education
Prevalence of pressure ulcers
in long-term care: a global review
Objective: To identify and update the prevalence and incidence of
pressure ulcers (PUs) in several countries, in people with long-term
conditions resident in care homes or nursing homes.
Methods: We followed the PRISMA guideline for systematic reviews.
However, due to funding constraints we do not claim this review to be
systematic but it is a narrative review informed by PRISMA. Medline,
Embase and CINHAL were searched for observational studies
reporting incidence or prevalence data. Data reported relevant head-
to-toe examination of PUs in residence in care or nursing homes.
Internal and external validity of the included studies were assessed
using the checklist devised by Hoy et al.1
Results: Inclusion criteria was met by 17 studies and included in the
incidence  ●  long-term care  ●  pressure ulcer  ● prevalence
P
ressure ulcers (PU, also known as pressure
sores, bedsores, decubitus ulcers and pressure
injuries) are wounds due to local interference
with circulation and have been known about
since the time of the ancient Egyptians.2
Prolonged pressure on a part of the body due to the
weight of the body or a limb, or a shearing force can
cause PUs, especially in patients with poor nutrition. PUs
range from reddening of the skin (category I, non-
blanchable erythema), to broken skin (category II, partial
thickness skin loss), to deep ulcers with exposed bone,
tendon or muscle (category III, full-thickness skin loss or
category IV, full-thickness tissue loss).3
PUs are common in older people but also in people
with disabilities, are frail or who use wheelchairs.4 It has
been assumed that all PUs are avoidable and that poor
quality nursing care is the cause of such injuries, though
this is disputed.2 It was found, for example, that in
100 consecutive admissions for fractured neck of femur,
most, if not all, PUs could be attributed to immobility
before admission to hospital, during emergency
department stay or while in the operating theatre5
rather than due to poor quality nursing care on the
ward. The problem has been that a PU may occur at any
stage in the patient journey to the ward, but only
becomes evident after admission to the ward as it may
take days for a deep tissue injury to break the skin
exposing a severe PU.6
*Denis Anthony,1,2 Professor of Health and Social Care, Emeritus Professor;
Dalyal Alosoumi,3 Assistant Professor; Reza Safari,2 Research Fellow
*Corresponding author email: d.anthony@derby.ac.uk
1  University of Leeds, UK.  2  University of Derby, UK.  3  King Saud University,
Saudi Arabia.
702
study. Some studies gave a full breakdown by category, some only gave
overall figures, and others excluded category I PUs. However, within
those constraints certain patterns are clear. Prevalence rates varied from
3.4–32.4%. Large differences in prevalence in different countries were
not explained by methodological differences. While some countries,
such as Germany, the Netherlands and the US had robust data, other
countries, such as the UK, had none.
Conclusion: PUs are a common problem in long-term care.
However, there are substantial differences between countries and
many countries have no published data.
Declaration of interest: The authors have no conflicts of interest
to declare.
As well as being painful for patients, PUs are expensive
to treat. Recent estimates of the cost of wounds (of
which PUs are one type) suggests a figure of £4.5–5.1
billion annually in the UK.7 It has also been estimated
that a PU adds about seven days to a patient hospital
stay.8 In the US, the treatment cost of a hospital-acquired
category IV (most severe) PU in an adult has been
estimated to be over $129,000,9 and there may be other
costs, including litigation. Costs increase with PU severity
because the time-to-heal is longer and the incidence of
complication is higher in more severe cases.10
Appropriate preventative interventions have been
reported to reduce the prevalence/incidence of
avoidable PUs.11 However, some PUs appear to be
unavoidable in the sense that when a risk assessment
has been conducted and all risk reduction strategies put
into place, some still occur, especially at end-of-life
stage.11 We have shown that by using the Pressure Ulcer
Daily Risk Assessment (PUDRA), built around the SSKIN
(Surface, Skin inspection, Keep moving, Incontinence
and moisture, Nutrition and hydration) care bundle
developed in 2009,12 avoidable PUs can be reduced.11
Thus, raising awareness (which is all a risk tool can do)
leads to meaningful prevention.
Given the long history of PU research, especially as it
is a common condition in older, frail people, it might
be assumed that long-term care homes for older people
would have strategies for preventing PUs. However, in
Wales (for example) police working on Operation
© 2019 MA Healthcare ltd
Jasmine, an investigation into neglect of older people
living in care homes in south Wales, investigated 100
alleged victims of negligent care, and the Flynn report13
concluded in those care homes investigated under
Operation Jasmine that:
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 education
‘older people’s injuries, pain and life-threatening deep
pressure wounds were unobserved, unreported, reported
inaccurately and/or reported belatedly.’
Before a problem can be addressed it has to be
acknowledged. Thus, knowledge of the extent of
problem of PUs in long-term care is needed.
There is no recent review of prevalence and incidence
studies of PUs in long-term care, the latest was published
in 1995.14 However, Smith focused on older people
which left a potential gap in the literature. There are
