Healing Status of Pressure Injuries Among Critically Ill Patients in a Turkish Hospital: A Descriptive, Retrospective Study

Evaluating the healing status of pressure injuries is important to planning medical and nursing care. Purpose: A descriptive, retrospective study was conducted to determine the healing status of pressure injuries among critically ill immobile patients. Methods: Data were obtained via medical record review of all patients admitted to a Turkish university hospital’s anesthesiology intensive care unit (ICU) between January 2008 and December 2015. Demographic (age, gender), medical (comorbidities, diagnosis, length of ICU stay), and pressure injury characteristics (number, location, stage, healing status, length, width, exudate amount, tissue type) were evaluated along with Pressure Ulcer Scale for Healing (PUSH) Tool scores. Data from all patients >18 years of age with an ICU stay >24 hours who had a pressure injury and whose records were complete were included in the study. Data were expressed as number, percentage, and mean and median values. Wilcoxon test, Spearman’s correlation analysis, and chi-square test were performed as appropriate. Pressure injuries were considered healed when the PUSH score equaled zero. Results: The study sample comprised 359 patients (60.97 ± 19.31 [range 19–95] years, 217 men, median length of stay 25 [range 1–363] days) with 672 pressure injuries. Most pressure injuries were located on the coccyx (278 [41.4%]), and 153 (22.8%) healed during ICU stay. Older age (r = 0.167; P = .002) and length of ICU stay (r = 0.238; P = .0001) were significantly correlated with having multiple pressure injuries. There was a statistically significant relationship between pressure injury location and stage and healing status (χ² = 28.993, P = .0001; and χ² = 60.200, P = .001, respectively). The lowest percentage of injuries healed were on the coccyx and were stage 4 and unstageable. Overall, the mean first PUSH score was significantly higher than the last assessment score (8.99 ± 3.82 to 7.28 ± 5.22, respectively; z = -10.807; P = .0001). Conclusion: Many immobile ICU  patients had multiple pressure injuries, especially patients who were older and who had a longer length of stay. Healing scores for pressure injuries were better at discharge or transfer and 22% of injuries were healed. Prospective studies comparing all factors that may contribute to pressure injury healing are warranted.

Critically ill hospital patients typically face prolonged periods of immobility due to the severity of their illness; in addition, hemodynamic instability, mechanical ventilation therapy, monitoring devices, and medical treatments make immobility necessary and inevitable.¹ Immobility is a factor in a variety of severe complications, including deep vein thrombosis, pulmonary insufficiency, muscular atrophy, decreased functional capacity, and pressure injuries.^1,2

A pressure injury is defined by the National Pressure Ulcer Advisory Panel (NPUAP) as “localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device.”³ Pressure injuries are one of the most significant health concerns and descriptive, observational, and experimental studies have shown they may involve severe pain, discomfort, impaired quality of life, prolonged hospital stay, increased health care costs, mortality, and morbidity.^4-6

Pressure injury development is a complex process with many contributory risk factors, especially among critically ill patients.^3,4 Immobility affects individual organ systems and has been shown to be the most important risk factor contributing to pressure injury occurrence.^1,4,6 The highest pressure injury rates among hospitalized individuals are reported in the critical care population. The NPUAP⁷ reported pressure injury incidence rates vary between 13.1% and 45.5% in critical care settings. In a cross-sectional, retrospective Turkish study⁸ conducted among a population of 20 175 patients, the pressure injury prevalence rate was found to be 3.3% and the overall pressure injury incidence rate for 5 years was 1.8%. A systematic review⁹ found pressure injury rates vary between 15% and 63% in Turkish intensive care units (ICUs).

