Research Article
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Determination of Pressure Injury Risk Factors in COVID-19 Patients Hospitalized in the Intensive Care Unit

Year 2025, Volume: 10 Issue: 3, 232 - 238, 15.09.2025
https://doi.org/10.26453/otjhs.1664017

Abstract

Objective: This study aimed to determine the risk factors for pressure injury in COVID-19 in intensive care unit.
Materials and Methods: A retrospective study was conducted using COVID-19 Intensive Care Unit archive data from April 2020 to July 2022. The study included patients aged 18 and over, with no pre-existing pressure injury, at high risk (Braden Score not between 6-12), and hospitalized in the ICU for at least 24 hours.
Results: A pressure injury developed in 25.2% of the patients. Among those who developed a pressure injury, 79.4% were classified as Stage I, characterized by redness, and 36.8% of the injuries occurred in the sacral region. A significant difference was observed in relation to age, length of stay, Braden score, albumin levels, hemoglobin levels, oxygen levels, and medications used between patients with pressure injuries and those without (p <0.05). The Braden scale was used for risk assessment. Factors independently associated with pressure injury were hemoglobin (1.398 [1.122-1.742]), hemoglobin (0.067 [0.007-0.643]), high-dose steroids (0.026 [0.002-0.317]) and oxygen (0.108 [0.012-0.964]).
Conclusions: It was found that stage I developed in patients, and the most pressure injuries were in the sacrum. The risk of pressure injury was associated with the Braden score, hemoglobin, high-dose steroids, and oxygen. Nurses should evaluate the risk of developing pressure injury in the intensive care unit. They should minimize the conditions that will threaten the safety of patients at risk.

Ethical Statement

Written approval to conduct the study was obtained from the Non-Interventional Clinical Research Ethics Committee of Cukurova University Faculty of Medicine (Date: 13.05.2022, decision no: 52). The requirement for individual patient consent was waived by the Clinical Research Ethics Committee due to the retrospective and anonymous nature of the study. The study was conducted in accordance with the tenets of the Declaration of Helsinki.

Thanks

Thank you to all patients and colleagues at Cukurova University Hospital COVID-19 ICU Departments in Turkey.

