Reducing Pressure Ulcer Incidence through Braden
Scale Risk Assessment and Support Surface Use
Edward H. Comfort, PhD
The past several years have seen an accumulation of evidence
that pressure ulcer incidence in hospitals can be reduced
markedly—in a number of cases nearly to zero—using risk
assessment based on the Braden Scale. Several hospitals, cited
in this article, have published results of internal studies
demonstrating the benefits, including cost savings, of placing
high-risk patients on specialized support surfaces upon
admission, without waiting for Stage I or II pressure ulcers to
develop. This study analyzes these results to arrive at a valid
statistical measure of the incidence reduction to be expected by
hospitals undertaking to implement such a policy.
Pressure ulcers are a significant cause of death in hospitals,1
although the recorded cause of death often disguises this fact.
Redelings et al1conclude, ‘‘pressure ulcers are associated with
fatal septic infections and are reported as a cause of thousands
of deaths each year in the United States.’’ However, these
figures are likely to be very low because, even in those cases
where pressure ulcers were an important contributing factor,
they are often unlikely to be listed as a cause of death.1
Despite the efforts of many people and organizations, the
prevalence of pressure ulcers in hospitals remained unchanged
at about 16% over a 6-year period from 1999 through 2004.2
The incidence of pressure ulcers in acute care facilities has
varied between 7% and 9% over the same period.2During that
6-year period, about 70% of individuals older than 65 years
with pressure ulcers also developed new pressure ulcers.2
The Braden Scale3was developed in 1988 as a means of
assessing the degree of risk of pressure ulcer development any
individual patient faces. Six factors are considered: sensory
ADVANCES IN SKIN & WOUND CARE & VOL. 21 NO. 7
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Edward H. Comfort, PhD, is Executive Director at the National Decubitus Foundation, Aurora, CO. Submitted on July 5, 2006; accepted in revised form on April 17, 2007.
OBJECTIVE: To collect available evidence showing that some
hospitals have been able to markedly reduce pressure ulcer
incidence despite broad surveys in previous recent years that
demonstrated little or no progress and to provide guidance to
hospitals through analysis of the evidence showing incidence
reduction to be expected by taking the measures indicated.
APPROACH: At the time of the article’s writing, a review of the
literature was conducted using PubMed. References were sought
that cited hospitals using the Braden Scale to identify at-risk
patients and providing pressure-reducing surfaces to those found
to be at risk. Nine hospitals were so identified. Each hospital
had reduced pressure ulcer incidence through risk assessment
followed by intervention that included support surface provision.
Statistical measures were used to establish confidence limits for
the noted improvements.
INTERVENTIONS: Each of the hospitals reviewed had imple-
mented a policy of risk assessment of all admitted patients using
the Braden Scale followed by implementation of best practices,
generally including assignment of patients judged to be at risk to
a pressure-reducing support surface.
MAIN OUTCOME MEASURES: Each hospital reported in the
literature a rate of nosocomial prevalence, both before and
after program implementation. All hospitals demonstrated
improvement, although the amount of improvement varied widely.
MAIN RESULTS: Realizing that each of the hospitals reviewed
started from different baselines, used different at-risk criteria,
did not utilize the same support surface, and may have
implemented a variety of additional interventions, it is perhaps not
surprising that the 95% confidence interval for incidence odds
ratio is broad, from 0.220 to 0.508 (meta-analysis), yet clearly
significant. Cost savings due to reduced need for rental of
expensive low-air-loss- or fluidized-bed therapy were reported.
CONCLUSIONS: Risk assessment of all admitted patients followed
by provision of specialized support surfaces to all deemed to be
at risk offers real hope of reducing the present very high rate of
hospital-caused pressure ulcers. With the growing understanding
that some pressure ulcers have their origin in deep tissue, it no
longer makes sense to wait for the appearance of Stage I or II
ulcers before taking action.
ADV SKIN WOUND CARE 2008;21:330–4