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 Table of Contents  
Year : 2017  |  Volume : 1  |  Issue : 6  |  Page : 14-16

Pressure ulcers in critically III patients in Saudi Arabia: An opportunity for collaborative research on an ugly disease

Department of Intensive Care, College of Medicine, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia

Date of Web Publication23-Nov-2017

Correspondence Address:
Hasan M Al-Dorzi
Department of Intensive Care, College of Medicine, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, ICU2, Mail Code 1425, P. O. Box: 22490, Riyadh 11426
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sccj.sccj_24_17

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Pressure ulcers are common in critically ill patients and are associated with increased morbidity, mortality and cost. Studies on pressure ulcer prevention and management indicate the need for multifaceted care and multidisciplinary involvement. However, there are obvious deficits in pressure ulcer prevention efforts and care worldwide. Studies on pressure ulcers acquired in the intensive care unit (ICU) in Saudi Arabia are scarce. We propose a study to determine in Saudi ICUs pressure ulcer prevalence, risk factors, management and outcomes to improve the related care processes.

Keywords: Epidemiology, intensive care, outcome and process assessment, pressure ulcer

How to cite this article:
Al-Dorzi HM. Pressure ulcers in critically III patients in Saudi Arabia: An opportunity for collaborative research on an ugly disease. Saudi Crit Care J 2017;1, Suppl S2:14-6

How to cite this URL:
Al-Dorzi HM. Pressure ulcers in critically III patients in Saudi Arabia: An opportunity for collaborative research on an ugly disease. Saudi Crit Care J [serial online] 2017 [cited 2023 Jun 4];1, Suppl S2:14-6. Available from: https://www.sccj-sa.org/text.asp?2017/1/6/14/219130

A pressure ulcer (PU) is a localized injury to the skin or underlying tissue and usually results from unrelieved pressure, shear, or friction, and occurs over bony prominences. It is considered a preventable adverse event of hospital care. Critically ill patients are at an increased risk for acquiring PUs compared with other patients because of the critical illness itself, its management, and the coexisting chronic disorders. Studies on the epidemiology of PU in critically ill patients showed variable results. A large international study found that hospital-acquired PU occurred in approximately 6% of patients, with the incidence being highest in the adult Intensive Care Units (ICUs).[1] The PU incidence was 10.3% in surgical ICUs and 12.1% in the medical ICUs,[1] with severe PUs developing in 3.3% of ICU patients.[1] Another study reported that 9.8% of ICU patients had PU on ICU admission with an incidence of 7.8% during ICU stay.[2] Published data from Saudi Arabia on PU epidemiology are scarce. Two studies showed high PU burden in hospitals. One prospective study conducted at Riyadh Military Hospital in 2006–2007 with follow-up for 8 weeks in the hospital reported a PU prevalence of 44.4% and incidence of 38.6% in hospitalized patients.[3] These high rates were, at least in part, attributed to unusually prolonged hospital stay. In a prospective cohort study conducted in two 24-bed ICUs at two tertiary care Ministry of Health hospitals in 2013, 84 patients were regularly screened until discharge or death (censored at 30 days) and the hospital-acquired PU incidence was 39.3%.[4]

PUs are associated with decreased quality of life and increased morbidity, mortality, and cost.[5],[6],[7] A systematic review found that the cost of PU treatment varied from 1.7 to 470.5 € per patient per day across different settings.[7] Additionally, PUs may cause emotional distress to patients and their families and frequently lead to their dissatisfaction with the health-care system and mistrust of the health-care providers. We did not find any study from Saudi Arabia addressing clinical outcomes or economic impact of hospital-acquired PU.[3],[4]

PU risk assessment, prevention and management are important to reduce PU burden in ICU patients. Comprehensive evidence-based guidelines on PU prevention and care were recently updated.[8],[9] However, clinical studies about this topic are uncommon and mostly of low-to-moderate quality. They emphasize the need for a multifaceted care approach and multidisciplinary involvement. In a before-after study, implementing PU-prevention guidelines was associated with a decrease in the incidence of stages 2–4 PUs from a baseline of 54 to 32/1000 patient-days 12 months after guideline implementation (P = 0.001).[10] A recent study evaluated a program that included the use of Braden scores to assess PU risk, a skin care protocol, fluidized repositioners, silicone gel adhesive dressings with staff education and motivation to prevent PUs, and found that the incidence of ICU-acquired PUs decreased by 69%, despite a 22% increase in patient load.[11] A randomized controlled trial that compared applying a silicone dressing on the sacrum and heels in trauma and critically ill patients (n = 219) in the emergency department, which was maintained throughout their ICU stay, with not doing so (n = 221), found significantly fewer patients with PUs in the intervention group compared with the control group (5 [3.1%] vs. 20 [13.1%], P = 0.001).[12] A systematic review of 26 studies showed with moderate strength of evidence that the integration of several core components improved the processes of care and reduced the PU rates.[13] The key components included the simplification and standardization of PU-specific interventions and documentation, involvement of multidisciplinary teams and leadership, use of designated skin champions, ongoing staff education, and sustained audit and feedback.[13]

