{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,27]],"date-time":"2026-05-27T18:41:24Z","timestamp":1779907284436,"version":"3.53.1"},"reference-count":46,"publisher":"Oxford University Press (OUP)","issue":"10","license":[{"start":{"date-parts":[[2016,10,1]],"date-time":"2016-10-01T00:00:00Z","timestamp":1475280000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2016,10,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Rationale<\/jats:title>\n                    <jats:p>Pressure ulcers are preventable events. Critically ill patients are particularly vulnerable. The Braden scale has been used to identify hospitalized patients at high risk for the development of pressure ulcers; however, this predictive tool has not been adequately validated for critically ill patients.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>We aimed to validate and improve the Braden scale for critically ill patients by adding clinical variables to the original scale.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a cohort study in 12 intensive care units (ICUs) within a network of hospitals in Brazil during 2013. We excluded patients who stayed less than 48 hours, patients with one or more pressure ulcers at admission, and those who developed a pressure ulcer within the first 48 hours. We evaluated the Braden scale and clinical variables through a competing risk analysis. Discrimination and calibration were evaluated using the Concordance index (C-index) and a calibration plot, respectively. We used bootstrapping to assess internal validation.<\/jats:p>\n                    <jats:p>Measurements and Main Results: Our primary outcome was incident pressure ulcer within 30 days of ICU admission. We analyzed 9,605 patients and observed 157 pressure ulcers (rate of 3.33 pressure ulcers\/1,000 patient-days). The majority of pressure ulcers were detected at stage I or II (28.7 and 66.2%, respectively). The Braden scale had good discrimination (C-index, 0.753; 95% confidence interval, 0.712\u20130.795), although its performance decreased for the most severely ill patients. We derived a modified predictive tool by adding eight clinical variables to the Braden scale: age, sex, diabetes mellitus, hematological malignancy, peripheral artery disease, hypotension at ICU admission, and need for mechanical ventilation or renal replacement therapy in the first 24 hours after ICU admission. The derived score had better discrimination and calibration than the original Braden scale. The best score cutoff was at least 6 points, with a sensitivity of 87% and a specificity of 71%.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The original Braden scale measured at ICU admission is a valuable tool for pressure ulcer prediction, although it is not accurate for severely ill patients. To overcome the limitations of the original scale, we derived a modified score with better performance, which may identify high-risk ICU patients and support target interventions. External validation of the proposed clinical prediction score is needed.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1513\/annalsats.201603-154oc","type":"journal-article","created":{"date-parts":[[2016,7,27]],"date-time":"2016-07-27T14:49:23Z","timestamp":1469630963000},"page":"1775-1783","source":"Crossref","is-referenced-by-count":16,"title":["The Challenge of Predicting Pressure Ulcers in Critically Ill Patients. A Multicenter Cohort Study"],"prefix":"10.1093","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4677-6862","authenticated-orcid":false,"given":"Otavio T.","family":"Ranzani","sequence":"first","affiliation":[{"name":"Amil Critical Care Group, Hospital Paulistano, S\u00e3o Paulo, Brazil"},{"name":"Respiratory Intensive Care Unit, Pulmonary Division, Heart Institute, Hospital das Cl\u00ednicas, University of S\u00e3o Paulo, S\u00e3o Paulo, Brazil; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Evelyn