NS5003, University of East London: Pressure Ulcer Literature Review

This literature review examines pressure ulcers, a significant health concern in hospitals, focusing on their causes, prevalence, and impact on patient outcomes. The review explores various aspects, including prevalence and assessment, prevention strategies such as silicon foam dressing, and the use of risk assessment tools. It analyzes the financial burden associated with pressure ulcers and discusses the importance of early risk assessment upon patient admission. The study utilizes a systematic approach, including a thorough search strategy across multiple databases, and categorizes the selected articles into themes such as prevention strategies, prevalence and assessment, financial burden, and risk assessment tools. The paper highlights the importance of research in identifying the causes of pressure ulcers and implementing effective prevention strategies to improve patient safety and reduce healthcare costs. The review also emphasizes the role of nurses and the impact of pressure ulcers on various stakeholders.

Running head: PRESSURE ULCER
Literature Review on Pressure Ulcer
Name of the Student
Name of the University
Author Note

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Abstract
Pressure ulcer is the damage of the skin and its underlying tissue caused by prolonged
pressure on a specific area of the body. Tissue necrosis is one of the severe consequences of
pressure ulcer. Hospital Acquired pressure ulcer is a growing health issue which requires the
attention of the stakeholders from health care industry. Use of risk assessment tool upon
admission of patient for assessing the risk of pressure ulcer in the patient can be critical
intervention to help the health care professionals keep a check on the incidence of pressure
ulcer. A systematic review of literature with definite search protocol was performed to gain
deeper insights on the information available on the pressure ulcer. The selected articles were
categorised into different themes, such as prevention strategies, prevalence and assessment,
financial burden and risk assessment tools.

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Table of Contents
Introduction....................................................................................................................3
Method...........................................................................................................................4
Search Strategy...........................................................................................................5
Selection Criteria........................................................................................................5
Study Selection...........................................................................................................6
Literature review............................................................................................................6
Prevalence and Assessment........................................................................................6
Prevention Strategies..................................................................................................7
Pressure Injury Risk Assessment...............................................................................9
Impact of Pressure Ulcer..........................................................................................10
Conclusion....................................................................................................................11
References....................................................................................................................13

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Introduction
Hospital acquired injuries are major health issue globally, of which pressure ulcer is
highlighted health concern in the current health care sector. Pressure ulcer are a type of
acquired injury that is caused due to constant pressure on the skin, which leads to breakdown
of the skin and its underlying tissues (Gardiner et al. 2016). The constant pressure on the
limited area of skin reduces the amount of oxygen received by the tissues underlying the skin
and nutrition cessation occurs (Beeckman et al. 2014). Pressure causes tissue ischaemia, that
is, restriction of blood supply to the tissues, which leads refrains the tissues from performing
cellular metabolic activities with shortage of oxygen supply (Oomens et al. 2015).
Continuous exposure to pressure on the skin without any relive increases the severity of
tissue ischaemia, causing tissue dysfunction or necrosis, that is, tissue death (Swisher et al.
2015). The most accurate description of pressure ulcer is given by the term ‘deformation
damage’. In pressure ulcer, localised damage due to tissue ischaemia or necrosis occurs and
the prime cause of tissue damage is the application of external force, which includes
compression, shear or both. In pressure ulcer is commonly known in the United Kingdom as
‘pressure sores’. However, the lack of open wounds in such medical injuries makes the use of
term ‘sores’ inappropriate. The European Pressure Ulcer Advisory Panel (EPUAP) accepts
the use of ‘pressure ulcer’ as the definitive term to denote the specific injury. Incidence of
pressure ulcers in hospital patients is constantly increasing with the count of over 24,000
patients between 2015-2016 reporting to have developed pressure ulcers during their stay at
the hospital and receiving treatment for other health issues (NHS Digital 2019). According to
NHS Digital (2019), the average length of stay for the patients acquiring pressure ulcers in
the hospital is 25 days. Pressure ulcer is a highly avoidable mistake and requires extensive
research on the possible causes and reasons that lead to development of such injuries to the
patient during their stay at the hospital. Incidence of pressure ulcer puts health outcome and

