Pressure Ulcer Prevalence and Care in Indonesian Hospitals: A Multicenter, Cross-sectional Evaluation Using an Extended Donabedian Model

Although the number of studies on pressure ulcer (PU) occurrence continues to grow, research regarding the quality of PU care and its effect on outcomes is limited. Using an extended Donabedian model, a 1-day, multicenter, cross-sectional evaluation of the quality of PU care was conducted in a convenience sample of Indonesian hospitals among patients ≥18 years of age in the medical, surgical, and intensive care units. Structure (ie, hospital attributes), process (recommended PU preventive measures), and outcome indicators (nosocomial PU prevalence excluding nonblanchable erythema), along with patient characteristics (age, gender, ethnicity, admission days, diseases [per ICD-10], recent surgery, PU categorization [4 categories according to National Pressure Ulcer Advisory Panel-European Pressure Ulcer Advisory Panel guidelines], PU history, care dependency, and Braden score) were examined.Patient data were collected by 2 nurses —1 from the patient’s unit and 1 from another unit — using the Landelijke Prevalentiemeting Zorgproblemen-International questionnaire, a paper-and-pencil survey translated into Indonesian. Heads of wards and nursing units completed the questionnaires at institutional and ward levels, respectively. The data were analyzed using descriptive and bivariate analyses, and multilevel logistic regression modeling was applied according to the generalized estimating equation approach. Among the 4 participating hospitals, 66 care units, 36 pairs of nurses, and 1132 adult patients (mean age 48.7 ± 17.4 years, 40.9% women) were involved. Ninety-one (91) patients developed 1 or more PUs; the nosocomial PU prevalence (excluding nonblanchable erythema, category I) was 3.6%. The most frequently used PU preventive measures were patient education (329, 29.1%), repositioning (269, 23.8%), and skin moisturizing (266, 23.5%). The factors most associated with nosocomial PU rate excluding category I were the inclusion of PU care in patient care files (P = .001), repositioning (P = .002), skin moisturizing (P = .009), age (P = .013), admission days (P = .001), care dependency scores (P = .047), immobility (P = .001), sensory perception limitation (P = .001), moist skin (P = .032, OR 13.74), and friction and shear problem (P = .001). The prevalence of nosocomial PUs in this study was comparable to previous research in the Netherlands and rather low, even though limited structural indicators and suboptimal preventive measures were noted. Also, outdated preventive measures such as massage, donuts, and water-filled gloves were still used. The quality of PU care in these hospitals may be improved by addressing the absence of structural factors, including protocols/guidelines. Future research is needed for guideline implementation programs in Indonesian hospitals. 

A pressure ulcer (PU) is defined as a localized injury to the skin and/or underlying tissue, usually over a bony prominence, that results from pressure and/or shear.^1,2 PUs can be classified into 4 categories: category I (nonblanchable erythema), category II (partial-thickness), category III (full-thickness skin loss), and category IV (full-thickness tissue loss).¹ A qualitative study³ has shown a PU is harmful, painful, and reduces patient quality of life. A prevalence and cost study⁴ found owing to the need for ongoing wound care materials, prolonged nursing care time, and longer admission days in the hospital, PUs are the most costly medical problem in the United States, especially for elderly patients. PU care accounts for 1% of the total Dutch health care budget⁵ and approximately 2.6% of the total National Health Service budget in the UK.⁶

According to the literature⁷ and an earlier evaluation study,⁸ the prevalence of hospital-acquired (nosocomial) PUs excluding Category I (excl cat I) is considered a relevant indicator of nursing-sensitive care. A review of the literature⁹ found category I PUs are less reliable to diagnose⁹ and therefore frequently excluded in nosocomial PU prevalence reports on quality-of-care performance.^10,11 Various health care policies related to PUs have been implemented to stimulate hospital awareness of the importance of lowering nosocomial PU rates and providing high-quality PU care. In the Netherlands, PU prevalence rates are published,¹² in the UK evaluations are conducted on avoidable and unavoidable PUs,¹³ and in the United States and Japan financial penalties are issued for nosocomial PUs.^14,15 

