[Audio] Pressure Injury Risk Assessment Scales in the Intensive Care Unit: Implementing an ICU Focused Pressure Injury Risk Assessment Scale. 

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Pressure Injury Risk Assessment Scales in the Intensive Care Unit: Implementing an ICU Focused Pressure Injury Risk Assessment Scale

Katie Streeter RN, BSN, TCRN  Jordan Pearson RN, BSN, CNOR

[Audio] The objectives of this presentation and project are to understand the background of pressure injuries in ICU patients. Address health and economic impacts of pressure injuries. Discuss incidence and prevalence of pressure injuries in ICU patients. And Compare pressure injury risk assessment scales used in the ICU.. 

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Understand the background of pressure injuries in ICU patients.  Address health and economic impacts of pressure injuries.  Discuss incidence and prevalence of pressure injuries in ICU patients.  Compare pressure injury risk assessment scales used in the ICU.

[Audio] Pressure injuries, also known as "pressure ulcers," are one of the most complex and most serious adverse complications that can occur while a patient is being treated in the hospital. Simply put, a pressure injury is caused by pressure, friction, and/or shearing effects that occur on the patient's tissue over a period of time (Apostolopoulou et al., 2014).
Pressure injuries are graded stage 1-4, unstageable, or deep tissue injury. Stage 1: Non-blanchable erythema of intact skin and erythema remains for greater than 1 hour after relief of pressure
Stage 2: Partial-thickness loss of skin with exposed dermis
Stage 3: Full-thickness loss of skin tissue; subcutaneous skin and muscle may be visible
Stage 4: Full-thickness loss of skin tissue; tendons, bone, and joints may be visible
Unstageable: Full-thickness loss of skin tissue that is obscured by eschar or slough
Deep tissue: Skin that is persistently non-blanchable, with maroon or purple discoloration
(Mondragon et. Al., 2024). 

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Injury to the patient caused over time by pressure, friction, and/or shearing effects.
 Stages: Stage 1 Stage 2 Stage 3 Stage 4 Unstageable  Deep Tissue

[Audio] When discussing preventable adverse events within a hospital, pressure injuries are considered to be one of the most costly and preventable events (Chaboyer et al., 2018)
Pressure injuries increase the length of stay for the patient and increase their mortality rate while costing the hospital more money in order to treat the patient (Zhang et al., 2021)
According to the National Pressure Ulcer Advisory Panel, which was established in 1986, if proper early prevention and detection methods were put into place, over half of the reported pressure injury cases could have been prevented. The development of a pressure injury is considered a direct indicator of quality of care and the patient's safety (Zhang et al., 2021)
Patients in the ICU are considered to be high risk patients when it comes to developing a pressure injury. Patient related factors that contribute to this risk include advanced age, limited activity and mobility, level of consciousness, changes in perfusion parameters and nutritional status, presence of comorbidities such as diabetes/CHF/COPD and chronic renal failure, fecal incontinence, medications such as vasopressors/sedatives/steroids, and low hemoglobin and plasma protein levels (Adibelli & Korkmaz, 2019)
With that being said, it is vital to use the correct pressure injury risk assessment scale that takes into consideration all of these risk factors when caring for patients in the ICU.. 

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Pressure injuries (PI) are the most costly & preventable events that can occur within a hospital Health & economic consequences  National Pressure Ulcer Advisory Panel   Quality of care and patient safety  ICU patients are considered HIGH RISK patients Over 40 different pressure injury risk assessment scales  ICU pressure injury risk assessment scale

[Audio] 2.5 million people develop pressure injuries yearly in the United States (Higgins et al., 2020)
The incidence of pressure injuries in ICU patients ranges from 2.8% - 53.4% while the incidence for medical-surgical patients is only 2.0% - 8.3% (Zhang et al., 2021) . The prevalence of pressure injuries in ICU patients is 14%-33% (Higgins et al., 2020)
These numbers make it very clear that ICU patients are high risk patients when it comes to developing a pressure injury.. 

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2.5 million people develop pressure injuries yearly in the United States Incidence in ICU patients: 2.8%-53.4 % Incidence in medical-surgical patients: 2.0%-8.3% Prevalence in ICU patients: 14 %-33%  Average cost per pressure injury: $50,000 Average yearly cost in the United States: $26.8 billion

[Audio] Pressure injuries are associated with significant health burdens and are preventable. Healthcare providers use risk assessment scales to identify patients at higher risk for pressure injuries and determine the amount and type of preventative interventions to decrease the incidence, or severity of pressure ulcers. Risk assessment scales, along with the clinical judgement and assessment of healthcare providers can help identify high risk patients and prevent pressure injuries.. 

