From the Editor: Sometimes We Might Need to Step Off the Scale(s)

The February issue of Ostomy Wound Management traditionally addresses the pressure ulcer, one of the most challenging of medical events. This month we present the results of prospective, descriptive research on medical device-related pressure ulcers and an evaluation of a risk analysis scale, both in the intensive care setting, as well as results of a pilot study assessing nurse’s opinions of 2 popular pressure ulcer risk scales. In light of the examinations and re-examinations of pressure ulcer risk scales we have published, I have a question: why in certain care arenas are pressure ulcer risk scales necessary? Isn’t pressure ulcer risk and subsequent response obvious to the advanced practice clinician managing the patient in these circumstances? Where does clinical common sense come in?

The inception of pressure ulcer risk scales developed by insightful wound care advocates such as Barbara Braden helped dispel the notion that a pressure ulcer (a bed sore back then) was no big deal and turn the tide for patients who suffered needlessly. Without question, practitioners should be educated to be aware of key factors that put patients at risk for pressure ulcers (another valid use of the scales). However, as a lay observer, I assert in persons requiring intensive care and in patients known to have compromised or fragile skin (eg, the very young and the very old), heightened suspicion of the potential for pressure ulcers and appropriate pressure ulcer prevention should be automatic. But as our Clinical Editor is quick to note, it isn’t.

A few examples: a person has been admitted through the emergency department—unless contraindicated, why not offer a protective surface between a sensitive coccyx or immobile heel and an unyielding gurney? A patient is in the ICU; obviously, his/her compromised health will impact the skin. Shouldn’t response be immediate and include implementing well-known evidence-based, preventive approaches (eg, support services, turning, protection from further injury)? An infant has a nasogastric tube placed — is official assessment required to provide a soft protective dressing?

Most protocols require pressure ulcer risk assessment within 24 hours of admission to a facility. In some cases, why does it need to take that long or even be officially conducted? I understand the need for a thorough pressure ulcer risk assessment for a patient admitted for nonemergent medical and surgical reasons. But why can’t the clinician assume some patients present as high risk? Is pressure ulcer prevention considered invasive or noncost-efficient? Proactive preventive intervention should be as reflexive as covering a cold patient with a blanket. Why can’t certain populations be managed according to an at-risk protocol, which my Clinical Editor informs me some ICUs already have instituted.

In Hanonu et al’s article in this issue regarding medical device-related pressure ulcers occurring in ICUs, 40% of participants developed a pressure ulcer over the course of the 6-week study. One would like to assume expedient preventive measures (not mentioned) might have lessened ulcer incidence. With these and other published data, preventive measures in the presence of medical devices are warranted without weighing and weighting the role of readily observed ill-health and immobility, especially when data presented by Ahtiala et al on a modified Jackson/Cubbin Scale, specifically developed for assessing ICU patients, documents risk with greater accuracy than its original version... or, as in Avsar et al, whether the Braden Scale or Waterlow Scale is more accepted by a specific group of nurses, who (as the author admits) are just discovering the benefits of using a risk assessment scale.

I am not demeaning valuable research that underscores the importance of assessing pressure ulcer risk. At this point, anyone not completing a pressure ulcer risk assessment will be in big trouble. In addition, although some authors have noted clinician assessment doesn’t always jive with results of formal risk assessment scale scores, a congruence has been found between the assessments of experienced nurses and risk scales. Research also supports that thorough assessment should incorporate both types of evaluation, ensuring the value of both approaches. Truth be told, the scales require a minimum amount of time to administer and help ensure documentation of skin examination. My question is whether we can safely assume risk in patients in specific circumstances. Our Clinical Editor suggests it might behoove researchers to conduct a study comparing the outcomes of an everyone-is-at-risk approach to completing risk scales and acting accordingly in some populations.

As a layperson, here’s my advice: Clinician, if warranted and not contraindicated by extenuating medical conditions, get thy ICU patient on an overlay. Be wary of any device that sits on or rubs against the skin of a frail elder or premature infant. In the interest of being PC (a proactive caregiver), go with your gut. Perhaps we can reach a point where we can save the checklist for patients whose conditions may or may not require pressure ulcer risk assessment, situations where the treatment is not obvious.

This article was not subject to the Ostomy Wound Management peer-review process.