Journal of Evaluation in Clinical Practice ISSN 1356-1294

Pressure ulcer prevention in intensive care patients: guidelines and practice

Eman S. M. Shahin BSc MSc RN PhD,1 Theo Dassen PhD RN2 and Ruud J. G. Halfens PhD3
1 2

Student, Department of Nursing Science, Centre for the Humanities and Health Sciences, Charit, Universittsmedizin Berlin, Berlin Professor, Head of Department of Nursing Science, Centre for the Humanities and Health Sciences, Charit, Universittsmedizin Berlin, Berlin 3 Associate Professor, Health Care Studies/Section Nursing Science, Faculty of Health Sciences, Universiteit Maastricht, the Netherlands

Keywords AHCPR, EPUAP, guidelines, ICU, pressure ulcer, prevention Correspondence Eman S. M. Shahin Department of Nursing Science Centre for the Humanities and Health Sciences Charit Universittsmedizin Berlin Berlin E-mail: eman.shahin@charite.de or emanshaheen@yahoo.com Accepted for publication: 14 February 2008 doi:10.1111/j.1365-2753.2008.01018.x

Abstract
Background Pressure ulcers are a potential problem in intensive care patients, and their prevention is a major issue in nursing care. This study aims to assess the allocation of preventive measures for patients at risk for pressure ulcers in intensive care and the evidence of applied pressure ulcer preventive measures in intensive care settings in respect to the European Pressure Ulcer Advisory Panel (EPUAP) and Agency for Health Care Policy and Research (AHCPR) guidelines for pressure ulcer prevention. Design The design of this study was a cross-sectional study (point prevalence). Setting The study setting was intensive care units. The sample consisted of 169 patients 60 patients from surgical wards, 59 from interdisciplinary wards and 50 from medical intensive care wards. Results The study results revealed that pressure reducing devices like mattresses (alternating pressure air, low air loss and foam) are applied for 58 (36.5%) patients, and all of these patients are at risk for pressure ulcer development. Most patients receive more than one nursing intervention, especially patients at risk. Nursing interventions applied are skin inspection, massage with moisture cream, nutrition and mobility (81.8%, 80.5%, 68.6% and 56.6%) respectively. Moreover, all applied pressure ulcer preventive measures in this study are in line with the guidelines of the EPUAP and AHCPR except massage which is applied to 8.8% of all patients. Conclusions The use of pressure reducing devices and nursing interventions in intensive care patients are in line with international pressure ulcer guidelines. Only massage, which is also being used, should be avoided according to the recommendation of national and international guidelines.

Introduction
All over the world, pressure ulcers remain a common health problem within different health care settings, especially in the intensive care setting [1]. The intensive care unit population has a high risk of developing pressure ulcers [2]. Additionally, Jiricka et al. [1] reported an incidence rate of more than 50% in intensive care patients, while the prevalence was 49% in the study by Weststrate and Heul [3]. Not all pressure ulcers can be avoided, but it is likely that the incidence can be reduced [4]. The European Pressure Ulcer Advisory Panel (EPUAP) highlights that the goals for pressure ulcer prevention are to: (1) identify at risk individuals needing prevention and specic factors placing them at risk; (2) maintain and improve tissue tolerance to pressure to prevent injury; (3) protect against the adverse effects of pressure; (4) shear and friction; and (5) improve the outcome for patients at risk of
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pressure damage through educational programmes to health care providers, patients and family [5]. There are several organizations which have developed guidelines for health professionals to prevent pressure ulcers, for instance the EPUAP which has been created to lead and support all European countries in the efforts to prevent and treat pressure ulcers. Its mission statement reads: to provide the relief of persons suffering from or at risk of pressure ulcers, in particular through research and the education of the public [6]. Another organization is the Agency for Health Care Policy and Research (AHCPR). AHCPR carries out its mission by conducting and supporting general health services research, including medical effectiveness research, facilitating development of clinical practice guidelines and disseminating research ndings and guidelines to health care providers, policymakers and the public [7]. Clinical practice guidelines are systematically developed statements to

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Pressure ulcer guidelines in ICU

Table 1 Evidence level of pressure ulcer preventive measures according to European Pressure Ulcer Advisory Panel (EPUAP) and Agency for Health Care Policy and Research (AHCPR) guidelines

