This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at:
To determine the prevalence rate and the potential risk factors of pressure ulcers (PUs) among patients in the intensive care unit (ICU) departments of the government hospitals in Palestine.
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.
The result of the analysis showed that the prevalence of pressure ulcers in the ICU departments was 33%, and the prevalence of PUs when excluding stage one was 7.3%. The common stage for pressure ulcers was stage one. It was also determined that the most common risk factors for the development of pressure ulcers were the number of days in the hospital, moisture, and friction.
According to the recent studies in the Asian States, the prevalence of pressure ulcers in Palestine is considerably higher than in China and Jordan. However, it is still lower than the prevalence reported in comparable published studies in Western Europe. Increasing the staff’s knowledge about PUs screening and preventive measures is highly recommended in order to decrease the burden of PUs.
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 [
A study conducted by Jiang in China shows that the prevalence rate of pressure ulcers was 1.58% (0.94-2.97%) [
There are different risk factors related to PUs development among ICU patients. Immobility and friction are important risk factors for PUs [
The days in hospital, skin moisture, and other neurological factors are significant risk factors for PUs development [
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 [
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 [
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.
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.
All patients were admitted to the ICUs departments between September 27, 2017, and October 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.
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) [
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.
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 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.
|
|
|
|||
---|---|---|---|---|---|
Female | 60 | 55.0 | |||
– | Male | 49 | 45.0 | ||
Nablus | 35 | 32.1 | |||
– | Qalqilia | 14 | 12.8 | ||
– | Ramallah | 43 | 39.4 | ||
– | Hebron | 12 | 11.0 | ||
– | Tulkarem | 4 | 3.7 | ||
– | Jenin | 1 | 0.9 | ||
Rafedia | 29 | 26.6 | |||
– | Al Watani | 9 | 8.2 | ||
– | DarwishNazal | 14 | 12.8 | ||
– | PMC | 45 | 41.3 | ||
– | Alia | 12 | 11.0 | ||
Underweight | 2 | 1.83 | |||
– | Normal | 31 | 28.44 | ||
– | Overweight | 46 | 42.20 | ||
– | Obese | 30 | 27.5 | ||
– | |||||
54.7 | 21.0 | 55.0 | 19.0 | 105 | |
78.2 | 16.4 | 80.0 | 40.0 | 125 | |
169.0 | 8.4 | 170.0 | 145 | 188 | |
27.3 | 5.2 | 27.1 | 13.0 | 42.9 |
Table
According to Table
|
– |
|
|
---|---|---|---|
Medical | 72 | 66.1 | |
– | Surgical | 19 | 17.4 |
– | Traumatic | 7 | 6.4 |
– | Gyna | 11 | 10.1 |
Yes | 70 | 35.8 | |
– | No | 39 | 64.2 |
Yes | 36 | 33 | |
– | No | 73 | 67 |
Yes | 109 | 100 |
The results in Table
The prevalence of PUs in the ICU department was 33%, and the prevalence of PUs when excluding Stage 1 was 7.3%.
Variables | – | Frequency | Percentage |
---|---|---|---|
PUs | Yes | 36 | 33 |
– | No | 73 | 77 |
PUs excluding stage 1 | Yes | 8 | 7.3 |
– | No | 101 | 92.6 |
The results in Table
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 PU (p-value=0,157).
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
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
Variable | – | PUs |
|
|
|
---|---|---|---|---|---|
– | – | Yes |
No |
– | – |
Gender | Male |
22 (61.1) |
38 (52.1) |
0.79a | 0.37 |
BMI Categories | Underweight Normal |
1 (2.8) |
1 (1.4) |
1.96 | 0.57 |
Mobility* | Independent |
5 (13.9) |
22 (30.1) |
3.69 | 0.15 |
Nutritional Status* | NPO |
16 (44.4) |
24 (32.9) |
1.38 | 0.23 |
Day Inpatient | 1-3 days |
7 (19.5) |
45 (68.4) |
40.88 | 0.001 |
Moisture* | Normal |
12 (33.3) |
39 (53.4) |
5.278 | 0.07 |
Friction* | No |
18 (50.0) |
62 (84.9) |
15.066 | 0.001 |
Ventilator | No |
21 (58.3) |
65 (91.6) |
14.854 | 0.001 |
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 [
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 [
The prevalence of PUs in ICU of government hospitals in Palestine was higher than North America (22%) [
Studies stated that malnutrition and BMI are associated with PUs prevalence [
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 [
PUs are likely to occur early in the hospital days as shown in Table
While immobility is found to be an important risk factor for PU [
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) [
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 [
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.
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.
No animals/ humans were used for the studies that are the basis of this research.
Before the assessment began, researchers explained the purpose of the study and received a consent form from each participant.
The authors declare that there is no conflict of interest, financial or otherwise.
These data represent doctors working in hospitals and are based on the ethical approval from An-Najah National University, IRB ethical committee. Data will be kept confidential and only findings will be submitted.
This work has been made by the efforts of the authors and the financial assistance has been provided from An-Najah National University.
The authors would like to thank all participants without whom there would be no study.