Predictive Validity of the Braden Scale for Patients in Intensive Care Units

Sookyung Hyun, RN, PhD; Brenda Vermillion, RN, DNP, ACNS-BC; Cheryl Newton, RN, MSN; Monica Fall, MS, RD, LD, CNSC; Xiaobai Li, PhD; Pacharmon Kaewprag, MEng; Susan Moffatt-Bruce, MD, PhD; Elizabeth R. Lenz, RN, PhD


Am J Crit Care. 2013;22(6):514-520. 

In This Article

Abstract and Introduction


Background Patients in intensive care units are at higher risk for development of pressure ulcers than other patients. In order to prevent pressure ulcers from developing in intensive care patients, risk for development of pressure ulcers must be assessed accurately.

Objectives To evaluate the predictive validity of the Braden scale for assessing risk for development of pressure ulcers in intensive care patients by using 4 years of data from electronic health records.

Methods Data from the electronic health records of patients admitted to intensive care units between January 1, 2007, and December 31, 2010, were extracted from the data warehouse of an academic medical center. Predictive validity was measured by using sensitivity, specificity, positive predictive value, and negative predictive value. The receiver operating characteristic curve was generated, and the area under the curve was reported.

Results A total of 7790 intensive care patients were included in the analysis. A cutoff score of 16 on the Braden scale had a sensitivity of 0.954, specificity of 0.207, positive predictive value of 0.114, and negative predictive value of 0.977. The area under the curve was 0.672 (95% CI, 0.663–0.683). The optimal cutoff for intensive care patients, determined from the receiver operating characteristic curve, was 13.

Conclusions The Braden scale shows insufficient predictive validity and poor accuracy in discriminating intensive care patients at risk of pressure ulcers developing. The Braden scale may not sufficiently reflect characteristics of intensive care patients. Further research is needed to determine which possibly predictive factors are specific to intensive care units in order to increase the usefulness of the Braden scale for predicting pressure ulcers in intensive care patients.


Patients admitted to the intensive care unit (ICU) have a higher incidence of pressure ulcers than general hospital patients.[1] In the United States, the prevalence of pressure ulcers in ICUs was from 16.6% to 20.7% in 2009[2] and the incidence in acute care settings can be as high as 38%.[3] Defined as an injury of an area of skin and underlying tissue related to prolonged pressure against the skin, a pressure ulcer may be acquired or may substantially worsen during hospitalization.[4] As a result, the cost and length of both ICU and hospital stays can increase, and patients' quality of life can be diminished by pain and infection.[3] An estimated 2.5 million patients are treated annually in acute care settings in the United States, and the estimated annual expenditure for treating pressure ulcers is $11 billion; however, pressure ulcers are largely preventable.[3] Therefore, accurate risk assessment is critical, particularly in high-risk populations such as ICU patients, in order to encourage effective implementation of targeted preventive measures.