EUROPEAN PRESSURE ULCER ADVISORY PANEL

A DRAFT EPUAP POSITION STATEMENT
On Risk Assessment in Pressure Ulcer Prevention and Management

The following text outlines a draft EPUAP position statement upon pressure ulcer risk assessment. This document will be discussed in depth during the Le Mans Open Meeting of the EPUAP. However, we would urge all members to consider this document and to e-mail suggestions or amendments to Tom Defloor at:

Tom.Defloor@rug.ac.be

The position statement is intended to reflect the state-of-the-art in risk assessment based upon the best available evidence. The text is accompanied by a supporting reference list outlining the breadth of material considered by the Working Group when developing the draft statement.

EUROPEAN PRESSURE ULCER ADVISORY PANEL

Draft Position Statement on Risk Assessment in Pressure Ulcer Prevention and Management

Authors:
Defloor T, Schoonhoven L, Clark M, Halfens R, Nixon J.
Comments received from:
Dealey C, Jacquerye A, MacLeod A, Scott E, Torra i Bou JE, Weststrate J.

This document sets out a draft statement and rationale for the European Pressure Ulcer Advisory Panel upon the issue of risk assessment in pressure ulcer prevention and management. This draft will change upon receipt of comments from EPUAP members, and should not be considered as the definitive document. The purpose of this statement is to guide clinicians towards the most appropriate course of action when considering the implementation of risk assessment. The statement is set out in two sections; firstly a series of propositions are offered, while in the second section the evidence base supporting each proposition is explored.

Actual risk
PROPOSITION 1
The purpose of risk assessment is to identify those patients who are in need of measures to prevent pressure ulcers.

PROPOSITION 2
Patients with an actual risk of developing pressure ulcers and/or with existing non-blanchable erythema or pressure ulcer lesions (grade 2 and higher) should receive appropriate preventive measures.

Risk assessment scales
PROPOSITION 3
Current risk assessment scales often over and under represent the risk of pressure ulcer development.

PROPOSITION 4
It is not possible to recommend a specific risk assessment scale.

Elements of Risk Analysis
PROPOSITION 5
While the origin of pressure ulcers is undoubtedly multi-factorial, reductions in activity and/or mobility are observable factors that have been consistently shown to increase the risk of pressure ulcer development. Patients with existing pressure ulcers (non-blanchable erythema or grade 2 and higher) have a higher risk of developing new pressure ulcers on other anatomical sites. The importance of other potential risk factors is less clear.

PROPOSITION 6
Acknowledging the limitations in both the reliability and validity of risk assessment scales there are indications that the risk of pressure ulcer development may be best assessed by means of a risk assessment scale in combination with assessment of skin and the clinical judgement of the nursing staff.

PROPOSITION 7
Assessment of risk should be a continuous process where changes in patient condition and/or skin appearance prompt formal re-assessment using a risk assessment tool and clinical judgement. In addition a formal risk assessment should take place on a regular basis, the frequency depending on the patient population.

Background to the Propositions
Pressure ulcer prevention is typically considered to begin with the formal, or informal, assessment that an individual client may be vulnerable to developing these wounds, these processes are described as 'Risk assessment'. The presumed value of risk assessment lies in reducing the probability that the client will develop a pressure ulcer following the implementation of preventive measures upon the perception that a 'risk' exists.

Preventive measures should (at least) be taken immediately if an non-blanchable erythema (grade 1 pressure ulcer) and/or pressure ulcers develop. Non-blanchable erythema is reversible in the majority of cases if preventive measures are implemented in good time (135). If these measures are not taken, non-blanchable erythema may develop into a more serious injury in many cases (7, 74).

Patients with existing pressure ulcers have a higher risk of developing new pressure ulcers on other sites (65; 189). Therefore, when a pressure ulcer has developed, immediate preventive measures should be taken to prevent pressure ulcers on other sites of the body.

A variety of risk assessment scales are used (1, 13, 17, 21, 28, 36, 51, 53, 55, 61, 75, 112, 184, 80, 99, 124, 132, 206, 217). Frequently used scales are the Norton scale (155), the Braden scale (155) and the Waterlow scale (206). Most scales have not been scientifically studied for reliability and validity (65, 147). The research available is aimed at sensitivity and specificity of the risk assessment scales. However, sensitivity and specificity are influenced by the preventive measures taken, the length of the observation period and the nature of the group of people studied. Therefore, the sensitivity and specificity figures are not straightforward measures that can be used to judge the performance of the risk assessment scales (65, 111, 69, 70).

Use of preventive measures in patients at risk has the effect of lowering the risk of the individual. Vice versa, stopping preventive measures in patients at risk has the effect of increasing the risk of the individual.
The risk assessment scales include some items for which the link to pressure ulcers has not been established in longitudinal research. The individual numeric value, which is given to these items, has also not been validated (183). In addition the items in many risk assessment scales are not or only vaguely described and to be completed by the nursing staff subjectively.

Despite the limitations the use of risk assessment scales may lead to the systematic assessment of the risk of pressure ulcers (98, 202). However, it is not possible to recommend any one risk assessment tool over its alternatives (180, 181).

Informal assessment of risk also occurs in clinical practice; this reflects the clinical judgement, primarily of nursing staff. There is a lack of evidence to show whether the exercise of clinical judgement or use of a risk assessment tool provides the most accurate prediction of vulnerability to pressure ulcer development. (202, 118).
There is limited evidence to suggest that the use of a risk assessment scale may help develop the clinical decision-making skills in the nursing staff (98, 202). The use of a risk assessment scale may not be the only criterion used when making a decision on taking preventive measures. It is recommended to use the risk assessment scale as an aid in combination with the clinical judgement of the nursing staff. The total score cannot be a criterion for taking preventive measures, if the nursing staff judges differently. The score is only indicative for the degree of risk and not for the preventive methods to be used.

Pressure ulcers are caused by an oxygen deficit due to tissue-deformation. The tissue-deformation is caused by pressure and shearing forces. Immobility and reduced activity are observable parameters of pressure and shearing forces (155, 65). For this reason preventive measures must be taken to prevent pressure ulcers in patients for whom it is difficult to change position independently and are bed or chairbound (155, 65).

Primarily these interventions are likely to be directed towards the management of tissue deformation resulting from localised applied forces.

The frequency of risk assessment requires consideration. A clientís condition will not remain static and the frequency of assessment (both formal and informal) will be driven by the nature of the client population. For this reason it is necessary to assess the changes in health status of the patient daily. The frequency for formal risk analysis (i.e. using a risk assessment scale in combination with clinical judgement) depends on the population. Times when a formal risk analysis should definitely take place: if a patient becomes bed or chairbound, if the patientís condition seriously deteriorates or improves, if there is a sudden change in punctuations.

Risk assessment may be inappropriate where specific circumstances exist. For example in Intensive Care preventive measures are probably a universal requirement given the nature of the client population. Other specific circumstances can be identified where preventive measures may not require formal risk assessment - where a client presents with non-blanchable erythema (grade 1 pressure ulcer) or any other grade of pressure ulcers then preventive measures are required. Non-blanchable erythema is likely to be reversible if preventive measures are implemented in a timely manner. Furthermore clients with existing pressure ulcers have a higher risk of developing new pressure ulcers at other body locations. Therefore, where a pressure ulcer has developed, immediate preventive measures should be taken to prevent further pressure ulcer developing upon other parts of the body.