Pressure Ulcers Prevalence and Potential Risk Factors Among Intensive Care Unit Patients in Governmental Hospitals in Palestine : A Cross-sectional Study

A quantitative, cross-sectional, descriptive analytical study was carried out in five government hospital intensive care units in four different Palestinian cities between September 27, 2017, and October 27, 2017. The data of 109 out of 115 (94.78%) inpatients were analyzed. The Minimum Data Set (MDS) recommended by the European Pressure Ulcer Advisory Panel (EPUAP) was used to collect inpatients’ information.


INTRODUCTION
Pressure Ulcers (PUs) are a significant problem in healthcare.They do not only affect the quality of life, morbidity and mortality of patients, but they also have an impact on healthcare costs [1].
A pressure ulcer is described as a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction.PUs vary in size and severity of the affected tissue layer, ranging from skin erythema to damaged muscle and underlying bone [2 -4].
A study conducted by Jiang in China shows that the prevalence rate of pressure ulcers was 1.58% (0.94-2.97%) [5], while the prevalence rate of PUs ranges from 8.8 -53.2% in Europe in which the incidence rate ranges from 7-71.6% [6].
There are different risk factors related to PUs development among ICU patients.Immobility and friction are important risk factors for PUs [2,7,8].Malnutrition and Body Mass Index (BMI) are associated with pressure injury prevalence.Therefore, routine and formal assessment of both BMI and nutritional status are important to enable the identification of patients with high risk of developing PUs [8 -10].
The days in hospital, skin moisture, and other neurological factors are significant risk factors for PUs development [11 -13].
On the other hand, protective methods can prevent PUs development.One method can be the use of dynamic surfaces which are found to be protective against PUs [14].
Although the studies on the prevalence of PUs in ICU departments are very limited, ICU patients' acquired PUs prevalence is significantly greater than that found in other patient groups.ICU patients are nearly four times more likely to develop PUs than non-ICU patients [15].In Palestine, there is no study found on assessing the prevalence and risk factors of PUs, despite the importance of studies on the prevalence of PUs among hospitals' patients, especially in ICU.Thus, information about PUs prevalence and risk factors is very limited and cannot be obtained retrospectively in Palestine.

Study Design
A cross-sectional study was used to identify the prevalence rate of PUs and potential risk factors associated with PUs development among ICU patients in Palestinian government hospitals.

Study Setting
The study was conducted in the Intensive Care Units (ICUs) of five governmental hospitals (Rafedia hospital, Al -Watani hospital, Darwish Nazal hospital, PMC hospital, and Alia hospital) in four different Palestinian cities.

Population and Sample
All patients were admitted to the ICUs departments between September 27, 2017, andOctober 27, 2017.The total population derived from five hospitals in four cities included 109 patients.The number of patients in Rafedia hospital was 29 (26.6%)patients, Al-Watani hospital was 9 (8.2%) patients, Darwish Nazal hospital was 14 (12.8%)patients, Palestinian Medical Complex (PMC) hospital was 45 (41.3%) patients and, finally, Alia hospital was 12 (11.0%)patients.All patients, 18 years or older, admitted to ICU departments were included, while patients who aged equal or less than 18 years, patients who did not accept participation, or patients who refused to sign informed consent, were excluded.

Data Collection
The researchers used data collection sheets that contained two sections.Section one contained the patient's characteristics such as age, gender, weight, height and BMI.The second section, based on the European Pressure Ulcer Advisory Panel (EUPAP) guidelines, contained the Risk assessment using the Braden Scale.The Braden Scale consists of six sub-scales: sensory perception, moisture, activity, mobility, nutrition, friction and shear.The classification system made by National Pressure Ulcer Advisory Panel (NPUAP) and EPUAP in 2009 is used in the recognition of pressure ulcers, including Stage I to Stage IV, the category of "unstageable", and "Suspected Deep Tissue Injury" (SDTI) [4,16].Each data collection member received training on data collection and PUs detection with the main aim of standardizing practices.Since the study focuses on PUs prevalence in ICU patients, if several PUs were found on the same patient, only the most severe was considered.Unstageable pressure ulcers or suspected deep tissue injuries were included as a separate category.
Approval of Institutional Review Board (IRB) at An-Najah National University and Ministry of Health was obtained.Data collection from selected hospitals was conducted daily for one month.Before the assessment began, researchers explained the purpose of the study and received a consent form from each participant.Initially, all patients who were admitted to ICU were assessed to determine any abnormalities such as abnormal heat, redness, and erythema.The assessment was focused on bony prominence areas.

