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Pressure ulcer prevalence andincidence in intensive care patients:a literature reviewEman SM Shahin, Theo Dassen and Ruud JG Halfens
ABSTRACTBackground: Pressure ulcers remain a common health problem worldwide within the different health-care settings, especially inintensive care settings.Aims: The aims of this were to systematically assess the recent prevalence and incidence of pressure ulcers in intensive care patients(20002005), the factors related to pressure ulcer prevalence and incidence and the methodological rigour of studies about pressureulcer prevalence and incidence in intensive care patients.Methods: The research design involved a review of literature for the period of 2000 to 2005, focused on the prevalence andincidence of pressure ulcers in intensive care patients.Results: The analysis of published papers revealed variations in pressure ulcer prevalence in intensive care settings ranging from 4%in Denmark to 49% in Germany, while incidence ranged from 38% to 124%. There was a wide variation in the prevalence and incidenceof pressure ulcers in intensive care patients as evidenced in the studies examined. There is also a gap between theory and practice in theprevention and treatment of pressure ulcers which needs to be addressed.Conclusion: Further research is needed regarding the effectiveness of nursing care on pressure ulcer development and intotreatments that may successfully prevent their occurrence in intensive care patients.
Key words: ICU Incidence Pressure ulcer Prevalence
BACKGROUNDPressure ulcers are still common in all hospitalized
patients, especially in intensive care units. Intensive
care patients have a high risk of developing pressure
ulcers. This is because they are almost invariably
limited in their overall physical activity and mobility,
resulting in a decreased ability to actively change their
position in bed. They often experience loss of sensory
perception, which frequently is the result of anaes-
thetics and sedative drugs, resulting in a lower level of
consciousness and cutaneous sensation (Jiricka et al.,
1995). In addition, intensive care patients are often
in a poor nutritional state because of a change in
metabolism as a result of a major trauma, burn or
sepsis or after major surgery (Dealy, 1992). Moreover,
intensive care patients with impaired circulation or
those using specific medication, such as vasoactive
drugs, are also at a high risk of developing pressure
ulcers (Keller et al., 2002).
Prevalence is based on the total number of existing
cases among the whole population at a given time
(Allcock et al., 1994; Keller et al., 2002). In contrast,
incidence measures the number of persons developing
new pressure ulcers during a period of time. It thereby
provides an insight into the nature of a group of
patients who are at risk of pressure ulcer development.
Both prevalence and incidence are affected by dis-
charge practices because they are influenced by the
length of time each patient remains within the care
setting. Moreover, if the prevention protocol is of poor
quality or if people do not comply with the protocol,
then preventive care is not optimal and therefore the
incidence may be higher. If the treatment protocol is
not optimal, this can lead to patients suffering from
their pressure ulcer for a longer period of time.
Authors: ESM Shahin, BSc, MSc, RN, PhD student, Department of
Nursing Science, Centre of Humanities and Health Sciences, Charite,
Universitatsmedizin, Berlin, Germany; Dr T Dassen, PhD, RN, Professor,
Director of Department of Nursing Science, Center of Humanities and
Health Sciences, Charite, Universitatsmedizin, Berlin, Germany; Dr RJG
Halfens, PhD, Associate Professor, Health Care Studies/Section Nursing
Science, Faculty of Health Sciences, Universiteit Maastricht, The
Netherlands.
Address for correspondence: ESM Shahin, Correspondent, PhD
student in Department of Nursing Science, Centre of Humanities and
Health Sciences, Charite, Universitatsmedizin, 10117, Berlin, Germany
E-mail: [email protected], [email protected]
LITERATURE REVIEW
2008 The Authors. Journal Compilation 2008 British Association of Critical Care Nurses, Nursing in Critical Care 2008 Vol 13 No 2 71
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Additionally, these patients are more likely to be
identified during a prevalence survey, and hence,
prevalence may be higher than in other hospitals
(European Pressure Ulcer Advisory Panel, 2002).
