Mapping the incidence and prevalence of
pressure ulcers in the UK:
a rapid literature review
27th February 2012
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Review history
Development Stage
Date
Name
Proforma agreed with
EAC
Literature search
completed
Early November 2011
Julian Flowers
Mid-November 2011 and
early February 2012
First draft completed
24th November 2011
Roy Marsh and east of
England library &
information services
Roy Marsh
Second draft completed
27th February 2012
Roy Marsh
Peer-reviewed
Final evidence review
completed
Contact information
Author: Roy Marsh, Research Fellow
Address:
Evidence Adoption Centre
Douglas House
18 Trumpington Road,
Cambridge
CB2 8AH
Tel. 01223 746161
roy.marsh@cpft.nhs.uk<mailto:roy.marsh@cpft.nhs.uk>
www.eac.cpft.nhs.uk
Peer-reviewer: TBA
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Table of contents
1
2
3
4
5
6
7
8
9
Executive summary ............................................................................................ - 5 Request / scope of the review ............................................................................. - 6 Introduction ........................................................................................................ - 7 Methods .............................................................................................................. - 9 4.1 Inclusion / exclusion criteria ........................................................................ - 9 4.2 Data sources ................................................................................................. - 9 4.3 Search strategy ............................................................................................. - 9 4.4 Quality assessment ..................................................................................... - 10 4.5 Data extraction ........................................................................................... - 10 4.6 Data analysis and synthesis ........................................................................ - 10 Results .............................................................................................................. - 11 5.1 Prevalence .................................................................................................. - 12 5.1.1
Prevalence – grades 2-4 ...................................................................... - 13 5.1.2
Prevalence – grades 2-4 (Hospitals) ................................................... - 15 5.1.3
Prevalence – all grades ....................................................................... - 17 5.1.4
Prevalence – breakdown by grade ...................................................... - 19 5.1.5
Exclusions from pooled data tables and charts ................................... - 21 5.2 Incidence .................................................................................................... - 22 5.3 Explaining the variations ........................................................................... - 23 5.4 Risk factors / predictors of pressure ulcers ................................................ - 24 5.4.1
Risk factors combined ........................................................................ - 24 5.4.2
Risk factors by individual study ......................................................... - 26 5.5 Methods studies ......................................................................................... - 31 5.6 The ‘Grey’ Literature ................................................................................. - 32 Conclusions ...................................................................................................... - 33 6.1 Implications for practice ............................................................................ - 33 6.2 Recommendations for further research ...................................................... - 33 6.3 Limitations of this review .......................................................................... - 33 Acknowledgements .......................................................................................... - 33 References ........................................................................................................ - 34 8.1 Studies included in the review ................................................................... - 34 8.2 Studies included only for risk factor identification.................................... - 37 8.3 Studies not included in the review ............................................................. - 39 Appendices ....................................................................................................... - 41 9.1 Appendix 1 – Search History .................................................................... - 41 9.2 Appendix 2 – EPUAP definition of pressure ulcer grades ........................ - 43 9.3 Appendix 3 – Individual study summaries ................................................ - 44 9.3.1
James 2010 (Hospital) ........................................................................ - 44 9.3.2
Gethin 2005 (Hospital) ....................................................................... - 44 9.3.3
Vanderwee 2007 (Hospital) ................................................................ - 45 9.3.4
Vanderwee 2011 (Hospital) ................................................................ - 45 9.3.5
Gallagher 2008 (Hospital) .................................................................. - 45 9.3.6
Bours 2001(Hospital) ......................................................................... - 46 -
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9.3.7
9.3.8
9.3.9
9.3.10
9.3.11
9.3.12
9.3.13
9.3.14
9.3.15
9.3.16
9.3.17
9.3.18
9.3.19
9.3.20
9.3.21
9.3.22
9.3.23
9.3.24
Kottner 2009c (Hospital) .................................................................... - 46 Stausberg 2005 (Hospital) .................................................................. - 46 Lindholm 2008 (Hospital) .................................................................. - 47 Schoonhoven 2007 (Hospital / incl. Incidence).................................. - 47 Stausberg 2005 (Hospital) .................................................................. - 48 Srinivasaiah 2007 (Mixed) ................................................................. - 48 Vowden 2009* (Mixed) ..................................................................... - 48 Lahmann 2005 (Mixed) ...................................................................... - 49 Lahmann 2006 (Mixed) ...................................................................... - 50 Margolis 2002 (Primary) .................................................................... - 50 McDermottScales 2009 (Primary) ...................................................... - 51 Raghavan 2002 (Primary / Spinal) ..................................................... - 51 Bick 2003 (Nursing) ........................................................................... - 51 Schoonhoven 2002 (Hospital / Incidence).......................................... - 52 Galvin 2002 (Hospital / Incidence) .................................................... - 52 Lardenoye 2009 (Hospital / Incidence) .............................................. - 53 Excluded - Kroger 2009 (Hospital) .................................................... - 53 Excluded - Popp 2006 (Nursing / Incidence) ..................................... - 53 -
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1 Executive summary
Pressure ulcers are a serious yet avoidable problem in hospitals, nursing homes and
other settings. The extent of the problem is, however, unclear, since there is no
national systematic and standardised process for reporting pressure ulcers.
To help fill this information gap, the EAC was asked by the Eastern Region Public
Health Observatory to carry out a mapping review of the published research literature
on the incidence and prevalence of pressure ulcers, on a population basis. The EAC
was also asked to identify a) key determinants of pressure ulcers, e.g. age, disease,
dependency, mobility and b) the methodological and contextual factors that are related
to variations in reported PU incidence and prevalence.
A rapid evidence review was carried out between end 2011 and early 2012. Sixty-four
audits or other data collections reporting the prevalence and/or incidence of pressure
ulcers were found, concerning the UK, Ireland, the Netherlands, Belgium, Germany
and pan-European studies. From the pooled data available, the prevalence of pressure
ulcers was broadly delimited? Is this the correct word? . The incidence of pressure
ulcers remains unclear.
Prevalence
The reported prevalence varies from 1.4% (Stausberg, 2005) to 28.7% (Bours, 2001).
Prevalence
10.27%
10.74%
15.19%,
Grades 2-4
Grades 2-4 Hospitals
All grades
95% CI
7.85%-12.7%.
8.31%-13.16%.
12.77%-17.62%
Pooled prevalence with CIs
Incidence
Only three studies were found that reported on incidence for all grades of pressure
ulcer. These suggest that there is tenfold difference in the incidence of pressure ulcers
between settings, possibly related to whether they are high or low risk settings.
Setting
Grade1
Grades2-4
Denominator Nos
Galvin2002
Schoonhoven2002
Lardenoye2009
Palliative care
Post-surgery
11.99%
10.89%
542
10.10%
10.10%
208
Long-term, all
patients
1.25%
1.13%
22,030
Incidence, as reported in three studies
Many risk factors were also reported in the literature and are listed in this review.
The reporting procedure itself may also affect the prevalence and incidence figures.
Much work is still needed to standardise reporting, and improve reliability.
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2 Request / scope of the review
The EAC was asked by Julian Flowers, Director of ERPHO, to do a mapping review
of epidemiological studies of the prevalence and incidence of pressure ulcers. As
specified in the review proforma, the aim was to provide background information that
would facilitate the following regional tasks:
1. Identify key issues in pressure ulcer measurement
2. Establish expected incidence and prevalence on a population basis and identify
a) key determinants e.g. age, disease, dependency, mobility and b) the
methodological and contextual factors that are related to variations in
reported PU incidence and prevalence
3. Apply estimates from the literature to the SHA population to give expected
ulcer incidence and prevalence rates
4. Establish the likely burden of pressure ulcers in terms of cost, quality of life
Not all the four tasks could be undertaken in this review, given the limited time and
human resources available. Task 1 (identifying the issues) has already been
documented in Fletcher (2001), while tasks 3 and 4 require extensive collation and
analysis of regional data, outside the scope of this review. The focus was therefore on
Task 2, and the principal questions identified and addressed were:


What is the incidence / prevalence of PU’s in the UK?
What are the risk factors for pressure ulcers?
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3 Introduction
‘Pressure ulcers are a potentially serious outcome of a failure of routine medical
and nursing care. The cost of treating a pressure ulcer varies from £1,064 (Grade
1) to £10,551 (Grade 4). The total cost in the UK was estimated in 2002 at £1.4–
£2.1 billion annually (4% of total NHS expenditure). Most of this cost is nurse
time. Pressure ulcers therefore represent a heavy cost burden in the UK.’ (Bick,
2003)
Many studies have attempted to measure the frequency with which patients
develop pressure ulcers. But findings are not comparable due to differences in the
methodologies used and the lack of a consistent, systematic and valid approach to
data collection.
Pressure ulcer frequency is calculated either as prevalence (the number of cases
at a given time) or incidence (the number of new cases occurring within a
predetermined time span). But there are variations in interpreting these two
definitions
The most widely accepted definition of incidence states that it is the percentage of
patients who develop a condition within an at-risk population. However, there
may not be agreement on how to define ‘at-risk.’ Equally other systems capture
data based on number of pressure ulcers rather than number of patients witha
pressure ulcer.
Moreover, if only new ulcers are recorded, it is not clear how to record recurrent
ulcers which may not have occurred in the current care setting.
Similarly, prevalence data does not specify whether patients developed ulcers as a
result of their care or whether they were admitted with them .
There are also differences in the grading systems used and variations in the
definition of grade I ulcers particularly if they are included or excluded from the
data.
All these differences make it difficult to know what the prevalence and incidence
of pressure ulcers actually is. It is also difficult to impose a performancemanagement system based on targets.
In these circumstance, a baseline review of reported surveys and audits of pressure
ulcers is needed, which takes note of the setting and method of assessment, along
with any risk factors.
Guidelines are also needed for assessing and reporting prevalence and incidence.
Work on this topic has been done by the European Pressure Ulcer Advisory Panel
(EPUAP).http://www.epuap.org/guidelines/
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(The above text is abridged from Fletcher, 2001).
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4 Methods
4.1 Inclusion / exclusion criteria
Design
Scope
Observational study (Audit, Survey, Questionnaire)
Methods discussions if relevant to PU assessment
Included
Primarily, any work reporting the incidence or prevalence of
pressure ulcers, based on the collection of real data
Secondarily, studies examining the suitability of identification
and auditing methods, or analysing data to identify causal
factors for pressure ulcers.
Excluded
Studies reporting on staff development for pressure ulcers, or
audits of the implementation of guidelines, or training reports.
Setting
Country
Language
Date
Grey?
Abstracts?
Quality of life studies (‘Living with a pressure ulcer,’ etc.)
