The Chinese Mandarin COMHON Index and Braden Scale to assess pressure injury risk in intensive care : An inter-rater reliability and convergent validity study

Journal article

Lovegrove, Josephine, Fulbrook, Paul, Yuan, Cui, Lin, Frances and Liu, Xian-Liang. (2025). The Chinese Mandarin COMHON Index and Braden Scale to assess pressure injury risk in intensive care : An inter-rater reliability and convergent validity study. Australian Critical Care. 38(1), p. Article 101093. https://doi.org/10.1016/j.aucc.2024.05.015
AuthorsLovegrove, Josephine, Fulbrook, Paul, Yuan, Cui, Lin, Frances and Liu, Xian-Liang
Abstract

Background
The COMHON Index is an intensive-care-specific pressure injury risk assessment tool, which has demonstrated promising psychometric properties. It has been translated into Chinese Mandarin but requires inter-rater reliability testing and comparison to the standard care instrument (Braden Scale) before clinical use.

Objectives
This study aimed to test and compare the inter-rater reliability and convergent validity of the Chinese Mandarin versions of the COMHON Index and Braden Scale.

Methods
The study was conducted in a Chinese comprehensive intensive care unit. Based on a sample size calculation, five registered nurse raters with at least 6-months experience independently conducted risk assessments for 20 adult patients using both the COMHON Index and Braden Scale. Intraclass correlations (ICC) for inter-rater reliability, standard errors of measurement (SEM), and minimally detectable change (MDC) were calculated. Convergent validity was assessed using Pearson Product Moment Correlation for sum scores and Spearman's rho for subscales.

Results
Inter-rater reliability of COMHON Index and Braden Scale sum scores was very high (ICC [1,1] = 0.973; [95% confidence interval 0.949–0.988]; SEM 0.54; MDC 1.50) and high (ICC [1,1] = 0.891; [95% confidence interval 0.793-0.951]; SEM 0.93; MDC 2.57), respectively. All COMHON-Index subscales demonstrated ICC values >0.6, whereas two Braden Scale subscales (Mobility, Activity) were below this threshold. Instrument sum scores were strongly correlated (Pearson's r = −0.76 [r2 = 0.58]; p < 0.001), as were three subscale item pairs (mobility rs = −0.56 [r2 = 0.32]; nutrition rs = −0.63 [r2 = 0.39]; level of consciousness/sensory perception rs = −0.67 [r2 = 0.45] p < 0.001).

Conclusion
Both the COMHON Index and Braden Scale demonstrated high levels of inter-rater reliability and measured similar constructs. However, the COMHON Index demonstrated superior inter-rater reliability and the results suggest that it better detects changes in patient condition and subsequently pressure injury risk. Further testing is recommended.

KeywordsBraden Scale; COMHON Index; critical care; critical care nursing; intensive care units; risk assessment; pressure injury; pressure ulcer
Year2025
JournalAustralian Critical Care
Journal citation38 (1), p. Article 101093
PublisherElsevier Ltd
ISSN1036-7314
Digital Object Identifier (DOI)https://doi.org/10.1016/j.aucc.2024.05.015
PubMed ID39129066
Scopus EID2-s2.0-85200967404
Open accessPublished as ‘gold’ (paid) open access
Page range1-6
FunderThe Prince Charles Hospital Foundation
National Health and Medical Research Council (NHMRC)
Publisher's version
License
File Access Level
Open
Output statusPublished
Publication dates
Online11 Jan 2025
Publication process dates
Accepted29 May 0202
Deposited03 Jun 2025
Grant IDPhD2019-01
Additional information

© 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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Pressure injury risk assessment in intensive care: comparison of inter-rater reliability of the COMHON (Conscious level, Mobility, Haemodynamics, Oxygenation, Nutrition) Index with three scales
Fulbrook, Paul and Anderson, Alissa. (2016). Pressure injury risk assessment in intensive care: comparison of inter-rater reliability of the COMHON (Conscious level, Mobility, Haemodynamics, Oxygenation, Nutrition) Index with three scales. Journal of Advanced Nursing (online version). 73(3), pp. 680 - 692. https://doi.org/10.1111/jan.12825
An evaluation of staff transitioning from a combined adult/child emergency department to a new paediatric emergency department: A qualitative study