Published nosocomial PU rates (excl cat I) show a wide range of prevalence, from almost 0 (0.5% in Austrian hospitals,¹⁶ 0.8 % in a Chinese hospital,¹⁷ and 0.9% in US hospitals¹⁸) to 2.1% in Swiss hospitals,¹⁶ 3.9% in Dutch hospitals,¹⁶ and 5.1% in Swedish hospitals.¹⁸ 

Adequate preventive measures such as identifying patients at risk for PUs, repositioning, assessing tissue viability, moisturizing skin, providing nutrition support, and using pressure-redistribution devices are required and should be practiced in daily nursing care in hospitals.² However, PU occurrence does not depend exclusively on the quality of nursing interventions; it is also related to the availability of hospital resources such as PU prevention protocols/guidelines, staff training, specialized wound care nurses, and pressure-redistribution devices.^1,16,19-21  

In Indonesia, where the number of nosocomial PU patients is registered monthly through the Hospital Information System,^19,22 PUs have been highlighted as one of the main health care problems in hospitals. Nevertheless, very few publications address PU occurrence, PU preventive measures, and other relevant aspects of the quality of PU care¹⁹ or the research^19,23 involves small sample sizes. This is also the case at an international level. Even though the number of studies on PU prevalence/incidence has increased tremendously internationally,² few published studies have evaluated the actual prevention measures and the availability of resources or facilities for PU care.^16,19-21 Assessing PU rates together with relevant aspects of PU care seems to indicate provision of more accurate and comprehensive information for monitoring the quality of care and prioritizing the quality of PU care will improve programs in hospitals. 

Since 1998, the Landelijke Prevalentiemeting Zorgproblemen (LPZ; Dutch National Prevalence Survey of Care Problems) has measured PU prevalence and some relevant indicators of the quality of PU care in the Netherlands annually²¹ and has included other countries in Europe and New Zealand in the past few years.^24,25 The measurement follows Donabedian’s model of quality of care.²⁶ Donabedian classified the assessment of quality of care into 3 components: structure, process, and outcome indicators. Structure refers to the attributes of the facility in which health care is delivered, including material resources (eg, support surfaces, dressings), organizational structure (eg, PU committee, PU guideline, and PU registration), and human resources (the number and qualifications of professionals, including education, training, and experience). Process is defined as what is involved in terms of giving and receiving care and includes both patients’ and health care professionals’ activities related to PU prevention and treatment measures. Outcome measures include the effect of care on patients’ health status. Process indicators involve preventive measures and structure indicators are hospital and ward structural quality indicators. 

The authors of this study developed an extended Donabedian model (see Figure 1). Specifically, patient characteristics were added to the model because they are highly associated with PU occurrence and PU preventive measures.²⁷ Patient characteristics can differ between hospitals/countries and therefore influence nosocomial PU rates.²⁸ 

This study aimed to evaluate the outcome indicator (nosocomial PU prevalence excl cat I), process indicators (PU preventive measures), and structural quality indicators (hospital/ward facilities and PU care resources), as well as patient characteristics related to PUs in Indonesian hospitals using the extended Donabedian model. This involved identifying specific determinant indicators and patient characteristics associated with the quality of PU care in Indonesian hospitals.

Research questions. The following research questions were addressed:

1. What is the nosocomial PU prevalence rate in Indonesian hospitals? 
2. What are the characteristics of PU patients in Indonesian hospitals?
3. What PU preventive measures are used in Indonesian hospitals?
4. What structural quality indicators (including wound care nurses, mono- and multidisciplinary meetings, guidelines, documentation files, patient education, discharge planning, PU committee, and PU courses) are available in Indonesian hospitals at the ward and institutional level? 
5. Are patient characteristics, preventive measures, and structural quality indicators at the ward and the institutional level associated with nosocomial PUs?