Any
UK, Ireland, Germany, Netherlands, Belgium1
English language
Since 2000
Yes (such as PCT or hospital prevalence audits)
Yes, but only if detailed enough (including methods, settings,
study group, country, timescale and summary results), and if
the full text could not be obtained at no cost within a few days.
4.2 Data sources



For reports and other ‘grey’ literature – Internet search.
For published literature – Medline and other popular databases, using Healthcare
Databases Advanced Search (via HDAS with reviewer’s NHS Athens ID).
Library & Information services search
4.3 Search strategy


HDAS (1) keyword, (2) subject headings
Google Advanced Search Permutations of the following terms: audit "pressure
ulcers" .uk (prevalence OR incidence) hospital
Results were scanned and downloaded if detailed data seemed to be readily available.
1
As advised by Jacqui Fletcher, on the grounds that data from these countries will be comparable and
reliable (see acknowledgements)
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.
4.4 Quality assessment
This was not feasible. The limitations of the studies included in this review should
nevertheless be clear from the study summaries, the data reported and the
accompanying notes.
4.5 Data extraction
Data was entered into a spreadsheet and used to generate various tables.
4.6 Data analysis and synthesis
Data was summarised in tabular form and narrative notes made on key points. Some
data pooling was attempted, and several Forest plots were created for various
permutations of studies. Extensive sub-group or sensitivity analysis was not attempted.
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Up to here
5 Results
Twenty-four audits or surveys reporting the prevalence and/or incidence of pressure
ulcers were found, concerning the UK, Ireland, the Netherlands, Belgium, Germany
and pan-European studies. Twenty-eight further relevant studies were found, without
reportable data, but a number reporting on risk factors for pressure ulcers.
Prevalence
The reported prevalence data shows wide variations, from 1.4% (Stausberg, 2005) to
28.7% (Bours, 2001).
Prevalence
10.27%
10.74%
15.19%,
Grades 2-4
Grades 2-4 Hospitals
All grades
95% CI
7.85%-12.7%.
8.31%-13.16%.
12.77%-17.62%
Pooled prevalence with CIs
Incidence
Only three studies were found which reported on incidence, for all grades of pressure
ulcer, as below. These suggest that there is an order of magnitude difference in the
incidence of pressure ulcers between ‘high-risk’ and ‘low-risk’ (Lardenoye) settings.
Setting
Grade1
Grades2-4
Denominator Nos
Galvin2002
Schoonhoven2002
Lardenoye2009
Palliative care
Post-surgery
11.99%
10.89%
542
10.10%
10.10%
208
Long-term, all
patients
1.25%
1.13%
22,030
Incidence reported in three studies
Risk factors
Many risk factors were reported in the literature and are listed in this review. There
was some disagreement between studies on a number of socio-demographic factors:
age, gender, unemployment status, educational level, living status.
Methods
Some methods studies also noted the potential impact of the reporting procedure itself
on prevalence and incidence figures. Improved assessment may mean higher figures.
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5.1 Prevalence
Prevalence is reported in this review in several ways –
1. Grades 2-4 in all settings
2. Grades 2-4 in hospitals only
3. All grades in all settings
The studies’ individual findings were meta-analysed and pooled in a Forest plot. The
confidence intervals were derived from the absolute reported figures using the
Standard Error formula for rates2. Heterogeneity was calculated for a ‘random effects’
model. Calculations were carried out in Microsoft Excel, using an open-access
template obtained from BMC, as submitted by a health research group at the
Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.3
Two spreadsheets are appended: 1) the raw data; 2) the meta-analysis and Forest plots..
The study findings varied hugely – by an order of magnitude between the highest and
lowest-reporting studies – and the heterogeneity figures were so large as to be almost
meaningless. This is hardly surprising, given that the studies varied along so many
dimensions – setting, eligibility criteria, data collection, reporting method, and so on.
Many of the studies’ confidence intervals nevertheless overlapped with the confidence
interval of the pooled result, indicating that some – albeit crude – generalisations may
still be made from the pooled data.
The tables and Forest plots below show the prevalence findings, in the three groups
defined above. Studies whose upper CI bound does not overlap with the pooled CI are
marked in bold red in the table. Studies whose lower CI bound does not overlap with
the pooled CI are marked in bold green in the table. Further charts show the
breakdown of prevalence by grade, for those studies which report all the grades.
Consideration is briefly given as to how the large variability in findings could be
explained. However, proper sensitivity analysis is needed, and other methodological
and contextual factors must also be taken into account. Such issues were beyond the
scope of this review.
2
3
An alternative method, using proportions, gave similar results for SE.
http://www.biomedcentral.com/1756-0500/5/52/abstract
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5.1.1 Prevalence – grades 2-4
The pooled prevalence of pressure ulcers (grades 2-4) was 10.27%, 95% CI 7.85%12.70%. The heterogeneity (Q) was 17.56.
Study
Margolis2002
Kottner 2009b Germany
Vanderwee2011 Belgium
Kottner 2007 Germany not eryth
Lahmann2005 Germany Whole sample
Kottner 2001 Germany not eryth
Kottner 2009a Germany
Lahmann2006 Germany At risk
Vanderwee2007 Europe
Lahmann2005 Germany At risk
Srinivasaiah2007 UK
Schoonhoven2007 Netherlands low
Vowden2009 UK
Gallagher2008 Ireland
James2010 UK Ortho
Schoonhoven2007 Netherlands high
Gethin2005 Ireland
Raghavan2002 UK
Bours2001 Netherlands
Bick2003 UK Audit2
James2010 UK Community
Bick2003 UK Audit1
Summary
Sample
Size
Outcome (as
a proportion)
217 41729
877 17429
1396 19968
1569 20000*
588 11179
2576 20000*
228
5493
892
8747
624
5947
533
4615
179
1645
157
1229
315
1735
64
672
48
581
249
1229
50
519
44
472
155
850
31
337
104
615
33
342
0.01
0.05
0.07
0.08
0.05
0.13
0.04
0.10
0.10
0.12
0.11
0.13
0.18
0.10
0.08
0.20
0.10
0.09
0.18
0.09
0.17
0.10
Events
23
22
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0.10
Although a sensitivity analysis was not carried out, it was noted that, without the large
weight of the Margolis (2002) study, which had a denominator of 41729, the pooled
prevalence was 10.65%, (95% CI 8.23%-13.08%), and the heterogeneity (Q) was 35.2.
(* a crude estimate, obtained by dividing total patient numbers for both studies by two).
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Prevalence of PUs grades 2-4. Y-axis: studies (low SE at top). X-axis: prevalence (%).
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5.1.2 Prevalence – grades 2-4 (Hospitals)
The pooled prevalence of pressure ulcers (grades 2-4) was 10.74%, 95% CI 8.31%13.16%. The heterogeneity (Q) was 25.97.
Study
Kottner 2009b Germany
Vanderwee2011 Belgium
Kottner 2007 Germany not eryth
Kottner 2001 Germany not eryth
Kottner 2009a Germany
Vanderwee2007 Europe
Schoonhoven2007 Netherlands low
Gallagher2008 Ireland
James2010 UK Ortho
Schoonhoven2007 Netherlands high
Gethin2005 Ireland
Bours2001 Netherlands
James2010 UK Community
Summary
Ref
14
13
12
11
10
9
8
7
6
5
4
3
2
1
Events
Sample
Size
Prevalence
(proportion_
877
1396
1569
2576
228
624
157
64
48
249
50
155
104
17429
19968
20000
20000
5493
5947
1229
672
581
1229
519
850
615
0.05
0.07
0.08
0.13
0.04
0.10
0.13
0.10
0.08
0.20
0.10
0.18
0.17
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Prevalence of PUs grades 2-4 in hospitals only. Y-axis: studies (low SE at top). X-axis:
prevalence (%).
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5.1.3 Prevalence – all grades
The pooled prevalence of pressure ulcers (all grades) was 15.19%, 95% CI 12.77%17.62%). The heterogeneity (Q) was 25.99.
PrevAll
PrevDenomNos
Outcome
(effect
size)
21
20
1600
2419
17429
19968
0.09
0.12
19
31
2234
0.01
18
17
16
15
1317
361
1846
76
11179
5493
8747
1854
0.12
0.07
0.21
0.04
14
13
12
118
1078
1129
294
363
81
124
244
78
162
99
49
55
2234
5947
4615
1645
1735
581
672
850
519
615
472
337
342
0.05
0.18
0.24
0.18
0.21
0.14
0.18
0.29
0.15
0.26
0.21
0.15
0.16
Reference
Kottner 2009b Germany
Vanderwee2011 Belgium
Stausberg2005 Germany Period
prevalence
Lahmann2005 Germany Whole
sample
Kottner 2009a Germany
Lahmann2006 Germany At risk
McDermottScales2009 Ireland
Stausberg2005 Germany Point
prevalence
Vanderwee2007 Europe
Lahmann2005 Germany At risk
Srinivasaiah2007 UK All settings
Vowden2009 UK
James2010 UK ortho
Gallagher2008 Ireland
Bours2001 Netherlands
Gethin2005 Ireland
James2010 UK community
Raghavan2002 UK spinal
Bick2003 UK Audit2
Bick2003 UK Audit1
Summary
11
10
9
8
7
6
5
4
3
2
1
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Prevalence of PUs, all grades. Y-axis: studies (low SE at top). X-axis: prevalence (%).
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5.1.4 Prevalence – breakdown by grade
ALL GRADES
Eight studies reported all four grades of prevalence ulcers, with two studies (Bick 2003
and James 2010) containing reports for more than one year or setting.
Reference
Bick2003 UK Audit 2
Bick2003 UK Audit 1
Gethin2005 Ireland
James2010 UK ortho
James2010 UK - hosp
Gallagher2008 Ireland Point prev
Bours2001 Netherlands
Srinivasaiah2007 UK
Vowden2009 UK
Vanderwee2007 Europe
Prev
Grade1
18
22
28
33
58
60
89
37
48
454
Prev
Prev
Prev
Prev
Denom
Grade2 Grade3 Grade4
Nos
28
1
2
337
26
4
3
342
29
8
13
519
29
19
0*
581
45
59
0*
615
46
14
4
672
100
44
11
850
109
58
12
1645
195
80
40
1735
282
199
143
5947
Prev All
49
55
78
81
162
124
244
294
363
1078
* Grade 3 includes grade 4.
Prevalence – absolute numbers for each grade.
Vanderwee (2007) is not included in the chart above, since the much-larger
denominator of that study makes the chart difficult to read.
