1.pressure UlcerAsnisa

Pressure Ulcer
in the Intensive Care Unit

14th-16th October 2014
Copthorne Orchid Tg. Bungah Pulau Pinang
Hair
Sebaceous
gland
Sweat Pore
Stratum
Stratum
Stratum
Stratum
Epidermis
corneum
granulosum
spinosum
basale
Erector pili
muscle
Dermis
Sweat gland
Hypodermis
Adipose
tissue
Hair bulb
Hair follicle
Arteriole
Venule
Motor
nerve
Sensory
nerve
Function
Structure and or Cell Involved
Protection against
Chemical, particles
Ultraviolet radiation
Antigen, haptens
Microbes
Horny layer
Melanocytes
Langerhans cells
Langerhans cells
Preservation of a balanced internal

environment
Horny layer
Prevent loss of water, electrolytes and

macromolecules
Horny layer
Shock absorber
Dermis and subcutaneous fat
Strong, yet elastic and compliant
Dermis and subcutaneous fat
Temperature regulation
Blood vessels, eccrine sweat glands
Insulation
Subcutaneous fat
Sensation
Specialised nerve endings
Lubrication
Sebaceous glands
Protection and prising
Nails
Calorie reserve
Subcutaneous fat
Vitamin D synthesis
Keratinocytes
Body odour
Apocrine sweat glands
Psychosocial display
Skin, lips, hair and nails
Problems and Outcomes

Pressure ulcers are associated with an adverse
patient outcomes and contribute to:
1.
2.
3.
4.
5.
6.
7.
Pain
Depression
Loss of function and independence
Increase incidence of infection and sepsis
Additional surgical costs
Prolonged hospital stay
Medico-legal ramifications
Definition
Pressure ulcer is a localised injury to the
skin and or underlying tissue usually over
the bony prominence as a result of pressure
or pressure in combination with shear and or
friction
Definition
A circumscribed area in which cutaneous
tissue has been destroyed and there is
progressive destruction of underlying tissue
caused by interference with circulation and
nutrition to the area.
Signs include blister or broken skin or sore
formation over pressure areas (redness is
excluded)
Malaysian Registry of Intensive Care
Stage 1 Non-Blanchable
Erythema
International NPUAP/EPUAP Pressure Ulcer Classification System 2014
Intact skin with

non-blanchable
erythema
Darkly pigmented
skin may not
have visible
blanching. Its
color may differ
from the
surrounding areas
The area may be

painful, firm
soft, warmer or
cooler from the
adjacent tissues
Stage 2 Partial Thickness Skin

Loss
Partial thickness
loss of dermis
Shiny or dry
shallow open
ulcer with
reddish pink bed
without slough or
bruising
May also
present as
intact or
open/ruptured
serum-filled or
serosanguinous
filled blister
Bruising
indicates
suspected deep
tissue injury
Stage 3 Full Thickness Skin

Loss
Full thickness
tissue loss
Subcutaneous fat
may be visible
but bone, muscle
or tendon are not
exposed.
Slough may be
present but does
not obscure the
depth of ulcer
Depth of ulcer
varies by
anatomical
location
Stage 4 Full Thickness Tissue

Loss
Full thickness
tissue loss
Bone, tendon and

muscle are
exposed. Slough
or eschar may be
present on some
parts of the
wound.
Undermining and
tunneling may be
present.
Depth of ulcer
varies by
anatomical
location
Deep Tissue Injury : Depth

Unknown
Purple or maroon
localised area of
discolored intact
skin or bloodfilled blister due
to damage of
underlying soft
tissue from
pressure and/or
shear
Preceded by
tissue that is
painful, firm,
mushy, boggy and
warmer or cooler
than adjacent
tissue.
May be difficult
to detect in
individuals with
dark skin tones
Unstageable : Depth Unknown

