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PRACTICE APPLICATIONS

Topics of Professional Interest

The Effectiveness of the Braden Scale as a Tool


for Identifying Nutrition Risk

RESSURE INJURIES ARE A


global
problem
affecting
approximately 2.5 million patients per year. These pressure
injuries can drastically impact the
patients quality of life, with increased
pain and infection1 as well as increased
costs to treat. The cost to treat a pressure injury, on average, is $20,900 to
$151,700, depending on the severity
and extent of the ulcer, and each pressure injury is thought to add approximately $43,180 to the cost of a
patients hospital stay.2 These injuries
also have been linked to increased
mortality, with approximately 60,000
yearly patient deaths in the United
States from complications of pressure
injuries.2 However, with the correct
identication of risk and prompt
intervention, they are most often
preventable.
Pressure injuries are localized
injuries that occur to the skin from
unrelieved pressure, decreasing the
blood ow in the capillaries, causing
tissue anoxia and cell death. This, in
turn, results in tissue damage and
possible ulceration.3 These injuries or
ulcerations have had many labels over
the years, including terms such as
decubitus, bedsores, and pressure
ulcers.4 In April 2016, an international
consensus met to review, dene, and
validate the current pressure ulcer
staging system that was developed by

This article was written by Wendy


Phillips, MS, RD, FAND, certied
nutrition support clinician, certied
lactation educator, and division director of clinical support, Morrison
Healthcare, St George, UT; and
Monica Hershey, RDN, clinical
dietitian, Kate Willcutts, DCN, RD,
certied nutrition support clinician and
co-clinical nutrition director, and
Janette Dietzler-Otte, RN, wound
ostomy care nurse, all at the University
of Virginia Health System,
Charlottesville.
http://dx.doi.org/10.1016/j.jand.2016.11.012

2017 by the Academy of Nutrition and Dietetics.

the National Pressure Ulcer Advisory


Panel in 1986. During that consensus
meeting, pressure ulcers were renamed
pressure injuries, and new denitions were developed to address the
stages of pressure injuries.5
Starting in 2008, the Centers for
Medicare and Medicaid Services
implemented payment penalties for
hospitals with high rates of hospitalacquired conditions,6 which includes
pressure injuries developed during the
hospital stay (often referred to as
hospital-acquired pressure ulcers).
Therefore, hospitals have strong motivation to prevent development of
pressure injuries and often are willing
to dedicate extra health care resources,
such as supplies and labor, to do so. To
focus resource allocation, one must
determine which patients are at highest risk of developing pressure injuries
and, therefore, need the most
interventions aimed toward preventing
actual development.
Nutrition and hydration play an
important role in preserving skin and
tissue strength, as well as in supporting
repair once pressure injuries have
occurred.7 Weight loss along with
inadequate energy and protein intake
are the two nutritional factors most
closely associated with pressure injury
development and slow healing. Problems with eating and unintentional
weight loss were found to be associated with a higher risk of pressure ulcer development in long-term care
residents,8 and a German study found
poor nutritional intake to be strongly
linked to the presence of pressure
injuries in both hospitals and nursing
homes.9 As discussed in the white
paper published in 2015 by National
Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel,
and Pan Pacic Pressure Injury Alliance, individuals with malnutrition, in
combination with multiple comorbidities, are at greater risk of developing
pressure
injuries.7
Approximately
one-third of patients who develop

pressure injuries do so because of issues related to malnutrition.10 Therefore, patients at risk for both
malnutrition and pressure injury
development need to be identied for
early
nutrition
assessment
and
intervention.

