ORIGINAL INVESTIGATION
Features of Pressure Ulcers in Hospitalized Older Adults Hu¨lya Eskiizmirli Aygo¨r, MSN; Sevnaz Sahin, MD; Emine So¨zen, MSN; Basak Baydal, HN; Fisun Senuzun Aykar, Prof Dr; and Fehmi Akc¸ic¸ek, Prof Dr
ABSTRACT BACKGROUND: The objectives of this study were to examine the prevalence and risk of pressure ulcers (PrUs) among hospitalized patients 65 years or older in a university hospital setting and to assess the potential for prevention and healing in that population. METHODS: The retrospective study conducted at the general medicine departments of Ege University Hospital in Izmir, Turkey, included 209 patients (115 females, 94 males) 65 years or older, who had been admitted to the hospital for a variety of reasons between April 1, 2011, and October 1, 2011. The following tools were used to collect data: a data collection form to identify the sociodemographic and medical characteristics of the patients, the Braden Risk Assessment Scale to assess the risk of PrUs, and a form to monitor PrUs, which included the site of the PrU, the category, and the PUSH (Pressure Ulcer Scale for Healing) score, a tool for tracking changes in PrUs status applied at weekly intervals. RESULTS: The mean patient age was 73 (6.4) years. The prevalence of PrUs was 5.8% during the hospital stay. Pressure ulcers appeared most frequently in the ischeal tuberosity area (40%), and 45.2% of all PrUs observed were category II. The comorbidities of the patients who had PrUs were as follows: rheumatoid arthritis, 40% (n = 5); acute renal failure, 24% (n = 3); multiple myeloma, 8% (n = 1); chronic renal failure, 8% (n = 1); pneumonia, 8% (n = 1); and acute lymphoblastic leukemia, 8% (n = 1). CONCLUSIONS: Pressure ulcers are a common healthcare complication in the older adult population, with potentially severe consequences. The most important intervention that healthcare professionals can make to reduce PrUs is to determine and address risk factors. KEYWORDS: pressure ulcers, older adults, prevention and healing ADV SKIN WOUND CARE 2014;27:122Y6
INTRODUCTION Pressure ulcers (PrUs) are defined as skin breakdown and deeper tissue damage of ischemic etiology secondary to external pressure, usually occurring over bony prominences.1 Pressure ulcers affecting older adults can cause significant mortality and morbidity, but often are preventable if appropriate and essential precautions are
taken. Older adult patients are more likely to experience PrUs because of their vulnerability due to the aging process and because of the increased incidence of chronic conditions.2,3 Pressure ulcers cause extreme discomfort to the patient and often lead to serious, life-threatening infections, which substantially increase the total cost of care.4 Pressure ulcers are a severe burden for patients, with negative psychological, physical, and social consequences that are damaging to health, well-being, and healthrelated quality of life.5 They are, in many cases, preventable, and prevention is more affordable than treatment of established ulcers. Current evidence indicates that risk assessment, skin care, education, using support surfaces, repositioning the patient, optimizing nutrition, and maintaining optimal sacral skin moisture are effective strategies to preventing PrUs.6 Pressure ulcer prevalence studies indicate that prevalence varies according to the patient characteristics of communities. Margolis et al7 evaluated 200,000 persons aged 65 years or older using a patient-record database called the General Practice Research Database. In that study, the prevalence of PrUs varied from 0.31% to 0.70%.7 Theisen et al8 evaluated 3198 patients 75 years or older in a 1350-bed German university hospital. Of those patients, 7.1% developed an ulcer during their hospitalization, of which 87.3% were classified as categories I and II.8 Moore and Cowman9 evaluated 1100 older individuals residing in 12 long-term-care settings in the Republic of Ireland and reported a PrU prevalence of 9%. Ferrell et al10 evaluated 3048 patients admitted to home care programs in the United States. In that study, it was identified that 9.12% developed at least 1 PrU, 37.4% had more than 1 ulcer, and 14.0% had 3 or more ulcers. Most of these were category II.10 Igarashi et al11 evaluated 720 randomly sampled, long-term-care hospitals in Japan and reported a PrU prevalence of 9.6%. Landi et al12 evaluated 3103 patients admitted to home care programs in Italy and identified a PrU prevalence of 18%. Casimiro et al13 evaluated 827 older adults in institutional settings in Spain and found a PrU prevalence of 35.7%. Research into PrU prevalence in older adults in Turkey is limited. Do¨ventaz et al14 evaluated 3101 individuals 60 years or older in a university hospital and found that the prevalence of PrUs was ¨ ztunc¸15 evaluated 404 patients 18 years or older 6.75%. Inan and O in a university hospital, reporting a PrU prevalence of 10.4%. This
Hu¨lya Eskiizmirli Aygo¨r, MSN, is a Nurse; Sevnaz Sahin, MD, is a Physician; and Basak Baydal, HN, is the Senior Director of Nursing, Internal Medicine at the Ege University Medical Faculty, Internal Medicine Department Geriatrics Section in Izmir, Turkey. Emine So¨zen, MSN, is a Research Assistant; and Fisun Senuzun Aykar, Prof Dr, is an Instructor at the Ege University Izmir Ataturk Institute of Health Science in Izmir, Turkey. Fehmi Akc¸ic¸ek, Prof Dr, is a Professor at Ege University. The authors have disclosed that they have no financial relationships related to this article. Submitted November 14, 2012; accepted in revised form March 8, 2013. ADVANCES IN SKIN & WOUND CARE & VOL. 27 NO. 3
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ORIGINAL INVESTIGATION
study was conducted to evaluate PrU risk, prevalence, and healing among hospitalized patients 65 years or older in a university hospital setting.
