of developing pressure ulcers should be a priority for all healthcare workers.
It is everyone’s responsibility to provide for the health, wellbeing, and safety of those we care for as well as ensuring that those who provide the care, have the knowledge and skills to carry out high quality, evidence-based care. Making Every Contact Count (MECC), developed by Public Health England, NHS England and Health Education England (HEE) (2016), suggests that every contact, every day should be seen as an opportunity to engage individuals in conversations about their pressure ulcer prevention care. This approach can be incorporated into the risk assessment process promoting a patient-centred approach.
A pressure ulcer risk assessment is considered an essential part of clinical practice and is used to identify individuals who are at risk of developing skin and tissue damage due to the prolonged effects of unrelieved pressure on the tissue. (Kottner & Coleman, 2023).
It is a complex concept that requires different approaches such as risk assessment tools (RAT), clinical judgement, skin assessment, with an understanding of all the factors which impact on each of these concepts. This then needs to be followed up with deciphering the clinical picture, planning the most effective care interventions in line with local policies, equipment availability, and what will be acceptable to the person receiving these interventions.
The development of risk assessment tools
A risk assessment tool comprises of several factors which is believed to place a patient at risk of developing pressure ulcers. However, they cannot predict that a pressure ulcer will occur (Fletcher, 2017). NICE (2024) states that we should consider using a validated risk assessment tool/scale to support clinical judgement when assessing for a person’s pressure ulcer risk.
One of the first PU risk assessment tools, Norton Risk Assessment Tool was created by Doreen Norton et al, in 1962 and looked at physical condition, mental state, activity, mobility, and incontinence but did not consider nutritional factors, shearing forces, or other comorbidities.
Judy Waterlow et al (1987) developed the Waterlow Risk Assessment Tool with a wider number of parameters which were based on her personal knowledge and literature review. This was limited at the time she published the tool and took into account the existing Norton tool (Charalambous et al, 2018). In 2005 this was revised to consider new evidence, but the tool remained unsupported by sufficient evidence, which despite its popularity, left a sense of doubt about the risk factors and scoring system included. Although it is not a perfect risk assessment tool, if used in conjunction with clinical judgement, it can serve as an indicator of PU risk.
In 1987, Barbara Braden and Nancy Bergstrom, in the United States, developed the Braden Scale which consists of 6 subscales (Mobility, Activity, Sensory Perception, Nutrition, Friction/Shear and Moisture) and each of these subscales have been established as valid and can be used independently (Kennerly et al, 2022).
Since the early development of these first 3 risk assessment tools, there have been over 40 variations created and they all vary in how they were developed, whether they were informed by literature, expert opinion, or adapted or expanded from an existing tool. Some have been created for specific healthcare specialities such as paediatrics, maternity, orthopaedics, end of life, intensive care, or community settings (Fletcher, 2023).
The ability of any tool to predict risk is determined through statistical testing which looks at the percentage of patients a tool identifies to be ‘at risk’ and might therefore go on to develop a pressure ulcer, alongside the percentage that a tool predicts ‘not to be at risk’ and therefore do not go on to develop pressure ulcers, but this does not take into account any care interventions to that patient (Fletcher, 2017).
A study, in 2015 by Wang et al, evaluated the inter-rater (use by different people) reliability of these 3 risk assessment tools in clinical practice. Their conclusion was that these scales should not be used in an intensive care setting and with caution in clinical practice due to the variable inter-rater reliability scores. Park and Lee (2016) suggested that none of these 3 tools can show a consistent measured value and therefore cannot predict the development of pressure ulcers, but that Norton had a higher sensitivity than Waterlow.
Following on from this, a 2020 Cochrane review looking at whether risk assessment tools are effective for the prevention of pressure ulcer formation, concluded there was low to very low quality of evidence that using a structured risk assessment tool is any more effective than assessing risk using clinical judgement (Afridi and Rathore, 2020).
The development of the PURPOSE-T risk assessment tool
The PURPOSE-T risk assessment tool was launched in 2014 following a five-phase process which initially reviewed the information available on identifying pressure ulcer risk factors, alongside a study identifying the most important risk factors. This was followed by the development of a PU conceptual framework and causal pathway leading to the design and pretesting of the tool, looking at improving acceptability and usability for nurses. Once designed, it was then clinically evaluated on 230 patients by expert nurses to ensure reliability, validity, data completeness, and usability.
The tool uses colour rather than a score to complete the patient’s personal risk profile and aids the planning of appropriate intervention. This is a 3-step approach starting with the Step 1 – screening stage, which is used for all patients, and designed to highlight those ‘not at risk’ and those ‘at risk’. For the ‘not at risk’ group there is no further screening required, and reassessment is based on future changes to their needs or physical condition.
Those screened as ‘at risk’ proceed to Step 2, a full assessment which leads to the decision pathway, a traffic light coloured section, which makes a clear distinction between patients with existing pressure ulcers, or scarring from previous PU, who need secondary prevention and treatment intervention, and those at risk who require primary prevention. Many organisations who implement PURPOSE-T, create clinical pathways based on the traffic light system, to guide staff through the expected interventions, considerations, and care plans, in line with their local policies, guidelines and clinical outcome expectations.
PURPOSE-T underwent a review in 2017 which considered the experiences of those clinicians who had initially implemented it in hospital and community, with information on medical devices and clinical judgement added to the tool (Leeds, 2014).
The current guidance on risk assessment
NICE (2024) states that clinicians should use a validated risk assessment score to support clinical judgement when assessing pressure ulcer risk, and recommends the Braden, Waterlow, PURPOSE-T and the Braden Q scale for children. The NICE guidance states that a risk assessment should be carried out for adults being admitted to secondary care, or care homes in which NHS care is provided, or receiving NHS care in other settings, such as primary and community care and emergency departments.
