quantitative research articles on pressure ulcers

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Amos Wung Buh 1 ,
Hassan Mahmoud 2 ,
http://orcid.org/0000-0001-5398-8508 Wenjun Chen 3 , 4 ,
Matthew D F McInnes 2 , 5 , 6 ,
http://orcid.org/0000-0002-3389-2485 Dean A Fergusson 6
1 Interdisciplinary School of Health Sciences , University of Ottawa , Ottawa , Ontario , Canada
2 School of Epidemiology and Public Health, Faculty of Medicine , University of Ottawa , Ottawa , Ontario , Canada
3 School of Nursing , University of Ottawa , Ottawa , Ontario , Canada
4 Xiangya School of Nursing , Central South University , Changsha , Hunan , China
5 Department of Radiology , University of Ottawa , Ottawa , Ontario , Canada
6 Clinical Epidemiology Program , Ottawa Hospital Research Institute , Ottawa , Ontario , Canada
Correspondence to Wenjun Chen; wchen140{at}uottawa.ca

Introduction Pressure ulcers are serious and potentially life-threatening problems across all age groups and across all medical specialties and care settings. The hospitalised elderly population is the most common group to develop pressure ulcers. This study aims to systematically review studies implementing pressure ulcer prevention strategies recommended in the Pressure Ulcer Prevention Practice Guidelines for the prevention of pressure ulcers among hospitalised elderly patients globally.

Methods and analysis A systematic review of all studies that have assessed the use of pressure ulcer prevention strategies in hospital settings among hospitalised elderly patients shall be conducted. A comprehensive search of all published articles in Medline Ovid, Cumulative Index to Nursing and Allied Health Literature, PubMed, Embase, Cochrane library, Scopus and Web of Science will be done using terms such as pressure ulcers, prevention strategies, elderly patients and hospital. Studies will be screened for eligibility through title, abstract and full text by two independent reviewers. Study quality and risk of bias will be assessed using the Joanna Briggs Institute for Meta-Analysis of Statistics Assessment and Review Instrument. If sufficient data are available, a meta-analysis will be conducted to synthesise the effect size reported as OR with 95% CIs using both fixed and random effect models. I 2 statistics and visual inspection of the forest plots will be used to assess heterogeneity and identify the potential sources of heterogeneity. Publication bias will be assessed by visual inspections of funnel plots and Egger’s test.

Ethics and dissemination No formal ethical approval or consent is required as no primary data will be collected. We aim to publish the research findings in a peer-reviewed scientific journal to promote knowledge transfer, as well as in conferences, seminars, congresses or symposia in a traditional manner.

PROSPERO registration number CRD42019129088.

geriatric dermatology
geriatric medicine
protocols & guidelines
orthopaedic & trauma surgery
wound management

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2020-043042

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Strengths and limitations of this study

This is a systematic review and meta-analysis of randomised controlled trials.

This review will be the first to synthesise the evidence regarding the effectiveness of guidelines used in pressure ulcer prevention for elderly patients in hospitals and offer the highest level of evidence for informed decisions on use of Pressure Ulcer Prevention Practice Guidelines (PUPPG) in prevention pressure ulcers in the elderly patients in hospital.

There may be heterogeneity of interventions used on eligible studies and incomplete information reported about the interventions in the literature which could limit our ability to statistically compare the effectiveness of interventions.

The main limitation of this review might be scarcity of randomised controlled trials on the use of PUPPG for preventing pressure ulcers in elderly patients, publication bias and methodological quality of grey literature that shall be found.

Pressure ulcers (PU) also known as pressure injuries are areas of localised damage to the skin and/or underlying structures due to pressure and/or friction and shear. 1 They are serious and potentially life-threatening problems across all age groups from the very young to the very old and across all medical specialties and care settings. 2 It has been documented that hospital admissions due to PU are 75% higher than admissions for any other medical conditions and that, the consequences of PU development in hospitalised patients are particularly serious. 2 Patients with hospital admission PU are three times more likely to be discharged to long-term care facilities and mortality of these patients is twice that of patients without hospital admission PU. 3 The cost of treatment of PU is 2.5 times than its prevention, and PU increases the length of stay in the hospital from 4 to 30 days, decreases quality of life, and increases pain, morbidity and mortality. 4

On international level, hospital-acquired PUs (sometimes called decubitus ulcers) are very common. 5 Although many of these cases are preventable, their point prevalence in Canadian hospitals for example is measured to be 25.1%. 6 Unfortunately, the high rates of such condition are associated with subsequent high burden on the healthcare system and the national economy considering the high cost of their management, and the frequent occurrence of associated significant morbidity and mortality. 5 According to the Ontario Case Costing Initiative database in 2013 using the European Pressure Ulcer Advisory Panel (EPUAP) staging system, it was estimated that the cost of management of stage II ulcer is up to US$40 000 and can reach more than double this price for managing a single case of stage IV ulcer. 7 A good example of the burden that PU add to the national economy was measured in USA; it was estimated that hospital acquired PUs increase the financial expenses on healthcare systems between US$6 and US$15 billion annually. 8

The National Pressure Ulcer Advisory Panel (NPUAP), the EPUAP and the Pan Pacific Pressure Injury Alliance (PPPIA) 9 have defined PU as a ‘lesion or a trauma to the skin and/or underlying tissue usually over a bony prominence and is the result of undiminished pressure, or pressure combination with shear, friction and moisture’. It is a degenerative progress attributable to biological tissues (skin and underlying tissues) being exposed to pressure and shearing forces. The pressure constrains the proper blood circulation and causes cell death, tissue necrosis and the development of ulcers. 9 While the quality of PU prevention and treatment has increased considerably over the past years, PUs remains a global concern because of its frequency of occurrence and negative consequences for patients and families as well as for the healthcare system. 10 Incidence of PUs for hospitalised patients ranges from 9% to 18%, among which the elderly population appears to be the most common group to develop the ulcers. 11 At the same time, many elderly patients are more vulnerable to be ‘stuck’ at a certain stage of PU for a long period of time and sometimes for the remainder of their lives. 12 This may result in longer length of hospital stay, heavier burdens for the healthcare system and family members, worst quality of life for elderly patients, which may also influence their mental health such as emotional stability. 13 14

NPUAP, EPUAP and PPPIA 9 developed the Pressure Ulcer Prevention Practice Guideline (PUPPG), which involves a range of evidence-based recommendations for PUs prevention that could be applied by healthcare professionals globally. Frequently used PU prevention strategies recommended in this guideline includes PU risk assessment, regular repositioning, prevention management plan, appropriate use of support surfaces and protection, continence management, patient education, skin protection, nutritional assessment and adequate nutrition. 15 It also includes some recommendations specifically for elderly people—‘protect aged skin from skin injury associated with pressure and shear forces’, taking into consideration that an aged person’s skin is vulnerable. 15

A number of studies have been conducted on the implementation of PU prevention strategies among hospitalised patients. One cluster randomised trial conducted in Canada revealed that multidisciplinary PU prevention groups are more cost effective than usual care and yields no significant improvement in the treatment of PUs. 16 Despite the existence of the guidelines on the prevention of PU, their effective utilisation in preventing PUs among hospitalised elderly patients varies in settings and countries. Also, although a number of studies have assessed strategies used in preventing PUs, there appears to be little or no information on systematic reviews that have assessed the effectiveness of guidelines used in PU prevention for elderly patients in hospitals. This study, therefore, aims to systematically review studies implementing PU prevention strategies recommended in the PUPPG for the prevention of PUs among hospitalised elderly patients globally.

The objective of this review is to assess the effectiveness of each of the strategies included in the PUPPG guideline in reducing the incidence and prevalence of hospital acquired PUs in hospitalised elderly patients in comparison to no strategy (usual practice), or other strategies. The review question is: what is the effectiveness of implementing each of the PU prevention strategies included in the PUPPG in decreasing the incidence and prevalence of PUs among hospitalised elderly patients compared with no strategies (basic usual care) or different prevention strategies?

Study design

This will be a systematic review and meta-analysis of published and unpublished studies that have assessed the use of PU prevention strategies in hospital settings among hospitalised elderly patients. The systematic review protocol has been developed and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria (see online supplemental appendix 1 ). 17

Supplemental material

Inclusion criteria, population included.

This systematic review will focus on studies that involved all vitally stable (not admitted in the intensive care unit) bed ridden hospitalised patients aged 60 or above.

Interventions

All studies that assessed the effect of PU preventive strategies found in the PUPPG, that were implemented on vitally stable bed ridden hospitalised patients aged 60 and above with an aim to decrease the occurrence of PUs, will be included in this review. Interventions will be limited to use of risk assessment, skin assessment, skin care, nutrition, position and repositioning, education and training, and medical devices care.

Interventions will be compared with other strategies to identify the most effective among them and/or will also be compared with no interventions (regular basic management).

In this study, the primary outcome will be directly related to the incidence of the disease among elderly hospitalised patients (incidence shall be considered as the proportion of hospitalised patients who developed PUs while in hospital). Included studies must measure study duration related incidence of the disease and/or its point prevalence and /or stage of PU (severity) as a measure of the effectiveness of the preventive strategies.

Types of studies

We will focus only on Quantitative studies—experimental and quasi-experimental studies. These might include randomised and non-randomised controlled trials in addition to comparative and before-and-after studies.

Only studies written in English will be included in this systematic review.

Search strategy

We will use a three-step strategy to find published and unpublished studies on PUs and their management. First, we will conduct an initial search through the Medline Ovid database using an analysis of text words found in the title and abstract, and the index terms used to describe the article. Second, we will use identified keywords and index terms to search for studies in identified databases. Finally, we will use the reference list of selected studies from the first and second searches to look for additional studies not found in the databases. For this study, we will consider only studies either published or unpublished in English.

The databases that shall be searched for this review will include Medline Ovid, Cumulative Index to Nursing and Allied Health Literature, PubMed, Embase, Cochrane library, Scopus and Web of Science. See online supplemental appendix 2 for the example searching strategy and results in Medline (Ovid). All these databases will provide published studies. To find unpublished studies on our topic, we will use Google, Grey Literature reports and the Centers for Disease Control and Prevention.

The keywords we will use for our initial searches in Medline Ovid will include ‘pressure ulcers’, ‘pressure sore’, ‘bed sore’, ‘pressure injuries’, ‘prevention strategies’, ‘elderly patients’ and ‘hospital’.