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Identify high risk patients Initiate early interventions Decrease the health burden on the patient Prevent longer hospital stays Decrease the economic impact for the patient and facility

[Audio] When it comes to the cost of treating pressure injuries, on average, each pressure injury cost the hospital $50,000 (Higgins et al., 2020)
Yearly, the average cost in the United States to treat pressure injuries is $26.8 billion (Higgins et al., 2020) President Bush signed the Deficit Reduction Act of 2005 which allowed for quality adjustment of Medicare payments for inpatient hospital services. The Deficit Reduction Act of 2005 is important in regard to pressure injuries because it required the Secretary of Health and Human Services to identify two hospital acquired conditions that could have been prevented through the application of evidence based guidelines and would be subject to the adjustment in payment. These acquired conditions were then given the name of "never event" with pressure injuries being one of them. Three years after the Deficit Reduction Act of 2005 was signed, the Centers for Medicare & Medicaid discontinued reimbursement to hospitals for hospital-acquired pressure injuries.. 

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Average cost per pressure injury: $50,000 Average yearly cost in the United States: $26.8 billion Deficit Reduction Act of 2005 “Never Events”  Centers for Medicare & Medicaid reimbursement

[Audio] The Braden Scale was created in 1987 for the general patient population (Higgins et al., 2020)
The Braden Scale is a subjective pressure injury risk assessment scale takes six factors into consideration when assessing a patients risk of developing a pressure injury: sensory perception, moisture, activity, mobility, friction & shear, and nutrition status (Higgins et al., 2020)
Scores for each factor range from 1 (least favorable) to 4 (most favorable condition) except for friction and shear for which a score of 3 indicates the most favorable condition (Higgins et al., 2020)
The range of overall scores is 6-23. The lower the score is, the higher risk the patient is to develop a pressure injury (Higgins et al., 2020)
The Braden Scale has an overall specificity, sensitivity, negative predictive value, and positive predictive value of 95%, 17%, 78%, and 53% respectively (Higgins et al., 2020)
Simply put, these numbers indicate that the Braden Scale demonstrates poor predictive qualities along with poor discriminatory ability in the ICU patient population (Higgins et al., 2020). 

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Created in 1987   Subjective Six Factors: sensory perception, moisture, activity, mobility, friction & shear, and nutrition status Range of scores is 6-23 Specificity: 95% Sensitivity: 17% Negative Predictive Value: 78% Positive Predictive Value: 53% Area Under the Curve: 0.710

[Audio] Braden Scale Adult (2022). [Chart]. NPCS Clinical Resources. https://www.mghpcs.org/EED/SK/resources.shtml. 

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[Audio] The Jackson Cubbin Scale was created in 1991 and later revised in 1999 (Higgins et al., 2020)
This scale is an objective scale that was made specifically for patients in the ICU (Higgins et al., 2020)
Takes 12 domains into consideration when assessing a patients risk for developing a pressure injury: age, weight, medical history, general skin condition, mental status, mobility, hemodynamic status, respiratory status, oxygen requirements, nutrition, incontinence, and hygiene (Higgins et al., 2020)
Each domain is scored from 1 (increased risk) to 4 (decreased risk) with a range of scores being 9-48
Lower score indicates higher risk for patient to develop a pressure injury Additionally, there are 1 point deductions for trips to the OR or imaging (CT or MRI) that happen in the preceding 48 hours, blood product transfusion in the preceding 24 hours, and hypothermia (core temp of less than or equal to 35 degrees Celsius) The Jackson Cubbin Scale has an overall specificity, sensitivity, negative predictive value, and positive predictive value of 92%, 54%, 87%, and 66% Indicating that it is a more suitable pressure injury risk assessment scale to use in the ICU when compared to the Braden Scale (Higgins et al., 2020). 

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Created in 1991 and later revised in 1999  Objective 12 Domains: age, weight, medical history, general skin condition, mental status, mobility, hemodynamic status, respiratory status, oxygen requirements, nutrition, incontinence, and hygiene Each domain is scored from 1 (increased risk) to 4 (decreased risk) 1 Point Deductions: trips to the operating room, imaging, blood product transfusion, and hypothermia Range of Scores: 9-48  Specificity: 92% Sensitivity: 54% Negative Predictive Value: 87% Positive Predictive Value: 66%

[Audio] Kim, E., Choi, M., Lee, J., & Kim, Y. A. (2013). Reusability of EMR data for applying cubbin and Jackson pressure ulcer risk assessment scale in critical care patients. Healthcare Informatics Research, 19 (4), 261-270. https://doi.org/10.4258/hir.2013.19.4.261. 

