A pressure ulcer (PrU) is a localized injury to the skin and/or deep tissues that is due to pressure, friction, or shearing forces. Pressure ulcers are strongly associated with serious comorbidities, particularly inadequate nutrition and immobility.1,2 Pressure ulcers increase hospital costs significantly. In the U.S., PrU care is about $11 billion annually and a cost of between $2,000 and $21,410 per individual PrU.3-5
The impact of nosocomial PrUs remains a key health and economic concern of acute care facilities worldwide. In the U.S., about 2.5 million inpatients annually develop some degree of a PrU during their hospital stay. The reported incidence rates range from 0.4% to 38%.3,6 Each year about 60,000 people die of complications of a PrU.3,6,7 Inadequate nutrition is a critical factor that contributes to the incidence of PrUs.8-12 Consequences of inadequate nutrition have included alterations in skin integrity resulting in PrUs, longer hospital stays, increased costs of care, and higher rates of mortality.9 As a patient’s nutritional status becomes compromised, the likelihood of developing a PrU increases, especially if an individual is immobilized.7,9-11,13
Braden Scale History
The Braden Scale for Predicting Pressure Sore Risk was developed by Barbara Braden, PhD, RN, and Nancy Bergstrom, PhD, RN, in 1987.14,15 Originally established for use in long-term care facilities, the scale is recommended by the National Pressure Ulcer Advisory Panel in its clinical practice guidelines and is the most frequently used risk assessment tool by nurses in acute care facilities worldwide.1
The scale is composed of 6 factors: sensory perception, moisture, activity, mobility, friction and shear, and nutrition.14 Each factor is scored on a scale of 1 to 4 points (friction and shear are scored on a point scale of only 1 to 3) for a total possible score of 6 to 23 points (the lower the score, the greater the assumed PrU risk).
The Braden nutrition subscale relies heavily on recording observed or patient self-reported eating habits. It is typically documented by nurses who assess the daily intake of meals: recording a score of 4 if the patient’s meal intake is excellent (eats most of every meal), 3 if the patient’s intake is adequate (eats more than half of most meals), 2 if the patient’s intake is probably inadequate (rarely eats a complete meal), and 1 if a patient’s intake is very poor (never eats a complete meal) (Table 1).14
Historically, the Braden scale is reported to have good reliability when used by registered nurses as a risk prediction tool.14,16 A recent review also reported high interrater reliability of the Braden scale total score among nurses, nursing assistants, and graduate assistants.17 However, other studies suggest certain subscales (such as sensory and nutrition) may have very low interrater reliability among nurses and poor PrU predictability.18,19 To date, there are no known studies evaluating the agreement of the Braden nutrition subscale primarily used by nurses and the VA Nutrition Classification Scheme (VANCS) used by dietitians.
The VA standard of care recommends that PrU risk assessments are documented for all hospitalized veterans within 24 hours of admission, daily, with transfers or discharges, and when there is a status change in the patient. In addition, nutritional assessments by dietitians (using the VANCS) are encouraged within 24 hours of acute care hospitalization.20
The VANCS performed by dietitians consists of 4 classifications: no nutritional compromise, mild nutritional compromise, moderate nutritional compromise, and severenutritional compromise. These classifications are based on well-documented “comprehensive approaches to defining nutritional status that uses multiple parameters” including nutrition history, weight (body mass index and weight loss), diagnoses, diet (and diet orders), brief physical assessment, and preliminary laboratory data (serum albumin/pre-albumin and total lymphocyte count).20,21
The predictive ability of a risk assessment tool is critical to its clinical effectiveness in determining a clinical outcome.17 The Braden scale has been used for more than 30 years in various settings without any significant change to the scale or subscales. In a 2012 study, 4 medical factors were found to be more predictive of PrUs than the Braden scale total score in a sample of 213 acutely ill adult veterans.8 By performing a retrospective study using logistic regression predictive models, severe nutritional compromise (as identified by a dietitian), pneumonia, candidiasis, and surgery were identified as stronger predictors of PrU risk than was the Braden total score.8
With malnutrition as one of the most significant predictive factors in PrU risk, it is critical to determine whether discrepancies exist between the Braden nutrition subscale used primarily by nurses and the VANCS used by dietitians. Hence, the overall purpose of this study was to determine the level of agreement between the Braden nutrition subscale scores documented by nurses and the VANCS used by dietitians and examine the relationship of these assessments with PrU development.