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LITERATURE REVIEW

Pressure ulcer prevalence and


incidence in intensive care patients:
a literature review
Eman SM Shahin, Theo Dassen and Ruud JG Halfens
ABSTRACT
Background: Pressure ulcers remain a common health problem worldwide within the different health-care settings, especially in
intensive 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 pressure
ulcer 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 and
incidence 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 incidence
of pressure ulcers in intensive care patients as evidenced in the studies examined. There is also a gap between theory and practice in the
prevention 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 into
treatments that may successfully prevent their occurrence in intensive care patients.
Key words: ICU Incidence Pressure ulcer Prevalence

BACKGROUND
Pressure 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 anaesthetics and sedative drugs, resulting in a lower level of
consciousness and cutaneous sensation (Jiricka et al.,

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

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 discharge 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.

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

71

Pressure ulcer prevalence and incidence

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 400 000
patients, while 13% of the patients developed new
pressure 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 previously 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 concerning 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 variation 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 prevalence 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 incidence


rates of pressure ulcers in intensive care patients?

What are the factors related to pressure ulcer

72

prevalence and incidence in


patients?
What can be said about the
rigour in the studies about
prevalence and incidence in
patients?

intensive care
methodological
pressure ulcer
intensive care

METHODOLOGY
A 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).

RESULTS
Prevalence of pressure ulcers in intensive care
settings
In 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). In
addition, the highest percentage of pressure ulcers was
found in patients with an infection (including sepsis),
569%. Furthermore, the majority of factors that were
significantly 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

2008 The Authors. Journal Compilation 2008 British Association of Critical Care Nurses

2008 The Authors. Journal Compilation 2008 British Association of Critical Care Nurses
Point prevalence
299 patients from different intensive
care specialties (29 general ICU
units, eight coronary, one medical,
two neurological, three surgical
and one cardiothoracic)
Denmark (three units and 24
patients), Italy (25 units and
150 patients), Germany (11 units
and 99 patients) and the
Netherlands (five units and
26 patients).
The excluded criteria were not
mentioned.
Questionnaire including two parts:
one part was answered by the
nurse manager and the second
part was answered by the intensive care nurse

Cross-sectional design (point


prevalence)

850 ICU patients (all ICU


specialties)

Design

Population (excluded
and included
criteria)

Instruments

To investigate the prevalence of


pressure ulcer in intensive care
units in four European countries
To investigate what organizational
and clinical strategies are used
in those countries to prevent
the development of pressure ulcer
in intensive care patients

To evaluate the prevalence,


risk factors and prevention
of pressure ulcers in Dutch
intensive care units

Purpose

Questionnaire including six


factors [patient, ward, institute characteristics, Braden
scale with two additional
risk factors (malnutrition and
incontinence), pressure ulcer
stages, site first observation
and dressing and supportive
surface used]

No excluded criteria was


mentioned

Weststrate and Heule (2001)

Bours et al. (2001)

Authors and years

Table 1 Pressure ulcer prevalence in intensive care units

Questionnaire including demographic data, pressure ulcer prevention, Braden scale, caredependency scale, pressure ulcer
stages according to European
pressure ulcer advisory panel,
location, duration and treatment
was used

The excluded criteria was not


mentioned

424 patients from 42 intensive care


units. Patients over 17 years were
included

Questionnaire including demographic data, Braden scale, skin


condition assessment tool, pressure ulcer stages according to the
agency for health-care policy and
research panel for predicting and
preventing pressure ulcers in
adults was used

To determine the effectiveness


of a skin care intervention
programme in preventing the
development of ulcers or the
progression from one stage to
another and to determine the
extent to which selected risk
factors were associated with
development and progression of
pressure ulcers
A simple interrupted time series
design
All patients admitted for open chest
surgery for a 6-month period.
Inclusion criteria: (more than
18 years old, had coronary artery
bypass graft and/or valve surgery
and admitted to cardiac surgery
intensive care unit or the cardiac
surgery intermediate unit. Exclusion criteria: (if patient received
mini-bypass grafts or had mitral
valve surgery because of shortness
of stay