Senna","family":"Simpson","sequence":"additional","affiliation":[{"name":"Amil Critical Care Group, Hospital Paulistano, S\u00e3o Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andr\u00e9 M.","family":"Japiass\u00fa","sequence":"additional","affiliation":[{"name":"Amil Critical Care Group, Hospital Paulistano, S\u00e3o Paulo, Brazil"},{"name":"Research Laboratory of Intensive Care, National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Danilo Teixeira","family":"Noritomi","sequence":"additional","affiliation":[{"name":"Amil Critical Care Group, Hospital Paulistano, S\u00e3o Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2016,10,1]]},"reference":[{"key":"2026020402531931700_bib1","doi-asserted-by":"crossref","first-page":"56","DOI":"10.1097\/00001786-200501000-00010","article-title":"Nosocomial pressure ulcer rates in critical care: performance improvement project","volume":"20","author":"Wolverton","year":"2005","journal-title":"J Nurs Care Qual"},{"key":"2026020402531931700_bib2","author":"European Pressure Ulcer Advisory Panel; National Pressure Ulcer Advisory Panel","year":"2009"},{"key":"2026020402531931700_bib3","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1024\/1012-5302.21.1.37","article-title":"[Validity of the Waterlow scale for pressure ulcer risk assessment in the intensive care unit: a prospective analysis of 698 patients] [article in German]","volume":"21","author":"Compton","year":"2008","journal-title":"Pflege"},{"key":"2026020402531931700_bib4","doi-asserted-by":"crossref","first-page":"468","DOI":"10.1007\/s11908-015-0468-7","article-title":"Pressure ulcers in the ICU patient: an update on prevention and treatment","volume":"17","author":"Krupp","year":"2015","journal-title":"Curr Infect Dis Rep"},{"key":"2026020402531931700_bib5","doi-asserted-by":"crossref","first-page":"1379","DOI":"10.1007\/s00134-002-1487-z","article-title":"Pressure ulcers in intensive care patients: a review of risks and prevention","volume":"28","author":"Keller","year":"2002","journal-title":"Intensive Care Med"},{"key":"2026020402531931700_bib6","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1016\/j.iccn.2010.08.006","article-title":"Knowledge, attitudes and barriers towards prevention of pressure ulcers in intensive care units: a descriptive cross-sectional study","volume":"26","author":"Strand","year":"2010","journal-title":"Intensive Crit Care Nurs"},{"key":"2026020402531931700_bib7","doi-asserted-by":"crossref","first-page":"362","DOI":"10.1111\/jep.12137","article-title":"Hospital-acquired pressure ulcers and risk of hospital mortality in intensive care patients on mechanical ventilation","volume":"20","author":"Manzano","year":"2014","journal-title":"J Eval Clin Pract"},{"key":"2026020402531931700_bib8","doi-asserted-by":"crossref","first-page":"397","DOI":"10.1007\/s00134-013-3188-1","article-title":"The impact of patient positioning on pressure ulcers in patients with severe ARDS: results from a multicentre randomised controlled trial on prone positioning","volume":"40","author":"Girard","year":"2014","journal-title":"Intensive Care Med"},{"key":"2026020402531931700_bib9","doi-asserted-by":"crossref","first-page":"536","DOI":"10.1016\/j.hrtlng.2012.05.008","article-title":"Backrest position in prevention of pressure ulcers and ventilator-associated pneumonia: conflicting recommendations","volume":"41","author":"Burk","year":"2012","journal-title":"Heart Lung"},{"key":"2026020402531931700_bib10","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1097\/00006199-198707000-00002","article-title":"The Braden scale for predicting pressure sore risk","volume":"36","author":"Bergstrom","year":"1987","journal-title":"Nurs Res"},{"key":"2026020402531931700_bib11","doi-asserted-by":"crossref","first-page":"94","DOI":"10.1111\/j.1365-2648.2006.03794.x","article-title":"Risk assessment scales for pressure ulcer prevention: a systematic