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Reusability of EMR Data for Applying Cubbin and Jackson Pressure Ulcer Risk
Assessment Scale in Critical Care Patients
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Objectives: The purposes of this study were to examine the predictive validity of the Cubbin and Jackson pressure ulcer risk as-
sessment scale for the development of pressure ulcers in intensive care unit (ICU) patients retrospectively and to evaluate the
reusability of Electronic Medical Records (EMR) data. Methods: A retrospective design was used to examine 829 cases admitted
to four ICUs in a tertiary care hospital from May 2010 to April 2011. Patients who were without pressure ulcers at admission to
ICU, 18 years or older, and had stayed in ICU for 24 hours or longer were included. Sensitivity, specificity, positive predictive val-
ue, negative predictive value, and area under the curve (AUC) were calculated. Results: The reported incidence rate of pressure
ulcers among the study subjects was 14.2%. At the cut-off score of 24 of the Cubbin and Jackson scale, the sensitivity, specific-
ity, positive predictive value, negative predictive value, and AUC were 72.0%, 68.8%, 27.7%, 93.7%, and 0.76, respectively. Eight
items out 10 of the Cubbin and Jackson scale were readily available in the EMR data. Conclusions: The Cubbin and Jackson scale
performed slightly better than the Braden scale to predict pressure ulcer development. Eight items of the Cubbin and Jackson
scale except mobility and hygiene can be extracted from the EMR, which initially demonstrated the reusability of EMR data for
pressure ulcer risk assessment. If the Cubbin and Jackson scale is a part of the EMR assessment form, it would help nurses per-
form tasks to effectively prevent pressure ulcers with an EMR alert for high-risk patients.
Keywords: Electronic Health Records, Pressure Ulcer, Risk Assessment, Nursing Assessment, Intensive Care Units
time as the cost increased with ulcer grade because the time that they can help nurses identify ICU patients at high-risk
to treat became longer due to complications [3]. for pressure ulcers more accurately while reducing the time
The occurrence of pressure ulcers during hospitalization is and efforts to apply a new pressure ulcer risk assessment
a significant patient safety indicator [4] and a nursing-sen- scale. However, there has been no research about whether
sitive outcome [5,6]. The criteria for evaluating healthcare and how information from EMRs structurally matches
institutions mandated by the Ministry of Health & Welfare with the items of the Cubbin and Jackson scale; therefore,
and the Korea Institute for Healthcare Accreditation [7] also more validation studies of the Cubbin and Jackson scale are
included pressure ulcer prevention as a necessary nursing needed to support its further use [14]. To address this issue,
service. Hence, nursing need assessment, nursing data col- we first examined the predictive validity of the Cubbin and
lection, and nursing process are required to prevent pressure Jackson scale on pressure ulcer development in ICU patients,
ulcers. and then evaluated the reusability of EMR data for the Cub-
In comparison with patients in general wards, patients bin and Jackson scale.
admitted to intensive care units (ICUs) are at high-risk for
pressure ulcers [8] as they have many risk factors resulting II. Methods
in immobilization, such as a mechanical ventilator, lowered
level of consciousness, decreased sensation, malnutrition, Before evaluating the reusability of EMR data for applying
edema, and fecal and urinary incontinence [9,10]. Thus, by the Cubbin and Jackson pressure ulcer risk assessment scale
identifying risk factors for pressure ulcers in ICUs and the in ICU patients, a retrospective study was conducted to ex-
high-risk groups, focused and effective nursing care prevents amine the predictive validity of pressure ulcer development
pressure ulcers, assures patients safety, and reduces the cost risk scales in medical and surgical ICU patients comparing
by decreasing the length of a hospital stay [11]. the Cubbin and Jackson scale and the Braden scale using
Pressure ulcer risk assessment scales have been developed nursing records extracted from EMR.
and used to identify high-risk groups for pressure ulcers. A
proper assessment scale focusing on specific patient groups, 1. Study Setting and Subjects
such as ICU patients, would be very important and would The subjects of this study were patients admitted to four
enable the provision of proper nursing care in timely man- ICUs (two medical and two surgical ICUs) at a university
ner. Although the Braden scale [12], most broadly used in hospital in Seoul, Korea where EMR has been fully utilized
clinical settings, has been developed for patients in general since 2005. The selection criteria were patients aged 18 years
wards, previous studies have shown that the Braden scale or older who stayed in the ICU longer than 24 hours and did
tends to overestimate the risks of developing pressure ul- not have pressure ulcers indicated in nursing records when
cer and thus has resulted in increased costs for pressure they were admitted to ICUs.