Study screening and selection

The titles, abstracts and full text of studies selected for this study will be reviewed by two independent researchers to identify studies that potentially meet the inclusion criteria outlined above. The Covidence software will be used for title, abstract and full-text screening. After importing references and inclusion/exclusion criteria into the Covidence software, two independent reviewers will screen titles of included studies according to the eligible criteria. Conflicts between those two reviewers will be resolved through discussion with a third reviewer. The same procedures shall be used for abstract screening. Following the abstract screening, full texts of these potentially eligible studies will be retrieved and independently assessed for eligibility by two reviewers. Any disagreement between the two reviewers over the eligibility of a particular study will also be resolved through discussion with the third reviewer. The process of study selection will be reported using the PRISMA flow diagram. 17

Assessment of methodological quality

Two independent reviewers will be used to assess the methodological validity of the quantitative papers that will be selected for retrieval prior to their inclusion in the review using standard critical appraisal tools from the Joanna Briggs Institute for Meta-Analysis of Statistics Assessment and Review Instrument (see online supplemental appendix 3 ). All disagreement between the two reviewers shall be settled through discussions.

Data extraction

After screening and selecting studies, key information from those studies will be extracted into an excel sheet for further analysis. We shall use a data extraction tool adapted from the standardised data extraction tool from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). Considering the information, we will need for the data synthesis of our study, we shall use the JBI-MAStARI to develop a data extraction tool specifically for quantitative research data extraction (see online supplemental appendix 4 ). The tool will be used to extract: (1) Study characteristics of reviewed papers, such as authors, year of publication, journal; (2) Methods of the study, including study design (randomised control trial (RCT), quasi-RCT, longitudinal, retrospective), research purpose and/or questions; (3) participant characteristics, country where the study took place, setting, population, sample size, age, sex, ethnicity, socioeconomic status and/or education level; (4) PU prevention strategies used in experimental group and control group (if applicable), (5) outcome measures and results and (6) conclusions of reviewed papers and any comments from reviewers. Two reviewers will independently perform data extraction. Authors of reviewed papers will be contacted in case of any missing details about their studies.

Data synthesis

A meta‐analysis of outcomes combining various studies included in the review shall be done. We will assess statistical heterogeneity with I 2 , which will indicate the percentage of the total variation across studies: 0%–40% low heterogeneity, 30%–60% moderate heterogeneity, 50%–90% may represent substantial heterogeneity and 75%–100% is considerable heterogeneity. If there is a substantial amount of heterogeneity (75%), then sources of heterogeneity will be examined through subgroup and sensitivity analyses. We will also use χ 2 test to test the heterogeneity and consider p<0.05 as statistically significant. A fixed‐effects model will be selected for significant homogeneous studies; otherwise we will apply a random‐effects model. All outcomes will be summarised using ORs and 95% CI. An OR <1 will represent a lower rate of outcome among the group of patients who were treated following the guidelines. Publication bias will be assessed by visual inspections of funnel plots and Egger’s test.

We will also provide a narrative synthesis of the findings from the included studies. The narrative synthesis shall be structured by describing the studies according to the type of intervention used. This will include the three categories of interventions recommend in the PUPPG guideline 9 :

Prevention of PUs, including risk factors and risk assessment, skin and tissue assessment, preventive skin care and emerging therapies for prevention of PUs.

Interventions for prevention and treatment of PUs, such as nutrition in PU prevention and treatment, repositioning and early mobilisation, repositioning to prevent and treat PUs, support surface and medical device-related PUs.

Treatment of PUs, for example, assessment of PUs and monitoring of healing, pain assessment and treatment, wound care, assessment and treatment of infection and biofilms, wound dressings for treatment of PUs and surgery for PUs. Results will be presented in tables, figures and graphs, followed by discussion.

Publication bias will be assessed in all analyses synthesising 10 or more studies to ensure adequate power in the analysis. 18 For investigation of the effect of small studies and publication bias, data from included studies will be entered into a funnel plot asymmetry test if we have at least 10 studies in the meta-analysis. Egger’s statistical test will be implemented using STATA/SE V.13 (StataCorp). The quality of supporting evidence will be assessed by the Grades of Recommendation, Assessment, Development and Evaluation. 19

Patient and public involvement

No patient involved.

Ethics and dissemination

This review will only use published literature and will not recruit participants. Therefore, no formal ethical approval or consent is necessary. It is anticipated that this systematic review will provide a detailed summary of the evidence of the effectiveness of the PUPPG in preventing the occurrence of PUs among elderly patients in hospital. It is also expected that the study will provide recommendations on the best PU preventive strategies applicable in healthcare settings. We aim to publish the research findings in a peer-reviewed scientific journal to promote knowledge transfer, as well as in various media, such as: conferences, seminars, congresses or symposia in a traditional manner.

Acknowledgments

The authors would like to thank Lindsey Sikora (librarian) for counselling in developing the searching strategies.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Data supplement 1

AWB and HM are joint first authors.

AWB and HM contributed equally.

Contributors AWB, HM and WC contributed to the conception of the research question and writing of the protocol. HM, AWB, WC, MDFM and DAF contributed to the development of search strategies, eligibility criteria and methodology for data synthesis. HM, AWB, WC, MDFM and DAF contributed to drafting of the protocol and provided approval for the final version of this protocol. HM, AWB and WC will work in duplicate to screen the titles and abstracts of all the materials obtained using the search strategy to exclude the articles that do not meet the eligibility criteria. HM, AWB and WC will evaluate the potentially eligible studies with the full text and further exclude studies with documentation of the reason for exclusion. All authors will contribute to the bias assessment strategy and data extraction criteria. HM, AWB and WC will independently extract data from the included studies. HM, AWB and WC will analyse the data and draft the manuscript. All authors will read, provide feedback and approve the final manuscript.

Funding This work was supported by Hunan Provincial Key Laboratory of Nursing, grant number (2017TP1004), Hunan Provincial Science and Technology Department, China.

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Pressure ulcers: Prevention and management

Affiliations.

1 Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts. Electronic address: [email protected].
2 Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts.
PMID: 30664906
DOI: 10.1016/j.jaad.2018.12.068

Prevention has been a primary goal of pressure ulcer research. Despite such efforts, pressure ulcers remain common in hospitals and in the community. Moreover, pressure ulcers often become chronic wounds that are difficult to treat and that tend to recur after healing. Especially given these challenges, dermatologists should have the knowledge and skills to implement pressure ulcer prevention strategies and to effectively treat pressure ulcers in their patients. This continuing medical education article focuses on pressure ulcer prevention and management, with an emphasis on the evidence for commonly accepted practices.

Keywords: chronic wounds; debridement; dressings; management; nutrition; pressure injury; pressure sore; pressure ulcer; prevention; repositioning; support surface; surgery; therapy; treatment; wound care; wound healing; wounds.

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Research article
Open access
Published: 20 May 2019

Nurses’ knowledge to pressure ulcer prevention in public hospitals in Wollega: a cross-sectional study design

Werku Etafa Ebi 1 ,
Getahun Fetensa Hirko 1 &
Diriba Ayala Mijena 2

BMC Nursing volume 18 , Article number: 20 ( 2019 ) Cite this article

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Pressure ulcer is a preventable medical complication of immobility. It has psychological, economic and social impact on individual and family. Its cost of treatment is more than twice of cost of prevention. It is primarily the nurses’ responsibility to prevent pressure ulcer. The aim of this study was to assess the nurses’ knowledge to pressure ulcer prevention in public hospitals in Wollega.

A descriptive multicenter cross-sectional study design using quantitative method was employed to collect data from 212 randomly selected nurses. Data was collected using structured two validated self-administered instruments of pressure ulcer knowledge test evaluate nurses’ knowledge. Mean scores were compared using the Mann-Whitney U and Kruskal-Wallis tests. Means, standard deviation, and frequencies were used to describe nurses’ knowledge levels and barriers to pressure ulcer prevention.

Analysis of the study displayed 91.5% had inadequate knowledge to pressure ulcer prevention. The mean of nurses’ knowledge in all theme and per item were 11.31 (SD = 5.97) and 0.43 (SD = 0.22).respectively. The study participants had the highest mean item score (2.65 ± 0.87) in nutrition theme, whereas, scored lowest on etiology and development (0.27 ± 0.18) and preventive measures to reduce duration of pressure (0.29 ± 0.18), The study also identified significant nurses read articles (0.000) and received training ( p = 0.003). Shortage of pressure relieving devices, lack of staff and lack of training were the most commonly cited perceived barriers to practice pressure ulcer prevention.

Conclusions

This study highlights areas where measures can be made to facilitate pressure ulcer prevention in public hospitals in Wollega zones, such as increase regular adequate further training of nurses regarding pressure ulcer/its prevention points.

Peer Review reports

Pressure ulcers (PUs) prevention remains a significant challenge for nurses [ 1 , 2 ], and its incidence is considered an indicator of poor quality of care [ 3 , 4 , 5 ]. Patients and families know that pressure ulcers are painful and slow to heal [ 5 ]. Some risk factors for the development of pressure ulcers/injuries include advanced age, immobility, incontinence, inadequate nutrition and hydration, neuro-sensory deficiency, device-related skin pressure, multiple comorbidities and circulatory abnormalities [ 5 , 6 , 7 ]. Ninety-five percent (95%) of pressure ulcers are avoidable [ 8 , 9 ].

The incidence of pressure ulcers in adults varies from 0 to 12% in acute care settings, 24.3 to 53.4% in critical care settings and 1.9 to 59% in elderly care settings [ 6 ]. The prevalence of pressure ulcer has decreased over time in the USA (2004–2011 [ 10 ], 2006–2009 [ 11 ]). Two different cross-sectional studies conducted at Felegehiwot and Dessie referral hospital, in Ethiopia reported 16.8 and 14.9% overall prevalence rate of PU, respectively [ 12 , 13 ]. Moreover, these studies identified risk factors PU such as prolonged hospitalization, slight limit of sensory perception, lack of regular positioning and activity, friction/shear [ 12 , 13 ].

The cost for treating pressure ulcer increased proportionally to the increase of the area and the development of PU category [ 14 ]. PU treatment cost per patient per day varied between 2.65 € to 87.57€ across all settings and ranged from 1.71€ to 470.49€ across different settings [ 15 ].

When caregivers practice the best care every time, patients can avoid needless suffering [ 5 ]. Pressure area care is an essential component of nursing practice, with all patients potentially at risk of developing a pressure ulcer [ 16 ]. It is nurses’ primary responsibility for maintaining skin integrity [ 17 , 18 ] and prevention of its complications [ 19 ]. Recognizing patients at risk of developing PU in early time is an essential part of the prevention care pathway [ 20 ]. The time nurses and healthcare assistant spent to patient care accounts for 90% of the overall costs for treating PUs, and 96% of the price in category I and II pressure ulcers [ 21 ].

Several studies have been undertaken to evaluate nurses’ knowledge to pressure ulcer prevention using different instruments, cutoff point and professional nurses (assistant, registered and students). A cross-sectional multicenter study [ 22 ] among nurses in Belgian hospitals reported that only 23.5% (130/553) of the nurses had scored ≥60% mean knowledge of pressure ulcer prevention. Demarr’e et al. [ 23 ] also displayed a low mean score (28.9%) of knowledge for registered nurses and nursing assistants ( n = 145) in nursing home settings. In contrast, a survey in a Swedish healthcare setting among nursing staff showed that all respondents displayed good knowledge on prevention and treatment of pressure ulcers. Gunningberg et al. [ 24 ] studied prevention of PUs in a hospital wards and found more than half of the participants had a knowledge deficit (< 60% mean score).