review","volume":"54","author":"Pancorbo-Hidalgo","year":"2006","journal-title":"J Adv Nurs"},{"key":"2026020402531931700_bib12","author":"National Institute for Health and Care Excellence (NICE)","year":"2014"},{"key":"2026020402531931700_bib13","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1097\/01.WON.0000438014.90734.a2","article-title":"Predictive capacity of risk assessment scales and clinical judgment for pressure ulcers: a meta-analysis","volume":"41","author":"Garc\u00eda-Fern\u00e1ndez","year":"2014","journal-title":"J Wound Ostomy Continence Nurs"},{"key":"2026020402531931700_bib14","doi-asserted-by":"crossref","first-page":"132","DOI":"10.1016\/j.jtv.2009.11.006","article-title":"Do risk assessment scales for pressure ulcers work?","volume":"19","author":"Anthony","year":"2010","journal-title":"J Tissue Viability"},{"key":"2026020402531931700_bib15","doi-asserted-by":"crossref","first-page":"359","DOI":"10.7326\/M14-1567","article-title":"Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians","volume":"162","author":"Qaseem","year":"2015","journal-title":"Ann Intern Med"},{"key":"2026020402531931700_bib16","doi-asserted-by":"crossref","first-page":"102","DOI":"10.1016\/j.jtv.2015.05.001","article-title":"Predictive validity of the Braden scale for pressure ulcer risk in hospitalized patients","volume":"24","author":"Park","year":"2015","journal-title":"J Tissue Viability"},{"key":"2026020402531931700_bib17","doi-asserted-by":"crossref","first-page":"514","DOI":"10.4037\/ajcc2013991","article-title":"Predictive validity of the Braden scale for patients in intensive care units","volume":"22","author":"Hyun","year":"2013","journal-title":"Am J Crit Care"},{"key":"2026020402531931700_bib18","doi-asserted-by":"crossref","first-page":"1285","DOI":"10.1111\/bjd.12915","article-title":"Which factors predict incident pressure ulcers in hospitalized patients? A prospective cohort study","volume":"170","author":"Petzold","year":"2014","journal-title":"Br J Dermatol"},{"key":"2026020402531931700_bib19","doi-asserted-by":"crossref","first-page":"248","DOI":"10.1111\/j.1742-481X.2011.00852.x","article-title":"Relationship between Braden scale score and pressure ulcer development in patients admitted in trauma intensive care unit","volume":"9","author":"Iranmanesh","year":"2012","journal-title":"Int Wound J"},{"key":"2026020402531931700_bib20","doi-asserted-by":"crossref","first-page":"1599","DOI":"10.1007\/s001340101061","article-title":"Prevalence, risk factors and prevention of pressure ulcers in Dutch intensive care units: results of a cross-sectional survey","volume":"27","author":"Bours","year":"2001","journal-title":"Intensive Care Med"},{"key":"2026020402531931700_bib21","doi-asserted-by":"crossref","first-page":"182","DOI":"10.1007\/s00134-013-3131-5","article-title":"Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study","volume":"40","author":"Noritomi","year":"2014","journal-title":"Intensive Care Med"},{"key":"2026020402531931700_bib22","doi-asserted-by":"crossref","first-page":"580","DOI":"10.1186\/s13054-014-0580-3","article-title":"Evaluation of a minimal sedation protocol using ICU sedative consumption as a monitoring tool: a quality improvement multicenter project","volume":"18","author":"Ranzani","year":"2014","journal-title":"Crit Care"},{"key":"2026020402531931700_bib23","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1097\/WON.0b013e318247cb82","article-title":"Prophylactic dressing application to reduce pressure ulcer formation in cardiac surgery patients","volume":"39","author":"Brindle","year":"2012","journal-title":"J Wound Ostomy Continence Nurs"},{"key":"2026020402531931700_bib24","doi-asserted-by":"crossref","DOI":"10.1007\/978-0-387-77244-8","volume-title":"Clinical prediction models: a practical approach to development, validation, and