In the two studies from Saudi Arabia, multiple interventions were used for PU prevention and included routine skin assessment and care by nurses, nutritional support, repositioning, use of support surfaces, and education and training of new staff.[3],[4] Routine PU risk assessment, recommended in the new guidelines,[8] was not performed in these studies.[3],[4] One study found that Braden scale, a PU risk assessment tool, was not better than the nurses' clinical judgment for assessing PU risk.[3] The other study identified the ICU length of stay and less frequent repositioning as independent predictors of the development of stages 2–4 PUs.[4]

PU occurrence is a recognized quality of care metric by many organizations including the Joint Commission International. Its prevention has become a key focus of many health-care institutions worldwide. However, health-care providers in general have suboptimal knowledge about PU definitions and care.[14],[15] In addition, physicians tend to be less involved in PU prevention and management than nurses, which may lead to suboptimal care. [Table 1] describes the knowledge gaps related to hospital-acquired PU in Saudi Arabia and the suggested methods to answer the corresponding research questions. We propose a study to establish in a mixed population of ICU patients in Saudi Arabia (a) the prevalence of PUs, (b) their predisposing factors, (c) the current management, and (d) the associated outcomes. These data will be crucial to direct and improve ICU care initiatives for PU prevention and optimal management.
Table 1: Knowledge gap related to hospital-acquired pressure ulcer in Saudi Arabia

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  References Top

VanGilder C, Amlung S, Harrison P, Meyer S. Results of the 2008-2009 International Pressure Ulcer Prevalence Survey and a 3-year, acute care, unit-specific analysis. Ostomy Wound Manage 2009;55:39-45.  Back to cited text no. 1
Terekeci H, Kucukardali Y, Top C, Onem Y, Celik S, Oktenli C. Risk assessment study of the pressure ulcers in Intensive Care Unit patients. Eur J Intern Med 2009;20:394-7.  Back to cited text no. 2
Saleh M, Anthony D, Parboteeah S. The impact of pressure ulcer risk assessment on patient outcomes among hospitalised patients. J Clin Nurs 2009;18:1923-9.  Back to cited text no. 3
Tayyib N, Coyer F, Lewis P. Saudi Arabian adult Intensive Care Unit pressure ulcer incidence and risk factors: A prospective cohort study. Int Wound J 2016;13:912-9.  Back to cited text no. 4
Price P. Health-related quality of life and the patient's perspective. J Wound Care 1998;7:365-6.  Back to cited text no. 5
Reddy M, Keast D, Fowler E, Sibbald RG. Pain in pressure ulcers. Ostomy Wound Manage 2003;49 4 Suppl:30-5.  Back to cited text no. 6
Demarré L, Van Lancker A, Van Hecke A, Verhaeghe S, Grypdonck M, Lemey J, et al. The cost of prevention and treatment of pressure ulcers: A systematic review. Int J Nurs Stud 2015;52:1754-74.  Back to cited text no. 7
Haesler E, editor. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Osborne Park, Australia: Cambridge Media; 2014.  Back to cited text no. 8
Qaseem A, Mir TP, Starkey M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2015;162:359-69.  Back to cited text no. 9
de Laat EH, Pickkers P, Schoonhoven L, Verbeek AL, Feuth T, van Achterberg T. Guideline implementation results in a decrease of pressure ulcer incidence in critically ill patients. Crit Care Med 2007;35:815-20.  Back to cited text no. 10
Swafford K, Culpepper R, Dunn C. Use of a comprehensive program to reduce the incidence of hospital-acquired pressure ulcers in an Intensive Care Unit. Am J Crit Care 2016;25:152-5.  Back to cited text no. 11
Santamaria N, Gerdtz M, Sage S, McCann J, Freeman A, Vassiliou T, et al. A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: The border trial. Int Wound J 2015;12:302-8.  Back to cited text no. 12
Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy: A systematic review. Ann Intern Med 2013;158(5 Pt 2):410-6.  Back to cited text no. 13
Gunningberg L, Mårtensson G, Mamhidir AG, Florin J, Muntlin Athlin Š, Bååth C. Pressure ulcer knowledge of registered nurses, assistant nurses and student nurses: A descriptive, comparative multicentre study in Sweden. Int Wound J 2015;12:462-8.  Back to cited text no. 14
Cox J, Roche S, Gandhi N. Critical care physicians: Attitudes, beliefs, and knowledge about pressure ulcers. Adv Skin Wound Care 2013;26:168-76.  Back to cited text no. 15


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