Peeler, Alison, Fulbrook, Paul Richard, Edward, Karen-Leigh and Kinnear, Frances B.. (2016). An evaluation of staff transitioning from a combined adult/child emergency department to a new paediatric emergency department: A qualitative study. Australasian Emergency Nursing Journal. 19(3), pp. 153 - 158. https://doi.org/10.1016/j.aenj.2016.05.004
Protocol for a pragmatic randomised controlled trial to evaluate effects of a brief intervention for emergency department attendees who present with moderate or high levels of non-specific psychological distress : A pilot study
Lawrence, Petra and Fulbrook, Paul. (2015). Protocol for a pragmatic randomised controlled trial to evaluate effects of a brief intervention for emergency department attendees who present with moderate or high levels of non-specific psychological distress : A pilot study. Pilot and Feasibility Studies. 1(33), pp. 1 - 9. https://doi.org/10.1186/s40814-015-0028-9
A survey of Australian nurses' knowledge of pressure injury/pressure ulcer management
Lawrence, Petra, Fulbrook, Paul and Miles, Sandra. (2015). A survey of Australian nurses' knowledge of pressure injury/pressure ulcer management. Journal of Wound Ostomy and Continence Nursing. 42(5), pp. 450 - 460. https://doi.org/10.1097/WON.0000000000000141
Critical care nursing organizations and activities : A fourth worldwide review
Williams, Ged, Fulbrook, Paul, Kleinpell, Ruth, Schmollgruber, Shelley and Alberto, Laura. (2015). Critical care nursing organizations and activities : A fourth worldwide review. International Nursing Review (online version). 62(4), pp. 453 - 461. https://doi.org/10.1111/inr.12205
Certainty and uncertainty about end of life care nursing practices in New Zealand intensive care units : A mixed methods study
Coombs, Maureen, Fulbrook, Paul, Donovan, Sarah, Tester, Rachel and deVries, Kay. (2015). Certainty and uncertainty about end of life care nursing practices in New Zealand intensive care units : A mixed methods study. Australian Critical Care. 28(2), pp. 82 - 86. https://doi.org/10.1016/j.aucc.2015.03.002
Validity of the paddington alcohol test in an Australian emergency department
Fulbrook, Paul, Lawrence, Petra and Watt, Kerrianne. (2015). Validity of the paddington alcohol test in an Australian emergency department. Alcohol and Alcoholism. 50(4), pp. 407 - 412. https://doi.org/10.1093/alcalc/agv024
The experiences of parents and nurses of hospitalised infants requiring oxygen therapy for severe bronchiolitis : A phenomenological study
Peeler, Alison, Fulbrook, Paul and Kildea, Susan. (2015). The experiences of parents and nurses of hospitalised infants requiring oxygen therapy for severe bronchiolitis : A phenomenological study. Journal of Child Health Care. 19(2), pp. 216 - 228. https://doi.org/10.1177/1367493513503587
Fear of falling : Association between the Modified Falls Efficacy Scale, in-hospital falls and hospital length of stay
Gettens, Stephanie and Fulbrook, Paul. (2015). Fear of falling : Association between the Modified Falls Efficacy Scale, in-hospital falls and hospital length of stay. Journal of Evaluation in Clinical Practice (online version). 21(1), pp. 43 - 50. https://doi.org/10.1111/jep.12226
Survey of an Australian general emergency department : Estimated prevalence of mental health disorders
Fulbrook, Paul and Lawrence, Petra. (2015). Survey of an Australian general emergency department : Estimated prevalence of mental health disorders. Journal of Psychiatric and Mental Health Nursing (online version). 22(1), pp. 30 - 38. https://doi.org/10.1111/jpm.12191
Issues and challenges associated with nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory: A qualitative study
Fulbrook, Paul, Conway, Aaron, Rolley, John and Page, Karen. (2014). Issues and challenges associated with nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory: A qualitative study. Journal of Clinical Nursing. 23(3-4), pp. 374 - 384. https://doi.org/10.1111/jocn.12147
Compliance with lipid-lowering medication after diagnosis of coronary heart disease
McKellar, Sandra and Fulbrook, Paul. (2014). Compliance with lipid-lowering medication after diagnosis of coronary heart disease. British Journal of Cardiac Nursing. 9(5), pp. 244 - 249.
