Pressure ulcer incidence and risk factors in ventilated intensive care patients

doi:10.1016/j.jcrc.2009.09.002

Journal of Critical Care

Volume 25, Issue 3, September 2010, Pages 469-476

https://doi.org/10.1016/j.jcrc.2009.09.002 Get rights and content

Abstract

Purpose

The aim of this study was to determine the incidence of pressure ulcers (PUs) in ventilated patients in all intensive care units (ICUs) in Granada (Spain) and identify risk factors for their development.

Materials and Methods

A prospective cohort study in 9 medical-surgical ICUs was conducted. Two hundred ninety-nine patients with more than 24 hours on mechanical ventilation (MV) were enrolled during 2 periods in a 5-month study. Pressure ulcers of patients were measured according to the European Pressure Ulcer Advisory Panel.

Results

Of the 299 patients initially enrolled, 47 (16%) developed PUs of at least grade II severity. The incidence density of PUs was 13.4 cases per 1000 patient-days of ICU stay and 19.6 cases per 1000 patient-days on MV. Logistic regression identified first-day respiratory sequential organ failure assessment (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.026-2.360; P = .037), fourth-day cardiovascular sequential organ failure assessment (OR, 1.33; 95% CI, 1.066-1.664; P = .012), age (OR, 1.042; 95% CI, 1.013-1.072; P = .004), winter period (OR, 4.60; 95% CI, 1.99-10.59; P < .001), and length of MV before PUs (OR, 1.042; 95% CI, 1.005-1.080; P = .024) as significant independent predictors of PU development.

Conclusions

Among other factors previously known in ventilated patients, duration of MV and winter period were identified as risk factors for PUs.

Introduction

Pressure ulcers (PUs) pose a major health care challenge and are associated with an increased risk of infection and sepsis [1], disability, high level of dependence [2], longer hospital stay, and higher hospitalization costs [2], [3], [4]. Their reported incidence in critical care patients varies widely from 1% to 56%, which can be attributed to differences in clinical settings, study populations, methodology, and the definition of a PU [5], [6], [7], [8], [9], [10]. More than 100 risk factors for the development of PUs in a general hospital population have been identified in the literature [3]. Critical care patients usually have multiple risk factors for a PU, which tends to have a greater effect in this patient population [6], [8], [11]. The risk of a PU varies among intensive care unit (ICU) patients and is higher in some subgroups, especially those on mechanical ventilation (MV) [12]. Some characteristics of patients who require MV make them especially susceptible to the development of PUs, including mobility limitations; loss of sensory perception due to sedation and analgesia; maceration of skin due to incontinence, sweating, or leaking wounds; and frequent hemodynamic and oxygenation disorders. Nevertheless, the importance of the different risk factors implicated remains controversial [6], [12].

Pressure ulcer prevention can often be successful and is less costly than the treatment of established ulcers [13]. The first step is to correctly identify the patients at risk, but available PU risk assessment scales are not useful to discriminate the risk of PU in critical or other hospitalized patients [6], [14], [15]. New scales have been proposed for ICU patients, but these have not been validated [16], [17]. Few studies have been published on the incidence of PU in ventilated patients, a high-risk group [18], [19], and none have analyzed their specific risk factors. Information on PU incidence and risk factors in patients on MV may be especially useful for the early and appropriate implementation of preventive measures, with the consequent costs savings [13]. With this background, the objectives of this study were to determine the incidence of PUs (≥grade II) in subjects receiving MV for more than 24 hours and to prospectively identify the main risk factors for the development of PUs by these patients in the ICU.

Section snippets

Methods

This prospective cohort study was conducted in all 9 ICUs (94 beds) in the 5 hospitals in Granada province (Spain) from January to March and June to July 2001, for a total of 5 months. The study was approved by the ethical committees of participating hospitals who waived the need for written informed consent.

We included all patients on MV with either endotracheal intubation or noninvasive ventilation for more than 24 hours during their ICU stay. Exclusion criteria were pregnancy and age greater

Patient characteristics

Of the total of 1563 patients admitted to the ICU during the 5 months of the study, 299 patients (19%) required MV for 24 hours or more and were enrolled in the study. None of these patients were lost to follow-up. Table 1, Table 2 show the demographic and clinical characteristics of the patients. The mean (SD) age was 60 (17) years, 68% were male, and the mean (SD) APACHE III score was 71 (26) points. The median time on MV was 5 days (IQR, 2-13), and the mean (SD) time was 10 (15) days. The

Discussion

In this series of 299 patients requiring MV for more than 24 hours, the incidence density of PUs (≥grade II) was 13.4 cases per 1000 patient-days of ICU stay. Various independent predictors of PU development were identified, including higher age, worse first-day respiratory SOFA score, worse fourth-day cardiovascular SOFA score, and, interestingly, the winter season and duration of MV.

Acknowledgments

This study would have not been possible without the collaboration of the nursing staff in participating ICUs.

