The Braden Scale for Predicting the Outcome and Prognosis of Pressure Injuries in Older Inpatients

A Multicenter, Retrospective Cohort Study

Yi-Ping Song, MM; Man-Li Zha, MM; Hong-Wu Shen, BM; Yang Li, BM; Lin Du, MM; Ji-Yu Cai, MM; Yi Qin, MM; Hong-Lin Chen, MD

Disclosures

Wounds. 2021;33(5):127-135. 

In This Article

Abstract and Introduction

Abstract

Introduction: The Braden scale is used to assess the risk of patients with pressure injuries (PIs), but there are limitations to the prediction of PI healing. There is a lack of tools for evaluating PI healing and outcome in clinical practice.

Objective:The purpose of this study was to examine the ability of the Braden scale to predict the outcome and prognosis of PIs in older patients.

Materials and Methods: Outcome indicator was the wound healing rate of patients with PIs at discharge. The receiver operating characteristic (ROC) and Hosmer-Lemeshow goodness-of-fit test were used to evaluate the discrimination and calibration.

Results: Completed data were available for 309 patients, 181 of whom (58.6%) were male. The Braden scale had poor discrimination to predict the outcome and prognosis of PIs with an area under the curve (AUC) of 0.63 (95% CI, 0.56–0.70; P = .01). Subgroup analyses showed the Braden scale had low diagnostic value for patients aged over 90 years (AUCROC = 0.56; 95% CI, 0.17–0.96; P = .738), patients with respiratory diseases (AUCROC = 0.51; 95% CI, 0.37–0.65; P = .908), and digestive system diseases (AUCROC = 0.59; 95% CI, 0.42–0.75; P = .342). The level of calibration ability by Hosmer-Lemeshow goodness-of-fit test was acceptable, defined as P >.200 (χ 2 = 6.59; P = .473). In patients aged more than 90 years (χ 2 = 4.88; P = .431) and female patients (χ 2 = 7.03; P = .425), the Braden scale was also fitting. It was not suitable for patients with respiratory diseases (χ 2 = 11.35; P = .078).

Conclusions: The Braden scale had low discrimination for predicting the outcome and prognosis of PIs in older inpatients. The development of a new tool is needed to predict healing in patients with preexisting PIs.

Introduction

Pressure injuries (PIs) are chronic, refractory wounds with a long healing cycle and require difficult treatment courses that result in a low rate of healing. The prevalence of PIs in the older population is high. Pressure injuries are one of the most significant problems in medical institutions, both domestically and abroad.[1] With the accelerated growth of the aging population, the numbers of people with PIs are likely to increase.[2] One study showed that 70% of PIs occurred in people over 70 years of age,[3] and a cohort study of 323 nursing home residents with advanced dementia found the prevalence of PIs to be as high as 38.7%.[4] A multicenter cross-sectional observation study in the United Kingdom found the prevalence of community PIs was 7.7%, with 84% of those affected being patients 65 years and older.[5]

Current treatments of PIs mainly rely on traditional debridement, flap reconstruction, and negative pressure drainage.[6,7] However, PIs appear to be highly resistant to treatment, for which the outcomes are slow or even ineffective. A retrospective study of 78 patients with PIs by Karahan et al[8] showed the rate of healing was only 35.6% at discharge or death. The refractory nature of PIs has led to the formation of a relatively large population of patients with PIs,[9] and as such the approach to healing PIs needs to be improved. Despite advances in treating PIs, an actual cure for them has proven to be elusive. A study by Payne et al[10] showed patients with stage 3 and 4 PIs would require 110 weeks to achieve healing.

Once PIs develop, the clinical treatments are not only difficult but also costly, bringing a heavy financial burden to patients and society. According to statistics published in 2011, annual medical expenses in the United States related to PI care amounted to $362 million to $3.3 billion.[11] Pressure injuries can also reduce quality of life.[12] Related literature has reported that the factors affecting the healing of PIs are numerous and complex.[13,14] These factors include adequate nutrition, circulatory disorders, moisture, artificial ventilation, and tissue perfusion changes. In addition, an increasing number of studies have indicated that albumin levels and blood count are also associated with the healing of PIs.[15,16]

Currently, the Braden scale is one of the most commonly used PI risk assessment scales.[8,17,18] Medical staff can quickly predict the likelihood of PIs, identify high-risk patients with PIs, and perform early intervention to reduce the incidence of PIs.[19] The positive role of the Braden scale in preventing the occurrence of PIs is widely recognized. The Braden scale includes sensory perception, nutrition, activity, mobility, moisture, and shear/friction. It produces a total risk score ranging from 6 to 23.[20] The Braden scale is primarily used in the risk assessment of PIs but has limitations with regard to predicting healing of PIs that have already occurred. Results of a study showed that only the friction or shear force in the entries of the Braden scale was related to the prognosis of PI healing.[21] The findings suggested that the Braden scale was not a useful tool for guiding care planning of patients who already have stage 1 PIs.[21] Clinical treatment and care of patients with PIs are mostly based on personal experiences. There is no scientific basis for using the Braden scale to predict the prognosis for patients with PIs. In addition, a review found the activity and nutrient subscales of the Braden scale are not suitable for predicting PI development.[22] Subjective factors are more likely to affect the results of the Braden scale.[23] In addition, to the authors' knowledge, no research has evaluated the value of the Braden scale in predicting the outcome and prognosis of PIs.

There are some alternative PI evaluation tools that are used in clinical practice, such as the Pressure Ulcer Scale for Healing (PUSH); the Bates-Jensen Wound Assessment Tool; and the Depth, Exudate, size, Inflammation/Infection, Granulation, Necrotic Tissue (DESIGN) tool.[24] These models are applicable to describing PIs in the development process, but these evaluations do not lend themselves to the task of predicting wound healing.[25] Existing tools for risk assessment and monitoring of healing are inadequate to meet an identified deficit in care planning.[26]

Whether the Braden scale can judge the prognosis of PIs in older patients remains to be studied. Moreover, there is a lack of tools in clinical practice to assess the outcome and prognosis of PIs. The aim of this study was to examine the utility of the Braden scale in predicting the outcome and prognosis of PIs as quantified by receiver operating characteristic (ROC) and calibration curve.

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