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: eman.shahin@charite.de, emanshaheen@yahoo.com

LITERATURE REVIEW

2008 The Authors. Journal Compilation 2008 British Association of Critical Care Nurses, Nursing in Critical Care 2008 Vol 13 No 2 71

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

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