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
Student, Department of Nursing Science, Centre for the Humanities and Health Sciences, Charité, Universitätsmedizin Berlin,
1

Berlin 2Professor, Head of Department of Nursing Science, Centre for the Humanities and Health Sciences, Charité,
Universitätsmedizin Berlin, Berlin 3Associate 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 Charité Universitätsmedizin
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
370
Abstract Background
© 2009 The Authors. Journal compilation © 2009 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 15 (2009) 370–374
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 (alter- nating 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 West- strate and Heul [3]. Not
all pressure ulcers can be avoided, but it is likely that the incidence can be reduced [4]. The European Pres- sure Ulcer Advisory Panel
(EPUAP) highlights that the goals for pressure ulcer prevention are to: (1) identify at risk individuals needing prevention and specific
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
pressure damage through educational programmes to health care providers, patients and family [5].
There are several organizations which have developed guide- lines 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 findings and guidelines to health care providers, policymakers and the public [7]. Clinical practice
guidelines are systematically developed statements to
E.S.M. Shahin et al. Pressure ulcer guidelines in ICU
Table 1 Evidence level of pressure ulcer pre- ventive measures according to European Pres- sure Ulcer Advisory Panel (EPUAP) and
EPUAP Guidelines
AHCPR Guidelines Preventive measures
(Evidence level)
(Evidence level)
Agency for Health Care Policy and Research
Identify at risk patients C C (AHCPR) guidelines
Pressure reducing devices
Mattresses C B Beds C B Cushions C C Heel protector Not mentioned C Elbow protector Not mentioned Not mentioned Sheepskin Not mentioned Not
mentioned Nursing intervention
Skin inspection C C Repositioning B B Mobility C C Massage with moisture cream C C Massage Not supported evidence (C)
 371 Not supported with
© 2009 The Authors. Journal compilation © 2009 Blackwell Publishing Ltd
evidence (B) Nutrition C C Patient education C A Family or carer education C A Plans and Scheduling C C Documentation C C Minimize exposure to
moisture C C
assist practitioner and patient decisions about appropriate health
is A in AHCPR guidelines. Massage over bony prominence is not care for specific clinical circumstances [8]. The aim of pressure
supported in both organizations. The evidence level for no support ulcer guidelines is to make specific recommendations to identify
is C in EPUAP and B in AHCPR guidelines. Furthermore, elbow at-risk patients, and to define early interventions for prevention of
protector and sheepskin are not mentioned in both organizations pressure ulcers. The guidelines may also be used to treat grade one
guidelines. However, heel protector is mentioned in EPUAP with pressure ulcers [7].
evidence level C and not mentioned in AHCPR guidelines [7,10]. The core of any guideline is the systematic review of the evi-
Recent research has demonstrated that some of the standard dence to lead the group in an informed debate about the value of
products used in health care settings may provide inadequate pro- treatment alternatives. The level of evidence consists of four
tection against the development of pressure ulcers, and may even levels: evidence I (A) from systematic review or meta Analysis or
exacerbate the risk of developing such an injury [11]. The aim of randomized controlled trials or at least one randomized controlled
this study is to assess the allocation of preventive measures for trial, evidence II (B) from at least one controlled trial without
patients at risk for pressure ulcers and the evidence of applied randomization or at least one other type of quasi-experimental
preventive measures in intensive care settings regarding EPUAP study, evidence III (C) from non-experimental descriptive studies,
and AHCPR guidelines. 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].
Research questions
Table 1 shows that pressure ulcer preventive measures in the
1 What is the allocation of pressure ulcer preventive measures for guidelines of EPUAP, 1998 (updated in 2001) and AHCPR, 1992
patients at risk for and with pressure ulcers? (last revising at November, 2007) are not quietly the same. There
2 What is the evidence of applying pressure ulcers preventive is a difference regarding the level of evidence for some preventive
measures in intensive care settings regarding EPUAP and AHCPR measures, and also some preventive measures are mentioned in
guidelines? 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,
Methods
skin inspection, mobility, massage with moisture cream, cushions, nutrition with evidence level C and reposition with evidence level
Design
B in both of them [7,10].