recent reviews of PUs in acute care institutions, such as
secondary or tertiary hospitals15 and reviews of PU
incidence and prevalence in intensive care units16,17 and
in children.18 Moore et al.19 considered all care settings
(hospitals, hospices, children, community and care
homes) but only in Ireland, Denmark, Sweden, Norway
and Iceland. In this study, long-term care incidence was
6.63%, 95% confidence interval (CI): 3.1–8.4%, but there
were only five long-term sites in this review and the focus
was Scandinavia, Ireland and Iceland. Hahnel et al.20
reviewed skin conditions, including PUs, and had data
for care homes but only gave overall prevalence figures
and included studies where no head-to-toe physical
examination had been conducted, thus comparisons
between countries were difficult to evaluate. Similarly, in
an Austrian review21 which was not solely focussed on
PUs, data from studies which used surveys were discussed
and no study employing head-to-toe physical
examination was offered.
Measuring prevalence may have an impact on
prevalence, as shown in Germany22 where a total
prevalence was 14.5% (7.9% excluding category I) in
2001 in the first prevalence survey but fell the next year
to 10.2% (6.4% excluding category I). There was a
significant increase in re-positioning which may have
accounted for the change in prevalence.
This paper updates the figures from the previous
review in 199514 for PU prevalence and incidence in
people with long-term conditions resident in care
homes or nursing homes for a number of countries.
Method
We originally intended to conduct a full systematic
review but were unable to obtain the necessary
resources. This review is informed by systematic review
methodology but we only claim to have conducted a
robust narrative review.
We used guidance and instructions suggested in the
PRISMA statement (Preferred Reporting Items for
Systematic reviews and Meta-Analyses).23 The standard
for conducting systematic reviews is that of the
Cochrane Collaboration and normally the Cochrane
Handbook of Systematic Reviews24 would give the
methodological underpinning for a review. However,
most reviews are concerned with the synthesis of
evidence of effects, particularly trying to establish the
effectiveness of various treatments.25 Our interest is
prevalence and incidence so the methods used in this
704
study will also be informed by the chapter on systematic
reviews of prevalence and incidence studies in the
Joanna Briggs Institute Reviewer’s Manual.25 As pointed
out in this chapter, ‘no clear guidance currently exists on
synthesizing frequency data from incidence and prevalence
estimates’ and the Joanna Briggs manual addresses this
shortcoming. The area of prevalence and incidence
studies are increasingly seen as important to estimate
the burden of health-care both now and in the future.25
Unlike randomised controlled trials (RCTs) which aim
to establish if an intervention is superior to another
intervention (which may be a control), prevalence and
incidence studies are observational. They give evidence
of the size of a medical condition but also where the
condition occurs. In this case, we are concerned not just
with how common PUs are, but where and when they
occur. Geographical location and variation between
groups (for example, gender, ethnic origin, pre-existing
medical conditions, age groups) inform health-care
planning and allocation of resources.
We registered the protocol on Prospero (www.crd.
york.ac.uk/PROSPERO/) as advised by the PRISMA
statement23 (number CRD42017070047). Modifications
to a protocol may be needed as reviews are by their
nature iterative. Public registration allows a judgement
to be made whether any modifications are appropriate.
Before registration some amendments were made based
on expert review. However, no further changes were
made to the protocal.
We have designed our search strategy employing the
methodology advocated by the Peer Review of
Electronic Search Strategies (PRESS) for systematic
reviews.26 The process involves two researchers, a
requester and a reviewer, both of whom are assumed to
be skilled in searching bibliographic databases. The
requester gives the search strategy to the reviewer, using
a form designed for the process. The reviewer reviews
the search strategy using the PRESS 2015 Guideline
Evidence-Based Checklist.26 This covers six areas:
translation of the research question; Boolean and
proximity operators; subject headings; text word
searching; spelling/syntax/line numbers and limits/
filters. If major amendments are proposed by the
reviewer, then a second PRESS review is undertaken
after amendment.
Specifically, the search designed by two of the team,
both of whom have conducted earlier reviews, was
reviewed by an external expert in systematic reviews of
prevalence and incidence of wounds, including PUs.
Changes were made to the strategy including adding
the databases Embase and CINAHL and expanding
searches from keywords to full text. It was also decided
to expand the focus from older people care to all long-
term care of adults, because PUs occur in young people
© 2019 MA Healthcare ltd
in long term care, for example wheelchair users. Thus,
we conducted a population study of all adults in long-
term care whereas the earlier review14 focused only on
older people. The databases used were, Medline, Embase
and CINAHL employing the following Boolean string:
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(Preval* OR incid*) AND (pressure ulcer* OR decubitus
ulcer* OR bedsore*) AND (residential facility* OR homes
for the aged* OR nursing home* OR rehabilitation
center* OR long term care* OR health services for the
aged) and searching on all text. Additionally, reference
