Journal of Tissue Viability (2016) 25, 75e82

www.elsevier.com/locate/jtv

Basic research

Analyses of pressure ulcer point prevalence

at the first skin assessment
in a Portuguese hospital
Pedro Miguel Garcez Sardo a,b,c,
Cláudia Sofia Oliveira Simões d,
José Joaquim Marques Alvarelhão a,
César Telmo de Oliveira e Costa a,b,
Carlos Jorge Cardoso Simões a,b,
Jorge Manuel Rodrigues Figueira b,
João Filipe Fernandes Lindo Simões a,
Francisco Manuel Lemos Amado d,
António José Monteiro Amaro a,
Elsa Maria Oliveira Pinheiro de Melo a,*

a
School of Health Sciences, University of Aveiro, Portugal
b
Centro Hospitalar do Baixo Vouga, EPE, Portugal
c
Instituto de Ciências Biomédicas Abel Salazar, University of Oporto, Portugal
d
Chemistry Department, QOPNA, University of Aveiro, Portugal

KEYWORDS Abstract Aim: To analyze the first pressure ulcer risk and skin assessment records
International classifi- of hospitalized adult patients in medical and surgical areas of Aveiro Hospital during
cation of diseases; 2012 in association with their demographic and clinical characteristics.
Nursing; Material and methods: Retrospective cohort analysis of electronic health record
Nursing assessment; database from 7132 adult patients admitted to medical and surgical areas in a Por-
Pressure ulcer; tuguese hospital during 2012. The presence of (at least) one pressure ulcer at the
Prevalence; first skin assessment in inpatient setting was associated with age, gender, type of

* Corresponding author. School of Health Sciences, University of Aveiro, Campus Universitário de Santiago, Agras do Crasto, 3810-
193 Aveiro, Portugal. Tel.: þ351 234 372 452.
E-mail addresses: pedro.sardo@ua.pt (P.M.G. Sardo), claudiasimoes@ua.pt (C.S.O. Simões), jalvarelhao@ua.pt
(J.J.M. Alvarelhão), cesar.costa.14052@chbv.min-saude.pt (C.T.deO.e Costa), carlos.simoes@chbv.min-saude.pt
(C.J.C. Simões), jorge.figueira.12415@chbv.min-saude.pt (J.M.R. Figueira), jflindo@ua.pt (J.F.F.L. Simões), famado@ua.pt
(F.M.L. Amado), antonio.amaro@ua.pt (A.J.M. Amaro), elsamelo@ua.pt (E.M.O.P.de Melo).

http://dx.doi.org/10.1016/j.jtv.2016.02.006
0965-206X/ª 2016 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.
76 P.M.G. Sardo et al.

Risk assessment admission, specialty units, length of stay, patient discharge and ICD-9 diagnosis.
Results: Point prevalence of participants with pressure ulcer category/stage IeIV of
7.9% at the first skin assessment in inpatient setting. A total of 1455 pressure ulcers
were documented, most of them category/stage I. The heels and the sacrum/coc-
cyx were the most problematic areas. Participants with pressure ulcer commonly
had two or more pressure ulcers.
Conclusions: The point prevalence of participants with pressure ulcer of our study
was similar international literature. The presence of a pressure ulcer at the first skin
assessment could be an important measure of frailty and the participants with pres-
sure ulcer commonly had more than one documented pressure ulcer. Advanced age or
lower Braden Scale scores or Emergency Service admission were relevant variables for
the presence of (at least) one pressure ulcer at the first skin assessment in inpatient
setting as well as respiratory, infectious or genitourinary system diseases.
ª 2016 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction adult patients at the first skin assessment in