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Prevalence – relative proportions for each grade
GRADES 1-2 VS. GRADES 3-4
Reference
Bick2003 UK Audit 2
Bick2003 UK Audit 1
Gethin2005 Ireland
James2010 UK ortho
James2010 UK - hosp
Gallagher2008 Ireland
Point prev
Bours2001 Netherlands
Srinivasaiah2007 UK
Vowden2009 UK
Vanderwee2007 Europe
Prev
Grade1-2
46
48
57
62
103
Prev Grade
3-4
3
7
21
19
59
106
189
146
243
736
18
55
70
120
342
Prevalence – numbers in ‘low’ and ‘high’ grades for each study
These figures were combined into two bands – ‘less severe’ (Gardes 1 and 2) and
‘more severe’ (Grades 3 and 4).
A Chi-Square test for this‘high’/’low’ breakdown returned a value of 50.65, meaning
that the studies have highly significantly different findings (at 9 d.f). That is, the
studies do not agree on the balance of more severe vs. less severe pressure ulcers.
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Prevalence – absolute numbers for the two grade bands.
Prevalence – relative proportions for the two grade bands
5.1.5 Exclusions from pooled data tables and charts



Kroger (2009) was excluded because it was not clear what the denominator was.
Popp (2006) was excluded because the prevalence (in either numbers or
percentages), and the denominator numbers were not given in the abstract.
A number of the studies also grouped their reports by clinical condition and/or
surgical procedure. It was not feasible for this review to take such groupings into
consideration. However, this could be done in a future version of the review..
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5.2 Incidence
There were very few studies reporting incidence. The three studies that reported
incidence for each grade of pressure ulcer used different assessment methods in
different settings. It was not therefore considered meaningful to try to pool the data or
make comparisons. It may nevertheless be noted that the largest study, based on longterm data for all patients, reported grade 2-4 incidence at a tenth of the rate of the two
other studies, which focused on patients who were (presumably, given the setting)
rather more likely to be bed-bound.
Study summaries are given in Appendix 3.
Setting
Grade1
Grade2
Grade3
Grade4
Grades2-4
Denominator Nos
Galvin2002
Schoonhoven2002 Lardenoye2009
Palliative care
Post-surgery
11.99%
3.51%
7.20%
0.18%
10.89%
542
Long-term, all
patients
10.10%
1.25%
0.67%
0.44%
0.02%
10.10%
1.13%
208
22,030
Notes:
Galvin (2002). Admitted with PU - 142. Developed PU in unit - 65.
Schoonhoven (2002). Developed in 2 days post surgery. Grade2 means ‘Grades 2-4.’
Lardenoye (2009). Cumulative incidence, from all patient admissions 1996-2004
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5.3 Explaining the variations
The pooled prevalence figure reported above would gain in credibility if they were
shown to align with the features that characterised some meaningful sub-group. But it
is not clear how best to define such a sub-group.
The studies could be divided between those whose findings fell inside the confidence
interval of the pooled result, and those whose CI fell outside. An attempt could then be
made to identify features that discriminated between the two groups. For example, the
following explanations could be found for some specific ‘high reporting’ studies:
Vowden2009 UK
Schoonhoven2007 Netherlands (high
band)
Bours2001 Netherlands
James2010 UK Community
Denominator was people with wounds
This was in fact the upper end of
Schoohoven’s response band, the lower
end falling within the pooled result CI
Patients or their relatives had to consent,
arguably biasing their response towards
those with greater health concerns who
wanted closer medical attention
This was from a 25% convenience
sample, in which the sampling frame was
‘considered to reflect areas where the
highest numbers of people with pressure
ulcers were expected.’
… and so on. However, this exercise can be criticised for its post hoc reasoning. A
proper analysis requires grouping criteria defined a priori.
Despite such uncertainty of interpretation, the pooled results suggest that the lowerreporting studies tended to be community-oriented, with large denominators – for
example, Kottner (2009b), Vanderwee (2011), and Lahmann (2005).
Many factors have been reported as the causes (or correlates) pressure ulcers, and they
are listed in a following section in this review.
Of note also is Kottner’s comment:
‘It is highly probable that the decrease of prevalence rates [noted in the sevenyear series of cross-sectional studies] was due to an increased awareness of the
pressure ulcer problem in Germany and subsequent efforts to improve pressure
ulcer prevention and treatment.’ (Kottner, 2009c)
That is, the variations in reported pressure ulcer prevalence (and incidence) may be
due, not only to the variations in their actual occurrence, but also to variations in the
rigour and intensity of the reporting itself.
The Coordinating Centre for the Adoption of Evidence Based practice and innovation
- 23 -
5.4 Risk factors / predictors of pressure ulcers
5.4.1 Risk factors combined
Some studies identified risk factors or predictors of pressure ulcers, with varying
degrees of explicitness and rigour. A more comprehensive review would analyse these
factors. Such analysis is not feasible in this review, so the factors are instead
summarised in the tables below.
The first table groups the factors variously reported as ‘significant’ or ‘non-significant’
in three categories: medical condition & history; care environment & management;
socio-demographic. The second table gives individual study summaries, along with
contextual information that should help in interpretation.
Some factors are found to be significant predictors in some studies, but non-significant
in others. Such lack of consensus is notable among the socio-demographic variables:
age; gender; educational level; employment status; living status.
Significant Predictors of pressure ulcer
occurrence or prevention
Medical
condition &
history
(Model 1) infection, age, length of stay, Braden score
(Model 2, without Braden) age, length of stay,
infection, moisture, mobility
Non-significant predictors
(i.e. shown to have no
effect)
cardiovascular diseases
cause of injury
level of injury
sepsis
bed bound
Braden score
cardiovascular diseases
cognitive impairment
decreased activity and immobility
dehydration
density of lesion
diabetes
friction
fragile skin
high Activity of Daily Living scores
history of pressure ulcers
HIV infection
hypertension
incontinence (both)
low and high weights
low serum albumin
moist skin
neurological level
respiratory disease
previous trauma
psychomotor agitation
PU area and nutrition
pulmonary disease
reduced mobility
sensory perception
The Coordinating Centre for the Adoption of Evidence Based practice and innovation
- 24 -
Care
environment
&
management
Sociodemographic
serum albumin level of less than 3
skin texture (N.B. Dubowitz neonatal maturation
assessment scale: score of 1 point or lower),
stroke
activity level
continuous veno-venous haemofiltration (CVVH),
delayed transfer to the SIU after injury.
Dopamin or Dobutamine
endotracheal intubation usage
higher cost weight
humidity
intermittent haemodialysis (IHD)
longer stay
mechanical ventilation (and duration of)
more likely to have had surgery,
neuroleptic or psychotropic medications
nutrition & nutritional supplements
rehospitalisation
sedation
surgical stabilization of neck injury before transfer to
the SIU
tracheostomy on admission to the SIU
type of therapy
valid and reliable PU assessrnent instrument
winter period
N.B. Dellefield (2006)
‘Organizational variables explained a very small
amount of variation (adjusted R2 = .04, p < .01)’
POSITIVE - lower licensed nurse centralization,
facilities participating exclusively in the Medicaid
program, turning, floating heels, alternating
mattresses
NEGATIVE - higher total nurse staffing level
African Americans
education less than high school
female
geriatric care
had a higher cost weight
had longer hospital stays
men
more likely to have had surgery
older
singles
smoking
unemployed
The Coordinating Centre for the Adoption of Evidence Based practice and innovation
longer mean length of
hospital stay (Chan 2005)
number of raters
proportion of qualified
nursing personnel
regular lifting of weight at
least once in an hour while
seated
risk assessment
documentation
Specifically re. surgery
duration of surgery
type of anaesthesia
traction
type of fracture
waiting time
warming or non warming
perioperatively
age
gender
employment status
living alone
N.B.
ETHNICITY. 'Greater PU
occurrence among blacks
may not result from
differential within-facility
treatment of blacks versus
whites. Rather, blacks are
more likely to reside in
facilities with poorer care
quality.'
(Cai 2010)
- 25 -
5.4.2 Risk factors by individual study
Reference
Title
Country
Population
Setting
SignifPredictors
Ash2002
An exploration of the occurrence of pressure
ulcers in a British spinal injuries unit
UK
144
Hospital
Bolourchifard20
09
Incidence of pressure ulcer and its risk factors
in patients at orthopedic wards
Iran
46 patients at orthopedic wards
orthopedic wards
Bours2001
Prevalence, risk factors and prevention of
pressure ulcers in Dutch intensive care units.
Results of a cross-sectional survey
Netherlands
Patients in hospital
Hospital - ICUs (all
types)
density of lesion, surgical stabilization of
neck injury before transfer to the SIU,
tracheostomy on admission to the SIU and
delayed transfer to the SIU after injury.
Old age, lengthy hospitalization, medical
diagnosis, type of therapy, decreased
activity and immobility
(Model 1) infection, age, length of stay,
total Braden score. (Model 2, without
Braden) age, length of stay, infection,
moisture, mobility
Cai2010
Pressure ulcer prevalence among black and
white nursing home residents in New York
State: evidence of racial disparity?
USA
Nursing home residents
Nursing homes
Campbell2009
Heel pressure ulcers in the orthopedic
population: incidence and prevention
Canada
Campbell2010
Heel pressure ulcers in orthopedic
PATIENTS: a prospective study of incidence
and risk factors in an acute care hospital
Canada
Capon2007
Pressure ulcer risk in long-term units:
prevalence and associated factors
Italy
NonSignifPredictors
ETHNICITY. 'Greater
PU occurrence among
blacks may not result
from differential withinfacility treatment of
blacks versus whites.
Rather, blacks are more
likely to reside in
facilities with poorer
care quality.'
presence of respiratory disease (after
orthopaedic surgery)
One hundred and fifty (150)
patients (average age 70.6
years) admitted for elective
orthopedic surgery or treatment
of a fractured hip
The Coordinating Centre for the Adoption of Evidence Based practice and innovation
acute care
Presence or absence of respiratory disease
hospital? ('longterm units ')
Previous stroke, previous trauma, cognitive
decline, cardiovascular diseases, high
Activity of Daily Living scores, low Braden
scores
- 26 -
Reference
Title
Country
Population
Setting
SignifPredictors
NonSignifPredictors
Chan2005
Prevalence, incidence and predictors of
pressure ulcers in a tertiary hospital in
Singapore
Singapore
NA
Hospital
Logistic regression found that the total
Braden score was the only significant
predictor of pressure ulcers.
older, had a longer mean
length of hospital stay,
history of cardiovascular
diseases or sepsis
Chen2005
Pressure ulcer prevalence in people with spinal
cord injury: age-period-duration effects
USA
community-residing people
with spinal cord injury
community
Injury cause, level of
injury
Chen2005
Pressure ulcer prevalence in people with spinal
cord injury: age-period-duration effects
USA
deFreitas2011
Pressure ulcers in the elderly: analysis of
prevalence and risk factors
Brazil
Residents
'long-stay
institutions'
elderly, men, African Americans, singles,
subjects with education less than high
school, unemployed, subjects with complete
injury, and subjects with history of pressure
ulcers, rehospitalisation, nursing home stay,
and other medical conditions
Pressure ulcers were more common among
the elderly, men, African Americans,
singles, subjects with education less than
high school, unemployed, subjects with
complete injury, and subjects with history
of pressure ulcers, rehospitalisation, nursing
home
stroke (60%) and hypertension (74.3%).