Preventive measures Identify at risk patients Pressure reducing devices Mattresses Beds Cushions Heel protector Elbow protector Sheepskin Nursing intervention Skin inspection Repositioning Mobility Massage with moisture cream Massage Nutrition Patient education Family or carer education Plans and Scheduling Documentation Minimize exposure to moisture

EPUAP Guidelines (Evidence level) C C C C Not mentioned Not mentioned Not mentioned C B C C Not supported evidence (C) C C C C C C

AHCPR Guidelines (Evidence level) C B B C C Not mentioned Not mentioned C B C C Not supported with evidence (B) C A A C C C

assist practitioner and patient decisions about appropriate health care for specic clinical circumstances [8]. The aim of pressure ulcer guidelines is to make specic recommendations to identify at-risk patients, and to dene early interventions for prevention of pressure ulcers. The guidelines may also be used to treat grade one pressure ulcers [7]. The core of any guideline is the systematic review of the evidence to lead the group in an informed debate about the value of treatment alternatives. The level of evidence consists of four levels: evidence I (A) from systematic review or meta Analysis or randomized controlled trials or at least one randomized controlled trial, evidence II (B) from at least one controlled trial without randomization or at least one other type of quasi-experimental study, evidence III (C) from non-experimental descriptive studies, such as comparative studies, correlation studies and case control studies and evidence IV (D) from expert committee reports or opinion and/or clinical experience of respected authorities [9]. Table 1 shows that pressure ulcer preventive measures in the guidelines of EPUAP, 1998 (updated in 2001) and AHCPR, 1992 (last revising at November, 2007) are not quietly the same. There is a difference regarding the level of evidence for some preventive measures, and also some preventive measures are mentioned in EPUAP guidelines and not mentioned in AHCPR guidelines and vice versa. The preventive measures that have the same level of evidence in both organizations are pressure ulcer risk assessment, skin inspection, mobility, massage with moisture cream, cushions, nutrition with evidence level C and reposition with evidence level B in both of them [7,10]. The preventive measures that have a different evidence level in both organizations are pressure reducing devices like mattresses and beds. These devices have evidence level C in EPUAP whereas their evidence level is B in AHCPR guidelines. Additionally, education regarding pressure ulcer prevention for patients and family or care givers is C in EPUAP guidelines, while its evidence level

is A in AHCPR guidelines. Massage over bony prominence is not supported in both organizations. The evidence level for no support is C in EPUAP and B in AHCPR guidelines. Furthermore, elbow protector and sheepskin are not mentioned in both organizations guidelines. However, heel protector is mentioned in EPUAP with evidence level C and not mentioned in AHCPR guidelines [7,10]. Recent research has demonstrated that some of the standard products used in health care settings may provide inadequate protection against the development of pressure ulcers, and may even exacerbate the risk of developing such an injury [11]. The aim of this study is to assess the allocation of preventive measures for patients at risk for pressure ulcers and the evidence of applied preventive measures in intensive care settings regarding EPUAP and AHCPR guidelines.

Research questions
1 What is the allocation of pressure ulcer preventive measures for patients at risk for and with pressure ulcers? 2 What is the evidence of applying pressure ulcers preventive measures in intensive care settings regarding EPUAP and AHCPR guidelines?

Methods
Design
A cross-sectional study (point prevalence). The data were collected on the rst day of the second week in April 2007.

Instrument
A questionnaire was developed containing questions regarding the patient demographics, pressure ulcer occurrence, grades, body
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sites of pressure ulcers, duration, origin, types of dressing and preventive measures. The grading system of the EPUAP was used [12]. The reliability and clinical utility of EPUAP was tested among 30 adult patients, which revealed a kappa level of 0.308 with agreement of 48.56% [13]. Additionally, the inter-rater agreement and accuracy of the EPUAP grading system using pressure ulcer photographs was 61.9% [14]. In addition, the Braden scale was used to assess the risk of developing pressure ulcers. The predictive validity of the Braden scale has been tested in more than one health care setting, which revealed that risk assessment with the Braden scale upon admission is highly predictive of pressure ulcer development in all settings [15].

application of pressure ulcer preventive measures was described using numbers and percentages. The prevalence was calculated with the following formula by Dassen et al. [16]: prevalence = number of patients with at least one pressure ulcers (numerator) divided by number of patients at risk for pressure ulcers (dominator) 100. Patients were dened to be at risk if the Braden score was 20. Chi-square was used to describe the differences between patients at risk and not at risk for pressure ulcers regarding pressure ulcer preventive measures.