Simonetti et al. [ 25 ] reported nursing students ( n = 742) PU knowledge score below the mean (51.1%, 13.3/26) about PU prevention. Similarly, Qaddumi & Khawaldeh [ 26 ] found that the majority (73%) of Jordanian nurses had scored lower than the mean knowledge about pressure ulcer prevention. Meanwhile, nurses had scored the lowest in themes related to PU etiology, preventive measures to reduce amount of pressure/shear, and risk assessment.

Tirgari et al. [ 27 ] displayed Iranian Intensive Care Unit (ICU) nurses had score lower knowledge than the average, meanwhile, it showed the highest mean score and the lowest mean scores in theme etiology and development, classification and observation. Gul A et al. [ 28 ] found that among 308 nurses in an acute care Turkish hospital using modified and translated version of the Pieper PUKT most participants (58.4%) answered at least 60% of the questions correctly and scores were highest for the prevention/risk assessment and lowest for the PU staging domain. Using a multicenter cross-sectional study design Usher et al. [ 29 ] reported the overall mean knowledge score 51.1% which less than cutoff point (60%) among Australian nursing students. Similarly, it identified the lowest nursing students’ knowledge score on the themes preventive measures to reduce the amount of pressure/shear (44.1%) and the duration of pressure/shear (48.5%).

However, Panagiotopoulou and Kerr [ 30 ], found good level of knowledge among Greek nurses in relation to risk factors and areas at risk for pressure ulcer, with the average level of agreement with expert opinion being 70.5%. Similarly, Tweed and Tweed [ 31 ] evaluated critical care nurses’ knowledge level of pressure ulcer care using a testing tool developed specifically for that study and reported adequate knowledge to pressure ulcer prevention nursing staffs. A cross-sectional survey conducted among 248 nurses in Gondar University hospital using instrument developed by authors reported that early more than half (54.4%) of the nurses had good knowledge of PU prevention of [ 32 ].

Panagiotopoulou and Kerr [ 30 ], found that lack of staff/manpower (94. 9%), lack of equipment (78. 8%) and overcrowding in the ward (79.1%) as the most frequently identified nurses’ barriers to practice PU prevention. Similarly, Qaddumi & Khawaldeh [ 26 ] also measured lack of time (34.1%), shortage of staff (24.4%,), the patient’s condition (17.8%), and lack of resources or equipment (19.3%) as the major barriers nurses face to prevent pressure ulcer. Moore and Price [ 33 ] identified lack of staff and time meanwhile Kallman and Suserud [ 34 ] reported lack of time, equipment, resources, and patient condition are the most frequently cited barriers. The study at Mulago, Ugandan teaching hospital also found heavy workload related to shortage of staff (94.6%) and shortage of pressure relieving devices uncooperative patient (62.5%), poor access to pressure ulcer literature (37.5%) and inadequate coverage about pressure ulcers during training (23.2%) [ 35 ]. Samuriwo, & Dowding [ 36 ] indicated that nurses rely on their own knowledge and experience rather than research evidence to decide what skin care to deliver.

In Ethiopia, it not nurses’ culture to assess patients who are at risk or had developed PU before admitted to wards though PU is an emerging problem in developing counties in line with increasing population aging and the burden of chronic non-communicable disease. It is also obvious that there are limitations of resources used to enhance nurses’ knowledge and skill with updated evidence based works that could improve quality of nursing care in Ethiopia. For instance poor access to internet, absence of libraries to acquire reading materials (articles or updates about PU), limited in service training about PU or its prevention. Currently, there is no evidence on nurses’ knowledge regarding PU prevention in public hospitals in Wollega zones, West Ethiopia. Therefore, this cross sectional study was undertaken to assess nurses’ knowledge and perceived barriers to practice PU prevention.

The objective of this study was to evaluate nurses’ knowledge to PU prevention and to determine nurses’ perceived barriers to PU prevention in public hospitals in Wollega, Oromiya, Ethiopia.

Study design and setting

Institutional based cross-sectional multi-center study using quantitative method was conducted from August 13–22, 2018. Thera are 10 public hospitals functional in Wollega zones. The study setting includes five public hospitals including one teaching hospital (Wollega University Referral Hospital), five Public Referral Hospitals: Nekemte, Gimbi, Nedjo, and Shambu Referral hospitals. Among ten hospitals, the investigators purposively selected five hospitals where large number of patients visit, referred and admitted. Wollega’s main town (Nekemte) is 330 km to the west from the capital city of the country, Addis Ababa, Ethiopia. .

Swedish missionaries introduced the modern nursing to Ethiopia around 1866. Then, Russia and French were delivering the nursing service in limited areas of Ethiopia. After the Second World War (1949), the Ethiopian Red Cross Society established the first nursing school in at Haile Selassie I hospital. Swedish Missionaries at the Princess Tsehai Memorial Hospital opened the second nursing school. These two nursing schools were only admitting females to train in nursing profession. Males were admitted to nursing programs in 1954 in Ethiopia in Nekemte nursing school found in the current study area, Wollega zones. Currently, in Ethiopia nursing profession could be educated after completed grade ten (enjoy college to be enrolled in nursing assistants) or twelve (enjoy Universities and enrolled in actual diploma in nursing after 4 years completion of study in nursing profession) [ 37 ].

Sample size and sampling procedure

The sample size was determined by using a single population proportion formula with the assumption of 54.4% Proportion [Gondar], 95% confidence level and 5% margin of error. Since the source of the population was less than 10,000 ( n = 420), a correction formula was used. Using 10% nonresponse the final sample size obtained was 220. Then, the number of participants in each selected hospital to take a similar proportion of participants were determined using the proportionate population sampling.

Study instrument

The questionnaire was administered in English language since it is a medium of instruction in nursing education in Ethiopia. A questionnaire used for data collection contained three parts (Additional file 1 ). Part one of the data collection was developed and included demographic characteristics such as gender, age, years of clinical experience in the nursing profession, level of current higher education, sources of PU knowledge, read articles about PU and training exposure to PU prevention.

Part two of data collection tool was Pressure Ulcer Knowledge Test Tool (PUKT), in an English version, to assess participant knowledge about pressure injuries that has acceptable reliability and validity, developed and validated by Beeckman et al. [ 38 ]. This instrument was validated for difficulty, discriminating index, and quality of the response alternatives. The internal consistency reliability (Cronbach’s α) was 0.77, and the 1-week test-retest interclass correlation coefficient (stability) was 0.88. Content validity index was 0.78 to 1.00. The item difficulty index of the questions ranged from 0.27 to 0.87, whereas values for item discrimination ranged from 0.29 to 0.65 [ 39 ].

The PUKT includes 26 multiple-choice questions in 6 categories: etiology and development (6), classification and observation (5), risk assessment (2), nutrition (1), preventive measures to reduce the amount of pressure (7), and preventive measures to reduce the duration of pressure (5) items. Each question has four answer options, and the fourth option is ‘I do not know the answer’ and scored zero points, which is included to prevent respondents from guessing the answer. Nurses who answered the item correctly scored one point, while who cannot answer correctly scored zero. This result in a final score between 0 and 26. Zero (0) and 26 scores represent nurses who incorrectly and correctly answered all nurses’ PU knowledge testing items from the total 26 items, respectively. The permission to use questionnaire communicated and obtained through the corresponding author electronic mail address from the corresponding author Beeckman [ 39 ]. Four nursing educators holding assistant professor and experienced researchers ensured the cultural and linguistic validity of instrument before the actual study conducted and determined the time required to complete filling the questionnaire after implemented comments.

The third part of the data collection tool was a list of barriers to the implementation of PU prevention. These instruments were adapted from the literature [ 26 , 33 , 35 ]. Some of items in the tool were modified as they are not applicable in Wollega nurses. Two types of options (‘Yes’ or ‘No’) were provided for nurses to select barriers that hinder nurses from exercising PU prevention points. It was used to identify nurses’ perceived barriers to practice PU prevention.

Data collection

Firstly, we made contact with each hospital medical director and matron to grant a permission with a copy of approved ethical clearance letter obtained from Wollega University Department of Nursing Ethical Review Committee to undertake the study. All medical directors and matrons readily accepted our request. Secondly, the head nurses asked for their cooperation to give the permanent nurses staff list in their unit. Nurses who had no an experience of direct patient care, were on vacation, and employed and had clinical nursing experience less than 1 year were exclude from the study. Nurses from all units in each hospital who fulfill the inclusion criteria were included in the study.

In each hospital, matron were responsible for supervising the staff nurses participated in the study to ensure no resources/any references materials were needed. Two bachelors of Science degree nurses were responsible for participant recruitment and distribution of the questionnaire. Staff nurses were randomly selected from their list given using lottery method until the required number of nurses obtained. Data facilitators informed staff nurses about the study verbally, and distributed the participant information sheet and consent form to those who voluntarily agreed to participate.

The self-administered questionnaire was distributed to each nurse during working hours at each hospitals. Voluntary participant staff nurses were informed not use any resources or ask other staffs for answers while completing the questionnaire. Staff nurses who were not volunteer were permitted not to participate. Staff nurses were allowed to leave complete the questionnaire. The time estimated to complete the questionnaire was a minimum of 30 min.

Data analysis

The data cleaning was done, entered into the computer using EPI data version 3.1 statistical packages, and checked for the consistency of data entry. The Statistical Package for Social Sciences (SPSS) version 20.0 (IBM Corporation, Armonk, NY) used for data analysis. Categorical variables computed as frequencies and percentages. Continuous variables compiled as mean and standard deviation (SD). The Mann- Whitney U and Kruskal-Wallis H tests were used to compare the mean score of independent groups. The statistical significance was set at p -value < 0.05.

Sociodemographic characteristics of nurses

The total number of eligible nurses was 220; of these, 212 were volunteered to participate in the study, a response rate of 96.3%. Most of them were males (131, 61.8%). The mean age among the study participants was 28.2 ± 5.2 (range 21–54) years. Majority of study participants (148, 69.8%) were a diploma holder in nursing, 71.2% had 5–10 years of clinical experience in the nursing profession. One hundred sixty (160, 75.5%) of the participants attended education on PU; almost half (49.5%) of them got PU education at University/ college education. One hundred fifty-six (156, 73.6%) did not read articles about pressure ulcer, while, 138 (65.1%) of the participants had no exposure to PU training as illustrated in (Table 1 ).

