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Reusability of EMR Data for Applying Cubbin and Jackson Pressure Ulcer Risk
Assessment Scale in Critical Care Patients

Article  in  Healthcare Informatics Research · December 2013

DOI: 10.4258/hir.2013.19.4.261 · Source: PubMed

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 Original Article
Healthc Inform Res. 2013 December;19(4):261-270.
http://dx.doi.org/10.4258/hir.2013.19.4.261
pISSN 2093-3681 • eISSN 2093-369X

Reusability of EMR Data for Applying Cubbin and

Jackson Pressure Ulcer Risk Assessment Scale in
Critical Care Patients
Eunkyung Kim, RN, MSN1, Mona Choi, RN, PhD2, JuHee Lee, RN, PhD2, Young Ah Kim, PhD3
1
Department of Nursing, Yonsei University Health System, Seoul; 2College of Nursing, Nursing Policy Research Institute, Yonsei University, Seoul; 3Department
of Medical Informatics, Yonsei University Health System, Seoul, Korea

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

Submitted: November 22, 2013 I. Introduction

Revised: 1st, December 19, 2013; 2nd, December 25, 2013
Accepted: December 25, 2013 Pressure ulcers cause patients’ pain and discomfort as well as
other physical, psychosocial, and financial problems, such as
Corresponding Author
the inevitability of operation, infection, and sepsis, disability
Mona Choi, RN, PhD
College of Nursing, Nursing Policy Research Institute, Yonsei Univer- and dependency, and thus, increased medical expenses and
sity, 50, Yonsei-ro, Seodaemoon-gu, Seoul 120-752, Korea. Tel: +82- mortality [1,2]. Although there is a lack of reports regarding
2-2228-3341, Fax: +82-2-392-5440, E-mail: [email protected] the medical cost of pressure ulcer in South Korea, pressure
This is an Open Access article distributed under the terms of the Creative Com- ulcers cost 9.1 billion to 11.6 billion dollars per year in the
mons Attribution Non-Commercial License (http://creativecommons.org/licenses/by- United States [2]. And the total treatment cost of pressure
nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduc-
tion in any medium, provided the original work is properly cited. ulcers in the UK is 1.4 to 2.1 billion pounds annually and
ⓒ 2013 The Korean Society of Medical Informatics that was 4% of the total National Health Service expenditure
in 2004, and 90% of this cost was related to nursing service
Eunkyung Kim et al

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.

262 www.e-hir.org http://dx.doi.org/10.4258/hir.2013.19.4.261

 Evaluation of Reusability of EMR Data

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

Categories of scale Score Operational definition

Age (yr)
<40 4
40–54 3 Age at the time of admission to the ICU
55–69 2
>70 1
Weight
Average weight 4
Obese 3 BMI on the medical record at the time of admission to the ICU
Cachectic 2
Any of above and edema 1 Edema on the assessment form
General skin condition
Intact 4 No pressure ulcer, no sore or sore none on the nursing record
Red skin 3 Redness on the nursing record
Grazed/excoriated skin 2 Abrasion, or bullae on the nursing record
Necrosis/exuding 1 Necrosis on the nursing record
Mental condition
Awake and alert 4
Agitated/restless/confused 3 Consciousness on the assessment form at the time of admission to the
Apathetic/sedated but responsive 2 ICU
Coma/unresponsive 1
Mobility
Fully ambulant 4 Not applicable
Walks with slight help 3 Not applicable
Very limited/chairbound 2 3 or 4 on position change score of Braden scale
Immobile/bedrest 1 1 or 2 on position change score of Braden scale
Hemodynamics
Stable without inotropic support 4 MBP ≥ 65 mmHg without inotropic support
Stable with inotropic support 3 MBP ≥ 65 mmHg with inotropic support
Unstable with inotropic support 2 55 mmHg < MBP < 65 mmHg with inotropic support
Critical with inotropic support 1 MBP ≤ 55 mmHg with inotropic support
Respiration
Spontaneous 4
CPAP/T-piece 3 Airway and oxygen supply on the assessment form at the time of
Mechanical ventilation 2 admission to the ICU
Breathless at rest/on exertion 1
Nutrition
Full diet, fluids 4 Prescription of regular diets or soft diets
Light diet/oral fluids/enteral feeding 3 Prescription of enteral nutrition, or full liquid diets without regular or
soft diets
Parenteral feeding 2 Prescription of TPN only without diets or enteral nutrition
Clear intravenous fluid only 1 No prescription of TPN, enteral nutrition or diets