Full thickness
tissue loss. Base
of the ulcer is
covered by slough
and/or eschar.
The true depth
cannot be
determined until
enough slough
and/or eschar has
been removed
Stable eschar on
the heels serve
as the bodys
natural
(biological)
cover and should
not be removed
Pathophysiology
Unrelieved pressure is the major
factor in the development of
pressure ulcer
The weight of the body squashes
the skin and tissue against the
bone reducing the blood supply
to the tissue
Pressure
Risk Factors
Intrinsic Factors
Extrinsic Factors
Excessive axial pressure
Immobility
Friction and shear forces
Sensory loss
Impact injury
Age
Heat
Body type
Moisture
Diseases
Posture
Poor nutrition
Infection
Incontinence
Risk Factors
70% of pressure ulcer occurs
in people above 65 years old
Thomas DR. Prevention and treatment of

pressure ulcers. J Am Med Dir. Assoc.
2006 Jan; 7(1): 46-59
Risk Factors
Hospital Acquired Pressure Ulcer
Results from the National Medicare Patient Safety Monitoring System
Study
Lyder CH, Yun Wang, Metersky M
Journal of American Geriatric Society 2012; 60(9): 1602-1608
Condition
Odd Ratio (95 CI)
P value
Carcinoma
1.07 (1.05-1.29)
<0.001
Chronic cardiac failure
1.11 (1.09-1.13)
<0.001
COAD
1.05 (1.02-1.07)
<0.001
Diabetes mellitus
1.07 (1.05-1.29)
0.001
Steroid
1.03 (1.00-1.07)
0.04
Obese
1.04 (1.01-1.07)
0.002
Smoking
1.00 (0.98-1.03)
0.8
Incidence and Prevalence

Incidence of hospital acquired pressure ulcer
was 4.5% and prevalence of pressure ulcer on
admission was 5.8%
16.7% of patients with pressure ulcer on
admission developed at least one pressure
ulcer at different location during
hospitalisation
Lyder CH, Yun Wang, Metesky M et al. Hospital acquired pressure
ulcers: results from the National Medicare Patient Safety Monitoring
System. J Am Geriatric Society 2012; 60 (9): 1603-1608
Hospital Population
Bergstrom et al. noted an incidence of 14 per
1000 patient-days (Stage 1-4).
Incidence of pressure ulcer excluding stage 1

was between 0.2 to 0.56 per 1000 patientdays
Bergstrom N, Braden B. A prospective study of pressure ulcer risk

among institutionalised elderly. J Am Geriatric Soc. 1992; 40: 747-758
Intensive Care Unit

Prospective observational study in 2 intensive
care units in Athens from Jan to Dec 2009,
incidence density of stage 2-4 pressure ulcers
: 13.9 per 1000 patient-days and 14.0 per
1000 mechanical ventilation-days
Apostolopoulo E, Tselebis A, Terzis K. Pressure ulcer incidence and risk

factors in ventilated intensive care patients. Health Science Journal
2014; 8(3): 333-342
Intensive Care Unit

Incidence of pressure ulcers among all
admission to ICU was 28 per 1000 patientdays. High risk patients (APACHE II > 15)
had incidence of 52 per 1000 patient-days
Bergstrom N, Demuth PJ. Braden BJ. A clinical trial of Braden Scale

for prediction of pressure sore risk. Nursing Clin. North Am 1987; 22:
417-426
Inman KJ, Sibbald WJ, Sneider H et al. Clinical utility and cost
effectiveness of an air suspension bed in the prevention of pressure
ulcer. JAMA 1993; 269: 1139-1143
Intensive Care Units in

Malaysia
Incidence of pressure ulcers ranged between
0.5 to 21.1 per 1000 patient-days with mean
of 6.6 per 1000 patient-days
MRIC Protocol definition; stage 1 pressure
ulcers are excluded from the study
Malaysian Registry of Intensive Care Report for 2013
Intensive Care Units in Malaysia

9
7.7
8
7.1
6.6
6.8
6.6
2012
2013
5.8
6
5
4
3
2
1
0
2008
2009
2010
2011
Pressure Ulcer per 1000 patient-days
Malaysian Registry of Intensive Care Report for 2013
Intensive Care Unit

Distribution of patients according to the number of
pressure ulcers
Number of pressure ulcers
Number of patients
28 (66.7%)
8 (19.7%)
4 (9.5%)
2 (4.8%)
Total
42 (100%)

2014; 8(3): 333-342
Intensive Care Unit

Pressure ulcer stage and site
Stage II
Stage III
Stage IV
Total
Sacrum
21
27
Hip
16
Heel
15
17
Head
Elbow
Total
48
12
64

2014; 8(3): 333-342
Pressure Ulcer in Bariatric

Patients
Bariatric patients are at risk of pressure ulcer
development for several reasons:
1. Nutritional status might not be optimum
2. Prone to develop protein malnutrition during
metabolic stress (even though they may have excess
body fat storage)
3. Adipose tissue commonly has decrease vascularity
4. Unable to change position or move independently due
to immobility
5. The moist environment in skinfold promotes bacterial
growth which can lead to fungal infections and
decreased integrity
Medical Device Related

