The greatest weapon in the war on pressure injury prevention may well be a risk assessment tool that tells caregivers who is most liable to develop an injury and how intense the injury might be.
A tool like that would help focus resources directly where they would be most useful. It would save time, money, and most probably, a great deal of suffering on the part of patients whose pressure injuries would be stopped early, before the most painful parts begin.
Unfortunately, that weapon is still in development, according to Dimitri Beeckman, Professor of Skin Integrity and Clinical Nursing at Ghent University in Belgium. "There are already more than 40 risk assessment scales available but debate continues about their usefulness," he said.
We might know what causes pressure injuries, but we have yet to develop reliable methods for spotting those who pose the greatest risks, he said.
The need for such a scale is so great, however, that every effort to find one that works will be worth the benefits it brings.
What Risk Assessment Needs to Measure
Since resources are always scarce compared to the need, risk assessment tools can help alleviate the financial crunch; if they can point to which patients need direct intervention and the most effective method of intervention, they could save both time and money.
Just as importantly, reliable risk assessment could help nurses and facility managers judge which patients are at the low risk end of the spectrum. "Not only is targeting the RIGHT patients key, but also NOT providing help to patients who don’t need it is significant! Everything costs," Prof. Beeckman explained.
Therefore, Prof. Beechman identifies three elements in effective risk assessment:
Sensitivity - to identify patients at risk of developing a pressure injury. This measures the number of positive cases correctly identified.
Specificity - to distinguish between those who are at risk from those not at risk. This measures the number of negative cases correctly identified.
Consistency - to identify both groups consistently and reliably. This determines the overall success of the measure to predict incidence of pressure injuries.
So far, risk assessment scales have not proven to be more effective than the rate of clinical judgment by trained nurses and experienced care workers, Prof. Beeckman testifies.
Current Methods of Risk Assessment... and Their Disadvantages
According to Prof. Beeckman, there are three current methods for risk assessment:
1. Numerical scales
This method assigns a risk factor score for patients so that care workers can see who is most vulnerable.
But according to Prof. Beeckman, many of the numerical scales fail to distinguish between causal factors such as immobility and significant risk factors such as people with diabetes or poor blood circulation. "So we have no idea how moisture or incontinence, for example, affects the total score," he reasoned.
He also noted that it is impossible to know if the scales are accurate tools for predicting the likelihood of a patient developing a pressure injury. Since a high score will trigger action to prevent any potential pressure injury, there is no way to know if the prediction was accurate and an injury was prevented, or if none would have developed anyway.
"It's impossible to know the real connection between risk scores and final outcome we’re measuring," he declared.
2. Clinical Judgment
This method is based on the expert knowledge of health workers and their ability to assess the probability of a patient developing pressure injuries. Nurses draw on well-known etiological factors and often expand the conditions covered by risk assessment scales.
Although this may be the most common way health facilities determine which patients are at the highest risk, the disadvantage lies in the fact that there is no objective criteria. This leads to questions about validity and reliability.
"Since there is no condition present that leads invariably to a pressure injury, you’re making an estimate about a condition to be developed," Prof. Beeckman disclosed.
3. Head-to-toe Assessment
This method involves a physical examination of the patient to determine if there are signs of pressure injuries starting to form. A nurse performing the assessment will look for signs of redness, edema, and hardness, among others.
Although this method has the benefit of a thorough examination of the skin surface, it has the drawback of being limited by what the eye can see. Damage on the cellular level is not visible to the naked eye and therefore the risk factor may not be fully discovered.
The Need is Growing
The battle against pressure injuries starts long before the first signs appear. Part of the battle is fought with better equipment, improved mattresses that help reduce or redistribute pressure, and better assessment of the patients themselves, including a holistic view of their risk factors.
But those on the front lines of the battle could be even more effective at preventing PI's if they had access to tools that help them determine better which patients need more of their attention. Budgets could go farther and patients could be given the care they need. Those who require greater prevention could receive that level of attention and those who are not at great risk could be spared the hassle of measures they don't need.
Risk assessment may be the final frontier of the battle. Technology may soon replace the need for numerical scales, clinical assessments, and even visual examinations.
It just might be the battle tool we need.