updating","author":"Steyerberg","year":"2009"},{"key":"2026020402531931700_bib25","doi-asserted-by":"crossref","first-page":"g5060","DOI":"10.1136\/bmj.g5060","article-title":"Interpreting and comparing risks in the presence of competing events","volume":"349","author":"Wolkewitz","year":"2014","journal-title":"BMJ"},{"key":"2026020402531931700_bib26","doi-asserted-by":"crossref","first-page":"555","DOI":"10.1097\/EDE.0b013e3181a39056","article-title":"Prognostic models with competing risks: methods and application to coronary risk prediction","volume":"20","author":"Wolbers","year":"2009","journal-title":"Epidemiology"},{"key":"2026020402531931700_bib27","doi-asserted-by":"crossref","first-page":"861","DOI":"10.1093\/ije\/dyr213","article-title":"Competing risks in epidemiology: possibilities and pitfalls","volume":"41","author":"Andersen","year":"2012","journal-title":"Int J Epidemiol"},{"key":"2026020402531931700_bib28","doi-asserted-by":"crossref","DOI":"10.1007\/978-1-4757-3462-1","volume-title":"Regression modeling strategies: with applications to linear models, logistic regression, and survival analysis","author":"Harrell","year":"2001"},{"key":"2026020402531931700_bib29","doi-asserted-by":"crossref","first-page":"704","DOI":"10.1016\/S0140-6736(09)61301-5","article-title":"Expansion of the prognostic assessment of patients with chronic obstructive pulmonary disease: the updated BODE index and the ADO index","volume":"374","author":"Puhan","year":"2009","journal-title":"Lancet"},{"key":"2026020402531931700_bib30","doi-asserted-by":"crossref","first-page":"774","DOI":"10.1016\/S0895-4356(01)00341-9","article-title":"Internal validation of predictive models: efficiency of some procedures for logistic regression analysis","volume":"54","author":"Steyerberg","year":"2001","journal-title":"J Clin Epidemiol"},{"key":"2026020402531931700_bib31","doi-asserted-by":"crossref","first-page":"5381","DOI":"10.1002\/sim.5958","article-title":"Estimating and comparing time-dependent areas under receiver operating characteristic curves for censored event times with competing risks","volume":"32","author":"Blanche","year":"2013","journal-title":"Stat Med"},{"key":"2026020402531931700_bib32","volume-title":"R: a language and environment for statistical computing","author":"R Development Core Team","year":"2015"},{"key":"2026020402531931700_bib33","doi-asserted-by":"crossref","first-page":"50","DOI":"10.1590\/S0104-11692011000100008","article-title":"Predictive validity of the Braden scale for pressure ulcer risk in critical care patients","volume":"19","author":"Serpa","year":"2011","journal-title":"Rev Lat Am Enfermagem"},{"key":"2026020402531931700_bib34","doi-asserted-by":"crossref","first-page":"361","DOI":"10.4037\/ajcc1995.4.5.361","article-title":"Pressure ulcer risk factors in an ICU population","volume":"4","author":"Jiricka","year":"1995","journal-title":"Am J Crit Care"},{"key":"2026020402531931700_bib35","doi-asserted-by":"crossref","first-page":"28","DOI":"10.1111\/jnu.12051","article-title":"A new theoretical model for the development of pressure ulcers and other dependence-related lesions","volume":"46","author":"Garc\u00eda-Fern\u00e1ndez","year":"2014","journal-title":"J Nurs Scholarsh"},{"key":"2026020402531931700_bib36","doi-asserted-by":"crossref","first-page":"974","DOI":"10.1016\/j.ijnurstu.2012.11.019","article-title":"Patient risk factors for pressure ulcer development: systematic review","volume":"50","author":"Coleman","year":"2013","journal-title":"Int J Nurs Stud"},{"key":"2026020402531931700_bib37","doi-asserted-by":"crossref","first-page":"1565","DOI":"10.1111\/j.1365-2702.2008.02757.x","article-title":"Assessing predictive validity of the modified Braden scale for prediction of pressure ulcer risk of orthopaedic patients in an acute care setting","volume":"18","author":"Chan","year":"2009","journal-title":"J Clin Nurs"},{"key":"2026020402531931700_bib38","doi-asserted-by":"crossref","first-page":"122","DOI":"10.1016\/j.apnr.2005.01.001","article-title":"Predicting