Treating pressure injuries in immobile patients can be a clinical challenge due to complex treatment, slow healing, and contributing adverse effects such as such as bone and joint infections, cellulitis, and sepsis.^3,4,6 Therefore, evaluating the healing process of pressure injuries is important in determining treatment progress and/or effectiveness.^10,11

The Pressure Ulcer Scale for Healing (PUSH) Tool. The PUSH Tool is a reliable, easy-to-use instrument developed to monitor the change in pressure injury status over time. The Tool assesses 3 parameters: surface area, exudate, and type of wound tissue. Surface area is determined by multiplying the greatest length by the greatest width. Wound area values between 0 cm² and 24 cm² then are scored on a 0 (0 cm²) to 10 (>24 cm²) scale. The amount of exudate (drainage) is determined at dressing removal before applying a topical agent and is assessed on a scale of 0 to 3, where 0 = none, 1 = light, 2 = moderate, and 3 = heavy. Tissue type is specified as necrotic tissue/eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than surrounding skin; score = 4), slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous; score = 3), granulation tissue (pink or beefy red tissue with a shiny, moist, granular appearance; score = 2), epithelial tissue (for superficial ulcers, new pink or shiny tissue/skin that grows in from the edges or as islands on the ulcer surface; score = 1), and closed/resurfaced (the wound is completely covered with epithelium/new skin; score = 0). The total PUSH score ranges from 0 to 17 and is obtained by summing the 3 parameter scores (see Figure 1). Changes in the score represent variation in injury healing. If the score decreases, the pressure injury is healing; if the score increases, the pressure injury is deteriorating.¹²

A prospective, methodological study¹⁰ conducted in a Turkish university hospital among 72 people with 86 pressure injuries showed total PUSH scores decreased significantly over the 8-week study period and significant differences in total PUSH scores were noted between healed and unhealed ulcers.

Alderden et al⁴ conducted a retrospective chart review of data from 87 patients treated at a level I trauma center and safety net hospital in Seattle, Washington. Among 111 hospital-acquired pressure injuries, 45.9% healed and 54.1% remained at discharge or death.

A retrospective study by Karahan et al¹¹ of 4 years of data from a private Turkish university hospital found 79.5% of the pressure injuries were stage 2, 75.6% were located in the sacral area, and 65.4% were present upon discharge or death. However, international research reflecting the healing status of pressure injuries among critically ill immobile patients is lacking. The aim of this study was to determine the healing status of pressure injuries among critically ill immobile patients.

This descriptive, retrospective study was performed to evaluate pressure injury characteristics and healing status among critically ill immobile patients in an anesthesiology ICU of a Turkish university hospital. The 1816-bed hospital is located in İzmir, Turkey; the anesthesiology ICU has a 27-bed capacity and cares for approximately 500 patients annually. The PUSH Tool has been used to evaluate all pressure injuries at the anesthesiology ICU since the end of 2007. Per institutional protocol, all pressure injuries are directly assessed and recorded according to PUSH Tool criteria by ICU nurses on admission, at each dressing change, and at least weekly thereafter until healing, patient discharge, or death.

Intensive care nurses are responsible for the prevention and care of pressure injuries; wound care nurses evaluate, determine the presence of a pressure injury, and give advice for planning appropriate care and management of pressure injuries. The existing hospital protocol concerning wound care requires at least weekly wound care nurse follow-up for patients with pressure injuries.

In this unit, pressure injuries are classified by ICU nurses based on NPUAP7 guidelines as follows: stage 1 is nonblanchable erythema of intact skin, stage 2 is partial-thickness skin loss with exposed dermis, stage 3 is injury with full-thickness skin loss, stage 4 involves injury with full-thickness skin and tissue loss, and unstageable is an injury with obscured full-thickness skin and tissue loss.

The data were obtained via review of the medical records of patients admitted to the university hospital’s anesthesiology ICU from January 2008 to December 2015 and were extracted between April and December 2016. The medical records from all consecutively admitted patients were reviewed and medical history, nursing assessment and monitoring forms, and PUSH scores were extracted for each patient who was admitted with or developed a pressure injury. The researchers performed the medical record reviews manually. In this study, the endpoint was defined as a pressure injury that either healed or remained at ICU discharge or death. When the total PUSH score was 0, the pressure injury was considered healed.

Inclusion criteria. Inclusion criteria stipulated the patient 1) had a pressure injury, 2) was >18 years of age, 3) had stayed at least 24 hours in the ICU, and that 4) pressure injury medical records were complete/not missing data.