Nurses’ knowledge to prevent pressure ulcer

Analysis of knowledge items showed that the mean score of nurses’ knowledge about pressure ulcer prevention was 0.43 ± 0.22. Among the six categories of PU knowledge assessment, the nutrition category had the highest mean item score (2.65 ± 0.87), and etiology and development (0.27 ± 0.18) and preventive measures to reduce the duration of pressure (0.29 ± 0.18), had the lowest mean item score (Table 2 ). Similarly, Table 3 shows the percentage of nurses’ response to each question of the PUKT. The percentage of correct answers ranged from (133, 62.7%) to 31, 14.2%). The highest correct answers belonged to theme nutrition, item number 6, and multiple choice “c” ‘which said that optimizing nutrition can improve the patients’ general physical condition that may contribute to a reduction of the risk of pressure ulcers (62.7% answered correctly). The lowest scores (14.2%) of correct answers found under classification and observation theme, item number 7 which stated “A pressure ulcer extending down to the fascia is a grade 3 pressure ulcer.” More than 14 % (31, 14.6%) answered correctly item number 1, “lack of oxygen causes pressure ulcers” (Table 3 ).

Nurses’ knowledge score to PU were higher among those who read articles about PUs ( P = .000) and attended training in the last ( P = .003). Similarly, there is a statistically significant difference in knowledge score among gender ( p = 0.000). The study identified variables such as gender, age, level of education, clinical experience in the nursing profession and source of education had no significant difference in knowledge score (Table 4 ).

Nurses’ perceived barriers to implement pressure ulcer prevention

A descriptive analysis identified the most common barriers of nurses to practice pressure ulcer prevention; Lack of staff/heavy workload (116, 54.7%), shortage of pressure relieving devices (117, 55.2%), lack of training (110, 51.9) and lack of multidisciplinary initiative (101, 47.6%) (Table 5 ).

The present study used a multicenter cross-sectional design aims to investigate the knowledge of nurses about pressure ulcer prevention in Wollega public hospitals and to identify nurses’ barriers to practice pressure ulcer prevention. The result displayed that the knowledge of nurses about pressure ulcer prevention in Wollega hospitals was poor. It showed only 18 (8.5%) of nurses scored above the mean score (answered 13 out of 26). Our study reported relatively lower mean knowledge score (0.43), in agreement with Tirgari et al. [ 27 ], who conducted study among 89 Iranian intensive critical care nurses and reported the mean score of pressure injury knowledge 0.44 using the same instrument.

However, our scores are lower than the result reported from similar studies and the same instruments of measurement. For instance, Qaddumi & Khawaldeh [ 26 ] using the same cutoff point showed Jordanian nurses are more knowledgeable about PU prevention than nurses in working in public hospitals in Wollega. Similarly, a multicenter study conducted by Beeckman et al. [ 22 ] among 533 Belgian nurses found a knowledge score of 49.6% using 60% as cutoff point using the same instrument. Additionally, Simonetti et al. [ 25 ] among seven schools of Italian nursing students reported relatively lower knowledge scores (51%) using the same cutoff point with Beeckman et al. [ 22 ].

Moreover, our scores are also lower than those reported from similar studies using different instrument (Pressure Ulcer Knowledge Assessment Tool) of measurement. Gunningberg et al. [ 24 ] displayed that a knowledge score of 61.0% for staff nurses, 59.3% for registered nurses and 55.4% for assistant nurses in Sweden. Demarré et al. [ 23 ] study result among 145 registered and assistant nurses reported unsatisfactory level (28.9%) in nursing home settings.

In the present study, nurses’ gender ( p = 0.000), nurses read articles ( p = 0.001) and last attended training ( p = 0.003) showed a significant difference to PU knowledge score. Qaddumi & Khawaldeh [ 26 ] in line with this study reported a significant difference between gender (male, 5.67% and female, 3.3%, p = 0.021). Tiragari et al. [ 27 ], Hulsenboom et al. [ 38 ], Li Z et al. [ 40 ], Kaddourah et al. [ 41 ] displayed nurses’ age is statistically significant to PU knowledge score in opposite to this study.

Our study also explained nurses’ knowledge score has no significant difference between education level ( p = 0.72). However, some studies [ 32 , 38 , 42 ] report indicates a higher knowledge score among those completed higher education. Similarly, Simonetti et al. [ 25 ] nursing students’ year of education ( p = < 0.001) and the number of department frequented during their clinical placement ( p = 0.001) were significantly related to knowledge score.

Moreover, the current study also showed nurses’ sources of education about PU prevention and clinical nursing experience had no significant difference to PU knowledge score by nurses. Meanwhile, it determined nurses who read articles about PU and receive training about PU had higher knowledge score than those who did not read and attended training about PU. Meanwhile, Beeckman et al. [ 39 ] explained nurses who attended additional training displayed higher knowledge scores than nurses who did not attend any additional training ( p = .002). Hulsenboom et al. [ 38 ] addressed nurses’ work experience, and educational level displayed higher knowledge score; Liz et al. [ 40 ] evaluated nurses with longer employment duration, previous training experience and who work in tertiary hospitals or critical care had higher knowledge score. A survey of Turkish nurses stated higher knowledge sore among nurses who read articles/books about PUs ( P = .002), and who had attended at lecture/conference/course on PUs in the past [ 28 ]. Tiragari et al. [ 27 ] in opposition to the current study result reported a significant difference between previous exposures to PU education.

Failing to practice prevention is not restricted to inadequate knowledge. Study finding also suggested that the common barriers such as shortage of pressure relieving devices (117, 55.25%), lack of staff/heavy workload (116, 54.7%), lack of training (110, 51.9%) and lack of multidisciplinary initiative (101, 47.6%). Shortage of pressure relieving devices are the most frequently cited perceived barriers for nurses to practice PU prevention in this study. From our experience, our country, Ethiopia, is a developing country, and medical equipment supplied for health institutions are insufficient. Requesting and using appropriate equipment, using turning charts or upgrading mattress can all be put in place as preventive measures [ 6 ].

The second nurses’ perceived barrier to carrying out PU prevention identified in this study is lack of staff/heavy workload. The time nurses and healthcare assistant spent on patient care accounts for the highest cost of PU treatment [ 21 ]. Qaddumi and Khawaldeh [ 26 ], recommended nurses give priority to other illness rather than PU prevention care and complain PU care as an interdisciplinary problem when staff shortages with the stress happened. In our country, Ethiopia, due to low economy the number of nurses employed in hospitals are less than required number. This cause nurses not to spend plenty of at bedside. To the authors’ knowledge, there is no fixed rule for the patient to nurse ratio in the study area.

Lack of training also mentioned among the ordinary nurses’ perceived barriers. Regular training courses and review of PI prevention guidelines can be useful in updating the knowledge of nurses on pressure injury prevention [ 43 ]. Furthermore, Keast et al. [ 44 ] recommended educational programs for the prevention of PUs should be structured, organized, and comprehensive and should be updated on a regular basis to incorporate new evidence and technologies. In our country, Ethiopia, PU there is no programmed training and formulated guideline about PU prevention.

Saleh et al. [ 45 ] stated “PU education program as a powerful tool for nurses to improve understanding of PU, keep abreast of current knowledge on PU, and eliminate patient’s suffering”. Feng et al. [ 46 ] suggested that an education programme for PU prevention not only show an increase in staff knowledge also it leads to a significant decrease in incidents of PUs. Lack of multidisciplinary initiative is another nurses’ obstacle to put into practice PU prevention. PU prevention needs multidisciplinary efforts and teamwork to contribute to successful care [ 26 ]. PU prevention practice is not only the nurses’ responsibility though it is an integral part of intensive care nursing [ 47 ].

Limitations

The study presents some limitations that need to be considered. Randomly selected participants may have been less motivated to complete the knowledge questionnaire, and the results might be too poor. Pretest was not conducted given the importance to use validate instruments. In addition, though nurses were informed not to exchange ideas and answers, diffuse information with each other and not to refer textbooks when completing the questionnaire, we have no guarantee if they complied with this instruction. However, we believed that the result of this study could be generalizable to all nurses working in the public hospitals in Wollega since the similar type of nursing education they receive and PU prevention points they practice.

This study demonstrates that majority of the nurses have insufficient knowledge to practice pressure ulcer prevention. Nurses who read articles reading articles and attended training in the showed a significant difference to PU knowledge score. Shortage of pressure relieving devices, lack of staff/heavy workload and inadequate training were the most frequently cited nurses’ barriers to practice PU prevention. Providing opportunity to access resources (readable about and pressure reliving devices to) PU prevention, in-service training/regular training, incorporating and prioritizing in nursing curriculum, and formulating guidelines are some of the primary points to enhance nurses’ knowledge about pressure ulcer prevention. Further research on using observational studies is needed to determine the actual rather than the perceived practice to PU prevention.

Abbreviations

Intensive Care Unit

Pressure Ulcer

Pressure Knowledge Test

Standard Deviation

Statistical Package for Social Sciences

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Acknowledgments

Our sincere gratitude goes to Wollega University, Institute of Health Science, for financial support. We would also like to extend our thanks to the data collectors, participants, hospitals directors, matrons, and head nurses for their support and cooperation.

The source of funding to carry out for this research was Wollega University. The funding organization has no role in the design of the study, collection, analysis, and interpretation of data and in writing the manuscript this was the role of authors.

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The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

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WE committed to the drafting of proposal, design, analysis, and interpretation of the data, and manuscript preparation. GF contributed to data collection, analysis, interpretation and drafted manuscript. DA engaged in data collection and analysis of data. WE declared authors were notified and permitted to proceed to publish the work. All authors read and approved the final manuscript. WE agree to hold accountable for all aspects of the work hence any questions related to the accuracy or integrity of the work should be directed to WE. The authors declare that this manuscript has not been presented to any other journal for publication. All authors read and approved the final manuscript.

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Ethical clearance was granted from Wollega University, Institute of Health Science, Department of Nursing Research Review Ethical Committee approved on 11/06/2018. Permission was obtained from each hospital administrative to conduct the study. All nurses were informed that their participation was voluntary and the procedure used did not pose any potential risk and their identities will be kept strictly confidential. Informed written consent forms were taken from all participants before participation.

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Ebi, W.E., Hirko, G.F. & Mijena, D.A. Nurses’ knowledge to pressure ulcer prevention in public hospitals in Wollega: a cross-sectional study design. BMC Nurs 18 , 20 (2019). https://doi.org/10.1186/s12912-019-0346-y

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Received : 03 January 2019

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DOI : https://doi.org/10.1186/s12912-019-0346-y

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GENERAL PURPOSE

To provide information on the effectiveness of active and reactive support surfaces in reducing the incidence and prevalence of pressure injuries (PIs) in adult ICU patients.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will: 1. Distinguish features of active and reactive support surfaces used in the ICU.2. Compare the PI incidence in patients using a variety of support surfaces.3. Synthesize recommendations for the use of support surfaces to reduce the risk of PI in adult ICU patients.