lists in papers were examined for relevant papers. These
search terms are an amalgam of those employed in
published reviews of long-term care and reviews of PU
incidence and prevalence.
We employed searching on all text with truncation
operators to ascertain if the numbers of papers returned
were too many to manage. If this was to be the case we
could have used proximity operators (for example) but
the numbers returned were manageable so we used the
simpler, more general search.
Selected papers were evaluated using the Joanna
Briggs Institute Critical Appraisal Instrument for Studies
Reporting Prevalence Data.25 We also used the Joanna
Briggs Institute Data Extraction Form for Prevalence
and Incidence Studies.27 This tool collects data on study
methods, subjects’ characteristics, outcomes, ethical
issues etc. Unlike the standard extraction tool for
systematic reviews which considers interventions and
effect sizes, this tool considers prevalence, incidence
and 95% confidence intervals (95%CI), which is more
appropriate for this review.
Studies were assessed for external and internal validity
using a checklist devised by Hoy et al.1 External validity
includes target population and sampling frame, random
selection and non-response bias. Internal validity includes
the process and mode of data collection, case definition,
reliability and validity of used study instruments, and
information about prevalence reporting and transparency.
‘High risk’ papers are those with insufficient information.
Papers are given scores for overall ‘low’, ‘moderate’ or
‘high’ risk of bias. There are currently no tools for
evaluating the methodological quality of secondary data
analysis, as noted by Hahnel et al.28 who employed the
Hoy tool for such studies, as we did in this study.
Inclusion criteria
Papers were limited to those with an abstract, published
from 2000 (as we are interested in contemporary data)
and where a full paper was available. Papers in English,
German, Dutch, French, Arabic or Farsi were considered.
However, if a paper appeared from its title to be relevant
and had no abstract we did attempt to locate the full
paper and included it if it was found to inform the
reviews. We only included studies where a head-to-toe
physical examination of the resident had been
conducted, employing standard PU classification, such
as the European Pressure Ulcer Advisory Panel (EPUAP)
minimum data set and categorisation system or the
equivalent US National Pressure Ulcer Advisory Panel
© 2019 MA Healthcare ltd
(NPUAP) methodology. Most studies employed two
assessors to examine residents but we included studies
that only used one as there is no evidence that this is
worse than two assessors. We allowed Minimum Data
Set (MDS, the current version is MDS 3.0) collected for
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Medicare or Medicaid. Data for MDS 3.0 are collected
from residents on admission, discharge and at regular
intervals during their stay (the frequency depends on
their clinical condition). The assessments are carried
out by qualified nurses who are required to physically
inspect the resident or minimally, to have received a
report from staff who have. Data on severity (category)
and anatomical location are recorded. The nurse is
personally responsible for accuracy of data and breaches
of data collection result in withholding of funds. Thus,
while ideally head-to-toe physical examination of
residents by independent assessors is the gold standard,
data collected by MDS 3.0 are robust. Similar data are
collected in Canada.
Exclusion criteria
Any study with a ‘moderate’ or ‘high’ risk of bias, which
is a score of <8 in the Hoy checklist, was not selected.
Any study that did not report prevalence or incidence
data, or where the sample size was not given, which
were the most common reasons for low scores on the
Hoy checklist, were not selected.
Abstracts of papers were read and where it appeared
they might meet the inclusion criteria they were
obtained in full text. The papers were selected by one
author and a second checked the selection was
appropriate. Similarly, one author read and assessed the
selected papers and removed any that did not meet the
inclusion criteria and a second checked this final
selection was appropriate.
Assessment of bias is recommended by PRISMA23
which also recommends evaluation of publication bias.
However, publication bias in prevalence or incidence
studies we believe is less likely to be a problem as in
these studies the outcome of interest is the size of the
problem and not whether a treatment does or does not
work. Investment in the efficacy of a treatment may
cause (often inadvertently) bias as treatments that fail
to show significant effects may be less likely to be
published  —  or even submitted for publication.
However, the size of a problem is likely to be of interest
regardless of the precise number obtained.
We decided not to combine prevalence rates of the
studies due to different methodological approaches. For
example, US and Canadian studies employed
administrative databases (albeit collected robustly by
trained nurses employed in the care homes) and other
studies used independent assessors.
Ethical approval
None was required as this is a review of previous studies.
Results
From an original search, 815 references were retrieved
after removal of duplicates, 50 (6.1%) of which appeared
to meet inclusion criteria following abstract screening.
Of these, 33 (66%) were found not to meet them in the
full text screening. Common reasons included data
taken from medical records, surveys or interviews with
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Table 1. Prevalence of pressure ulcers

