Factors affecting the incidence and prevalence of pressure ulcers in COVID‐19 patients admitted with a Braden scale below 14 in the intensive care unit: Retrospective cohort study

The pandemic of coronavirus (COVID‐19) has significantly increased the admission of patients with extensive complications, especially for respiratory support, to intensive care units (ICUs) worldwide. These patients also suffer from pressure ulcers (PUs) as another complication that occurs due to increased length of hospitalisation and acute conditions of patients. Therefore, this study aimed to evaluate the incidence and prevalence of PU and the factors affecting it in COVID‐19 patients admitted to ICUs. This cohort retrospective study used registry data in Imam Reza Hospital located in west of Iran. Four hundred and forty‐five COVID‐19 patients older than 20 years hospitalised in corona ICUs from 20 March 2020 to 30 December 2020, with a Braden score of less than 14 were included in the study. To investigate the relationship between variables in rate prevalence, univariate logistic regression analysis was used to calculate odds ratio, and for incidence rate in estimating PU risk generated in ICUs, hazard ratio was calculated using cox regression. One hundred and eighty‐three (41.12%) patients were male. The mean age of patients was 63 (SD = ±9.78) years. A total of 1152 cases of PU were generated, with the highest prevalence of PU with 234 cases in the sacrum. One hundred and seventy‐six (55.87%) patients underwent non‐invasive ventilation ulcers. The prevalence of PU was 79.7%. The highest prevalence was found in people over 80 years with 90.67%. The incidence ratio was 46.74%. The highest number of new cases was seen in diabetic patients with 60.96%. First‐degree ulcers were the most common degree of ulceration in 252 (55.38%) patients. Incidence and prevalence excluding first‐degree wounds were 24.04% and 49.66%, respectively. Age, Braden score, BMI, comorbidity, diabetes mellitus, stool incontinence, Glasgow coma scale, vasopressor, and length of hospital stay were significantly associated with PU (P < .05). The incidence and prevalence of PU in patients were high in this study. The length of hospitalisation and Braden score were the most important factors in the development of PU. The widespread prevalence of COVID‐19 and the relatively long stay of patients in the ICU created unfavourable conditions for patients and the treatment system, therefore, it emphasised the use of appropriate measures to prevent PU to avoid double costs and longer stays.     

IPARZINE‐SKR study: randomized,double‐blind clinical trial of a new topical product versus placebo to prevent pressure ulcers

This study compared the efficacy of a new topical agent (IPARZINE‐4A‐SKR) on preventing category I pressure ulcers (PUs) over a 2‐week period, compared with a placebo. A double‐blind, randomised, multi‐centre, placebo‐controlled clinical trial in two parallel groups was conducted. The primary objective was to compare PU incidence between groups. Hospital and socio‐sanitary centre patients (n = 194) at risk of developing a PU (Braden scale) were randomised into two groups. The intervention group included 99 patients, and the placebo group comprised 95 patients. Patients were comparable in terms of age, sex and PU risk. In both groups, patients had a high risk of developing PUs. The product was applied on the sacrum, trochanters and heels. Six PUs (incidence = 6·1%) were detected in the intervention group versus seven (incidence = 7·4%) in the placebo group. Differences were not statistically significant (z = 0·08; P = 0·94), relative risk = 0·82 (95% confidence interval = 0·29–2·36). The main limitation of the study was the sample size and, therefore, the main difficulty encountered was in determining whether the product is ineffective or simply has not been used with sufficient patients. In conclusion, it is not possible to confirm that there are any differences between the studied and the placebo treatments in the prevention of PUs. The results obtained were similar to those obtained in studies of PU prevention using products based on topical fatty acids.     

Concordance of Shape Risk Scale,a new pressure ulcer risk tool,with Braden Scale

The occurrence of pressure ulcers was examined in a cross‐sectional study in 23 health care facilities and in home care involving 548 patients. The screening of pressure ulcer risk was assessed simultaneously using the Braden Scale and the new Shape Risk Scale (SRS), and the results were compared. The overall prevalence of pressure ulcers in the study population was 15·5% (85/548). The Braden Scale was performed as described in the literature. The direct concordance of the Braden and SRS scales was 46%. In more than 90% of cases, the SRS classified patients as well as or better than the Braden Scale. The SRS allocates patients significantly different from the Braden Scale into the risk categories, especially the difference is significant between the low and medium‐risk categories. The greatest advantage of SRS to Braden Scale is that it correctly identifies patients with low risk of pressure ulcers. It is interesting that the two risk scores, taking into consideration the basically different pathophysiological factors, can still give rather similar results. The users considered that both scales are easy to use.     