Dellefield2006
Organizational correlates of the risk-adjusted
pressure ulcer prevalence and subsequent
survey deficiency citation in California
nursing homes.
USA
897 California
nursing homes
deSouza2010
Incidence of pressure ulcers in the
institutionalized elderly
Brazil
long-term care
facilities
Fujii2010
Incidence and risk factors of pressure ulcers in
seven neonatal intensive care units in Japan: a
multisite prospective cohort study
Japan
All infants admitted to the
NICU and kept in incubators
from seven hospitals during the
study period were recruited to
the study
neonatal intensive
care units
Gallagher2008
Prevalence of pressure ulcers in three
university teaching hospitals in Ireland
Ireland
patients
3 teaching hospitals
Galvin2002
An audit of pressure ulcer incidence in a
palliative care setting
UK
542 people with terminal
illness, age 35-90, average
68yrs, average stay 15 days
specialist palliative
care unit
The Coordinating Centre for the Adoption of Evidence Based practice and innovation
Organizational variables explained a
VERY small amount of the variation
(adjusted R2 = .04, p < .01. POSITIVE lower licensed nurse centralization and
facilities participating exclusively in the
Medicaid program. NEGATIVE - higher
total nurse staffing level
female gender, regular use of neuroleptic or
psychotropic medications, and a history of
pressure ulcers
skin texture (Dubowitz neonatal maturation
assessment scale: skin texture score of 1
point or lower), endotracheal intubation
usage
Reduced mobility, urinary incontinence,
cognitive impairment, low serum albumin,
length of stay
'as a result of the individual's particular
tumour or the condition being treated.'
Age, gender, risk
assessment
documentation
- 27 -
Reference
Title
Country
Population
Setting
SignifPredictors
Gunningberg20
04
Risk, prevalence and prevention of pressure
ulcers in three Swedish healthcare settings
Sweden
Old age, geriatric care, low Braden score
and incontinence
4654
university hospital,
a general hospital
and a nursing home
Hospital
Haleem2008
Pressure sores and hip fractures
UK
Jackson2011
Incidence of hospital-acquired pressure ulcers
in acute care using two different risk
assessment scales: results of a retrospective
study
Jenkins2010
Pressure ulcer prevalence and incidence in
acute care.
USA
Kottner2009
The trend of pressure ulcer prevalence rates in
German hospitals: results of seven crosssectional studies.
Germany
all patients
225 hospitals
increased length of hospital stay, density of
lesion, surgical stabilization of neck injury
before transfer to the SIU, tracheostomy on
admission to the SIU and delayed transfer
to the SIU after injury.
Use of a valid and reliable PU risk
assessrnent instrument (Braden vs. 'A
locally developed PU risk assessment
instrument') may reduce the incidence of
severe PUs.
Braden score of less than 18 (84%), serum
albumin level of less than 3 (74%), fecal
and/or urine incontinence (73%), fragile
skin (67%), and bed bound (63%)
Braden score
Lahmann2006
Pressure ulcers in German nursing homes and
acute care hospitals: prevalence, frequency,
and ulcer characteristics.
Germany
21,574 German hospital
patients and nursing home
residents
nursing homes and
acute care hospitals
Persons with lower Braden scale scores had
more ulcers and more severe pressure ulcers
Lardenoye2009
Assessment of Incidence, Cause, and
Consequences of Pressure Ulcers to Evaluate
Quality of Provided Care
Netherlands
'During the study period,
22,030 patients were admitted
to our surgical ward'
Hospital
Age and female sex
Lindholm2008
Hip fracture and pressure ulcers - the PanEuropean Pressure Ulcer Study
Europe
635
Hospital
Manzano2010
Incidence, prevention and treatment of
pressure ulcers in intensive care PATIENTS: a
longitudinal study
Spain
Two hundred ninety-nine
patients with more than 24
hours on mechanical ventilation
(MV)
age >or=71 (P = 0.020), dehydration (P =
0.005), moist skin (P = 0.004) and total
Braden score (P = 0.050) as well as
subscores for friction (P = 0.020), nutrition
(P = 0.020) and sensory perception (P =
0.040). Also diabetes (P = 0.005) and
pulmonary disease (P = 0.006).
Duration of mechanical ventilation and
winter period
hospital
The Coordinating Centre for the Adoption of Evidence Based practice and innovation
NonSignifPredictors
the number of raters
Waiting time for
surgery, duration of
surgery, warming or non
warming perioperatively,
type of anaesthesia,
traction and type of
fracture
- 28 -
Reference
Title
Country
Population
Setting
SignifPredictors
Nicastri2004
Incidence and risk factors associated with
pressure ulcers among patients with HIV
infection
Italy
patients with advanced human
immunodeficiency virus type 1
(HIV-1) infection
acute care
infectious disease
units
being female, length of hospitalization, and
clinical markers of HIV infection
Nijs2009
Incidence and risk factors for pressure ulcers
in the intensive care unit.
Belgium
intensive care units
Pizarro2007
Prevalence of pressure ulcers in an assisted
residence for the elderly
Spain
Assisted residence
history of vascular disease, treatment with
Dopamin or Dobutamine, intermittent
haemodialysis (IHD) or continuous venovenous haemofiltration (CVVH),
mechanical ventilation. Also positive:
turning, floating heels, alternating
mattresses
incontinence, use of nutritional supplements
Popp2006
The impact of the proportion of qualified
nursing personnel on the incidence of pressure
ulcers in nursing homes
Germany
nursing home inhabitants (n =
2813)
Nursing homes
Raghavan2002
Prevalence of pressure sores in a community
sample of spinal injury patients
UK
all patients who were being
followed up by a regional spinal
injuries unit. The mean age of
the participants was 47 years
(SD 14.7); 76% (341) were
males. The mean time since
injury was 13 years (SD 10.6).
All had traumatic spinal injury
except two who had spina
bifda.
community
Smoking. pre-existing medical problems
Rogenski2006
Incidence of pressure ulcers at a university
hospital
Incidence and risk factors for pressure ulcers
in a hospital complex
Brazil
hospital
Sayar2009
Incidence of pressure ulcers in intensive care
unit patients at risk according to the Waterlow
scale and factors influencing the development
of pressure ulcers
Turkey
patients in intensive care units
Age and humidity, time of hospitalization
and nutrition, PU area and nutrition
psychomotor agitation, urinary
incontinence, sedation and mechanical
ventilation
Length of stay and activity level
Stausberg2005
Pressure ulcers in secondary care: incidence,
prevalence, and relevance
Germany
cohort of 25,075 cases
Salome2011
Brazil
The Coordinating Centre for the Adoption of Evidence Based practice and innovation
NonSignifPredictors
proportion of qualified
nursing personnel
Regular lifting of weight
at least once in an hour
while seated, age,
gender, neurological
level, employment
status, living alone and
faecal and urinary
incontinence
Older, were more likely to have had
surgery, had longer hospital stays, and had a
higher cost weight
- 29 -
Reference
Title
Country
Population
Setting
SignifPredictors
Stausberg2005
Pressure ulcers in secondary care: incidence,
prevalence, and relevance
Germany
25,075
Hospital
longer stay, more likely to have had
surgery, higher cost weight
VanGilder2009
Body mass index, weight, and pressure ulcer
prevalence: an analysis of the 2006-2007
INTERNATIONAL PRESSURE ULCER
PREVALENCE Surveys
USA
The Coordinating Centre for the Adoption of Evidence Based practice and innovation
NonSignifPredictors
Low BMI, patients with both low and high
weights. One in 10 patients were extremely
obese.
- 30 -
5.5 Methods studies
Although this review did not focus on methodology, several methodological studies
should be mentioned, since they highlight factors that affect the reliability of reported
prevalence figures.
Defloor (2004 and 2006) examined the interrater and intrarater reliability of classifying
pressure ulcers according to the European Pressure Ulcer Advisory Panel classification
system when using photographs of pressure ulcers and incontinence lesions.
Results
The inter-rater reliability for the 473 participating nurses was low (p < 0.001, kappa =
0.37). Non-blanchable erythema was often confused with blanchable erythema and
incontinence lesions. Also, incontinence lesions were frequently not correctly classified.
The intra-rater agreement was also low (kappa = 0.38). Specifically, differentiation
between pressure ulcers and incontinence lesions seemed to be difficult.
This finding is at odds with that of Kottner (2009a), who found that: ‘the number of
raters did not influence the observed pressure ulcer prevalence rate. Adequate preparation
and training of ward nurses for data collection seem to be sufficient to achieve reliable
data.’
It is not clear how to reconcile Defloor and Kottner’s opposing findings.
Kottner (2010) also examined the use of statistical process control for monitoring the
prevalence of hospital-acquired pressure ulcers. This drew on a secondary data analysis
using novel statistical approaches, and shows that apparent trends in prevalence may in
fact be an artefact of the reporting methods. Thus:
‘Institutions that participated regularly in all survey years were identified. Riskadjusted nosocomial pressure ulcers prevalence rates, grade 2 to 4 (European
Pressure Ulcer Advisory Panel system) were calculated per year and hospital.
Descriptive statistics, chi-square trend tests, and P charts based on statistical
process control (SPC) were applied and compared. Six of the 905 healthcare
institutions participated in every survey year and 11,444 patients in these six
hospitals were identified as being at risk for pressure ulcers. Prevalence rates per
year ranged from 0.05 to 0.22.
Results. Chi-square trend tests revealed statistically significant downward trends in
four hospitals but based on SPC methods, prevalence rates of five hospitals varied
by chance only. Results of chi-square trend tests and SPC methods were not
comparable, making it impossible to decide which approach is more appropriate.’
The researchers concluded that;
‘Empirical evidence about the decrease of nosocomial pressure ulcer prevalence
rates in the Netherlands is contradictory and limited.’
- 31 -
5.6 The ‘Grey’ Literature
An extensive Internet search found many hospital and PCT reports and other documents
referring to pressure ulcers – why they were important, and how to report their prevalence
and incidence. Thirty-eight of these were downloaded for reading, and are listed in the
References.
