From Screening to Full Risk Assessment in Pressure Injury Prevention: Targeting the Right Care to the Right Patients

INTRODUCTION Imagine an 84-year-old woman newly admitted to a hospital unit for older persons. She has been admitted from a residential facility due to a serious case of community-acquired pneumonia and dehydration. At admission, she needs personal assistance to transfer from the bed to the chair and has to be transferred to the bathroom by means of a wheelchair. Existing comorbidities are left ventricular heart failure with reduced ejection fraction and reduced physical activity as of Class II of the New York Heart Association classification,1 hypertension, urinary incontinence, and mild cognitive impairment. A nurse or physician may easily associate this scenario with a patient with an increased risk of pressure injury (PI) as there are clear-cut indications to existing risk factors, including impaired mobility, increased exposure to moisture, and perhaps limited abilities to recognize and properly respond to elevated risk exposure, just to name the most obvious ones. Thus, risk assessment appears to be crucial in this case, as clearly the patient is at risk. However, think of another case, for example, a psychiatric setting where a patient (64 y old) is admitted to a psychiatric facility due to a serious psychotic crisis. She additionally suffers from chronic musculoskeletal pain and has oxygen-dependent chronic obstructive pulmonary disease (COPD) after a long-term history of smoking cigarettes (>30 pack years). Before admission, she lived in a sheltered housing facility because she needed personal assistance in activities of daily living. Although she ambulates independently, she spends most of the time lying in bed due to her psychosis. When the nursing aide assists her with personal hygiene on day 5 postadmission, she notes a 2 cm (length)×3 cm (width)×0.5 cm (depth) open wound with no necrotic tissue in the wound bed in the sacral area that is eventually diagnosed as a stage 2 PI. No PI risk or preventative measures have been considered for this patient up to this point in time. As the risk factors were less overt at admission, the patient’s needs for PI prevention have been unfortunately missed. Detailed assessment after detection of the PI reveals that the patient also suffers from peripheral arterial disease, malnutrition, occasional urinary incontinence, and a lack of personal hygiene when toileting. The purpose of a PI risk assessment is to accurately detect those patients who have risk factors and to support decision-making on the appropriate preventative measures. For decades, there have been debates about the best methods for the assessment of PI risk and the role of standardized risk assessment tools such as the Norton, Waterlow, or the Braden scales.2 However, these debates often constrict risk assessment to a matter of choosing the right risk assessment tool, thereby ignoring the complexity of factors that influence the efficacy and efficiency of risk assessment. Therefore, in 2019, the 3rd edition of the International Guideline on pressure injury prevention and treatment took on a more comprehensive view of the conditions and methods of risk assessment and introduced a 2-step approach as a suggestion for good practice.3 The 2 steps are an initial screening to be carried out in all individuals admitted to the care service, followed by a full risk assessment step to be conducted in those individuals considered at risk via screening. This article explains the rationale behind this approach, defines core concepts, and describes strategies for implementation, based on examples of national policies and alternative risk assessment tools. BACKGROUND Risk assessment is a clinical reasoning process that includes the collection and appraisal of information about an individual’s current health state (presence of risk factors) to reach conclusions about whether the individual is at risk of developing a PI in the near future. Because identification of patients at risk is not an end in itself, but the foundation of the care plan, the outcome of the risk assessment must include the detection of individual risk factors, especially those amenable to change, informing subsequent interventions. Clinical reasoning is defined as “a context-dependent way of thinking and decision-making in professional practice to guide practice actions”4 and is assumed to be critical for doing “the right thing in the right way at the right time.”5 Although it is sometimes synonymously used with the concept of clinical judgment, in this article the latter is understood as the outcome of the professionals’ reasoning process, regardless which methods were used to collect and analyze the observable data.6 However, both health professionals’ clinical reasoning and their clinical judgments are complex and determined by factors inherent to the individuals to be assessed, the assessing professionals, and the care environment (Figure 1).7 A major aim of evidence-based strategies for PI assessment is to help health professionals negotiate this complexity safely so that each individual at risk has a high chance of being identified as at risk and receiving the preventative care they require. Equally, individuals currently not at risk should be easily and safely identified as such, obviating the need for specialist PI prevention interventions to prevent unnecessary and wasteful utilization of resources.FIGURE 1: CONCEPTUAL FRAMEWORK OF THE INFLUENCING FACTORS ON PRESSURE INJURY RISK ASSESSMENT BASED ON CLINICAL REASONING THEORIES6 Copyright Katrin Balzer, et al. All permission requests for this image should be made to the copyright holder.In many care settings, patients vary in terms of the presence or absence of PI risk factors. In statistical terms, this variability reflects differences in patients’ pretest probability of PI development, that is, the probability of the patients to