Trends in nurse-administered procedural sedation and analgesia across cardiac catheterisation laboratories in Australia and New Zealand: Results of an electronic survey
Conway, Aaron, Rolley, John, Page, Karen and Fulbrook, Paul. (2014). Trends in nurse-administered procedural sedation and analgesia across cardiac catheterisation laboratories in Australia and New Zealand: Results of an electronic survey. Australian Critical Care. 27(1), pp. 4 - 10. https://doi.org/10.1016/j.aucc.2013.05.003
South African critical care nurses' views on end-of-life decision-making and practices
Fulbrook, Paul, Langley, Gayle, Schmollgruber, Shelley, Albarran, John and Latour, Jos. (2014). South African critical care nurses' views on end-of-life decision-making and practices. Nursing in Critical Care. 19(1), pp. 9 - 17. https://doi.org/10.1111/nicc.12026
Sleep assessment of hospitalised patients : A literature review
Fulbrook, Paul, Hoey, Lynn and Douglas, James. (2014). Sleep assessment of hospitalised patients : A literature review. International Journal of Nursing Studies. 51(9), pp. 1281 - 1288. https://doi.org/10.1016/j.ijnurstu.2014.02.001
Perceived barriers to healthy lifestyle activities in midlife and older Australian women with type 2 diabetes
McGuire, Amanda, Anderson, Debra and Fulbrook, Paul. (2014). Perceived barriers to healthy lifestyle activities in midlife and older Australian women with type 2 diabetes. Collegian. 21(4), pp. 301 - 310. https://doi.org/10.1016/j.colegn.2013.07.001
Clinical practice guidelines for nurse-administered procedural sedation and analgesia in the cardiac catheterization laboratory : A modified Delphi study
Fulbrook, Paul, Conway, Aaron, Rolley, John and Page, Karen. (2014). Clinical practice guidelines for nurse-administered procedural sedation and analgesia in the cardiac catheterization laboratory : A modified Delphi study. Journal of Advanced Nursing. 70(5), pp. 1040 - 1053. https://doi.org/10.1111/jan.12337
The first 18 months: Parental choices regarding their infant's health care needs
Kearney, Lauren and Fulbrook, Paul. (2014). The first 18 months: Parental choices regarding their infant's health care needs. Neonatal, Paediatric and Child Health Nursing. 17(3), pp. 17 - 22.
Risk factors for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory : a matched case-control study
Conway, Aaron, Page, Karen, Rolley, John and Fulbrook, Paul. (2013). Risk factors for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory : a matched case-control study. European Journal of Cardiovascular Nursing. https://doi.org/10.1177/1474515112470351
Decreasing pressure injury prevalence in an Australian general hospital : a ten-year review
Miles, Sandra, Fulbrook, Paul, Nowicki, Tracy and Franks, Cherie. (2013). Decreasing pressure injury prevalence in an Australian general hospital : a ten-year review. Wound Practice & Research.
Improving statistical analysis of matched case-control studies in nursing literature
Conway, Aaron, Rolley, John, Fulbrook, Paul, Page, Karen and Thompson, David. (2013). Improving statistical analysis of matched case-control studies in nursing literature. Research in Nursing and Health. https://doi.org/10.1002/nur.21536
Understanding the experiences of mothers who are breastfeeding an infant with tongue-tie : a phenomenological study
Edmunds, Janet, Fulbrook, Paul and Miles, Sandra. (2013). Understanding the experiences of mothers who are breastfeeding an infant with tongue-tie : a phenomenological study. Journal of Human Lactation. https://doi.org/10.1177/0890334413479174
Children's conceptions of their parent's lung transplant
Fulbrook, Paul, Leisfield, T and Wiggins, K. (2013). Children's conceptions of their parent's lung transplant. Journal of Child Health Care. https://doi.org/10.1177/1367493512450625
A survey of Italian intensive care nurses' knowledge levels
Fulbrook, Paul. (2012). A survey of Italian intensive care nurses' knowledge levels. Not Listed - Awaiting Journal Creation.