ulcers prevention as well as unnecessary nursing workload Among 2,710 patients who were admitted to ICUs for one
[13,14]. Other assessment scales have also been developed, year from May 2010 to April 2011, 1,614 were electronically
and the Cubbin and Jackson scale [15] is one that is specifi- selected based on the selection criteria. The total number of
cally focused on ICU patients. It has been reported to show subjects who were finally included in the data analysis was
better ability to predict pressure ulcer development in this 829 after excluding subjects whose nursing records had miss-
population than the Braden scale [8,16,17]. The Cubbin and ing data on essential variables of the Cubbin and Jackson
Jackson scale includes ICU specific items, such as hemody- scale and the Braden scale. In case of multiple admissions to
namics and respiration, whereas the Braden scale has items ICUs of one patient during the study period, only the admis-
that can apply to any clinical settings. Because the Braden sions for the initial hospitalization and re-hospitalization
scale is widely used in hospitals, it is speculated that the were included due to concern about the influence of severity
Braden scale is more convenient to utilize than the Cubbin from the same hospitalization on pressure ulcer develop-
and Jackson scale [18] in terms of time and effort of nurses’ ment.
assessment, and a hospital may want to have a universal tool
for hospital-wide statistics. 2. Measurements and Variables
When promoting a practical way of using the Cubbin and The pressure ulcer risk assessment scales included in this
Jackson scale for ICU patients, it is important to investigate study were the Cubbin and Jackson scale to evaluate the va-
whether the data already existing in current Electronic Med- lidity of its application to ICU patients and the Braden scale
ical Records (EMRs) are reusable in an effective way, such that is generally used across all wards in hospitals.
1) Cubbin and Jackson scale al skin condition, mental condition, mobility, hemodynam-
This scale was developed by Cubbin and Jackson in 1991 [13] ics, respiration, nutrition, incontinence, and hygiene. Each
for ICU patients, and consists of 10 items: age, weight, gener- item has a 4-point scale; thus, the point total is 40. The lower
Table 1. Operational definitions of Cubbin and Jackson scale for this study
Table 1. Continued
the point total is, the higher the likelihood of pressure ulcer assistance from a nurse informatician, and then further re-
development is. To use EMR data to match the Cubbin and view of the EMRs was performed for semi-structured or un-
Jackson items, operational definitions were created as shown structured fields (e.g., nutrition, incontinence) that required
in Table 1. For example, for hemodynamic criteria, mean researchers’ inspection for text data or understanding of the
blood pressure, which most accurately reflects the blood context associated with other data fields. The scores of the
flow of tissue, was used, and the lowest value on the day of two pressure ulcer risk assessment scales from all patients
ICU admission was extracted. Then ‘stable’ or ‘unstable’ was were obtained upon the admission. The Braden scale was
determined after literature review and discussion with ICU extracted from the information already existing in the EMR,
and trauma specialists. and the items of the Cubbin and Jackson scale were extracted
from the EMR based on the operational definitions given in
2) Braden scale Table 1.
The Braden scale consists of 6 items, including sensory per-
ception, moisture, activity, mobility, nutrition, and friction/ 4. Data Analysis
shearing. Friction/shearing is on a 3-point scale, and other 5 Descriptive statistics were used to describe the charac-
items are on a 4-point scale. The possible score range is from teristics of the subjects and pressure ulcers. The scores of
6 to 23, and the lower the point total is, the higher the risk of the pressure ulcer risk assessment scales were compared
pressure ulcer development [12]. The Braden scale is the in- between the pressure ulcer development group and non-
strument assessed by each shift at ICUs in the study site, and pressure ulcer group using a t-test. The predictive validity of
the values at admission to the ICU were used in this study. the scales, such as sensitivity, specificity, positive predictive
Finally, a total of 24 items were extracted from EMRs to value, negative predictive value, and receiver operating char-
possibly match items of the Cubbin and Jackson and Braden acteristics (ROC) curve with area under the curve (AUC)
scales, along with other variables including sex, hospital de- were obtained. Data analysis was performed using SPSS ver.