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safety of the patient in serious risk and causes substantial health burden. In addition to the
risk of patient’s health outcome and safety, pressure ulcers put additional burden on the
health economy, with over £3.8 million spend every day for treating damages cause by
Hospital Acquired Pressure Ulcers (HAPUs) (NHS Digital 2019). Pressure ulcers have been
categorised into four grades based on the severity of the injury. Grade I is determined by
intact skin’s non-blanchable erythema and discoloration of the skin, oedema and hardness of
the skin. In Grade II, the ulcer remains superficial with partial thickening of skin and its loss.
In Grade III, tissue necrosis with full thickening loss of skin and in Grade IV, extensive
damage to the bone along with tissue necrosis occurs (Edsberg et al. 2016).
The following paper aims at conducting a systematic review of literature to achieve
relevant information on the incidence of pressure ulcer in hospital patient. The systematic
review of literature will also aim at reviewing the consequences of such injuries, impact on
the major stakeholders, prevention strategies for pressure ulcers and the perceived barriers,
nursing attitude and perceptions towards the incidence of such hospital acquired injuries.
Extensive study design will be ensured to search for relevant literature and the selected
articles will be critically analysed to draw conclusions on the research topic of pressure ulcers
in hospital patients.
Method
The following systematic review of literature aims at reviewing the available
literature on the Hospital Acquired Pressure Ulcers. To conduct the systematic review of
literature, few search protocols will be followed to find the most suited and relevant literature
on the research topic. As the extent of research topic is wide, several aspects constituting the
sub-categories of the topic will be search for and used to find literature relevant to the topic.
These aspects include incidence of pressure ulcers, risk factors leading to pressure ulcer,

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prevention strategies, role of nurses, perceived barriers to prevention, and impact on the
major stakeholders.
Search Strategy
A well-structured search strategy is considered to be the core of a systematic review
of literature. To find relevant literature, a thorough search was conducted in several databases
including MEDLINE, PubMed Central, Cochrane Library, BioMed Central and EMBASE.
The use of keywords to search for the literature was ensured to be highly relevant to the
research topic to increase the relativity and integrity of the search results. The keywords that
were used to conduct the search were pressure ulcers, hospital acquired pressure ulcers,
pressure sores, bedsores, preventions strategies, risk factors, nursing perception, economic
burden, evidence based practice, perceived barriers and impact on patient. In the advanced
search option available in the databases, Boolean operators ‘AND’ and ‘OR’ were used
between the keywords to perform search of literature available in the databases. In the initial
few searches made in the databases, the Boolean operator ‘AND’ was used to gather greater
amount of literatures available relevant to the research topic. The Boolean operator ‘OR’ was
then used to limit and refine the searches and to ensure higher relevancy of the search results
to the research topic (McGowan et al. 2016). With the help of filter application, certain
limitation to the basic characteristics of the search articles. These limitations included the
language and date of publication. The language of publication for the articles was limited to
English language only and the date of publication was given a range of 2013-2019.
Selection Criteria
The primary inclusion criteria of the articles found from search results was published
status of the article and only peer-reviewed published articles were made eligible to be
selected in the review. Unpublished articles, editorial letters and opinion papers were not
selected for the study. Articles were made eligible for inclusion in the review only if they

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were published between the years 2013-2019. The language of publication was restricted to
English only to ensure better global understanding of the research topic (Aromataris and
Riitano 2014). Articles that were published in any language other than English were not
include in the study, even if they were highly relevant to the research topic.
Study Selection
With the help of the aforementioned search strategy, relevant studies were included
for the systematic review of literature on the chosen research topic. The following section of
literature review performs critical analysis of the selected studies and draws conclusions from
them.
Literature review
The selected articles are subcategorised into different themes to draw better
understanding on each aspect of the research topic. Following section of the paper will
critically analyse the selected articles and aim at finding supporting evidences to draw
conclusion on the study conducted.
Prevalence and Assessment
A discussion paper by Coleman et al. (2014) aimed at proposing a new conceptual
framework for pressure ulcer after analysing the current determinants of the pressure ulcer
backed up by evidences. The paper uses a systematic review and a consensus study as data
sources to find epidemiological, physiological and biomechanical evidence to link them to
the new conceptual framework for pressure ulcer. The key finding of the research is the
proposal of a new framework on pressure ulcer that is based on biomechanical and
physiological components and their impact on the damage thresholds, stresses and internal
strains. The new framework proposed by the authors in the paper is of great clinical use as it
critically helps the nurses to develop their basic understanding on the determinants of
pressure ulcer and perform better injury assessment.