develop a PI, the authors assumed before taking any history or physical examination.8 This pretest probability is based on epidemiological knowledge and clinical experiences, and it determines the likelihood that any assessment would yield important information that helps to rule in or rule out risk.8 Basically, target populations in health care vary between 2 extremes of pretest probability: (1) populations where all or the majority of individuals show a very low pretest probability of PI risk, as, for example, in mental health care, and (2) populations in which all individuals, or the majority, show a high pretest probability of PI risk, such as individuals in geriatric care wards,9 intensive care units9,10 units, or long-term care homes.11 It could be determined that almost all target populations contain individuals who are at risk of developing a PI and require preventative care. Thus, even if a PI risk can be ruled out quite readily for those who are active, mobile, cognitively aware, and in good health, there is a need for some form of systematic risk assessment should these conditions change. However, the risk assessment must be efficient to target resources to those actually at risk. Furthermore, the closer a population is located to the high-risk extreme, the less likely the risk assessment would add relevant information to confirm the at-risk status because the risk is obvious for the majority before any assessment inquiry is conducted. Nevertheless, systematic assessment of all modifiable risk factors is still required to target preventative measures to the individual risk profile. TWO-STEP APPROACH To account for these population-specific requirements for PI risk assessment and to avoid waste of resources, the 2-step approach has been introduced as a “Good Practice Statement” in the 2019 3rd edition of the International Guideline on pressure injury prevention and treatment.3 As described above, this approach consists of 2 risk assessment steps: first, a screening step for all newly admitted patients, followed by a full risk assessment step only targeting those assumed to be at risk as an outcome of the first step (Figure 2). Both steps should be carried out using a structured approach, that is, they should follow evidence-based local protocols that describe the procedures and instruments to apply to predefined individuals at each step of the risk assessment. Also, at each step, the outcome of the risk assessment should be recorded in the individual’s medical record.FIGURE 2: TWO-STEP APPROACH FOR PRESSURE INJURY RISK ASSESSMENT AS SUGGESTED IN THE INTERNATIONAL GUIDELINE OF PRESSURE INJURY/ULCER PREVENTION AND TREATMENT3 Copyright Katrin Balzer, et al. All permission requests for this image should be made to the copyright holder.Screening Screening is a specific form of inquiry that aims to detect individuals at risk of a health condition of interest in groups among whom the majority do not show “known signs or symptoms of that disease or condition.”12 The outcome used is dichotomous, that is, the risk is ruled out or not. In terms of PI risk assessment, this screening step specifically targets populations that contain individuals with a low-test probability of PI risk. This step aims to detect those individuals for whom an elevated risk cannot be ruled out at the current moment and thus requires a more comprehensive risk assessment. The screening step should be conducted as early as possible after admission to a health care service and should be carried out on all newly admitted individuals, that is, at the first contact with the health professional after admission to the hospital, even in the emergency department, or at the first visit in the community setting.3 Because certain individuals in the target groups will be free of any risk factor, it is important that the screening step is both efficient and accurate. Therefore, screening inquiries should draw on signs or symptoms that are easy to assess and highly predictive in the target population, such as inactivity, immobility, spinal cord deficits, and impaired cognition.3,13,14 The implementation considerations in the 2019 International Guideline suggest that “major risk factors for pressure injury development in the target population” should be considered for the structured screening.3 Based on the risk factors recommended for risk assessment in the 2019 guideline, major risk factors are understood as those for which evidence shows a high likelihood that they influence individuals’ susceptibility to PI (Table 1).3,15 This category comprises impaired mobility and activity or any otherwise high potential for friction and shear. Also, existing Stage 1 PIs are classified as such a major risk factor because they put individuals at risk of additional as well as more severe PIs. By contrast, risk factors for which existing evidence indicates only a moderate or weak likelihood that they influence the susceptibility to PIs (Table 1)3 are less suitable for screening. The risk of false positive or false negative classifications would otherwise be too high. TABLE 1 - CATEGORIES OF RISK FACTORS RECOMMENDED FOR RISK ASSESSMENT IN THE INTERNATIONAL GUIDELINE OF PRESSURE INJURY/ULCER PREVENTION AND TREATMENT3 Evidence-based Likelihood That Factor Influences Susceptibility to Pressure Injuries/Ulcers Recommendation Risk Factorsa High Consider the affected individual to be at risk •Limited mobility•Limited activity•High potential for friction and shear•Existing Stage 1 PI (risk of deterioration to Stage 2 or higher) Moderate Consider the impact of the presence of this risk factor on the individual’s risk •Diabetes mellitus•Perfusion and circulation deficits•Impaired nutrition status•Increased body temperature Weak Consider the potential impact of the presence of this risk factor on the individual’s risk •Oxygenation deficits•Moisture•Impaired sensory perception•Laboratory blood tests, eg, albumin or hemoglobin levels•Existing