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PAPERS: Lisette Schoonhoven, Jeen R E Haalboom, Mente T Bousema, Ale Algra, Diederick E Grobbee, Maria H Grypdonck, and Erik Buskens Prospective cohort study of routine use of risk assessment scales for prediction of pressure ulcers BMJ 2002; 325: 797 [Abstract] [Full text]

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Tissue pH and pressure sores.

Richard G Fiddian-Green   (11 October 2002)

A holistic assessment needs more than just a pressure ulcer risk scale.

Helen J Longhurst   (17 October 2002)

Issues of Pressure Ulcer Risk Assessment

Peter J Franks, Donna Chaloner, Christine J Moffatt   (4 November 2002)

Tissue pH and pressure sores. 11 October 2002
Richard G Fiddian-Green, None None Send response to journal: Re: Tissue pH and pressure sores.	If pressure sores are the product of impaired tissue oxygenation, as is most likely, then the primary determinant of the likelihood of their development and healing will by the tissue pH (1,2). This might derived from measurements of transcutaneous pCO2 and arterial pH as in the tonometric method. The most important factors, other than local pressure interfering with tissue perfusion, are likely to be the adequacy of sytemic tissue oxygenation, best assessed from measurements of gastric intramucosal pH, and local infection. Lipopolysacchardides that might be present in colonising bacteria, notably E Coli, impair the uptake and utilization of oxygen probably by uncoupling oxidative phsophorylation. The prevention and management of pressure sores might be improved by attention to these pathogenetic mechanisms. 1. Fiddian-Green RG. Gastric intramucosal pH, tissue oxygenation and acid -base balance. Br J Anaesth. 1995 May;74(5):591-606. Review 2. Fiddian-Green RG. Monitoring of tissue pH: the critical measurement. Chest. 1999 Dec;116(6):1839-41
A holistic assessment needs more than just a pressure ulcer risk scale. 17 October 2002
Helen J Longhurst, primary Nurse Caversham Group Practice, NW5 2UP Send response to journal: Re: A holistic assessment needs more than just a pressure ulcer risk scale.	As a District Nurse who can nurse some very sick people, I often come across pressure ulcers. We use the Walsal Pressure Score Index to determine the likelihood of our patients developing a pressure ulcer. However, even though a valuble tool, it still does not distract from the fact that personal experience and holistic assessments greatly influence the outcome of how care is delivered to the patient, 'risk assessment tools should only be used as an aide memoire and should not replace clinical judgement',(RCN, 2001). There are many reasons why a person develops a pressure ulcer and they are often combined. They also develop in differing ways. At the end of the day we must assume that everyone has the potential to develop a pressure ulcer and treat holistically with all the facts. RCN (2001) Pressure Ulcer Risk Assessment and Prevention http://www.nelh.nhs.uk/guidelinesdb/html/PrUlcer-ft.htm#PrUlcer-SUMMARY- 2[online] [16th October 2002]
Issues of Pressure Ulcer Risk Assessment 4 November 2002
Peter J Franks, Professor of Health Sciences Thames Valley University, 32-38 Uxbridge Road, London W5 2BS, Donna Chaloner, Christine J Moffatt Send response to journal: Re: Issues of Pressure Ulcer Risk Assessment	Dear Sir Re: Prospective cohort study of routine use of risk assessment scales for prediction of pressure ulcers. BMJ 2002; 325: 797 We read with interest the article by Schoonhoven on risk assessment scales in pressure ulcer prevention [1]. As the authors point out there are at least 40 risk assessment scales in the literature of which to our knowledge none have been developed using sound epidemiological principles, with few undertaking formal assessments of validity and repeatability. It is perhaps unsurprising that these tools consistently fail to predict pressure ulcer development in at risk patients. We believe that there are a number of fundamental issues around the use of these scales. Firstly, whilst it is known that these scales are poor predictors of pressure ulcer development, nurses are encouraged to use them in order to meet the clinical governance agenda. The NICE guidelines recommend their use as an aide memoire which should not replace clinical judgement [2]. We would agree that nurses should not rely on these scales, but they do at least offer a framework for assessment. Clinical judgement on the other hand is much less easy to define, and will depend on a variety of reasons, not least the individual practitioners’ experience of dealing with similar patients. This leads to a paradox, that nurses are expected to assess the risk of pressure ulcer development, but using tools that are of limited value. The evidence from the present study is that they may have some value in detecting those who develop pressure ulcers (43.5 to 89.5% sensitivity in the total group, 72.9 to 95.9% in sub-population), but with high numbers of false positive responses. This has huge resource implications by providing prevention in patients who will not go on to develop pressure ulceration. Using the Braden scale, which has the highest PPV (8.1%), would mean that 728 of the 2190 patient weeks (33%) would use preventative measures to save 59 ulcers developing (assuming a 100% prevention success in those identified). This would also fail to identify 76 patients who would receive no prevention but who would develop a pressure ulcer. Furthermore there are issues around how practitioners' select which patients should undergo a risk assessment. Nurses frequently make decisions on who should be formally assessed for pressure risk, and thus they are pre-screening patients for consideration of pressure ulcer risk. Here clinical judgement is taking place before any formal risk assessment is undertaken. Whilst identifying patients at risk is a key component of pressure ulcer prevention, it is as important to provide good evidence on the ability of pressure relieving devices to prevent pressure ulceration. There are few quality RCTs on the use of pressure relief in reducing the incidence of pressure ulceration in patient groups, and of those undertaken the success in prevention is less than ideal. An investigation of a pressure relieving mattress in high risk patients with femoral neck fracture reduced the first week incidence of pressure ulceration from 65% down to 25% (p=0.013), but these trials are rare, and even with optimum care one quarter of patients still developed an area of ulceration. With changes in demography, earlier discharge from hospital, the threat of litigation and an ever higher reliance on community services, nurses and clinicians will need more potent evidence to support their management of patients 'at risk' of pressure ulceration. 1. Schoonhoven L, Haalboom JRE Bousema MT et al. Prospective cohort study of routine use of risk assessment scales for prediction of pressure ulcers. BMJ 2002; 325: 797 2. NICE. Pressure ulcer risk assessment and prevention. Inherited Clinical Guideline B. National Institute of Clinical Excellence, April 2001 3. Hofman A Geelkerken RH Wille J. Pressure sores and pressure- decreasing mattresses: controlled clinical trial. Lancet 1994; 343: 568- 571 Yours truly, Peter J Franks Professor of Health Sciences Donna Chaloner Nurse specialist, Walsall Primary Care Trust Christine J Moffatt Professor of Nursing Competing interests:   None declared