References

  • Erden S, Artiklar T, Tura İ, Türkmen A. Assessment of procedural pain in patients with COVID-19 in the intensive care unit. Pain Manag Nurs. 2022;23(5):596-601. doi:10.1016/j.pmn.2022.03.002
  • Alhazzani W, Møller MH, Arabi YM, et al. Surviving sepsis campaign: Guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Crit Care Med. 2020;48(6):440-469. doi:10.1097/CCM.0000000000004363
  • Phua J, Weng L, Ling L, et al; Asian Critical Care Clinical Trials Group. Intensive care management of coronavirus disease 2019 (COVID-19): Challenges and recommendations. Lancet Respir Med. 2020;8(5):506-517. doi:10.1016/S2213-2600(20)30161-2
  • Şengül T, Erden S, Karadağ A, Yılmaz D, Gökduman T. Overlooked pain assessment records in patients with pressure injuries during the COVID-19 pandemic: A retrospective data analysis. Adv Skin Wound Care. 2024;37(3):162-166.
  • McEvoy NL, Friel O, Clarke J, et al. Pressure ulcers in patients with COVID-19 acute respiratory distress syndrome undergoing prone positioning in the intensive care unit: A pre- and post-intervention study. Nurs Crit Care. 2023;28(6):1115-1123 doi:10.1111/nicc.12842.
  • Trevellini C. Challenges faced with morbidity obese patients during COVID-19. The 2020 Virtual Meeting of the European Pressure Ulcer Advisory Panel (EPUAP). https://www.epuap.org/wp-content/uploads/2020/09/epuap2020-virtual-abstract-book.qxp_sestava-1.pdf. Accessed October 2020.
  • Aksoy M, Büyükbayram Z. The prevalence, characteristics, and related factors of pressure injury in medical staff wearing personal protective equipment against COVID-19 in Turkey: A multicenter cross-sectional study. J Tissue Viability. 2022;31(2):207-212. doi:10.1016/j.jtv.2022.03.004
  • Kavutlu M, Engin E, Şenol D, Karacan A. COVID-19 hastalarında prone pozisyonunun tedavi seyri üzerine etkisi. Turk J Intensive Care. 2022;20:252.
  • Hadaya J, Benharash P. Prone positioning for acute respiratory distress syndrome (ARDS). JAMA. 2020;324(13):1361. doi:10.1001/jama.2020.14901
  • Lucchini A, Bambi S, Mattiussi E, et al. Prone Position in Acute Respiratory Distress Syndrome Patients: A Retrospective Analysis of Complications. Dimens Crit Care Nurs. 2020;39(1):39-46. doi:10.1097/DCC.0000000000000393
  • Moore Z, Patton D, Avsar P, et al. Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the COVID-19 emergency. J Wound Care. 2020;29(6):312-320. doi:10.12968/jowc.2020.29.6.312
  • Kıraner E, Kaya H. Covid-19 tanısı ile yoğun bakımda yatan hastalarda basınç yaralanmalarının ve risk faktörlerinin retrospektif analizi. Yoğun Bakım Hemşireliği Dergisi. 202;25(3):139-151.
  • Bergstrom N, Demuth PJ, Braden BJ. A clinical trial of the Braden Scale for predicting pressure sore risk. Nurs Clin North Am. 1989;22(2):417-428.
  • Oğuz S, Olgun N. Braden Ölçeği ile hastaların risklerinin belirlenmesi ve planlı hemşirelik bakımının bası yaralarının önlenmesindeki etkinliğinin saptanması. Hemsirelikte Arastirma Gelistirme Dergisi. 1997;2(1):131-135.
  • Bourkas AN, Zaman M, Sibbald RG. COVID-19 and Hospital-Acquired Pressure Injuries: A Systematic Review. Adv Skin Wound Care. 2023;36(8):421-434. doi:10.1097/ASW.0000000000000005
  • Beyene RT, Derryberry SL Jr, Barbul A. The effect of comorbidities on wound healing. Surg Clin North Am. 2020;100(4):695-705. doi:10.1016/j.suc.2020.05.002
  • Huang J, Cheng A, Kumar R, et al. Hypoalbuminemia predicts the outcome of COVID-19 independent of age and co-morbidity. J Med Virol. 2020;92(10):2152-2158. doi:10.1002/jmv.26003
  • Lampersberger LM, Bauer S, Osmancevic S. Prevalence of falls, incontinence, malnutrition, pain, pressure injury, and restraints in home care: A narrative review. Health Soc Care Community. 2022;30(6):e3656-e3669. doi:10.1111/hsc.14021
  • Hoffmeister B, Aguilar Valdez AD. Elevated admission C-reactive protein to albumin ratios are associated with disease severity and respiratory complications in adults with imported falciparum malaria. Trans R Soc Trop Med Hyg. 2022;116(5):492-500. doi:10.1093/trstmh/trab167
  • Tura İ, Arslan S, Türkmen A, Erden S. Assessment of the risk factors for intraoperative pressure injuries in patients. J Tissue Viability. 2023;32(3):349-354. doi:10.1016/j.jtv.2023.04.006
  • Anthony D, Rafter L, Reynolds T, Aljezawi M. An evaluation of serum albumin and the sub-scores of the Waterlow score in pressure ulcer risk assessment. J Tissue Viability. 2011;20(3):89-99. doi:10.1016/j.jtv.2011.04.001
  • Akan C, Sayın Y. Prevalence of pressure injuries and risk factors in long-term surgical procedures. Bezmialem Sci. 2021;9(1):75-83. DOI: 10.14235/bas.galenos.2020.3820
  • Hatanaka N, Yamamoto Y, Ichihara K, et al. A new predictive indicator for development of pressure ulcers in bedridden patients based on common laboratory tests results. J Clin Pathol. 2008;61(4):514-518. doi:10.1136/jcp.2007.050195
  • Jacq G, Valera S, Muller G, et al. Prevalence of pressure injuries among critically ill patients and factors associated with their occurrence in the intensive care unit: The Pressure study. Aust Crit Care. 2021;34(5):411-418. doi:10.1016/j.aucc.2020.12.001
  • Agarwal A, Basmaji J, Muttalib F, et al. High-flow nasal cannula for acute hypoxemic respiratory failure in patients with COVID-19: Systematic reviews of effectiveness and its risks of aerosolization, dispersion, and infection transmission. Can J Anaesth. 2020;67(9):1217-1248. doi:10.1007/s12630-020-01740-2
  • Ogawa K, Asano K, Ikeda J, Fujii T. Non-invasive oxygenation strategies for respiratory failure with COVID-19: A concise narrative review of literature in pre- and mid-COVID-19 era. Anaesth Crit Care Pain Med. 2021;40(4):100897. doi:10.1016/j.accpm.2021.100897
  • Gattinoni L, Coppola S, Cressoni M, et al. COVID-19 does not lead to a "typical" acute respiratory distress syndrome. Am J Respir Crit Care Med. 2020;201(10):1299-1300. doi:10.1164/rccm.202003-0817LE
  • González-Méndez MI, Lima-Serrano M, Martín-Castaño C, et al. Incidence and risk factors associated with the development of pressure ulcers in an intensive care unit. J Clin Nurs. 2018;27(5-6):1028-1037. doi:10.1111/jocn.14091
  • Challoner T, Vesel T, Dosanjh A, Kok K. The risk of pressure ulcers in a proned COVID population. Surgeon. 2022;20(4):e144-e148. doi:10.1016/j.surge.2021.07.001
  • Melo CMD, Bueno ADLG, Rossetto TL, et al. Pressure injury in intensive care unit: Prevalence and associated factors in patients with COVID-19. Rev Gaúcha Enferm. 2023;44:e20210345.