Data collection. Data obtained from the medical record review were recorded into a data collection form developed by the researchers for this study in accordance with the relevant literature.3,5,12 The form consisted of 16 items and compiled the following variables: demographic (age, gender), medical (comorbidities, diagnosis, length of ICU stay), and pressure injury (number, location, stage, healing status, length, width, exudate amount, tissue type) characteristics and initial and last recorded PUSH scores. For patients having more than 1 pressure injury, each pressure injury was evaluated separately and the PUSH score for each pressure injury was recorded.

Data analysis. The data were entered into and analyzed using SPSS for Windows, version 16.0 (SPSS Inc, Chicago, IL). Descriptive data for patients were expressed as number, percentage, and mean and median values. Compliance of the quantitative variables with the normal distribution was assessed using the Kolmogorov-Smirnov test. For not normally distributed data, Wilcoxon test and Spearman’s correlation analysis were used. For nominal and ordinal variables, a chi-square test also was performed. A P value <.05 was considered statistically significant.

Ethical considerations. This study was approved by the Scientific Ethics Committee of Ege University, Nursing Faculty, and the institution in which the research would be conducted. The data obtained from medical record reviews were deidentified either directly or indirectly. Because of the design of the study, patients were not assessed directly; therefore, informed consent was not necessary.

Of the 3862 medical records reviewed, 359 (9%)  met the inclusion criteria and were abstracted for the study. Figure 2 shows the sampling flow diagram of the study sample.
Mean patient age was 60.97 ± 19.31 (range 18–95) years, 217 participants (60.4%) were male, 120 (33.4%) had comorbidities, and all 359 (100%) experienced respiratory failure. Median length of ICU stay was 25 (range 1–363) days. Patients had a variety of medical conditions (see Table 1).

Pressure injury characteristics. Among the 359 study patients, 189 (52.6%) had 1 pressure injury, 83 (23.1%) had 2 pressure injuries, 46 (12.8%) had 3 pressure injuries, 28 (7.8%) had 4 pressure injuries, 11 (3.1%) had 5 pressure injuries, and 2 (0.6%) had 6 pressure injuries. Table 2 includes all the pressure injury characteristics.

The potential confounding variables (eg, gender [U = 15039; P = .676] and comorbidities [U =13212.500; P = .185]) were not statistically associated with the number of pressure injuries incurred. Older age (r = 0.167; P = .002) and longer length of ICU stay (r =0.238; P = .0001) were significantly correlated with the number of pressure injuries. Increased age and prolonged hospital stay increased the number of pressure injuries a person developed. In other words, pressure injury was correlated with increased age and prolonged hospital stay.

Pressure injury healing measures. Among the 672 pressure injuries, 153 (22.8%) healed and 519 (77.2%) remained unhealed upon ICU discharge or death. However, 330 (49.1%) pressure injuries demonstrated improvement per their PUSH scores during the patients’ ICU stay (see Table 2).

A statistically significant relationship was noted between pressure injury location and healing status (χ² = 28.993; P = .0001); fewer healed pressure injuries were noted in the coccyx than other anatomical locations. A statistically significant difference was determined between the pressure injury stage and healing status (ie, advanced stage pressure injuries tended not to heal) (χ²= 60.200; P = .0001) (see Table 3).

Overall, the mean PUSH score decreased significantly from 8.99 ± 3.82 to 7.28 ± 5.22 during ICU stay (z = -10.807; P = .0001) (see Table 4).

Numerous studies have noted nurses have the most active role in the prevention, care, and healing of pressure injuries in immobile patients,^3,5,11 making evaluation of the healing status of pressure injuries one of the fundamental responsibilities of nurses caring for critically ill immobile patients. The aim of this retrospective study was to determine the healing status of pressure injuries among critical immobile patients.

