LAUSR

Dear Editors, With great interest, we read the recent paper by Lovegrove et al who developed pressure injury (PI) preventive interventions based on risk categories of the Consciousness, Mobility, Heamodynamics, Oxygenation, Nutrition (COMHON) Index. PI prevention in clinical practice is a complex and challenging task, and initiatives aimed at guiding and improving setting-specific PI prevention are highly welcome. Because the authors use the latest International Guideline for prevention and treatment of PIs as background for their work, some assumptions and statements should be put into context: First, citing the International Guideline, the authors state: “PI prevention begins with risk assessment, which should be undertaken using a structured risk assessment scale combined with clinical judgement.” We would like to clarify that such a statement does not exist in the International Guideline. We feel very concerned about this wrong and misleading citation, which Lovegrove et al used to justify their risk assessment approach. We invite the authors and all guideline users to study the comprehensive 35 pages “Risk Factors and Risk Assessment” chapter in the International Guideline in detail, which presents a comprehensive summary of PI risk assessment evidence of the last decades, to ensure correct citations and appropriate interpretations. Second, the International Guideline does state that when performing a comprehensive PI risk assessment, a structured approach that includes a comprehensive skin assessment and clinical judgement should be used. The structured approach must ensure that all relevant risk factors for the particular patient group and clinical setting are considered. Standardised risk assessment tools (scales, indices) may be used as one part of the risk assessment; however, a risk assessment tool does not replace a comprehensive structured approach. When a risk assessment tool is used, additional risk factors must be also considered, because the currently available tools do not include all relevant factors for individual patients and clinical situations. Third, for years it has been widely accepted that total (sum) scores of PI risk assessment tools and corresponding “risk levels” are neither reliable nor valid, and there is no evidence that their use improves clinical decision-making. Evidence supporting instrument measurement properties such as reliability or (predictive) validity does not indicate whether using a PI assessment tool to conduct a risk assessment improves clinical practice and patient outcomes. Therefore, concepts such as “effectiveness” or “effects” of PI assessment tools should only be used when there is appropriate intervention studies investigating risk assessment tool effects. Finally, while we fully understand the desire to develop prevention protocols that are more specific than described in the International Guideline, the output of recommended interventions listed in Table 4 is disillusioning. The International Guideline cautions, “Do not rely on a total risk assessment tool score alone as a basis for risk based prevention” (page 60). Every PI preventive intervention must address the individual risk factors, with a direct link between exposures to direct PI risk factors (such as immobility) and interventions directly addressing these factors. Subscale scores from risk assessment tools may be useful in identifying some (but not all) modifiable risk factors. However, by definition, the total score from a risk assessment tool cannot provide the details necessary for focused risk-based preventive interventions, resulting in over-, under-, or inappropriate use of preventive services and supplies. For example, classifying an individual as “low risk” based on the total COMHON score does not justify not using heel off-loading devices or specialised cushions when sitting out of bed. PI prevention planning should be determined based upon the level of mobility, the duration of sitting, and the Received: 28 September 2020 Accepted: 20 October 2020