Unfortunately, although some of the reports contained actual data on pressure ulcer
prevalence and incidence, none of them contained more than summary data, or explicit
details of the data collection procedures, or anything resembling ‘raw’ data. Some specific
data collection tools and methods were described. Overall, however, the attempt to locate
useful data on prevalence and incidence was unproductive. It was not feasible to contact
individuals in the organisations concerned – although it is clear that this is necessary for
comparative audit purposes.
- 32 -
6 Conclusions
This rapid evidence assessment / mapping review has found a wide range of values for
pressure ulcer prevalence and incidence reported in the published research literature. The
reasons for this variation are many. Reporting methods vary in scope, duration, data
collection procedures and analysis (particularly the choice of denominator). There are also
condition- and patient-specific factors which are here documented, but not analysed.




Despite the uncertainty, a rough confidence interval for the likely prevalence of
pressure ulcers has been determined. This varies according to setting and to which
studies are included in the meta-analysis.
The risk factors for pressure ulcers have also been identified, and include a wide range
of patient- and condition-specific variables. Studies disagreed about the significance
of socio-demographic variables.
Contextual information has been mapped that should help in interpreting the relevance
of the risk factors and reported prevalence figures.
Limited information has been found in the published literature on the incidence of
pressure ulcers.
6.1 Implications for practice
Some of the studies mapped by this review may be usable for estimating pressure ulcer
prevalence and incidence in the eastern region, using suitably-collected local data.
6.2 Recommendations for further research
There is considerable scope for more extensive data collection and analysis. This will
require personal communication with researchers and with the people involved in local
pressure ulcer audits in the UK health services.
6.3 Limitations of this review



This review is the work of a single person, and has not yet been peer-reviewed
Full texts were not obtained if they were in print only, or were chargeable.
The analysis of the prevalence and incidence data collected was limited. Further
analysis is possible, if this was considered to be potentially informative.
7 Acknowledgements
Jacqui Fletcher, Senior Professional Tutor, Department of Dermatology and Wound
Healing, Cardiff University, for information, advice and the full text of key references.
- 33 -
8
References
8.1 Studies included in the review
Bennett G, Dealey C, Posnett J. The cost of pressure ulcers in the UK. Age and ageing [Internet].
2004 May [cited 2011 Aug 17];33(3):230–5. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/15082426
Bick D, Stephens F. Pressure ulcer risk: audit findings. Nursing standard (Royal College of
Nursing (Great Britain): 1987) [Internet]. 2003;17(44):63–6, 68, 70 passim. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/12889395
BOURS GJJW, LAAT ED, HALFENS RJG, LUBBERS M. Prevalence, risk factors and
prevention of pressure ulcers in Dutch intensive care units: Results of a cross-sectional survey.
Intensive care medicine [Internet]. [cited 2012 Feb 24];27(10):1599–605. Available from:
http://cat.inist.fr/?aModele=afficheN&cpsidt=14138219
Buttery J. Pressure ulcer audit highlights important gaps in the delivery of preventative care in
England and Wales 2005-2008. EWMA Journal. 2009;9(3):27–31.
Defloor T, Schoonhoven L. Inter-rater reliability of the EPUAP pressure ulcer classification
system using photographs. Journal of clinical nursing [Internet]. 2004 Nov;13(8):952–9. Available
from: http://www.ncbi.nlm.nih.gov/pubmed/15533101
Fletcher J. How can we improve prevalence and incidence monitoring? Journal of wound care
[Internet]. 2001 Sep;10(8):311–4. Available from:
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Fletcher J (2003) Measuring the prevalence and incidence of chronic wounds. Professional Nurse
18 (7) 384 - 388
Gallagher P., Barry P., Hartigan I., McCluskey P., O’Connor K. OM. Prevalence of pressure
ulcers in three university teaching hospitals in Ireland. Journal of Tissue Viability. 17(4):103–9.
Galvin J. An audit of pressure ulcer incidence in a palliative care setting. International Journal of
Palliative Nursing [Internet]. 2002;8(5):214–21. Available from:
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04
Gethin G, Jordan-O’Brien J, Moore Z. Estimating costs of pressure area management based on a
survey of ulcer care in one Irish hospital. Journal of wound care [Internet]. 2005 Apr;14(4):162–5.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/15835226
James J, Evans J a, Young T, Clark M. Pressure ulcer prevalence across Welsh orthopaedic units
and community hospitals: surveys based on the European Pressure Ulcer Advisory Panel
minimum data set. International wound journal [Internet]. 2010 Jun;7(3):147–52. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/20602646
- 34 -
Kottner J. HR. Using statistical process control for monitoring the prevalence of hospital-acquired
pressure ulcers. Ostomy Wound Management. 2010;56(5):54–8.
Kottner J., Wilborn D., Dassen T. LN. The trend of pressure ulcer prevalence rates in German
hospitals: results of seven cross-sectional studies. Journal of Tissue Viability,. 18(2):36–46),.
Kottner J, Tannen A, Dassen T. Hospital pressure ulcer prevalence rates and number of raters.
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http://www.ncbi.nlm.nih.gov/pubmed/19220611
Kottner J, Tannen A, Halfens R, Dassen T. Does the number of raters influence the pressure ulcer
prevalence rate? Applied nursing research : ANR [Internet]. 2009 Feb [cited 2012 Feb
6];22(1):68–72. http://www.ncbi.nlm.nih.gov/pubmed/19171298
Lahmann N.A., Halfens R.J. DT, Citation: Ostomy/wound management F2006. Pressure ulcers in
German nursing homes and acute care hospitals: prevalence, frequency, and ulcer characteristics.
Ostomy Wound Management. 2006;52(2):20–33.
Lahmann NA, Halfens RJG DT. Prevalence of pressure ulcers in Germany. Journal of Clinical
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Lardenoye JWHP, Thiéfaine J a JG, Breslau PJ. Assessment of incidence, cause, and
consequences of pressure ulcers to evaluate quality of provided care. Dermatologic surgery :
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Lindholm C., Sterner E., Romanelli M., Pina E., Torra Y Bou J., Hietanen H., Iivanainen A.,
Gunningberg L., Hommel A., Klang B. DC. Hip fracture and pressure ulcers - The Pan-European
Pressure Ulcer Study - Intrinsic and extrinsic risk factors. International Wound Journal. 5(2):315–
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Macfarlane G, Meyer S, Lachenbruch C. Body Mass Index , Weight , and Pressure Ulcer
Prevalence. Journal of Nursing Care Quality. 2009;24(2):127–35.
Margolis DJ, Bilker W, Knauss J, Baumgarten M, Strom BL. The incidence and prevalence of
pressure ulcers among elderly patients in general medical practice. Annals of epidemiology
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care setting in Ireland. Journal of wound care [Internet]. [cited 2012 Feb 7];18(10). Available
from: http://cat.inist.fr/?aModele=afficheN&cpsidt=22032213
Raghavan P, Raza W a, Ahmed YS, Chamberlain M a. Prevalence of pressure sores in a
community sample of spinal injury patients. Clinical rehabilitation [Internet]. 2003
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Schoonhoven L, Bousema MT BE. The prevalence and incidence of pressure ulcers in
hospitalised patients in The Netherlands: a prospective inception cohort study. International
Journal of Nursing Studies. 2007;44(6):927–35.
- 35 -
Schoonhoven L, Defloor T, Grypdonck MHF. Incidence of pressure ulcers due to surgery. Journal
of clinical nursing [Internet]. 2002 Jul;11(4):479–87. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/12100644
Srinivasaiah N, Dugdall H, Barrett S, Drew PJ. A point prevalence survey of wounds in north-east
England. Journal of wound care [Internet]. 2007 Nov;16(10):413–6, 418–9. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/18065016
Stausberg J., Kroger K., Maier I., Schneider H. NW. Pressure ulcers in secondary care: incidence,
prevalence, and relevance. Advances in skin & wound care. 2005;18(3):140–5.
Vanderwee K., Defloor T., Beeckman D., Demarre L., Verhaeghe S., Van Durme T. GM.
Assessing the adequacy of pressure ulcer prevention in hospitals: A nationwide prevalence survey.
BMJ Quality and Safety. 2011;:2044–5415.
Vanderwee K, Clark M, Dealey C, Gunningberg L, Defloor T. Pressure ulcer prevalence in
Europe: a pilot study. Journal of evaluation in clinical practice [Internet]. 2007 Apr [cited 2012
Feb 22];13(2):227–35. http://www.ncbi.nlm.nih.gov/pubmed/17378869
Vowden KR, Vowden P. A survey of wound care provision within one English health care
district. Journal of tissue viability [Internet]. 2009 Feb [cited 2012 Feb 6];18(1):2–6. Available
from: http://www.ncbi.nlm.nih.gov/pubmed/19103490
Vowden KR, Vowden P. The prevalence, management, equipment provision and outcome for
patients with pressure ulceration identified in a wound care survey within one English health care
district. Journal of tissue viability [Internet]. 2009 Feb [cited 2012 Feb 6];18(1):20–6. Available
from: http://www.ncbi.nlm.nih.gov/pubmed/19097794
- 36 -
8.2 Studies included only for risk factor identification
Some studies were not included as sources of data, but were included by virtue of their
identifying potential risk factors for pressure ulcers.
Cai (2010). Pressure ulcer prevalence among black and white nursing home residents in New
York State: evidence of racial disparity? Medical Care, 01 March 2010, vol./is. 48/3(233-239),
00257079
Campbell KE, Woodbury MG HP. Heel pressure ulcers in orthopedic patients. Ostomy Wound
Management. 2010;56(2):44-54.
Bolourchifard F, Abdolrahimi M, Yaghmaei F. Incidence of pressure ulcer and its risk factors in
patients at orthopedic wards. Journal of Nursing and Midwifery. 2009;19(67). Iran.
Capon A., Pavoni N., Mastromattei A. DLD. Pressure ulcer risk in long-term units: prevalence
and associated factors. Journal of Advanced Nursing. 58(3):263-272.
Chan (2005). Prevalence, incidence and predictors of pressure ulcers in a tertiary hospital in
Singapore. Journal of Wound Care, 01 September 2005, vol./is. 14/8(383-387), 09690700
Chen Y., DeVivo M.J., Jackson A.B. Pressure ulcer prevalence in people with spinal cord injury:
age-period-duration effects. Archives of Physical Medicine and Rehabilitation, June 2005, vol./is.
86/6(1208-1213), 0003-9993 (Jun 2005)
de Freitas M.C., Medeiros A.B., Guedes M.V., de Almeida P.C., de Galiza F.T., Nogueira J.M..