Pressure ulcers in four Indonesian hospitals: prevalence,patient characteristics,ulcer characteristics,prevention and treatment

The objective of this article was to study characteristics of pressure ulcer patients and their ulcers, pressure ulcer preventive and treatment measures in four Indonesian general hospitals. A multicentre cross‐sectional design was applied to assess pressure ulcers and pressure ulcer care in adult patients in medical, surgical, specialised and intensive care units. Ninety‐one of the 1132 patients had a total of 142 ulcers. Half (44·0%) already had pressure ulcers before admission. The overall prevalence of category I–IV pressure ulcers was 8·0% (95% CI 6·4–9·6), and the overall nosocomial pressure ulcer prevalence was 4·5% (95% CI 3·3–5·7). Most pressure ulcer patients had friction and shear problems, were bedfast, had diabetes and had more bedridden days. Most ulcers (42·3%) were category III and IV. One third of the patients had both pressure ulcers and moisture lesions (36·3%) and suffered from pain (45·1%). The most frequently used prevention measures were repositioning (61·5%), skin moisturising (47·3%), patient education (36·3%) and massage (35·2%). Most pressure ulcer dressings involved saline‐impregnated or antimicrobial gauzes. This study shows the complexities of pressure ulcers in Indonesian general hospitals and reveals that the quality of pressure ulcer care (prevention and treatment) could be improved by implementing the recent evidence‐based international guideline.     

The prevalence of pressure ulcers in a tertiary care pediatric and adult hospital.

OBJECTIVE: To describe the pressure ulcer prevalence, stage and body location, and demographic characteristics of patients with pressure ulcers at a tertiary care adult hospital and a tertiary care pediatric hospital. DESIGN: Prevalence survey. SETTING AND SUBJECTS: A total of 513 inpatients, including 416 adults admitted to a tertiary care hospital and 97 children admitted to a tertiary care pediatric hospital. Only inpatients with mental health-related diagnoses were excluded. INSTRUMENTS: The Kinetics Concepts International's Prevalence and Incidence Study Collection Form was used to assess variables, including demographic information; presence, location, and stage of pressure ulcers; and presence of special support surfaces. METHODS: All patients had head-to-toe skin assessments performed during an 8-hour period by teams of 3 multidisciplinary staff members. Kinetics Concepts International's Prevalence and Incidence Program software and Microsoft Excel were used for data entry and analysis. RESULTS: Combined pressure ulcer prevalence was 26.3%, with 29.2% in adult patients and 13.1% in pediatric patients. The most common body locations for pressure ulcers were the sacrum (22.1%), heels (14.8%), ears (12.9%), elbows (10.6%), and the buttocks (6.8%). Forty-eight percent of the ulcers were stage I, 36% Stage II, 6% Stage III-IV, and 10% unable to stage. CONCLUSIONS: Overall combined pressure ulcer prevalence and common body locations were consistent with findings from comparable hospitals. Patients at the extreme ends of the age spectrum had an increased risk of pressure ulcers. Stage I and II ulcers occurred most frequently. Potential prevention and early management strategies may be effective in decreasing the prevalence of these ulcers.     