BACKGROUND
Pressure Injury Screening Tools
Multiple tools are available to identify
the risk for development of a pressure
injury. The Norton Scale, the Braden
scale, Waterlow Scale, and the BradenQ scale are a few of these, with the
Braden scale being the most widely
used in US hospitals. The Braden scale
for Predicting Pressure Sore Risk11 is an
assessment tool that was developed by
Barbara Braden in 1987 and tested by
several clinicians as a part of a research
project. Since that time, this pressure
injury prediction tool has been integrated into nursing assessment of
pressure injury risk in various health
care settings in the United States and
around the world. Compared with
similar pressure injury risk assessment
scales such as the Norton or Waterlow
scales, the Braden scale has been found
to have the most ideal combination of
sensitivity (57.1%), specicity (67.5%),
and risk estimation (odds ratio4.08,
95% CI2.56-6.48).12 The Braden scale
assesses patients by using six categories, each found to play a role in
pressure injury formation: sensory
perception, moisture, activity, mobility,
nutrition, and friction and shear. Each
category is scored from 1 to 4 (or 1 to 3
for friction/shear), to yield a maximum
cumulative score of 23. In the acute
care setting, patients are often assessed
by nursing staff on admission and
again every set number of hours
beyond that (for example, once every
12-hour nursing shift or once per day).
Based on a patients total Braden score,
patients are determined to be at mild
(score of 15-18), moderate (13-14),

JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

PRACTICE APPLICATIONS
high (10-12), or severe (9) risk for
developing a pressure injury.
Nutrition is one of the six subscales
of the overall Braden scale and is
intended to gauge a patients usual
food intake pattern by considering how
much of their meals they typically
consume, their average protein intake,
whether they are consuming any
nutritional supplements, and whether
they are receiving nutrition via enteral
or parenteral nutrition.11 Neither the
total Braden scale score nor the nutrition subscale score have been independently validated for use as a tool to
predict risk of malnutrition.
Hospital policies and procedures
often dictate certain interventions
by multidisciplinary care teams to
appropriately monitor, prevent, and
treat pressure injuries based on the
degree of risk predicted by the total
Braden scale score. Because malnutrition has been proven to increase pressure injury risk and delay healing,7-10,13
one of these interventions is often a
referral to a registered dietitian nutritionist (RDN) for patients with a low
total Braden score or nutrition subscale
score. Of note, an informal survey of
acute care hospitals in the United
States indicated that the cutoff score
for the Braden scale scores that trigger
a nutrition referral are inconsistent.
Some hospitals use the nutrition subscale score in addition to the overall
Braden scale score for risk stratication
and determination of whether to refer
a patient to the RDN13 (M. Hershey,
personal communication at statewide
nutrition conference of the Virginia
Academy of Nutrition and Dietetics,
April 12, 2016).
Regardless of the cutoff value used to
initiate an RDN referral for further
assessment and nutrition intervention,
the total Braden scale score has not
been validated to identify patients for
whom specialized nutrition assessment and intervention by an RDN is
necessary or appropriate. Furthermore,
since its development in 1987, of the
numerous studies that have been conducted to assess the validity of the
Braden scale and its subscales for predicting pressure injury risk, many have
concluded that the Braden scale is
highly overpredictive of actual pressure
injury development.14-16 In other
words, not all patients who are
predicted to develop a pressure
injury actually develop one. This
2

overprediction could be seen as a major aw of the Braden scale, weakening


its practical utility overall, especially as
it relates to nutrition screening and
referral to the RDN. As explained in one
review,16 the accurate assessment and
identication of patients at risk for
developing a pressure injury may lead
to appropriate measures to prevent
actual injury development. Conversely,
perhaps the Braden scale truly did
identify people in whom pressure injuries never would have developed
and, therefore, resulted in the
implementation of unnecessary and
potentially
costly
preventative
interventions.16
In addition to the Braden scale score
possibly being overpredictive of
actual pressure injury development, it
is difcult to determine based on
existing literature whether individual
subscales, including nutrition, are
independently predictive of true risk.
Four studies analyzed the validity of
the subscales in the critical care population,15,17-19 and none found the
nutrition subscale score to be independently predictive of pressure injury
development. The weakest subscale of
the Braden scale was found to be the
nutrition subscale, according to
another study conducted on elderly
inpatients, because the nutrition subscale did not accurately distinguish
which patients were more likely to
develop pressure injuries.20
One of the limitations of the nutrition subscale is that patients receiving
enteral or parenteral nutrition, despite
potentially meeting their estimated
energy and protein requirements, can
score no higher on the Braden scale
than a 3, or adequate. A score of 4
(excellent) can be achieved only by
those patients who are meeting their
nutrition needs orally, potentially
resulting in an unnecessarily lower
nutrition subscale score and, therefore,
total Braden scale score. Another
important limitation to any of these
studies is the potential for the Braden
scale to be inaccurate, particularly for
the nutrition subscale. Although the
other ve subscales are scored based
on current status, nutrition is scored
based on usual dietary patterns, which
can lead to confusion and inaccuracies
when scoring.13 This can lead to inaccuracy in scoring the Braden scale,
because many nurses score this subscale using the current intake due to

JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

lack of knowledge of how the subscale


is designed; in addition, some hospitalized patients cannot communicate
adequately and, therefore, cannot provide information about usual dietary
patterns. The current literature does
not describe how much the nutrition
subscale score changes over time during a patients hospital course or to
what degree it inuences the overall
Braden scale score.

Malnutrition Screening Tools


Because nutrition status can inuence
skin integrity and wound healing,
malnutrition should be prevented or
treated whenever possible for all patients. In the context of this article, this
fact is particularly true for patients
who also have been identied as being
at risk for pressure injury development. Several validated nutrition
screening tools exist, and they were
evaluated by the Academy of Nutrition
and Dietetics in 2009 for validity and
reliability as part of their Evidence
Analysis Library process.21 Of the 11
tools evaluated, the Malnutrition
Screening Tool (MST) was shown to
have both validity and reliability to
accurately identify nutrition problems
in acute care hospitals, whereas its
simplicity has allowed hospitals to
easily adopt this tool. This helps to
assess nutrition status and predict poor
clinical outcomes related to malnutrition, thereby identifying those patients
needing a nutrition assessment and
intervention by an RDN.22
The MST, completed on admission to
the hospital, includes questions
regarding an adult patients recent
appetite and weight changes, with
scores assigned based on the patients
or caregivers response to the questions. If the patient states that he or she
has lost weight recently without trying,
then the nurse proceeds to ask how
much weight has been lost and assigns
points based on the categories shown
in Table 1. The patient or caregiver is
then asked whether they have been
eating poorly because of decreased
appetite; if yes, an additional point is
assigned. The weight loss and appetite
scores are then totaled; if a patient
scores 2 or more points on the
screening tool, he or she is considered
at nutritional risk, and a referral should
be sent to the RDN to complete a more
in-depth assessment and determine
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PRACTICE APPLICATIONS
Table 1. Categorization of
unintentional weight loss with
corresponding points assigned
using the validated Malnutrition
Screening Tool
If yes, how much weight
(kilograms) have you lost?
1-5

6-10

11-15

>15

Unsure

whether nutrition interventions are


necessary.
Intervening on all patients at risk for
malnutrition (or already identied as
malnourished) is important, because
all malnourished patients are at higher
risk for developing a pressure injury.
Therefore, a validated nutrition
screening tool with high sensitivity and
specicity for predicting malnutrition,
such as the MST, should be used in all
hospital settings. Not all patients at risk
for developing a pressure injury would
be simultaneously at risk for malnutrition and, therefore, not all patients
identied as at risk for pressure injury
development should be referred to the
RDN unless they are rst identied as
being at risk for malnutrition. This
would ensure that health care resources, such as RDN services, are used
in a cost-effective manner. The goal of
this project was to determine how
often the Braden scale total score or the
nutrition subscale score would be in
agreement with the MST score for
predicting patients in need of a full
nutrition assessment and nutrition care
plan intervention.

were chosen based on a higher incidence of pressure ulcers than other


units in this 585-bed hospital as well as
compliance of the nursing staff in
regularly completing both the Braden
scale and the MST. Data were collected
during the rst consecutive 6 days of
each patients hospital stay, based on
the hospitals average length of stay for
that scal year. The following data
points were collected for each patient:
nursing unit, Medical Record Number,
age, Braden score on admission, nutrition subscale score on admission, MST
score on admission, whether the Braden scale score and MST score would
have both triggered an RDN referral,
using a cutoff score of 18, highest and
lowest Braden scores during rst 6
days of hospital stay and difference, the

difference between the highest and


lowest nutrition subscale score during
the rst 6 days of hospital stay,
whether the patient was seen by an
RDN, and what the nutrition intervention was, if any. Data were recorded in
an Excel spreadsheet (Excel Professional Plus, 2010, Microsoft Corporation). Inclusion criteria included those
patients admitted for more than 24
hours who were at least 18 years of
age. Exclusion criteria included more
than 24 hours having passed between
collection of initial Braden score and
the MST score, or the MST not being
completed within 24 hours of admission, or the patient being younger than
18 years. Data were only collected for
patients who were at least at mild risk
for pressure injury development and,