Several studies have examined the pressure ulcer
prevalence in different countries over the last 25 years.
Most of these studies were conducted in Europe
(Britain, the Netherlands and Scandinavia) and USA.
One of the studies was conducted by ODea (1995)
in Europe (the Netherlands, Italy, UK and Germany)
involving adult patients in 177 hospitals, and it
revealed a prevalence of 111% (n = 18 882) (Thoroddsen,1999). The incidence of pressure ulcers in the German
population in general was 05% resulting in 400 000patients, while 13% of the patients developed newpressure ulcers during their treatment in German
hospitals (Leffmann et al., 2002). In addition, in 2001
in USA, the national pressure ulcer advisory panel
reported updates to the incidence and prevalence
findings in different care settings from those pre-
viously reported in 1991, namely, that the prevalence in
critical care was 22%, while the incidence ranged from
8% to 40% (National Healing Corporation, 2005).
However, over the past few decades, only little
research has been conducted and published concern-
ing pressure ulcers in the intensive care setting, even
though it is obvious that critically ill patients are at
high risk for pressure ulcers. In view of this, it is
surprising that not all ICU patients develop pressure
ulcers (Keller et al., 2002).
Previous reviews of studies about pressure ulcer
prevalence and incidence in different countries, such
as USA and European countries, have shown a varia-
tion in the results. In this respect, the prevalence and
incidence studies in the different countries cannot be
compared because each study had different patient
characteristics, sample size and research methodology.
Therefore, it is essential to analyse the recent preva-
lence and incidence studies of pressure ulcers in
intensive care settings, to assess factors related to
pressure ulcer prevalence and incidence and to assess
the methodological rigour of these studies.
RESEARCH QUESTIONS
What are the recent prevalence and incidencerates of pressure ulcers in intensive care patients?
What are the factors related to pressure ulcerprevalence and incidence in intensive care
patients?
What can be said about the methodologicalrigour in the studies about pressure ulcer
prevalence and incidence in intensive care
patients?
METHODOLOGYA search was carried out by using the databases
CINAHL and PubMed including only literature from
2000 to 2005. The keywords used were a combination
of pressure ulcer, pressure sore, decubitus ulcer, bed
sore and prevalence and incidence. The inclusion
criteria were fulfilled if articles were written in English
or German, if their titles included intensive care unit/
patients or critically ill patients and prevalence and/or
incidence of pressure ulcers, if studies were published
from 2000 to 2005 and if a purposed population
consisted of intensive care patients only. A total of 41
articles about pressure ulcers, published from 2000 to
2005, were found in CINAHL and PubMed. Of these,
24 articles discussed pressure ulcer incidence and
prevalence in various health-care settings. Upon
further differentiation, 17 articles focused on pressure
ulcers in intensive care patients and included the
following aspects: incidence, prevalence, prevention,
risk factors and risk assessment scales. After reviewing
the abstracts of these articles with regard to the
inclusion criteria, seven articles were deemed to be
relevant for the purpose of this review. Five of the
seven articles focused on the prevalence of pressure
ulcers in intensive care settings in various specialties
(see Table 1), while the other two articles focused on
the incidence of pressure ulcers within a specialized
intensive care setting (neurological and surgical) (see
Table 2).
RESULTSPrevalence of pressure ulcers in intensive caresettingsIn the Netherlands (2001), a cross-sectional point
prevalence study, conducted in 1998 and 1999 in all
specialties of intensive care, established that less than
one-third of intensive care patients suffered from
pressure ulcers and that the most common sites were
heels and sacrum (394% and 252%, respectively). Inaddition, the highest percentage of pressure ulcers was
found in patients with an infection (including sepsis),
569%. Furthermore, the majority of factors that weresignificantly associated with the presence of pressure
ulcers included infections, age, length of stay, moisture
and mobility. There is also a significant difference in
the overall prevalence and in the prevalence of grade 1
and grade 2 ulcers in patients who had undergone
surgery and those who had not (Bours et al., 2001).
