Appl Clin Inform 2013; 04(02): 251-266
DOI: 10.4338/ACI-2012-12-RA-0056
Research Article
Schattauer GmbH

Enhancement of Decision Rules to Increase Generalizability and Performance of the Rule-Based System Assessing Risk for Pressure Ulcer

J. Choi
1   University of Wisconsin Milwaukee, College of Nursing, Milwaukee, Wisconsin, United States
H. Kim
2   University of California, San Diego, Division of Biomedical Informatics, La Jolla, California, United States
› Author Affiliations
Further Information

Publication History

received: 29 December 2012

accepted: 25 May 2013

Publication Date:
19 December 2017 (online)


Background: A rule-based system, the Braden Scale based Automated Risk Assessment Tool (BART), was developed to assess risk for pressure ulcer in a previous study. However, the BART illustrated two major areas in need of improvement, which were: 1) the enhancement of decision rules and 2) validation of generalizability to increase performance of BART.

Objectives: To enhance decision rules and validate generalizability of the enhanced BART.

Method: Two layers of decision rule enhancement were performed: 1) finding additional data items with the experts and 2) validating logics of decision rules utilizing a guideline modeling language. To refine the decision rules of the BART further, a survey study was conducted to ascertain the operational level of patient status description of the Braden Scale.

The enhanced BART (BART2) was designed to assess levels of pressure ulcer risk of patients (N = 99) whose data were collected by the nurses. The patients’ level of pressure ulcer risk was assessed by the nurses using a Braden Scale, by an expert using a Braden Scale, and by the automatic BART2 electronic risk assessment. SPSS statistical software version 20 (IBM, 2011) was used to test the agreement between the three different risk assessments performed on each patient.

Results: The level of agreement between the BART2 and the expert pressure ulcer assessments was “very good (0.83)”. The sensitivity and the specificity of the BART2 were 86.8% and 90.3% respectively.

Conclusion: This study illustrated successful enhancement of decision rules and increased general-izability and performance of the BART2. Although the BART2 showed a “very good” level of agreement (kappa = 0.83) with an expert, the data reveal a need to improve the moisture parameter of the Braden Scale. Once the moisture parameter has been improved, BART2 will improve the quality of care, while accurately identifying the patients at risk for pressure ulcers.

Citation: Choi J, Kim H. Enhancement of Decision Rules to Increase Generalizability and Performance of the Rule-Based System Assessing Risk for Pressure Ulcer. Appl Clin Inf 2013; 4: 251–266