Design. This 1-day study followed a multicenter, multilevel (patient, ward, institution) cross-sectional design.^24,25 All adult patients (≥18 years old) in the medical, surgical, and intensive care units were included. The maternity/obstetric, psychiatric, rehabilitation, skin, eye, and nose and throat care units were excluded due to expected low PU prevalence rates.²⁹

Setting. Indonesia has 260 public and private referral hospitals with more than 200 beds located in 31 provinces,³⁰ each offering a complete range of facilities.³¹ These hospitals are managed by public and private sectors.³² Because of Indonesian communal culture, patients’ family members are directly involved in providing daily care, except in the intensive care unit.³³ 

This study used a convenience sample; 15 large general hospitals (10 public and 5 private) located on different islands and provinces in Indonesia were invited to participate by registered mail sent from the Nursing Program of Riau University in Indonesia on August 6, 2012. The research proposal and LPZ-international questionnaire data collection procedure were enclosed with the invitation letter.²⁹ The recruitment of participating hospitals took 2 months.

The ethics committee of each participating hospital approved the study. Patients gave their verbal informed consent and/or their relatives/legal representatives were asked for permission. The identities of patients were kept anonymous, and patients had the option to refuse to participate during the assessment procedure. 

Measurement instrument. The LPZ-International questionnaire was developed based on a literature review and responses from a Delphi panel in 1997 and now is used as a uniform national registration system in the Netherlands to measure annual PU prevalence. The module consists of 6 parts: 1) the structural quality indicators at hospital level; 2) the structural quality indicators at ward level; 3) patient characteristics related to PU risk, including the Braden Scale and Care Dependency Scale (CDS); 4) PU preventive measures; 5) PU characteristics; and 6) PU wound dressings applied. This questionnaire also has been adopted in several European countries in various health care settings, but the content validity of the questionnaire for measuring the quality of PU care has not been evaluated.

The original LPZ questionnaire was translated into Indonesian³⁴; the document went through several phases (forward translation, backward translation, evaluation between the original English questionnaire, and backward translation results, along with assessment of the clarity of Indonesian wording) to reach equivalence between the English and Indonesian versions of the LPZ questionnaires. After the forward-backward translation, which is the most recommended technique for translating questionnaires,³⁵ 18 Indonesian experts evaluated the clarity of the Indonesian wording to ensure it was equivalent to the English version in terms of semantics and idiom.

The Indonesian experts evaluated the content validity of the questionnaire for measuring the quality of PU care in Indonesian hospitals.³⁴ Most questions (77.5%) had good Item Content Validity Index (I-CVI) results. The experts suggested adding items regarding number of bedridden days, previous PUs, skin allergies, wound infections, wound cleansing, and debridement to the questionnaire. Other psychometric properties (interrater agreement and reliability) of the categorization of PUs, the Braden Scale, and the CDS were evaluated as good.³⁴ 

Patient characteristics, PU preventive measures, and nosocomial PU prevalence were assessed at the patient level. The availability of structural quality indicators related to PU prevention was assessed at the ward and institutional levels. Patient characteristics such as age, gender, skin color related to ethnicity, number of admission days, diseases, surgery in the past 2 weeks, length of surgery, PU history in the past 5 years, care dependency (CDS),³⁶ and PU risk scale score (Braden Scale) were assessed related to PUs.³⁷ The patient’s diseases were categorized according to the adapted version of the Tenth Revision of the International Classification of Diseases (ICD-10).³⁸ 

Braden Scale score was assessed to determine patient PU risk. The scores ranged from 6 to 23; a low score indicates a high risk of PU.³⁷ A cut-off point of 21 was used to classify at-risk versus non-risk patients.^16,39 Care dependency was assessed using the CDS. The CDS assesses 15 care dependency items using 5 Likert scale categories from 1 (completely dependent) to 5 (almost independent). Patients with a CDS sum score <68 can be classified as care-dependent.⁴⁰ 

Data collection procedure. The first author trained a team of ward nurses to participate in the patient assessment on the selected measurement day. This involved instruction on the measurement procedure and practical use of PU categories, the Braden Scale, and the CDS. The team of ward nurses received a written data collection manual containing all of the information provided during training. 