partments, ICU length of stay, use of restraint and ventilator, 18.0 (SPSS Inc., Chicago, IL, USA).
and diagnosis with diabetes mellitus (DM). In addition, pres- The EMR reusability was evaluated by applying the follow-
sure ulcer was determined when patients developed pressure ing criteria to assess data corresponding to each item of the
ulcers during their ICU stay. EMR [19]: 1) Complete match with structured data: one-to-
one match with a certain item of a structured input screen;
3. Data Collection Procedure 2) Complete match with nursing statement: no match with
Upon the approval of the Institutional Review Board of Col- an item of a structured input screen but match with nursing
lege of Nursing, Yonsei University (IRB 2012-1007), all data statements; 3) Suboptimal match: no match with an item
fields were initially obtained from the EMR system with of a structured input screen but it is possible to logically
extract information from more than two data items and/ hemodynamics, respiration, nutrition, incontinence, and
or standardized statements; and 4) Incomplete match: no hygiene, where the group in which pressure ulcers developed
match with data from either a structured screen or nursing scored worse than their counterparts. However, there was no
statements that is difficult to presume any information when significant difference in age and general skin condition.
combining those. The total Braden scale scores were 12.94 ± 2.38 in the pres-
III. Results
Table 2. Subjects’ characteristics and pressure ulcer development
1. Subjects’ Characteristics and Associated Factors of (n = 829)
Pressure ulcer 2
Category c p-value
Yes (n = 118) No (n = 711)
Sex 4.85 0.028
Male 85 (28.0) 437 (61.5)
Female 33 (72.0) 274 (38.5)
Age (yr) 1.23 0.747
<40 11 (9.3) 83 (11.7)
40–54 24 (20.3) 158 (22.2)
55–70 44 (37.3) 264 (37.1)
>70 39 (33.1) 206 (29.0)
BMI (kg/m²) 1.08 0.584
Low (<18.5) 14 (11.9) 64 (9.0)
Normal (18.5≤ and <25) 72 (61.0) 458 (64.4)
Obese (≥25) 32 (27.1) 189 (26.6)
ICU stay (day) 193.22 <0.001
1–4 33 (28.0) 597 (84.0)
5–8 30 (25.4) 64 (9.0)
9–12 23 (19.5) 26 (3.7)
≥13 32 (27.1) 24 (3.4)
Discharge status 65.76 <0.001
Transferred 73 (61.9) 635 (89.3)
Died 43 (36.4) 66 (9.3)
Discharged 2 (1.7) 10 (1.4)
Diabetes mellitus 10.69 <0.001
No 94 (79.7) 640 (90.01)
Yes 24 (25.3) 71 (9.99)
Edema 24.39 <0.001
No 73 (61.9) 582 (81.9)
Yes 45 (38.1) 129 (18.1)
Ventilator applied 96.28 <0.001
No 10 (8.5) 407 (57.2)
Yes 108 (91.5) 304 (42.8)
Restraint applied 82.51 <0.001
No 11 (9.3) 385 (54.1)
Yes 107 (90.7) 326 (45.9)
MBP (mmHg) 32.89 <0.001
≤55 29 (24.6) 66 (9.3)
64–54 37 (31.3) 161 (22.6)
≥65 52 (44.1) 484 (68.1)
Values are presented as number (%).
BMI: body mass index, ICU: intensive care unit, MBP: mean blood pressure.
sure ulcer development group and 14.69 ± 2.01 in the non- score on five items out six, namely, sensory perception,
pressure ulcer group (t = 7.554, p < 0.001). When comparing moisture, mobility, nutrition, and friction/shearing (data not
the scores per item by groups to examine whether or not shown).
pressure ulcers developed, there was a significantly higher
Table 4. Differences in item scores of Cubbin and Jackson scale by pressure ulcer development (n = 829)
Pressure ulcer
Item t p-value
Yes (n = 118) No (n = 711)
Age 2.06 ± 0.95 2.17 ± 0.98 1.103 0.124
Weight 2.53 ± 1.34 3.09 ± 1.16 4.294 <0.001
General skin condition 3.97 ± 0.18 3.97 ± 0.21 0.281 0.779
Mental condition 2.49 ± 1.12 3.35 ± 1.01 7.852 <0.001
Mobility 1.36 ± 0.48 1.61 ± 0.49 5.142 <0.001
Hemodynamics 2.65 ± 1.18 3.40 ± 0.96 6.553 <0.001
Respiration 2.63 ± 0.93 3.25 ± 0.97 6.723 <0.001
Nutrition 1.57 ± 0.55 1.73 ± 0.84 2.705 0.007
Incontinence 3.73 ± 0.69 3.91 ± 0.42 2.779 0.006
Hygiene 1.46 ± 0.66 1.73 ± 0.65 4.142 <0.001
Total 22.98 ± 3.30 26.49 ± 3.51 10.605 <0.001
Values are presented as Mean ± standard deviation.
