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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.,
2008 The Authors. Journal Compilation 2008 British Association of Critical Care Nurses, Nursing in Critical Care 2008 Vol 13 No 2
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RESEARCH QUESTIONS
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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
Design
Population (excluded
and included
criteria)
Instruments
Purpose
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
(continued)
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Data collection
and collector
Statistic description
Assessment point
Results
Table 1 (Continued)
2008 The Authors. Journal Compilation 2008 British Association of Critical Care Nurses
Purpose
Design
Population (exclusion
and inclusion)
Instruments
Assessment point
Statistic description
Results
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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
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
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
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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
REFERENCES
Allcock N, Wharrad H, Nicolson A. (1994). Interpretation of
pressure sore prevalence. Journal of Advanced Nursing; 20: 3745.
Bours GJJ, De Laat E, Halfens RJG, Lubbers M. (2001).
Prevalence, risk factors and prevention of pressure ulcers in
Dutch intensive care units results of cross-sectional survey.
Journal of Intensive Care Medicine; 27: 15991605.
Dealy C. (1992). The prevention of pressure sores in long-term
ICU patients. British Journal of Intensive Care; 2: 3439.
Eachempati SR, Hydo LJ, Barie PS. (2001). Factors influencing the
development of decubitus ulcers in critically ill surgical
patients. Journal of Critical Care Medicine; 29: 16781682.
European Pressure Ulcer Advisory Panel. (2002). Prevalence and
Incidence Monitoring. Vol. 4. Oxford, UK: European Pressure
Ulcer Advisory Panel.
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