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Categories of scale
Age (yr)
40-54
55-69
Weight
Average weight
Obese
e c tic
Any of above and edema
General skin condition
Inta ct
Red skin
Grazed/ excoriated skin
Necrosis/
Mental condition
Awake and alert
Agitated/ restless/ confused
Apathetic/sedated but responsive
Coma 'unresponsive
Mo bility
Fully ambulant
Walks with slight help
Very limited/chairbound
Immobile/bedrest
Hemodynamics
Stable Without inotropic support
Stable with inotropic support
Unstable With inotropic rt
Critical With inotropic support
Respiration
Spontaneous
CPAP/T-piece
Mechanical ventilation
Breathless at rest/on exertion
Nutrition
Full diet, fluids
Light diet/oral fluids/enteral feeding
paren teral feeding
Clear intravenous fluid only
Score
4
3
2
4
2
4
3
3
4
3
2
3
3
2
Operational definition
Age at the time of admission to the ICU
BMI on the medical record at the time of admission to the ICU
Edema on the assessment form
No pressure ulcer, no sore or sore none on the nursing record
Redness on the nursing record
Abrasion, or bullae on the nursing record
Necrosis on the nursing record
Consciousness on the assessment form at the time of admission to the
ICU
Not applicable
Not applicable
3 or 4 on position change score of Braden scale
1 or 2 on position change score of Braden scale
MBP 65 mmHg Without inotropic support
MBP 2 65 mmHg with inotropic support
55 mmHg < MBP < 65 mmHg With inotropic support
MBP 55 mmHg With inotropic support
Airway and oxygen supply on the assessment form at the time Of
admission to the ICU
Prescription of regular diets or soft d]ets
Prescription of enteral nutrition, or full liquid diets without regular or
soft diets
Prescription of TPN only without diets or enteral nutrition
No prescription of TPN, enteral nutrition or diets

[Audio] When comparing the difference in the Braden scale verse the Jackson Cubbin scale it is important to know why the different scales should be used among different hospital populations. The Braden scale is a general risk assessment scale while the Jackson Cubbin scale is created specifically for ICU patient population due to the significant limitations when it comes to assessing them (Zhang et al., 2021).
The Braden scale scores are based on 6 risk factors of the patient: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
This scale takes the following twelve factors into consideration: age, weight, past medical history, general skin condition, mental condition, mobility, hemodynamics, respiratory status, oxygen requirement, nutrition, incontinence, and hygiene (Adibelli & Korkmaz, 2019).
The Jackson Cubbin also allows for deductions in points based on if the patient went to the operating room or has imaging such as a computed tomography scan (CT). According to the National Pressure Ulcer Advisory Panel, which was created in 1986, if early prevention and detection methods were put into place, over half of the reported pressure injury cases could have been prevented. This is why the appropriate use of risk assessment tools is important in the prevention of pressure ulcers, and why we are incorporating the Jackson-Cubbin Scale into practice in ICU patient populations.. 

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Jackson-Cubbin Scale
 Created specifically for ICU patients 12 risk factors assessed  Allows for deduction in points

Braden Scale
 Created as a general risk assessment 6 risk factors assessed

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Adibelli, S., & Korkmaz, F. (2019). Pressure Injury Risk Assessment in Intensive Care Units: Comparison of the Reliability and Predictive Validity of the Braden and Jackson/Cubbin Scales. Journal of Clinical Nursing, 28 (23-24), 4595-4605. https://doi.org/10.1111/jocn.15054 Apostolopoulou, E., Tselebis, A., Terzis, K., Kamarinou, E., Lambropoulos, I., & Kalliakmanis,  A. (2014). Pressure Ulcer Incidence and Risk Factors in Ventilated Intensive Care Patients. Health Science Journal, 8 (3), 333-342.  Braden Scale Adult (2022). [Chart]. NPCS Clinical Resources. https://www.mghpcs.org/EED/SK/resources.shtml Chaboyer, W. P., Thalib, L., Harbeck, E. L., Coyer, F. M., Blot, S., Bull, C. F., Nogueira, P. C., & Lin, F. F. (2018). Incidence and Prevalence of Pressure Injuries in Adult Intensive Care Patients: A Systematic Review and Meta-Analysis. Critical Care Medicine, 46 (11), 1074–1081. https://doi.org/10.1097/ccm.0000000000003366  Higgins, J., Casey, S., Taylor, E., Wilson, R., & Halcomb, P. (2020). Comparing the Braden and Jackson/Cubbin Pressure Injury Risk Scales in Trauma-Surgery ICU Patients. Critical Care Nurse, 40 (6), 52-61. https://doi.org/10.4037/ccn2020874 Kim, E., Choi, M., Lee, J., & Kim, Y. A. (2013). Reusability of EMR data for applying cubbin and Jackson pressure ulcer risk assessment scale in critical care patients. Healthcare Informatics Research, 19 (4), 261-270. https://doi.org/10.4258/hir.2013.19.4.261  Mondragon N, Zito PM. Pressure Injury. [Updated 2024 Feb 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557868/ Zhang, Y., Zhuang, Y., Shen, J., Chen, X., Wen, Q., Jiang, Q., & Lao, Y. (2021) Value of Pressure Injury Assessment Scales for Patients in the Intensive Care Unit: Systematic Review and Diagnostic Test Accuracy Meta-Analysis. Intensive and Critical Care Nursing, 64, 103009. https://doi.org/10.1016/j.iccn.2020.103009

