Pressure ulcer risk assessments ‘like flipping a coin’

Current guidelines for preventing pressure ulcers are outdated and existing risk assessment tools are “like flipping a coin”, an international expert says.

Current guidelines for preventing pressure ulcers are outdated and existing risk assessment tools are “like flipping a coin”, an international expert says.

Netherlands-based Dick Schilstra, a trained tissue viability nurse who now specialises in medical devices for pressure care as Group Product Manager at TSS Invacare, was in Sydney this month to address a conference about developments in pressure wound care.

Dick Schilstra

Mr Schilstra says current practices and risk assessments are outdated, lack reliability and often do more harm than good.

“There’s a lot of knowlege among healthcare staff about pressure ulcers but quite often it’s outdated knowledge,” he told Community Care Review after speaking at the ATSA Independent Living Expo on May 9.

“As health care workers we like to check boxes and get an answer that says ‘this patient is not at risk’.

“But there are 92 different risk assessment tools for the same problem and they all have a scientific reliability of round about 30-50 per cent, so it’s just like flipping a coin.”

What is a pressure wound?

A pressure wound is localised injury to the skin or tissue resulting from sustained pressure or pressure combined with shear, or friction.

Sustained pressure on a body part – frequently the heels, sacrum, shoulder blades or elbows – blocks blood flow and oxygen to tissue, interfering with waste removal and resulting in a chemical imbalance.

External factors like pressure, shear, moisture and “microclimate” contribute to the formation of pressure ulcers, as well as  intrinsic factors like frailty, mental capacity and nutrition.

Pressure ulcers are categorised into four stages, ranging from a red mark to a wound that goes down to the bone.

In Australia pressure wounds cost $285 million a year, Mr Schilstra said. “There’s a very big financial cost to this problem,” he told the conference.

Risk assessment

It is important for carers to assess a person’s risk of developing a pressure ulcer, Mr Schilstra says, but they shouldn’t just rely on a risk assessment tool.

It is important to use clinical judgement taking in individual circumstances as well, he says.

While there is a choice of 92 different risk assessment tools, the type of tool used tends to depend on geography. In Australia and the UK the Waterlow Pressure Risk Assessment Chart is most common, while in other parts of the world the Norton Scale or Braden Risk Assessment Tool is more common.

But Mr Schilstra says the problem of pressure ulcers is too complex to capture in a single risk assessment tool.

“There are so many influencing factors,” he says.

“The main causation of pressure ulcers are pressure and shear. But if a patient is old, or has diabetes, for example that’s a different profile than a patient that has asthma and is in a bed and has difficulty breathing.

“That patient has a very different type of risk profile which is not captured within risk assessment tools.”


Repositionining is also vital in avoiding pressure ulcers, but it’s done in the wrong way it can make the problem worse, Mr Schilstra says.

He says there have been some significant research developments, but these have not been adopted in practices.

For example, recent research showing that tissue deformation can quickly cause skin damage has implications for repositioning techniques, which if done incorrectly can result in tissue deformation.

“Quite often nurses ‘grab’ a patient in way that causes tissue deformation and that’s a recipe for disaster if you’re not doing it right,” he says.

Mr Schilstra says home healthcare workers face specific challenges when it comes to pressure wounds. This includes having less time to spend with patients, who often also have limited finances to ensure they are getting the best beds and mattresses given the wide range of therapeutic options.

“For home care nurses it’s very important to involve the patient and the family because they are always there,” he says.

“For home nursing staff its very important to keep their knowledge up to date so they can instruct the patient’s family on techniques like correct positioning.

“There’s a lot of team work and the team involves the patient and their family.”

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4 thoughts on “Pressure ulcer risk assessments ‘like flipping a coin’

  1. HI Dick,
    Totally disagree. I’ll stick to what the International PI guidelines recommendations thanks.

  2. The article : Pressure ulcer risk assessments ‘like flipping a coin’ needs clarification for the Australian context. It was reported that there are 4 stages of pressure injuries. This does not reflect Australian evidence based clinical practice guidelines that identify 6 stages of pressure injuries.
    Clinical practice guidelines never suggest that a single risk assessment is all encompassing in the identification of risk, prevention, treatment and evaluation of pressure injuries and practicing in this way is detrimental to the people we care for. A pressure risk assessment is one part of a process of clinical judgement and assessment that informs care.
    To generalize that healthcare workers have “a lot of knowledge …….about pressure ulcers but quite often it’s outdated knowledge,” is offensive without publishing evidence to back up this statement. The organization I work for (and many others) make a concerted effort to educate staff and improve processes and resources based on the current available research. Auditing processes are put in place to ensure that these interventions lead to translation of evidence into practice and quality outcomes.

  3. Hi Traci Nowicki,

    I totally agree, that was also exactly the message of my presentation.
    We need to stick to what the guidelines tell us. My point is that I have experienced quite some examples of referring to just a risk assessment score to determine a therapeutic surface choice or determining which preventative measures should be taken.
    That is not how these tools were intended to be used.
    There should be an individual approach to determine which riskfactors of P.U. development are present in each patient and there should be an individual careplan to address these.
    In terms of therapeutic surface selection, the same approach should be used (see PU guidelines for this) and based upon that you can choose the most appropriate type of product that is available. Therapeutic surface selection process is not a “one size fits all” type of excercise.
    Hope this makes it more clear.

  4. Hi Kylie Elder,

    The remark “like flipping a coin” was made in the context of if you rely on a risk assessment tool like e.g. Waterlow or Braden as a stand alone instrument for determining the risk of PU development in a patient.

    There are 4 categories of PU, the other 2 you probably refer to are Suspected Deep Tissue Injury and Unstageable. I do acknowledge these in my presentation but they have not been adopted in the guidelines as an official category (yet). Just to make this more clear 🙂
    I agree that single risk assessment is not being all encompassing and this is also mentioned in the international guidelines. It should be used as a part of the total process. That is exactly my message as well.

    I acknowledge that there are healthcare organizations that are putting in a lot of effort in keeping their healthcare staff updated and educated on PU development, doing P&I studies to monitor their performance etc. A lot of good initiatives are being developed and put in to practice.
    However this is not the case everywhere unfortunately. I am still witnessing situations that are concerning in this respect. e.g. misinterpretations of guidelines recommendations and product centered protocols. I hope that these things become a thing of the past very quickly and more and more facilities are putting in the same kind of effort you are experiencing in your facility.

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