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Rev Clin Esp. 2016;xxx(xx):xxx---xxx

Revista Clnica
Espaola
www.elsevier.es/rce

ORIGINAL ARTICLE

Pressure ulcers in patients hospitalized in internal

medicine: Associated factors and mortality
J. Dez-Manglano a,b,c, , C. Fernndez-Jimnez a , M.P. Lambn-Aranda a ,
M.C. Landa-Santesteban a , S. Isasi de Isasmendi-Prez a , P. Moreno-Garca a ,
E. Bejarano-Tello a , J. Barranco-Usn a , E. Munilla-Lpez a , E. del Corral-Beamonte a,b,c ,
IMPIMI researchers study

a
Servicio de Medicina Interna, Hospital Royo Villanova, Zaragoza, Spain
b
Grupo de Investigacin en Comorbilidad y Pluripatologa de Aragn, Instituto Aragons de Ciencias de la Salud, Zaragoza, Spain
c
Departamento de Medicina, Dermatologa y Psiquiatra, Universidad de Zaragoza, Spain

Received 31 March 2016; accepted 19 July 2016

KEYWORDS Abstract
Pressure ulcers; Objective: To determine the prevalence of pressure ulcers in patients hospitalized in internal
Mortality; medicine and the clinical factors and risk of death associated with its presence.
Internal medicine Patients and methods: Prospective cohort study with patients hospitalized in internal
medicine. We recorded the age, sex, presence of pressure ulcers, degree of ulceration, Barthel
index, Norton scale, major diagnostic category, length of hospital stay and weight of the
diagnosis-related groups. We compared the clinical characteristics of the patients with or
without ulcers and analyzed the mortality after 3 years based on the presence of ulcers.
Results: The study included 699 patients, 100 of whom (14.3%) had pressure ulcers (27 with
grade I, 17 with grade II, 21 with grade III, 25 with grade IV and 10 with unknown grade).
The Barthel index (OR 0.985; 95% CI 0.972---0.998; p = .022) and Norton scale (OR 0.873; 95% CI
0.780---0.997; p = .018) are independently associated with ulcers. Twenty-three percent of the
patients with ulcers died during hospitalization, 68% died within a year, and 83% died within 3
years. The presence of pressure ulcers was independently associated with mortality (HR, 1.531;
95% CI 1.140---2.056; p = .005).

Please cite this article as: Dez-Manglano J, Fernndez-Jimnez C, Lambn-Aranda MP, Landa-Santesteban MC, Isasi de Isasmendi-Prez
S, Moreno-Garca P, et al. lceras por presin en pacientes ingresados en Medicina Interna: factores asociados y mortalidad. Rev Clin Esp.
2016. http://dx.doi.org/10.1016/j.rce.2016.07.003
Corresponding author.

E-mail address: jdiez@aragon.es (J. Dez-Manglano).

More information about IMPIMI researchers study is available in Appendix.

2254-8874/ 2016 Elsevier Espa

na, S.L.U. and Sociedad Espa
nola de Medicina Interna (SEMI). All rights reserved.

RCENG-1299; No. of Pages 7

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Conclusions: Pressure ulcers are common in patients hospitalized in internal medicine, and
their presence is associated with higher short, medium and long-term mortality.
2016 Elsevier Espa na, S.L.U. and Sociedad Espanola de Medicina Interna (SEMI). All rights
reserved.

PALABRAS CLAVE
lceras por presin;
Mortalidad;
Medicina Interna
lceras por presin en pacientes ingresados en Medicina Interna: factores asociados
y mortalidad
Resumen
Objetivo: Determinar la prevalencia de las lceras por presin en pacientes hospitalizados en
Medicina Interna y los factores clnicos y riesgo de muerte asociados a su presencia.
Pacientes y mtodos: Estudio prospectivo de cohortes con pacientes ingresados en Medicina
Interna. Se recogieron la edad, sexo, presencia de lceras por presin, grado de la lcera, ndice
de Barthel, escala de Norton, categora diagnstica mayor, duracin de la estancia hospitalaria
y peso del grupo relacionado de diagnstico. Se compararon las caractersticas clnicas de los
pacientes con o sin lceras y se analiz la mortalidad al cabo de 3 a
nos en funcin de la presencia
de lceras.
Resultados: Se incluyeron 699 pacientes, de los que 100 (14,3%) presentaron lceras por presin
(27 de grado I, 17 de grado II, 21 de grado III, 25 de grado IV y 10 de grado no conocido). El
ndice de Barthel (OR 0,985 IC95% 0,972-0,998; p = 0,022) y la escala de Norton (OR 0,873 IC95%
0,780---0,997; p = 0,018) se asociaron de forma independiente con las lceras. Durante el ingreso
fallecieron el 23% de los pacientes con lceras, al cabo de un a no el 68% y a los 3 a
nos el 83%.
La presencia de lceras por presin se asoci de forma independiente con la mortalidad (HR
1,531, IC95% 1,140---2,056, p = 0,005).
Conclusiones: Las lceras por presin son frecuentes en los pacientes hospitalizados en Medicina
Interna y su presencia se asocia con mayor mortalidad a corto, medio y largo plazo.
2016 Elsevier Espa na, S.L.U. y Sociedad Espa nola de Medicina Interna (SEMI). Todos los
derechos reservados.

