刘 明，古 勤，袁浩斌，冯荣楷（澳门理工学院高等卫生学校）

1 Introduction

Pressure ulcers（PU）development is amajor problem，which has been regarded as an essential indicator of patient care quality［1］.It causes patients’severe emotional and physical stress as well as creating asignificant financial burden on themselves and the whole healthcare system［2］.The cost of hospitalization，caring，lost earnings by the patients and sometimes family caretakers are explicitly visible，while the impact of loss of self－esteem，continuous pain，and possible depression are difficult to quantify but are certainly existing［3］.Patients with pressure ulcers cost 50%more in acute care hospitals in the USA［4］.In the UK，the attributable cost of wound care in 2006－2007 was 9.89million pounds［5］，and in China，according t datafrom epidemiological studies，the incidence o chronic ulcers in surgical hospitalized patients is 1.5%t 20.3%，which brings ahuge financial burden to pa tients，families and healthcare systems［6］.The inten sive care unit（ICU）patients are under high risk o pressure ulcers development［7，8］with incidence o 10.5%to 45.5%.Patients in the ICU frequently suf fer from severe conditions that are risk factors o pressure ulcers including，multisystem organ failure multiple comorbidities，hemodynamic instability，sen sory impairment，incontinence and limited mobili ty［9－11］.Groeneveld and colleagues reported that th prevalence of pressure ulcer in the ICU was 26.3%，with 29.2%in adult patients and 13.1%in pediatric patients［7］；while Kates and Callahan reported up to 40%of critical care patients have pressure ulcers［12］.However，it is well recognized that pressure ulcers can be effectively prevented by various accurate risk assessment tools［13］，in which the Braden scale，Norton scale，Gouglas scale，Waterlow scale，and Cubbin ＆Jackson scale are most widely used.Each of these scales has been reported to have reasonable predictive value across settings.According to Seongsook，only limited number of studies have criticized the validity of different scales for patients in the ICUs who are at higher risk of developing pressure ulcers［10］.Brown［14］stated that the effectiveness of a tool can be examined with several indicators：①sensitivity，also referred as the true－positive（TP）rate of a tool，the percentage of people who develop apressure ulcer；②specificity，also referred as the true－negative（TN）rate of a tool，the percentage of people who do not develop apressure ulcer and were classified as not at risk；③positive predictive value（PPV），the percentage of people classified as at risk who develop apressure ulcer；④negative predictive value（NPV），the percentage of people classified as not at risk who do not develop apressure ulcer.The American National Pressure Ulcer Advisory Panel further advised that an ideal‘at risk’assessment tool should：（a）be easy to use；（b）have good predictive value；（c）have a high sensitivity；（d）have a high specificity［15］.Therefore，it is very important to identify the most reliable，sensitive and appropriate tool for clinical practice.

2 Pressure ulcer risk assessment tools used in ICU patients

2.1 Braden scale The Braden scale was first presented by Bergstrom and Braden［16］.The scale is composed of six subscales：Activity，mobility，nutritional status，moisture，sensory perception，friction and shear.The minimum score for each item is 1and the maximum score is 3or 4with the potential scores ranging from 6to 23.Low score indicates high risk of pressure ulcer development and the cutoff scores between≤14and≤18have been used in different studies.

2.2 Norton scale The Norton scale，developed in 1979and revised in 1987［17］，is composed of five subscales（general physical condition，mental state，activity，mobility and incontinence）with a 4－point scale（1＝very bad，4＝good）.The maximum score is 20with the cut－off score of≤14or≤16.

2.3 Waterlow scale The Waterlow scale consists of ten categories（sex／age，build／weight for height，appe tite，mobility，continence，medication，skin type，tissu malnutrition，neurological deficit，major surgery o trauma），each containing a number of subscales，whic is allocated a‘risk score’ranging from 0（most favor able）to 6／8（least favorable）with maximum score o 20and cut－off score of≤10to≤16［17］.

2.4 Cubbin ＆Jackson scale The Cubbin ＆Jack son scale was developed by Cubbin and Jackson as modification of the Norton scale used for intensiv care patients.It includes ten variables（age，weight general skin，mental condition，mobility，haemodynam ic status，respiration，nutrition，incontinence and hy giene），and uses a 4－point scale.The total score range from 10to 40，the lower the score（cut－off score≤26），the higher the risk of pressure ulcers develop ment［18］.

3 Aims

This study aims：①to describe current scientifi evidence of pressure ulcer risk assessments for IC patients；②to identify the most accurate scale for pre dicting ICU patients pressure ulcer risk；③to mak recommendations for clinical practice based on thes findings.