A study of pressure ulcer prevalence in four
European countries established that pressure ulcer
prevalence ranged from 4% in Denmark to 49% in
Germany, even though 71% of all intensive care units
used hospital prevention and treatment protocol and
Pressure ulcer prevalence and incidence
72 2008 The Authors. Journal Compilation 2008 British Association of Critical Care Nurses
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Table
1Pressure
ulcerprevalen
cein
intensivecare
units
Autho
rsan
dyears
Bourset
al.(200
1)Weststratean
dHeu
le(200
1)Heinrichs
andDassen(200
3)Po
kornyet
al.(200
3)Pend
eran
dFrazier(200
5)
Purpose
Toevalua
tetheprevalen
ce,
riskfactorsan
dpreven
tion
ofpressure
ulcers
inDutch
intensivecare
units
Toinvestigatetheprevalen
ceof
pressure
ulcerin
intensivecare
units
infour
Europe
ancoun
tries
Toassess
pressure
ulcerprevalen
ce,
riskfactors,
stag
es,preven
tion
andtrea
tmen
tin
intensivecare
patie
nts
Tode
term
inetheeffectiven
ess
ofaskin
care
interven
tion
prog
rammein
preven
tingthe
developm
entof
ulcers
orthe
prog
ressionfrom
onestag
eto
anothe
ran
dto
determ
inethe
extent
towhich
selected
risk
factorswereassociated
with
developm
entan
dprog
ressionof
pressure
ulcers
Todeterm
inetheprevalence
ofderm
alpressure
ulcers
insubjects
beingventilatedan
dto
describ
etherelatio
nshipbetw
eensystem
icoxygenation,
tissueperfusionan
dtheprevalence
ofderm
alpressure
ulcers
Toinvestigatewha
torga
nizatio
nal
andclinical
strategies
areused
inthosecoun
triesto
preven
t
thede
velopm
entof
pressure
ulcer
inintensivecare
patie
nts
Design
Cross-sectio
nalde
sign
(point
prevalen
ce)
Pointprevalen
ceCross-sectio
nalstud
yde
sign
(point
prevalen
ce)
Asimpleinterrup
tedtim
eserie
s
design
Descriptiv
e,correlationa
lstud
y
Popu
latio
n(exclude
d
andinclud
ed
crite
ria)
850ICU
patie
nts(allICU
specialties)
299pa
tientsfrom
differen
tintensive
care
specialties
(29ge
neralICU
units,e
ight
corona
ry,o
nemed
ical,
twone
urolog
ical,threesurgical
andon
ecardiothoracic)
424pa
tientsfrom
42intensivecare
units.Pa
tientsover
17yearswere
includ
ed
Allpa
tientsad
mitted
forop
enchest
surgeryfora6-mon
thperio
d.
Inclusioncrite
ria:(m
orethan
18yearsold,
hadcorona
ryartery
bypa
ssgraftan
d/or
valvesurgery
andad
mitted
tocardiacsurgery
intensivecare
unitor
thecardiac
surgeryinterm
ediate
unit.
Exclu-
sion
crite
ria:(if
patie
ntreceived
mini-b
ypassgrafts
orha
dmitral
valvesurgerybecauseof
shortness
ofstay
40pa
tientsbe
ingad
mitted
tomed
ical
intensivecare
unitof
aho
spita
linthemidwestern
USA
.Thesampleconsists
ofCau
ca-
sian
s,31
(775
%);African
-American
s,7(175
%)an
dothe
rs,
2(0
2).Other
inclusioncrite
ria:
thepa
tientswereolde
rthan
18years,
beingventilatedfor
morethan
24h,
exclud
ingpa
-tie
ntswith
para-or
quad
riplegia
priorto
theirad
mission
totheun
it
Noexclud
edcrite
riawas
men
tione
dDen
mark(three
units
and24
patie
nts),Ita
ly(25un
itsan
d
150pa
tients),German
y(11un
its
and99
patie
nts)
andthe
Nethe
rland
s(fiveun
itsan
d
26pa
tients).