OBJECTIVE

To identify and analyze scientific evidence on the effectiveness of active and reactive support surfaces in reducing the incidence and prevalence of pressure injury (PI) in adult ICU patients.

DATA SOURCES

PubMed, ProQuest, ScienceDirect, Wiley Online Library, ClinicalKey for Nursing, Cochrane Library, and secondary searches.

STUDY SELECTION

Studies were included if they related to support surfaces, involved adult ICU patients aged ≥18 years, and the primary outcome measured was incidence or prevalence of PI. The initial search resulted in 8,357 articles; after exclusions, 31 complete texts were assessed for feasibility. A total of eight articles were included in this review. A bias risk assessment was performed using the Cochrane Risk of Bias Assessment Tool.

DATA EXTRACTION

Data were extracted by one reviewer and summarized in a table of study results that was examined and verified by two other reviewers.

DATA SYNTHESIS

Reactive (constant low pressure) support surfaces included viscoelastic foam mattresses, static air mattresses, and low-air-loss mattresses, whereas the active support surface consisted of alternating-pressure air mattresses. Alternating pressure mattress and viscoelastic foam mattress use both resulted in significantly lower PI incidence.

CONCLUSION

Support surface use is limited, and no particular type is proven to be superior to others. Clinicians should select support surfaces based on their therapeutic features and how well they meet the patient’s particular needs.

ICU; incidence; pressure injury; prevalence; prevention; support surface

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Quantitative Pressure Measurement in Areas at High Risk of Pressure Ulcers in Different Positions: Pilot Study

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First Online: 22 September 2023
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Junhee Lee 12 , 13 &
Joon Shik Yoon 13 , 14

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This study aimed to quantitatively analyze pressure parameters in different high-risk areas depending on the position. We reviewed the clinical records of trials of 20 healthy adults on a multi-actuated bed accompanied with pressure sensor mat. We collected average, maximal, minimal pressure, and area in the supine and bilateral side-tilt positions. Also, we analyzed the difference between each at-risk area, depending on positions. In the supine position, pressure parameters of the head, shoulders, sacrum, coccyx, and heels showed significant differences, except between the right and left heels. In the right side-tilt position, all pressure measurements of the ear, shoulder, elbow, hip, knee, and lateral ankle were significantly different. In the left side-tilt position, most of the pressure parameters of the ear, shoulder, elbow, hip, knee, and lateral ankle were significantly different, except between the elbow and ankle. We found that frequent position changing is more important than achieving optimum positioning.

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Biomechanical Changes on the Typical Sites of Pressure Ulcers in the Process of Turning Over from Supine Position: Theoretical Analysis, Simulation, and Experiment

Support pressure distribution for positioning in neutral versus conventional positioning in the prevention of decubitus ulcers: a pilot study in healthy participants.

Pressure Ulcer Prevention System Based in Capacitive Sensors

Patient care
Patient positioning
Pressure ulcer

1 Introduction

Pressure ulcers are skin and/or underlying tissue lesions caused by the limitation of blood circulation owing to the combination of increased pressure, friction, and sheer force on specific parts of the body [ 1 , 2 ]. These pressure injuries are closely related to loss of quality of life, impairment in mobility, and increased mortality, both directly and indirectly [ 3 ].

Repositioning patients every 2 h (q2hr) to prevent continuous high pressure on a specific body part is the mainstream of pressure sore care, and it has been considered a guideline for general patient care [ 4 , 5 ]. However, previous studies have shown that standard turning does not sufficiently relieve the high skin-bed pressure on peri-sacral areas, such as the sacrum, coccyx, and ischial tuberosity, even in non-disabled adult subjects. This may explain why pressure ulcers still develop despite preventive methods, including regular patient repositioning [ 6 ]. In addition, recording repositioning has not been standardized or automated, and remains manual. This causes a lack of optimal repositioning and incomplete documentation of a patient’s position.

Several studies have focused on a preventive solution for pressure ulcers with real-time position monitoring systems. In particular, devices that use sensors to detect pressure are considered to be one of the most effective methods because they minimize care-giver's effort [ 7 ]. It is also important because there has been issues about the pressure monitoring while sleeping. Furthermore, these devices used to modify care plans while preventing the development of pressure ulcers [ 8 ]. Comprehensive understanding of the monitoring information gathered from devices is necessary to increase optimal patient repositioning by clinical staff. An integrated analysis is needed between pressure monitoring information and known positions to prevent pressure ulcers.

There is a lack of research evaluating pressure measurements in various positions considering the risk areas of each position. This study aimed to clarify the key clinical implications for preventing pressure ulcers by quantitatively analyzing acquired pressure parameters in high-risk areas depending on position.

2 Materials and Methods

2.1 study design.

In this study, we retrospectively analyzed the clinical records of trials conducted on a multi-actuated bed with an applied pressure sensor. From August to September 2022, the clinical records of 20 healthy individuals were obtained. The inclusion criteria were: 1) over 18 years of age, 2) no underlying disease, and 3) no limitations on activity. The reviewed data were recorded in a structured form. Additionally, we collected demographic data such as age, gender, height, weight, and body mass index (BMI).

This study was approved by the Institutional Review Board of Korea University Guro Hospital (2022GR0463).

2.2 Pressure Sensing with Multi-actuated Bed

A calibrated XSENSOR IX500:256.256.22 (XSENSOR Technology Corporation, Calgary, Canada) pressure mapping system with X3 software (v8) was used. XSENSOR is considered the gold standard for pressure mapping and has been used in several studies [ 5 , 9 , 10 ]. The XSENSOR mat consists of 65,536 sensing points, has a total area of 63.5 cm × 53.3 cm and a sensing area of 29.5 cm × 29.5 cm. The manufacturer’s specifications state that the pressure mat showed high durability in subsurface testing, an accuracy rate of ±10% of the calibrated values, a sampling frame rate of 6.2 frames per second, and a spatial resolution of 1.15 mm. The device was calibrated to measure pressure from 0 to 200 mmHg. IP readings were transferred from the XSENSOR mat to a handheld monitor.

A modern automatic bed setting (Jeong In ENS Corporation, Republic of Korea) was used in conjunction with the XSENSOR mat. Repositioning to the lateral tilt (i.e., turning) position and supine position are the most routine methods for patients’ position change [ 11 ]. The multi-actuated bed supported three standard positions for the prevention of pressure ulcers: right-side tilt, 30°; left-side tilt, 30°; and supine [ 12 ].

Illustration of three different position with measurement. (a) is side-tilt 30° position, (b) is supine position and (c) is example of pressure sensing measurements.

In particular, the side-tilt and supine positions have different high-risk areas for the development of pressure ulcers. In the supine position, pressure ulcers frequently occur at the head (occiput), bilateral shoulders (scapula), sacrum, coccyx, and bilateral heels. In the lateral tilt position, pressure ulcers easily develop in the ear, shoulder (upper humerus), elbow outer side (lateral epicondyle), hip (greater trochanter), knee outer side (fibular head), and lateral ankle outer side (lateral malleolus). [ 13 , 14 ] We considered these differences regarding positioning on the evaluations and selected the most highly recorded areas in each risk area.

The sensor mat was placed above the bed, and the pressure was continuously monitored for 10 min in three positions. In total, 30 min was needed for each evaluation [ 5 ]. Recorded data included average pressure (N/cm2), peak pressure (N/cm2), minimal pressure (N/cm2), and area (cm2). The settings are illustrated in Fig. 1 .

2.3 Statistical Analysis

Using the Wilcoxon signed-rank test, the quantitative difference between pressure parameters depending on the risk areas of each position was analyzed. For the descriptive analysis, the median and inter-quarter range of measurements were suggested for metric evaluations. SPSS version 26.0 software (SPSS Inc., Chicago, IL, USA) was used for all analyses, with the statistical significance level set at p < 0.05.

Ten patients were male and 10 were female. The median age of participants was 28 years (25.25–31.5); median height was 167.0 cm (162.0–172.75); median weight was 63.5 kg (50.25–70.0); and median BMI was 21.12 kg/m 2 (18.75–23.87).

3.1 Pressure Measurements at Risk Area of Supine Position

The pressure parameters in the supine position in high-risk areas are listed in Table 1 . All four pressure measurements of the head and bilateral shoulders, right heel; coccyx and left heel, right heel were different. Pressure measurements of the head and left heel were different, except for average pressure. The pressure measurements of the sacrum and right heel were different, except for maximal pressure. Pressure measurements of the left shoulder and left heel; right shoulder and left heel; sacrum and left heel were different, except for minimal pressure. Pressure measurements of the left shoulder and sacrum, coccyx; right shoulder and sacrum, coccyx; sacrum and coccyx were different, except in the area. The average and minimal pressures of the left and right shoulders were different. The maximal pressure and areas of the head and coccyx; left shoulder and right heel were different. The areas of the right shoulder and right heels were different. There was no statistically significant differences between the right and left heels.

3.2 Pressure Measurements at Risk Area of Right Side-Tilt Position

The pressure measurements in the side-tilt position to the right in the high-risk areas are presented in Table 2 . All four pressure measurements of the ear and shoulder, elbow, knee, ankle; shoulder and knee, ankle; elbow and hip; hip and knee, ankle were different. The pressure measurements of the ear and hip were different, except for maximal pressure. The pressure measurements of the shoulder and elbow were different, except for minimal pressure. The pressure measurements of the shoulder and hip were different, except for the area. The minimal pressures and areas of the knee and ankle were different. The minimal pressures at the elbow and ankle were different. The elbow and knee areas were different.

3.3 Pressure Measurements at Risk Area of Left Side-Tilt Position

The pressure measurements in the side-tilt position to the left in high-risk areas are also presented in Table 2 . All four pressure measurements of the shoulder and knee; elbow and hip; hip and knee, ankle were different. The pressure measurements of the ear and hip were different, except for maximal pressure. The pressure measurements of the ear and shoulder, elbow, knee, ankle; shoulder and elbow; knee and ankle were different, except for minimal pressure. Pressure measurements of the shoulder and hip were different, except for the area. The maximal pressure and area of the shoulder and ankle were different. The elbow and knee areas were different. There was no statistically difference between the elbow and the ankle.

3.4 Pressure Change Depending on Position

To detect the pressure change depending on positions, we compared the areas with anatomical rotation. We matched the followings: head (occiput) on supine position and bilateral ears on side-tilt position, bilateral shoulder on supine position and bilateral shoulders on side-tilt position, sacrum on supine position and bilateral hip on side-tilt position, bilateral heel on supine position and bilateral lateral ankle on side-tilt position.

