Study design and sample selection. The study used a retrospective, cross-sectional design. The study sample consisted of patients with a PU hospitalized in a major university hospital in various internal medicine departments (geriatrics, oncology, diabetes, general internal medicine, pneumonia, nephrology, hematology, hepatology, gastroenterology, rheumatology, endocrinology, bone marrow, and special internal medicine wards) between January 1, 2010, and December 31, 2014.
All admitted patients were evaluated for PUs by trained nurses using the Braden Scale during initial hospital admission and subsequent hospitalization. Inclusion criteria specified study participants must be at least 18 years old, hospitalized for at least 24 hours, and have a PU indicator monitoring form included in their records. All patients with current and developing PUs were followed with this form. All patients with PUs were included in the study.
Measurements/Instruments. Data were extracted from patient files and electronic patient records retroactively using the Patient Information Form, scores/assessments from the Braden Scale instrument, and the Pressure Ulcer Indicator Form.
Patient Information Form. This form contains patient sociodemographic characteristics (age and gender) and clinical information (medical diagnoses and hospital department).
The Braden Scale. The Braden Scale was developed by Barbara Braden and Nancy Bergstrom in 1987.16 It has 6 subscales: moisture, mobility, activity, nutrition, sensory perception, and friction/shear. Scores can vary between 6 and 23. The lower the score, the higher the predicted risk. Ayello and Braden17 identified incremental changes in risk based on the percentage of patients who can be expected to develop PUs: a score of 15 to 16 indicates the patient is at risk; 13 to 14, at moderate risk; 10 to 12, at high risk; and 9 or below, at very high risk. In patients age 75 and above, a score of 15–18 represents low risk.17,18 Levels of risk also may be used to determine the aggressiveness of preventive efforts and to assess their success. This study also grouped PU risk assessment according to these criteria. Braden Scale validity and reliability for use in Turkey was determined by Pınar and Oğuz18 in 1998 (Cronbach alpha value of 0.88).
Pressure Ulcer Indicator Form. Used to monitor patient medical diagnosis, this instrument contains the Braden score, the department where the PU occurred, PU stage according to NPUAP classification,1 PU location, and the treatments and results of those treatments. All patients are evaluated for PU risk on admittance to the hospital using the Braden Scale. If the patient is determined to be at risk, the score is entered into the risk section on the Pressure Ulcer Indicator Form. If the patient already had a PU, patient information was entered into the follow-up section. If the ulcer developed after admission, it was recorded again. The Pressure Ulcer Indicator Form includes only the monitoring data of patients developing PU in 2010; as of 2012, the Braden Scale was added to the indicator form,19 noting patients admitted to the hospital who have extant PUs and a Braden score of <17.
The Pressure Ulcer Indicator Form also contains a protocol for necessary nursing interventions (depending on the risk assessment scores and ulcer features) to be used to prevent PUs. Examples of measures in this section include conducting risk assessment and skin evaluation, ensuring proper nutrition, repositioning the patient, and providing support surfaces. Patients with PUs transferred to the acute care unit are monitored with this form until they are either discharged from the hospital or die.
A monthly PU monitoring form was maintained for all patients who already had PUs. The information on this form was recorded as an indicator of nursing care. This form determined nursing care interventions and ulcer characteristics.
According to a review by Dealey20 of current evidence related to skin care and PU prevention, the most important principle in skin care is personal hygiene. The skin should be kept clean and dry and washed with a hypoallergenic soap. A moisturizing lotion should be used on dry, cracked, or flaking skin to prevent skin moisture loss. In addition, hot water should be avoided and sheets should be kept dry and wrinkle-free.
Clinical status change/patient outcome. This refers to provision of health care measures determined on the basis of the clinical status of the patient. For example, once treatment is no longer necessary, a patient is discharged. If his/her condition worsens, he/she is transferred to the ICU.
Healing process. This refers to the process through which the ulcer improves or heals. If the ulcer was no longer visible, it was considered healed. The term stable was used if the ulcer stage remained unchanged. If the ulcer worsened, it was considered to be deteriorating.
Data collection/procedures. Digital data bank records were used to identify eligible patients admitted between January 1, 2010, and December 31, 2014. Information was obtained manually from the hospital archives by one of the authors between January and December 2015 and recorded on the electronic data collection form in the patient records.
Data analysis. Raw data collected from patient records were entered into the statistical analysis packet program and grouped (eg, by Braden scores, disease diagnoses, number of PUs, nursing interventions). Data were analyzed using SPSS for Windows, version 13.0 (SPSS Inc, Chicago, IL). The results are presented as number, percent distributions, and averages. Main pathology, clinical process, and healing process were compared using Pearson’s chi-square. One-way analysis of variance was used to compare Braden score means according to diagnoses; Student’s t test was used to compare age groups. The level of significance was set at P <.05 for all analyses.
Incidence and prevalence calculations. Prevalence is a frequently used epidemiological measure of how commonly a condition or disease occurs in a population. Incidence measures the rate of occurrence of new cases of a condition or disease.19 Prevalence and incidence calculations included all patients with PUs in the hospital. All hospitalized patients were evaluated using the Braden Scale. Prevalence rates were calculated for the different years.
Prevalence was calculated using the following formula:
The incidence is calculated using the following formula:
Ethical considerations. All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The study protocol was approved by the Istanbul University Cerrahpasa Medical Faculty Ethics Committee (Voucher no:/references: 83045809/8255). Informed consent was not obtained because the study was retrospective. All data analyzed were collected as part of routine diagnosis and treatment.