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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

1Student, Department of Nursing Science, Centre for the Humanities and Health Sciences, Charit, Universittsmedizin Berlin, Berlin2Professor, Head of Department of Nursing Science, Centre for the Humanities and Health Sciences, Charit, Universittsmedizin Berlin, Berlin3Associate 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 (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, Jirickaet 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 pressureulcers. 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

Journal of Evaluation in Clinical Practice ISSN 1356-1294

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 15 (2009) 370374370

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assist practitioner and patient decisions about appropriate health

care for specific clinical circumstances [8]. The aim of pressure

ulcer guidelines is to make specific recommendations to identify

at-risk patients, and to define 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 evi-

dence 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 orrandomized 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 ofevidence 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, edu-

cation 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 pro-

tection against the development of pressure ulcers, and may even

exacerbate the risk of developing such an injury [11]. The aim ofthis 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 first day of the second week in April 2007.

Instrument

A questionnaire was developed containing questions regarding the

patient demographics, pressure ulcer occurrence, grades, body

Table 1 Evidence level of pressure ulcer pre-

ventive measures according to European Pres-

sure Ulcer Advisory Panel (EPUAP) and

Agency for Health Care Policy and Research

(AHCPR) guidelines

Preventive measures

EPUAP Guidelines

(Evidence level)

AHCPR Guidelines

(Evidence level)

Identify at risk patients C C

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)

Not supported with

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

E.S.M. Shahin et al. Pressure ulcer guidelines in ICU

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd 371

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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 agree-

ment 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. Thepredictive 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].

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 defi-

nitions 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, informedconsent 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 character-

istics were described using mean and standard deviation. The

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 (domina-

tor) 100. Patients were defined to be at risk if the Braden score

was20. Chi-square was used to describe the differences between

patients at risk and not at risk for pressure ulcers regarding pres-sure 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 of20. The total prevalence of pressure ulcers was

27.2%. The 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

patients with and without pressure ulcer regarding gender, age and

body mass index. However, a significant difference (P =

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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 significant difference (P = 0.01) between

patients at risk and not at risk for pressure ulcer regarding the

allocation of pressure ulcer preventive measures (special mat-

tresses, skin inspection, reposition, massage with moisture cream

and nutrition).

The study results revealed that all applied pressure ulcer pre-

ventive measures are in line with the EPUAP and AHCPR guide-

lines 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 mini-

mizing 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 interdisciplinaryICU. The most appliedpressure 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, massagewith 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

significant 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 pres-

sure ulcer development is higher among this patient population,

and mobility as a measure for pressure ulcer prevention is indi-

cated to decrease further pressure ulcers. However, except in inten-

sive care wards, regular repositioning alone as a method of

pressure relief is unlikely to be successful. It is labour intensive,

and it is often difficult or impossible for patients especially when

they have numerous catheter or monitoring lines or unstable frac-

tures [20]. Massage is always contraindicated when tissue is

inflamed. So it is extremely important to recognize the signs of

early inflammation because there is increasing agreement that

pressure ulcers are related to a chronic form of inflammation.

Therefore, the massage with oily substances or substances con-

taining 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, ran-

domization did not take place in this study sample.

Table 3 Preventive measures allocation for

patients at risk and not at risk for pressure

ulcers

Preventive measures AR (n = 132) NAR (n = 2 7) Total (n = 159) P-value*

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

cream

120 (90.9%) 8 (29.6%) 128 (80.5%) 0.000

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 c arer 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.

E.S.M. Shahin et al. Pressure ulcer guidelines in ICU

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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 inICU patients like repositioning frequency and skin assessment.

More research is also needed regarding the effectiveness of pres-

sure reducing devices in intensive care patients.

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