Table 5. Matches of Electronic Medical Record data with Cubbin and Jackson scale
IV. Discussion ulcer development that were related with general and clinical
features identified in this study included ICU length of stay,
The purposes of this study were to examine the predictive patient’s condition at the time of discharge, DM, edema, use
validity of the Cubbin and Jackson scale for pressure ulcer of mechanical ventilator, restraint application, and mean
development in ICU patients retrospectively and to assess blood pressure.
the reusability of EMR data for the Cubbin and Jackson General edema and increased weight are associated with
scale. Therefore, we first discuss the characteristics of pres- aggravation of skin condition [23]. In particular, the use of a
sure ulcers, risk factors of pressure ulcer development, and mechanical ventilator causes edema due to positive pressure,
the predictive validity of the Cubbin and Jackson scale. Then, which thus can lead to the development of pressure ulcers
we discuss the reusability of EMR data. [24,25]. Also, using restraints often causes pressure ulcer
development in critical care patients [26]. DM is reported
1. Risk Factors of Pressure Ulcer Development as a risk factor of pressure ulcers [21], and it was also a sig-
The total number of subjects in this study was 829, and nificant risk factor in this study. Additionally, the incidence
pressure ulcer incidence during ICU stay was 118 (14.2%). of pressure ulcers was higher in the group with lower mean
Although the incidence rates of pressure ulcers differ de- blood pressure. Mean blood pressure lower than 60 to 70
pending on the data-collection methods used or the char- mmHg was associated with impaired skin condition [13,23].
acteristics of patients, it was lower in this study than in
other studies. Pressure ulcers occur in 31.3% of neurologic, 2. The Predictive Validity of the Cubbin and Jackson and
medical, and surgical ICU patients [17] and 28.6% of medi- Braden Scales
cal ICU patients [20] in Korea. In addition, it is reported It is essential to study the predictive validity of a scale that
that 34.4% [11] or 18.7% [18] of medical and surgical ICU can detect the risk of pressure ulcers to prevent lengthening
patients developed pressure ulcers in overseas studies. As of hospital stay and spending on unnecessary medical cost.
severity, surgery, and mechanical ventilator are known risk Based on the data analysis in this study, the sensitivity, speci-
factors of pressure ulcers [21-23], pressure ulcers also tend to ficity, positive predictive value, and negative predictive value
develop more frequently at immediate admission because of at the cut-off point of 24 were 72%, 68.8%, 27.7%, and 93.7%
the high doses of inotropics infused and the difficulty of po- for the Cubbin and Jackson scale. For the Braden scale, they
sition change due to unstable hemodynamics and the perfor- were 93.2%, 16.6%, 15.6%, and 93.7%, respectively, at the
mance of necessary procedures. The risk factors of pressure cut-off point of 16. In a previous study with a prospective
study design, the sensitivity, specificity, positive predictive or errors can be minimized through further education for
value, and negative predictive value of the Cubbin and Jack- nurses about documenting appropriately or EMR structure
son scale were 89%, 61%, 51%, and 92% [17]. modification [27].
Given that the AUC calculated in this study was 0.711 in In the era of Big Data, the reuse of patient documentation
the Braden scale, and 0.763 in the Cubbin and Jackson scale, [28] and structured data format [29] has been greatly em-
the value in the Cubbin and Jackson scale was slightly higher phasized. The use of standardized statements is a significant
but lower than the validity from previous studies. This is consideration in using the data of electronic nursing records
probably because we used proxies for mobility and hygiene given that the documentation on nursing records is more
that were derived from a mobility item of the Braden scale unstructured documentation than structured documenta-
without directly identifying skin conditions from either tion [19]. Also, if researchers study the structure of nursing
observation or nursing records. However, there have been information of EMR and develop the knowledge and capac-
several previous studies indicating that the ability of the ity of data usage, structured documentation would support
Cubbin and Jackson scale to predict pressure ulcer develop- the broader use of nursing record data [30] and ultimately
ment is more accurate than that of the Braden scale in ICU increase the efficiency of nursing services.