Results
The study results revealed that 83% of all patients were at risk for pressure ulcers based on the total score of the Braden scale with a cut-off point of 20. The total prevalence of pressure ulcers was 27.2%. The highest prevalence of pressure ulcers was among surgical patients with 39% (18 patients), while the lowest prevalence was among interdisciplinary patients with 18.8% (9 patients). There is no signicant difference among intensive care unit (ICU) specialities regarding age, body mass index, Braden score and the number of patients at risk for pressure ulcers. Table 2 shows no signicant differences between the group of patients with and without pressure ulcer regarding gender, age and body mass index. However, a signicant difference (P = <0.01) was found between patients with and without pressure ulcer regarding Braden score and patients at risk for pressure ulcer. The preventive measures that were applied in this study were pressure reducing devices which include 58 (36.5%) special mattresses (alternating pressure air, low air loss and foam) and four (2.5%) special beds (alternating pressure air and low air loss). Special cushions (gel, water, foam, circle and air) were applied to 28 (17.6%) patients. Further nursing interventions that were applied were repositioning 66 (41.5%), mobility 90 (56.6%), skin inspection 130 (81.8%), massage with moisture cream 128 (80.5%), avoidance of nutritional and uid decit 109 (68.6%), patient education 64 (40.3%), family or carer education 33 (20.8%), avoidance of shear and friction by keeping patient linen as straight as possible 51 (32%) and massage 14 (8.8%). Table 3 shows that pressure reducing devices such as mattresses (alternating pressure air, low air loss and foam) are the most applied devices for patients at risk for pressure ulcers. However, more than one nursing intervention is applied for most of the
Table 2 Characteristics of patients with pressure ulcers versus patients without pressure ulcers

Sample
Hospitals all over Germany were invited to participate in the study. For the purpose of this study, only adult intensive care patients in surgical, medical and interdisciplinary specialities were included a total of 169 patients from 18 hospitals (60 patients from surgical, 50 patients from medical and 59 patients from interdisciplinary wards). An exclusion criterion was patients younger than 18 years of age.

Data collection
Researchers trained the coordinators in all participating hospitals. Each coordinator trained the ward nurses in gathering the data. Each trained nurse was provided with standard pictures and denitions of each pressure ulcer grade. The prevalence study was carried out on a set day of the second week of April 2007 in all participating hospitals. The trained ward nurses examined all patients in the selected intensive care specialities.

Ethical considerations
Permission to conduct the study was obtained from the Berlin medical ethics committee. Prior to data collection, informed consent was obtained from the patients, either in person or from one of their representatives.

Data analysis
Data were analysed using spss version 15. The sample characteristics were described using mean and standard deviation. The
+ Pressure ulcer n = 37

Variables Gender Male n (%) Female n (%) Age Mean standard deviation Body mass index mean standard deviation Braden score mean standard deviation Patients at risk n (%)

Pressure ulcer n = 124

P-Value*

25 (25%) 12 (19.7%) 67.8 25.8 12 5.7

75 (75%) 49 (80.3%) 66.9 26.1 14.8 4.9

ns ns ns ns 0.01 0.01

12.2 2.9 36 (27.3%)

16.6 4.2 96 (72.7%) 0.05.

*P-values calculated with t-test and signicant level considered if P ns, not signicant. P-value calculated with chi-square.

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Table 3 Preventive measures allocation for patients at risk and not at risk for pressure ulcers

Preventive measures Pressure reducing devices Mattresses Beds Cushions Nursing intervention Skin inspection Repositioning Mobility Massage with moisture cream Massage Nutrition Patient education Family or carer education

AR (n = 132)

NAR (n = 27)

Total (n = 159)

P-value*

56 (42.4%) 4 (3%) 28 (21.2%) 121 (91.7%) 65 (49.2%) 78 (59%) 120 (90.9%) 12 (11.4%) 100 (75.8%) 53 (40.2%) 29 (21.9%) 0.05.