inpatient setting; [3] To identify the location of
Pressure ulcers continue to be a challenge to pressure ulcers in hospitalized adult patients at
healthcare professionals [1e3] and represent an the first skin assessment in inpatient setting; and
indicator of healthcare quality [4e6]. In fact, [4] To analyze the demographic and clinical char-
effective pressure ulcer prevention depends on acteristics of hospitalized adult patients who had
health care professionals (especially nurses) that (at least one) pressure ulcer at the first skin
identify patients who are particularly vulnerable assessment in inpatient setting.
to pressure damage due to their specific risk fac-
tors [1e3]. Nowadays more than 30 pressure ulcer
risk assessment scales are known worldwide and 2. Material and methods
are used in clinical practice [7e9]. However, pre-
ventive measures are not always effectively 2.1. Design
implemented [10,11] and the prevalence of pres-
sure ulcers in hospitals is still high [12]. This study was designed as a retrospective cohort
In order to follow national guidelines [13], analysis of electronic health record database from
Registered Nurses and/or Clinical Nurses Specialist adult patients admitted to medical and surgical
should perform a pressure ulcer risk assessment areas of the Aveiro Hospital from January 1, 2012
using the Braden Scale (Attach 1) as well as a skin to December 31, 2012.
integrity assessment using the Skin Assessment
Tool (Attach 2) every 24 h in emergency rooms and 2.2. Sample/participants
intensive care units. In inpatient settings that
assessment should be performed at admission and The inclusion criteria were: [1] Patients with 18
repeated every 48 h during the length of stay. At years old at the time of admission; [2] Patients
“Centro Hospitalar do Baixo Vouga, EPE e Unidade admitted and discharged in 2012; [3] Patients with
de Aveiro” (Aveiro hospital) these systematic as- emergency service or programmed hospital admis-
sessments have been carried out (only) in inpatient sion. The exclusion criteria were: [1] Patients with
settings since 2012. less than 24 h’ length of stay; [2] Patients admitted
The purpose of this study was to analyze the to specialties of Psychiatry, Gynecology, Obstetrics
first pressure ulcer risk and skin assessment re- and Intensive Care; [3] Patients without pressure
cords of hospitalized adult patients in medical and ulcer risk assessment and/or skin assessment at the
surgical areas of Aveiro Hospital during 2012 in admission in inpatient setting.
association with their demographic and clinical
characteristics. 2.3. Ethical issues and approval
Specific objectives were defined as follows: [1]
To calculate the prevalence of pressure ulcers in The study was performed after Hospital Council
hospitalized adult patients at the first skin Board and Ethics Committee approval. Confiden-
assessment in inpatient setting; [2] To identify the tiality of the participants was maintained and no
category/stage of pressure ulcers in hospitalized names or identifying information was recorded.
Pressure ulcer point prevalence in Portugal 77

2.4. Data collection characterization. Overall prevalence and the

prevalence in the different groups were calculated
All data were extracted from electronic health as [(number of participants with a pressure ulcer/
record database with the collaboration of Hospital number of participants in a population at a
Informatics and Systems Analysis Service and particular point of time) x 100] [17].
included the following variables: first pressure Odds ratio (OR) were calculated by univariate
ulcer risk assessment (Braden Scale score), first logistic regression.
skin assessment (Skin Assessment Tool record),
age, gender, type of admission (emergency service
or programmed), specialty unit (medical or surgi- 3. Results
cal), patient discharge outcome (discharge,
decease or transference to another hospital/ This study included 7132 participants, 52.1% were
health institution) and diagnosis. male and 47.9% were female, with the mean age
The Braden Scale score ranges from 6 to 23 and 65.8  18.1 years (mean  SD). The majority of
is composed by six factor sub-scales: “sensory participants were admitted from emergency service
perception”, “moisture”, “activity”, “mobility”, (71.5%) to surgical (61.1%) or medical (38.9%) units
“nutrition” and “friction/shear forces”. Each sub- (Table 1). The participants were grouped according
scale is rated 1 to 4, except for “friction/shear to the International Classification of Diseases Version
forces”, which is rated 1 to 3 (the smallest value 9 (ICD-9) as the following diagnoses group: Digestive
corresponds to a higher risk of developing pres- (20%); Respiratory (13%); Musculoskeletal (10%),
sure ulcers). The total score is used to predict Genitourinary (9%), Cardiac (9%), Vascular (9%),
overall risk of pressure ulcer development Traumatisms/Fractures (8%), Neoplasms (7%), In-
[14e16]. Following national guidelines [13] par- fectious (3%), Endocrine/Metabolic (2%), Central
ticipants with Braden Scale score  16 were Nervous (2%), Skin (2%), Hematologic (1%) and Others
classified as “at risk of developing pressure ul- (5%).
cers”, and participants with a Braden Scale At the first pressure ulcer risk assessment 2333
score > 16 were classified as “not at risk of (32.7%) of the participants were classified as “at
developing pressure ulcers”. risk of developing pressure ulcer” (Braden Scale
The Skin Assessment Tool is composed by a body score  16) and at the first skin assessment 560
chart that identifies 29 different areas to assess (7.9%) participants had at least one pressure ulcer
the skin integrity and/or the presence of pressure documented.
ulcers, their location, size, depth and category/ Using a univariate logistic regression model,
stage [13]. The anatomical location was recorded having a pressure ulcer was significantly associated
according to national guidelines [13] which iden- with gender, admission, specialty, dichotomized
tify 29 areas of developing pressure ulcers. Those Braden Scale score, group age, patient discharge
locations were converted to the regions recom- (Table 1) or diagnosis (Fig. 1).
mended by EPUAP and NPUAP, prior to the data At the first skin assessment, 6.8% of the men and
analysis. Thus, the final location was organized 9.0% of the women had (at least) one pressure
into the following anatomical regions: Occiput; ulcer category/stage IeIV [OR 1.36 (95% CI,
Ear; Scapula; Spinous Process; Shoulder; Elbow; 1.15e1.62)]. Only 0.4% of the participants with a
Iliac Crest; Sacrum/Coccyx; Ischial Tuberosity; programed admission had (at least) a pressure
Trochanter; Knee; Malleolus; Heel; Toe. The ulcer at the first skin assessment while 10.8% of the
anatomical regions registered in Portugal but not participants with an emergency service admission
part of the recommended EPUAP and NPUAP re- had at least one pressure ulcer documented [OR
gions were included in the category “Others”. 27.29 (95% CI, 14.09e52.82)]. Only 2.6% of the
The variable age was divided in seven groups, participants of surgical units had (at least) one
namely 18e29, 30e39, 40e49, 50e59, 60e69, pressure ulcer at the first skin assessment while
70e79 and  80 years old. 16.0% of the participants of medical units had (at
least) one pressure ulcer documented [OR 7.05
2.5. Data analysis (95% CI, 5.71e8.71)].
Considering only the 2333 participants classified
Data were analyzed using the Statistical Package as “at risk of developing a pressure ulcer” (Braden
for the Social Sciences (SPSS) software, version Scale score  16), 539 participants (23.1%) had at
21.0. Descriptive statistics were calculated for the least one pressure ulcer documented. So, the odds
demographic and clinical variables and sample of having a pressure ulcer at the first skin
78 P.M.G. Sardo et al.