A cross-sectional study (point prevalence). The data were collected The preventive measures that have a different evidence level in
on the first day of the second week in April 2007. 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, edu-
Instrument
cation regarding pressure ulcer prevention for patients and family
A questionnaire was developed containing questions regarding the or care givers is C in EPUAP guidelines, while its evidence level
patient demographics, pressure ulcer occurrence, grades, body
Pressure ulcer guidelines in ICU E.S.M. Shahin et al.
sites of pressure ulcers, duration, origin, types of dressing and
application of pressure ulcer preventive measures was described preventive measures. The grading system of the EPUAP was used
using numbers and percentages. The prevalence was calculated [12]. The reliability and clinical utility of EPUAP was tested
with the following formula by Dassen et al. [16]: prevalence = among 30 adult patients, which revealed a kappa level of 0.308
number of patients with at least one pressure ulcers (numerator) with agreement of 48.56% [13]. Additionally, the inter-rater agree-
divided by number of patients at risk for pressure ulcers (domina- ment and accuracy of the EPUAP grading system using pressure
tor) ¥100. Patients were defined to be at risk if the Braden score ulcer photographs was 61.9% [14]. In addition, the Braden scale
was 20. Chi-square was used to describe the differences between was used to assess the risk of developing pressure ulcers. The
patients at risk and not at risk for pressure ulcers regarding pres- predictive validity of the Braden scale has been tested in more than
sure ulcer preventive measures. 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].
Results
The study results revealed that 83% of all patients were at risk for Sample
pressure ulcers based on the total score of the Braden scale with a
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.
372
 cut-off point of 20. The total prevalence of pressure ulcers was 27.2%. The
© 2009 The Authors. Journal compilation © 2009 Blackwell Publishing Ltd
highest prevalence of pressure ulcers was among sur- gical patients with 39% (18 patients), while the lowest prevalence was among
interdisciplinary patients with 18.8% (9 patients). There is no significant 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 significant differences between the group of
Data collection
patients with and without pressure ulcer regarding gender, age and body mass index. However, a significant difference (P = <0.01)
Researchers trained the coordinators in all participating hospitals.
was found between patients with and without pressure ulcer Each coordinator trained the ward nurses in gathering the data.
regarding Braden score and patients at risk for pressure ulcer. Each trained nurse was provided with standard pictures and defi-
The preventive measures that were applied in this study were nitions of each pressure ulcer grade. The prevalence study was
pressure reducing devices which include 58 (36.5%) special mat- carried out on a set day of the second week of April 2007 in all
tresses (alternating pressure air, low air loss and foam) and four participating hospitals. The trained ward nurses examined all
(2.5%) special beds (alternating pressure air and low air loss). patients in the selected intensive care specialities.
Special cushions (gel, water, foam, circle and air) were applied to 28 (17.6%) patients. Further nursing interventions that Ethical
considerations
were applied were repositioning 66 (41.5%), mobility 90 (56.6%),
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.
skin inspection 130 (81.8%), massage with moisture cream 128 (80.5%), avoidance of nutritional and fluid deficit 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%).
Data analysis
Table 3 shows that pressure reducing devices such as mattresses (alternating pressure air, low air loss and foam) are the most Data were
analysed using SPSS version 15. The sample character-
applied devices for patients at risk for pressure ulcers. However, istics were described using mean and standard deviation. The
more than one nursing intervention is applied for most of the
Variables
Pressure ulcer n = 124 Table 2 Characteristics of patients with pres-
P-Value*
sure ulcers ulcers versus patients without pressure Gender
Male n (%)‡ 25 (25%) 75 (75%) ns† Female n (%)‡ 12 (19.7%) 49 (80.3%) ns† Age Mean standard deviation 67.8 12 66.9 14.8 ns† Body mass index
mean standard deviation 25.8 5.7 26.1 4.9 ns† Braden score mean standard deviation 12.2 2.9 16.6 4.2 0.01 Patients at risk n (%)‡ 36 (27.3%) 96
(72.7%) 0.01
*P-values calculated with t-test and significant level considered if P 0.05. †ns, not significant. ‡P-value calculated with chi-square.
+ Pressure ulcer n = 37
E.S.M. Shahin et al. Pressure ulcer guidelines in ICU
Table 3 Preventive measures allocation for patients at risk and not at risk for pressure
Preventive measures AR (n = 132) NAR (n = 27) Total (n = 159†) P-value*
ulcers
Pressure reducing devices
Mattresses 56 (42.4%) 2 (7.4%) 58 (36.5%) 0.01 Beds 4 (3%) – 4 (2.5%) no valid cases Cushions 28 (21.2%) – 28 (17.6%) 0.01 Nursing intervention
Skin inspection 121 (91.7%) 9 (33.3%) 130 (81.8%) 0.000 Repositioning 65 (49.2%) 1 (3.7%) 66 (41.5%) 0.000 Mobility 78 (59%) 12 (44.4%) 90
(56.6%) 0.112 Massage with moisture
120 (90.9%) 8 (29.6%) 128 (80.5%) 0.000 cream Massage 12 (11.4%) 2 (7.4%) 14 (8.8%) 0.564 Nutrition 100 (75.8%) 9 (33.3%) 109 (68.6%) 0.000
Patient education 53 (40.2%) 11 (40.7%) 64 (40.3%) 0.559 Family or carer education 29 (21.9%) 4 (14.8%) 33 (20.8%) 0.154
*P-value calculated with chi-square P 0.05. †Missed data are 10 values. AR, at risk; NAR, not at risk.