To assess pressure ulcer prevalence,


risk factors, stages, prevention
and treatment in intensive care
patients

Cross-sectional study design (point


prevalence)

Pokorny et al. (2003)

Heinrichs and Dassen (2003)

(continued)

Data were collected from the


computerized medical record
using an investigator-devised data
collection form. The Braden scale
was used for pressure ulcer risk
assessment

40 patients being admitted to


medical intensive care unit of
a hospital in the midwestern USA.
The sample consists of Caucasians, 31 (775%); AfricanAmericans, 7 (175%) and others,
2 (02). Other inclusion criteria:
the patients were older than
18 years, being ventilated for
more than 24 h, excluding patients with para- or quadriplegia
prior to their admission to the unit

Descriptive, correlational study

To determine the prevalence of


dermal pressure ulcers in subjects
being ventilated and to describe
the relationship between systemic
oxygenation, tissue perfusion and
the prevalence of dermal pressure
ulcers

Pender and Frazier (2005)

Pressure ulcer prevalence and incidence

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74

Part 1 was filled in by nurse manger,


and part 2 was filled in by
intensive care nurse looking after
the patient the time of assessment

Data were analysed by using


statistical software program
(SPSS 90)

Each patient who had consented to participate was


assessed by two nurses.
And for unconscious patients, their family were
asked for approval

Data were analysed using SPSS,


all the P values reported
were two-tailed, means and
SD, unless otherwise indicated; potential risk factors
for pressure ulcer were assessed by logistic regression
if the P value < 005 on
a univariate analysis in the
sample, the Hosmer-Lemeshow
goodness-of-fit statistic by
calculating Pearson chisquare statistic of observed
and expected frequencies.
Also, odds ratios and
their corresponding 95%
confidence intervals were
calculated for those risk
factors that were statistically
significant
Prevalence of pressure ulcer
was 287%

Data collection
and collector

Statistic description

SPSS, statistical package for social science.

Pressure ulcer prevalence varied in


the countries, i.e. in Denmark
it was 4%, in Italy, 14%; in
Germany, 49% and in the
Netherlands, 38%

Answered by the nurse manager and


intensive care nurse on 1 day at
the same time

The data were collected in one


day, on 26 May 1998 and
20 April 1999

Assessment point

Results

Weststrate and Heule (2001)

Authors and years

Bours et al. (2001)

Table 1 (Continued)

Pressure ulcer prevalence rate falls


between 209% and 395%

Software program SPSS was used.


Chi-square calculation, mean
And P value with significant level at
P < 005

At time of admission of patient and


every 12 h throughout the hospital stay in over 6 months period

The data were collected in 1 day in


the first week in April 2001 and in
1 day in the first week in April
2002.
Data were collected by nurse who
gives direct care for the patient

Pressure ulcer prevalence decreased


from 117% before the implementation of skin care intervention
program (SCIP) to 68% during
the intervention period

Patient received the nursing intervention (by nurse looking after


patient) to maintain skin integrity
twice daily from admission to
discharge, and education was
provided to select activities on
a self-help basis
Discriminate or comparative analysis
(before and after intervention)
Statistically significant if P < 005

Pokorny et al. (2003)

Heinrichs and Dassen (2003)

20% of subjects developed dermal


pressure ulcer while being ventilated during their stay in the
medical intensive care unit

Frequency, mean, SD, t-test for


comparing groups, Pearsons correlation used for variables at an
interval or ratio level, Kendall t
used for variables at an ordinal
level and significant if P < 005

No consent was taken from the


patients. The data were collected
from the computerized medical
record using an investigatordevised data collection form

No specific point for assessment but


review of the subjects medical
records within 3 months period

Pender and Frazier (2005)

Pressure ulcer prevalence and incidence

2008 The Authors. Journal Compilation 2008 British Association of Critical Care Nurses

Pressure ulcer prevalence and incidence

Table 2 Pressure ulcer incidence in intensive care units


Authors and years

Purpose

Design
Population (exclusion
and inclusion)