Characteristics of hospitalised US veterans with nosocomial pressure ulcers

The objective of this study was to describe demographic and clinical characteristics of hospitalised US veterans with nosocomial pressure ulcer (NPU) referred to a certified Wound, Ostomy & Continence Nurse (WOCN). We conducted a retrospective review of electronic records at a Veterans Affairs Medical Center in the northwestern USA. Records of veterans with NPU referred to a WOCN (n = 29) from May 2005 to June 2006 were reviewed. Location and stage of pressure ulcer(s), Braden score on admission and when the ulcer was first noted, day of hospital stay when the ulcer was first noted, medical diagnoses and clinical conditions and events such as surgery, hypoxemia, hypoalbuminemia and hypotension were recorded. Mean age of the patients was 69·8. The most common location was the sacrum/coccyx. Most ulcers were stage 1 when identified. Braden score during admission classified half of the sample at risk, but 81% of Braden scores at ulcer occurrence were <18. Ninety percent of the sample had three or more comorbidities. Over half had died in the 1–14 months after the reviewed hospitalisation. Hospitalised veterans referred for WOCN consultation had multiple risk factors and comorbid conditions, including hypoxemia, serum albumin depletion, anaemia and hypotension. Veterans cared for in Veterans Affairs Medical Centers are known to have multiple health problems, and those in this sample not only had nosocomial pressure ulcer, but also other physiological derangements that may shorten survival.     

Pressure ulcer prevalence across Welsh orthopaedic units and community hospitals: surveys based on the European Pressure Ulcer Advisory Panel minimum data set

The survey used the European Pressure Ulcer Advisory Panel (EPUAP) methodology for the collection of pressure ulcer prevalence data. The orthopaedic survey was conducted across all National Health Service Trusts in Wales between 2 and 6 July 2007 while the community hospital survey covering 25% of all community hospital beds was conducted between 21 April 2008 and 2 May 2008. Data were gathered upon 1196 patients (581, 48·6% within orthopaedic units with 615 located in community hospitals). Of these patients, 81 (13·9%) and 162 (26·7%) had pressure ulcers in orthopaedic and community hospitals, respectively. Where patients presented with multiple pressure ulcers, the most severe pressure ulcer was recorded. Across both surveys, most pressure ulcers were reported to be either category I or II with 91 category I wounds (33 in orthopaedic units and 58 in community hospitals). Severe (categories III and IV) pressure ulcers affected 78 patients (19 in orthopaedic units and 59 in community hospitals). Adoption of the EPUAP pressure ulcer prevalence methods can help achieve consistent data upon pressure ulcer prevalence in different health care organisations and specialities. The adoption of a consistent data collection capture methodology is a clear prerequisite for the compilation of meaningful pressure ulcer prevalence data sets at a national level.     

Point prevalence of wounds in a sample of acute hospitals in Canada

To provide new information on wound prevalence and the potential resource impact of non healing wounds in the acute sector by summarising results from wound audits carried out at 13 acute hospitals in Canada in 2006 and 2007. Audits were carried out in each hospital by the same independent team of advanced practice nurses using standard data‐collection forms. The results reported here were derived from the summary reports for each hospital. A total of 3099 patients were surveyed (median 259 patients per hospital). In the sample hospitals, the mean prevalence of patients with wounds was 41·2%. Most wounds were pressure ulcers (56·2%) or surgical wounds (31·1%). The mean prevalence of pressure ulcers was 22·9%. A majority of pressure ulcers (79·3%) were hospital‐acquired, and 26·5% were severe (Stage III or IV). The rate of surgical wound infection was 6·3%. Forty‐five percent of patients had dressings changed at least daily and the mean dressing time was 10·5 minutes. Wounds are a common and potentially expensive occurrence in acute hospitals. Any wound has the potential to develop complications which compromise patient safety and increase hospital costs. Ensuring consistent, best‐practice wound management programmes should be a key priority for hospital managers.     

A prospective window into medical device‐related pressure ulcers in intensive care

The aim of this study was to determine the prevalence, severity, location, aetiology, treatment and healing of medical device‐related pressure ulcers (PUs) in intensive care patients for up to 7 days. A prospective repeated measures study design was used. Patients in six intensive care units of two major medical centres, one each in Australia and the USA, were screened 1 day per month for 6 months. Those with device‐related ulcers were followed daily for up to 7 days. The outcome measures were device‐related ulcer prevalence, pain, infection, treatment and healing. Fifteen of 483 patients had device‐related ulcers and 9 of 15 with 11 ulcers were followed beyond screening. Their mean age was 60·5 years, and most were men, overweight and at increased risk of PU. Endotracheal (ET) and nasogastric (NG) tubes were the cause of most device‐related ulcers. Repositioning was the most frequent treatment. Four of 11 ulcers healed within the 7‐day observation period. In conclusion, device‐related ulcer prevalence was 3·1%, similar to that reported in the limited literature available, indicating an ongoing problem. Systematic assessment and repositioning of devices are the mainstays of care. We recommend continued prevalence determination and that nurses remain vigilant to prevent device‐related ulcers, especially in patients with NG and ET tubes.     