4 Methods

4.1 Data collection A systematic review was de signed which employed a predetermined explicit meth odology to comprehensively search，select，and ap praise studies.Medline，CINAHL，Journals＠Ovid Science Direct，and CAJ（1995－2010）were used t search for publications on the basis of the followin key words：Pressure ulcer，pressure sore，risk predic tion and predictive validity，successively combine with intensive care unit or ICU patients.Appropriat Chinese key words and strategies were applied i searching related articles from CAJ（China Academi Journal）.The research assistants screened the ab stracts of all the publications on the basis of the inclu sion criteria，which included：①studies of the use o risk assessment scale for ICU patient pressure ulce prediction；②design of study used controlled clinica trials or prospective cohort studies.After screening b the principal researchers，the full－text articles were re trieved.

4.2 Data analysis The selection procedure resulte in 11valid prospective publications，8in English and in Chinese.The setting，design，sample size，cut－of point and effective indicators of a tool in each stud were examined.The important detailed information o the studies is exhibited in Table 1.Four measures（th Douglas scale，Gosnell scale，Anderson scale，and Mainland China scale）were excluded from analysis because each of them was applied in one study only.The variances of the four popularly used scales（the Bra－den，Norton，Waterlow and Cubbin ＆Jackson scales were examined by analysis of variance（ANOVA）.Se table 1.

Table 1 Important Information of Included Studies（n＝11）

5 Results and Discussion

The analysis of variance（ANOVA）demonstrates that there was no statistically significant difference between these four popularly used scales in ICU population（table 2）.It may be because of the small sample size that only 11clinical trial research articles were included in this literature analysis.When carefully checking the results of individual study reports，it was found that the Braden scale was the most popularly used scale（9studies with a total population of 1 219）；the sensitivity（from 23.0%to 97.0%）and the specificity（from 26.0%to 100.0%）which were very divergent；the cut－off point also varied（16，17，1 and 20）.However，the cut－off point at 16was recom mended by most of researchers［1，10，21，22，27］.The Water low scale has been used in 3studies（a total populatio of 1 138）with the sensitivity from 47.1%to 80.0%，an the specificity from 29.0%to 82.5%at the 16as th cut－off point；while the Norton scale has also been ap plied in 3studies（a total population of 418）with th sensitivity from 49.0%to 73.0%and the specificit from 47.0%to 100.0%，and the cut－off point was 1 to 25.

Table 2 Comparison of Predictions of Four Scales（Mean±SD）%

Though the Cubbin ＆ Jackson scale was not popularly used（3studies with a total population of 519）and no statistically significant difference of predictive power compared to other three scales，howev－er，it has higher mean score of sensitivity，PPV an NPV（See table 2）.Both Seongsook et al［10］and Ki et al［1］reported Cubbin ＆Jackson scale had the high est positive predictive validity and specificity whe compared with other two scales（Waterlow scale and Braden scale）.Boyle and colleagues also claimed the Cubbin ＆Jackson scale demonstrated better sensitivity and PPV in their comparative study of risk assessment among ICU patients［21，28］.It is because Cubbin＆Jackson scale was specifically modified from the Norton scale for using in intensive care patients［28］.Nevertheless，this scale has not been used in mainland China or Macao clinical area.

6 Conclusions

From this systematic literature review and analysis，the conclusion to be drawn is that the Braden scale is the most popularly used risk assessment scale while the Cubbin ＆Jackson scale is the most powerful and efficient pressure ulcer risk prediction tool in ICU patients.However，clinical trial studies are needed to further validate the effectiveness of these two scales when applied to local populations.

［1］Kim EK，Lee SM，Lee E，et al.Comparison of the predictive validity among pressure ulcer risk assessment scales for surgical ICU patients［J］.Australian Journal of Advanced Nursing，2009，4：87－94.

［2］Augustin M，Maier K.Psychosomatic aspects of chronic wounds［J］.Dermatology and Psychosomatics，2003，4：5－13.

［3］Pancorbo－Hidalgo PL，Garcia Fenandez FP，Lopez－Medin IM，et al.Risk assessment scales for pressure ulcer prevention：A systematic review［J］.Journal of Advanced Nursing，2006，1：94－110.

［4］Pelham F，Keith M，Smith A，et al.Pressure ulcer prevalence and cost in the US population［J］.American Medical Directors Association，2007，8：B20.

［5］Posnett J，Franks PJ.The burden of chronic wounds in the UK［J］.Nursing Times，2008，3：44－47.