METHODS This study included 209 patients (115 women, 94 men) 65 years or older as part of a retrospective study in the general medicine department (n = 129), which includes an intensive care unit (n = 12) at Ege University Hospital in Izmir, Turkey. The study was performed from April 1, 2011, to October 1, 2011. The data were collected retrospectively from archived patient files and recorded on a special form designed by the lead researcher. The study procedures were approved by the Ege University Medical Faculty and Medical Faculty Research Ethics Committee. The data collection form captured patients’ demographic information, patient medical diagnosis, and duration of hospital stay. Both the Braden Risk Assessment Scale and the Pressure Ulcer Scale for Healing (PUSH) were recorded weekly.16,17 The Braden Scale is often the preferred tool for assessing the risk of PrUs. It consists of 6 categories: sensory perception (how the patient responds to pressure-related discomfort), moisture (how exposed skin is to moisture), activity (how physically active the patient is), mobility (whether the patient can change and control body position), nutrition (what the patient normally eats), and friction/shear. The total score can vary from 6 to 23, with a lower score indicating a higher risk. Patients with a Braden Scale score of less than 18 (or a low score on any subscale) require intervention.16,18 Pınar and Oguz19 established the validity and reliability of a Turkish language version of the Braden Scale for Pressure Sore Risk. The Braden Scale is used by nurses in all wards of the authors’ hospital. The PUSH provides a valid measure of PrU healing over time and accurately differentiates a healing from a nonhealing ulcer. It is a clinically practical, evidence-based tool for tracking changes in PrU status when applied at weekly intervals. The PUSH scale comprises 3 parameters: surface area of the wound, quantity of exudates in the wound, and tissue type of the wound. Total scores change from 0 to 17, with higher scores indicating more severe ulcers.17,20 Data were analyzed using SPSS (Statistical Package for the Social Sciences, Chicago, Illinois) version 15. Statistical association was tested with the W2 test.
(SD, 6) years in the study. The mean hospital length of stay was 11.7 (SD, 8) days. The mean medication number was 6 (SD, 3.22). Pressure ulcer prevalence was detected at 5.8% (n =1 2). No PrUs developed in 197 patients (94.2%). Ten patients (4.7%) had PrUs prior to hospitalization. Two patients who had no PrUs before hospitalization developed a PrU during hospitalization. Four patients who had PrUs prior to hospitalization developed additional PrUs while hospitalized. The mean age of patients who developed new PrUs during hospitalization was 78.5 (SD, 11) years. The mean hospital length of stay was 25 (SD, 11) days. The mean medication number was 6 (SD, 3). Their diagnoses were rheumatoid arthritis, chronic renal failure, and multiple myeloma. Four patients (33%) had only 1 PrU, 4 patients (33%) had 2 PrUs, 2 patients (17 %) had 3 PrUs, and 2 patients (17%) had 4 PrUs. The majority of PrUs were located on the ischeal tuberosity (40%), coccyx (18%), and sacrum (12%) (Figure 1). Eleven (42%) patients’ PrUs were category I, and 13 (50%) patients’ PrUs were category II (Figure 2). Two PrUs resolved during hospitalization. The most common diseases of the patients were malignancy, 10.6% (n = 39); diabetes, 8.2% (n = 30); acute renal failure, 6.8% (n = 25); and rheumatoid arthritis, 6.5% (n = 25). Nine percent (n = 61) of patients had a chronic condition; 28.2% (n = 58) of patients had 2 chronic conditions; 20.6% (n = 43) of patients had 3 chronic conditions; and 12.4% (n = 26) of patients had 4 chronic conditions. The mean Braden Scale score was 19. Two patients who had no PrUs prior to hospitalization developed a PrU during hospitalization. Four patients who had PrUs before hospitalization developed new PrUs while hospitalized. In other words, 6 patients (2.8%) developed a new PrU during hospitalization. The medical conditions of the patients who had PrUs before admission were as follows: rheumatoid arthritis, 40% (n = 5); Figure 1. FREQUENCY OF PRESSURE ULCERS OBSERVED AT EACH SITE
RESULTS A total of 1469 patients 18 years or older were admitted to the internal medicine and intensive care unit during the data collection process. Two hundred nine patients (15%) 65 years or older were included in the study. Of these, 110 (55.8%) of patients were female, and 87 (44.2%) were male. Their mean age was 72.8 WWW.WOUNDCAREJOURNAL.COM
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Figure 2. FREQUENCY OF CATEGORY OF PRESSURE ULCERS OBSERVED AT EACH SITE
acute renal failure, 24% (n = 3); multiple myeloma, 8% (n = 1); chronic renal failure, 8% (n = 1); pneumonia, 8% (n = 1); and acute lymphoblastic leukemia, 8% (n = 1). The medical conditions of patients who developed a new PrU during hospitalization were as follows: rheumatoid arthritis, 50% (n = 3); multiple myeloma, 17% (n = 1); acute renal failure, 17% (n = 1); and chronic renal failure, 17% (n = 1).