Country Year n Pressure ulcer category sDTI Total Total Total Reference
% excluding excluding
category category
I II III IV Unstage-
I % I or II %
able

Austria 2012 696 3.5 Halfens et al. 2013 37

Canada 2004–7 16,531 9.1 Thein et al. 2010 38

Germany 2001 1347 11.8 6.1 Lahmann et al.

200539

Germany 2017 280 9.3 2.6 Hahnel et al. 201740

Germany 2003 3499 8.8 4.3 Tannen et al. 200631

Germany 2004 2531 6.4 Tannen et al. 200841

Germany 2005 3530 6.1 Mertens 200842

Germany 2007 2817 5.8 Shahin et al. 201043

Germany 2008 3070 1.8 2.2 1.1 0.2 5.3 3.6 1.3 Lahmann et al.
201033

Germany 2009 5531 0.0 4.3 2.8 0.9 Kottner et al. 201030

Germany 2017 2085 3.4 2.1 Lechner et al. 201744

Hong Kong 2006–7 346 16.5 5.2 0.9 0.0 0.6 23.1 6.6 1.4 Kwong et al. 200929

Jordan 2013 118 6.8 6.8 1.7 1.7 16.9 10.2 3.4 Aljezawi et al. 201445

Netherlands 1998 3267 17.5 8.5 3.7 2.7 32.4 14.9 11.2 Bours et al. 200246

Netherlands 2004 10,098 31.4 Tannen et al. 200841

Netherlands 2003 6273 29.2 12.5 Tannen et al. 200631

Netherlands 2012 12,653 2.2 Halfens et al. 201337

Sweden 2011 18,592 8.1 3.0 2.0 1.3 14.5 6.4 3.3 Gunningberg et al.47
2013

US 2006–7 46,044 14.6 Temkin-Greener et al.

201248

US 2012 2,936,146 Not 4.9 1.0 0.7 1.8 1.7 10.1 5.2 Ahn et al. 201634
given

sDTI—suspected deep tissue injury

no physical examination, no data on prevalence or
incidence or no sample size given. This left 17 (34%) for
inclusion in the final review.
Only one study reported an incidence29 of 25% in
Hong Kong care homes but this was a small sample
(n=346). Another study,30 gave a 95%CI of 3.8–4.9% for
all PUs, and 95%CI of 2.4–3.2% for PUs excluding
category I, so we have not reported them for other
studies. Some studies reported uncategorised PUs and/
or suspected deep tissue injury, but most did not.
Prevalence rates covering several
years were given in four studies,30–33 in which case the
shows. This cannot be explained purely by different
methods as in many cases (comparisons between
Germany and the Netherlands being the prime example)
the methods are identical and the surveys carried out
simultaneously by a combined team from both countries.
Internal and external validity of the studies
The Hoy scores for each included study are given in
Table 2.
Discussion
Where surveys are repeated in the same population, the
© 2019 MA Healthcare ltd

most recent one was chosen. Some studies gave a full
breakdown by category, some only gave overall figures
and some excluded category I PUs. However, within
those constraints certain patterns are clear, for example
there are large differences between countries, as Table 1
later surveys show lower prevalence. This is possibly
due to the effect of the survey in raising awareness of
the problems of PUs.
A high prevalence of severe ulcers (categories III or IV)
is reported in the Netherlands but the data are 20 years