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Pressure Injury Risk Assessment Scales in the Intensive Care Unit: Implementing an I-C-U Focused Pressure Injury Risk Assessment Scale

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The objectives of this presentation and project are to understand the background of pressure injuries in I-C-U patients. Address health and economic impacts of pressure injuries. Discuss incidence and prevalence of pressure injuries in I-C-U patients. And Compare pressure injury risk assessment scales used in the I-C-U-.

Pressure injuries
 also known as "pressure ulcers
" are one of the most complex and most serious adverse complications that can occur while a patient is being treated in the hospital. Simply put
 a pressure injury is caused by pressure
 friction
 and/or shearing effects that occur on the patient's tissue over a period of time (Apostolopoulou and others
 2014).
Pressure injuries are graded stage 1-4
 unstageable
 or deep tissue injury. 
Stage 1: Non-blanchable erythema of intact skin and erythema remains for greater than 1 hour after relief of pressure
Stage 2: Partial-thickness loss of skin with exposed dermis
Stage 3: Full-thickness loss of skin tissue; subcutaneous skin and muscle may be visible
Stage 4: Full-thickness loss of skin tissue; tendons
 bone
 and joints may be visible
Unstageable: Full-thickness loss of skin tissue that is obscured by eschar or slough
Deep tissue: Skin that is persistently non-blanchable
 with maroon or purple discoloration
(Mondragon et. Al.
 2024)

When discussing preventable adverse events within a hospital
 pressure injuries are considered to be one of the most costly and preventable events (Chaboyer and others
 2018)
Pressure injuries increase the length of stay for the patient and increase their mortality rate while costing the hospital more money in order to treat the patient (Zhang and others
 2021)
According to the National Pressure Ulcer Advisory Panel
 which was established in 1986
 if proper early prevention and detection methods were put into place
 over half of the reported pressure injury cases could have been prevented. 
The development of a pressure injury is considered a direct indicator of quality of care and the patient's safety (Zhang and others
 2021)
Patients in the I-C-U are considered to be high risk patients when it comes to developing a pressure injury. Patient related factors that contribute to this risk include advanced age
 limited activity and mobility
 level of consciousness
 changes in perfusion parameters and nutritional status
 presence of comorbidities such as diabetes/CHF/COPD and chronic renal failure
 fecal incontinence
 medications such as vasopressors/sedatives/steroids
 and low hemoglobin and plasma protein levels (Adibelli & Korkmaz
 2019)
With that being said
 it is vital to use the correct pressure injury risk assessment scale that takes into consideration all of these risk factors when caring for patients in the I-C-U-.

2.5 million people develop pressure injuries yearly in the United States (Higgins and others
 2020)
The incidence of pressure injuries in I-C-U patients ranges from 2.8%  53.4% while the incidence for medical-surgical patients is only 2.0%  8.3% (Zhang and others
 2021) . 
The prevalence of pressure injuries in I-C-U patients is 14%-33% (Higgins and others
 2020)
These numbers make it very clear that I-C-U patients are high risk patients when it comes to developing a pressure injury.

Pressure injuries are associated with significant health burdens and are preventable. 
Healthcare providers use risk assessment scales to identify patients at higher risk for pressure injuries and determine the amount and type of preventative interventions to decrease the incidence
 or severity of pressure ulcers. 
Risk assessment scales
 along with the clinical judgement and assessment of healthcare providers can help identify high risk patients and prevent pressure injuries.