Pressure Ulcer
Cervical collars
Bedpans
Endotracheal tube holder
Face mask for NIPPV
Fecal containment device
Nasal cannulas
Pulse oximeter probe
Radial artery catheters
Compression devices
Splint and braces
Urinary catheters
Wrist bands
Published frequency of device related pressure ulcer
Reference
Type of device
Frequency
Davies et al 1995
Cervical collars
33% up to 5 days, 44% over 5 days
Wille et al 2000
Pulse oximetry
5%
Jones at al 1994
NIPPV mask
17%. 55% experienced discomfort
Boesch at al 2012
Tracheostomy
8.1% pre-intervention, 0.3% postintervention
Jaul 2011
Various (tubes, catheters and fixation

tape)
6/26 hospital-acquired pressure ulcer
Weng 2008
Non-invasive ventilation
96.7% in control group, 53.3% in

intervention group
Van Gilder et al 2009
Not specified
10%
Apold et al 2012
Various, including stabilisation collars

and other immobilisers, respiratory
equipment, orthotics and tubing
29%
Black et al 2010
Not specified
34.5%
Pressure ulcer location from information on 255 hospital acquired category 3,4 or unstageable
pressure ulcer (Apold and Rydrych 2012)
Body location
Device related pressure ulcer n (%)
Non-device related pressure ulcer

n (%)
Head/face/neck
45 (70.3)
12 (7.8)
Other/multiple
14 (21.9)
9 (5.8)
Heel/ankle/foot
13 (20.3)
26 (16.9)
Coccyx/buttock
5 (7.8)
104 (67.5)
Sacrum
1 (1.6)
26 (16.9)
Apold J, Rydrych D. Preventing device-related pressure ulcers. Using data to guide

statewide changes. J Nurs Care Qual 2012 27(1): 28-34
Problems and Outcomes

Pressure ulcers are associated with an adverse
patient outcomes and contribute to:
1.
2.
3.
4.
5.
6.
7.
Pain
Depression
Loss of function and independence
Increase incidence of infection and sepsis
Additional surgical costs
Prolonged hospital stay
Medico-legal ramifications
Hospital Outcomes
Association between hospital outcome and pressure ulcer development
Total
With
Pressure
Ulcer
Without
Pressure
Ulcer
P-value
Mortality n(%)
Within 30-days of
discharge
2551
(4.0)
353 (15.3)
2198 (4.4)
<0.001
In-hospital
1892 (3.6)
258 (11.1)
1634 (3.3)
<0.001
Readmission within 30
days after discharge
9235
(17.8)
523 (22.6)
8712 (17.6)
<0.001
Length of stay
Days, mean SD
5.25.7
11.610.0
4.015.3
<0.001
Lyder CH, Yun Wang, Metersky M. Hospital-acquired pressure ulcer:

results from the National Medicare Patient Safety Monitoring System
Standby. J Am. Geriatric Soc. 2012; 60 (9): 1602-1608
Hospital Outcomes
Hierarchical generalized linear model of participant outcomes with pressure ulcer
development
Estimate
P-value
Within 30-days of discharge
1.69 (1.61-1.77)
<0.01
In-hospital
2.81 (2.44-3.23)
<0.01
1.33 (1.23-1.45)
<0.01
Mortality, odd ratio (95% confidence

interval)
Readmission within 30 days after discharge

Odd ratio (95% confidence interval)
Length of stay, mean 2SD
With pressure ulcer
2.11 (2.07-2.15)
Without pressure ulcer
1.25 (1.25-1.28)
<0.01
Lyder CH, Yun Wang, Metersky M. Hospital-acquired pressure ulcer: results

from the National Medicare Patient Safety Monitoring System Standby. J
Am. Geriatric Soc. 2012; 60 (9): 1602-1608
Sepsis
In patients with stage III and IV pressure
ulcers manifesting signs of sepsis, the wound
is considered as a primary source until proven
otherwise.
Mortality rate in patients with bacteremia and
pressure ulcers are 50%
Rudensky B, Lipschits M, Isaacsohn M. Infected pressure sores:

Comparison of methods for bacterial identifications. South Med J 1992;
85: 901-903
Osteomyelitis
Osteomyelitis is a potential complication
when pressure ulcer developed over bony
prominence
Pressure ulcers located over joint merit
close attention for potential development of
septic arthritis
Hibbs P. The economics of pressure ulcer prevention. Decubitus 1988; 1:

32-38
Mortality
1-year mortality rate of nursing home resident
with pressure ulcer was 50% compare to 27%
without pressure ulcer
35% of them who developed pressure ulcer
within the first 3 months die within 1 year
compared to 25% who did not developed
pressure ulcer
Brandies GH, Morris JN, Nash DJ. The epidemiology and natural history
of pressure ulcers in elderly nursing home residents. JAMA 1990; 264:
2905-2909
Mortality
An 180-day mortality rate of 69% was noted in
patient who developed stage IV pressure ulcers
with an average of 47 days from ulcer to onset
of death
In one study, pressure ulcer were found to be

significant marker for mortality in long-term
care patient
Berlowitz DR, Wilking SV. Risk factors for pressure sores: A comparison of crosssectional and cohort derived data. J Am Geriatric Soc 1989; 37: 1043-1050
Berlowitz DR et al. Effect of pressure ulcers on the survival of long-term care
resident. J Gerontol A Biol. Sci Med. 1997; 52: M106-110
Berlowitz DR et al. Predictors of pressure ulcer healing among long-term care
residents. J Am Geriatric Soc 1997; 45: 30-34
Brown G. Long-term outcome of full thickness pressure ulcers: healing and
mortality. Ostomy Wound Manage 2003; 49: 42-50
Cost
1.3 million adults (US) have a pressure ulcer
with estimated cost of USD500 to
USD40,000 to heal each ulcer
The US Healthcare spends more than USD1.0
billion annually to treat pressure ulcer
Joint Commission on Accreditation of Healthcare Organization (JCAHO). Draft
candidate 2007 National Patient Safety Goals Requirements and Implementation
Expectations: long term care program (on-line) {cited 2006 May 2nd} Available
from internet: http://www.jointcommission.org/NR/rdonlyres/53EA8AE9A-E21E4133-898E-97C958B0FD1F/0/07_npsg_ltc.pdf
American Medical Directors Association (AMDA) Pressure ulcers: percentage of
patients with pressure ulcers that heal. In: We care: toolkit for the
implementation of the clinical practice guidelines for pressure ulcer . 2004
Cost
Estimated treatment cost associated with
pressure ulcers
Patients who developed pressure ulcer
during hospitalization
USD 6 billions/year
Average added Medicare hospital days due

to pressure ulcers
2.2 million-days/year
Estimated treatment cost per pressure

ulcer (stage dependent)
USD 2,000 USD 40,000
Cost of reconstructive surgery for

pressure ulcer
USD 25,000 per patient
Addition variable costs associated with

pressure ulcer in acute care
USD 1300 per patient or USD

80 per day
Frantz RA, Gardner S, Harvey P et al

The cost of treating pressure ulcers in a long-term care facility.
Decubitus 1991; 4: 37-45
Pressure Ulcer and Litigation

In the past, relatives and patients appeared to
accept that pressure ulcer were an evitable
result of chronic condition and reduce mobility.
Now they are viewed as evidence of a failure to

provide reasonable standard of care and action
can be brought against those responsible for
compensation
Caroline Fife MD CWS
Director of Clinical Research at the Memorial Hermann Center for
Wound Healing
Associated Professor, Division of Cardiology, University of Texas Health
Science Center, Houston, Texas
Avoidable Pressure Ulcer

Pressure ulcers are considered to be
avoidable when
1. The patients clinical condition and risks
factors were not evaluated.
2. Care plan and implemented interventions
were not consistent with patients needs,
goals and recognised standard of practice
3. Impact of intervention were not monitored
and evaluated, and revised as appropriate
Unavoidable Pressure Ulcer

Pressure ulcer is considered to be unavoidable
when the patient developed pressure ulcer in
spite of:
1. Clinical condition and risk factors has been
evaluated
2. Care plan and implemented interventions
were consistent with patients needs, goals
and recognised standard of care
3. Impact of interventions were monitored and
revised as appropriate.
Unavoidable Pressure
Ulcer
4. Individual person
refused to adhere to
preventive strategies in
spite of education of
the consequences of
non-adherence.
Legal Implications
What Patients and Families Hear
Developing bedsore is a clear signs of elder
abuse. Bedsores are signs of negligence.
Hospitals have strict guideline for preventing
bedsores. If the staff follow protocol, your
loved one would not have developed a bedsore.
Failure to have sufficient number of nurses
leads to skin breakdown, which can be
eliminated by hiring additional nurses
Clinical Liability
Painful for Everyone
Adam versus Valencia Health Care
Center California 2008
Death from sepsis caused by decubitus
ulcer : US 2.0 million compensatory
damage award
Director of Clinical Research ay Memorial Hermann Center
for Wound Healing
Associated Professor, Division of Cardiology, University of
Texas Health Science Center, Houston Texas
Kevin Yankewsky JD
Partner, Fullbright and Jaworski LLP, Health-Law HealthLitigation Department
Houston, Texas
Clinical Liability
Brown versus Menorah Home and
Hospital New York 2007
Medical malpractice : negligent