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old. Given that overall prevalence figures have gone
down (from 32.4% in 1998 to 29.2% in 2003) it is likely
current figures will be improved.31 In the very large and
relatively recent survey34 in the US, 5.2% had a severe
ulcer (exckuding category I and II). Even the lowest
prevalence of severe ulcers (in Germany) was over 1%.33
There are large gaps in the literature in geographical
terms (there is nothing in terms of regional prevalence
from the UK for example — though the Welsh Wound
Innovation Centre have given prevalences of 7.7%
(n=117) and 15.6% (n=134) for two care homes.35 In
many studies, the categories of ulcer are not reported.
Incidence is given in one small scale study.29 There is a
need for further prevalence studies. Incidence studies are
also needed, though these are more expensive to conduct.
Comparing these results to the previous review by
Smith14 shows little progress in PU prevention. The
earlier review considered only older people in nursing
homes. While this review is wider in scope, in practice
we only found data from care homes and most of the
residents of these institutions are older people, so a direct
comparison is reasonable. In the review by Smith review,
prevalence was 7–23%. The later German studies in this
review are lower than any figure in Smith.14 but the
Netherlands figures are higher than any seen in Smith.
As the author of this study points out
‘residents at higher risk for developing ulcers are those
who have limited ability to reposition themselves, cannot
sense the need to reposition, have faecal incontinence, or
cannot feed themselves’ and later ‘because resident
characteristics can identify residents likely to develop
ulcers, preventive measures can be implemented early’.
As the German studies show, annual prevalence
surveys have led to reduced prevalence which was
attributed to preventive interventions. While not all PUs
are avoidable, simple preventive measures reduce
incidence—and hence prevalence. Despite the
improvements in some countries, there remains scope
for significant improvements in many others.
For example, There are about 290,000 residents in

Table 2. Hoy tool scores for each included study

External validity Q1–Q4 Included study

Internal validity Q5–Q10
Summary score Q11 37 38 39 40 31 41 42 43 33 30 44 29 45 46 47 48 34

1. Was the study target population a close ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü

representation of the national long-term care
population in relation to relevant variables
such as age/gender?

2. Was the sampling frame a true or close ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü

representation of the target population?

3. Was some form of random selection used ü ü ü x ü ü ü ü ü ü ü x x ü ü ü ü

to select the sample, OR, was a census
undertaken?

4. Was the likelihood of non-participation x ü x x x x x x x x x x x x x ü ü

bias minimal?

5. Were data collected directly from the ü x ü ü ü ü ü ü ü ü ü ü ü ü ü x x

subjects (as opposed to medical records or
administrative databases)?

6. Were acceptable case definition of ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü

pressure ulcer used?

7. Was a reliable and accepted diagnosis ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü

method for pressure ulcer utilised?

8. Was the same mode of data collection ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü

used for all subjects?

9. Was the length of the shortest ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü

prevalence/incidence period for the
pressure ulcers appropriate?

10. Were the numerator(s) and ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü

denominator(s) for the calculation of the
prevalence/incidence of pressure ulcers
© 2019 MA Healthcare ltd

appropriate?

11. Summary item on the overall risk of 9 9 9 8 9 9 9 9 9 9 9 8 8 9 9 9 9

study bias

Yes (low risk)—ü; No (high risk)—x

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 education
nursing/care homes in England and Wales,36 and we
estimate about 58,000 PUs may be expected in this
population, based on the stated values of 20% prevalence.
The potential for nationwide savings are therefore huge.
Limitations
We have limited papers to those written in English,
German, Dutch, French, Arabic or Farsi. We found
almost all relevant papers were written in English or
German so this is unlikely to affect the results.
Conclusions
PUs are a common problem in long-term care. However,
there are substantial differences between countries and
many countries have no published data. Prevalence
varied by a order of magnitude between countries with
rates of 32.4% in the Netherlands and 3.4% in the most
recent German study. However, the Netherlands study
is dated and prevalence may now be lower. Some
countries have no data, for example the UK. Germany
is unusual in having annual prevalence studies which
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●● Why are there different prevalence rates in different countries?
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independent skin examinations?
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708
show a continual reduction in PU prevalence.
Given the lack of data from many countries, including
the UK, there is a need to conduct similar prevalence
surveys in (for example) the UK as those completed
in Germany.
We have recently conducted a survey of care homes
in the UK asking for their estimates of prevalence in
their homes and information on preventive measures
in use. We anticipate this review and the survey may
result in greater awareness of the problem of PUs in
long-term care. However, data from audit (for example)
will be an underestimate and independent head-to-toe
examination of a large sample of residents in diverse
geographical areas is needed. We have applied for
funding to conduct such a prevalence survey. We
encourage colleagues in other countries with few or no
data to also conduct such surveys. Currently, we are
exploring possible work in Saudi Arabia. JWC
Acknowledgements
The authors extend their appreciation to the International Scientific
Partnership Program ISPP at King Saud University for funding this
research work through ISPP.
review of the neglect of older people living in care homes investigated as
Operation Jasmine. https://tinyurl.com/y5srkpcg (accessed 14 October 2019)
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malnutrition parameters and pressure ulcers in hospitals and nursing home.
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