Each patient was assessed by 2 trained nurses together (1 from the patient’s own care unit and 1 from another care unit) to increase the reliability of the measurement results^24,34 and to preclude underreporting of PU patients and their categories.¹⁰ The trained nurses obtained/abstracted other patient variables (eg, length of admission, surgery, and so on) from patient charts. The heads of the nursing units in the hospital or their representatives completed the questionnaire on structural quality indicators at the institutional level. The heads of the wards completed the structural quality indicator questionnaires at ward level. All data were collected using the paper-and-pencil questionnaire. 

Data analysis. Data were entered and analyzed using IBM SPSS Statistics 19 (SPSS, Chicago, IL). Nosocomial PU prevalence (excl cat I) was calculated as the proportion of patients who had developed a Category II or higher PU during their hospital stay.⁸ Descriptive analyses (frequencies and proportions) were performed on patient characteristics. Evaluation of preventive measures was conducted on interventions that included both recommended and nonrecommended preventive measures based on the European Pressure Ulcer Advisory Panel-National Pressure Ulcer Advisory Panel (EPUAP-NPUAP) guideline^1,2 and on the availability of structural quality indicators at the care unit and hospital levels. 

Bivariate analyses (independent t-test or chi-squared test) were performed to evaluate the association between all variables (patient characteristics, the recommended preventive measures or process indicators, and structural indicators) and the outcome indicator (nosocomial PU excl cat I). 

Subsequently, the significant variables (P <.05) from the bivariate analysis were subjected to multilevel logistic regression modeling according to the generalized estimating equation (GEE) approach and multiple imputations for the missing data. 

Of the 15 invited large hospitals, 4 public hospitals from 4 provinces located on 3 islands agreed to participate. One (1) private hospital refused to participate without mentioning a reason, and the other hospitals had not replied by September 30, 2012. 

Two (2) weeks were spent preparing to collect measurements (ie, training, organizing, and recruiting nurses as data collectors) for each hospital. The actual data collection took place on 1 day for each hospital. Data collection including preparation time for collection for the 4 hospitals took a total of 2 months (from October 9 to December 9, 2012). 

Sixty-six (66) care units participated and 36 pairs of nurses (72 care unit nurses) were involved in the data collection. Most patients (1132, 95.7%) agreed to participate. Reasons for nonparticipation included refusal (9 patients), unavailability (21 patients), too ill/terminal (10 patients), and unknown (10 patients). The assessment time lasted between 3 and 30 minutes per patient depending on the patient’s condition; the average assessment time was 9.2 minutes (SD 5.9). 

Outcome indicator: nosocomial PU prevalence. Of the 91 PU patients, 51 developed 1 or more PUs (Category I to Category IV) during their hospital stay. The highest PU categories per patient were Category I (10 patients), Category II (22 patients), Category III (12 patients), and Category IV (7 patients). The nosocomial PU prevalence rate (excl cat I) for all patients was 3.6% (95% CI 2.5-4.7). 

Patient characteristics. Table 1 shows all patients reviewed in the hospitals, including those with and without PU. The mean age of patients was 48.7 years (SD 17.4). The top 3 patient diseases/disorders were digestive disorders (13.8%), genitourinary disorders (13.0%), and neoplasms (11.4%). The mean duration of hospital stay was 9.5 days (SD 9.4). Slightly more than 1 quarter of the patients (25.7%) had a history of being bedridden, with an average of 3.7 bedridden days (SD 15.5). Most patients (70.7%) were at-risk PU patients (Braden Score ≤20) and care-dependent (70.7%). 

The expected frequencies of patient diseases, PU history, skin color related to ethnicity, and skin allergy in relation to nosocomial PUs were <5. Age, length of admission, bedridden days, CDS score, and Braden Scale scores had significant P values (P <.05). Braden Scale items are described in Table 2. 

