What are the recommended preventive measures for pressure injury prevention in patients with a Braden score (Braden Scale for Predicting Pressure Sore Risk) of more than 18?

Pressure Injury Prevention in Patients with Braden Score >18

Even patients with Braden scores above 18 require systematic pressure injury prevention measures, as the Braden Scale has limited discriminatory ability and intermediate-risk scores are paradoxically associated with higher injury rates in certain populations.

Understanding the Braden Scale Limitations

The Braden Scale demonstrates low sensitivity and specificity for predicting pressure ulcers across all patient populations 1. In trauma and burn patients specifically, a Braden score ≤18 showed 100% sensitivity but only 6% specificity, with positive likelihood ratios never reaching clinically useful thresholds 2. This means the scale identifies nearly everyone who will develop an ulcer but also flags many who won't, resulting in poor discrimination.

Critically, patients with intermediate Braden subscale scores (not the lowest-risk category) actually demonstrate the highest likelihood of developing pressure injuries 3. This counterintuitive finding suggests that focusing prevention efforts solely on patients scoring ≤18 may miss substantial at-risk populations.

Core Prevention Protocol for All At-Risk Patients

Risk Assessment and Monitoring

• Perform systematic risk assessment using the Braden Scale upon admission, recognizing its limitations as a screening rather than definitive diagnostic tool 1.
• Conduct daily visual and tactile skin assessments of all pressure-prone areas (sacrum, heels, ischium, occiput), with documentation of findings 1, 4.
• Reassess risk regularly based on clinical condition changes, as static scores do not capture evolving patient status 4, 5.

Repositioning Strategy

• Implement systematic repositioning every 2-4 hours around the clock for all patients, regardless of Braden score, with pressure zone checks at each turn 4.
• Use the 30-degree tilt position rather than standard 90-degree lateral rotation, which reduces pressure on bony prominences (relative risk 0.62, though evidence quality is low) 4.
• Avoid the flat supine position entirely, as this concentrates pressure on vulnerable areas 4.
• Document each position change with time and skin assessment findings to ensure adherence 4.

Despite high reported compliance rates (67-84% in acute care settings), actual repositioning adherence remains a persistent challenge 6.

Support Surface Selection

• Choose advanced static mattresses or advanced static overlays as first-line prevention for all at-risk patients, including those with Braden scores >18 1, 4.
• Do not use alternating-air mattresses or overlays, as evidence shows no clear benefit over static surfaces and they incur significantly higher costs 1.
• When using advanced pressure-reducing mattresses, repositioning intervals can be extended to 4 hours without increased ulcer incidence 4.

Skin Care and Moisture Management

• Keep skin clean and dry at all times, addressing incontinence promptly as urinary or fecal incontinence increases skin maceration and ulcer risk 1, 4.
• Apply barrier sprays and lubricants judiciously to protect skin from friction during repositioning 1.
• Use skin cleansers other than soap and fatty acid-containing creams, which have shown decreased pressure ulcer risk in low-quality evidence 1.
• Minimize skin friction and pressure through proper technique during all patient handling 1, 4.

Nutritional Support

• Provide protein supplementation for patients with nutritional deficiencies, as malnutrition significantly impairs wound healing and increases ulcer risk 1, 4, 5.
• Nutritional support was used in only 55-82% of at-risk patients in recent surveys, indicating substantial room for improvement 6.

Heel Protection

• Elevate heels off the bed surface using specialized devices or pillows to avoid interosseous contact 4, 7.
• Only 60% of patients with severe pressure injuries received heel elevation, while 31.9% received none despite not being documented as contraindicated 6.

Early Mobilization

• Begin mobilization as soon as medically stable, starting with passive range-of-motion exercises for at least 20 minutes per zone 4.
• Progress to active mobilization using a structured protocol aiming for the highest achievable mobility level at each session 4.
• Early mobilization within 72 hours of ICU admission is the standard definition 4.

Implementation Framework

Establish a multicomponent prevention program that includes 1, 4:

• Simplification and standardization of pressure ulcer interventions and documentation
• Multidisciplinary team involvement with designated leadership
• "Skin champions" who educate staff about prevention strategies
• Ongoing staff education through team meetings and motivational campaigns
• Sustained audit and feedback with regular prevalence monitoring

This bundled approach has demonstrated cost savings of approximately $11.5 million annually in hospital systems while significantly reducing pressure ulcer prevalence 4.

Special Considerations for Higher Braden Scores

Subscale-Specific Interventions

Tailor interventions to individual Braden subscale scores rather than relying solely on total scores 3, 8. One ICU implementing subscale-specific protocols achieved a 63.5% reduction in hospital-acquired pressure injuries 8.

Patient Participation

• Actively involve patients in their own pressure injury prevention through education about repositioning, skin checks, and nutrition 1.
• Provide high-quality patient education resources that are accessible and understandable 1.
• Recognize that patient participation improves clinician-patient communication, increases satisfaction, and reduces clinician workload 1.

Common Pitfalls to Avoid

• Do not assume patients with Braden scores >18 are low-risk and exempt from prevention protocols, as the scale's poor specificity means many will still develop injuries 2.
• Do not delay repositioning for hemodynamically stable patients, as vasopressor use is not a contraindication to position changes 4.
• Do not rely on elastic compression stockings, which should not be used for pressure injury prevention 1.
• Avoid overreliance on alternating-air surfaces given lack of superiority evidence and higher costs 1.

Organizational Requirements

• Form multidisciplinary teams with designated leaders for pressure injury prevention 4, 5.
• Implement regular audits and feedback on pressure ulcer rates 4, 5.
• Address staffing overload that makes adherence to repositioning schedules difficult 5.
• Ensure adequate availability of advanced support surfaces 5.