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Another study conducted by Jiang et al. (2014) aimed at benchmarking the prevalence
rate of pressure ulcers in China and provide a detailed understanding of the risk factors and
pressure ulcer characteristics to the readers. The researchers conduct a multi-cross-sectional
study in 11 general hospitals and one university hospital in China. To collect information of
the inpatients, the authors use the MDS (Minimum Data Set) recommended by the EUPAP
(European Pressure Ulcer Advisory Panel). The sample size of the study is huge, with over
39952 number of inpatients participating in the study. The chosen study design for the study
provides greater validity with high reliability. The research findings conclude that 631
patients out of the total count of 39952 inpatients were suffering from pressure ulcer, which
determines the prevalence rate of 1.58% in the 12 hospitals. The study also revealed that the
incidence of hospital acquired pressure ulcer was 0.63%. The common locations found to be
impacted by pressure ulcer in patients were iliac crests, heels, and sacrum and the common
stage of pressure ulcer found in the inpatients were grade I and II. The research provides
exclusive evidence that the prevalence rate of hospital acquired pressure ulcers in China is
significantly lower than that reported in several European countries.
Prevention Strategies
A study conducted Tayyib and Coyer (2016) aimed at reviewing the effectiveness of a
single preventive strategy for pressure ulcer in Intensive Care Units (ICU) for adult patients.
The authors conducted a systematic review of literature to find information relevant to their
research objective. The studies preferred for the selection in the literature review were
comparative studies, quasi-experimental, and randomised control trials. Two independent
reviewers were employed to adjudge the methodological validity of the article prior to their
inclusion for further analysis. Several prevention strategies that were reviewed from the 25
selected studies were role of education in preventing hospital acquired pressure ulcers,
support surfaces, repositioning schedule, skin-care regimen, effect of silicon foam dressing

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strategy and effectiveness of nutrition. The research findings conclude that among all the
aforementioned preventive strategies for pressure ulcers in hospital patients, the silicon foam
dressing was most effective strategy in reducing the incidence of hospital acquired pressure
ulcers with effect size over 95%. The data collected systematic review of literature conducted
by the authors was limited for past 15 years, that is, from 2000 to 2015. The broad range of
study reviewing ensure that the validity of the research findings are high with greater
reliability and evidence supporting them.
Another study conducted by Latimer, Gillespie, and Chaboyer (2017), aimed at
determining the clinical, patient and contextual factors that lead to prediction of the
prevention strategies for pressure injury and their implementation among the acute care
medical patients. The authors conducts an observational study in two Australian hospitals
with patients having limited mobility. The sample size of the participants included in the
study was 241 and semi-structured observations along with chart audits were implemented by
the researchers under observational study design. For data analysis, the researchers perform
multiple regression analyses along with multiple logistic regression to identify the predictors
of different prevention strategies of pressure injuries including patient education, regular
repositioning and support surfaces. According to the research findings, only 46.9% patients
were assessed for pressure injury risk and the most common preventive strategies
implemented by the health care providers was repositioning of the patient. Moreover, with
the increase in mobility disability in the patient, the implementation of support surfaces such
as pressure relieving mattresses increased.
An important conclusion that can be drawn from the above two studies is that support
surfaces such as pressure relieving mattresses and silicon foam dressing acted as the most
effective preventive strategies followed by regular repositioning of the patient. Moreover, the
implementation of preventive strategies hugely dependent on the pressure injury risk

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assessment done on the admission of the patient, and low assessment rates mean that several
patients at increased risk of attaining pressure ulcer may be missed.
Pressure Injury Risk Assessment
A study conducted by Moore and Patton (2019) aimed at reviewing the use of risk
assessment tool and its efficacy in reducing the incidence of pressure ulcers in healthcare
settings. The authors state that several international pressure ulcer prevention guidelines
recommend the use of risk assessment tool, however, the link of its use to reduction in the
incidence of the injury is very little known. The authors conduct a systematic review of two
studies that included 1,487 participants. The tools used in the study included Braden risk
assessment tool, Waterlow risk assessment tool, Ramstadius risk assessment tool, all of the
three tools in association with clinical judgement and use of clinical judgement alone. The
study provides no conclusive evidence to support the use of any particular tool to reduce the
incidence of pressure ulcer in healthcare settings. Lack of certainty in evidence puts a threat
on the validity of the research findings from this study (Cook et al. 2014).
García-Fernández, Pancorbo-Hidalgo, and Agreda (2014) conducted a systematic
review with meta-analysis to find the predictive capacity of clinical judgement and risk
assessment scales and tools for pressure ulcer in health care settings. The researchers
searched for relevant literature published between 1962 and 2010 in several languages
including English, German, Korean, Portuguese, Spanish, and Greek. The authors used the
Critical Appraisal Skills Program checklist to adjudge the validity and reliability of the
studies. The researchers used sensitive analysis along with the use of random-effect model to
conduct meta-analysis. In the systematic review, 57 studies were identified of which 31 were
validation study. The predictive capacity of the risk assessment scales were measure as
relative risk (RR) with confidence intervals of 95%. The identified risk assessment scales for
pressure ulcers in health care settings were Braden, Waterlow, Cubbin-Jackson, EMINA,

