Part 2: pressure ulcer assessment: implementation and revision of CALCULATE

Critically ill patients are a vulnerable group at very high risk of developing pressure ulcers, and the incidence varies within critical care.

A number of strategies were used to implement the pressure ulcer assessment tool CALCULATE across four adult critical care units. Strategies included, nursing leadership, the provision of definitions for each risk factor, information laid out on posters at each patient's bedside, changes to pre-printed nursing documentation and a 30-min focused training package. Two local audits were conducted to measure the number and types of risk factors occurring in patients with pressure ulcers, and to assess the frequency of assessments and gain feedback on the usability of the tool in practice.

Critical care acquired pressure ulcer incidence was 3.4%. The two most commonly occurring risk factors were impaired circulation (82%) and mechanical ventilation (75%). Patients had a mean score of 4, and 65% had 4 or more reported risk factors. Feedback on the usability of the tool was mainly positive.

The tool CALCULATE was relatively straightforward to implement and was likely to be due to the design and the various change strategies used to implement the new approach. The seven point tool was revised to an eight point score based on nurses' clinical feedback.

Research is required to further enhance and develop pressure ulcer assessment. Meanwhile CALCULATE offers an easy to use and appropriate tool to assist in the identification of patients at an elevated risk of pressure ulcer damage.

Careful choice of change management strategies are needed when implementing a new assessment tool. CALCULATE should be considered for use in critical care for pressure ulcer assessment, but used alongside nurses' clinical judgement and observations of skin.