Figure 3. FREQUENCY OF BRADEN RISK ASSESSMENT SCALE SCORE
The mean Braden Risk Assessment Scale score of patients with PrUs was 13. There were 159 patients (76%) deemed at low risk for PrU development with a Braden Scale score between 19 and 23; 33 patients (15.7%) scored between 15 and 18 and were classified at mild risk for PrUs; 9 patients (4.3%) scored 13 to 14, indicating moderate risk; 7 patients (3.3%) scored 10 to 12 and were classified as high risk; and 1 patient (0.4%) scored 9 or less, indicating a very high risk (Figure 3). The mean Braden Risk Assessment Scale score did not change in any patient from admission to clinic up to discharge. Ten patients (patients 4.7%) had a PrU prior to hospitalization. The mean PUSH was 8.6 on admission to hospital and 7.4 on discharge. During hospitalization, 69.2% of the PrUs did not change, 11.5% of the PrUs improved, and 7.8% of the PrUs resolved completely. However, in 11.5% of patients, the PrUs deteriorated (Figure 4). The most common medical conditions of patients whose PrUs did not change during hospitalization were rheumatoid arthritis (n = 1), multiple myeloma (n = 1), acute renal failure (n = 2), and acute lymphoblastic leukemia (n = 1). There appears to be no statistical difference in gender or age between the patient group who exhibit PrUs and those who have none (P 9 .05). The likelihood of having a PrU increased with the number of chronic diseases a patient had.
DISCUSSION Patients were monitored using the Braden Scale during their stay in the clinic. The authors found a PrU prevalence of 5.8% in the group of 209 patients in medical and intensive care units. The authors’ finding is comparable to that of Do¨ventaz et al,14 who reported a 6.75% prevalence rate in 1303 patients 60 years or older at a university hospital.14 It is also broadly similar to Figure 4. FREQUENCY OF OBSERVED PRESSURE ULCER HEALING
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Theisen et al,8 who reported a 7.1% prevalence rate in 3198 patients 75 years or older conducted at a 1350-bed German university. The most common site for PrUs in this study was the ischeal tuberosity (40%), followed by the coccyx (18%) and the sacrum (12%). Moore and Cowman9 reported that the majority of PrUs occurred over the sacrum (58%) and the heel (25%).9 ¨ ztunc¸15 reported the most common site as the sacrum Inan and O (43.9%), followed by the trochanters (17.9%) and heels (13.7%). ¨ zgenel et al22 also reported that the Lepisto¨ et al21 and O majority of PrUs occurred over the sacrum (33% and 43%, respectively). In a study of 2420 US patients, Horn et al23 found that PrUs usually occurred on the heels (22%), with the sacrum ranked fourth, accounting for 12%. The findings in the studies of ¨ ztunc¸, Lepisto¨ et al, and O ¨ zgenel Moore and Cowman, Inan and O et al are mutually supportive but contrast with the results of this study. The differences may have been attributable to the differences in the size of the sample. In the authors’ study, category II PrUs were most common (50%). This finding is similar to that of Ferrell et al,10 who reported that 40.3% of the PrUs observed in their study were category II.10 Moore and Cowman9 reported that 33% of the PrUs observed in their study were category II. By contrast, category I PrU was most common in Uzun and Tan’s24 study, accounting for 72.3% of all observed ulcers. Thirty-four percent of the authors’ patients were deemed to be at risk for PrU development. The authors’ findings are similar to ¨ ztunc¸,15 who reported that 35.7% of a group those of Inan and O of 404 patients were at risk for PrU development in a universitybased hospital in Adana, Turkey.15 Ferrell et al10 reported that 30% were at risk in a group of 3048. Risk identification is crucial as it signals the need to implement an individualized prevention program. Education and training are needed to increase clinical awareness of the value of risk assessment in patient care. Thirtyfour percent of the patients were identified as being at risk according to the Braden Scale, but new PrUs developed in only 12% of the at-risk patient group for whom precautions were taken. These precautions were as follows: positioning every 2 hours, skin care, antifriction cream, friction and tearing prevention, heel protection, moisture management, diet control, provision of an air bed, and mobility. In this study, 69.2% of PrUs did not change, 11.5% PrUs improved, 7.8% PrUs fully resolved, and 11.5% of PrUs deteriorated during hospitalization. This finding is similar to that of Do¨ventaz et al,14 who reported that 57.5% of PrUs did not change, whereas 16.3% improved, 17.5% fully resolved, and 8.8% deteriorated. Despite all precautions, such as positioning every 2 hours, skin care, and friction and tearing prevention, 3 patients’ PrUs deteriorated during hospitalization. These patients’ diagnoses
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were chronic renal failure, rheumatoid arthritis, and pneumonia. The mean hospital stay was 24 days, and the mean age was 74 years. There was no statistical difference in gender or age between the patient groups with and without PrUs in the authors’ study. This finding is similar to the studies by Landi et al12 and Casimiro et al.13 The likelihood of developing a PrU increased with the number of chronic medical conditions a patient had but was not significantly affected by gender or age. The diagnoses of the diseases were: rheumatoid arthritis/arthritis, multiple myeloma, and renal failure. By contrast, in Landi et al,12 patients with PrUs did not show a significant difference in comorbidity. The patterns of PrU development in the studies of Landi et al12 and Casimiro et al13 differed from those observed in the authors’ hospital. Six patients (2.8%) developed a new PrU during hospitalization. The most important intervention that healthcare professionals can make to reduce PrUs is to determine the risk factors, and the most objective, reliable, and cost-effective method of doing this is to use risk assessment tools. At Ege University Hospital, all patients are considered to be at risk for PrU development. The Braden Risk Assessment is applied on admission to hospital and once every week by nurses. Any patient whose Braden score is less than or equal to 18 is positioned every 2 hours. The patient’s skin is kept clean and dry and moistened. Measures to prevent friction and tearing and to provide heel protection, support surface control, dietary control, and motion exercise are reviewed every 2 hours.