treatment of decubitus ulcer : US1.25
million compensatory damage award
Director of Clinical Research ay Memorial Hermann Center for
Wound Healing
Kevin Yankewsky JD
Houston, Texas
Clinical Liability
Wilson versus Genesis Health Care
Corporation Pennsylvania 2008
Wrongful death due in part to decubitus
ulcer: US3.5 million compensatory
damage award
Wound Healing
Kevin Yankewsky JD
Houston, Texas
Clinical Liability
Myers versus National Healthcare
Corporation Tennessee 2007
Wrongful death/medical malpractice :

death from decubitus ulcer: US4.1M
compensatory damage award, US28M
punitive damage award
Wound Healing
Kevin Yankewsky JD
Houston, Texas
What Drives Patients/Families

to Attorney?
Greed
Grief
Anger
Search for answer
Director of Clinical Research ay Memorial Hermann Center for Wound
Healing
Associated Professor, Division of Cardiology, University of Texas Health
Science Center, Houston Texas
Kevin Yankewsky JD
Partner, Fullbright and Jaworski LLP, Health-Law Health-Litigation
Department
Houston, Texas
Documentation
You must evaluate your documentation system
with an eye towards both how it will be used for
patient care needs and how it will look to
litigation adversaries years later
Your documentation will always be the first
thing a plaintiffs lawyer looks at when
evaluating his or her case
A plaintiffs lawyer will always use your
documentation in ways you do not intend when
building his or her case
Management of
Pressure Ulcer
in the Intensive
Care Unit
Pressure Ulcer
Acute Care
Assessment and
Prevention Pathway
Admission
Thorough skin assessment
Consensus Paper from the

International Expert Wound Care
Advisory Panel 2008
Is there a risk of pressure

ulcer or skin breakdown
Yes
Develop an individualised care

plan for treating and
preventing further skin
breakdown
Yes
Braden score <18 or other

risk factors
No
Assess pressure ulcer risk
daily. Braden scale or
validated tool. Complete
holistic review for risk factors
Braden score >18
Reassess the skin and

pressure ulcer risk daily
No
Is there a risk for skin

breakdown or pressure ulcer?
Develop targeted
interventions to address each
risk areas and include in the
individualised care plan
Review outcomes of plan and
interventions
daily
Pressure Ulcer
Acute Care
Assessment and
Prevention Pathway
Admission

Advisory Panel 2008

Yes

breakdown
Yes

risk factors
No
Braden score >18

No

Develop targeted
interventions
daily
Pressure Ulcer
Acute Care
Assessment and
Prevention Pathway
Admission

Advisory Panel 2008

Yes

breakdown
Yes

risk factors
No
Braden score >18
No


A thorough skin-to-toe skin

inspection on admission
Documentation
Develop targeted
interventions
daily
Pressure Ulcer
Acute Care
Assessment and
Prevention Pathway
Admission

Advisory Panel 2008

Yes

breakdown
Yes

risk factors
No
Braden score >18

No

Initiate treatment (treatment

bundle) if skin breakdown
present and monitor ulcer
healing
Prevent progression of
existing pressure ulcer
(prevention bundle)
Develop targeted
interventions
Documentation
daily
Document Pressure Ulcer on

Admission or Transfer-in
Pressure Ulcer
Date and time of

skin assessment
Site and Stage

Size (length x width x depth)
Tract, tunneling, undermining
Necrotic tissues
Exudates
Granulation, epithelialization
Pain?
Surrounding
Tissue
Erythema
Maceration
Induration
Treatment of Pressure Ulcer

European Pressure Ulcer Advisory Panel, National Pressure Ulcer
Advisory Panel and Pan-Pacific Pressure Injury Alliance Guideline 2014
1. Classification of pressure ulcer

2. Assessment of pressure ulcer and monitoring of
healing
3. Pain assessment and treatment
4. Wound care : cleansing and debridement
5. Assessment and treatment of infection and
biofilms
6. Wound dressing
7. Biological dressing for treatment of pressure ulcer
8. Growth factors
9. Biophysical agents
10. Surgery
Wound Assessment and