Yoğun Bakım Ünitesinde Yatan COVID-19 Hastalarının Basınç Yaralanması Risk Faktörlerinin Belirlenmesi

Year 2025, Volume: 10 Issue: 3, 232 - 238, 15.09.2025
https://doi.org/10.26453/otjhs.1664017

Abstract

Amaç: Bu çalışmanın amacı yoğun bakım ünitesinde COVID-19'a bağlı bası yarası risk faktörlerini belirlemektir.
Materyal ve Metot: Nisan 2020 ile Temmuz 2022 tarihleri ​​arasında COVID-19 yoğun bakım arşiv verileri kullanılarak retrospektif bir çalışma gerçekleştirildi. Çalışmaya 18 yaş ve üzeri, önceden mevcut basınç yarası olmayan, yüksek risk altında olan (Braden Skoru 6-12 puan arasında olmayan) ve en az 24 saat yoğun bakımda yatan hastalar dâhil edildi.
Bulgular: Bir basınç yarası, hastaların %25.2'sinde gelişti. Basınç yarası gelişenlerin %79.4'ü, kızarıklıkla karakterize edilen Evre I olarak sınıflandırıldı ve yaraların %36.8'i sakral bölgede meydana geldi. Basınç yarası olan ve olmayan hastalar arasında yaş, yatış süresi, Braden skoru, albümin seviyesi, hemoglobin düzeyi, oksijen seviyesi ve kullanılan ilaçlarla ilgili anlamlı bir fark gözlendi (p<0.05). Risk değerlendirmesi için Braden ölçeği kullanıldı. Basınç yaralanmasıyla bağımsız olarak ilişkili faktörler (1,398 [1,122-1,742]), hemoglobin (0,067 [0,007-0,643]), yüksek doz steroid (0,026 [0,002-0,317]) ve oksijen (0,108 [0,012-0,964]) bulundu.
Sonuç: Hastalarda evre I geliştiği ve en fazla basınç yaralanmasının sakrumda olduğu bulundu. Basınç yaralanması riski Braden skoru, hemoglobin, yüksek doz steroid ve oksijen ile ilişkiliydi. Hemşireler yoğun bakım ünitesinde basınç yaralanması gelişme riskini değerlendirmelidir. Risk altındaki hastaların güvenliğini tehdit edecek koşulları en aza indirmelidirler.

Ethical Statement

Çalışmanın yürütülmesi için Çukurova Üniversitesi Tıp Fakültesi Girişimsel Olmayan Klinik Araştırmalar Etik Kurulu'ndan yazılı onam alındı ​​(Tarih: 13.05.2022, karar no: 52). Çalışmanın retrospektif ve anonim niteliği nedeniyle Klinik Araştırmalar Etik Kurulu, bireysel hasta onamı gerekliliğinden feragat etti. Çalışma Helsinki Bildirgesi ilkelerine uygun olarak yürütüldü.