LIMITATIONS The study was conducted with 209 patients 65 years or older in a university hospital in Turkey, and the results may not be generalized.
CONCLUSION The prevalence of PrUs was found to be 5.8%. Pressure ulcer risk assessment indicated that 34% of the authors’ patients were deemed at risk for PrU development. Ulcers occurred most frequently in the sacral area. Slightly less than half of the PrUs present were category II. The most common location of PrU in the authors’ study was the ischeal tuberosity area (40%). A continued focus must be maintained on training staff so they are able to identify patients at risk of PrU development.
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REFERENCES
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1. Magalhaes MG, Gragnani A, Veiga DF, et al. Risk factors for pressure ulcers in hospitalized elderly without significant cognitive impairment. Wounds 2007;19:20-4. 2. S$ ahin S, Akc¸ic¸ek F. Yas$ lı Hastada Bası Yaraları O¨nleme, Tanı ve Tedavisi. Pressure Sores: Prevention, Diagnosis, and Treatment in Geriatric Patients. Akad Geriatri 2009:139-146. 3. Inouye SK, Studenski S, Tinetti ME, et al. Geriatric syndromes: clinical, research and policy implications of a core geriatric concept. J Am Geriatr Soc 2007;55:780-91.
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4. Russo AC, Steiner C, Spector W. Hospitalizations Related to Pressure Ulcers among Adults 18 Years and Older, 2006. Rockville, MD: US Agency for Healthcare Research and Quality: Healthcare Cost and Utilization Project (HCUP); 2008. www.hcup-us.ahrq.gov/reports/statbriefs/ sb64.jsp. Last accessed January 27, 2014. 5. Gorecki C, Brown MJ, Nelson EA, et al. Impact of pressure ulcers on quality of life in older patients: a systematic review. J Am Geriatr Soc 2009;57:1175-84. 6. NPUAP. Pressure Ulcer Prevention Points. http://www.npuap.org/resources/educationaland-clinical-resources/pressure-ulcer-prevention-points. Last accessed December 3, 2013. 7. Margolis D, Bilker W, Knauss J, et al. The incidence and prevalence of pressure ulcers among elderly patients in general medical practice. Ann Epidemiol 2002;12:321-5. 8. Theisen S, Drabik A, Stock S. Pressure ulcers in older hospitalised patients and its impact on length of stay: a retrospective observational study. J Clin Nurs 2012;21:380-7. 9. Moore Z, Cowman S. Pressure ulcer prevalence and prevention practices in care of the older person in the Republic of Ireland. J Clin Nurs 2012;21:362-71. 10. Ferrell BA, Josephson K, Norvid P, et al. Pressure ulcers among patients admitted to home care. J Am Geriatr Soc 2000;48:1042-7. 11. Igarashi A, Yamamoto-Mitani N, Gushiken Y, et al. Prevalence and incidence of pressureulcers in Japanese long-term-care hospitals. Arch Gerontol Geriatr 2013;56:220-6. 12. Landi F, Onder G, Russo AR, et al. Pressure ulcer and mortality in frail elderly people living in community. Arch Gerontol Geriatr 2007;1:217-23. 13. Casimiro C, Lorenzo A, Usa L. Prevalence of decubitus ulcer and associated risk factors in an institutionalized Spanish elderly population. Nutrition 2002;18:437-8. 14. Do¨ventaz A, Bic¸en E, Neymen A, et al. Prevalence of pressure sores in elderly patients at the General Medicine Department of Cerrahpaza Medical Faculty, Istanbul University, Akademik
15. 16. 17. 18. 19.
