How Well Does the Braden Nutrition Subscale Agree With the VA Nutrition Classification Scheme Related to Pressure Ulcer Risk?

Methods

The parent study was approved by the University of Florida Institutional Review Board before data collection. This secondary analysis of the parent study examined data already collected by Cowan and colleagues, which demonstrated the significance of nutritional compromise in PrU risk.⁸

The de-identified data subset consisted of general demographics, hospital length of stay, specific diagnoses, Braden scores, PrU status, and registered dietician nutritional classification data from 213 acutely ill veterans admitted to North Florida/South Georgia Veterans Health System (NF/SGVHS) in Florida for more than 3 days between January and July 2008.⁸ The sample consisted of 100 veterans with nosocomial PrUs and 113 veterans without PrUs during their admission.

Scoring

Using the de-identified dataset, the variables of interest (VANCS, Braden nutrition subscale score, and the presence/absence of PrU) were coded. The VANCS was given a corresponding score ranging from 1 to 4 (1, severe nutritional compromise; 2, moderate nutritional compromise; 3, mild nutritional compromise; and 4, no nutritional compromise). The Braden nutrition subscale ranged from 1 to 4 (1 very poor nutrition; 2, probably inadequate nutrition; 3, adequate nutrition; and 4, excellent nutrition). PrU development was coded as 0, no PrU development and 1, PrU development. All nutritional assessments had been recorded in the electronic health record before any PrU reported in the parent study.

Statistical Analysis

After coding the variables of interest, the data were transferred into SAS v 9.4 (Cary, NC). The data collected compared VANCS and Braden nutrition subscale results. In addition, the authors examined the agreement between the score assigned to the VANCS and Braden nutrition subscale results with a weighted κ analysis. Further, to determine the relationship between PrU and each of the nutrition assessment methods, chi-square or Fisher exact tests were conducted. The level of significance was set at .05.

Additionally, the authors computed sensitivity and specificity of the Braden nutrition subscale using the VANCS as the gold standard. The severe and moderately compromised categories of the VANCS combined to form the high-risk category, and the mild-to-no compromise categories were combined to form the low-risk category. The Braden nutrition subscale was similarly dichotomized with the very poor and probably inadequate intake forming the high-risk category and the adequate and excellent intake forming the low-risk category. Sensitivity and specificity of the Braden were then calculated.

Results

Nursing assessments using the Braden nutrition subscale were completed on 213 patients whose mean age (SD) was 71.0 (10.6) years. The VANCS documented by dietitians was completed on 205 patients. For 7 patients, a nutrition assessment was documented only by the Braden nutrition subscale and not the VANCS. Most of the patients were male (97%, n = 206), and white (81.4%, n = 171). The weighted κ statistic used to measure agreement between the Braden nutrition subscale and the VANCS was .17 (95% confidence interval = .07, .28).

Landis and colleagues suggest that a κ value of .17 may be interpreted as “fair” agreement.²² Figure 1 shows the agreement seen between the Braden nutrition subscale and VANCS. There was no strong agreement identified. Within each VANCS (severe compromise, moderate compromise, mild compromise, or no compromise), the numbers of patients rated as 1 (very poor intake), 2 (intake probably inadequate), or 3 (intake adequate) on the Braden nutrition subscale is given.

Figure 2 shows the percentage of patients who developed a PrU during hospitalization among different measures of Braden nutrition subscale vs VANCS. In Figure 2, nutritional categories 1, 2, and 3 correspond to very poor intake (Braden)/severe compromise (VANCS), probably inadequate intake (Braden)/moderate compromise (VANCS), and adequate intake (Braden)/mild compromise (VANCS), respectively. There were 3 patients who had a no compromise VANCS; none of these had a PrU, so their data are not represented in Figure 2.

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Discussion

Findings from this study indicate that the VANCS documented by dietitians is superior in assessing nutritional risk and predicting the development of PrUs in acutely ill hospitalized veterans compared with the Braden nutrition subscale. This study also shows that the Braden nutrition subscale did not accurately predict PrU development in acutely ill veterans. This finding concurs with the Serpa and Santos study in which the Braden nutrition subscale scores were not predictive for PrU development in hospitalized patients.²³ They found that serum albumin levels and subjective global nutrition assessments were superior nutritional predictors of PrU development. These findings suggest modifications or enhancements are needed to address how nurses assess nutritional risk for PrUs in hospitalized patients.