pressure ulcer risk with the modified Braden, Braden, and Norton scales in acute care hospitals in mainland China","volume":"18","author":"Kwong","year":"2005","journal-title":"Appl Nurs Res"},{"key":"2026020402531931700_bib39","doi-asserted-by":"crossref","first-page":"613","DOI":"10.1097\/WON.0b013e31826a4d83","article-title":"Predictive power of the Braden scale for pressure sore risk in adult critical care patients: a comprehensive review","volume":"39","author":"Cox","year":"2012","journal-title":"J Wound Ostomy Continence Nurs"},{"key":"2026020402531931700_bib40","doi-asserted-by":"crossref","first-page":"R128","DOI":"10.1186\/cc10241","article-title":"Multiple-center evaluation of mortality associated with acute kidney injury in critically ill patients: a competing risks analysis","volume":"15","author":"Clec\u2019h","year":"2011","journal-title":"Crit Care"},{"key":"2026020402531931700_bib41","doi-asserted-by":"crossref","first-page":"389","DOI":"10.7326\/0003-4819-157-6-201209180-00002","article-title":"Development and validation of a coronary risk prediction model for older U.S. and European persons in the Cardiovascular Health Study and the Rotterdam Study","volume":"157","author":"Koller","year":"2012","journal-title":"Ann Intern Med"},{"key":"2026020402531931700_bib42","doi-asserted-by":"crossref","first-page":"598","DOI":"10.1164\/rccm.201408-1457ED","article-title":"The art of making predictions: statistics versus bedside evaluation","volume":"190","author":"Amaral","year":"2014","journal-title":"Am J Respir Crit Care Med"},{"key":"2026020402531931700_bib43","doi-asserted-by":"crossref","first-page":"283","DOI":"10.1097\/00003246-200102000-00011","article-title":"Incidence of pressure ulcers in a neurologic intensive care unit","volume":"29","author":"Fife","year":"2001","journal-title":"Crit Care Med"},{"key":"2026020402531931700_bib44","doi-asserted-by":"crossref","first-page":"1168","DOI":"10.1152\/japplphysiol.00389.2011","article-title":"The effects of deformation, ischemia, and reperfusion on the development of muscle damage during prolonged loading","volume":"111","author":"Loerakker","year":"2011","journal-title":"J Appl Physiol (1985)"},{"key":"2026020402531931700_bib45","doi-asserted-by":"crossref","first-page":"815","DOI":"10.1007\/s001340050671","article-title":"The clinical relevance of the Waterlow pressure sore risk scale in the ICU","volume":"24","author":"Weststrate","year":"1998","journal-title":"Intensive Care Med"},{"key":"2026020402531931700_bib46","doi-asserted-by":"crossref","first-page":"671","DOI":"10.1016\/j.ijnurstu.2009.11.005","article-title":"Pressure ulcer risk assessment in critical care: interrater reliability and validity studies of the Braden and Waterlow scales and subjective ratings in two intensive care units","volume":"47","author":"Kottner","year":"2010","journal-title":"Int J Nurs Stud"}],"container-title":["Annals of the American Thoracic Society"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/annalsats\/article-pdf\/13\/10\/1775\/66664229\/annalsats_13_10_1775.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/annalsats\/article-pdf\/13\/10\/1775\/66664229\/annalsats_13_10_1775.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,4]],"date-time":"2026-02-04T07:53:36Z","timestamp":1770191616000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/annalsats\/article\/13\/10\/1775\/8448822"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2016,10,1]]},"references-count":46,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2016,10,1]]},"published-print":{"date-parts":[[2016,10,1]]}},"URL":"https:\/\/doi.org\/10.1513\/annalsats.201603-154oc","relation":{},"ISSN":["2329-6933","2325-6621"],"issn-type":[{"value":"2329-6933","type":"print"},{"value":"2325-6621","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2016,10]]},"published":{"date-parts":[[2016,10,1]]}}}