Statistical Analysis
All analyses were done with the software package SPSS 18.0.Descriptive analysis, mean, median, standard deviation, maximum, minimum, percentage and frequency were used.The Chi-Square test was used to present the relationship between risk factors and PUs development, in which the significance is 0.05 or less.

Ethical Considerations
Ethical approval by IRB (Institutional Review Board) at An-Najah National University and the Ministry of Health was obtained.The patient's caregiver/relative signed the consent form before the assessment began and a code number was used rather than the participant's name in order to maintain privacy.

General Data of Patients
Table 1 shows the characteristics of participants.Fifty-five percent of the participants were female, and most of the participants were from Ramallah (39.4%).In addition, most participants were from PMC hospital (41.3%).The mean age of participants was 54.7 years old and ranged from 19-105 years.The mean weight of participants was 78.2 kg, with a mean height of 169 cm and ranged from 145 -188 cm.The mean BMI of participants was 27.3 and ranged from 13.0 -42.9 for all participants.Most participants (42.2%) were overweight, whereas 28.44% had normal BMI.Furthermore, 27.5% of participants were obese and 1.83% of participants were underweight.

Medical Records of Participants
According to Table 2, most participants (66.1%) were medical cases, 17.4% of participants were surgical cases, 6.4% of participants were traumatic cases and 10.1% were gynecological cases.Also, 35.8% of participants had a medical history, 33% of participants had a surgical history, and all participants were on medication.

The Prevalence of Pressure Ulcers
The results in Table 3 exhibit that out of the 109 patients, 36 patients have pressure ulcers.
The prevalence of PUs in the ICU department was 33%, and the prevalence of PUs when excluding Stage 1 was 7.3%.

Risk Factors for PUs
The results in Table 4 exhibit that most cases in the PU were male.The Chi-Square test exhibited no relation between PU and gender (p value=0.371).
The results also show that most participants who had PU exhibit normal or overweight BMI category, and the Chi-Square test exhibited no signs of BMI on the development of 157).
Most participants who had PUs were in dependent mobility category (80.6%), and the Chi-Square test on the relation between mobility category and PUs revealed no significant relation between PUs and mobility category (p-value =0.157).
Of patients with PUs, 44.4% were NPO, whereas 55.6% were on a diet, and the Chi-Square test showed no significant relation between PUs with nutritional status (p-value = 0.239).
Table 4 also shows that longer the stay of patients in the ICU department increased the risk of PUs development.The result of the Chi-square test revealed a significant relationship between increased days in hospital and PUs (p value=0.001).
The results also exhibit that 22 (55.6%)participants who had PUs had dry skin; Chi-square test results exhibited no significant relation between the moisture and PUs development (p-value = 0.071).
The results in Table 4 exhibit that 50% of patients who developed PUs were exposed to friction, while 85% of patients who did not develop PUs, were not exposed to friction.The results showed that there is a significant relation between PUs development and friction (p-value= 0.001).