Thanks

Türkiye'deki Çukurova Üniversitesi Hastanesi COVID-19 Yoğun Bakım Ünitelerindeki tüm hastalara ve meslektaşlarıma teşekkür ederim.

References

  • Erden S, Artiklar T, Tura İ, Türkmen A. Assessment of procedural pain in patients with COVID-19 in the intensive care unit. Pain Manag Nurs. 2022;23(5):596-601. doi:10.1016/j.pmn.2022.03.002
  • Alhazzani W, Møller MH, Arabi YM, et al. Surviving sepsis campaign: Guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Crit Care Med. 2020;48(6):440-469. doi:10.1097/CCM.0000000000004363
  • Phua J, Weng L, Ling L, et al; Asian Critical Care Clinical Trials Group. Intensive care management of coronavirus disease 2019 (COVID-19): Challenges and recommendations. Lancet Respir Med. 2020;8(5):506-517. doi:10.1016/S2213-2600(20)30161-2
  • Şengül T, Erden S, Karadağ A, Yılmaz D, Gökduman T. Overlooked pain assessment records in patients with pressure injuries during the COVID-19 pandemic: A retrospective data analysis. Adv Skin Wound Care. 2024;37(3):162-166.
  • McEvoy NL, Friel O, Clarke J, et al. Pressure ulcers in patients with COVID-19 acute respiratory distress syndrome undergoing prone positioning in the intensive care unit: A pre- and post-intervention study. Nurs Crit Care. 2023;28(6):1115-1123 doi:10.1111/nicc.12842.
  • Trevellini C. Challenges faced with morbidity obese patients during COVID-19. The 2020 Virtual Meeting of the European Pressure Ulcer Advisory Panel (EPUAP). https://www.epuap.org/wp-content/uploads/2020/09/epuap2020-virtual-abstract-book.qxp_sestava-1.pdf. Accessed October 2020.
  • Aksoy M, Büyükbayram Z. The prevalence, characteristics, and related factors of pressure injury in medical staff wearing personal protective equipment against COVID-19 in Turkey: A multicenter cross-sectional study. J Tissue Viability. 2022;31(2):207-212. doi:10.1016/j.jtv.2022.03.004
  • Kavutlu M, Engin E, Şenol D, Karacan A. COVID-19 hastalarında prone pozisyonunun tedavi seyri üzerine etkisi. Turk J Intensive Care. 2022;20:252.
  • Hadaya J, Benharash P. Prone positioning for acute respiratory distress syndrome (ARDS). JAMA. 2020;324(13):1361. doi:10.1001/jama.2020.14901
  • Lucchini A, Bambi S, Mattiussi E, et al. Prone Position in Acute Respiratory Distress Syndrome Patients: A Retrospective Analysis of Complications. Dimens Crit Care Nurs. 2020;39(1):39-46. doi:10.1097/DCC.0000000000000393
  • Moore Z, Patton D, Avsar P, et al. Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the COVID-19 emergency. J Wound Care. 2020;29(6):312-320. doi:10.12968/jowc.2020.29.6.312
  • Kıraner E, Kaya H. Covid-19 tanısı ile yoğun bakımda yatan hastalarda basınç yaralanmalarının ve risk faktörlerinin retrospektif analizi. Yoğun Bakım Hemşireliği Dergisi. 202;25(3):139-151.
  • Bergstrom N, Demuth PJ, Braden BJ. A clinical trial of the Braden Scale for predicting pressure sore risk. Nurs Clin North Am. 1989;22(2):417-428.
  • Oğuz S, Olgun N. Braden Ölçeği ile hastaların risklerinin belirlenmesi ve planlı hemşirelik bakımının bası yaralarının önlenmesindeki etkinliğinin saptanması. Hemsirelikte Arastirma Gelistirme Dergisi. 1997;2(1):131-135.
  • Bourkas AN, Zaman M, Sibbald RG. COVID-19 and Hospital-Acquired Pressure Injuries: A Systematic Review. Adv Skin Wound Care. 2023;36(8):421-434. doi:10.1097/ASW.0000000000000005
  • Beyene RT, Derryberry SL Jr, Barbul A. The effect of comorbidities on wound healing. Surg Clin North Am. 2020;100(4):695-705. doi:10.1016/j.suc.2020.05.002
  • Huang J, Cheng A, Kumar R, et al. Hypoalbuminemia predicts the outcome of COVID-19 independent of age and co-morbidity. J Med Virol. 2020;92(10):2152-2158. doi:10.1002/jmv.26003