Open Access community child health clinics : the everyday experience of parents and child health nurses
Kearney, Lauren and Fulbrook, Paul. (2012). Open Access community child health clinics : the everyday experience of parents and child health nurses. Journal of Child Health Care. 16(1), pp. 5 - 14. https://doi.org/10.1177/1367493511419874
Effect of feedback on ventilator care bundle compliance : before and after study
Lawrence, Petra and Fulbrook, Paul. (2012). Effect of feedback on ventilator care bundle compliance : before and after study. Nursing in Critical Care. 17(6), pp. 293 - 301. https://doi.org/10.1111/j.1478-5153.2012.00519.x
A survey of European intensive care nurses' knowledge levels
Fulbrook, Paul, Albarran, John W., Baktoft, Birte and Sidebottom, Ben. (2012). A survey of European intensive care nurses' knowledge levels. International Journal of Nursing Studies. 49(2), pp. 191 - 200. https://doi.org/10.1016/j.ijnurstu.2011.06.001
Critical care nursing organizations and activities: A third worldwide review
Williams, Ged, Bost, Nerolie, Chaboyer, Wendy, Fulbrook, Paul, Alberto, Laura, Thorsteinsdóttir, Rósa, Schmollgruber, Shelley and Chan, David. (2012). Critical care nursing organizations and activities: A third worldwide review. International Nursing Review. 59(1), pp. 73 - 80. https://doi.org/10.1111/j.1466-7657.2011.00926.x
Person-centered medicine and chronic disease :the role of interdisciplinary education and treatment adherence
Boyle, Cathy, Post, Gerardus, Masel, Philip, Fulbrook, Paul and Clark, Kevin. (2011). Person-centered medicine and chronic disease :the role of interdisciplinary education and treatment adherence. International Journal of Person Centered Medicine. 1(3), pp. 606 - 611.
Tongue-tie and breastfeeding: A review of the literature
Edmunds, Janet, Miles, Sandra J. and Fulbrook, Paul. (2011). Tongue-tie and breastfeeding: A review of the literature. Breastfeeding Review (print version). 19(1), pp. 19 - 26.
The ventilator care bundle and its impact on ventilator-associated pneumonia: A review of the evidence
Lawrence, Petra and Fulbrook, Paul. (2011). The ventilator care bundle and its impact on ventilator-associated pneumonia: A review of the evidence. Nursing in Critical Care (print version). 16(5), pp. 222 - 234. https://doi.org/10.1111/j.1478-5153.2010.00430.x
Die anwesenheit von angehörigen während der kardiopulmonalen reanimation / the presence of family members during cardiopulmonary resuscitation
Fulbrook, Paul. (2010). Die anwesenheit von angehörigen während der kardiopulmonalen reanimation / the presence of family members during cardiopulmonary resuscitation. Intensiv: Fachzeitschrift fuer Intensivpflege und Anaesthesie. 18(1), pp. 38 - 40.
Preparation of nurses for novice entry to perioperative practice: Evaluation of a short education program
Allanson, Anne Maree and Fulbrook, Paul. (2010). Preparation of nurses for novice entry to perioperative practice: Evaluation of a short education program. ACORN : The Journal of Perioperative Nursing in Australia. 23(2), pp. 14 - 27.
Bed safety off the rails
Nowicki, Tracy, Fulbrook, Paul and Burns, Cheryl. (2010). Bed safety off the rails. Australian Nursing and Midwifery Journal. 18(1), pp. 31 - 34.