DISCUSSION
This study is aimed at identifying the prevalence rate and the potential risk factors of pressure ulcers among patients in the ICU departments of government hospitals in Palestine.
Although detection, assessment, and management of possible risks before an injury occurs are keystones of PUs prevention [17], identification of potential risks is also important.However, results from this study and others reviewed suggest that PUs development is aggravated by the sum of multiple, rather than single, risk factors in the one critically ill individual [18].This study assessed the prevalence of PUs among ICU adult patients in Palestine.The prevalence of PUs was 33% and the prevalence of PUs higher than stage 1 was 7.34%.It also shows that days in the hospital, Mechanical Ventilators (MV), and friction were significant risk factors for PUs development.On the other hand, BMI, moisture and immobility did not have any statistically significant relation with PUs development.
A study applied in Jordan found that the prevalence of PU was lower (16%) than the prevalence of the present study (33%) among which a total sample of 295 participants had similar participants' characteristics such as gender and age; 58% of their samples were male and 42% were female.The mean age in their study was 49.1 years [19].In the present study, the sample was 109 participants, of which 55% were female and 45% were male, the mean of age was 54.7 years.Another study done by Fiona Coyer found the prevalence of PUs to be 11.5% and prevalence of PUs > stage 1 to be 11.2% [20].
Studies stated that malnutrition and BMI are associated with PUs prevalence [8 -10].Therefore, routine and formal assessment of both BMI and nutritional status are important to enable the identification of patients at high risk of PUs.The present study supports that the BMI was not associated with PUs development, whereas malnutrition could be the factor associated with skin injury prevalence [23].It also demonstrated the limitations of BMI as a nutritional assessment measure.Morbid obesity is a significant and independent risk factor for PUs development.However, the clustering of nutritional risk factors (morbid obesity and malnutrition) substantially increases this risk.Therefore, routine and formal assessment of both BMI and malnutrition status are important to enable the identification of patients at high risk of PUs.The study conducted by Ness et al. (2017) revealed a significant relationship between BMI category and PUs development (pvalue = 0.001), and exhibited that the underweight and morbidly obese have a higher risk of developing PUs [9], in contrast with results of the present study which show no relation between the BMI category and PUs developments (pvalue = 0.579).The difference between results can be explained because only 1.83% of the samples were underweight and few cases were morbidly obese, which are insufficient to exhibit the effect of low weight and morbid obesity on PUs development.
The present study exhibits that 24.56% of patients had friction caused by the rank of the sheet, and friction had a significant effect on PUs development (p value= 0.001).In comparison, other studies revealed a significant relationship between friction and PUs category [2,7,8].This may be because friction between skin and other surfaces, such as bed sheets, causes loss of stratum corneum that leads to the loss of blood flow to the skin and cause ulceration.
PUs are likely to occur early in the hospital days as shown in Table 4 and may develop within the first week of hospitalization in ICU.Thus, there was a significant relationship between the increase in the number of days in the hospital with the development of PUs (p-value = 0.001).In comparison, a study conducted in Korea (2017) showed a relation between increase in the number of inpatient days and PUs developments [24], and a study conducted in the United States showed a relation between increase in the number of inpatient days and PUs developments (p-value< 0.05) [25].These studies' results were consistent with the present study results that revealed that inpatient days are a risk factor for PUs development.These results can also be explained by suggesting that most critical cases stay for long periods in hospital and little attention is given to their nutrition and mobility, increasing pressure on the small points and decreasing perfusion of blood in these sites, resulting in an increased risk for ulceration.
While immobility is found to be an important risk factor for PU [2,7,8], the results of the present study exhibit that there is no significant relation between immobility and development of PUs (p-value = 0.157).This difference in the results can be explained by the fact that 75.2% of samples were conscious and 71.6% of the samples were independent of mobility.This means that most participants were able to change their position from time to time, leading to pressure relief on bony prominences, and improvement in the circulation of these sites, preventing PUs.Further results of the present study show that moisture has no relationship with PUs development (p-value = 0.071) in contrast with results of the study conducted in Germany, which exhibit a significant relation between PUs and moisture (p-value = 0.010) [12].These differences may be due to the small sample size of the study which might be seen from the marginal level of p-value (p-value = 0.071).
The present study also demonstrated a significant relation between PUs development and mechanical ventilators (p-value = 0.001) in comparison to a study conducted in Spain, which found a significant relationship between MV and PUs development (p-value = 0.037) [26].These results can be explained by noting that mechanically ventilated patients were immobile, suffered from malnutrition, and were exposed to friction.These factors increased pressure on the small points and decreased perfusion of blood in these sites, resulting in an increased risk for ulceration.There may be a gap between theory and practice regarding the care of ICU patients who are at high risk for PUs.Furthermore, in addition to the small sample size of the study, a meaningful comparison cannot be made between the various studies because of the different grading systems for PUs, different methods of data collection and population characteristics.Finally, the absence of standardized protocols in screening and managing PUs in the governmental hospitals in Palestine could be one of the main reasons for these inconsistent results.

CONCLUSION
The prevalence of PUs was 33% and most of them were in Stage I.When excluding Stage 1 PUs, the prevalence was 7.34%.Many factors affected PUs prevalence, including the number of days in the hospital, friction, and medical devices such as ventilators.Moisture, immobility, nutritional status, and BMI were not associated with PUs prevalence.In this study, change of position had little effect on PUs development which could be explained by the staff's lack of knowledge [27] and a lack of PUs risk screening led to changing positions for those who had already developed PUs, and missed those who were at risk.The study findings confirmed that the assessment and the prevention efforts and screening, in addition to increasing the staff's knowledge about PUs preventive measures in Palestine hospitals, must be improved in order to decrease the burden of PUs.

LIMITATIONS
Local studies led to small sample size.In addition, there was a difficulty controlling all hospitals which were selected, in which results were dependent on other nurses to collect data.Increase in budget related to long distances between hospitals and difficulty in observing patients several times a day were observed.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE
Potential participants were approached by the researchers after ethical approval had been granted by Institutional Review Board (IRB) at An-Najah National University and Ministry of Health.

HUMAN AND ANIMAL RIGHTS
No animals/ humans were used for the studies that are the basis of this research.

CONSENT FOR PUBLICATION
Before the assessment began, researchers explained the purpose of the study and received a consent form from each participant.

Table 3 . Prevalence of PUs of participants among ICU departments (N=109).
PUs: pressure ulcers ICU: intensive care unit