Process indicators: PU preventive measures. The proportion of preventive measures related to specific patient circumstances (Braden Scale items) is described in Table 3. Of 771 at-risk PU patients (Braden Scale ≤20), 30% received information on PU prevention. Almost half of the bedridden patients (46.3%) were repositioned by nurses and/or family members; 35.9% who had friction issues received skin moisturization treatment. One (1) out of 4 patients with poor or probable inadequate nutrition status according to their Braden Scale subscores received nutrition support such as increased protein for preventing PUs. A small percentage of bedridden patients (11.2%) used a pressure-redistributing mattress (mattress overlay, air fluidized/low air loss, alternating air, or viscoelastic foam mattress). Floating the heels of bedridden patients was less common (16.5%). Non guideline-recommended preventive measures provided included massage, donuts, and water-filled gloves. Preventive measures associated with nosocomial PUs were repositioning (P = .001), skin moisturizing (P = .001), and nutrition support (P = .021). 

Structural quality indicators. More than half of the wards had an admission and discharge handover policy (72.7%), included PU care in their patient care files (62.1%), and held nursing care team discussions about PU care (51.5%). Almost half of the wards had implemented multidisciplinary discussions on PU care (48.5%), had PU risk assessment files (45.5%), and monitored the implementation of PU care (40.9%). The availability of a PU/wound care nurse (25.8%) and PU prevention products (25.8%) was limited. Only 1 ward had a patient information brochure about PU prevention. Structural indicators associated with nosocomial PUs were the monitoring of prevention and treatment at ward level (P = .056), the availability of patient risk assessment care files (P = .033), the availability of prevention and/or treatment PU care files (P = .005), and the provision of discharge planning (P = .047) (see Table 4). 

At the institutional level, the number of nosocomial PU patients was centrally registered in all hospitals. Only 1 of the 4 hospitals had a PU protocol/guideline. This hospital also organized a course for nurses about PU prevention and treatment. 

Multilevel analysis. Thirteen (13) variables found to be significant at the patient level were selected for further multilevel logistic regression modeling: age, admission days, bedrest days, total CDS score, sensory perception, moisture, activity, mobility, nutrition, friction and shear, repositioning, skin moisturizing, and nutrition support. Four (4) additional variables found to be significant at ward level (monitoring of PU care, patient risk assessment care files, inclusion of PU care in patient care files, and discharge planning documentation files) also were further assessed. Mobility was divided into 2 categories: 1) completely immobile and 2) very limited, slightly limited, no limitation) because no PU patient experienced slight or no mobility limitation. 

The data were sampled according to a 2-level design because patients were nested within wards. In total, 83 observations (7.3%) were missing. Assuming these were missing at random, a multiple imputation (with 5 imputations) procedure was performed. The imputed data then were analyzed using a GEE logistic regression method. When compared with the standard logistic regression, no substantial differences were found. This is because the ward differences (within-ward correlation) were very small and not significantly different from zero and the results did not differ from the standard logistic regression analysis. Moreover, the results based on the imputed data did not change much when compared to the data based on the nonimputed complete case situation. 

Subsequently, the imputed data were analyzed using standard logistic regression (backward stepwise) methods, with a threshold P <.05 to identify the specific patient characteristic and determinant indicators of quality of PU care associated with the nosocomial PUs. 