Compared to the pressure on head (occiput) in supine position, average pressure was stationary on right ear and decreased on left ear. Also, maximal and minimal pressure were decreased on right ear and increased on left ear, respectively. In comparison of the pressure on bilateral shoulder in supine position and side-tilt position, average and maximal pressure were increased on right side-tilt shoulder; and minimal pressure was decreased on right side-tilt shoulder. In addition, maximal pressure was increased on left side-tilt shoulder; average pressure and minimal pressure were decreased on left side-tilt shoulder. Compared to the pressure on sacrum in supine position, all pressure parameters were increased on right hip. Also, average and minimal pressure were increased and maximal pressure was decreased on left hip. In comparison between the pressure on bilateral heal in supine position and bilateral lateral ankle in side-tilt position, all pressure parameters were decreased on bilateral side-tilt positions.

4 Discussion

Position change for reducing pressure and preventing ulcers have been the standard methods of patient care [ 1 , 12 , 15 , 16 ]. However, studies showed failure in reducing the incidence of pressure ulcers [ 15 , 18 , 19 , 20 ]. Although maintaining the skin contact pressure below 32 mmHg is expected to decrease the possibility of developing pressure ulcers, the effectiveness of repositioning patients for pressure sore prevention remains unclear [ 6 ].

Previous studies conducted with non-disabled population and pressure mapping system [ 5 , 6 ]. They emphasized the high-risk of pressure area as peri-sacral area and greater trochanters. Our research was the first study which quantitively tracked the pressure parameters with position change and describe the clear pressure difference between each high-risk pressure ulcer areas. Furthermore, we clarified the importance of frequent position change in patient care for preventing pressure ulcers.

Depending on the position, various findings were observed with quantitative measurements. In the supine position, the average, maximal, and minimal pressure measurements were higher on the head, sacrum, and coccyx than on the shoulder and heel. This might be due to the bilateral distribution of body weight in the shoulder and heel. In the right and left side-tilt positions, we compared the right side and the left side of the body, respectively. The average, maximal, and minimal pressure measurements were higher on the bilateral ear than on the bilateral shoulder and elbow on the upper side of the body. In addition, these three pressure parameters appeared to be higher on the bilateral hip than on the bilateral knee and lateral ankle on the lower side of the body.

Although there were minor differences in the composition of pressure measurements with statistical significance, we clarified the clear differences between pressure values in each risk area. In the supine position, most pressure parameters of the head, shoulder, sacrum, coccyx, and both heels showed significant differences, except between the right and left heels. In addition, in the right side-tilt position, all pressure measurements of the ear, shoulder, elbow, hip, knee, and lateral ankle were significantly different. In the left side-tilt position, most of the pressure parameters of the ear, shoulder, elbow, hip, knee, and lateral ankle were significantly different, except between the elbow and ankle. The difference between right-side tilt and left-side tilt might be explained by the small amount of recruited data, and it would be expected to be covered by larger scale analysis.

In comparing descriptive measurements with positional rotation, the changes in pressure parameters at each high-risk area did not show a consistent pattern. This result suggest that it is more important to change the posture frequently than to make an ideal posture in patient care for preventing pressure ulcers.

This study has some limitations. First, the pressure measurement by the sensor did not directly express the exact pressure loading on the tissue [ 20 ]. However, pressure sensor tracking remains one of the most popular methods for pressure monitoring. The clear presentation of pressure change in real time reflects a good representation of the pressure on the surface of the skin. Therefore, it allows us to intuitively recognize the increasing and decreasing pressures. Second, we only used the measured records of participants with a single brand of modern ward bed and sensor monitoring interface. However, we expected that the results would be similar, regardless of the type of hardware system. The pressure measurements at various positions are expected to be different for different beds/sensor mats; however, there is no doubt that the general trends should be reflected in the results. Finally, we studied the data of healthy adults, but not of patients. In patients with a high risk of developing pressure ulcers, the condition of the soft tissue in the affected area is clearly different from that of the general population. Therefore, there are many variables to consider regarding the risk factors for pressure ulcers, such as nutritional status, capillary blood flow, friction force and shear force. In this point of view, we considered that healthy participants were more likely to show a clear tendency of pressure measurements in each high-risk area at different positions and positional change. Further study of patients with classified impairments is necessary, because these results with normal population may appear differently depending on the patient’s variables.

5 Conclusion

This study quantitatively examined pressure distribution depending on position and found that the risk areas for pressure ulcers in different positions have different pressure distributions in a healthy population. These findings suggest clinical implications for positioning depending on patient impairment. Further studies with a larger patient population are needed to evaluate the actual risk of developing pressure ulcers in patients and to establish positioning methods to achieve optimum status to decrease pressure ulcer risk.

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Acknowledgments

This research was funded by the Translational Research Program for Care Robots funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HK20C0018).

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Junhee Lee & Joon Shik Yoon

Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea

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Bessam Abdulrazak

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Lee, J., Yoon, J.S. (2023). Quantitative Pressure Measurement in Areas at High Risk of Pressure Ulcers in Different Positions: Pilot Study. In: Jongbae, K., Mokhtari, M., Aloulou, H., Abdulrazak, B., Seungbok, L. (eds) Digital Health Transformation, Smart Ageing, and Managing Disability. ICOST 2023. Lecture Notes in Computer Science, vol 14237. Springer, Cham. https://doi.org/10.1007/978-3-031-43950-6_19

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Int J Prev Med

The Incidence of Pressure Ulcers and its Associations in Different Wards of the Hospital: A Systematic Review and Meta-Analysis

Lotfolah afzali borojeny.

Department of Plastic Surgery, Shahrekord University of Medical Sciences, Shahrekord, Iran

Ahmed N. Albatineh

1 Department of Community Medicine and Behavioral Sciences, Faculty of Medicine, Kuwait University, Kuwait

Ali Hasanpour Dehkordi

2 Social Determinants of Health Research Center, School of Allied Medical Sciences, Shahrekord University of Medical Sciences, Shahrekord, Iran

Reza Ghanei Gheshlagh

3 Spiritual Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran

Pressure ulcer is a health problem worldwide that is common among inpatients and elderly people with physical-motor limitations. To deliver nursing care and prevent the development of pressure ulcers, it is essential to identify the factors that affect it. This global systematic review and meta-analysis was conducted with the aim of evaluating the incidence of pressure ulcers in observational studies. In this study, databases including Web of Science, Embase, PubMed, Scopus, and Google Scholar were searched to collect data. Articles published from 1997 to 2017 about the factors influencing the incidence of pressure ulcers were retrieved and their results were analyzed using meta-analysis according to the Random-Effects Model. The heterogeneity of studies was investigated using the I 2 statistic. Data were analyzed using the R and Stata software (version 14). In this study, 35 studies were included in the final analysis. The results showed that the pooled estimate of the incidence rate of pressure ulcer was 12% (95% CI: 10–14). The incidence rates of the pressure ulcers of the first, second, third, and fourth stages were 45% (95% CI: 34–56), 45% (95% CI: 34–56), 4% (95% CI: 3–5), and 4% (95% CI: 2–6), respectively. The highest incidence of pressure ulcers was observed among inpatients in orthopedic surgery ward (18.5%) (95% CI: 11.5–25). According to the final results, better conditions should be provided to decrease the incidence of pressure ulcers in different wards, especially orthopedics, and in patients with diabetes.

Introduction

Pressure Ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.[ 1 ] Nowadays, pressure ulcers are the third most costly disease after cancers and cardiovascular diseases. The mortality rates from this disease are 2 to 6 times as much as from other diseases, with 60,000 deaths annually due to this complication.[ 2 ] Pressure ulcer occurs more frequently in the tissues of the extremities of the body and in bony extensions such as sacrum and heel in inpatients. The most important risk factors for pressure ulcers are low physical activity, decreased consciousness, urinary and fecal incontinence, malnutrition, and advanced age.[ 3 ]

It is estimated that about 2.5 million hospitalizations in the United States are due to pressure ulcers.[ 4 ] The pressure ulcers have different classifications one of which has been proposed by the National Council/HSE Wound Conference Oral presentation according to which ulcers are classified into three categories, the most common type of which is the type one with the prevalence rate of approximately 44%. In fact, pressure ulcer is one of the problems that are still underestimated despite advances in medicine. The first step to prevent an increase in the incidence of pressure ulcers is the identification of its risk factors, although there is currently no consensus on its risk factors.[ 5 ] Pressure ulcer is a major concern for patients and healthcare staff, and understanding the disease process and prophylactic methods is so important that counseling and prevention systems for it have been developed in the USA and Europe.[ 6 ]

The pressure ulcer is associated with pain, patient's reduced autonomy, increased risk of infection and sepsis, the conduction of additional surgical procedures on the patient, long periods of hospital stay, and the imposition of more costs on the patient, his/her family, and health care system.[ 7 , 8 , 9 ] Patients with pressure ulcers have significant physical-social and self-care dysfunction and may experience certain complications such as depression, pain, topical infection, osteomyelitis, sepsis, and even death.[ 10 , 11 ]

The incidence of pressure ulcer is different in the clinical setting, but its incidence rate ranges from 4% to 38% in hospitalization wards and the mortality rate due to pressure ulcers and its associated secondary complications among the elderly is approximately 68%.[ 12 ] A study in an elderly care home in Hapan showed that more than 91% of the total study population had pressure ulcer at various intensities.[ 5 ] In the USA, about $11 billion is spent annually by the healthcare system for the prevention and treatment of pressure ulcers. In the UK, 4% of the total treatment costs are allocated for the treatment of pressure ulcers. In addition to the extra costs spent on the treatment of the pressure ulcers, there is bed reservation and associated costs arising from hospitalization. These ulcers also cause the nursing staff an increase in workload by 50%.[ 6 ] The assumption that external pressure is the only cause of pressure ulcers has led to ignoring other pathogenic causes of pressure ulcers, which usually lead to failure of the prevention and treatment process. Therefore, identifying the causative agents and preventive measures may lead to implementing more effective interventions.[ 13 ] In order to deliver better nursing care and to reduce the incidence of pressure ulcers, it is important to study its incidence rate and the factors influencing it in different wards, as well as to identify the factors that cause early diagnosis and prevention of the complication.[ 14 ]

Various studies around the world to investigate the incidence of pressure ulcer have had different results. Understanding the current situation is the first step in planning to reduce the incidence of pressure ulcer and control this problem. Therefore, the aim of this systematic review and meta-analysis is to estimate the incidence of each stage of pressure ulcers and highlight the factors involved in its incidence in different wards of a hospital setting.

Materials and Methods

In this systematic review and meta-analysis, the incidence of pressure ulcer based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was assessed.[ 15 ]

Search strategy

In this study, Web of Science, Embase, PubMed, Scopus, and Google Scholar were searched to collect relevant articles. Relevant articles were retrieved according to a systematic search protocol and using search terms, such as pressure ulcers, decubitus ulcer, pressure injury, pressure sore, bedsore, incidence, and as well as all possible combinations. The main outcome of this study is the reported incidence of pressure ulcer. Accordingly, 111 articles were investigated. Irrelevant and duplicate studies were excluded from the analysis and the articles that were published in non-English languages were also excluded. To access more articles, searches were made as backward (i.e., reviewing the reference lists of eligible articles) and forwards (i.e. reviewing papers that were cited in eligible studies).