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This retrospective and correlational study was conducted between March 2021- May 2022. The electronic patient data were obtained from 148 surgical and medical patients exposed to vasopressor agents in the intensive care unit. Data on patients' demographic and clinical characteristics were evaluated using descriptive statistical methods (number, percentage, mean, standard deviation). Logistic regression modelling was used to assess independent relationships with pressure injury risk; results are reported as odds ratios (OR) and 95% confidence intervals (CI).
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To examine the thoughts, deliberations and actual practices of intensive care unit (ICU) nurses regarding pressure injury (PI) prevention.
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ICU nurse practices in PI prevention lack systematic approaches and evidence-based recommendations. These disadvantages emerge as inter- and intra-individual variances in implementing preventive practices in actual practice. Considering these divergences is crucial for the effective management of PI risk.
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Citation Excerpt :
This result is consistent with the findings of previous studies (Cox, 2011; Cremasco et al., 2013; Nassaji et al., 2014; Tayyib et al. 2016). Patients who required MV were 10.25 times more likely to have MDRPIs than patients who did not, which was supported by other studies (Manzano et al., 2010; Cox and Roche, 2015). In our study, 64 of the 84 patients with MDRPIs received MV for more than 24 h. Perhaps the need for prolonged MV is an indication of both immobility and severe illness, both of which are associated with an increased risk for PIs.
This study aimed to investigate the cumulative incidence, characteristics, and risk factors of medical device-related pressure injuries (MDRPIs), including patient outcomes, in the intensive care unit (ICU) of a university hospital.
A prospective observational cohort study.
The study was conducted in an university hospital between November 2019 and October 2020.
The study included patients over the age of 18 years who had a device in situ and stayed in the ICU for more than 24 h. Each device was monitored twice a day for 15 days; the clinical assessment was performed daily until ICU discharge or death. The Case Report Form, MDRPI Monitoring Form, Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation (APACHE-II), Braden Scale, National Pressure Injury Advisory Panel (NPIAP) staging and categories, and Glasgow Coma Scale (GCS) were used for data collection. Patients with and without MDRPIs were compared for demographic and clinical characteristics, length of ICU stay, and mortality by using t-test and Chi-square test. Cumulative incidence was calculated. Logistic regression model was used to investigate risk factors.
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Citation Excerpt :
First, Cremasco et al.23 found that the SAPS II score was independently associated with PI. Second, Manzano et al.24 found that the Sequential Organ Failure Assessment score was independently associated with PI among critically ill patients. Third, recently, in a retrospective study of 4899 patients admitted to the ICU, Ahtiala et al.25 found that the first-day total Sequential Organ Failure Assessment score and its respiratory and cardiovascular subcategory scores were the most important predictors of PI.
The prevalence of pressure injuries (PIs) in critically ill patients has been extensively studied, but there is uncertainty regarding the risk factors. The main objective of this study was to describe the prevalence of PIs in critically ill patients. Secondary objectives were to describe PI, use of preventive measures for PI, and factors associated with occurrence of PI in the intensive care unit (ICU).
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Systematic review and meta-analysis of incidence and prevalence
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Fifteen studies met the criteria for inclusion in the systematic review, of which 14 were incidence studies. Heterogeneity was significant and there was large observed variance between studies. The 95% confidence interval of cumulative incidence across all 14 studies, with an overall sample size of 6371, was 9.8–25.6%. In 11 studies that included all-stage pressure injury the 95% confidence interval was 8.3–28.3%. In seven studies in which Stage 1 pressure injury was excluded, the 95% confidence interval was 5.8–22.7%. In the single prevalence study included, which excluded Stage 1 pressure injury, prevalence was 8.8%.
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View all citing articles on Scopus

¹: See Appendix A.

View full text

Respiratory/VentilationPressure ulcer incidence and risk factors in ventilated intensive care patients

Abstract

Purpose

Materials and Methods

Results

Conclusions

Introduction

Section snippets

Methods

Patient characteristics

Discussion

Acknowledgments

Aust Crit Care

Med Intensiva

Applied Nursing Research

Intensive Crit Care Nurs

Chest

Crit Care Nurs Clin North Am

AORN J

Bacteremia associated with decubitus ulcers

Arch Intern Med

Patients' stories of living with a pressure ulcer

J Adv Nurs

Pressure ulcer prevention and management

JAMA

Effect of pressure ulcers on length of hospital stay

Infect Control Hosp Epidemiol

Pressure sores among hospitalized patients

Ann Intern Med

Pressure ulcers in intensive care patients: a review of risk and prevention

Intensive Care Med

Pressure ulcer risk factors in an ICU population

Am J Crit Care

The clinical relevance of the Waterlow pressure sore risk scale in the ICU

Intensive Care Med

Hospital-acquired pressure ulcers. Risk factors and use of preventive devices

Arch Intern Med

Incidence and risk factors for pressure ulcers in the intensive care unit

J Clin Nurs

Preventing pressure ulcers: a systematic review

JAMA

Prospective cohort study of risk assessment scales for prediction of pressure ulcers

BMJ

Development of a new risk assessment scale for predicting pressure ulcers in an intensive care unit

Nurs Crit Care

Respiratory/Ventilation
Pressure ulcer incidence and risk factors in ventilated intensive care patients