Pressure injury prevention : continence, skin hygiene and nutrition management
Roosen, Kerri, Fulbrook, Paul and Nowicki, Tracy. (2010). Pressure injury prevention : continence, skin hygiene and nutrition management. Australian Nursing Journal. 18(2), pp. 31 - 34.
EfCCNa survey: European intensive care nurses' attitudes and beliefs towards end-of-life care
Latour, Jos M., Fulbrook, Paul Richard and Albarran, John W.. (2009). EfCCNa survey: European intensive care nurses' attitudes and beliefs towards end-of-life care. Nursing in Critical Care. 14(3), pp. 110 - 121. https://doi.org/10.1111/j.1478-5153.2008.00328.x
Provision of child health services 2005-2009: Evaluation of an open access clinic
Kearney, Lauren, Fulbrook, Paul Richard and Howlett, Lorrie. (2009). Provision of child health services 2005-2009: Evaluation of an open access clinic Queensland Health.
Changing the mindset: An inter-disciplinary approach to management of bariatric patient
Nowicki, Tracy, Burns, Cheryl, Fulbrook, Paul Richard and Jones, Jacqueline. (2009). Changing the mindset: An inter-disciplinary approach to management of bariatric patient. Collegian. 16(4), pp. 171 - 175. https://doi.org/10.1016/j.colegn.2009.03.002
Intensive and critical care nursing perspectives
Williams, G. F., Fulbrook, Paul Richard, Alexandrov, A. W., Montanez, W. Canon, Salisu-Kabara, H. M. and Chan, D. W.K.. (2009). Intensive and critical care nursing perspectives. In In A. Gullo, J. Besso and P.D.Lumb & G.F.Williams (Ed.). Intensive and critical care medicine pp. 119 - 132 Springer-Verlag.
A clinical improvement project to develop and implement a decision-making framework for the use of seclusion
Hyde, Sandra, Fulbrook, Paul Richard, Fenton, Keryn and Kilshaw, Michael. (2009). A clinical improvement project to develop and implement a decision-making framework for the use of seclusion. International Journal of Mental Health Nursing. 18, pp. 398 - 408. https://doi.org/10.1111/j.1447-0349.2009.00631.x
The effectiveness of a caring protocol: An evaluation study
Fulbrook, Paul. (2009). The effectiveness of a caring protocol: An evaluation study. Journal of Research in Nursing. 14(4), pp. 317 - 318. https://doi.org/10.1177/1744987108093360
The presence of family members during cardiopulmonary resuscitation: Position statement
Lynch, Fiona, Fulbrook, Paul, Latour, Jos, Albarran, John, de Graaf, Wouter, Devictor, Denis and Norekval, Tone. (2008). The presence of family members during cardiopulmonary resuscitation: Position statement. Infant: for neonatal and paediatric healthcare professionals (print version). 4(2), pp. 44 - 45.
Enteral feeding practices in European ICUs: A survey from the European federation of critical care nursing associations (EFCCNA)
Roynette, C., Numico, Anke Bongers, Fulbrook, Paul, Albarran, John and Hofman, Z.. (2008). Enteral feeding practices in European ICUs: A survey from the European federation of critical care nursing associations (EFCCNA). e-SPEN Journal: the European e-journal of clinical nutrition and metabolism. 2(2), pp. 33 - 39. https://doi.org/10.1016/j.eclnm.2007.10.004
Paediatric critical care nurses' attitudes and experiences of parental presence during cardiopulmonary resuscitation: A European survey
Fulbrook, Paul, Latour, Jos and Albarran, John. (2007). Paediatric critical care nurses' attitudes and experiences of parental presence during cardiopulmonary resuscitation: A European survey. International Journal of Nursing Studies. 44(7), pp. 1238 - 1249. https://doi.org/10.1016/j.ijnurstu.2006.05.006
Critical care nursing organizations and activities - a second worldwide review: Original article
Willia, Ged, Chaboyer, Wendy, Alberto, Laura, Thorsteinsdottir, Rosa, Schmollgruber, Shelley, Fulbrook, Paul, Chan, Dominic and Bost, Nerolie. (2007). Critical care nursing organizations and activities - a second worldwide review: Original article. International Nursing Review. 54(2), pp. 151 - 159. https://doi.org/10.1111/j.1466-7657.2007.00543.x