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Eunkyung Kim et al

Table 1. Continued

Categories of scale Score Operational definition

Incontinencea
None/anuric/catheterized 4 None/anuric/catheterized on clinical assessment form
Urine 3 Not applicable
Feces 2 More than two bowel movements per day
Urine, feces 1 Not applicable
Hygiene
Competent in maintaining own hygiene 4 Not applicable
Maintaining own hygiene with slight help 3 4 on position change score of Braden scale
Requiring much assistance 2 3 on position change score of Braden scale
Fully dependent 1 1 or 2 on position change score of Braden scale
ICU: intensive care unit, BMI: body mass index, MBP: mean blood pressure, CPAP: continuous positive airway pressure, TPN: total
parenteral nutrition.
a
As most patients have Foley catheters in ICU, it is considered that there is practically no urinary incontinence.

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

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 Evaluation of Reusability of EMR Data

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 Development Category No. (%) Mean ± SD

The total number of subjects used in the final analysis was Sex
829. Among them, 522 (63.0%) were men, and the average Male 522 (63.0)
age of the subjects was 59.77 years (standard deviation [SD], Female 307 (37.0)
14.87 years). The average body mass index (BMI) and ICU Age (yr) 59.77 ± 14.87
length of stay were 23.14 kg/m2 (SD, 3.77 kg/m2) and 1.43 <40 94 (11.3)
days (SD, 0.88 days), respectively. The incidence of pressure 40–54 182 (22.0)
ulcers during ICU stay was 14.2% (n = 118) (Table 2). 55–70 308 (37.1)
As shown in Table 3, there was no significant difference ≥70 245 (29.6)
of age and BMI between groups with pressure ulcer de-
BMI (kg/m²) 23.14 ± 3.77
velopment and no development. The length of stay of the
Low (<18.5) 78 (9.4)
two groups showed a significant difference (χ2 = 193.22, p
Normal (18.5≤ and <25) 530 (63.9)
< 0.001); the incidence of pressure ulcers increased as the
Obese (≥25) 221 (26.7)
length of stay was prolonged. The number of patients who
ICU stay (day) 1.43 ± 0.88
died upon discharge was statistically higher in the pressure
1–2 533 (64.3)
ulcer development group than their counterparts (χ2 = 65.76,
3–4 97 (11.7)
p < 0.001).
5–6 58 (7.0)
Subjects who had DM showed a higher incidence of pres-
7 141 (17.0)
sure ulcer development (25.26% vs. 9.99%) with a statistical
Discharge status
significance (χ2 = 10.69, p < 0.001). If subjects had edema
Transferred 708 (85.4)
at the time of admission, pressure ulcers developed more
Died 109 (13.2)
than those without (38.1% vs. 18.1%; χ2 = 24.39, p < 0.001).
Discharged 12 (1.4)
Similarly, subjects who had to use a ventilator (χ2 = 96.28, p
Diabetes mellitus
<0.001) and restraints (χ2 = 82.51, p < 0.001) showed a sig-
No 734 (88.5)
nificantly higher incidence of pressure ulcer development
Yes 95 (11.5)
than their counter parts. Subjects who had hemodynamic
status with less than or equal to 55 mmHg mean blood pres- Edema
sure were 29 (24.6%) in the pressure ulcer development No 655 (79.0)
group and 66 (9.3%) in the non-pressure ulcer group (χ2 = Yes 174 (21.0)
32.89, p < 0.001). Restraint applied
No 396 (47.8)
2. Item Scores of the Cubbin and Jackson Scale Yes 433 (52.2)
The scores of the Cubbin and Jackson scale at the time of Ventilator applied
admission to the ICU are shown in Table 4. The total score No 417 (50.3)
of the Cubbin and Jackson scale was 22.98 ± 3.30 in the pres- Yes 412 (49.7)
sure ulcer development group and 26.49 ± 3.51 in the non- Pressure ulcer
pressure ulcer group, which showed statistical significance No 711 (85.8)
(t = 10.605, p < 0.001). There was a significant difference be- Yes 118 (14.2)
tween the two groups in 8 out of 10 items of the Cubbin and SD: standard deviation, BMI: body mass index, ICU: intensive
Jackson scale, including weight, mental condition, mobility, care unit.

