Transcript

Hi, my name is Cathy Milne, and I am the editor of WoundSource as well as the co-chair for WoundCon. I am so glad to have you with me today.

So, we are talking about pressure injury risk assessment tools. So, it's very, very interesting when you start looking at the literature. So, I think the first question I get is that there are several risk tools out there. There's the Braden scale, the Norton scale, the Waterlow scale, in fact there’s over 40 scales out there in the literature. And so the question is, that I always get, is how effective are these tools? Well, it really depends.

So, one of the things that we have to think about is what is there, there are no requirements that we use a certain scale in our risk assessment. What we need to do, because a risk assessment tool is a planning tool. It is not an intervention. It helps guide you into where you need to individualize the patient's care. So, if you start looking at the more common scales out there, and that would be the Braden, the Norton, the Waterlow, then you have to look at the literature, and it's out there. It's not even—AI can tell you about how sensitive and specific these tools are, but that varies by setting. And so you might have a tool that works better in critical care than it does in home health. And clearly, the pediatric patient population has their own scales because they're different kind of species, right? They're smaller, their skin may be, if they're neonates, they're not well developed. So, you have to think, where am I going to use this scale? And what is the specificity and accuracy of these tools?

Now, that being said, I do want to say one thing. There are some limitations you need to know of. The Braden is no longer free by getting on the Braden website. That has now been sold to a group of people who have now taken this scale, and they offer other materials along with the use of the scale. So, if you haven't gotten permission from them, you really should start talking with your legal department and with these people who now own the copyright to the scale. And then you can work it out from there, but please be mindful that this is no longer Barbara Braden's property. Poor Barbara Braden, you know, passe a few years ago. And her only requirement is that you register with her site. This is now changed. So please, please, please look at bradenscale.com and follow the lead there.

So, now you have a scale number. So, let's take the Braden Scale or the Norton scale or the Waterlow scale. So, it comes up with a number, and then you are to use it. But most the common thing that I see is that people use that total number instead of looking at the subset scores. So, you might still be greater than, let's say for the Brayden scale or the Norton scale, you are no longer at risk, you're not deemed at risk. But if you look at the subscale, so let's say you walk well, you can transfer well, you eat well, but you are incontinent all the time. Now your moisture scale will be very, very low or very, very high, depending on which scale you're looking at. But anyway, everything else is normal except for this one subset. So, that's what puts you at risk. So, you should be planning your interventions on the subscales, not the total altogether. You may have a score that shows you're at high risk for breakdown, but you still have to look at that they're still at high risk, but focus on those subscores, because that's where targeted interventions will make a huge difference.

Now, one of the things that we should be thinking about is it's really not the scale that you're using, it is what you do with the scale. So, it's all about the intervention. So, when you look at the Cochrane review and other meta-analysis, it's not the individual scale applied. It's part of the bundle of interventions. The interventions for pressure injury prevention are risk assessment, a physical exam of the patient, targeted interventions that are focused on friction reduction, shear reduction, moisture reduction, nutritional interventions to improve the patient's overall health. So, those are the basics, but we also have to think about the things that are not covered in the majority of these scales. And that is the comorbidities.

There's one out in England that they're using, I think it's called the Cubbin/Jackson pressure injury risk assessment. It's very, it's wonderful. However, it's very long. We in the US probably don't have time to implement it. And we also would have problems with integrating it into our EMR because of the algorithmic ability of this scale. However, so it's once you come up with that assessment. So, again, risk assessment, physical exam, interventions targeted at specific areas where you have identified at risk, including diabetes, age—if you're over 65, you are at risk—a low hemoglobin. There are over 100 risk factors out there that will make you more prone to a pressure injury. For critical care, we know it's respiratory failure and the use of vasopressors. So, you have to tailor those additional factors of the patient to the clinical setting.

Now, we have to start thinking about emerging tools and technologies; it's out there, and they're wonderful. So, when we start to look at who has developed a pressure injury, we only wait until our eyes show us something, right? What we should be thinking about, and if our institution can support us, we should be looking at technologies. There's infrared technology, there's ultrasound technology. And there are other things probably in the works right now that may help us predict pressure injury or actually discover pressure injury before our eyes see it. And that's good for us in terms of a regulatory aspect, but these technologies don't help us prevent. They help us see things that have already occurred before we see them.

Now, will AI come up with something in the near future or even the distant future? There's probably a really good indication out there that you might be able to predict algorithmically and there's a great intro article literature that was written by Dr. William Padula that talks about this. So, I think the future for prevention and early intervention is going to be wide open for us. And I’m looking forward to the future.