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Pressure ulcers: effectiveness of risk-assessment tools. A randomised controlled trial (the ULCER trial)
  1. Joan Webster1,
  2. Kerrie Coleman2,
  3. Alison Mudge3,
  4. Louise Marquart4,
  5. Glenn Gardner1,5,
  6. Monica Stankiewicz6,
  7. Julie Kirby7,
  8. Catherine Vellacott7,
  9. Margaret Horton-Breshears7,
  10. Alice McClymont7
  1. 1Centre for Clinical Nursing, Royal Brisbane and Women's Hospital, Brisbane, Australia
  2. 2Wound Integrity, Royal Brisbane and Women's Hospital, Brisbane, Australia
  3. 3Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, Australia
  4. 4Queensland Institute of Medical Research/Royal Brisbane and Women's Hospital Statistics Unit, Queensland Institute of Medical Research, Brisbane, Australia
  5. 5School of Nursing and Midwifery, Queensland University of Technology, Kelvin Grove, Australia
  6. 6Specialist Wound Clinic, Royal Brisbane and Women's Hospital, Brisbane, Australia
  7. 7Royal Brisbane and Women's Hospital, Brisbane, Australia
  1. Correspondence to Professor Joan Webster, Level 2, Centre for Clinical Nursing, Royal Brisbane and Women's Hospital, Butterfield Street, Herston QLD 4029, Australia; joan_webster{at}


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).

  • Effectiveness
  • patient outcomes
  • randomised controlled trial

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  • Funding The study was funded by research grants from the Queensland Nursing Council, the Royal Brisbane and Women's Hospital Private Practice Fund, the Royal Brisbane and Women's Hospital Research Foundation and a Queensland Health Nursing Research Grant.

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval Ethics approval was provided by the RBWH Human Research Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.