Vol. 19 • No. 4 • December 2013 www.e-hir.org 265

Eunkyung Kim et al

Table 3. Differences of subjects’ characteristics by pressure ulcer development (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

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 Evaluation of Reusability of EMR Data

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.

3. Validity and ROC of Pressure Ulcer Risk Assessment

Scales
For the cut-off point to calculate the validity of each scale,
the cut-off point suggested by the developer of each instru-
ment was used. The sensitivity, specificity, positive predictive
value, and negative predictive values were 72.0%, 68.8%,
27.7%, and 93.7% for the Cubbin and Jackson scale and
93.2%, 16.6%, 15.6%, and 93.7% for the Braden scale, with
the cut-off points of 24 and 16, respectively.
The ROC curve and AUC of each scale were obtained to
compare the predictive validity for the subjects’ pressure
ulcer development. The AUC showed 0.763 for Cubbin and
Jackson scale, and 0.711 for Braden scale, which indicates Figure 1. The receiver operating characteristics curve of Cubbin
that the Cubbin and Jackson scale performed slightly better and Jackson scale and Braden scale. The area under
to predict pressure ulcer development (Figure 1). the curve (AUC) showed 0.763 for Cubbin and Jackson
scale, and 0.711 for Braden scale.

4. Reusability of Existing EMR Data for Cubbin and Jackson

Scale Looking into more details, age, mental condition, respiration,
This study investigated the reusability of 10 items in order to and incontinence showed complete matching with structured
examine the feasibility of EMR use for the Cubbin and Jack- data, and skin condition showed complete matching with
son scale. The reusability of EMR data was analyzed by ap- structured statement. The examples of suboptimal matches,
plying criteria [19], such as complete match with structured in which matching was possible by combining more than two
data, complete match with nursing statement, suboptimal data items, were weight, hemodynamics, and nutrition. For
match, and incomplete match. We were able to extract data weight, BMI on the clinical record and edema or no edema on
from 6 structured input screens on EMR, such as timeline the assessment form was used. For hemodynamics, both mean
worksheet, clinical medical records, nursing records, nutri- blood pressure on the clinical record and inotropic use on the
tion, medication, and the assessment form used in the ICU medication screen were used. Nutritional treatment and total
of the hospital. Four items out of 10 matched completely parenteral nutrition on the medication screen were used for
with structured data items, one item matched completely nutrition. Activity and hygiene showed incomplete matching,
with structured statement, three items with a suboptimal which could not be obtained from the organized screen of
match, and two items with an incomplete match (Table 5). EMR and data of standardized statements.

Vol. 19 • No. 4 • December 2013 www.e-hir.org 267

Eunkyung Kim et al

Table 5. Matches of Electronic Medical Record data with Cubbin and Jackson scale

Complete match with Complete match with

Cubbin and Jackson item Suboptimal matchc Incomplete matchd
structured dataa nursing statementb
Age √
Weight √
General skin condition √
Mental condition √
Mobility √
Hemodynamics √
Respiration √
Nutrition √
Incontinence √
Hygiene √
Total (10 items) 4 1 3 2
a b
One-to-one match with a certain item of a structured input screen. No match with an item of a structured input screen but match
with nursing statements. cNo match with an item of a structured input screen, but it is possible to logically extract information from
more than two data items and/or standardized statements. dNo match with data from either a structured screen or nursing state-
ments that is difficult to presume any information when combining those.

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

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 Evaluation of Reusability of EMR Data

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
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