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Geriatri Kongre Kitabı. http://akademikgeriatri.org/geriatriKitap2011.pdf. Last accessed January 27, 2014. Inan DG, O¨ztunc¸ O¨. Pressure ulcer prevalence in Turkey. A sample from a university hospital. J Wound Ostomy Continence Nurs 2012;39:409-13. Braden Scale for Predicting Pressure Sore Risk. http://www.in.gov/isdh/files/Braden_Scale.pdf. Last accessed December 3, 2013. Pressure Ulcer Scale for Healing (PUSH). http://www.npuap.org/wp-content/uploads/2012/ 02/push3.pdf. Last accessed December 3, 2013. Stotts NA, Gunningberg L. How to try this: predicting pressure ulcer risk. Using the Braden Scale with hospitalized older adults: the evidence supports it. Am J Nurs 2007;107:40-9. Pınar R, ve Og˘uz S. ‘‘Norton ve Braden Bası Yarası Deg˘erlendirme O¨lc¸eklerinin Yatag˘a Bag˘ımlı Aynı Hasta Grubunda Gu¨venilirlik ve Gec¸erlig˘inin Sınanması’’, Ulusla arası Katılımlı VI Ulusal Hems$iirelik Kongresi, Ankara. 1998:172-5. Gardner SE, Frantz RA, Bergquist S, et al. A prospective study of the Pressure Ulcer Scale for Healing (PUSH). J Gerontol A Biol Sci Med Sci 2005;60:93-7. Lepisto¨ M, Erikson E, Hietanen H, et al. Patient with pressure ulcers in Finnish hospitals. Int J Pract 2001;7:280-7. O¨zgenel GY, Kahvecı R, Akın S, et al. Basi Yaralarında Tedavi Prensiplerimiz ve Sonuc¸larımız. Uludag˘ U¨niversitesi Tıp Faku¨ltesi Dergisi [Uludag˘ Univ Med Faculty J]. 2002;28:27-32. http://uludagtipdergisi.org/pdf/pdf_UTF_243.pdf. Last accessed January 27, 2014. Horn SD, Bender SA, Bergstrom N, et al. Description of the national pressure ulcer long-term care study. Am Geriatr Soc 2002;50:1816-25. Uzun O¨, Tan MA. Prospective, descriptive pressure ulcer risk factor and prevalence study at a university hospital in Turkey. Ostomy Wound Manage 2007;53:44-56.
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Features of Pressure Ulcers in Hospitalized Older Adults Hu¨lya Eskiizmirli Aygo¨r, MSN; Sevnaz Sahin, MD; Emine So¨zen, MSN; Basak Baydal, HN; Fisun Senuzun Aykar, Prof Dr; and Fehmi Akc¸ic¸ek, Prof Dr
ABSTRACT BACKGROUND: The objectives of this study were to examine the prevalence and risk of pressure ulcers (PrUs) among hospitalized patients 65 years or older in a university hospital setting and to assess the potential for prevention and healing in that population. METHODS: The retrospective study conducted at the general medicine departments of Ege University Hospital in Izmir, Turkey, included 209 patients (115 females, 94 males) 65 years or older, who had been admitted to the hospital for a variety of reasons between April 1, 2011, and October 1, 2011. The following tools were used to collect data: a data collection form to identify the sociodemographic and medical characteristics of the patients, the Braden Risk Assessment Scale to assess the risk of PrUs, and a form to monitor PrUs, which included the site of the PrU, the category, and the PUSH (Pressure Ulcer Scale for Healing) score, a tool for tracking changes in PrUs status applied at weekly intervals. RESULTS: The mean patient age was 73 (6.4) years. The prevalence of PrUs was 5.8% during the hospital stay. Pressure ulcers appeared most frequently in the ischeal tuberosity area (40%), and 45.2% of all PrUs observed were category II. The comorbidities of the patients who had PrUs were as follows: rheumatoid arthritis, 40% (n = 5); acute renal failure, 24% (n = 3); multiple myeloma, 8% (n = 1); chronic renal failure, 8% (n = 1); pneumonia, 8% (n = 1); and acute lymphoblastic leukemia, 8% (n = 1). CONCLUSIONS: Pressure ulcers are a common healthcare complication in the older adult population, with potentially severe consequences. The most important intervention that healthcare professionals can make to reduce PrUs is to determine and address risk factors. KEYWORDS: pressure ulcers, older adults, prevention and healing ADV SKIN WOUND CARE 2014;27:122Y6
INTRODUCTION Pressure ulcers (PrUs) are defined as skin breakdown and deeper tissue damage of ischemic etiology secondary to external pressure, usually occurring over bony prominences.1 Pressure ulcers affecting older adults can cause significant mortality and morbidity, but often are preventable if appropriate and essential precautions are