patients [8,16,17]. Thus, further studies are needed to verify Although this study is limited as a retrospective study by
the scale prospectively prior to development of an EMR data using operational definitions for hemodynamics, mobility,
form. Also, re-evaluation and adjustment of cut-off points incontinence, and hygiene, the reusability of EMR data to
are needed to enhance the prediction ability of the scale. assess pressure ulcer risks by using the Cubbin and Jackson
When a scale with high sensitivity and positive prediction scale has been initially demonstrated. Nurses manually enter
ability without considering specificity is used, nurses might data to identify patients at high-risk of pressure ulcers de-
miss patients who need preventive nursing care. Therefore, velopment using pressure ulcer risk assessment scales on a
it is important to choose a scale with high sensitivity and regular basis. Therefore, it is more desirable to maximize the
negative prediction ability to provide care to patients with use of data already collected and stored through EMR and
possible pressure ulcer development. If there are scales with minimize the number of items nurses have to document.
similar sensitivity and negative prediction ability, a scale This helps to decrease the workload by facilitating pressure
with fair specificity and positive prediction ability should be ulcer risk assessment by nurses and focuses on the timely
the choice. Therefore, the Cubbin and Jackson scale would and effective prevention of pressure ulcers for high-risk
be more appropriate than the Braden scale based on the patients by adding the electronic nursing assessment of the
study findings. Cubbin and Jackson scale to current EMR systems.
3. The Reusability of the EMR of the Cubbin and Jackson Conflict of Interest
Scale
Another important objective of this study was to examine No potential conflict of interest relevant to this article was
the reusability of nursing data in applying the pressure ulcer reported.
risk assessment scale to predict pressure ulcer development
in critical care patients. In the extraction of 10 items in the References
Cubbin and Jackson scale, 8 items (i.e., age, weight, general
skin condition, mental condition, hemodynamics, respira- 1. Nijs N, Toppets A, Defloor T, Bernaerts K, Milisen
tion, nutrition, and incontinence) were extracted using EMR K, Van Den Berghe G. Incidence and risk factors for
data as they had either a complete match with structured pressure ulcers in the intensive care unit. J Clin Nurs
data, a complete match with nursing statement, or a subop- 2009;18(9):1258-66.
timal match, whereas two items (mobility and hygiene) did 2. Agency for Healthcare Research and Quality. Prevent-
not match with EMR data fields. When nurses are dissatis- ing pressure ulcers in hospitals: a toolkit for improving
fied with the method of documentation, nurses often enter quality of care. Rockville (MD): Agency for Healthcare
information into the nursing record with free text rather Research and Quality; 2011 [cited at 2013 Dec 18].
than choosing standardized statements. Free text has the Available from: http://www.ahrq.gov/professionals/
advantage that it is relatively fast and expression is unre- systems/long-term-care/resources/pressure-ulcers/pres-
strained, but it is difficult to extract data in a standardized sureulcertoolkit/index.html.
and coded format for further reuse. Also, inappropriate data 3. Bennett G, Dealey C, Posnett J. The cost of pressure ul-
cers in the UK. Age Ageing 2004;33(3):230-5. patients. Am J Crit Care 2011;20(5):364-75.
4. Hughes RG. Patient safety and quality: an evidence- 18. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-
based handbook for nurses. Rockville (MD): Agency for Medina IM, Alvarez-Nieto C. Risk assessment scales for
Healthcare Research and Quality; 2008. pressure ulcer prevention: a systematic review. J Adv
5. Furukawa MF, Raghu TS, Shao BB. Electronic Medical Nurs 2006;54(1):94-110.
Records, nurse staffing, and nurse-sensitive patient out- 19. Cho IS, Yoon HY, Park SI, Lee HS. Availability of nurs-
comes: evidence from the national database of nursing ing data in an electronic nursing record system for a de-
quality indicators. Med Care Res Rev 2011;68(3):311-31. velopment of a risk assessment tool for pressure ulcers. J
6. Bergquist-Beringer S, Gajewski B, Dunton N, Klaus Korean Soc Med Inform 2008;14(2):161-8.
S. The reliability of the National Database of Nursing 20. Kim HJ, Jeong IS. Optimal time interval for position
Quality Indicators pressure ulcer indicator: a triangula- change for ICU patients using foam mattress against pres-
tion approach. J Nurs Care Qual 2011;26(4):292-301. sure ulcer risk. J Korean Acad Nurs 2012;42(5):730-7.