Although NICE focuses primarily on NHS patients, it is important within our professional duty of care and quest to ‘cause no harm’ by ensuring all patients in healthcare settings are assessed for their risk of pressure ulcer development.
The National Wound Care Strategy Programme (NWCSP) in their 2024 publication, which is relevant to NHS England – Pressure ulcer clinical recommendations and pathways, NWCSP-PU-Clinical-Recommendations-and-pathway-Updated-21st-May-2024.pdf(nationalwoundcarestrategy.net) – recommends that everyone receiving care from a health professional should be screened for pressure ulcer risk using the PURPOSE-T tool, or another validated risk assessment tool that as a minimum, contains the same risk factors.
Risk assessment should be undertaken within 6 hours of admission to a hospital or care home (with nursing) setting, or in a community health care service at the first face-to-face visit. Where things have progressed, in line with changes to provision of services and recognition of workload pressures, where appropriate, risk assessments can be conducted by virtual contact via telephone or video and can be based on questions asked of the patient about their skin.
Accurate documentation of both the risk assessment tool outcome and the holistic clinical judgement remains crucial, not just for the communication of care needs, but also as reassurance that we are doing everything we can to prevent a patient’s risk of developing pressure ulcers. This should include reassessment if there is a change in a patient’s condition, circumstance or environment (moving between healthcare services) (NICE, 2024, NWCSP, 2024).
Summary
In summary, pressure ulcer risk assessments remain an essential component of our modern healthcare as it promotes the early detection of patients at risk of developing pressure ulcers and enables us to create individualised care plans, enhance communication of risk, and therefore prioritise effective care interventions. By prioritising the knowledge and skills required to undertake a quality and comprehensive risk assessments, we may be able to influence better patient outcomes and more effective use of resources (Coyer, 2017. Gonzalez 2020).
References
Afridi, A. Rathore, F,A. (2020). Are risk assessment tools effective for the prevention of pressure ulcer formation? A Cochrane Review Summar with Commentary. American Journal of Physical Medicine & Rehabilitation. 99(4):p 357-358, Available at: Are Risk Assessment Tools Effective for the Prevention of Pr… : American Journal of Physical Medicine & Rehabilitation (lww.com)
Charalambous C, Koulori A, Vasilopoulos A, Roupa Z. (2018) Evaluation of the Validity and Reliability of the Waterlow Pressure Ulcer Risk Assessment Scale. Med Arch. 72(2):141-144. doi: 10.5455/medarh.2018.72.141-144. PMID: 29736104; PMCID: PMC5911172
Coyer, F. M. et al (2017) The effectiveness of pressure ulcer risk assessment tools in identifying patients at risk. International Wound Journal. 14 (6) 1047-1053.
Fletcher, J. (2017). An overview of pressure ulcer risk assessment tools. Wounds UK. Vol 13 (1) Pg 18 – 26
Fletcher, J., (2023). Use of PURPOSE-T in practice: an evidence-based pressure ulcer risk assessment tool. Meeting report, Wounds UK. Vol 19(1) Pg, 58-63. Available at https://www.directhealthcaregroup.com/app/uploads/WUK19-1_DHG-PurposeT.pdf
Gonzalez, E. G, et al (2020). Personalized prevention strategies for pressure ulcers: A systematic review. Journal of wound care. 29 (7) 374-380
Houltin, L. Gunningburg, L. Coleman, S. Karlsson, AC. (2021). Pressure ulcer risk assessment- registered nurses’ experiences of using PURPOSE T: A focus group study. Journal of Clinical Nursing. Vol, 31 (1-2) Pg 231-239.
Kennerly SM, Sharkey PD, Horn SD, Alderden J, Yap TL. (2022) Nursing Assessment of Pressure Injury Risk with the Braden Scale Validated against Sensor-Based Measurement of Movement. Healthcare (Basel). 10(11):2330. doi: 10.3390/healthcare10112330. PMID: 36421654; PMCID: PMC9690319.
Kottner, J. Coleman, S. (2023). The theory and practice of pressure ulcer/injury risk assessment: a critical discussion. (2023). Journal of Wound Care. Vol. 32, no. 9 (education).
Kottner, J. Coleman, S. Balzer, K. (2024), Pressure ulcer risk assessment: Where will the journey take us?, International Journal of Nursing Studies. Vol 150, (https://www.sciencedirect.com/science/article/pii/S0020748923002110)
Leeds (2014). Pressure Ulcer Risk Primary or Secondary Evaluation (PURPOSE T) Version 2 User Manual. PURPOSE-T-version-2-User-Manual-V2.pdf (leeds.ac.uk) National Institution for care excellence (2024) How should I assess a person’s risk of developing a pressure ulcer? https://cks.nice.org.uk/topics/pressure-ulcers/diagnosis/risk-assessment/
NICE (2024). Pressure ulcer: Prevention and management. www.nice.org.uk/guidance/cg179
Park, S-H and Lee, H.S., (2016). Assessing Predictive Validity of Pressure Ulcer Risk Scales – A systematic Review and Meta-Analysis. Iran Journal of Public Health, 45(2). Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4841867/#:~:text=In%20the%20results%20of%20detailed,2%3D93.06%2C%20P%3C.
Public Health England., NHS England., Health Education England (2016) Making Every Contact Count (MECC); a consensus statement. London. https://www.england.nhs.uk/wp-content/uploads/2016/04/making-every-contact-count.pdf
Wang LH, Chen HL, Yan HY, Gao JH, Wang F, Ming Y, Lu L, Ding JJ.(2015) Inter-rater reliability of three most commonly used pressure ulcer risk assessment scales in clinical practice. Int Wound J. 12(5):590-4.