Instruments

Assessment point

Data collection and collector

Statistic description

Results

Fife et al. (2001)

Eachempati et al. (2001)

Determine the risk factors for pressure ulcers in an


intensive care setting
Evaluate the Braden scale as a predictor of pressure ulcer
in critically ill patients
Determine whether pressure ulcer is likely to occur early
in the hospital stay
Cohort study of patients with no pre-existing ulcers with
3 month enrolment period
A total of 186 patients admitted to neurological intensive
care and neurological intermediate unit 12 h before
the intervention was included. Patients who have
pressure ulcer stage 2 or more on initial assessment,
discharged from the unit <24 h after admission,
diagnosis of brain death on life support pending organ
donation and not evaluated by nursing staff within
12 h after admission were excluded
Braden scale, pressure ulcer assessment based on the
definition of each stage, preventive measures according to hospital standards and Glasgow Coma Scale
were used
Within 12 h of admission, the first assessment was
completed, then every 4 days, the patients were
assessed or at discharge (3-month study period from
June 1 to August 31)
Consent obtained from patients or family. Ten participating
nurses having a special training in evaluating pressure
ulcer, standardized photographic methods and completing study documents including Braden scale
Univariate analysis was conducted to assess the
association of new ulcer development with age and
gender, potential risk factors, admitting diagnosis and
the range of Braden scale
Contingency tables, correlation analysis and point biserial
correlation techniques were employed. The correlation
coefficient reported the point biserial because the
development of new sore is recorded as 0 = no and
1 = yes

What patient factors contributed to the formation of


decubitus ulcer in our critically ill patients, and
hypothesis that these ulcers occurred more often in
elderly patients with length of stay >7 days and high
severity of illness

Second level of analysis utilized multivariable techniques


(regression and logistic regression analysis) to evaluate
the concurrent effect of several factors in the
development of ulcers
Third level of analysis used these techniques on the
subgroup of patients who had low Braden scores using
both paired and unpaired analysis. P value considered
significant if P < 005
The incidence rate was 124% during patients stay in the
unit. All patients were at risk of pressure ulcer

2008 The Authors. Journal Compilation 2008 British Association of Critical Care Nurses

Prospective study design


A total of 2615 patients admitted in surgical intensive
care unit were included in the phase 1, for which the
data were collected prospectively from 1 January 1993
to 1 June 1997
In phase 2, all patients admitted to the surgical intensive
care unit from 1 January 1998 to 31 August 1998
were included. Again, followed prospectively for
decubitus ulcer
Demographic data, APACHE score, Cornell risk score and
multiple organ dysfunction score were used

First phase from 1 January 1993 to 1 June 1997


Second phase from 1 January 1998 to 31 August 1998

Committee of human rights of research of Weill Medical


college of Cornell University waived the need for
approval of the study. The data were collected from
medical records
Phase 1 and phase 2 was analysed separately, data
presented as mean values standard error
Difference in coordinate variables was analysed by chisquare and Fishers exact test
Continuous variables were analysed by univariate analysis
of variance
In phase 2 data, variables with a univariate P < 015
were subjected to a correlation matrix and then tested
for independence of effect by multiple logistic
regression
Odds ratios with 95% confidence interval was calculated
for significant variables for the multivariate analysis

Chi-square goodness-of-fit was calculated to evaluate the


calibration of the multivariate analysis

Overall incidence of pressure ulcer in phase 1 was 38%


and in phase 2 was 80% (in 1993 it was 09%, in
1994 it was 06, in 1995 it was 32%, in 1997 it was
56% and in 1998 it was 80%)
97% of all pressure ulcers in phase 2 (developed in
patients who had a length of stay >7 days)

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Pressure ulcer prevalence and incidence