Pressure ulcers in the elderly: analysis of prevalence and risk factors. Revista Gaucha de
Enfermagem, March 2011, vol./is. 32/1(143-50), 0102-6933;0102-6933 (2011 March)
Dellefield M.E Organizational correlates of the risk-adjusted pressure ulcer prevalence and
subsequent survey deficiency citation in California nursing homes. Research in Nursing & Health,
01 August 2006, vol./is. 29/4(345-358), 01606891 Available in fulltext at EBSCOhost
De Souza D.M.S.T., De Gouveia Santos V.L.C. Incidence of pressure ulcers in the
institutionalized elderly. Journal of Wound, Ostomy, & Continence Nursing, May 2010, vol./is.
37/3(272-6), 1071-5754;1528-3976 (2010 May-Jun)
Fujii K., Sugama J., Okuwa M., Sanada H., Mizokami Y. Incidence and risk factors of pressure
ulcers in seven neonatal intensive care units in Japan: a multisite prospective cohort study.
International Wound Journal, October 2010, vol./is. 7/5(323-328),
Gunningberg L. Risk, prevalence and prevention of pressure ulcers in three Swedish healthcare
settings. Journal of Wound Care, July 2004, vol./is. 13/7(286-90), 0969-0700;0969-0700 (2004
July)
Haleem S, Heinert G, Parker MJ. Pressure sores and hip fractures. Injury, February 2008, vol./is.
39/2(219-23), 0020-1383;0020-1383 (2008 Feb)
Jenkins M.L., O'Neal E. Pressure ulcer prevalence and incidence in acute care. Advances in skin
& wound care, December 2010, vol./is. 23/12(556-559), 1538-8654 (Dec 2010)
- 37 -
Kroger K., Niebel W., Maier I., Stausberg J., Gerber V. SA. Prevalence of pressure ulcers in
hospitalized patients in Germany in 2005. Gerontology. 2009;55(3):281–7.
Manzano F., Navarro M.J., Roldan D., Moral M.A., Leyva I., Guerrero C., Sanchez M.A.,
Colmenero M., Fernandez-Mondejar E. Pressure ulcer incidence and risk factors in ventilated
intensive care patients. Journal of Critical Care, September 2010, vol./is. 25/3(469-476), 08839441 (September 2010)
Nicastri E, Viale P, Lyder CH, Cristini F, Martini L, Preziosi G, Dodi F, Irato L, Pan A, Petrosillo
N, Gruppo HIV ed Infezioni Ospedaliere. Incidence and risk factors associated with pressure
ulcers among patients with HIV infection. Advances in Skin & Wound Care, June 2004, vol./is.
17/5 Pt 1(226-31), 1527-7941;1527-7941 (2004 Jun
Nijs N., Toppets A., Defloor T., Bernaerts K., Milisen K., Van Den Berghe G. Incidence and risk
factors for pressure ulcers in the intensive care unit. Journal of Clinical Nursing, May 2009,
vol./is. 18/9(1258-1266), 0962-1067;1365-2702 (May 2009).
Pizarro (2007). Prevalence of pressure ulcers in an assisted residence for the elderly. Gerokomos,
01 September 2007, vol./is. 18/3(52-55), 1134928X
Popp J, Pröfener F, Stappenbeck J, Reintjes R WP. The impact of the proportion of qualified
nursing personnel on the incidence of pressure ulcers in nursing homes [German]. Pflege.
2006;19(5):303–7.
Salome, Geraldo Magela. Incidence and risk factors for pressure ulcers in a hospital complex
[Portuguese]. Revista Nursing, 01 September 2011, vol./is. 14/160(491-495), 14158264
Sayar S., Turgut S., Dogan H., Ekici A., Yurtsever S., Demirkan F., Doruk N., Tasdelen B.
Incidence of pressure ulcers in intensive care unit patients at risk according to the Waterlow scale
and factors influencing the development of pressure ulcers. Journal of Clinical Nursing, March
2009, vol./is. 18/5(765-774), 0962-1067;1365-2702 (March 2009)
Stausberg J., Kroger K., Maier I., Schneider H., Niebel W. Pressure ulcers in secondary care:
incidence, prevalence, and relevance. Advances in skin & wound care, April 2005, vol./is.
18/3(140-145), 1527-7941 (Apr 2005)
VanGilder C., MacFarlane G., Meyer S., Lachenbruch C. Body mass index, weight, and pressure
ulcer prevalence: an analysis of the 2006-2007 International Pressure Ulcer Prevalence Surveys.
Journal of Nursing Care Quality, April 2009, vol./is. 24/2(127-35), 1057-3631;1550-5065 (2009
Apr-Jun)
- 38 -
8.3 Studies not included in the review
These studies were not included for various reasons, largely because they were from
excluded countries, or because the full text or data was not readily available. The studies
may be relevant to a more comprehensive version of this review or to follow-on reviews.
Bale S, Dealey C, Defloor T, Hopkins A, Worboys F. The experience of living with a pressure
ulcer. [Internet]. Nursing times. 103(15):42–3. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/17476848
Elliott, J. Are we reducing pressure ulcer incidence? an exploratory study by one acute trust.
Journal of Tissue Viability, 01 November 2009, vol./is. 18/4(125-125), 0965206X
Evans J., Andrews B. Pressure ulcer prevalence across Wales--All Wales Tissue Viability Nurse
Forum. Journal of Tissue Viability, 01 November 2009, vol./is. 18/4(122-123), 0965206X
Gorecki C, Nixon J, Madill a, Firth J, Brown JM. What influences the impact of pressure ulcers on
health-related quality of life? A qualitative patient-focused exploration of contributory factors.
Journal of tissue viability [Internet]. 2012 Feb [cited 2012 Feb 6];21(1):3–12. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/22137874
Gorecki C., Brown J.M., Nelson E.A., Briggs M., Schoonhoven L., Dealey C., Defloor T., Nixon
J.. Impact of pressure ulcers on quality of life in older patients: a systematic review. J Am Geriatr
Soc 57(7): 1175-83. July 2009
Hopkins A, Dealey C, Bale S, Defloor T, Worboys F. Patient stories of living with a pressure
ulcer. Journal of advanced nursing [Internet]. 2006 Nov [cited 2012 Feb 6];56(4):345–53.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/17042814
Jackson S.S Incidence of hospital-acquired pressure ulcers in acute care using two different risk
assessment scales: results of a retrospective study. Ostomy Wound Management, May 2011,
vol./is. 57/5(20-7).
Lahmann N., Halfens R.J.G., Dassen T. Effect of non-response bias in pressure ulcer prevalence
studies. Journal of Advanced Nursing, July 2006, vol./is. 55/2(230-236), 0309-2402;1365-2648
(July 2006) Available in fulltext at EBSCOhost
Levett (2000). Survey of pressure ulcer prevalence in nursing homes. Elderly Care, July 2000,
vol./is. 12/5(12-6), 1369-1856 (2000 Jul/Aug)
Phillips L., Buttery J.. Exploring pressure ulcer prevalence and preventative care. Nursing Times.
2009 Apr 28;105(16): 34-6. In: ProQuest Medical Library [database on the Internet] [cited 2012
Feb 24]. Available from: http://www.proquest.com/ Document ID: 1712997871
Rogenski NM, Santos VL. [Incidence of pressure ulcers at a university hospital]. [Portuguese]
Estudo sobre a incidencia de ulceras por pressao em um hospital universitario. Revista LatinoAmericana de Enfermagem, July 2005, vol./is. 13/4(474-80), 0104-1169;0104-1169 (2005 JulAug)
- 39 -
Shahin E.S.M., Dassen T., Halfens R.J.G. Incidence, prevention and treatment of pressure ulcers
in intensive care patients: a longitudinal study. International Journal of Nursing Studies, April
2009, vol./is. 46/4(413-421), 0020-7489 (April 2009)
Sheerin F, Gillick A, Doyle B. Pressure ulcers and spinal-cord injury: incidence among
admissions to the Irish national specialist unit. Journal of Wound Care, March 2005, vol./is.
14/3(112-5), 0969-0700;0969-0700 (2005 Mar)
Stephens F., Bick D. Organisational perspective: a pressure ulcer risk assessment and prevention
audit: an RCN pilot. Nursing Management - UK, 01 June 2002, vol./is. 9/3(24-29), 13545760.
Available in fulltext at EBSCOhost
Williams S, Watret L, Pell J. Case-mix adjusted incidence of pressure ulcers in acute medical and
surgical wards. Journal of Tissue Viability, October 2001, vol./is. 11/4(139-42), 0965-206X;0965206X (2001 Oct)
- 40 -
9 Appendices
9.1 Appendix 1 – Search History
29th December 2011 - Keyword
No.
3
8
10
11
13
17
18
Database
Search term
BNI, MEDLINE,
(incidence OR prevalence).ti
CINAHL
((measur* OR collect* OR survey OR monitor* OR
MEDLINE
surveillance OR assess* OR estimat* OR audit* OR "case
notes" OR records)).ti
("pressure ulcer*" OR "pressure sore*" OR "presssure
MEDLINE
wound*" OR decubitus).ti
BNI, MEDLINE,
3 AND 10 [Limit to: Publication Year 2000-2011]
CINAHL
MEDLINE
8 AND 10 [Limit to: Publication Year 2000-2011]
BNI, MEDLINE, 3 AND 8 AND 10 [Limit to: Publication Year 2000-2011 and
CINAHL
English Language]
BNI, MEDLINE,
3 AND 8 AND 10 [Limit to: Publication Year 2000-2011]
CINAHL
Hits
152903
716473
5301
519
255
29
68
28th December 2011 – Subject headings
No.
Database
5
exp PRESSURE ULCER/cl,di,ep,nu,pc [cl=Classification,
MEDLINE di=Diagnosis, ep=Epidemiology, nu=Nursing, pc=Prevention &
Control]
6
MEDLINE exp INCIDENCE/
150696
7
MEDLINE exp PREVALENCE/
156697
8
MEDLINE
9
MEDLINE exp DATA COLLECTION/
10
MEDLINE
11
Search term
exp CLINICAL AUDIT/ OR exp MANAGEMENT AUDIT/
OR exp MEDICAL AUDIT/
exp QUESTIONNAIRES/mt,st,td,ut [mt=Methods,
st=Standards, td=Trends, ut=Utilization]
exp DIAGNOSIS/ OR exp EARLY DIAGNOSIS/ OR exp
NURSING DIAGNOSIS/cl,mt,og,st,td,ut [cl=Classification,
MEDLINE
mt=Methods, og=Organization & Administration, st=Standards,
td=Trends, ut=Utilization]
Hits
5757
27690
1261324
7167
5627054
14
MEDLINE 8 OR 9 OR 10
1280571
15
MEDLINE 6 OR 7
16
MEDLINE 5 AND 14
1547
17
MEDLINE 5 AND 15
692
292997
- 41 -
No.