Table 5 identifies the most significant variables related to the outcome indicator (prevalence of PU categories II through IV). This table also shows the association of patient characteristics with nosocomial PUs excl cat I with a correction for structural quality indicators and preventive measures at the ward and hospital levels. A variation was found in nosocomial PU prevalence rates and quality of PU care among the hospitals. The variables associated with the nosocomial PU rate (excl cat I) were the inclusion of PU care in patient care files (OR 8.171; 95% CI 2.322-28.752), repositioning (OR 4.573; 95% CI 1.749-11.953), skin moisturizing with cream or oil (OR 3.629; 95% CI 1.382-9.533), age (OR 1.036; 95% CI 1.008-1.065), number of admission days (OR 1.079; 95% CI 1.040-1.120), CDS (OR 1.041; 95% CI 1.001-1.083), mobility (OR 0.055; 95% CI 0.013-0.232), completely limited sensory perception versus no limitation (OR 0.055; 95% CI 0.009-0.326), occasionally moist versus rarely moist skin (OR 13.738; 95% CI 1.247-151.370), and friction and shear problem versus no friction and shear problem (OR 24.456; 95% CI 3.757-159.209). 

This study is the first to depict the quality of PU care in 4 Indonesian hospitals using a multicenter study involving a large number of patients (N = 1132). The quality of PU care was evaluated by an extended Donabedian model of quality of care including patient characteristics. The overall nosocomial PU prevalence (excl cat I) as an outcome indicator was 3.6%. Despite the lower availability of structural quality indicators in these Indonesian hospitals, the nosocomial PU prevalence in these Indonesian hospitals (3.6%) was lower than in Swedish hospitals (5.1%)¹⁸ and comparable with Dutch hospitals (3.9%).¹⁶ 

The rather low PU prevalence in these 4 Indonesian hospitals might be explained by the patient characteristics: the average age of patients hospitalized in Indonesia (mean 48.7 years, percentile 25%–75%; range 35–61 years) was much lower than the hospitalized patients in the Netherlands (67.8 years).¹⁶ Because the Indonesian economy is growing, life expectancy also is increasing³²; this may result in an increasing number of elderly patients in Indonesian hospitals who will be more likely to have a PU.^41-43

Preventive measures used in the 4 Indonesian hospitals can best be compared with the results from the LPZ-International study in the Netherlands.¹⁶ Fewer pressure-redistributing mattresses were used for at-risk patients (6.1%) than in Dutch hospitals (94.5%). When fewer pressure-redistributing mattresses are used, repositioning should be performed more frequently.¹ The proportion of repositioning for at-risk patients in these Indonesian hospitals (28.8%) was somewhat similar to Dutch hospitals (27.9%). However, not all at-risk patients need repositioning. Half of the bedridden patients in the 4 Indonesian hospitals (46.3%) received repositioning from nurses and/or family members. Providing information on PU prevention can improve the proportion of repositioning measures. In this study, 30% of at-risk PU patients and/or their families received information and instructions on PU prevention measures. This is similar to the Dutch hospitals (30.3%). At-risk PU patients in Dutch hospitals received more prevention measures for dehydration and/or malnutrition (47.9%) than patients in the Indonesian hospitals (22.4%). The proportion of persons receiving skin moisturizing in the Indonesian hospitals was slightly higher than in Dutch hospitals (18.5%). 

Although all 4 hospitals centrally registered the number of PU patients, the number of PU/wound care nurses and availability of guidelines, PU courses/training, PU preventive products, and information brochures at institutional level was limited. Only 1 of the 4 hospitals had a PU prevention protocol, even though international evidence-based PU guidelines are available^1,44 and have recently been updated.² As a result, outdated preventive measures such as massage, donuts, and water-filled gloves still were applied. Translating the most recent evidence-based guidelines into Indonesian, disseminating them to all hospitals, and providing refresher courses about PU care may contribute to better PU prevention in clinical practice.

In the multilevel analysis, differences among wards were small and not significantly different from zero. One reason could be some patients stayed in more than 1 ward during their admission time in the hospitals. However, the researchers did not register patient movement among wards. 

The inclusion of PU care in patient care files (OR 8.171), repositioning (OR 4.573), and skin moisturizing with cream or oil (OR 3.629) was >1 (ie, patients with nosocomial PUs received more repositioning and skin moisturizing and had PU care noted in their files than non-PU patients). 