Table 1 Characterization of the study participants (n ¼ 7132). Characterization of the participants who had (at
least) one pressure ulcer documented at the first skin assessment (n ¼ 560). The odds ratio (OR) for having a
pressure ulcer at the first skin assessment was presented for each variable.
Skin assessment All participants Participants with PU OR (95% CI)
n ¼ 7132 (100%) n ¼ 560 (7.9%)
Gender
Male 3716 (52.1%) 252 1
Female 3416 (47.9%) 308 1.36 (1.15e1.62)
Age
18e29 342 (4.8%) 1 1
30e39 429 (6.0%) 5 4.02 (0.47e34.58)
40e49 621 (8.7%) 3 1.66 (0.72e15.98)
50e59 899 (12.6%) 14 5.39 (0.71e41.18)
60e69 1234 (17.3%) 31 8.79 (1.20e64.60)
70e79 1766 (24.8%) 136 28.45 (3.97e204.14)
80 1841 (25.8%) 370 85.77 (12.00e612.67)
Admission
Programmed 2035 (28.5%) 9 1
Emergency service 5097 (71.5%) 551 27.29 (14.09e52.82)
Patient discharge
Discharge 5314 (74.5%) 140 1
Decease 377 (5.3%) 126 9.43 (7.64e11.65)
Transference 1441(20.2%) 294 18.77 (14.31e24.63)
Specialty
Surgery 4358 (61.1%) 115 1
Medicine 2774 (38.9%) 445 7.05 (5.71e8.71)
Braden Scale score
> 16 4799 (67.3%) 21 1
 16 2333 (32.7%) 539 68.36 (44.06e106.07)