A European survey of enteral nutrition practices and procedures in adult intensive care units
Fulbrook, Paul, Bongers, Anke and Albarran, John. (2007). A European survey of enteral nutrition practices and procedures in adult intensive care units. Journal of Clinical Nursing. 16(11), pp. 2132 - 2141. https://doi.org/10.1111/j.1365-2702.2006.01841.x
The presence of family members during cardiopulmonary resuscitation: European federation of critical care nursing associations, European society of paediatric and neonatal intensive care and European society of cardiology council on cardiovascular
Fulbrook, Paul, Latour, Jos, Albarran, John, de Graaf, Wouter, Lynch, Fiona, Devictor, Denis and Norekval, Tone. (2007). The presence of family members during cardiopulmonary resuscitation: European federation of critical care nursing associations, European society of paediatric and neonatal intensive care and European society of cardiology council on cardiovascular. European Journal of Cardiovascular Nursing. 6(4), pp. 255 - 258. https://doi.org/10.1016/j.ejcnurse.2007.07.003
Understanding the experiences of mothers who are breast feeding an infant with tongue-tie: a hermeneutic phenomenology study.
Miles, Sandra and Fulbrook, Paul. (2007). Understanding the experiences of mothers who are breast feeding an infant with tongue-tie: a hermeneutic phenomenology study [Dataset]. Australian Catholic University. https://doi.org/10.26199/acu.85095
Portable oxygen: Longer for less with oxymizer pendant
Fulbrook, Paul and Serginson, John. (2006). Portable oxygen: Longer for less with oxymizer pendant. Airways Journal (print version). 4(2), pp. 105 - 108.
Education for outreach: Development of an inter-professional MSC in critical care
Fulbrook, Paul and Cockerell, Janet. (2005). Education for outreach: Development of an inter-professional MSC in critical care. Nursing in Critical Care. 10(5), pp. 255 - 262. https://doi.org/10.1111/j.1362-1017.2005.00123.x
Advancing the clinical perspective: A practice development project to develop the nurse practitioner role in an acute hospital trust
Walsgrove, Hilary and Fulbrook, Paul. (2005). Advancing the clinical perspective: A practice development project to develop the nurse practitioner role in an acute hospital trust. Journal of Clinical Nursing. 14(4), pp. 444 - 455. https://doi.org/10.1111/j.1365-2702.2004.01089.x
Realizing advanced nursing practice through reflection
Fulbrook, Paul. (2004). Realizing advanced nursing practice through reflection. Nursing in Critical Care. 9(6), pp. 255 - 256. https://doi.org/10.1111/j.1362-1017.2004.00089.x
Developing a network protocol: Nurse-led weaning from ventilation
Fulbrook, Paul, Delaney, N., Rigby, J., Sowden, A., Trevett, M., Turner, L. and Whittam, A.. (2004). Developing a network protocol: Nurse-led weaning from ventilation. Connect: The World of Critical Care Nursing. 3(2), pp. 28 - 37.
Why do student nurses leave? Suggestions from a Delphi study
Fulbrook, Paul. (2003). Why do student nurses leave? Suggestions from a Delphi study. Nurse Education Today. 23(6), pp. 449 - 458. https://doi.org/10.1016/S0260-6917(03)00063-7
Developing best practice in critical care nursing: Knowledge, evidence and practice
Fulbrook, Paul. (2003). Developing best practice in critical care nursing: Knowledge, evidence and practice. Nursing in Critical Care. 8(3), pp. 96 - 102. https://doi.org/10.1046/j.1478-5153.2003.00010.x
Care bundles in critical care: A practical approach to evidence-based practice
Fulbrook, Paul and Mooney, Sharon. (2003). Care bundles in critical care: A practical approach to evidence-based practice. Nursing in Critical Care. 8(6), pp. 249 - 255. https://doi.org/10.1111/j.1362-1017.2003.00039.x