［6］Xue X，Liu H，Jing XS，et al.Predicting pressure sore risk with the Braden（modified），Norton and WCUMS scales［J］.Chinese Journal of Nursing，2004，4：241－243［in Chinese］.

［7］Groeneveld A，Anderson M，Allen S，et al.The prevalence of pressure ulcers in a tertiary care pediatric and adult hospital［J］.Journal of Wound Care Nursing，2004，3：108－116.

［8］Shahin E，Dassen T，Halfens R.Incidence，prevention and treatment of pressure ulcers in intensive care patients：A longitudinal study［J］.International J of Nursing Studies，2009，4：413－421.

［9］Elliott R，McKingley S，Fox V.Quality improvement program to reduce the prevalence of pressure ulcer in an intensive care unit［J］.Am J Crit Care，2008，4：328－334.

［10］Seongsook J，Ihnsook J，Younghee L.Validity of pressure ulcer risk assessment scales：Cubbin and Jackson，Braden，and Douglas scale［J］.International Journal of Nursing Studies，2004，41：199－204.

［11］Keller PB，Wille J，Bamshorst BV，et al.Pressure ulcers in intensive care patients：A review of risks and prevention［J］.Intensive Care Medicine，2002，10：1379－1388.

［12］Kates RJ，Callahan A.Fighting back against pressure ulcers［J］.Critical Care Nursing，2009，5：34－40.

［13］VanGilder C，Amlung S，Harrison P，et al.Results of the 2008 2009international pressure ulcer prevalence survey and a 3－year acute care，unit－specific analysis［J］.Ostomy Wound Manage ment，2009，11：39－45.

［14］Brown JS.The Braden scale：A review of the research evidenc［J］.Orthopaedic Nursing，2004，1：30－38.

［15］Smith LN，Booth N，Douglas D，et al.A critique of‘at risk’pres sure sore assessment tools［J］.Journal of Clinical Nursing，2005 4：153－159.

［16］Bergstrom N，Braden BJ，Laguzza A，et al.The Braden scale fo predicting pressure sore risk［J］.Nursing Research，1987，4：205 210.

［17］Norton D.Calculating the risk：Reflections on the Norton sca［J］.Decubitus，1989，3：24－31.

［18］Waterlow J.A risk assessment card［J］.Nursing Times，1985 48：49－55.

［19］Venden－Bosch T，Montoye C，Satwicz M.Predictive validity the Braden scale and nurse perception in identifying pressure u cer risks in intensive care patients［J］.Applied Nursing Re search，1996，2：80－86.

［20］Westrate JT，Hop WC，Vreeling AW，et al.The clinical relevanc of the Waterlow pressure sore risk scale in the ICU［J］.Intensiv Care Med，1998，8：815－820.

［21］Boyle M，Green M.Pressure sores in intensive care：Defining the incidence and associated factors and assessing the utility of tw pressure sore risk assessment tools［J］.Australian Critical Care 2001，1：24－30.

［22］Curley MA，Razmus IS，Roberts KE，et al.Predicting pressure u cer risk in pediatric patients：The Braden－Q Scale［J］.Nursin Research，2003，1：22－23.

［23］Jalali R，Rezaie M.Predicting pressure ulcer risk：Comparing th predictive validity of 4scales［J］.Advances in Skin ＆ Woun Care，2005，2：92－97.

［24］Feuchtinger J，Halfens R，Dassen T.Pressure ulcer risk assess ment immediately after cardiac surgery －does it make a diffe ence？A comparison of three pressure ulcer risk assessment in struments within a cardiac surgery population［J］.Nursing i Critical Care，2007，1：42－49.

［25］Gu XR，Kuang XL，Lou JH.Applicability of Braden－Q scale fo the prediction of pressure ulcers development in children in Main land China［J］.J Nursing Sciences，2009，4：6－8［in Chinese］.

［26］Li X，Zhu Y.Predicting pressure score risk in ICU patients wit the Braden，Norton，Anderson scales and Chinese scale［J］.Mod ern Medical Journal，2010，6：616－619［in Chinese］.

［27］Tian AW，Liu T，Li L，et al.Study on applicability of Braden ra ing scale for assessment of risk factors for pressure sores of crit cal patients in primary hospitals［J］.Chinese Nursing Research 2010，5：1174－1175［in Chinese］.

［28］Cubbin B，Jackson C.Trial of a pressure ulcer risk calculator fo intensive therapy patients［J］.Intensive Care Nursing，1991，1：4 44.