Database
18
MEDLINE 5 AND 11
19
MEDLINE 16 OR 17 OR 18
21
MEDLINE
22
Search term
16 OR 17 OR 18 [Limit to: Publication Year 2000-2011 and
(Age Groups All Aged 65 and Over) and English Language]
Duplicate filtered: [16 OR 17 OR 18 [Limit to: Publication Year
MEDLINE 2000-2011 and (Age Groups All Aged 65 and Over) and
English Language]]
Hits
794
2055
489
489
471 unique results
18 duplicate results
.
- 42 -
9.2 Appendix 2 – EPUAP definition of pressure ulcer grades
Category/Stage I: Non-blanchable erythema
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. .
Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding
area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.
Category I may be difficult to detect in individuals with dark skin tones. May indicate “at risk”
persons.
Category/Stage II: Partial thickness
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed,
without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous
filled blister.Presents as a shiny or dry shallow ulcer without slough or bruising*. This category
should not be used to describe skin tears, tape burns, incontinence associated dermatitis,
maceration or excoriation.
*Bruising indicates deep tissue injury.
CategoryStage III: Full thickness skin loss
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not
exposed. Slough may be present but does not obscure the depth of tissue loss. May include
undermining and tunneling.The depth of a Category/Stage III pressure ulcer varies by anatomical
location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous
tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can
develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly
palpable.
Category/Stage IV: Full thickness tissue loss
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present.
Often includes undermining and tunneling.The depth of a Category/Stage IV pressure ulcer varies
by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose)
subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend
into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule)
making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or
directly palpable.
- 43 -
9.3 Appendix 3 – Individual study summaries
This section contains structured summaries of the studies reviewed. The actual results are
shown in the main body of the report.
9.3.1 James 2010 (Hospital)
Title
Country
Population
PU System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
Comment
Pressure ulcer prevalence across Welsh orthopaedic units and community
hospitals: surveys based on the European Pressure Ulcer Advisory Panel
minimum data set
UK (Wales)
The surveyed patients tended to be elderly with 223 (38.4%) and 401 (65.2%)
of all orthopaedic and community hospital patients, respectively, aged at least
80 years old. Most patients were female in both surveys: orthopaedic units 371
(63.9%) and community hospitals 383 (62.4%).
EPUAP
13 selected specialities (orthopaedics and community hospitals) across all NHS
settings within Wales.
Two serial point prevalence surveys: 1) orthopaedic survey; 2) community
hospital survey
Survey, using the EPUAP pressure ulcer minimum data.
The specialities were selected following discussion within the All-Wales
Tissue Viability Nurses Forum (AWTVNF) and were considered to reflect
areas where the highest numbers of people with pressure ulcers were expected.
Used 27 specialist tissue viability nurses, trained beforehand. But no IRR test.
Used same method as Vowden (2004). Sampling frame was ' considered to
reflect areas where the highest numbers of people with pressure ulcers were
expected.'
Omissions and existing PU's badly reported, so not clear what coverage was.
Also unsure about IRR, since large proportion of ulcers reported by just two
people.
Orthopaedic - all patients.
Community - 'A 25% convenience sample was taken across all Welsh
community hospital beds'
Researchers’ notes: 'The process was not without its challenges. The EPUAP
data collection tool required completion of a Braden score for all patients;
however, this tool was not in use within Wales prior to (or indeed after) the
audits were performed with a required lengthy training on the correct use of
the Braden scale.'
So it is not clear how accurate the assessments were, or what the inter-rater
agreement was
9.3.2 Gethin 2005 (Hospital)
Title
Country
Population
Estimating costs of pressure area management based on a survey of ulcer care
in one Irish hospital
Ireland
All wards except paediatrics, psychiatry and day wards
- 44 -
PU Categ System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
EPUAP
626-bed Irish acute hospital
Cross-sectional pilot survey
Tissue viability nurses trained in the data-collection tool to increase IRR
All available patients on the day
9.3.3 Vanderwee 2007 (Hospital)
Title
Country
Population
PU Categ System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
Pressure ulcer prevalence in Europe: a pilot study
Belgium, Italy, Portugal, UK, Sweden
All patients admitted before midnight on the day of the survey and older than
18 years
EPUAP
25 Hospitals
Survey
Pressure ulcer experts from different European countries developed a data
collection instrument, which included five categories of data: general data,
patient data, risk assessment, skin observation and prevention. A convenience
sample of university and general hospitals of Belgium, Italy, Portugal, UK
and Sweden participated in the study. In each participating hospital, teams of
two trained nurses who collected the data on the wards were established.
All patients admitted before midnight on the day of the survey and older than
18 years
9.3.4 Vanderwee 2011 (Hospital)
Title
Country
Population
PU Categ System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
Assessing the adequacy of pressure ulcer prevention in hospitals: a
nationwide prevalence survey
Belgium
Patients
EPUAP
hospitals
All wards except day care, psychiatry, paediatric and maternity. (PUs are
seldom observed in patients admitted to these wards)
cross-sectional survey and observation
19 968 patients.
9.3.5 Gallagher 2008 (Hospital)
Title
Country
Population
PU Categ System
Prevalence of pressure ulcers in three university teaching hospitals in
Ireland
Ireland
patients
European Pressure Ulcer Advisory Panel
- 45 -
Setting
Data Source
Data Collection
Data Notes
Prev denominator
3 teaching hospitals
Skin check
Eight teams of one doctor and one nurse visited 672 adult patients over a 2day period in three teaching hospitals Not clear how patients were selected
Patients visited during audit
9.3.6 Bours 2001(Hospital)
Title
Country
Population
PU Categ System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
Comment
Prevalence, risk factors and prevention of pressure ulcers in Dutch intensive
care units. Results of a cross-sectional survey
Netherlands
Patients admitted to hospital
EPUAP
Hospital - ICUs (all types)
Cross-sectional design
'each patient who had consented to participate was physically examined by
two nurses. [If unconscious] the patients family was asked for approval.'
Patients who had consented
The need for consent is a source of selection bias – the very ill and critically
ill may not have been in a position to consent, which may have resulted in
under-reporting.
9.3.7 Kottner 2009c (Hospital)
Title
Country
Population
PU Categ System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
The trend of pressure ulcer prevalence rates in German hospitals: results of
seven cross-sectional studies.
Germany
All patients
225 hospitals
Seven annual pressure ulcer prevalence surveys, from 2001 to 2007
The sample was stratified according to pressure ulcer risk and speciality.
The two years 2001 and 2007 are reported in the accompanying spreadsheet
All patients
9.3.8 Stausberg 2005 (Hospital)
Title
Country
Population
PU Categ System
Setting
Data Source
Data Collection
Pressure ulcers in secondary care: incidence, prevalence, and relevance
Germany
Cohort of 25,075 cases, but 2234 assessments
Descriptive, cohort, cross-sectional survey.
‘From a cohort of 25,075 cases, information on pressure ulcer status on
- 46 -
Prev denominator
Data Notes
Comment
admission was recorded for 20,283 cases. From 3237 selected cases, the
pressure ulcer team made 2234 assessments.’
Not clear from the abstract how the ‘cases’ were ‘selected.’
Not clear what the denominator actually is without the full text
9.3.9 Lindholm 2008 (Hospital)
Title
Country
Population
PU Categ System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
Hip fracture and pressure ulcers - the Pan-European Pressure Ulcer Study
Sweden, Finland, UK (North) and Spain, Italy and Portugal (South),
patients admitted for hip fracture surgery
EPUAP
Hospital
The study protocol agreed upon was designed in three main sections. Section A
was aimed at collecting patient- and care-related data at the Accident and
Emergency (A&E) Department. Section B comprised questions related to
perioperative care and in section C data regarding postoperative care were
recorded. The patients were followed up until discharge or for 7 days,
whichever was shorter. The patients’ skin was inspected in specified locations
(occiput, scapulae, hips, sacrum, ischium, elbows, daily heels, back of calves
and thighs and ankles) and documented on an anatomical drawing.
Classification of PU was standardised and a ‘pressure ulcer card’ with colour
pictures guiding the investigators to the correct classification.
Most ulcers were grade 1, and there was no grade 4 PU at discharge.
9.3.10 Schoonhoven 2007 (Hospital / incl. Incidence)
Title
Country
Population
PU Categ System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
Comment
The prevalence and incidence of pressure ulcers in hospitalised patients in
The Netherlands: a prospective inception cohort study
Netherlands
1536 patients admitted to the surgical, internal, neurological and geriatric
wards for more than 5 days between January 1999 and June 2000.
Occurrence of a pressure ulcer grade 2 or worse, European Pressure Ulcer
Advisory Panel.
Two large hospitals, one general (530-beds) and one teaching (1042-beds), in
The Netherlands
A prospective inception cohort study. ‘Non-selected, though not strictly
random sample,’ from whom ‘1229 patients (80%) consented to participate
and had a complete follow-up. Follow-up once a week until pressure ulcer
occurrence, discharge or length of stay over 12 weeks. Pressure ulcers
developing following admission (not clear from abstract how this was
ascertained).
Not clear from abstract - 'Consented and had follow-up'?
As per Bours (2001). The need for consent is a source of selection bias – the
very ill and critically ill may not have been in a position to consent, which
- 47 -
may have resulted in under-reporting.
9.3.11 Stausberg 2005 (Hospital)
Title
Country
Population
PU Categ System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
Pressure ulcers in secondary care: incidence, prevalence, and relevance
Germany
25075
Period and point prevalence
Hospital
Descriptive, cohort, cross-sectional survey
As demonstrated by the present study, differences between the 2
prevalence measurements are mainly due to the confounding of point
prevalence rates by length of stay. Length of stay determines the
probability of inclusion in a cross-sectional study and should be
considered in pressure ulcer trials in the future. 'In an unselected hospital
sample one can expect a period prevalence rate of 2% and a point
prevalence rate of 10%. ' '
Not clear from abstract
9.3.12 Srinivasaiah 2007 (Mixed)
Title
Country
Population
PU System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
Comment
A point prevalence survey of wounds in north-east England
UK
'Different risk assessment tools were used in the acute trust and in the
community. Waterlow score was used in the acute trust and a mixture of
Waterlow and Walsall' scores were used in the community.
5 trusts in Yorkshire - acute trust and its primary care trusts, nursing and
residential homes, hospice and local prisons.population of approximately
590,000
Point prevalence interface audit
A team of tissue viability nurses (TVNs) and audit staff. In the acute hospital
trust, a TVN and a member of the audit department visited each ward over a
two-day period to gather data from ward nurses on all inpatients with a wound.
