Assessment of the accuracy of the CALCULATE scale for pressure injury in critically ill patients

Published:February 26, 2022DOI:



      Pressure injury is damage to the skin and underlying soft tissue that occurs in response to intense and/or prolonged skin pressure. The Braden scale is the most used in health services to assess pressure injury. However, this scale was not specifically developed for critically ill patients. The Critical Care Pressure Ulcer Assessment Tool Made Easy (CALCULATE) scale was developed for patients in intensive care units.


      The objective of this study was to compare the accuracy of the CALCULATE scale with that of Braden in predicting the risk of pressure injury in critically ill patients.


      This was a prospective cohort study, involving patients who did not have pressure injury on admission to the intensive care unit of a tertiary hospital in the city of Porto Alegre, Brazil. Data collection took place between January and July 2020 using the Braden and CALCULATE scales, in addition to clinical and sociodemographic variables. Patients were followed up until discharge from the intensive care unit or death.


      Fifty-one patients were included in the study. Of these, 29 (56.9%) developed pressure injury. To predict pressure injury onset, the areas under the receiver operator characteristic curve of the Braden scale on the first day and the lowest score during the first 3 days were 0.71 (0.56–0.86) and 0.70 (0.53–0.87), respectively. The areas under the receiver operator characteristic curve of the CALCULATE scale on the first day and the highest score during the first 3 days were 0.91 (0.82–0.99) and 0.92 (0.85–1.00), respectively. In the logistic regression analysis, the CALCULATE scale on the first day remained an independent predictor of pressure injury onset after controlling for age and length of stay in the intensive care unit.