Pressure injury characteristics. Previous data demonstrating rates between 5.9% and 88% were supported by this study; in addition, most pressure injuries occurred in the pelvic region (buttocks 16.8%, coccyx 41.4%), similar to previous research.^{4,5,10,11,13-17}
Age has been found to be one of the most important factors contributing to pressure injury development; the subcutaneous fat layer, dermal thickness, and sensory perception (affecting the need to adjust position) decrease as patients age, leading to rapid tissue injury.^6,15 In the current study, older persons had more pressure injuries than their younger counterparts. The current study also supports a correlation between prolonged ICU stay and a greater number of pressure injuries per person, as noted in previous research.^6,14

Pressure injury healing. Pressure injury healing is often unsuccessful or delayed due to many factors that can interfere with the biological healing process.^3,4,10 In addition, critically ill patients with pressure injuries are at high risk for delayed healing because of the increased use of devices and medications, hemodynamic instability, and immobility.^3,4,6

Güneş¹⁰ conducted a prospective, methodological study in Turkey among 72 adults in which 23% of the 86 stage 2 or greater pressure injuries were healed and significant reduction was noted in PUSH scores during the 8-week study period. Also, significant differences were specified in total PUSH scores between healed and unhealed ulcers each week, starting with the first week of the study.

A retrospective study by Alderden et al⁴ that described patient characteristics and risk factors associated with pressure injury outcome among 87 patients with 111 hospital-acquired pressure injuries reported 51 ulcers healed (45.9%) and 60 ulcers remained at discharge or death (54.1%).

A retrospective study¹¹ conducted among 78 adult patients in a private Turkish university hospital found 65.4% of pressure injuries did not heal during the hospitalization period; this study also noted pressure injuries are more likely to heal in mobile patients than in immobile patients (ie, immobility was a significant factor of healing status.)

A secondary analysis of data by Palese et al,¹³ which evaluated the healing time of stage 2 pressure injuries in patients served by a network of 46 health care centers in northern Italy, indicated that the average healing duration of pressure injuries was 22.9 days and 56.7% of the pressure injuries did not heal within 10 weeks.

In the current study, most (77.2%) of the pressure injuries remained unhealed at patient discharge from the ICU or death. However, the mean PUSH score decreased significantly during ICU stay (z = -10.807; P = .0001). Despite the presence of various risk factors in these critically ill immobile patients, pressure injury healing scores decreased over time.

This study has some limitations. First, the pressure injury healing measures may not have fully reflected pressure injury outcomes because data were abstracted from ICU records only; the pressure injuries may have healed following transfer from the ICU. Moreover, some specific risk factors and applied treatment modalities (eg, dressing type, topical agents) for pressure injuries could not be obtained from the medical records. In addition, obtaining the data from a single ICU may limit generalizability because the healing scores may be influenced by ICU-specific factors such as knowledge and competence of nurses regarding the ability to assess pressure injuries. In the ICU in which the study was conducted, the pressure injuries are assessed by ICU nurses, but follow-up evaluations are performed by experienced wound care nurses. The researchers did not directly observe the pressure injuries. Although nursing documentation in the ICU is standardized, measurements and assessments of pressure injuries may vary.

A descriptive, retrospective study conducted to evaluate pressure injury characteristics and healing status among critically ill immobile patients found the majority of pressure injuries were stage 2 and occurred in the pelvic region. Although healing scores improved over time, the majority of pressure injuries remained unhealed at the time of death or discharge from the ICU. Future prospective observational studies comparing the factors that may contribute to healing are warranted.

Dr. Alcan is an Assistant Professor, Surgical Nursing Department, İzmir Bakirçay University Faculty of Health Sciences Nursing Department;  and Dr. van Giersbergen is a Professor, Ege University Faculty of Nursing, İzmir, Turkey. Ms. Dincarslan, Ms. Hepcivici, and Ms. Kaya are anesthesiology intensive care unit nurses, Ege University Hospital. Please address correspondence to: Aliye Okgün Alcan, PhD, Assistant Professor, Surgical Nursing Department, İzmir Bakirçay University Faculty of Health Sciences Nursing Department, Gazi Mustafa Kemal Mahallesi Kaynaklar Caddesi Seyrek-Menemen 35660 İzmir, Turkey; email: aliyeokgun@gmail.com or aliye.alcan@bakircay.edu.tr.