2 (7.4%) 9 (33.3%) 1 (3.7%) 12 (44.4%) 8 (29.6%) 2 (7.4%) 9 (33.3%) 11 (40.7%) 4 (14.8%)

58 (36.5%) 4 (2.5%) 28 (17.6%) 130 (81.8%) 66 (41.5%) 90 (56.6%) 128 (80.5%) 14 (8.8%) 109 (68.6%) 64 (40.3%) 33 (20.8%)

0.01 no valid cases 0.01 0.000 0.000 0.112 0.000 0.564 0.000 0.559 0.154

*P-value calculated with chi-square P Missed data are 10 values. AR, at risk; NAR, not at risk.

patients at risk like skin inspection, massage with moisture cream, mobility, nutrition and education. The other nursing interventions were applied for less than half of the patients at risk. Additionally, this table shows also a signicant difference (P = 0.01) between patients at risk and not at risk for pressure ulcer regarding the allocation of pressure ulcer preventive measures (special mattresses, skin inspection, reposition, massage with moisture cream and nutrition). The study results revealed that all applied pressure ulcer preventive measures are in line with the EPUAP and AHCPR guidelines except massage which was applied although it should be avoided according to both organizations. Further measures of the preventive guidelines of EPUAP and AHCPR not applied in this study are plans and scheduling of care, documentation and minimizing skin exposure to moisture. Preventive measures that were applied in intensive care but that are not included in the guidelines of EPUAP and AHCPR were elbow protectors applied to three patients and sheepskin applied to only one patient.

Discussion
The results of this study revealed a pressure ulcer prevalence of 27.2% which was 39% in surgical ICU, 28.9% in medical ICU and 18.8% in interdisciplinary ICU. The most applied pressure reducing devices were mattresses (alternating pressure air, low air loss and foam). More than one nursing intervention was applied for most of the patients in this study like skin inspection, nutrition, massage with moisture cream, mobility and patient and family education. This study revealed also that all applied preventive measures in this study agree with the EPUAP and AHCPR guidelines except massage which should be avoided according to the guidelines of both organizations. Additionally, one of the important results of this study was that most of the pressure ulcer preventive measures (pressure reducing devices and nursing interventions) were applied to patients at risk for pressure ulcer development. The study by Weststrate and Heule [3], found that there are no signicant differences between the types of reducing pressure

mattresses like low air loss and alternating pressure air mattresses in ICU patients. Additionally, there is limited evidence for low air loss mattresses in reducing the incidence of pressure ulcers in ICU patients [3]. Moreover, one study suggested that low-air-loss beds are more effective than standard foam beds in preventing pressure ulcers for persons in ICU [17]. The study of Cullum [18] reported that turning beds that were used for pressure ulcer prevention were also applied to immobile intensive care patients to promote chest drainage. Immobility is the most important risk factor related to pressure ulcer development [19]. In this respect, ICU patients are always limited in movement and mobility because of the severity of illness and their health condition. Therefore, the risk for pressure ulcer development is higher among this patient population, and mobility as a measure for pressure ulcer prevention is indicated to decrease further pressure ulcers. However, except in intensive care wards, regular repositioning alone as a method of pressure relief is unlikely to be successful. It is labour intensive, and it is often difcult or impossible for patients especially when they have numerous catheter or monitoring lines or unstable fractures [20]. Massage is always contraindicated when tissue is inamed. So it is extremely important to recognize the signs of early inammation because there is increasing agreement that pressure ulcers are related to a chronic form of inammation. Therefore, the massage with oily substances or substances containing petroleum jelly is recommended to prevent desquamation [21].

Study limitations
This study includes several limitations. The small sample size limits generalizability, and does not represent the ICU populations. It also limited the using of some statistical processes such as multivariate analysis and also leads to a type two error of the sampling. Moreover, not all intensive care specialities and no unconscious patients were included in this study. In addition, randomization did not take place in this study sample.

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Conclusions
The conclusion that derived from this study revealed that almost all recommendations of pressure ulcer guidelines were applied in intensive care patients. However, massage should be avoided based on the recommendation of the national and international pressure ulcer prevention guidelines. Additionally, more research is needed to evaluate the implementation of preventive measures in ICU patients like repositioning frequency and skin assessment. More research is also needed regarding the effectiveness of pressure reducing devices in intensive care patients.

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