When it comes to the cost of treating pressure injuries
 on average
 each pressure injury cost the hospital $50
000 (Higgins and others
 2020)
Yearly
 the average cost in the United States to treat pressure injuries is 26 point 8  billion dollars (Higgins and others
 2020) 
President Bush signed the Deficit Reduction Act of 2005 which allowed for quality adjustment of Medicare payments for inpatient hospital services. 
The Deficit Reduction Act of 2005 is important in regard to pressure injuries because it required the Secretary of Health and Human Services to identify two hospital acquired conditions that could have been prevented through the application of evidence based guidelines and would be subject to the adjustment in payment. 
These acquired conditions were then given the name of "never event" with pressure injuries being one of them. 
Three years after the Deficit Reduction Act of 2005 was signed
 the Centers for Medicare & Medicaid discontinued reimbursement to hospitals for hospital-acquired pressure injuries.

The Braden Scale was created in 1987 for the general patient population (Higgins and others
 2020)
The Braden Scale is a subjective pressure injury risk assessment scale takes six factors into consideration when assessing a patients risk of developing a pressure injury: sensory perception
 moisture
 activity
 mobility
 friction & shear
 and nutrition status (Higgins and others
 2020)
Scores for each factor range from 1 (least favorable) to 4 (most favorable condition) except for friction and shear for which a score of 3 indicates the most favorable condition (Higgins and others
 2020)
The range of overall scores is 6-23. The lower the score is
 the higher risk the patient is to develop a pressure injury (Higgins and others
 2020)
The Braden Scale has an overall specificity
 sensitivity
 negative predictive value
 and positive predictive value of 95%
 17%
 78%
 and 53% respectively (Higgins and others
 2020)
Simply put
 these numbers indicate that the Braden Scale demonstrates poor predictive qualities along with poor discriminatory ability in the I-C-U patient population  (Higgins and others
 2020)

Braden Scale Adult (2022). [Chart]. N-P-C-S Clinical Resources. mghpcs

The Jackson Cubbin Scale was created in 1991 and later revised in 1999 (Higgins and others
 2020)
This scale is an objective scale that was made specifically for patients in the I-C-U (Higgins and others
 2020)
Takes 12 domains into consideration when assessing a patients risk for developing a pressure injury: age
 weight
 medical history
 general skin condition
 mental status
 mobility
 hemodynamic status
 respiratory status
 oxygen requirements
 nutrition
 incontinence
 and hygiene (Higgins and others
 2020)
Each domain is scored from 1 (increased risk) to 4 (decreased risk) with a range of scores being 9-48
Lower score indicates higher risk for patient to develop a pressure injury  
Additionally
 there are 1 point deductions for trips to the OR or imaging (CT or M-R-I--) that happen in the preceding 48 hours
 blood product transfusion in the preceding 24 hours
 and hypothermia (core temp of less than or equal to 35 degrees Celsius) 
The Jackson Cubbin Scale has an overall specificity
 sensitivity
 negative predictive value
 and positive predictive value of 92%
 54%
 87%
 and 66% 
Indicating that it is a more suitable pressure injury risk assessment scale to use in the I-C-U when compared to the Braden Scale (Higgins and others
 2020)

Kim
 E.
 Choi
 M.
 Lee
 J.
 & Kim
 Y A  (2013). Reusability of E-M-R data for applying cubbin and Jackson pressure ulcer risk assessment scale in critical care patients. Healthcare Informatics Research
 19 (4)
 261-270. doi

When comparing the difference in the Braden scale verse the Jackson Cubbin scale it is important to know why the different scales should be used among different hospital populations.  The Braden scale is a general risk assessment scale while the Jackson Cubbin scale is created specifically for I-C-U patient population due to the significant limitations when it comes to assessing them (Zhang and others
 2021).
The Braden scale scores are based on 6 risk factors of the patient: sensory perception
 moisture
 activity
 mobility
 nutrition
 and friction/shear.
This scale takes the following twelve factors into consideration: age
 weight
 past medical history
 general skin condition
 mental condition
 mobility
 hemodynamics
 respiratory status
 oxygen requirement
 nutrition
 incontinence
 and hygiene (Adibelli & Korkmaz
 2019).
The Jackson Cubbin also allows for deductions in points based on if the patient went to the operating room or has imaging such as a computed tomography scan (C-T---). 
According to the National Pressure Ulcer Advisory Panel
 which was created in 1986
 if early prevention and detection methods were put into place
 over half of the reported pressure injury cases could have been prevented. This is why the appropriate use of risk assessment tools is important in the prevention of pressure ulcers
 and why we are incorporating the Jackson-Cubbin Scale into practice in I-C-U patient populations.