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Pressure Sore Predictor, Norton and clinical judgement. The pooled predictive capacity
indicators produced by meta-analysis were Cubbin-Jackson (RR = 8.63); Waterlow (RR =
2.66); EMINA (RR = 6.17); Pressure Sore Predictor Scale (RR = 21.4); Norton (RR = 3.69);
Braden (RR = 4.26); and clinical judgment (RR = 1.89). According to the researchers from
the study, all risk assessment tools were found to be effective in predicting the probable
incidence of pressure incidence in patients when used in association with clinical judgement.
However, the use of clinical judgement alone in assessing the pressure ulcer risk in the
patient is marked as ineffective by the researchers and not recommended. This study by
García-Fernández, Pancorbo-Hidalgo, and Agreda (2014) is useful in bringing into reader’s
attention the suitable risk assessment scales and tools available that can be used in health care
settings to predict the risk of pressure ulcer in patients. However, the publishing date range
for the study is too wide which indicates inclusion of studies that can be up to 3 decades
older. This puts a serious threat to the validity of the research findings as such old data cannot
be taken into consideration or implied in clinical practice.
From the above studies, it can be concluded that further research is required on
assessing the efficacy of using risk assessment scales and tools in predicting the risk of
pressure ulcer in patients upon admission. Moreover, the tools and scales currently in practice
are Braden, Waterlow, Cubbin-Jackson, EMINA, Pressure Sore Predictor, and Norton, along
with clinical judgement by the nursing professionals.
Impact of Pressure Ulcer
Demarré et al. (2015) conducted a study to get a detailed insight on the financial
burden caused by the incidence of pressure ulcer in adult population. The authors conducted a
systematic review of literature for published articles up to the year 2013 and retrieved 2542
article of which 17 articles were selected. According to the research findings the average cost
associated with treatment of pressure ulcer for a day ranged from €1.71 to €470.49 in

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different health care settings. The researchers conclude that increase in the severity of the
pressure ulcer injury substantially increase the associated cost of treatment. The study
provides a very conclusive evidence on the financial burden caused by the incidence of
pressure ulcer and paves way for further health economic studies in the same topic in future.
Meddings et al. (2015) conducted a retrospective study to assess the financial effect of
pressure ulcers by the Hospital‐Acquired Conditions Initiative (HACI) in the year 2008. The
participants for the study included adult patients discharged from acute-care hospitals. The
study analysed the measurement of prevalence rate of pressure ulcer pre and post the
initiative in the year 2008. The findings from the study conclude that the prevalence rate of
pressure ulcer before the monetary assistance initiative was at 0.28% and post the initiative in
2009, reduced to 0.27%, indicating negligible change from the payment changes made in the
2008 initiative.
Conclusion
From the above systematic review of literature, it can be concluded that hospital
acquired pressure ulcer is a swiftly increasing health concern globally. Pressure ulcer is the
injury caused by the stop of blood flow to the tissues, primarily due to prolonged pressure at a
particular position. Tissue necrosis can occur in critical stages of pressure ulcer and put a
severe threat to patient’s health outcome and safety. The four stages of pressure ulcer include
Grade I, II, III, and IV, where Grade IV is the most sever condition of pressure ulcer. Several
prevention strategies for pressure ulcer have been researched and implemented in clinical
practice, which include use of support surfaces, patient education, regular repositioning of the
patient and providing nutrition to the patient. The most effective preventive strategy
determined by the above analysis of review of literature is the use of support surfaces, such as
preventive mattresses or silicon foam dressing of the patient. It is important that clinical
assessment is performed upon admission of the patient to assess the risk of pressure ulcer in

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the patient and the use of risk assessment scales and tools along with clinical judgement
should be ensured. The risk assessment tools and scales include Braden, Waterlow, Cubbin-
Jackson, EMINA, Pressure Sore Predictor, and Norton. Hospital acquired pressure ulcers are
avoidable and the increase in the incidence of such cases puts immense financial burden on
the patient and health care sector.

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