61% of employed nurses specialized in the prevention


and treatment of pressure ulcers. The most common
risk factors were immobility, inactivity, limited to no
reaction, incontinence, oedema, a surgery less than
24 h ago and surgery more than 24 h ago (Weststrate
and Heule, 2001).
However, the study about pressure ulcers in Germany (2001) revealed that the pressure ulcer prevalence rate in intensive care specialties differed from
that of other settings. About half of the patients
suffered from a pressure ulcer grade 1. Additionally,
patients with pressure ulcers were older than those
without a pressure ulcer (the mean age of the sample
was 663 years with SD = 147). Moreover, patients
with pressure ulcers had a lower body mass index,
with 413% of them having a body mass index of less
than 20. In this study, there is no significant relationship between the duration of surgery and pressure
ulcers (Heinrichs and Dassen, 2003).
In East Carolina, a study in two intensive coronary
care units for patients with open heart surgery
assessed the effect of the implementation of skin care
intervention programmes on the prevalence of pressure ulcers in a cardiac surgery intensive care unit
(CSICU) and a cardiac surgery intermediate unit. It was
established that the prevalence of pressure ulcers
decreased from 117% prior to the implementation of
the programme to 68% during the intervention
period. Additionally, about 79% of all patients
suffering from pressure ulcers had a pressure ulcer
grade 1, and 25% of the initial injuries had occurred by
the end of the day of surgery. Amongst the patients
with skin injuries, there were significantly more
women, significantly more older patients, significantly more patients with a longer duration of stay
and patients who had to wait a long time before
surgery was carried out. In addition, the most
frequent risk factors for patients with skin injuries
were hypertension, obesity, diabetes and heart failure,
with 67% of the patients with early-stage injuries
suffering from heart failure (Pokorny et al., 2003).
A descriptive correlation study (2005), conducted in
an intensive care unit in a Midwestern hospital in USA,
revealed that 20% of patients developed a pressure
ulcer while being ventilated during their stay in the
medical intensive care unit. The first stage of pressure
ulcers developed in 25% of the patients during an
average duration of stay of 521 days, and the second
stage developed in 125% of the patients who stayed
between 1 and 33 days. Just one person developed
a third grade pressure ulcer after having been
ventilated in the intensive care unit for 19 days.
Nobody developed a fourth grade pressure ulcer
(Pender and Frazier, 2005).
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Incidence of pressure ulcers in intensive care


settings
A cohort study in Texas, conducted in neurological
intensive care in 2001, revealed that all patients were at
risk of developing pressure ulcers. The incidence of
pressure ulcers in patients with incontinence (urine or
stool) in contrast to continent patients was also
significantly different. The incidence was 261% in
incontinent patients and 104% in the continent group.
Furthermore, the pressure ulcer incidence rates for
patients with an albumin level of or below 35 g/L was
214%, whereas for the normal albumin group it was
77%. Forty-two per cent of the patients with multiple
diagnoses developed a pressure ulcer within just three
days. In addition, 50% of underweight patients
developed a pressure ulcer, while only 57% of overweight patients developed a pressure ulcer. In this
study, a body mass index of 1924 was considered
normal. However, no significant relation was found
between developing a pressure ulcer and age or
gender, length of stay and Braden score (Fife et al.,
2001).
A prospective study (2001) conducted in New York
revealed that the incidence rate of pressure ulcers from
1993 to 1997 was only about half the incidence rate
from January 1998 to August 1998. There is a significant
difference between these two phases with regard to
age, length of stay in intensive care unit, days confined
to bed since admission and days without nutrition.
Ninety-seven per cent of these ulcers also developed in
patients who had stayed in intensive care for more than
7 days. The majority of pressure ulcers occurred in
patients with sepsis. In addition, the multivariate
analysis revealed that age, days in bed, days without
any nutrition and especially time passed since admission independently predicted a pressure ulcer formation, whereas the severity of the illness upon admission
and the degree of organ dysfunction did not
(Eachempati et al., 2001).