Medical device related pressure ulcers in hospitalized patients

Most pressure ulcers occur over bony prominences such as heels and the sacrum. However, the National Pressure Ulcer Advisory Panel recognises that pressure ulcers can also occur on any tissue under pressure and thereby can develop beneath medical devices. This article reports on results from a secondary analysis of existing data collected by The Nebraska Medical Center on pressure ulcer quality improvement initiatives and outcomes. The purpose of this study was to quantify the extent of the problem and identify risk factors for medical device related (MDR) pressure ulcer development in hospitalised patients. A subset of data collected during eight quarterly pressure ulcer incidence and prevalence studies (N = 2178) was created and analysed. The overall rate of hospital‐acquired pressure ulcers was 5·4% (113 of 2079). The proportion of patients with hospital‐acquired ulcers related to medical devices was 34·5% (39 of 113). Findings indicate that if a patient had a medical device, they were 2·4 times more likely to develop a pressure ulcer of any kind. Numerous risk factors for pressure ulcer development were identified; however, none differentiated between those with MDR and traditional pressure ulcers.     

Prevalence and incidence rates of pressure ulcers in an Emergency Department

Older patients represent an increasing population in emergency department (ED) with underlying diseases and longer ED length of stay, which are potential risk factors of pressure ulcers (PUs). The aim of the study was to determine the prevalence and incidence rates of PUs in an Emergency Department and to analyse variables related to PUs occurrence. The study was carried out in the Emergency Department of Bordeaux (France), and included 602 patients from 1 to 15 June 2010. All the potential body sites of pressure were examined at admission and discharge for all the patients by trained nurses. Comorbidity score, list of treatment, length of stay (hours), PUs (including stage I) and C‐reactive protein (CRP) level were systematically recorded. A total of 47 (7·8%) patients had prevalent PUs at admission and 74 (12·3%) at discharge. The cumulative incidence was 4·9% and the incidence density was 5·4 per 1000 patients per hour. In multivariate analysis, higher comorbidities (OR 1·3; P = 0·014) and CRP levels (OR 1·005; P = 0·017) were both independent risk factors for developing PU. In conclusion, these data show that even a very short stay to the ED is sufficient to induce PUs especially stage I.     

The prevalence of pressure ulcers in community‐dwelling older adults: A study in an Indonesian city

The objectives of this study were to investigate the prevalence and the characteristics of pressure ulcers (PU) in community‐dwelling older adults in Indonesia, including specific characteristics of the PU patients and their use of formal and informal care. A cross‐sectional design was used for the study, with 325 participants aged 60 years or older, randomly chosen from the general community. The overall PU prevalence and the PU prevalence excluding category 1 were 10.8% (95% confidence interval [CI], 5.8‐15.8) and 5.2% (95% CI 0.2‐10.2), respectively. Category 1 PUs were mostly (34.3%) located on knees and toes, while category 2 and higher PUs were mostly (70.4%) located on the shoulder, sacrum, and hip. The main factors that contributed strongly to PUs among older adults in the community were the degree of physical activity, problems with sensory perception, and having a history of stroke. None of the participants with a PU received wound care or information about PUs from formal caregivers and only 11.4% received wound care from family caregivers. This study shows that pressure ulcers in community‐dwelling older adults in Indonesia are a relevant and largely unaddressed problem. Developing an intervention program to manage the PU problem in the community is recommended.     

Microclimate and development of pressure ulcers and superficial skin changes

This study aims to evaluate the microclimate and development of pressure ulcers and superficial skin changes. A prospective cohort study was conducted in an acute care ward in Indonesia. Risk factors for pressure ulcers and superficial skin changes were identified based on the Bergstrom Braden conceptual model. Microclimate data were collected every 3 days for 15 days while the development of pressure ulcers and superficial skin changes was observed every day. Pressure ulcers and superficial skin changes were developed in 20 of the 71 participants. Total mean difference in skin temperature was higher for patients with pressure ulcers and superficial skin changes (0·9 ± 0·6°C) compared with controls (0·6 ± 0·8°C) (P = 0·071). Binary logistic regression predictor values for pressure ulcers and superficial skin changes were 0·111 for type of sheet and 0·347 for Braden Scale results. In conclusion, difference in skin temperature seems to be a predictor for pressure ulcer development and superficial skin changes, while synthetic fibre sheets are able to maintain a beneficial microclimate.     