categories over 60 years old, particularly in the

group age 80 years old [OR 85.77 (95% CI,
12.00e612.67)], compared with the category of
18e29 years old.
Considering the patient discharge outcome, we
found that among the 560 participants who had
(at least) one pressure ulcer at the first skin
assessment 126 (22.5%) died during the length of
stay, 140 (25.0%) were discharged and 294 (52.5%)
were transferred to other hospital/institution.
Considering ICD-9 diagnoses, the prevalence of
participants with pressure ulcer was higher in the
participants diagnosed with respiratory (27%), in-
fectious (21%) and genitourinary system (13%) dis-
Fig. 1 Prevalence of participants with pressure ulcer
eases (Fig. 1).
at the first skin assessment in inpatient setting according
Among the 560 participants with pressure ulcer,
to the ICD-9 diagnosis.
60.4% had two or more pressure ulcers, with a total
of 1455 pressure ulcers category/stage IeIV
assessment were significantly higher [OR 68.36 recorded at the first skin assessment in inpatient
(95% CI, 44.06e106.07)] for the participants with setting during 2012. Most of the pressure ulcers
Braden Scale Scores  16. recorded (42.3%) were category/stage I. The most
Also, the odds of having a pressure ulcer frequent anatomical locations were the heels
documented in the first skin assessment increased (28.9%), the sacrum/coccyx (22.4%) and the tro-
with age and were significantly higher in the chanters (12.4%) (Table 2).
Pressure ulcer point prevalence in Portugal 79

participants would be classified as “at risk of

Table 2 Pressure ulcers documented at the first
skin assessment according to their category/stage,
developing pressure ulcers”.
location and frequency of pressure ulcers per If we considered only the participants classified
participant with pressure ulcer. as “at risk of developing a pressure ulcer”,
approximately one fourth of them (23.1%) had at
Pressure ulcers
least one pressure ulcer documented in the first
n ¼ 1455 100% skin assessment. On the other hand, if we only
Category/stage considered the participants classified as “not at
I 616 42.3% risk of developing a pressure ulcer” we realize that
II 245 16.8% only 21 participants (0.4%) had a pressure ulcer
III 204 14.0% documented in the first skin assessment. In fact, in
IV 390 26.8% our sample the participants classified as “at risk of
Anatomical location
developing a pressure ulcer” are the ones with
Occiput 2 0.1%
Ear 24 1.6%
higher odds of having (at least) one pressure ulcer
Scapula 7 0.5% at the first skin assessment.
Spinous process 1 0.1%
Elbow 13 0.9% 4.2. Pressure ulcer point prevalence
Iliac crest 5 0.3%
Sacrum/coccyx 326 22.4% Our study showed a point prevalence of partici-
Ischial tuberosity 6 0.4% pants with pressure ulcers of 7.9% category/stage
Trochanter 180 12.4% IeIV at the first skin assessment in inpatient
Knee 9 0.6% setting. Similar results (7.8%) were reported in a
Malleolus 100 6.9% prospective study [22] in an Emergency Depart-
Heel 421 28.9%
ment in France and in a point prevalence study
Toe 65 4.5%
Other 296 20.3%
[23] in a tertiary Hospital of India.
Frequency of PU Participants with PU A multicentre study [18] developed in 8 Portu-
1 222 39.6% guese hospitals showed a higher prevalence of
2 133 23.8% participants with pressure ulcer (11.5%) category/
3 83 14.8% stage IeIV. That data reflected the first skin
4 40 7.1% assessment in each institution but their sample
5 82 14.6% included participants of Critical Care Services
Ratio PU/patient with PU 2.60 (Intensive Care Units and Emergency Room).
A multicentre survey [10] developed in 25 hospital
sites across 5 European countries reported an overall
point prevalence of participants with pressure ulcer
4. Discussion of 18.1% (Category/Stage IeIV) and a point preva-
lence of participants with pressure ulcer in 3 Portu-
Our study investigated the patients hospitalized in guese hospitals of 12.5% (Category/Stage IeIV).
medical and surgical areas of Aveiro Hospital and However, it also included a large sample of “Inten-
analyzed the characteristics of participants that sive” and “Acute Care/High Dependence” partici-
already had (at least) one pressure ulcer at the pants and the data did not reflect the first skin
first skin assessment in inpatient setting. assessment in inpatient setting.
As far as Portuguese Islands studies [4] were
4.1. Pressure ulcer risk concerned, a prevalence participants with pressure
ulcers of 9.0% in Azores and 22.7% in Madeira was
Considering the cut-off point of 16, established by reported. However, these data included partici-
Portuguese guidelines [13], the participants clas- pants from different care settings, namely hospi-
sified as “at risk of developing pressure ulcers” at tals, primary care facilities and nursing homes.
the first pressure ulcer risk assessment comprises National [4,10,18] and international [10,23e25]
approximately one third of the study population. study reports on pressure ulcer prevalence had
Similar results were reported in other studies specific methodological approaches and different
[3,10,18] in Portuguese hospitals. If we considered variables in analysis/involved, nevertheless high-
the cut-off point of 18, used in other international est prevalence usually were reported in Intensive
studies [19e21], more than a half of our Care Units and Geriatric wards [10,18,21,26]
80 P.M.G. Sardo et al.