taken. Older adult patients are more likely to experience PrUs because of their vulnerability due to the aging process and because of the increased incidence of chronic conditions.2,3 Pressure ulcers cause extreme discomfort to the patient and often lead to serious, life-threatening infections, which substantially increase the total cost of care.4 Pressure ulcers are a severe burden for patients, with negative psychological, physical, and social consequences that are damaging to health, well-being, and healthrelated quality of life.5 They are, in many cases, preventable, and prevention is more affordable than treatment of established ulcers. Current evidence indicates that risk assessment, skin care, education, using support surfaces, repositioning the patient, optimizing nutrition, and maintaining optimal sacral skin moisture are effective strategies to preventing PrUs.6 Pressure ulcer prevalence studies indicate that prevalence varies according to the patient characteristics of communities. Margolis et al7 evaluated 200,000 persons aged 65 years or older using a patient-record database called the General Practice Research Database. In that study, the prevalence of PrUs varied from 0.31% to 0.70%.7 Theisen et al8 evaluated 3198 patients 75 years or older in a 1350-bed German university hospital. Of those patients, 7.1% developed an ulcer during their hospitalization, of which 87.3% were classified as categories I and II.8 Moore and Cowman9 evaluated 1100 older individuals residing in 12 long-term-care settings in the Republic of Ireland and reported a PrU prevalence of 9%. Ferrell et al10 evaluated 3048 patients admitted to home care programs in the United States. In that study, it was identified that 9.12% developed at least 1 PrU, 37.4% had more than 1 ulcer, and 14.0% had 3 or more ulcers. Most of these were category II.10 Igarashi et al11 evaluated 720 randomly sampled, long-term-care hospitals in Japan and reported a PrU prevalence of 9.6%. Landi et al12 evaluated 3103 patients admitted to home care programs in Italy and identified a PrU prevalence of 18%. Casimiro et al13 evaluated 827 older adults in institutional settings in Spain and found a PrU prevalence of 35.7%. Research into PrU prevalence in older adults in Turkey is limited. Do¨ventaz et al14 evaluated 3101 individuals 60 years or older in a university hospital and found that the prevalence of PrUs was ¨ ztunc¸15 evaluated 404 patients 18 years or older 6.75%. Inan and O in a university hospital, reporting a PrU prevalence of 10.4%. This
Hu¨lya Eskiizmirli Aygo¨r, MSN, is a Nurse; Sevnaz Sahin, MD, is a Physician; and Basak Baydal, HN, is the Senior Director of Nursing, Internal Medicine at the Ege University Medical Faculty, Internal Medicine Department Geriatrics Section in Izmir, Turkey. Emine So¨zen, MSN, is a Research Assistant; and Fisun Senuzun Aykar, Prof Dr, is an Instructor at the Ege University Izmir Ataturk Institute of Health Science in Izmir, Turkey. Fehmi Akc¸ic¸ek, Prof Dr, is a Professor at Ege University. The authors have disclosed that they have no financial relationships related to this article. Submitted November 14, 2012; accepted in revised form March 8, 2013. ADVANCES IN SKIN & WOUND CARE & VOL. 27 NO. 3
122
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ORIGINAL INVESTIGATION
study was conducted to evaluate PrU risk, prevalence, and healing among hospitalized patients 65 years or older in a university hospital setting.
METHODS This study included 209 patients (115 women, 94 men) 65 years or older as part of a retrospective study in the general medicine department (n = 129), which includes an intensive care unit (n = 12) at Ege University Hospital in Izmir, Turkey. The study was performed from April 1, 2011, to October 1, 2011. The data were collected retrospectively from archived patient files and recorded on a special form designed by the lead researcher. The study procedures were approved by the Ege University Medical Faculty and Medical Faculty Research Ethics Committee. The data collection form captured patients’ demographic information, patient medical diagnosis, and duration of hospital stay. Both the Braden Risk Assessment Scale and the Pressure Ulcer Scale for Healing (PUSH) were recorded weekly.16,17 The Braden Scale is often the preferred tool for assessing the risk of PrUs. It consists of 6 categories: sensory perception (how the patient responds to pressure-related discomfort), moisture (how exposed skin is to moisture), activity (how physically active the patient is), mobility (whether the patient can change and control body position), nutrition (what the patient normally eats), and friction/shear. The total score can vary from 6 to 23, with a lower score indicating a higher risk. Patients with a Braden Scale score of less than 18 (or a low score on any subscale) require intervention.16,18 Pınar and Oguz19 established the validity and reliability of a Turkish language version of the Braden Scale for Pressure Sore Risk. The Braden Scale is used by nurses in all wards of the authors’ hospital. The PUSH provides a valid measure of PrU healing over time and accurately differentiates a healing from a nonhealing ulcer. It is a clinically practical, evidence-based tool for tracking changes in PrU status when applied at weekly intervals. The PUSH scale comprises 3 parameters: surface area of the wound, quantity of exudates in the wound, and tissue type of the wound. Total scores change from 0 to 17, with higher scores indicating more severe ulcers.17,20 Data were analyzed using SPSS (Statistical Package for the Social Sciences, Chicago, Illinois) version 15. Statistical association was tested with the W2 test.