Evaluation of prevalence and incidence of pressure ulcers and their relationship with mattresses used in a general hospital intensive care unit

This study evaluated the prevalence and incidence of pressure ulcers (PU) and their relationship with mattresses (standard, foam, low-air-loss replacement) in an ICU. Ninety-five patients were randomized into three groups. The effect of the mattress was assessed by the presence of at least one PU of any stage and to the presence of at least one PU of stage 2 or higher. We evaluated the PU point prevalence, PU-free time, and PU incidence. At the first observation 35% of patients had at least one PU of any stage. Analysis showed a significant difference among the three mattress types. With regard to the incidence of at least one PU, there was a direct relationship between mattress type and the cumulative incidence of PU.     

Length of surgery and pressure ulcers risk in cardiovascular surgical patients: a dose–response meta‐analysis

The aim of this study was to assess the relationship between length of surgery (LOS) and pressure ulcer (PU) risk in cardiovascular surgery patients. PubMed and Web of Science were systematically searched. We compared LOS difference between PU (+) group and PU (‐) group. We also examined the dose–response effect of this relationship. The mean LOS in the PU(+) groups ranged from 252·5 to 335·7 minutes, compared with 233·0 to 298·3 minutes in PU(?) groups. The LOS was higher in PU(+) groups compared with PU(?) groups [weighted mean difference (WMD) = 36·081 minutes; 95% CI: 21·640–50·522 minutes; Z = 4·90, P = 0·000]. The funnel plot showed no publication bias. A significant dose–response association was also found between the LOS and the risk of surgery‐related pressure ulcers (SRPU, model χ² = 9·29, P = 0·000). In the linear model, the PU OR was 1·296 (95% CI 1·097–1·531) for a 60‐minute increase in the LOS intervals and 13·344 (95% CI 2·521–70·636) for a 600‐minute increase. In a spline model, the OR of PU increased almost linearly along with the LOS. Our meta‐analysis indicated that LOS was an important risk factor for pressure ulcers in cardiovascular surgical patients.     

Hip fracture and pressure ulcers - the Pan-European Pressure Ulcer Study - intrinsic and extrinsic risk factors

Pressure ulcers (PU) in patients with hip fracture remain a problem. Incidence of between 8.8% and 55% have been reported. There are few studies focusing on the specific patient-, surgery- and care-related risk indicators in this group. The aims of the study were: - to investigate prevalence and incidence of PU upon arrival and at discharge from hospital and to identify potential intrinsic and extrinsic risk factors for development of PU in patients admitted for hip fracture surgery, - to illuminate potential differences in patient logistics, surgery, PU prevalence and incidence and care between Northern and Southern Europe. Consecutive patients with hip fracture in six countries, Sweden, Finland, UK (North) and Spain, Italy and Portugal (South), were included. The patients were followed from Accident and Emergency Department and until discharge or 7 days. Prevalence, PU at discharge and incidence were investigated, and intrinsic and extrinsic risk indicators, including waiting time for surgery and duration of surgery were recorded. Of the 635 patients, 10% had PU upon arrival and 22% at discharge (26% North and 16% South). The majority of ulcers were grade 1 and none was grade 4. Cervical fractures were more common in the North and trochanteric in the South. Waiting time for surgery and duration of surgery were significantly longer in the South. Traction was more common in the South and perioperative warming in the North. Risk factors of statistical significance correlated to PU at discharge were age >or=71 (P = 0.020), dehydration (P = 0.005), moist skin (P = 0.004) and total Braden score (P = 0.050) as well as subscores for friction (P = 0.020), nutrition (P = 0.020) and sensory perception (P = 0.040). Comorbid conditions of statistical significance for development of PU were diabetes (P = 0.005) and pulmonary disease (P = 0.006). Waiting time for surgery, duration of surgery, warming or non warming perioperatively, type of anaesthesia, traction and type of fracture were not significantly correlated with development of PU.