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A risk assessment scale for pressure ulcers in children

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VOL: 103, ISSUE: 14, PAGE NO: 32-33

Jane Willock, RGN, RSCN, BSc, PGDipEd, MSc; Mona Baharestani, PhD, CWOCN, FCCWS, FAPWCA, is director of wound healing, Long Island Jewish ; Denis Anthony, RMN, RGN, RN (Canada), BA, MSc, PhD

Jane Willock is senior lecturer, faculty of health and sports sciences, University of Glamorgan, and nurse practitioner, children?s investigations unit, University Hospital of Wales, Cardiff; Dr Mona Baharestani is director of wound healing, Long Island Jewish Medical Centre, New York; Professor Denis Anthony, is head of postgraduate research studies, faculty of health and life sciences, De Montfort University, Leicester.

Abstract: Willock, J. et al (2007) A risk assessment scale for pressure ulcers in children.

Aim: To develop a pressure ulcer risk assessment scale for children using statistical methods and patient data.

Method: Data on 336 children admitted to 11 hospitals was collected using questionnaires. The data was studied to compare the characteristics of children who had developed pressure ulcers with the characteristics of the representative sample of hospitalised children. The significance of the children’s characteristics in the development of pressure ulcers was then estimated and a risk assessment scale developed.

Results: Using the significance values as a guide, the Glamorgan Paediatric Pressure Ulcer Risk Assessment Scale was developed. High weightings were assigned to immobility and pressure on the skin, but a lower weighting was given to anaemia. At a risk score of 10 the scale was 100% sensitive but 50.2% specific. It is difficult to assess true sensitivity and specificity due to the impact of preventive measures. At a risk score of 15, the scale was 98.4% sensitive and 67.4% specific. The area under the ROC curve was found to be 0.912, giving the Glamorgan scale a predictive validity of 91.2%.

Discussion: The Glamorgan scale appears to be the first paediatric pressure ulcer risk assessment scale developed statistically using patient data. The sensitivity, specificity and predictive validity of the Glamorgan scale appears to be greater than the Braden Q scale, but testing with new data sets is required.

Conclusion: The Glamorgan scale may give a more accurate estimate of risk than other scales, but it is important to note that no risk assessment scale can be 100% accurate. Nurses should examine and try to resolve the individual problems that contribute to the total risk. Pressure ulcer risk assessment scales are used to identify patient risk, level of risk and type of risk. While more than 200 published pressure ulcer risk factors have been cited, (Salzberg et al, 1999), not all characteristics are relevant to all patient groups, and clearly it would be impossible and impractical to incorporate more than a few risk factors into an assessment scale. Adult pressure ulcer risk assessment scales were initially developed based on patient observation (Norton et al, 1962; Waterlow, 1985) and later on literature reviews (Braden and Bergstrom, 1987), which identified factors believed to predispose patients to pressure ulcer development.

Although some risk assessments have undergone extensive testing, the individual predictive value of each item was not taken into account, and nor were comprehensive analyses of all variables performed (Haalboom et al, 1999). The prevalence of pressure ulcers in hospitalised children has been estimated between 0.47% and 13.1% (Baldwin, 2002; Groeneveld et al, 2004; Willock et al, 2000; Waterlow, 1997; McLane et al, 2004; Dixon and Ratcliff, 2005) and up to 27% in paediatric intensive care units (Zollo et al, 1996; Curley et al, 2003; Curley et al, 2000). However, there are very few research publications describing the characteristics of children with pressure ulcers (McCord et al, 2004; Willock et al, 2005; Willock et al, 2000).

Ten published paediatric risk assessment scales have been identified, of which six are modifications of adult risk assessment scales (Quigley and Curley, 1996; Garvin, 1997; Huffines and Logsdon, 1997; Pickersgill, 1997; Samaniego, 2003; Suddaby et al, 2005). Two risk assessments are based on patient observation (Bedi, 1993; Olding and Patterson, 1998), one on a review of relevant literature (Cockett, 1998), and one on a multi-centre survey but this was not predictive (Waterlow, 1997; Waterlow, 1998). No published studies were identified using statistical methods to develop a pressure ulcer risk assessment scale directly from patient data.


An initial survey of 265 patients (seven of whom had pressure ulcers) in a children’s hospital in England was performed to obtain detailed patient characteristic data representative of a paediatric hospitalised population. Detailed questionnaires were developed based on a review of the paediatric and adult pressure ulcer literature and extensive discussions with paediatric nurses experienced in pressure ulcer prevention and care. Using these questionnaires, data on the characteristics of 336 paediatric inpatients in 11 hospitals was collected as described in Table 1 (Willock et al, 2000; Willock et al, 2005).

Table 1. Details of the sample of children

SitesRoyal Liverpool Children’s Hospital Eleven hospitals in England and Wales*
Data collection type Prevalence study - all inpatients during one day Incidence study in three wards over one month Survey of children who developed pressure ulcers (and some with similar characteristics who did not develop pressure ulcers)  
Sample size: With pressure ulcer 4 3 54    
Without pressure ulcer 179 79 17  
Sample characteristics Mainly Caucasian, aged from one day to 17 years 11 months, 60% boys    Mainly Caucasian, aged three weeks to 17 years and eight months, 61% boys


* The 11 hospitals in England and Wales were:                                                                                                                                              

  • Birmingham Children’s Hospital
  • Bristol Royal Hospital for Children
  • Pilgrim Hospital, Lincolnshire
  • Queen’s Medical Centre, Nottingham
  • Royal Liverpool Children’s Hospital
  • Royal London Hospital
  • Royal Manchester Children’s Hospital
  • Royal National Orthopaedic Hospital
  • St George’s Hospital London
  • St Mary’s Hospital London
  • University Hospital of Wales, Cardiff

A prevalence study measures the proportion of cases in a population at a point in time, and an incidence study measures the proportion of new cases presenting over a period of time. This sort of data is more representative of the general hospitalised paediatric population than an unstructured survey, and can be used to compare with data from a population of children specifically with pressure ulcers. The European Pressure Ulcer Advisory Panel’s (EPUAP, 2005) and the National Pressure Ulcer Advisory Panel’s (NPUAP, 2003) pressure ulcer staging systems were used. Local ethical approval was obtained for the single site study, and multi-centre ethics approval was obtained for the study in 11 hospitals. Data collectors in both studies received standardised training on pressure ulcer identification and questionnaire administration. Data collected from both studies was combined so that the characteristics of children who had developed pressure ulcers could be compared with the characteristics of the representative sample of hospitalised children. As the data were predominantly nominal, chi-square tests were performed using SPSS (Statistical Package for the Social Sciences version 12) to estimate the significance of the children’s characteristics in the development of pressure ulcers.


Table 2. The level of significance of variables associated with pressure ulcers in children



Level of significance


Difficult to position







Equipment pressing or rubbing
Reduced mobility
Prolonged surgery
Persistent pyrexia
Poor peripheral perfusion
Low serum albumin
Weight below 10 thcentile for age
Inadequate nutrition
Incontinence inappropriate for age .003
Hypothermia .027
Poor tissue oxygenation .194
Reduced conscious level .236
Weight over the 90 thcentile for age .275
Self care ability inappropriate for age .465



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