(SD, 6) years in the study. The mean hospital length of stay was 11.7 (SD, 8) days. The mean medication number was 6 (SD, 3.22). Pressure ulcer prevalence was detected at 5.8% (n =1 2). No PrUs developed in 197 patients (94.2%). Ten patients (4.7%) had PrUs prior to hospitalization. Two patients who had no PrUs before hospitalization developed a PrU during hospitalization. Four patients who had PrUs prior to hospitalization developed additional PrUs while hospitalized. The mean age of patients who developed new PrUs during hospitalization was 78.5 (SD, 11) years. The mean hospital length of stay was 25 (SD, 11) days. The mean medication number was 6 (SD, 3). Their diagnoses were rheumatoid arthritis, chronic renal failure, and multiple myeloma. Four patients (33%) had only 1 PrU, 4 patients (33%) had 2 PrUs, 2 patients (17 %) had 3 PrUs, and 2 patients (17%) had 4 PrUs. The majority of PrUs were located on the ischeal tuberosity (40%), coccyx (18%), and sacrum (12%) (Figure 1). Eleven (42%) patients’ PrUs were category I, and 13 (50%) patients’ PrUs were category II (Figure 2). Two PrUs resolved during hospitalization. The most common diseases of the patients were malignancy, 10.6% (n = 39); diabetes, 8.2% (n = 30); acute renal failure, 6.8% (n = 25); and rheumatoid arthritis, 6.5% (n = 25). Nine percent (n = 61) of patients had a chronic condition; 28.2% (n = 58) of patients had 2 chronic conditions; 20.6% (n = 43) of patients had 3 chronic conditions; and 12.4% (n = 26) of patients had 4 chronic conditions. The mean Braden Scale score was 19. Two patients who had no PrUs prior to hospitalization developed a PrU during hospitalization. Four patients who had PrUs before hospitalization developed new PrUs while hospitalized. In other words, 6 patients (2.8%) developed a new PrU during hospitalization. The medical conditions of the patients who had PrUs before admission were as follows: rheumatoid arthritis, 40% (n = 5); Figure 1. FREQUENCY OF PRESSURE ULCERS OBSERVED AT EACH SITE
RESULTS A total of 1469 patients 18 years or older were admitted to the internal medicine and intensive care unit during the data collection process. Two hundred nine patients (15%) 65 years or older were included in the study. Of these, 110 (55.8%) of patients were female, and 87 (44.2%) were male. Their mean age was 72.8 WWW.WOUNDCAREJOURNAL.COM
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Figure 2. FREQUENCY OF CATEGORY OF PRESSURE ULCERS OBSERVED AT EACH SITE
acute renal failure, 24% (n = 3); multiple myeloma, 8% (n = 1); chronic renal failure, 8% (n = 1); pneumonia, 8% (n = 1); and acute lymphoblastic leukemia, 8% (n = 1). The medical conditions of patients who developed a new PrU during hospitalization were as follows: rheumatoid arthritis, 50% (n = 3); multiple myeloma, 17% (n = 1); acute renal failure, 17% (n = 1); and chronic renal failure, 17% (n = 1).
Figure 3. FREQUENCY OF BRADEN RISK ASSESSMENT SCALE SCORE
The mean Braden Risk Assessment Scale score of patients with PrUs was 13. There were 159 patients (76%) deemed at low risk for PrU development with a Braden Scale score between 19 and 23; 33 patients (15.7%) scored between 15 and 18 and were classified at mild risk for PrUs; 9 patients (4.3%) scored 13 to 14, indicating moderate risk; 7 patients (3.3%) scored 10 to 12 and were classified as high risk; and 1 patient (0.4%) scored 9 or less, indicating a very high risk (Figure 3). The mean Braden Risk Assessment Scale score did not change in any patient from admission to clinic up to discharge. Ten patients (patients 4.7%) had a PrU prior to hospitalization. The mean PUSH was 8.6 on admission to hospital and 7.4 on discharge. During hospitalization, 69.2% of the PrUs did not change, 11.5% of the PrUs improved, and 7.8% of the PrUs resolved completely. However, in 11.5% of patients, the PrUs deteriorated (Figure 4). The most common medical conditions of patients whose PrUs did not change during hospitalization were rheumatoid arthritis (n = 1), multiple myeloma (n = 1), acute renal failure (n = 2), and acute lymphoblastic leukemia (n = 1). There appears to be no statistical difference in gender or age between the patient group who exhibit PrUs and those who have none (P 9 .05). The likelihood of having a PrU increased with the number of chronic diseases a patient had.
DISCUSSION Patients were monitored using the Braden Scale during their stay in the clinic. The authors found a PrU prevalence of 5.8% in the group of 209 patients in medical and intensive care units. The authors’ finding is comparable to that of Do¨ventaz et al,14 who reported a 6.75% prevalence rate in 1303 patients 60 years or older at a university hospital.14 It is also broadly similar to Figure 4. FREQUENCY OF OBSERVED PRESSURE ULCER HEALING
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Theisen et al,8 who reported a 7.1% prevalence rate in 3198 patients 75 years or older conducted at a 1350-bed German university. The most common site for PrUs in this study was the ischeal tuberosity (40%), followed by the coccyx (18%) and the sacrum (12%). Moore and Cowman9 reported that the majority of PrUs occurred over the sacrum (58%) and the heel (25%).9 ¨ ztunc¸15 reported the most common site as the sacrum Inan and O (43.9%), followed by the trochanters (17.9%) and heels (13.7%). ¨ zgenel et al22 also reported that the Lepisto¨ et al21 and O majority of PrUs occurred over the sacrum (33% and 43%, respectively). In a study of 2420 US patients, Horn et al23 found that PrUs usually occurred on the heels (22%), with the sacrum ranked fourth, accounting for 12%. The findings in the studies of ¨ ztunc¸, Lepisto¨ et al, and O ¨ zgenel Moore and Cowman, Inan and O et al are mutually supportive but contrast with the results of this study. The differences may have been attributable to the differences in the size of the sample. In the authors’ study, category II PrUs were most common (50%). This finding is similar to that of Ferrell et al,10 who reported that 40.3% of the PrUs observed in their study were category II.10 Moore and