Braden Scale items describe risk factors for PU.³⁷ In this study, mobility (OR 0.055; 95% CI 0.013-0.232) and sensory perception (OR 0.055; 95% CI 0.009-0.326) seemed to be  protective variables or their potential effect on PU development was reduced because they were adjusted or corrected using preventive measures such as repositioning.²⁰ Patients with completely limited mobility and limited sensory perception stayed in the intensive care units, were repositioned regularly, and had pressure-redistributing mattresses. Interestingly, occasionally moist versus rarely moist skin (OR 13.738; 95% CI 1.247-151.370) and a friction and shear problem versus no friction and shear problem (OR 24.456; 95% CI 3.757-159.209) remained risk factors even though these variables could be addressed by applying moisture cream/oil to protect the skin. However, other preventive measures such us floating heels, using elbow or heel protectors, changing linen, patient lifting, and avoiding the use of diapers may influence skin moisture and friction and shear problems.

Furthermore, Indonesia has a warm, humid climate that could influence patients’ skin moisture and increase the risk of developing PUs and moisture lesions.⁴⁵ Preventive measures related to patients with skin moisture and friction and shear problems need to be improved.

Of the 15 large hospitals that potentially could have participated, only 4 (26.6%) agreed, so the findings are not a full representation of the quality of PU care in all Indonesian hospitals. The low response rate possibly could have been improved by personal follow-up to every invited hospital, but the transportation costs due to the location of the hospitals, broadly dispersed over many islands, would have been prohibitive.

Furthermore, random sampling was not possible in this study because of the willingness of hospitals to support this study. A central organization of measurements and the support and recommendation of the Ministry of Health would be much more effective for evaluating the quality of PU care at a national level.

In addition, the hospitals in this study did not perform the measurements on the same day, which is not in line with the LPZ-International study protocol.²⁴ Distance learning for the institutional coordinators may help this become a future reality. 

Even though this study involved a large number of patients, some patient characteristic variables and preventive measure indicators had expected frequencies <5 and therefore were excluded in the extended multilevel analyses. A larger national measurement might increase the proportion of the variables (ie, additional analyses could be done on the interaction between patient characteristics and preventive measures). Furthermore, the extended theoretical framework of Donabedian’s model showed an association between structural indicators and prevention measures. However, in this study, the association between structure and process indicators could not be evaluated as suggested in the Donabedian model because of the limited number of participating hospitals. 

PUs represent an important health care problem in Indonesian hospitals. This study reveals several quality indicator issues related to PU care in these hospitals. The prevalence of nosocomial PUs in this study was comparable to Dutch hospitals, even though limited structural indicators and suboptimal preventive measures were noted. Also, a number of outdated preventive measures still were applied in these Indonesian hospitals.

Taking into account future demographics of an increasingly larger number of elderly people, steps are needed to improve the quality of PU care, starting with the availability of an evidence-based guideline. Also, courses on PU prevention should be offered and relevant process and structural quality indicators must be implemented and improved. A well-designed prevention program also is needed that focuses on skin moisture and patients with friction and shear problems to reduce the occurrence of PUs. 

Larger studies using an extended Donabedian evaluation model to measure the quality of PU care are recommended to provide data-driven decision-making at hospital/national level and for continuous monitoring of care quality. 

Dr. Amir is a lecturer, Nursing Department, Universitas Riau, Pekanbaru, Indonesia. Dr. Tan is an associate professor, Department of Methodology and Statistics; and Dr. Halfens is an associate professor, Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands. Prof. Lohrmann is a university professor, Department of Nursing Science, Medical University of Graz, Graz, Austria. Prof. Schols is a professor, Department of Health Services Research and Department of Family Medicine, CAPHRI, Maastricht University.

Please address correspondence to: Yufitriana Amir, PhD, Universitas Riau, Program Studi Ilmu Keperawatan, Jalan Pattimura no 9 Gedung G, Pekanbaru, Riau  28131, Indonesia; email: amiryufitriana@gmail.com or yufitriana.amir@lecturer.unri.ac.id.