The search strategy for the Pabmed database was as follows: (((“pressure ulcer”[MeSH Terms] OR (“pressure”[All Fields] AND “ulcer”[All Fields]) OR “pressure ulcer”[All Fields] OR (“pressure”[All Fields] AND “ulcers”[All Fields]) OR “pressure ulcers”[All Fields]) AND tiab[All Fields]) OR ((”pressure ulcer”[MeSH Terms] OR (“pressure”[All Fields] AND “ulcer”[All Fields]) OR “pressure ulcer”[All Fields] OR (“decubitus”[All Fields] AND “ulcer”[All Fields]) OR “decubitus ulcer”[All Fields]) AND tiab[All Fields]) OR “pressure injury”[All Fields] OR ((”pressure ulcer”[MeSH Terms] OR (“pressure”[All Fields] AND “ulcer”[All Fields]) OR “pressure ulcer”[All Fields] OR (“pressure”[All Fields] AND “sore”[All Fields]) OR “pressure sore”[All Fields]) AND tiab[All Fields]) OR “bed sore”[All Fields]) AND (“epidemiology”[Subheading] OR “epidemiology”[All Fields] OR “incidence”[All Fields] OR “incidence”[MeSH Terms]).

Selection of studies and data extraction

At first, all articles in which the incidence of pressure ulcer was noted among were collected by two independent researchers. The inclusion criteria were: observational studies that reported a pressure ulcer, access to full text of articles, and publication of articles in English. To minimize the risk of bias assessment, searching for articles, selecting studies, evaluating the methodological quality of articles, and extracting data independently were done by two researchers, and any disagreement was resolved by discussion. Exclusion criteria included lack of addressing the risk factors for the incidence of pressure ulcers, being a duplicate, and review articles. A form was used to record the selected information, including the name of the first author, year of publication, geographical location of the study, ward, type of scale, sample size, and the mean age of patients. We assessed the methodological quality of articles based on the ten selected items of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist (title and abstract, goals and hypotheses, research environment, inclusion criteria, sample size, statistical methods, descriptive data, interpretation of findings, research limitation, and funding).[ 16 ]

Statistical analysis

The variance of each study was calculated using the binomial distribution formula and the weight for each study equals the reciprocal of the variance. We evaluated the heterogeneity between the studies by Q-Cochran test with a significant level less than 0.1 and I 2 index. The I 2 index of heterogeneity was classified into less than 25% (low heterogeneity), 25% to 75% (moderate heterogeneity), and more than 75% (high heterogeneity).[ 17 ] The incidence of pressure ulcers in different wards was investigated by using the subgroup analysis, and the results of the studies were combined using the random-effects meta-analysis. Meta-regression was used to investigate the relationship between the incidence of PU and year of publication and mean age of patients.

The funnel plot based on the Begg's regression test was used to determine the publication bias. Data analysis was performed using the Stata software (version 11.2) and R statistical software.

In the present study, 35 articles of adequate quality relevant to the incidence of pressure ulcers and the associated factors in different wards published from 1997 to 2017 were reviewed. The process of selecting and screening articles is presented in the following flowchart [ Figure 1 ].

An external file that holds a picture, illustration, etc.
Object name is IJPVM-11-171-g001.jpg

Screening flowchart showing the selection of qualified articles according to the PRISMA statement

A total of 37,971 patients, of which 53% were males and 47% females, were included in the studies and thus were included in the final analysis. The general information of the articles included in the current review is presented in Table 1 .

General information of reviewed articles

Author	Year	Place	Mean age±SD	Sample size	Incidence	Unit	Scale Type
Cox[ ]	2011	United States	69±17	347	18.7	ICU	Braden
Schindler .[ ]	2011	United States	-	5346	10.2	ICU	Braden
Boyle and Green[ ]	2001	Australia	57.5	534	5.2	ICU	Waterlow
Webster .[ ]	2010	Australia	65.3	274	4.4	ICU	Waterlow
Gunningberg .[ ]	2017	Sweden	81±8.5	190	1.3	Internal	Norton
Dhanda .[ ]	2015	India	-	228	16.39	Orthopedic	Braden
James .[ ]	2010	UK	80	581	13.9	Orthopedic	Braden
Mallah .[ ]	2015	United States	44.69±30.07	420	6.63	General	Braden
Palese .[ ]	2017	Italy	82.2	1464	8.5	Emergency	Braden
Sanada .[ ]	2007	Indonesia	50.9±17	105	33.3	ICU	Braden
Sanada .[ ]	2008	Japan	55.2±18.4	253	27	ICU	Suriadi and Sanada
Sayar .[ ]	2009	Turkey	55.7	140	14.3	ICU	Waterlow
Schoonhoven .[ ]	2002	Netherlands	-	208	21.2	ICU	Braden
Sebastián-Viana .[ ]	2016	Spain	60.4	9220	6	Surgical	modified Norton
Shahin .[ ]	2009	Germany	-	121	3.3	Nephrological ICU	Braden
Deng .[ ]	2017	China	57.81±16.72	468	20.1	ICU	Braden
Cremasco .[ ]	2013	Brazil	55.5±18.8	160	34.4	ICU	Braden
Fujii .[ ]	2010	Japan	32.5	81	16	ICU	Braden
GonzálezMéndez .[ ]	2017	Spain	59.76±14.3	335	8.1	ICU	Braden
Kaitani .[ ]	2010	Japan	62.3±16.1	98	11.2	ICU	Braden & Bergstrom
Lahmann .[ ]	2012	Germany	66.4±14.7	2237	14.9	nephrological ICU	Braden & Bergstrom
Ranzani .[ ]	2016	Brazil	-	9605	3.33	ICU	Charlson
Tsaras .[ ]	2016	Greece	58.9±18.8	210	2	ICU	Cubbin and Jackson
Nijs .[ ]	2009	Belgium	64	520	20.1	Nephrological ICU	Norton
Bååth .[ ]	2016	Sweden	86.3±7.2	183	14.6	ICU	Braden
Perneger .[ ]	2002	Switzerland	61.4±19.1	1190	14.3	General	Norton and Braden
Becker .[ ]	2017	Brazil	63.1±18.1	332	13.6	ICU	Braden
Webster .[ ]	2011	Australia	62.6±19.3	1231	6.8	Internal	Waterlow
Baumgarten .[ ]	2006	United States	-	201	6.2	Emergency	Braden
Manzano .[ ]	2010	Spain	60±17	299	16	Surgical	Braden
Olson .[ ]	1996	United States	63±16.6	38	2.6	Nephrology	Braden
Yatabe .[ ]	2013	Japan	85±7.6	422	7.1	ICU	Braden
Maida .[ ]	2008	Canada	724±13.2	415	22.4	Oncology	Braden
Hendrichova .[ ]	2008	Italy	74	414	6.7	Oncology	Karnofsky
Gunningberg .[ ]	2001	Sweden	84.4±7.2	101	29	Orthopedic	Braden

The results of this study showed that the overall incidence of pressure ulcer in different wards across the world is 12% (95% CI: 10–14). In Figure 2 , the incidence rates of pressure ulcers in different wards reported by various studies based on the Random-Effects Model are shown.

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The incidence rates of pressure ulcers in the hospital departments based on the Random-Effects Model; the midpoint of every segment indicates the estimate of the incidence; the length of the line represents 95% confidence interval in each study; and the diamond indicates the pooled estimate for incidence rate of pressure ulcers for all studies in the hospital departments from 1997 to 2017 across the world

The incidence rates of the pressure ulcers of the first, second, third, and fourth stages were 45% (95% CI: 34–56), 45% (95% CI: 34–56), 4% (95% CI: 3–5), and 4% (95% CI: 2–6), respectively [ Table 2 ].

Incidence rates of pressure ulcers of different stages

Pressure ulcer stage	Incidence rate(95% CI)
Stage I	45(95% CI: 34%-56%)
Stage II	45(95% CI: 34%-56%)
Stage III	4(95% CI: 3%-5%)
Stage IV	4(95% CI: 2%-6%)

The most commonly affected area was sacrum with a frequency of 44% (95% CI: 28–59), followed by buttocks with a frequency of 15% (95% CI: 10–20), heel with a frequency of 15% (95% CI: 12–18), and trochanter with a frequency of 4% (95% CI: 2–6). The prevalence of diabetes mellitus in patients developing pressure ulcer was 20% (95% CI: 10–31). The highest incidence of pressure ulcers was observed in patients in orthopedics wards (18.5%, 95% CI: 11.5–25) and the least was in nephrology wards (2.6%, 95% CI: 2.5–7.7) [ Table 3 ]. Meta-regression results showed that there is no relationship between the incidence of pressure ulcers and the age of patients and the year of publication ( P > 0.05).

Incidence rates of pressure ulcers in different hospital departments

Unit name	Numbers of studies	Pressure ulcer incidence
ICU	18	13.7%(95% CI: 10.9-16.5)
Internal	2	4.1%(95% CI: 1.3-9.5)
Orthopedic	3	18.5%(95% CI: 11.5-25)
General	2	10.5%(95% CI: 3-18)
Surgical	2	10.8%(95% CI: 10-20.6)
Nephrological ICU	3	12.8%(95% CI: 4.6-20.9)
Nephrology	1	2.6%(95% CI: 2.5-7.7)
Emergency Department	2	6.2%(95% CI: 2.9-9.5)
Oncology	2	14.5%(95% CI: 9-29.8)

The publication bias was not significant ( P = 0.08; Figure 3 ).