Cowman9 reported that 33% of the PrUs observed in their study were category II. By contrast, category I PrU was most common in Uzun and Tan’s24 study, accounting for 72.3% of all observed ulcers. Thirty-four percent of the authors’ patients were deemed to be at risk for PrU development. The authors’ findings are similar to ¨ ztunc¸,15 who reported that 35.7% of a group those of Inan and O of 404 patients were at risk for PrU development in a universitybased hospital in Adana, Turkey.15 Ferrell et al10 reported that 30% were at risk in a group of 3048. Risk identification is crucial as it signals the need to implement an individualized prevention program. Education and training are needed to increase clinical awareness of the value of risk assessment in patient care. Thirtyfour percent of the patients were identified as being at risk according to the Braden Scale, but new PrUs developed in only 12% of the at-risk patient group for whom precautions were taken. These precautions were as follows: positioning every 2 hours, skin care, antifriction cream, friction and tearing prevention, heel protection, moisture management, diet control, provision of an air bed, and mobility. In this study, 69.2% of PrUs did not change, 11.5% PrUs improved, 7.8% PrUs fully resolved, and 11.5% of PrUs deteriorated during hospitalization. This finding is similar to that of Do¨ventaz et al,14 who reported that 57.5% of PrUs did not change, whereas 16.3% improved, 17.5% fully resolved, and 8.8% deteriorated. Despite all precautions, such as positioning every 2 hours, skin care, and friction and tearing prevention, 3 patients’ PrUs deteriorated during hospitalization. These patients’ diagnoses
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were chronic renal failure, rheumatoid arthritis, and pneumonia. The mean hospital stay was 24 days, and the mean age was 74 years. There was no statistical difference in gender or age between the patient groups with and without PrUs in the authors’ study. This finding is similar to the studies by Landi et al12 and Casimiro et al.13 The likelihood of developing a PrU increased with the number of chronic medical conditions a patient had but was not significantly affected by gender or age. The diagnoses of the diseases were: rheumatoid arthritis/arthritis, multiple myeloma, and renal failure. By contrast, in Landi et al,12 patients with PrUs did not show a significant difference in comorbidity. The patterns of PrU development in the studies of Landi et al12 and Casimiro et al13 differed from those observed in the authors’ hospital. Six patients (2.8%) developed a new PrU during hospitalization. The most important intervention that healthcare professionals can make to reduce PrUs is to determine the risk factors, and the most objective, reliable, and cost-effective method of doing this is to use risk assessment tools. At Ege University Hospital, all patients are considered to be at risk for PrU development. The Braden Risk Assessment is applied on admission to hospital and once every week by nurses. Any patient whose Braden score is less than or equal to 18 is positioned every 2 hours. The patient’s skin is kept clean and dry and moistened. Measures to prevent friction and tearing and to provide heel protection, support surface control, dietary control, and motion exercise are reviewed every 2 hours.
LIMITATIONS The study was conducted with 209 patients 65 years or older in a university hospital in Turkey, and the results may not be generalized.
CONCLUSION The prevalence of PrUs was found to be 5.8%. Pressure ulcer risk assessment indicated that 34% of the authors’ patients were deemed at risk for PrU development. Ulcers occurred most frequently in the sacral area. Slightly less than half of the PrUs present were category II. The most common location of PrU in the authors’ study was the ischeal tuberosity area (40%). A continued focus must be maintained on training staff so they are able to identify patients at risk of PrU development.
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4. Russo AC, Steiner C, Spector W. Hospitalizations Related to Pressure Ulcers among Adults 18 Years and Older, 2006. Rockville, MD: US Agency for Healthcare Research and Quality: Healthcare Cost and Utilization Project (HCUP); 2008. www.hcup-us.ahrq.gov/reports/statbriefs/ sb64.jsp. Last accessed January 27, 2014. 5. Gorecki C, Brown MJ, Nelson EA, et al. Impact of pressure ulcers on quality of life in older patients: a systematic review. J Am Geriatr Soc 2009;57:1175-84. 6. NPUAP. Pressure Ulcer Prevention Points. http://www.npuap.org/resources/educationaland-clinical-resources/pressure-ulcer-prevention-points. Last accessed December 3, 2013. 7. Margolis D, Bilker W, Knauss J, et al. The incidence and prevalence of pressure ulcers among elderly patients in general medical practice. Ann Epidemiol 2002;12:321-5. 8. Theisen S, Drabik A, Stock S. Pressure ulcers in older hospitalised patients and its impact on length of stay: a retrospective observational study. J Clin Nurs 2012;21:380-7. 9. Moore Z, Cowman S. Pressure ulcer prevalence and prevention practices in care of the older person in the Republic of Ireland. J Clin Nurs 2012;21:362-71. 10. Ferrell BA, Josephson K, Norvid P, et al. Pressure ulcers among patients admitted to home care. J Am Geriatr Soc 2000;48:1042-7. 11. Igarashi A, Yamamoto-Mitani N, Gushiken Y, et al. Prevalence and incidence of pressureulcers in Japanese long-term-care hospitals. Arch Gerontol Geriatr 2013;56:220-6. 12. Landi F, Onder G, Russo AR, et al. Pressure ulcer and mortality in frail elderly people living in community. Arch Gerontol Geriatr 2007;1:217-23. 13. Casimiro C, Lorenzo A, Usa L. Prevalence of decubitus ulcer and associated risk factors in an institutionalized Spanish elderly population. Nutrition 2002;18:437-8. 14. Do¨ventaz A, Bic¸en E, Neymen A, et al. Prevalence of pressure sores in elderly patients at the General Medicine Department of Cerrahpaza Medical Faculty, Istanbul University, Akademik
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