CONDUCTING THE ASSESSMENT


Comparison of MST and Braden
Scale Scores
This assessment was approved by the
Institutional Review Board at the hospital under review. Data were collected
from the medical charts of 121 patients
admitted to the following units with an
initial Braden score of 18 or less: surgical/trauma/burn intensive care unit
(ICU), medical ICU, thoracic cardiovascular postoperative ICU, and four
medical/surgical units. These units
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Figure. Survey of registered nurses to evaluate knowledge of scoring the nutrition


sub-scale of the Braden Scale.
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

PRACTICE APPLICATIONS
Table 2. Comparison of Braden Scale score with Malnutrition Screening Tool
(MST) scorea
MST Score
Braden risk category

Mild

38

Moderate

20

High

11

12

71

18

Very high

Total

11

73

27

19

15

121

The total score on the Braden Scale places the patient in a risk category of either none, mild, moderate, high, or very
high. This table indicates the corresponding score on the MST for each of the patients in each of those Braden risk
categories, with the total number of patients in each group indicated in the table.

therefore, patients with a Braden


scale score greater than 18 were
excluded.

Nursing Survey to Determine


Accuracy of Braden Scale Scoring
Because of the concerns explained in
the background section regarding the
potential for error on scoring the
nutrition subscale of the Braden scale
by registered nurses (RNs), a survey
was administered to RNs to ascertain
their knowledge of how the nutrition
subscale score of the Braden scale
should be assessed and scored (Figure).
Seventy surveys were distributed by
hand to the seven units being studied
by the primary investigator (M. H.),
with 44 completed and returned (63%
response rate). Responses were obtained from acute care and intensive
care RNs (54.5% of surveys from acute
care and 45.5% of surveys from intensive care RNs).

FINDINGS
Comparison of MST and Braden
Scale Scores
The average age of the 121 patients was
61.9 years, with 40% of patients from
ICUs and 60% from acute care units. The
average initial Braden scale score was
14.2 for ICU patients and 15.4 for patients on acute care units.
Of the 121 patients, 89 (73.5%) had an
MST of either 0 or 1, which would indicate that the patients were not at risk for
malnutrition. Of those patients, 16 (18%)
were in the high or very high risk Braden
scale category, with the other 82% of
patients being in the mild to moderate
risk Braden scale category (Table 2). Of
the 121 patients, 32 patients (26.5%)
scored 2 points on the MST, indicating
risk for or presence of malnutrition. Of
these, only 5 (16%) had a Braden scale
score in the high risk or very high risk
category. This would suggest little correlation between the malnutrition risk

Table 4. Indication of patients seen


by a registered dietitian nutritionist
(RDN) in each of the Braden scale risk
categories

Table 3. Comparison of nutrition subscale scores of the Braden scale with the
Malnutrition Screening Tool (MST) scorea
MST Score
Nutrition subscores

Total

32

11

10

63

38

53

71

18

15

121

a
The score on the nutrition subscale is compared to the MST score. This table indicates the corresponding score on the
MST for each of the patients with each of the nutrition subscale scores, with the total number of patients in each group
indicated in the table.

JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

score and the pressure injury development risk score. Because of the variance
in the way scores are distributed within
risk categories between the MST and the
Braden scale, the data were not distributed in a way that would allow for data
analysis to determine whether this was
a statistically signicant difference.
Because of the nature of the scale itself
and current research on the utility and
reliability of the Braden scale, for
assessment coordinators to change the
score categories would have been
inconsistent and undesirable. A similar
pattern was seen when the nutrition
subscale scores were compared against
the MST score (Table 3). Interestingly, no
patients received a 4 (excellent) on the
nutrition subscale score, and only 5 of
121 received a 1 (very poor).
Although the Braden scale score is not
used as a nutrition screening referral in
this hospital, and only 26.5% of the patients scored 2 or more points on the
MST, 65% of patients who scored less
than 18 on the Braden scale were seen
by an RDN (Table 4). Patients in the very
high risk category were seen 100% of the
time (n2), and patients in the high risk
category were seen 79% of the time
(n19). Likewise, 100% of patients with
a nutrition subscale score of 1 (n5) and
73% of those with a nutrition subscale
score of 2 (n62) were seen by the RDN.
This conrms that other measures are in
place to trigger RDN involvement in the
patients care, and the Braden scale
score or the nutrition subscale score are
not necessary triggers for RDN referral.
Results of the survey to assess
nursing training on how to score the
nutrition subscale of the Braden, their
scoring condence, and knowledge of
scoring criteria conrmed the potential

Seen by RDN
Braden risk
category

%
Yes No Seen

Mild

43 30

60%

Moderate

19

70%

High

15

79%

Very high

0 100%

79 42

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PRACTICE APPLICATIONS
Table 5. Percent of nurses
answering with the desired response
on the nursing survey
Question 1: Trained on scoring 23%
the nutrition subscale of the
Braden scale?
Question 2: Condent in scoring 50%
the nutrition subscale of the
Braden scale?
11%
Question 3: Scoring nutrition
subscale of the Braden scale
using correct assessment?
Question 4: Can correctly
describe what the various
subscores indicate?

59%

Question 5: Knows where to


nd nutrition subscale
scoring criteria on Epic?

64%

for scoring errors when completing the


Braden scale. Whereas 64% of nurses
surveyed knew where to nd the
scoring criteria in the electronic medical record, 59% could provide correct
descriptions of what each nutrition
subscale score indicated, and 50% felt
condent in scoring the nutrition subscale; only 11% were actually assessing
patients nutrition status using the
correct criteria. Furthermore, only 23%
indicated they were trained on how to
score the nutrition subscale, indicating
that training in this area is lacking at
this particular institution. Survey
results are listed in Table 5.

IMPLICATIONS FOR PRACTICE


A strength of this assessment is that it
compares the use of a pressure injury
development risk score against a validated nutrition screening tool to identify patients in need of an RDN referral.
In addition, it examines nurses knowledge on completion of the nutrition
subscale score. Limitations of this
assessment include a small sample size
and the inability to distribute the data
for intended statistical analyses, as discussed in the Findings section. The data
collection time of 6 days vs a longer
period is also a limitation, because
pressure injury formation may take
longer than 6 days. Future research
should include multiple hospitals with a
larger sample size for a longer period to

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see whether the results are generalizable to a larger population across multiple facilities.
Effective use of an overall Braden
scale score or the nutrition subscale
score as a nutrition screening trigger
for a referral to the RDN for subsequent
assessment and intervention depends
on its accuracy and interrater reliability. Numerous studies note the
inconsistency of the scales scores and
overpredictability for forecasting risk
of developing a pressure injury. The
literature suggests that the nutrition
subscale score is the most inaccurate of
all the scores, likely because of the
difference in how it is assessed
compared with the other subscales.
This assessment conrmed those outcomes, because most of the nursing
staff surveyed are incorrectly assessing
patients nutrition risk using the Braden scale. Inaccurate scoring could
produce an unnecessarily high number
of RDN referrals, leading to additional,
unwarranted work for the RDN that
could be directed toward patients
at higher nutritional risk. Because
malnourished patients are at greater
risk of developing pressure injuries, for
purposes of targeting nutrition intervention, identifying patients at risk for
malnutrition, not necessarily those at
risk for developing pressure injuries, is
important. The use of a validated
nutrition screening tool, such as the
MST,22 can help to identify these patients. Ongoing communication with
the health care team and adequate
documentation of key assessment factors such as percent meal intake and
intake of oral, enteral, and parenteral
nutrition during a patients hospital
stay can help the RDN identify which
patients are in need of specialized
nutrition interventions to prevent
all malnutrition-associated adverse
events, including pressure injuries.

References
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DISCLOSURES
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
No potential conict of interest was reported by the authors.

FUNDING/SUPPORT
No authors have any conicts of interest or funding sources to disclose.

JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

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