      We found that the CALCULATE scale may be more accurate than the Braden scale as a tool to assess the risk of developing pressure injury in critically ill patients.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Australian Critical Care
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Saranholi T.L.
        Evaluation of the accuracy of the Calculate and Braden scales in predicting the risk of pressure injury in an intensive care unit.
        ([Master's dissertation]) State University Júlio de Mesquita Filho, Botucatu,(SP)2018: 55
        • Otto C.
        • Schumacher B.
        • Wiese L.P.L.
        • Ferro C.
        • Rodrigues R.A.
        Risk factors for the development of pressure injury in critical patients.
        Nurs Focus. 2019 February; 10 ([Internet]) ([cited 2019 October 04]. Available from:): 7-11
        • Labeau S.O.
        • Afonso E.
        • Benbenishty J.
        • et al.
        Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study.
        Intensive Care Med. 09 october 2020; 47 ([Internet]) (Available from: [cited 30 november, 2020]): 160-169
        • Coyer F.
        • Chaboyer W.
        • Lin F.
        • et al.
        Pressure injury prevalence in Australian intensive care units: a secondary analysis.
        Aust Crit Care. 2021; (Available from:)
        • Barakat-Johnson M.
        • Lai M.
        • Wand T.
        • Li M.
        • White K.
        • Coyer F.
        The incidence and prevalence of medical device-related pressure ulcers in intensive care: a systematic review.
        J Wound Care. 2019; 28 (Available from:): 512-521
        • Padula W.
        • Delarmente B.
        The national cost of hospital-acquired pressure injuries in the United States.
        Int Wound J. 2019; 16 (Available from:): 634-640
        • Ahtiala M.H.
        • Kivimäki R.
        • Laitio R.
        • Soppi E.T.
        The association between pressure ulcer/injury development and short-term mortality in critically ill patients: a retrospective cohort study.
        Wound Manag Prev. 2020; 66 (Available from:): 14-21
        • Agency for Healthcare Research and Quality, (AHRQ)
        AHRQuality indicators™.
        2018 (Available from:)
        • European Pressure Ulcer Advisory Panel
        National pressure injury advisory panel and pan-pacific pressure injury alliance.
        in: emily Haesler Prevention and treatment of pressure ulcers/injuries: quick reference guide. EPUAP/ NPIAP/PPPIA, 2019 (Available from:)
        • Arroyo-López MdC.
        • Robayna-Delgado MdC.
        • Chinea-Rodríguez C.D.
        • Martín-Meana C.
        • Lorenzo-García J.M.
        • Jiménez-Sosa A.
        Moving average as a method of assessing risk of pressure injury using the COMHON index (conscious level, Mobility, Hemodynamic, Oxygenation, Nutrition) for patients in the intensive care units.
        Aust Crit Care. 2021; (Available from:)
        • Ranzani O.T.
        • Simpson E.S.
        • Japiassú A.M.
        • Noritomi D.T.
        The challenge of predicting pressure ulcers in critically ill patients: a multicenter cohort study.
        Ann Am Thoracic Soci. June 21, 2016; 13 ([internet]) ([Cited 2021 june 15]. Available at:): 1775-1783
        • Richardson A.
        • Barrow I.
        Part 1: pressure ulcer assessment - the development of critical care pressure ulcer assessment tool made Easy (CALCULATE).
        British Assoc Nursing in Critical Care. 2015 November; 20 ([internet]) ([cited 2019 August 15]. Available from:): 308-314
        • Theeranut A.
        • Ninbanphot S.
        • Limpawattana P.
        Comparison of four pressure ulcer risk assessment tools in critically ill patients.
        Nurs Crit Care. 2020 April; 26 ([ internet]) ([cited 2020 September 05] Available at:): 48-54
        • Hanley J.A.
        • McNeil B.J.
        A method of comparing the areas under receiver operating characteristic curves derived from the same cases.
        Radiology. 1983; 148 (Available from:): 839-843
        • Padula W.V.
        • Pronovost P.J.
        • Makic M.B.F.
        • et al.
        Value of hospital resources for effective pressure injury prevention: a cost-effectiveness analysis.
        BMJ Qual Saf. 2019; 28 ([internet]) ([cited 2020 august 15]. Available at:): 132-141
        • Alderden J.
        • Pepper G.A.
        • Wilson A.
        • et al.
        Predicting pressure injury in critical care patients: the machine learning model.
        Am J Crit Care. 2018 Nov; 27 ([ internet]) ([ cited 2020 august 08] Available from:): 461-468
        • Wei M.
        • Wu L.
        • Chen Y.
        • et al.
        Predictive validity of the braden scale for pressure ulcer risk in critical care: a meta-analysis.
        Nurs Crit Care. 2020 6 Jan; 25 ([internet]) (Available from: [cited 2020 august 25]): 165-170
        • Deschepper M.
        • Labeau S.O.
        • Waegeman W.
        • et al.
        Pressure injury prediction models for critically ill patients should consider both the case-mix and local factors.
        Intensive Crit Care Nurs. 2021; 65 (Available from:): 103033
        • Loudet C.I.
        • Marchena M.C.
        • Maradeo M.R.
        • et al.
        Reducing pressure ulcers in patients with prolonged acute mechanical ventilation: a quasi-experimental study.
        Rev. bras. to have. intensive. 2017 Mar; 29 ([Internet]) ([cited 2021 Mar 14]. Available from:): 39-46
        • Swafford K.
        • Culpepper R.
        • Dunn C.
        Use of a comprehensive program to reduce the incidence of hospital-acquired pressure ulcers in an intensive care unit.
        Am J Crit Care. 2016 Mar; 25 ([internet]) ([cited 2020 jul 18]. Available from:): 152-155
        • Still M.D.
        • Cross L.C.
        • Dunlap M.
        • et al.
        The turn team: a novel strategy for reducing pressure ulcers in the surgical intensive care unit.
        J Am Coll Surg. 2013 Mar; 216 ([Internet]) ([cited 2021 jan 19]Available from:): 373-379
        • Behrendt R.
        • Ghaznavi A.M.
        • Mahan M.
        • Craft S.
        • Siddiqui A.
        Continuous bedside pressure mapping and rates of hospital-associated pressure ulcers in a medical intensive care unit.
        Am J Crit Care. 2014 Mar; 23 ([Internet]) ([cited 2021 Feb 18]. Available from:): 127-133
        • Alshahrani B.
        • Sim J.
        • Middleton R.
        Nursing interventions for pressure injury prevention among critically ill patients: a systematic review.
        J Clin Nurs. 2021; 30 (Available from:): 2151-2168
        • Manzano F.
        • Pérez A.M.P.
        • Ruiz S.M.
        • et al.
        Hospital-acquired pressure ulcers and risk of hospital mortality in intensive care patients on mechanical ventilation.
        J Eval Clin Pract. 2014 Aug; 20 ([ internet]) ([cited 2020 jun 17]. Available from:): 362-368
        • Levine J.M.
        • Delmore B.
        • Cox J.
        Skin failure: concept review and proposed model.
        Adv Skin Wound Care. 2021; (Available from:)