Theexclud
edcrite
riawas
not
men
tione
d
Theexclud
edcrite
riawereno
t
men
tione
d.
Instrumen
tsQuestionn
aire
includ
ingsix
factors[patient,ward,
insti-
tute
characteristics,
Brad
enscalewith
twoad
ditio
nal
riskfactors(m
alnu
trition
and
incontinence),pressure
ulcer
stag
es,site
first
observation
anddressing
andsupp
ortive
surfaceused]
Que
stionn
aire
includ
ingtw
opa
rts:
onepa
rtwas
answ
ered
bythe
nurseman
ager
andthesecond
part
was
answ
ered
bytheinten-
sive
care
nurse
Que
stionn
aire
includ
ingde
mo-
grap
hicda
ta,pressure
ulcerpre-
vention,
Brad
enscale,
care-
depe
nden
cyscale,
pressure
ulcer
stag
esaccordingto
Europe
anpressure
ulcerad
visory
pane
l,locatio
n,du
ratio
nan
dtrea
tmen
twas
used
Que
stionn
aire
includ
ingde
mo-
grap
hicda
ta,Brad
enscale,
skin
cond
ition
assessmen
ttool,pres-
sure
ulcerstag
esaccordingto
the
agen
cyforhe
alth-carepo
licyan
d
research
pane
lforpred
ictin
gan
d
preven
tingpressure
ulcers
in
adults
was
used
Datawerecollected
from
the
compu
terized
med
ical
record
usingan
investigator-devised
data
collectionform
.TheBrad
enscale
was
used
forpressure
ulcerrisk
assessmen
t
(continued
)
Pressure ulcer prevalence and incidence
2008 The Authors. Journal Compilation 2008 British Association of Critical Care Nurses 73
-
Table
1(Con
tinue
d)
Autho
rsan
dyears
Bourset
al.(200
1)Weststratean
dHeu
le(200
1)Heinrichs
andDassen(200
3)Po
kornyet
al.(200
3)Pend
eran
dFrazier(200
5)
Assessm
entpo
int
Theda
tawerecollected
inon
eda
y,on
26May
1998
and
20April19
99
Answered
bythenu
rseman
ager
and
intensivecare
nurseon
1da
yat
thesametim
e
Theda
tawerecollected
in1da
yin
thefirst
weekin
April20
01an
din
1da
yin
thefirst
weekin
April
2002
.
Attim
eof
admission
ofpa
tient
and
every12
hthroug
hout
theho
spi-
talstay
inover
6mon
thspe
riod
Nospecificpo
intforassessmen
tbu
treview
ofthesubjects
med
ical
recordswith
in3mon
thspe
riod
Datacollection
andcollector
Each
patie
ntwho
hadcon-
sented
topa
rticipatewas
assessed
bytw
onu
rses.
And
forun
consciou
spa
-tie
nts,
theirfamily
were
askedforap
proval
Part1was
filledin
bynu
rseman
ger,
andpa
rt2was
filledin
by
intensivecare
nurselook
ingafter
thepa
tient
thetim
eof
assess-
men
t
Datawerecollected
bynu
rsewho
givesdirect
care
forthepa
tient
Patie
ntreceived
thenu
rsinginter-
vention(bynu
rselook
ingafter
patie
nt)to
maintainskin
integrity
twiceda
ilyfrom
admission
to
discha
rge,
anded
ucationwas
provided
toselect
activ
ities
on
aself-he
lpba
sis
Noconsen
twas
takenfrom
the
patie
nts.
Theda
tawerecollected
from
thecompu
terized
med
ical
record
usingan
investigator-
devisedda
tacollectionform
Statistic
descrip
tion
Datawerean
alysed
usingSPSS,
allthePvalues
repo
rted
weretw
o-tailed,
means
and
SD,un
less
otherw
iseindi-
cated;
potentialriskfactors
forpressure
ulcerwereas-
sessed
bylogistic
regression
ifthePvalue