  • Lampersberger LM, Bauer S, Osmancevic S. Prevalence of falls, incontinence, malnutrition, pain, pressure injury, and restraints in home care: A narrative review. Health Soc Care Community. 2022;30(6):e3656-e3669. doi:10.1111/hsc.14021
  • Hoffmeister B, Aguilar Valdez AD. Elevated admission C-reactive protein to albumin ratios are associated with disease severity and respiratory complications in adults with imported falciparum malaria. Trans R Soc Trop Med Hyg. 2022;116(5):492-500. doi:10.1093/trstmh/trab167
  • Tura İ, Arslan S, Türkmen A, Erden S. Assessment of the risk factors for intraoperative pressure injuries in patients. J Tissue Viability. 2023;32(3):349-354. doi:10.1016/j.jtv.2023.04.006
  • Anthony D, Rafter L, Reynolds T, Aljezawi M. An evaluation of serum albumin and the sub-scores of the Waterlow score in pressure ulcer risk assessment. J Tissue Viability. 2011;20(3):89-99. doi:10.1016/j.jtv.2011.04.001
  • Akan C, Sayın Y. Prevalence of pressure injuries and risk factors in long-term surgical procedures. Bezmialem Sci. 2021;9(1):75-83. DOI: 10.14235/bas.galenos.2020.3820
  • Hatanaka N, Yamamoto Y, Ichihara K, et al. A new predictive indicator for development of pressure ulcers in bedridden patients based on common laboratory tests results. J Clin Pathol. 2008;61(4):514-518. doi:10.1136/jcp.2007.050195
  • Jacq G, Valera S, Muller G, et al. Prevalence of pressure injuries among critically ill patients and factors associated with their occurrence in the intensive care unit: The Pressure study. Aust Crit Care. 2021;34(5):411-418. doi:10.1016/j.aucc.2020.12.001
  • Agarwal A, Basmaji J, Muttalib F, et al. High-flow nasal cannula for acute hypoxemic respiratory failure in patients with COVID-19: Systematic reviews of effectiveness and its risks of aerosolization, dispersion, and infection transmission. Can J Anaesth. 2020;67(9):1217-1248. doi:10.1007/s12630-020-01740-2
  • Ogawa K, Asano K, Ikeda J, Fujii T. Non-invasive oxygenation strategies for respiratory failure with COVID-19: A concise narrative review of literature in pre- and mid-COVID-19 era. Anaesth Crit Care Pain Med. 2021;40(4):100897. doi:10.1016/j.accpm.2021.100897
  • Gattinoni L, Coppola S, Cressoni M, et al. COVID-19 does not lead to a "typical" acute respiratory distress syndrome. Am J Respir Crit Care Med. 2020;201(10):1299-1300. doi:10.1164/rccm.202003-0817LE
  • González-Méndez MI, Lima-Serrano M, Martín-Castaño C, et al. Incidence and risk factors associated with the development of pressure ulcers in an intensive care unit. J Clin Nurs. 2018;27(5-6):1028-1037. doi:10.1111/jocn.14091
  • Challoner T, Vesel T, Dosanjh A, Kok K. The risk of pressure ulcers in a proned COVID population. Surgeon. 2022;20(4):e144-e148. doi:10.1016/j.surge.2021.07.001
  • Melo CMD, Bueno ADLG, Rossetto TL, et al. Pressure injury in intensive care unit: Prevalence and associated factors in patients with COVID-19. Rev Gaúcha Enferm. 2023;44:e20210345.
There are 30 citations in total.

Details

Primary Language English
Subjects Surgical Diseases Nursing​​
Journal Section Research article
Authors

Ilknur Tura 0000-0002-1371-9458

Fatmagül Üstünel 0000-0001-6861-5464

Sevilay Erden 0000-0002-6519-864X

Publication Date September 15, 2025
Submission Date March 24, 2025
Acceptance Date August 19, 2025
Published in Issue Year 2025 Volume: 10 Issue: 3

Cite

AMA Tura I, Üstünel F, Erden S. Determination of Pressure Injury Risk Factors in COVID-19 Patients Hospitalized in the Intensive Care Unit. OTJHS. September 2025;10(3):232-238. doi:10.26453/otjhs.1664017

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