patients at risk like skin inspection, massage with moisture cream,
mattresses like low air loss and alternating pressure air mattresses mobility, nutrition and education. The other nursing interventions
in ICU patients. Additionally, there is limited evidence for low air were applied for less than half of the patients at risk. Additionally,
loss mattresses in reducing the incidence of pressure ulcers in ICU this table shows also a significant difference (P = 0.01) between
patients [3]. Moreover, one study suggested that low-air-loss beds patients at risk and not at risk for pressure ulcer regarding the
are more effective than standard foam beds in preventing pressure allocation of pressure ulcer preventive measures (special mat-
ulcers for persons in ICU [17]. The study of Cullum [18] reported tresses, skin inspection, reposition, massage with moisture cream
that turning beds that were used for pressure ulcer prevention were and nutrition).
also applied to immobile intensive care patients to promote chest The study results revealed that all applied pressure ulcer pre-
drainage. Immobility is the most important risk factor related to ventive measures are in line with the EPUAP and AHCPR guide-
pressure ulcer development [19]. In this respect, ICU patients are lines except massage which was applied although it should be
always limited in movement and mobility because of the severity avoided according to both organizations. Further measures of the
of illness and their health condition. Therefore, the risk for pres- preventive guidelines of EPUAP and AHCPR not applied in this
sure ulcer development is higher among this patient population, study are plans and scheduling of care, documentation and mini-
and mobility as a measure for pressure ulcer prevention is indi- mizing skin exposure to moisture. Preventive measures that were
cated to decrease further pressure ulcers. However, except in inten- applied in intensive care but that are not included in the guidelines
sive care wards, regular repositioning alone as a method of of EPUAP and AHCPR were elbow protectors applied to three
pressure relief is unlikely to be successful. It is labour intensive, patients and sheepskin applied to only one patient.
and it is often difficult or impossible for patients especially when they have numerous catheter or monitoring lines or unstable frac-
Discussion
tures [20]. Massage is always contraindicated when tissue is inflamed. So it is extremely important to recognize the signs of The results
of this study revealed a pressure ulcer prevalence of
early inflammation because there is increasing agreement that 27.2% which was 39% in surgical ICU, 28.9% in medical ICU and
pressure ulcers are related to a chronic form of inflammation. 18.8% in interdisciplinary ICU. The most applied pressure reducing
Therefore, the massage with oily substances or substances con- devices were mattresses (alternating pressure air, low air loss and
taining petroleum jelly is recommended to prevent desquamation foam). More than one nursing intervention was applied for most of
[21]. 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
Study limitations
massage which should be avoided according to the guidelines of
This study includes several limitations. The small sample size both organizations. Additionally, one of the important results of this
limits generalizability, and does not represent the ICU populations. study was that most of the pressure ulcer preventive measures
It also limited the using of some statistical processes such as (pressure reducing devices and nursing interventions) were applied
multivariate analysis and also leads to a type two error of the to patients at risk for pressure ulcer development.
sampling. Moreover, not all intensive care specialities and no The study by Weststrate and Heule [3], found that there are no
unconscious patients were included in this study. In addition, ran- significant differences between the types of reducing pressure
domization did not take place in this study sample.
© 2009 The Authors. Journal compilation © 2009 Blackwell Publishing Ltd 373
Pressure ulcer guidelines in ICU E.S.M. Shahin et al.
Conclusions
9. Eccles, M. & Mason, J. (2001) How to develop cost-conscious guide-
line, Technology Assessment, 5 (16), 8. 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.
10. European Pressure Ulcer Advisory Panel (1998) Pressure ulcer pre- vention guidelines (updated in 2001). 3(3), Oxford, UK. Available at:
http://www.epuap.org/glprevention.html (last accessed 25 February 2009). 11. Defloor, T. (2000) The effect of position and mattresses on interface
pressure. Applied Nursing Research, 13 (1), 2–11. 12. European Pressure Ulcer Advisory panel (2001) Guide to pressure ulcer grading, 3(3). Available at:
http://www.epuap.org/review3_3/ More research is also needed regarding the effectiveness of pres-
index.html (last accessed 1 February 2008). sure reducing devices in intensive care patients.