7. Korea Institute for Healthcare Accreditation. Survey 21. Alderden J, Whitney JD, Taylor SM, Zaratkiewicz S.
standards for healthcare accreditation. Seoul: Ministry Risk profile characteristics associated with outcomes of
of Health & Welfare; 2011. hospital-acquired pressure ulcers: a retrospective review.
8. Shahin ES, Dassen T, Halfens RJ. Pressure ulcer preva- Crit Care Nurse 2011;31(4):30-43.
lence in intensive care patients: a cross-sectional study. J 22. Compton F, Hoffmann F, Hortig T, Strauss M, Frey J,
Eval Clin Pract 2008;14(4):563-8. Zidek W, et al. Pressure ulcer predictors in ICU patients:
9. Theaker C. Pressure sore prevention in the critically ill: nursing skin assessment versus objective parameters. J
what you don't know, what you should know and why it’s Wound Care 2008;17(10):417-20, 422-4.
important. Intensive Crit Care Nurs 2003;19(3):163-8. 23. Curry K, Kutash M, Chambers T, Evans A, Holt M, Pur-
10. Manzano F, Navarro MJ, Roldan D, Moral MA, Leyva cell S. A prospective, descriptive study of characteristics
I, Guerrero C, et al. Pressure ulcer incidence and risk associated with skin failure in critically ill adults. Os-
factors in ventilated intensive care patients. J Crit Care tomy Wound Manage 2012;58(5):36-8, 40-3.
2010;25(3):469-76. 24. Brunk D. Are pressure ulcers really a ‘Never Event’?
11. Cremasco MF, Wenzel F, Zanei SS, Whitaker IY. Pres- Chest Physician 2011;6(3):6.
sure ulcers in the intensive care unit: the relationship 25. Schindler CA, Mikhailov TA, Kuhn EM, Christopher
between nursing workload, illness severity and pressure J, Conway P, Ridling D, et al. Protecting fragile skin:
ulcer risk. J Clin Nurs 2013;22(15-16):2183-91. nursing interventions to decrease development of pres-
12. Bergstrom N, Braden BJ, Laguzza A, Holman V. The sure ulcers in pediatric intensive care. Am J Crit Care
Braden Scale for Predicting Pressure Sore Risk. Nurs 2011;20(1):26-34.
Res 1987;36(4):205-10. 26. Hine K. The use of physical restraint in critical care.
13. Cubbin B, Jackson C. Trial of a pressure area risk calcu- Nurs Crit Care 2007;12(1):6-11.
lator for intensive therapy patients. Intensive Care Nurs 27. Cho IS. Assessing the quality of structured data entry
1991;7(1):40-4. for the secondary use of Electronic Medical Records. J
14. Sousa B. Translation, adaptation, and validation of Korean Soc Med Inform 2009;15(4):423-31.
the Sunderland Scale and the Cubbin & Jackson Re- 28. Takabayashi K, Doi S, Suzuki T. Japanese EMRs and IT
vised Scale in Portuguese. Rev Bras Ter Intensiva in medicine: expansion, integration, and reuse of data.
2013;25(2):106-14. Healthc Inform Res 2011;17(3):178-83.
15. Boyle M, Green M. Pressure sores in intensive care: de- 29. Kim Y, Park H, Kim HG, Kim YO. The development of
fining their incidence and associated factors and assess- medical record items: a user-centered, bottom-up ap-
ing the utility of two pressure sore risk assessment tools. proach. Healthc Inform Res 2012;18(1):10-7.
Aust Crit Care 2001;14(1):24-30. 30. Cho IS, Chung E. Predictive Bayesian network model
16. Jun S, Jeong I, Lee Y. Validity of pressure ulcer risk using electronic patient records for prevention of
assessment scales; Cubbin and Jackson, Braden, and hospital-acquired pressure ulcers. J Korean Acad Nurs
Douglas scale. Int J Nurs Stud 2004;41(2):199-204. 2011;41(3):423-31.
17. Cox J. Predictors of pressure ulcers in adult critical care