Stage 1 PI (risk of any additional PI)•Age Abbreviation: PI, pressure injury.aOnly those recommended for general populations (ie, not for specific populations or care settings such as operation theater) with strong or weak strength of recommendation, excluding those based on good practice statement.Copyright Katrin Balzer, et al. All permission requests for this image should be made to the copyright holder. Assessment of risk factors at the screening stage should draw on readily accessible information such as patient history, admission documents, or direct patient observation. A head-to-toe skin assessment or physical should not be carried out at the screening However, in high-risk populations such as those in geriatric care or intensive care where all individuals show PI risk factors, the screening step may be and a direct full risk assessment, including head-to-toe skin assessment, would be (Figure 2). population-specific should be defined in local taking account the of risk factors in the target populations of For individuals ruled out as being at risk the screening step, no are required any in the health conditions For the a full risk assessment should follow (Figure 2). Risk Assessment The full risk assessment in the step 2 of the assumed at-risk status and detection of individual risk factors, especially the modifiable ones. At this risk assessment step, all relevant risk factors should be In the International the epidemiological evidence of the of PI, including risk factors, is and systematic of risk factors in the target populations of interest also information A full risk assessment may the of standardized be it specific risk assessment or tools for the assessment of specific risk factors such as the conditions or tissue The of risk factors and instruments to may vary on the target population, because not all risk factors are relevant in each For example, a assessment of medical that influence PI risk may be more relevant in care or intensive care units, in settings with less in or geriatric care settings, individual and physical activities are to be to assess patients’ risk exposure and to interventions for long-term of physical Furthermore, skin assessment tools and methods should be used that are suitable to detect relevant skin in with To that all relevant risk factors are considered a full risk assessment should draw on the and information of all health currently in the treatment of the individual in Thus, have a role in PI risk assessment and it should be an to is that the outcome of full risk assessment should not be dichotomous, that is, between at-risk and not at-risk but should also include a of risk factors for those identified at risk. This as well as preventative should be accessible to all who should be to identified risk factors and required preventative measures. As of the prevention plan, for a full of the PI risk should be in to the of the of measures to the exposure to pressure and AND ON RISK The 2-step approach has been for the of pretest probability the health care settings and thus population-specific requirements for the of risk It also reflects the 2-step of the Pressure Risk or a risk assessment that has been by et based on a systematic of the evidence of risk factors for PI A 2-step approach of PI risk assessment has been introduced by national in For example, in the on and in a and on the prevention and of PIs that between a screening and a risk and skin assessment The screening step should be carried out in all individuals as as possible after admission to the health care service, in predefined populations with high risk, who should full risk assessment. 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The do not include the of specific tools for the full risk assessment, the to an appropriate standardized nutrition screening However, in clinical of risk assessment Braden and population-specific assessment such as instruments on care be TABLE 2 - OF THE ON PI RISK ASSESSMENT IN AND and for PI prevention in nursing care Screening populations populations high-risk cord injury or limited mobility, limited and a high potential for friction and and with a medical in with with and with All populations high-risk populations geriatric due to obvious mobility or PIs Stage At admission At admission Risk factors to risk factors to current or exposure to pressure or friction and or such as medical or on with eg, for of status at pressure especially or PIs of Stage or head-to-toe or tools in screening of the specific tools recommended based on outcome ruled no current when health not ruled full risk assessment ruled no current when health not ruled full risk assessment risk assessment populations populations from screening step with risk not ruled out after screening populations from screening step with risk not ruled out after screening Risk factors to and PIs category health and skin status at pressure and existing Stage sensory of exposure to and before and and at and of and tissue and temperature and especially and tissue and skin and tissue tissue skin and screening nutrition assessment in individuals with risk of or with existing PI especially assessment individuals’ abilities to in lying or and to between and and resources Assessment of existing risk factors nutrition by nursing assessment and of professionals’ inquiries or tools specific tools nutrition of a with and in the target comprehensive of a specifically health in health care of risk assessment and eg, tools specific tools the of assessment Risk assessment for the assessment of nursing care eg, and abilities screening tools based on outcome ruled no current when health and risk factors development and implementation of an prevention by the or and the ruled no current when health and risk factors development and implementation of an prevention by the or and the body PI, pressure Pressure Risk or Katrin Balzer, et al. 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