Pressure ulcers: effectiveness of risk-assessment tools. A randomised controlled trial (the ULCER trial)

BMJ Qual Saf. 2011 Apr;20(4):297-306. doi: 10.1136/bmjqs.2010.043109. Epub 2011 Jan 24.


Objective: To evaluate the effectiveness of two pressure-ulcer screening tools against clinical judgement in preventing pressure ulcers.

Design: A single blind randomised controlled trial.

Setting: A large metropolitan tertiary hospital.

Participants: 1231 patients admitted to internal medicine or oncology wards. Patients were excluded if their hospital stay was expected to be 2 days or less.

Interventions: Participants allocated to either a Waterlow (n=410) or Ramstadius (n=411) screening tool group or to a clinical judgement group (n=410) where no formal risk screening instrument was used.

Main outcome measure: Incidence of hospital acquired pressure ulcers ascertained by regular direct observation. Use of any devices for the prevention of pressure ulcers, documentation of a pressure plan and any dietetic or specialist skin integrity review were recorded.

Results: On admission, 71 (5.8%) patients had an existing pressure ulcer. The incidence of hospital-acquired pressure ulcers was similar between groups (clinical judgement 28/410 (6.8%); Waterlow 31/411 (7.5%); Ramstadius 22/410 (5.4%), p=0.44). Significant associations with pressure injury in regression modelling included requiring a dietetic referral, being admitted from a location other than home and age over 65 years.

Conclusion: The authors found no evidence to show that two common pressure-ulcer risk-assessment tools are superior to clinical judgement to prevent pressure injury. Resources associated with use of these tools might be better spent on careful daily skin inspection and improving management targetted at specific risks.

Study registration: The trial was registered with the Australian and New Zealand Clinicat Trials Registry (ACTRN 12608000541303).

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Female
  • Humans
  • Internal Medicine / statistics & numerical data
  • Male
  • Middle Aged
  • Oncology Service, Hospital / statistics & numerical data
  • Pressure Ulcer / diagnosis
  • Pressure Ulcer / prevention & control*
  • Risk Assessment / methods
  • Single-Blind Method
  • Young Adult