Methodological rigour
The study results showed that three studies reported
exclusion and inclusion criteria (Fife et al., 2001;
Pokorny et al., 2003; Pender and Frazier, 2005), while
four studies reported just inclusion criteria (Bours et al.,
2001; Eachempati et al., 2001; Weststrate and Heule,
2001; Heinrichs and Dassen, 2003). Moreover, two
studies reported that informed consent was obtained
from patients or their families (Bours et al., 2001; Fife
et al., 2001). Three studies did not report anything about
the informed consent (Weststrate and Heule, 2001;
Heinrichs and Dassen, 2003; Pokorny et al., 2003). Two
studies stated that informed consent was not needed

2008 The Authors. Journal Compilation 2008 British Association of Critical Care Nurses

Pressure ulcer prevalence and incidence

because the data in the medical records had already


been evaluated. Data collectors varied between the
studies. In one study (Bours et al., 2001), each patient
was assessed by two nurses. In three other studies,
each patient was assessed by only one nurse
(Weststrate and Heule, 2001; Heinrichs and Dassen,
2003; Pokorny et al., 2003). In another study (Fife et al.,
2001), the overall data were collected by 10 trained
nurses, but the ratio of nurses to each patient was not
mentioned. In two of the studies, data were collected
from medical records (Eachempati et al., 2001; Pender
and Frazier, 2005). The studies also differed in their
design. Two studies had a prospective design
(Eachempati et al., 2001; Fife et al., 2001), one was
a correlation study (Pender and Frazier, 2005) and one
an intervention study (Pokorny et al., 2003), while three
studies were point prevalence studies (Bours et al.,
2001; Weststrate and Heule, 2001; Heinrichs and
Dassen, 2003) (see Tables 1 and 2).

DISCUSSION
Prevalence
The study about prevalence, risk factors and prevention of pressure ulcers in Dutch intensive care units
showed that pressure ulcer prevalence is higher in the
national prevalence survey than in other studies.
Patients who had undergone surgery also showed
a significantly higher prevalence of pressure ulcers
than patients who had not. The prevalence study in
four European countries has shown a wide variation in
the pressure ulcer prevalence among these countries.
There are also differences in the prevalence between
studies that were conducted within the same countries,
e.g. in the Netherlands. This study established higher
pressure ulcer prevalence than another study in
intensive care did, although both studies were implemented in the same year. Furthermore, although about
71% of 11 intensive care units used prevention and
treatment protocols and 61% had specialized nurses for
pressure ulcer prevention and treatment, pressure
ulcer was still a problem in these intensive care units
(Weststrate and Heule, 2001).
The prevalence study in Germany (2003) revealed
that pressure ulcer prevalence in surgical intensive
care (115%) and in internal medicine intensive care
(87%) was lower than in interdisciplinary intensive
care (186%), where about half of all patients with
pressure ulcers have had an operation in the previous
2 weeks (Heinrichs and Dassen, 2003). The study
conducted in a CSICU revealed a decrease in pressure
ulcer prevalence following the programmes implementation. It argued that the observation of the
patients skin could have increased staff nurses

awareness of the patients risk of pressure ulcers.


The study concluded that the progression of pressure
ulcers can be altered by nursing care. The number of
patients with pressure ulcers depends, to a great
extent, on frequent clinical assessment and consistently applied nursing intervention (Pokorny et al.,
2003). Age, length of stay and mobility are also
significantly associated with pressure ulcer incidence
(Bours et al., 2001; Eachempati et al., 2001; Pokorny
et al., 2003).

Incidence
However, another study (Fife et al., 2001) stated that
there is no significant relation between gender, age and
length of stay and the development of pressure ulcers.
In addition, other studies found that there is a significant relationship between development of pressure
ulcers and immobility (Bours et al., 2001; Eachempati
et al., 2001; Fife et al., 2001; Weststrate and Heule, 2001;
Heinrichs and Dassen, 2003; Pender and Frazier, 2005).
Furthermore, patients who are being ventilated are
vulnerable to skin injuries. There is also a significant
relation between the level of albumin, incontinence
(urine and/or stool), vasoactive medication and some
diagnoses such as spinal cord injury and heart failure
(Fife et al., 2001; Weststrate and Heule, 2001).