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Object name is IJPVM-11-171-g003.jpg

Begg's Funnel plot for evaluation of publication bias

The results of this systematic review and meta-analysis show that the overall incidence of pressure ulcers in inpatients is 12% worldwide. Most studies in this field have been conducted in European countries. In a study that was conducted in three countries, the Netherlands, Germany, and Italy, including 177 hospitals, 11.1% of inpatients were reported to have pressure ulcer, which is consistent with our findings.[ 50 ] Meanwhile, extensive studies in the United States have estimated the frequency of pressure ulcers to be between 8% and 40%.[ 35 ] In terms of the stage of ulcers, the results of the present study also indicated that most of the ulcers were of first and second stages, which is in agreement with other studies which have shown that the majority of the samples suffered from first and second stage ulcers.[ 51 ] The results of this study showed that the most commonly affected area by pressure ulcer is sacrum, followed by buttocks, heels, and trochanters. Given the fact that the amount of pressure exerted on the ulcer is very effective, studies have shown that, depending on the patient's sleeping position or the use of wheelchairs, pressure ulcers can be developed at certain points, so that in patients laying on the back or sitting on a wheelchair, the possibility of development of ulcers is higher in the hips, sacrum, and heels than in other areas.[ 14 ] Regarding diabetes, the data show that the incidence of pressure ulcers in diabetic patients is almost twice as much as that in patients without diabetes mellitus, which indicates a direct correlation between diabetes and incidence of pressure ulcer. The previous studies also confirm this finding so that according to the results of Pokorny et al . (2003), diabetes mellitus, along with certain factors such as obesity and high blood pressure, is among the most common risk factors for incidence of pressure ulcers.[ 52 ] The results of Liu et al . (2012) study also show that diabetic patients are five times more likely to develop pressure ulcers than healthy individuals.[ 53 ]

In addition, decreased blood flow in these patients is effective in increasing the incidence of pressure ulcers due to the formation of athermanous plaques.[ 54 ] Our findings among inpatients in different wards have shown that the highest frequency of pressure ulcers is observed among inpatients in orthopedics wards, followed by those in oncology wards and ICUs, and the least frequency of incidence is observed in nephrology wards. Given that previous studies have shown that lack of movement is one of the main risk factors for the development of pressure ulcers, it seems that patients in the orthopedic wards who are comparatively less able to move are more likely to develop pressure ulcers.[ 55 ] In a study conducted on orthopedic patients, the results showed that 16% of patients with hip fractures also developed pressure ulcer.[ 56 ] With regards to inpatients in the oncology ward, because the majority of patients admitted to this department are in the final stages of the disease and have clinically inappropriate conditions, they have the most risk factors for pressure ulcer.[ 48 ] The use of opioid drugs is higher in hospitalized cancer patients, which can be effective in reducing their movement and increasing the likelihood of developing pressure ulcers.[ 48 ] ICU patients are also more likely to develop pressure ulcer due to lack of movement and prolonged hospital stay, so there is a direct correlation between the duration of hospital stay and the incidence of pressure ulcers.[ 32 , 36 ] Other factors contributing to the development of pressure ulcers in ICU patients include dehydration and increased body temperature.[ 57 ]

In this study, the least frequency of pressure ulcers was observed among inpatients in nephrology wards. Future studies are recommended to simultaneously address risk factors such as age, weight, and anemia along with the data obtained in this study, and also to closely examine underlying illnesses of people with pressure ulcer to obtain better results. Since pressure ulcers may lead to death, prolongation of treatment, increase in treatment costs and in general, irreparable complications for the patient and the family, the study of their incidence rate, causative factors, and prevention along with efficient training of workforce should be incorporated into the priorities of health care systems across the globe.

Limitations of the study

Lack of access to the full text of some articles and lack of reporting the necessary information in some other articles were the main limitations of this study.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

COMMENTS

Quality of life of patients with pressure ulcers: a systematic review
Introduction. A pressure ulcer (PU) is an injury on the surface of the skin or the underlying tissue, usually over a bone prominence caused by prolonged pressure or shearing [].PUs can occur on the areas of the coccyx, the heels, the foot, the hips, the shoulders, the knees, the ankles, the elbows, and the ear flaps [2,3].PUs are caused by three factors a) prolonged pressure over bone ...
Nursing care for older patients with pressure ulcers: A qualitative
The main strength of this study is the use of a validated and scientifically robust qualitative method to explore nursing care for patients with pressure ulcers in a geriatric ward. This could not have been achieved using a quantitative study. A limitation is the relative small number of interviewed participants.
Effectiveness on hospital‐acquired pressure ulcers prevention: a
1. INTRODUCTION. Despite all advances in health care, pressure ulcers (PUs) remain an old worldwide public health problem related to patient safety. 1, 2, 3 Hospital‐acquired PUs are one of the most harmful events in the clinical context. 1, 2 PUs, recently known as pressure injuries, 4, 5, 6 are defined as skin injuries and/or underlying tissue damage localised over a bony prominence ...
Interventions for pressure ulcers: a summary of evidence for ...
A quantitative, pooled analysis and systematic review of controlled trials on the impact of electrical stimulation settings and placement on pressure ulcer healing rates in persons with spinal ...
Effects of implementing Pressure Ulcer Prevention Practice Guidelines
Methods and analysis A systematic review of all studies that have assessed the use of pressure ulcer prevention strategies in hospital settings among hospitalised elderly patients shall be conducted. A comprehensive search of all published articles in Medline Ovid, Cumulative Index to Nursing and Allied Health Literature, PubMed, Embase, Cochrane library, Scopus and Web of Science will be done ...
Quality of life of patients with pressure ulcers: a systematic review
Aim: The aim of this systematic review was to investigate the impact of pressure ulcers on the patients' quality of life involving mental/emotional, spiritual, physical, social, cognitive dimensions, and pain. Methods: A systematic literature search of published articles in the English language during the past 15 years was conducted.
PDF Interventions for pressure ulcers: a summary of evidence for ...
critically appraise all the relevant research. Within a PU - pressure ulcer; *One 'empty' review was of wound-care teams for both prevenng and treang pressure ulcers (Moore et al. 2 015).
Pressure Ulcer Trends in the United States: A Cross-Sectional
Research article. First published online February 24, 2023. ... One investigation found no decrease in hospital-acquired pressure ulcers after the 2008 payment change. 13 Other work has supported this conclusion, and suggested that pressure injury rates have plateaued from 2015-2019. 14 In contrast, ...
Complications and psychological impact of pressure ulcers on patients
By incorporating both quantitative and qualitative data, a comprehensive understanding of the psychological consequences of pressure ulcers was achieved to create focused interventions that assist both patients and caregivers during this challenging period. ... This finding is consistent with research, suggesting that pressure ulcers are more ...
Pressure ulcer prevention knowledge, practices, and their associated
A pressure ulcer is a localized skin injury and underlying tissue, usually as a result of friction or pressure against the surface of the skin. ... Research article. First published online June 20, 2022. Pressure ulcer prevention knowledge, practices, and their associated factors among nurses in Gurage Zone Hospitals, South Ethiopia, 2021.
Review of the Current Management of Pressure Ulcers
The pressure ulcer scale for healing (PUSH tool) is a commonly used tool developed by the NPUAP, which grades pressure ulcers based on size of wound, wound bed tissue type, and exudate amount (Table 3). 30 Another commonly used scale is the Bates-Jensen wound assessment tool which scores wounds based on size, depth, wound edges, tissue ...
Preventing pressure ulcers in nursing homes using a care ...
We conducted a mixed methods feasibility study of the use of this care bundle in one nursing home in the North of England using an uncontrolled, before-and-after study design. We collected quantitative data on pressure ulcer prevention behaviours of the nursing home staff and pressure ulcer incidence rates for 5 weeks prior to implementing the ...
Effectiveness of Pressure Ulcer Prevention Strategies for Adult ...
research, meta-analysis/data pooling, nursing practice ABSTRACT Background: Pressure ulcers are associated with substantial health burden, but could be pre-ventable. Hospital-acquired pressure ulcers (HAPUs) prevention has become a priority for all healthcare settings, as it is considered a sign of quality of care providing. Intensive care unit
Pressure ulcers: Prevention and management
Prevention has been a primary goal of pressure ulcer research. Despite such efforts, pressure ulcers remain common in hospitals and in the community. Moreover, pressure ulcers often become chronic wounds that are difficult to treat and that tend to recur after healing. Especially given these challenges, dermatologists should have the knowledge ...
Nurses' knowledge to pressure ulcer prevention in public hospitals in
Pressure ulcers (PUs) prevention remains a significant challenge for nurses [1, 2], and its incidence is considered an indicator of poor quality of care [3,4,5].Patients and families know that pressure ulcers are painful and slow to heal [].Some risk factors for the development of pressure ulcers/injuries include advanced age, immobility, incontinence, inadequate nutrition and hydration, neuro ...
Pressure Ulcers: Developing Clinical Indicators in Evidence-based
The mean age and the length stay of the study subjects was 58.9 ± 18.8 and 12.0 ± 17.6, respectively. The prevalence of pressure ulcers was 24.3%, representing 2524 days of hospitalization were allocated (patient-days). The incidence rate (IR) of pressure ulcers was 2 cases per 100 patient-days IR=0.02; (95% CI: 0.015-0.026) [data not shown].
Pressure ulcers: Prevention and management
Prevention has been a primary goal of pressure ulcer research. Despite such efforts, pressure ulcers remain common in hospitals and in the community. Moreover, pressure ulcers often become chronic wounds that are difficult to treat and that tend to recur after healing. Especially given these challenges, dermatologists should have the knowledge and skills to implement pressure ulcer prevention ...
Reducing the Incidence and Prevalence of Pressure Injury in ...
Final screening was conducted to identify nonrelevant outcome with the research question. Inclusion articles were determined and evaluated by two authors. ... OR Prevalence OR Pressure Injury OR Ulcers Pressure OR Bed Sore OR Pressure ... only in narrative form rather than as quantitative data. 14-18,20,21 Two articles had an unclear risk of ...
Hospital-Acquired Pressure Injuries in Critical and Progressive Care
The Pressure Ulcer Prevention Inventory (PUPI) 7 was designed using the NPUAP definition of unavoidable pressure injury 3 and Braden and Bergstrom's conceptual model of the etiology of pressure injuries. 8 The PUPI operationalized the 4 key concepts that are thought to capture the construct of unavoidable HAPIs and demonstrated acceptable ...
Effectiveness on hospital‐acquired pressure ulcers prevention: a
1 INTRODUCTION. Despite all advances in health care, pressure ulcers (PUs) remain an old worldwide public health problem related to patient safety. 1-3 Hospital-acquired PUs are one of the most harmful events in the clinical context. 1, 2 PUs, recently known as pressure injuries, 4-6 are defined as skin injuries and/or underlying tissue damage localised over a bony prominence, resulting from ...
Implementation of Pressure Injury Prevention Strategies in Acute Care
Since 2009, the National Pressure Injury Advisory Panel (NPIAP), European Pressure Ulcer Advisory Panel (EPUAP), and Pan Pacific Pressure Injury Alliance (PPPIA) have develop and updated guidelines for the prevention and treatment of pressure injuries based on research evidence and expert opinion.1 The last 20 years of PI research has seen a ...
Quantitative Pressure Measurement in Areas at High Risk of Pressure
Pressure ulcers are skin and/or underlying tissue lesions caused by the limitation of blood circulation owing to the combination of increased pressure, friction, and sheer force on specific parts of the body [1, 2].These pressure injuries are closely related to loss of quality of life, impairment in mobility, and increased mortality, both directly and indirectly [].
The Incidence of Pressure Ulcers and its Associations in Different
The main outcome of this study is the reported incidence of pressure ulcer. Accordingly, 111 articles were investigated. Irrelevant and duplicate studies were excluded from the analysis and the articles that were published in non-English languages were also excluded. ... (STROBE) checklist (title and abstract, goals and hypotheses, research ...

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1 Introduction

2 Materials and Methods

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3.3 Pressure Measurements at Risk Area of Left Side-Tilt Position

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4 Discussion

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