13. Pedley, G. E. (2004) Comparison of pressure ulcer grading scales: a study of clinical utility and inter-rater reliability. International Journal of Nursing
Studies, 41 (2), 129–140. References
14. Russell, L. & Reynolds, T. M. (2001) How accurate are pressure ulcer grades? an image-based survey of nurse performance. Journal of 1. Jiricka, M.
K., Ryan, P., Cavalho, M. V. & Bukvicka, J. (1995) Pres-
Tissue Viability, 11 (2), 46–50. sure ulcer risk factors in an ICU population. American Journal of
15. Bergstrom, N., Braden, B., Kemp, M., Champagne, M., & Ruby, E. Critical Care, 4 (5), 361–367.
(1998) Predicting pressure ulcer risk: a multisites study of the predic- 2. Feuchtinger, J., Halfens, R. & Dassen, T. (2007) Pressure ulcer risk
tive validity of the Braden scale. Applied Nursing Research, 47 (5), assessment immediately after cardiac surgery- does it make a differ-
261–269. ence? A comparison of three pressure ulcer risk assessment instru-
16. Dassen, T., Tannen, A. & Lahmann, N. (2006) Pressure ulcer, the scale ments within a cardiac surgery population. Nursing in Critical Care,
of the problem. In Science and Practice of Pressure Ulcer Management 12 (1), 42–49.
(ed. M. Romanelli), pp. 1–6. London: Springer. 3. Weststrate, J. T. M. & Heule, F. (2001) Prevalence of PU, risk factors
17. Inman, K. J., Sibbald, W. J., Rutledge, F. S. & Clark, B. J. (1993) and use of pressure ulcer-relieving mattresses in ICU patients. Connect
Clinical utility and cost- effectiveness of an air suspension bed in the the World of Critical Care Nursing, 1 (3), 77–82.
prevention of pressure ulcers. The Journal of the American Medical 4. Bennett, G., Dealy, C. & Posnett, J. (2004) The cost of pressure ulcers
Association (JAMA), 269 (9), 1139–1143. in the UK. Age and Aging, 33 (3), 230–235.
18. McInnes, E., Bell-Syer, S. E. M, Dumville, J. C., Legood, R. & 5. Gunningberg, L. (2005) Are patients with or at risk of pressure ulcers
Cullum, N. A. Support surface for pressure ulcer prevention, Cochrane allocated appropriate prevention measures? International Journal of
Database of Systematic Reviews 2008, Issue 4. Art. No.: CD001735. Nursing Practice, 11 (2), 58–67.
DOI: 10.1002/14651858.CD001735.pub3. 6. European Pressure Ulcer Advisory Panel (2007) Pressure Ulcer
19. Lindgren, M., Unosson, M., Fredrikson, M. & Ek, A. C. (2004) Immo- Prevention Guidelines. Available at: http://www.epuap.org/
bility – a major risk factor for development of pressure ulcers among glprevention.html (last accessed 25 February 2009).
 adult hospitalized patients: a prospective study. Scandinavian Journal 7. Agency for Health Care Policy and Research (AHCPR) (1992) Pres-
of Caring Sciences, 18 (1), 57–64. sure Ulcers in Adults: Prediction and Prevention. Clinical Practice
20. Bliss, M. (2000) Medical management of pressure ulcers. part 2, Guideline Number 3, AHCPR Pub. No. 92-0047. (last revising 10,
Pressure relief, adapted from a talking given at the Fifth Oxford January, 2007) Available at: http://www.ncbi.nlm.nih.gov/books/
European Wound Healing Summer School held at St Anne’s College. bv.fcgi?rid=hstat2.chapter.4409 (last accessed 28 December 2007).
Oxford, London, 28 June – 1 July. 8. Field, M. J. & Lohr, K. N. (1990) Clinical practice guidelines: Direc-
21. Duimel-Peeters, I. (2005) Preventing pressure ulcers with massage? tions for new program. National Academy Press Washington, DC.
Some say it works, others disagree.Ay, there’s the rub. Wound Wise, Page 50. Available at: http://www.nap.edu/openbook/0309043468/
105 (8), 31–32. Available at: http://www.epuap.org/review3_3/ html/R1.html (last accessed 25 February 2009).
index.html.
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