A TVN also collected data in this way from the local hospice. On the same
date, all district nurses employed by the PCTs were asked to provide data on
every patient with a wound on their active case load. Meanwhile, senior staff
from the nursing homes, the local hospice and Hull and East Riding prisons
collected data on all of their patients with wounds, which were then reported to
a visiting TVN.
Patients reporting wounds.
As below. The denominator is not the general populatiion.
9.3.13 Vowden 2009* (Mixed)
Title
A survey of wound care provision within one English health care district
- 48 -
Country
Population
PU System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
Comment
UK
People in the collection area
EPUAP
Acute and community. 2 acute trusts, 1 primary care trust (PCT) (covering the
population served previously by four separate PCT’s) and all 72 nursing homes
located within the 25 postal code districts.
Questionnaire
This survey used different data collection methods for acute care and nursing
homes, compared with the PCTs,
 Acute care and nursing homes
Data collector visits to the nursing homes or wards or clinics in acute care
settings, with a resulting 100% response rate.'
 PCTs
Data collection was under the control of the District Nurse Team Leader who
had responsibility for ensuring that all patients with wounds had their data
recorded by the Practice Nurses.
1735 qnaires were returned
Results were not reported in enough detail to calculate the prevalence and
incidence per setting.
Patients reporting wounds.
The denominator is clearly not comparable with other studies that are based on
overall patient numbers. A better denominator would be the District's Nurse's
patient register – but this was not available. The study reported the total
population of the trusts’ geographical areas as 487,000+, but this makes no
sense to use as a denominator, given the scope of the questionnaire.
Vowden (2009b) has a slightly different – and rather harder to interpret – set
of findings, though apparently based on the same survey.
9.3.14 Lahmann 2005 (Mixed)
Title
Country
Population
PU Categ System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
Prevalence of pressure ulcers in Germany
Germany
66 institutions - nursing homes and hospitals
Survey
Researchers trained the coordinators of all participating hospitals and nursing
homes. Each coordinator then trained the ward nurses to gather the data used in
the survey. Only those ward nurses were trained who were fully qualified staff
nurses. Standard pictures and definitions of each ulcer grade were given to
each trained nurse. Each participant, either personally or represented by a
relative, had to give their informed consent.
Braden scale (cut-off < or =20) was applied to define 'at risk'
Both 'whole sample' and 'people at risk'
- 49 -
9.3.15 Lahmann 2006 (Mixed)
Title
Country
Population
PU Categ System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
Pressure ulcers in German nursing homes and acute care hospitals:
prevalence, frequency, and ulcer characteristics.
Germany
21,574 German hospital patients and nursing home residents
EPUAP
nursing homes and acute care hospitals
two cross-sectional surveys
Researchers trained the coordinators of all participating hospitals and
nursing homes regarding data gathering and each coordinator subsequently
trained fully qualified (at least 3 years’ nursing training) nurses on staff. All
trained nurses received standard pictures and definitions of each ulcer grade
'people 'at risk' (Braden score of =<20) '
9.3.16 Margolis 2002 (Primary)
Title
Country
Population
PU Categ System
Setting
Data Source
Data Collection
Data Notes
The incidence and prevalence of pressure ulcers among elderly patients in
general medical practice
UK
65+ years, 10% random sample of one million individuals in GPRD. The
prevalence for 1996, the most recent year, was used, with 41279 individuals.
OXMIS codes (Oxford Medical Information System)
General practice
10% sample of yearly GPRD
Retrospective audit. Some cross-checking of audit against q’naire response by
random samples of GPs.
Period prevalence was defined as the number of individuals with pressure
ulcers at any time during a given calendar year divided by the number of
individuals in the eligible population during that calendar year.
Incidence was defined as the number of new cases, as defined above, of
pressure ulcers among eligible individuals 65 years of age and older divided by
the total number of eligible person-years. An individual could only be counted
once as a new case.
Grade of ulcer was not reported. Only stage 2 or worse wounds
Individuals were eligible if: 1) they received care from a GP who participates
in the GPRD; 2) they had at least two consultations with the GP while they
were 65 years of age or older; and 3) they did not have a prior diagnosis of a
pressure ulcer. The start point was defined as six months after the first office
visit and the endpoint as the last database record.
Prev denominator
Population was by definition healthier than those in nursing homes, hospitals,
or home care. The rates can therefore be expected to be lower than – and not
comparable with – those reported in studies focusing on the hospitalised.
Number of individuals in the eligible population
- 50 -
9.3.17 McDermottScales 2009 (Primary)
Title
Country
Population
PU Categ System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
Comment
Prevalence of wounds in a community care setting in Ireland
Ireland
NA (EPUAP?)
COMMUNITY - intellectual disability, psychiatry, GP practices, prisons, longterm care private nursing homes, long-term care, public nursing homes and the
community/public health (district) nursing services. NOT ACUTE SERVICES.
Census point prevalence wound survey ('tool') …..97.2% response rate.
The overall prevalence of 2.17 per 1000 population in this survey is lower than
that reported by Srinivasaiah and colleagues and by Vowden and Vowden, who
found that 3.55 people per 1000 population had wounds. The difference is
probably due to the exclusion of acute services from this survey; for example,
32% of the people with wounds reported by Vowden and Vowden (2009b)
were in acute services.'
Comment by Michael Clark: 'This study did not report the accuracy with which
the community nurses reported wounds. This gap is also noticeable in previous
population-based surveys, such as that by Vowden and Vowden. The
uncertainty around the accuracy of wound reporting is the major weakness in
this audit, and steps should be taken to formally ascertain inter-rater reliability
in future wound audits. Identification of wounds may also have posed
challenges for the present study: The participating nurses were provided with
visual guides to the different presentations of pressure ulcers but text-based
definitions of other wound types.’
9.3.18 Raghavan 2002 (Primary / Spinal)
Title
Country
Population
PU Categ System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
Prevalence of pressure sores in a community sample of spinal injury patients
UK
all patients who were being followed up by a regional spinal injuries unit.
The mean age of the participants was 47 years (SD 14.7); 76% (341) were
males. The mean time since injury was 13 years (SD 10.6). All had traumatic
spinal injury except two who had spina bifda.
National Pressure Ulcer Advisory Panel (NUPAP)
community
questionnaire
postal questionnaire
Respondents to qnaire
9.3.19 Bick 2003 (Nursing)
Title
Country
Population
Pressure ulcer risk: audit findings
UK
All residents in the nursing care homes, including younger patients with a
disability
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PU Categ System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
Direction of bias
EPUAP
Four NHS trusts and two independent nursing care homes across England and
Wales
Retrospective audit
Initial risk assessment by 'practitioner with 'appropriate and adequate training'
(various grades of nurse). Then a retrospective review of the patient
documentation by the auditors and assessment of the patient's skin to verify
accuracy of any recording of tissue damage.
No of patients (but numerator = ulcers, not patients)
Higher
9.3.20 Schoonhoven 2002 (Hospital / Incidence)
Title
Country
Population
PU Categ System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
Incidence of pressure ulcers due to surgery
Netherlands
In-house? 4 grades
Hospital
Daily skin inspection
Data were not collected by the nurses but by the researcher and three observers.
The skin of the patients was observed on the evening before surgery and, if the
patient’s condition allowed it, postoperatively on arrival at the ICU or on the
ward and subsequently daily for 14 days or until discharge, whichever occurred
first. When patients developed a pressure ulcer they were observed daily until
discharge or until the pressure ulcer had healed. The size and colour of the
lesion, stage and skin condition were described every day.
Detailed registration system documents causes and consequences of PU
Patients undergoing surgery lasting more than 4 hours from cardiac surgery,
gastroenterology, head and neck oncology, neurosurgery, oncology,
orthopaedics, plastic surgery, urology and vascular surgery
9.3.21 Galvin 2002 (Hospital / Incidence)
Title
Country
Population
PU Categ System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
An audit of pressure ulcer incidence in a palliative care setting
UK
542 people with terminal illness, age 35-90, average 68yrs, average stay 15
days
Waterlow (1985) Pressure Sore Risk Assessment Tool AND Stirling Pressure
Sore Severity Scale
Specialist palliative care unit
Retrospective audit
Info on PU was recorded within 6hrs of admission, Admitting or discharge
nurse transferred this to the 'ward data collection tool.' Missing patients were
traced. A single auditing nurse 'spent some time educating nursing staff on the
importance of accurately observing what they saw.'
Admitted with PU - 142.
Developed PU in unit - 65.
All patients
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9.3.22 Lardenoye 2009 (Hospital / Incidence)
Title
Country
Population
PU Categ System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
Assessment of Incidence, Cause, and Consequences of Pressure Ulcers to
Evaluate Quality of Provided Care
Netherlands
'During the study period, 22,030 patients were admitted to our surgical ward'
International Association of Enterostomal Therapists and modified by the
National Pressure Ulcer Advisory Panel.
Hospital
Complications (adverse events?) register
Audit of records
Complications (adverse events?) register
9.3.23 Excluded - Kroger 2009 (Hospital)
Title
Country
Population
PU Categ System
Setting
Data Source
Data Collection
Data Notes
Prev denominator
Comment
Prevalence of pressure ulcers in hospitalized patients in Germany in 2005:
data from the Federal Statistical Office
Germany
full-time patients
Age-adjusted prevalence / full-time patients with presure ulcers
Hospitals
National Statistics
Not clear.
Full-time patients with presure ulcers?
The denominator is not clear. There is reference to 'additional diagnosis'
meaning 'occurred during stay in hospital', which implies that the figures
refer to incidence, not prevalence. Also, the denominator is not clear – by
implication, it is the 16 million annual patients in German hospitals, which
makes PU comparison with other studies impossible (and distorts the pooled
data analysis). Until the full text is obtained, this study cannot be properly
interpreted.
9.3.24 Excluded - Popp 2006 (Nursing / Incidence)
Title
Country
Population
PU Categ System
Setting
Data Source
Data Collection
The impact of the proportion of qualified nursing personnel on the incidence of
pressure ulcers in nursing homes
Germany
Nursing home inhabitants (n = 2813)
NA
Nursing homes
Routine survey on pressure ulcers
Nursing homes participating in this survey were asked for information about
their proportion of qualified personnel and some additional factors that could
possibly influence the incidence of bedsores.
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Data Notes
Prev denominator
Comment
Divided into three groups according to groups according to whether they have
been cared for by low (< 50%), medium (50-60%) or high (> or = 60%)
proportion of qualified personnel
Not clear from the abstract.
This study compared nursing homes with high, medium and low proportions of
qualified nursing staff. No significant difference was found in pressure ulcer
incidence between these three groups. Further data requires the full text.
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