Management
Documentation
Wound Care
Date and time
Frequency regime
Antibiotics
Necrotic tissues
Wound and
Surrounding Tissue
Description
Site, size, stage

Exudates
Signs of healing
Inflammation, maceration etc.
Activities
Cleansing and debridement
Dressing
Next wound assessment and
management
Nurse
Prevent Progression of Pressure Ulcer

The SSKIN-Care Bundle
Images from: Anne Cuyvus Pressure Ulcer: A Pressing Matter. Jessa Ziekenhuis. Jessa
Hospital, Hasselt, Belgium
Wound Care
Monitor Progress of Wound
Healing
Record and track healing of pressure ulcer
in an organized and systematic way.
Facilitate communication about wound status
and aid in care planning across discipline
Pressure Ulcer Scale for Healing (PUSH)
and Bates-Jensen Wound Assessment Tool
(BWAT)
Pressure Ulcer
Acute Care
Assessment and
Prevention Pathway
Admission

Advisory Panel 2008

Yes

breakdown
Yes

risk factors
No
Braden score >18

No

Risk assessment using a

validated Pressure Ulcer
Risk Assessment Score
Develop targeted
Document all findings

interventions
daily
Pressure Ulcer
Acute Care
Assessment and
Prevention Pathway
Admission

Advisory Panel 2008

Yes

breakdown
Yes

risk factors
No
Braden score >18

Apply Skin-care bundle to

prevent pressure ulcer in
high risk individuals
Documentation
No

Develop targeted
interventions
daily
Prevent Development of Pressure Ulcer

The SSKIN Care Bundle
Images from: Anne Cuyvus Pressure Ulcer: A Pressing Matter. Jessa Ziekenhuis. Jessa
Hospital, Hasselt, Belgium
Thank You
for your attention!!

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Pressure Ulcer

in the Intensive Care Unit

Structure and or Cell Involved

Preservation of a balanced internal

Prevent loss of water, electrolytes and

Dermis and subcutaneous fat

Strong, yet elastic and compliant

Dermis and subcutaneous fat

Blood vessels, eccrine sweat glands

Specialised nerve endings

Protection and prising

Apocrine sweat glands

Skin, lips, hair and nails

Problems and Outcomes

Intact skin with

The area may be

Stage 2 Partial Thickness Skin

Stage 3 Full Thickness Skin

Stage 4 Full Thickness Tissue

Bone, tendon and

Deep Tissue Injury : Depth

Unstageable : Depth Unknown

Excessive axial pressure

Friction and shear forces

Thomas DR. Prevention and treatment of

Odd Ratio (95 CI)

Chronic cardiac failure

Incidence and Prevalence

Incidence of pressure ulcer excluding stage 1

Bergstrom N, Braden B. A prospective study of pressure ulcer risk

Intensive Care Unit

Apostolopoulo E, Tselebis A, Terzis K. Pressure ulcer incidence and risk

Intensive Care Unit

Bergstrom N, Demuth PJ. Braden BJ. A clinical trial of Braden Scale

Intensive Care Units in

Malaysian Registry of Intensive Care Report for 2013

Intensive Care Units in Malaysia

Pressure Ulcer per 1000 patient-days

Malaysian Registry of Intensive Care Report for 2013

Intensive Care Unit

Apostolopoulo E, Tselebis A, Terzis K. Pressure ulcer incidence and risk

Intensive Care Unit

Apostolopoulo E, Tselebis A, Terzis K. Pressure ulcer incidence and risk

Pressure Ulcer in Bariatric

Medical Device Related

Published frequency of device related pressure ulcer

33% up to 5 days, 44% over 5 days

17%. 55% experienced discomfort

8.1% pre-intervention, 0.3% postintervention

Various (tubes, catheters and fixation

6/26 hospital-acquired pressure ulcer

96.7% in control group, 53.3% in

Van Gilder et al 2009

Various, including stabilisation collars

Device related pressure ulcer n (%)

Non-device related pressure ulcer

Apold J, Rydrych D. Preventing device-related pressure ulcers. Using data to guide

Problems and Outcomes

Lyder CH, Yun Wang, Metersky M. Hospital-acquired pressure ulcer:

Within 30-days of discharge

Mortality, odd ratio (95% confidence

Readmission within 30 days after discharge

Without pressure ulcer