Top nurse warns risk assessment tools are not backed by evidence
The director of the national nursing research unit has called into question the worth of clinical risk assessment tools routinely relied on by thousands of frontline nurses.
Such tools are also now forming the basis of indicators, or metrics, being introduced to measure the quality of nursing care across the health service in areas such as pressure ulcer prevention and falls.
But Professor Peter Griffiths has told Nursing Times there is “no clear evidence” that many of the tools currently used accurately predict risk and help improve clinical outcomes.
Professor Griffiths, who contributed to research on metrics that fed into the next stage review, cited the Waterlow score – a numerical system used for 25 years to assess pressure ulcer risk – as an example of a particularly ineffective risk assessment tool.
“The Waterlow score was designed to raise awareness of pressure ulcers and hugely over-predicts risk. It is fine if it is being used to focus efforts and attention in this area, but it is not fine if it is being used as a clinical risk assessment tool to target intervention strategies,” he said.
Reducing the number of pressure ulcers has been highlighted by the chief nursing officer for England, Dame Christine Beasley, as one of eight “high impact actions” that should be implemented by nurses to improve patient care and reduce NHS costs (news, page 1, 17 November)
And, as Nursing Times revealed last week, the Department of Health is considering linking the amount hospital trusts get paid to how well they perform in clinical areas such as reducing pressure ulcers (news, page 1, 1 December).
But Heart of England Foundation Trust chief nurse Mandie Sunderland, who helped pioneer the introduction of nursing quality indicators in the North West, suggested that while not perfect, the current risk scores were the best available.
She said they were a useful first step - and it was necessary to work with what was available unless better tools were developed.
“A fundamental issue for improving care in areas such as pressure ulcers and falls is to first assess if a patient is at risk. We have adopted risk assessment tools [as part of nursing metrics] to help nurses identify patient needs, and signpost them to who needs further care,” she said.
United Lincolnshire Hospital Trust’s lead nurse in tissue viability Mark Collier acknowledged that such risk assessments had “not been researched enough to be specifically used as absolute measures of quality”.
“Tools should be used as a baseline, but they also need to be reused when it is clinically indicated or in line with NICE guidance. It must not be just a paper filling exercise,” he said.
“There is definitely an argument for doing an analysis of what we already have and developing amalgamated tools, or generic templates, that can be tailored to patient groups,” he added.
A spokesperson for the Department of Health said it is up to local organisations to consider which tools they want to use as part of ongoing risk assessment, but that the DH “would always expect trusts to evaluate against the best evidence in terms of which tools they use.”
She added that the Department of Health is working with strategic health authorities and service providers to develop measurement methodology and definitions for pressure ulcers, and further guidance and materials to support nursing staff in implementing the chief nursing officer’s high impact interventions will be available next year.