Pressure Ulcer Prevention: Is PURPOSE-T the Future of Risk Assessment?
"A new clinical evaluation tool aims to revolutionize pressure ulcer risk assessment and improve patient outcomes. Learn how PURPOSE-T is changing the game."
Pressure ulcers, also known as bedsores, are localized injuries to the skin and underlying tissue, often occurring over bony prominences. These ulcers pose a significant threat to patient health and safety, leading to pain, infection, prolonged hospital stays, and increased healthcare costs. Effective prevention is critical, and structured risk assessment is the cornerstone of any successful prevention strategy.
Traditional pressure ulcer risk assessment instruments (PU-RAIs) have faced criticism for their methodological limitations, inadequate conceptual frameworks, and inconsistent inclusion of key risk factors like skin status. These shortcomings can undermine the accuracy and effectiveness of risk assessments, potentially leading to inadequate preventative measures.
To address these challenges, researchers have developed a new instrument called the Pressure Ulcer Risk Primary or Secondary Evaluation Tool (PURPOSE-T). This article explores the clinical evaluation of PURPOSE-T, examining its psychometric properties, clinical usability, and potential to improve pressure ulcer prevention in healthcare settings.
The Scale of the Problem
Pressure-ulcer burden remains substantial, with global incidence among adults aged 60 and above increasing between 1990 and 2021. A 2026 study reported that 67.9% of pressure ulcers were hospital acquired, while 32.1% were pre-existing. The same study found that 64.2% of patients had an ulcer at one site, 21% at two sites, and 9.9% at additional sites.
Standardized Assessment, Imperfect Tools
Standardized risk assessment helps clinicians identify patients at risk and quantify that risk. However, research has identified methodological limitations in existing instruments, and nurses may face barriers to implementing pressure-ulcer risk scales. Prevention also depends on actions beyond scoring, including nutritional optimization, repositioning, and appropriate support surfaces.
From Ancient Recognition to Formal Classification
Pressure ulcers have been recognized for thousands of years; pressure sores have been identified in Egyptian mummies more than 5,000 years old. The Norton Scale was developed in the 1960s and became widely used for assessing pressure-ulcer risk in adults. In 1975, J. Darrell Shea created a system for classifying pressure sores, which later evolved in the late 1980s into a four-category system.
PURPOSE-T: A New Approach to Pressure Ulcer Risk Assessment
PURPOSE-T was created to improve limitations of existing instruments, incorporating key elements:
- A systematic review of existing literature.
- A consensus study involving experts and healthcare professionals.
- Development of a robust conceptual framework.
- Rigorous pre-testing and refinement.
Accuracy Remains Limited
A 2015 review examined risk assessment and prevention of pressure ulcers. It reported that the reviewed risk factors identified people at increased risk, but that sensitivities and specificities were low. The review also found that diagnostic accuracy did not differ between the assessment approaches it evaluated.
Prevention Is Not Always Straightforward
Pressure injuries have long been framed as largely preventable through appropriate nursing interventions. That framing is challenged by work examining assumptions about pressure-injury prevention. It suggests that prevention should not be treated as a simple guarantee that appropriate care will eliminate every injury.
Tools May Not Change Outcomes
The Cochrane review reported that using the Waterlow or Ramstadius risk-assessment tools may make little or no difference to pressure-ulcer incidence or severity. By contrast, the National Pressure Ulcer Advisory Panel recommends structured assessment, such as the Braden Scale, to identify people at risk as soon as possible and within 8 hours. These recommendations and trial findings indicate that structured assessment is supported as a practice process, while the comparative effect of particular tools on outcomes remains uncertain.
The Future of Pressure Ulcer Prevention
The clinical evaluation of PURPOSE-T demonstrated very good inter-rater and test-retest reliability, indicating its consistency and accuracy. The tool also showed moderate to high convergent validity, meaning it aligns with other established measures of similar constructs.
Assessment Requires Evidence and Judgment
An NCBI review reported that assessment and staging of pressure ulcers remained at the level of expert opinion. More recent mapping work concluded that the evidence is sufficient to support recommendations and good-practice statements for pressure-ulcer risk assessment. Together, these sources point to a field that has developed practical guidance while still retaining important evidence limitations.
A Market Moving Toward Technology
Fortune Business Insights projects that the pressure-ulcer prevention market will grow from $1.26 billion in 2026 to $1.80 billion by 2034, at a 4.6% CAGR. Healthcare Trends 2025 identifies artificial intelligence in risk assessment and advanced support surfaces as emerging trends. A separate market source expects steady growth in pressure-ulcer detection devices between 2025 and 2035, linked to the increasing geriatric population, although another projection reports different growth rates for related markets.
A Complex Care Challenge
Pressure-ulcer prevention is a complex care challenge rather than a single-score problem. Risk assessment must be connected to timely prevention, consistent clinical practice, and ongoing reassessment. Differences in patient condition, care settings, staffing, and implementation can affect how well prevention strategies work in practice.
Care Practices Affect Patient Experience
Evidence links pressure-ulcer risk with patients’ health status and behaviour. One clinical risk case study described a grade-four pressure ulcer developing after basic nursing-care steps were missed. Case studies from aged-care residents also examined their perspectives and satisfaction with turning and positioning devices, showing why prevention involves both clinical execution and patients’ lived experiences.
Nurses found PURPOSE-T easy to use, thorough, and helpful in identifying patients at risk for pressure ulcers. The tool's color-coded system and detailed skin assessment were particularly well-received. These features promoted careful skin examination and facilitated communication among healthcare providers.
PURPOSE-T represents a promising step forward in pressure ulcer prevention. By addressing the limitations of traditional risk assessment tools and incorporating evidence-based practices, PURPOSE-T has the potential to improve patient outcomes and reduce the burden of pressure ulcers on healthcare systems. Further research is needed to evaluate the tool's long-term impact on care processes and patient outcomes, as well as to adapt and implement it in diverse healthcare settings.