showing the influence of illness severity [26,27] 4.5. Study limitations

and age [28] in this specific domain.
The presence of pressure ulcers could be a While the pressure ulcer risk and skin assessment
measure of frailty, and, in our study, the highest was performed in a systematic way in inpatient
odds of having a pressure ulcer at the first skin settings that did not happen in emergency service.
assessment in inpatient setting were associated Our data only included the first pressure ulcer risk
with advanced age or lower Braden Scale scores. and skin assessment in inpatient setting but did not
According to ICD-9 Diagnosis, our results showed follow up the participants during the length of stay.
that participants with respiratory, infectious or There is lack of documentation related to
genitourinary system diseases were the ones with pressure ulcer characteristics and our data only
higher percentage of pressure ulcers at the first showed the pressure ulcer category/stage and
skin assessment in inpatient setting. In fact, acute anatomical location.
respiratory failure [29], respiratory diseases [30] There are important variables and/or risk fac-
and infections [28,30] had already been docu- tors that may help us to improve our findings
mented to be associated with patients’ (risk of) (namely co-morbidities, dependence level,
pressure ulcer presence/development. therapeutics, anthropometric, physiological
and/or biochemical data) that could be collected
4.3. Pressure ulcer category/stage with different methodological designs and the
implementation of new clinical and research
At the first skin assessment in inpatient setting tools.
most of the pressure ulcers (42.3%) were classified
in category/stage I. These results were signifi- 4.6. Implications to future research
cantly higher than the ones reported in Portuguese
hospitals [18] where only 18.3% of the pressure
This study reported the prevalence of participants
ulcers identified were category/stage I. Some au- with (at least one) pressure ulcer at the first skin
thors [18,21] suggest that there may be a lack of assessment in inpatient setting and highlighted
identification and/or documentation of pressure some of their clinical and demographic charac-
ulcers in some study reports, especially category/ teristics. Our results showed that the participants
stage I. So we believe that this difference could be
with pressure ulcer at the first skin assessment
the result of the improvement in skin assessment,
in inpatient setting commonly had more than
pressure ulcer assessment, classification and
one pressure ulcer. In fact, the presence of (at
documentation during the last years.
least) one pressure ulcer is an important measure
We have a significantly lower percentage of of frailty and could be an important predictor
pressure ulcers category/stage IV (26.8%) compared of the patient outcome. However, more studies
to other study [18] which reported a percentage of are needed to document other characteristics
36.5% pressure ulcers category/stage IV in Portu- of those who had and/or developed pressure ul-
guese hospitals. However, our numbers still repre-
cers during the length of stay, their clinical evo-
sent more than one fourth of all pressure ulcers
lution, their discharge outcome and the
documented, with all the costs and care needs
characteristics/evolution of the pressure ulcers
associated.
themselves.
4.4. Pressure ulcer location
5. Conclusion
The most frequent anatomical locations for the
pressure ulcers were the heels (28.9% category/ The results of our study showed a point prevalence
stage IeIV) and the sacrum/coccyx (22.4% cate- of participants with pressure similar to other
gory/stage IeIV). These two locations together recent internationals studies. Most of the pressure
comprise a half of all pressure ulcers documented ulcers recorded were category/stage I. The heels
at the first skin assessment in inpatient setting. and the sacrum/coccyx were the most problematic
Similar results were reported in Portuguese hos- areas. The presence of a pressure ulcer at the first
pitals [10,18] where the heels and the sacrum/ skin assessment could be an important measure of
coccyx were the most problematic areas. Howev- frailty and the participants with pressure ulcer
er, in other countries, namely in UK [10,31], Italy commonly had more than one documented pres-
[10], India [23], and Japan [32] the pressure ulcers sure ulcer. The highest odds of having a pressure
at sacrum/coccyx were in larger number. ulcer at the first skin assessment in inpatient
Pressure ulcer point prevalence in Portugal 81

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the Hospital Administration, Informatics and Sys-
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Cláudia Simões thank the post-doctoral grant [17] Defloor T, Clark M, Witherow A, Colin D, Lindholm C,
Schoonhoven L, et al. EPUAP statement on prevalence and
from project New Strategies Applied to Neuro-
incidence monitoring of pressure ulcer occurrence. J Tis-
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