Methodological rigours
Some methodological details should be addressed to
interpret and compare the study results (Feuchtinger
et al., 2005). As stated in the methodological parts of
all studies reviewed, not all details were reported. In
this sense, a study about methodological rigour stated
that in spite of the fact that researchers report on
the methodologies they use, they rarely justify their
appropriation or discuss their practical applications
(Maggs-Rapport, 2001). Data collection has four
dimensions: structure, quantifiability, objectivity and
researcher obtrusiveness (Polit and Beck, 2004). As the
methodological parts shows in Tables 1 and 2, there is
a lack of objectivity in all studies except in the study
(Bours et al., 2001) where each patient was assessed by
two nurses. In addition, two studies collected data
from medical records that are a threat to the validity of
the data. In this respect, Polit and Beck (2004) stated
that when researchers are not responsible for collecting and recording data, they may be unaware of the
records limitations and biases. Two major sources of
bias in records are selective deposit (level of addressing
questions representative of the existing records) and
selective survival (level of recording technique across
the time). If the available records are not the entire set
of all such records possible, researchers must address

2008 The Authors. Journal Compilation 2008 British Association of Critical Care Nurses

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Pressure ulcer prevalence and incidence

the question of how representative existing records are.


Many record keepers intend to maintain an entire
universe of records but may fail to adhere to this ideal.
Lapses from the ideal may be the result of systematic
bias. Other difficulties sometimes decrease the data
accuracy, e.g. if the records are old or when codes and
symbols that had meaning to the record keepers may
have to be translated to be usable for the researcher
(Polit and Beck, 2004). In this respect, this study
revealed that more than factors affected the internal
validity of most of the studies as sample being
randomization, which all studies are not randomized.
Moreover, none of the studies reported the percentage
of non-responsiveness except one study (Heinrichs
and Dassen, 2003), where the response rate was 813%.
Therefore, it is not clear whether the sample size in
these studies was large enough to avoid drawing
inaccurate statistical conclusions.

CONCLUSION
Based on the results of previous studies about recent
prevalence and incidence of pressure ulcers in intensive care settings, pressure ulcer prevalence varied
from 4% to 49%, whereas the incidence ranged from
38% to 124%. Furthermore, in CSICUs, the period in

which a skin injury developed was rather short. The


pressure ulcer grade 1 plays an important role in the
prevalence of pressure ulcers in intensive care patients.
Nursing intervention and regular skin care have a great
influence on the reduction of pressure ulcer prevalence
in intensive care patients. Additionally, there is a gap
between theory and practice in the prevention and
treatment of pressure ulcers. Therefore, more research
on pressure ulcers in intensive care settings is needed
regarding different aspects such as the gap between
theory and practice, the effectiveness of nursing care
on pressure ulcer development and the requirements
for and the qualification of nurses specialized in
pressure ulcer prevention and treatment in intensive
care settings. Demographic data such as age also play
an important role in the development of pressure
ulcers. The development of pressure ulcers may be
decreased if the patient is assessed for the risk of
pressure ulcer upon his/her admission and if a regular assessment is followed by an appropriate action
or intervention. Furthermore, methodological rigour
should be considered as much as possible to enhance
the internal validity of studies, hence, getting accurate
incidence and prevalence rates of pressure ulcers in
intensive care settings.

WHAT IS KNOWN ABOUT THIS TOPIC

Pressure ulcers are a common health problem in intensive care settings.


Research studies about prevalence and incidence of pressure ulcers in intensive care settings are limited.
There is a wide variation between prevalence and incidence rates.
WHAT THIS PAPER ADDS

Prevalence and incidence studies cannot be compared with each other.


Incidence or period prevalence may be a more suitable research method for evaluating pressure ulcers in intensive care settings.
More research is needed regarding aspects such as the gap between theory and practice, the enhancement of methodological
rigour of research in intensive care settings and the effectiveness of nursing care on pressure ulcer development.

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