Background The aim of this study was to determine the prevalence of

The aging of the population is reected in the patients
treated in the departments of internal medicine.1 In one
study, the mean age of patients hospitalized in depart-
ments of internal medicine was 79.9 years and has increased
between 8 and 19 years in the last 20 years.2 An increase has
also been observed in the patients disability.3
Elderly patients with disability frequently experience
pressure ulcers as the result of concomitant diseases, immo-
bility and, on occasion, decient nutrition.4---6 Over the last
15 years in Spain, several epidemiological surveys have been
conducted on pressure ulcers, and the prevalence in hospi-
talized patients remains approximately 8%.7---9 Sixty percent
of pressure ulcers observed in hospitalized patients develop
in the hospital, and a third of these are in advanced stages
(III or IV).9 In 2013, the prevalence of pressure ulcers was
7.41% in the Spanish medical departments.9
Pressure ulcers can become infected and complicated
easily, with bleeding, necrosis and pain appearing and
requiring prolonged care. Pressure ulcers are considered a
factor of poor prognosis for hospitalized patients and are
associated with increased mortality, both if the patient
presents them on admission and when they are acquired
during hospitalization.10---12
pressure ulcers in patients hospitalized in internal medicine
departments, the factors associated with their presence and
their inuence on short, medium and long-term mortality.
Patients and methods
Design
The Minimal Intervention in Patients Hospitalized in Inter-
nal Medicine (IMPIMI) study13,14 (Appendix) is an intervention
study with 2 parallel groups designed to reduce the dura-
tion of urinary tract catheterization and intravenous uid
treatment. The intervention was applied to 1 of 2 groups.
Twice a week during the meeting of the therapeutic team
of physicians and nurses, an assessment was conducted
on withdrawing the bladder catheters, nalizing the intra-
venous uid treatment, the onset of pressure ulcers and the
early detection of delirium.
Procedures
The study included all unselected patients hospitalized in
the department of internal medicine during the months of
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Pressure ulcers in patients hospitalized in internal medicine
October 2010, January 2011, May 2011 and October 2011.
On admission, a nurse interviewed each patient, their rela-
tives or companions to assess the patients functional state
and risk of pressure ulcers. After the discharge, the medical
history data and data from the administrative database on
hospital discharges were extracted. The following informa-
tion was collected from each patient: age, sex, residence
(home or assisted living), ability to perform basic activi-
ties of daily life, risk of presenting pressure ulcers, onset
of delirium during hospitalization, presence of pressure
ulcers, use during hospitalization of urinary catheter, intra-
venous uid therapy, placement of nasogastric catheter or
percutaneous gastrostomy, major diagnostic category at dis-
charge, duration of the hospitalization and mean weight
of the diagnosis-related group (DRG). The ability to per-
form the basic activities of daily life was assessed with the
Barthel index, which includes 10 tasks: feeding, bathing,
dressing, grooming, voiding, defecation, going to the toi-
let, transferring, walking and climbing up and down stairs.15
The range of scores is 0 to 100; the higher the score, the
greater the individuals capacity. Thus, 0 corresponds to
absolute dependence and 100 represents total autonomy
for basic activities of daily life. The Barthel index prior
to admission in the stable phase was recorded. The risk
of presenting pressure ulcers was assessed with the Norton
scale, which records 5 parameters: physical state, men-
tal state, activity, movement and incontinence.16 The scale
ranges from 5 to 20; the lower the score, the greater the
risk of pressure ulcers. The presence of pressure ulcers was
assessed at admission and every day during the hospital-
ization. The severity of the pressure ulcers was graduated
from I to IV,17 and the highest degree pressure ulcer was
recorded when there were more than one. We also recorded
whether the patient presented pressure ulcers at the time of
discharge.
A 3-year follow-up was subsequently conducted by
reviewing the medical history, by telephone or by consulting
the National Death Index.
The study was approved by the Clinical Research Ethics
Committee of Aragon (PI 12/0009), and the patients or
their relatives provided their consent for inclusion in the
study.
Statistical analysis
The qualitative and quantitative variables are presented as
absolute frequencies (percentages), and means (standard
deviation), respectively. The comparison of qualitative
variables was conducted with the chi-squared test. The
Kolmogorov---Smirnov test was employed to verify that the
quantitative variables did not follow a normal distribu-
tion. The quantitative variables were compared with the
Mann---Whitney U test.
To assess the association of each variable with the pres-
ence of pressure ulcers, we constructed a multivariate
logistic regression model that included those variables with
a p < .1 in the univariate model. To study the association of
the variables with mortality, we performed a Cox propor-
tional regression and Kaplan---Meier survival curves with the
log-rank test. In all cases, the level of statistical signicance
was p < .05. The statistical analysis was conducted with the
SPSS statistical package, version 22.0.
3
October 2010 January 2011 May 2011 October 2011
203 admissions 188 admissions 201 admissions 176 admissions
Admissions
n=768
Readmissions
n=54
Patients
n=714
No data on ulcers
n=15
Included patients
n=699
Patients with ulcers Patients without ulcers
n=100 n=599
Figure 1 Diagram of the patient selection process.
Results
We included 699 patients with a mean age of 74.6 (15.2)
years. Fig. 1 shows the patient selection diagram. Pressure
ulcers occurred in 100 (14.3%) patients, 27 of whom had
grade 1, 17 had grade 2, 21 had grade 3 and 25 had grade 4;
this datum was not available for 10 patients. In 69 cases, the
pressure ulcers started at home, 25 cases occurred during
hospitalization and 3 cases occurred in both circumstances.
At discharge, the pressure ulcers were in the process of
healing in 86 patients.
Factors associated with the presence of pressure
ulcers
Table 1 shows the characteristics of patients with and with-
out pressure ulcers. The patients with pressure ulcers were
older, mostly women, resided in assisted living and had
greater disability in basic activities of daily life. The patients
with pressure ulcers had a greater frequency of infec-
tious diseases and delirium and fewer hepatic, biliary and
pancreatic diseases. The placement of a vesical catheter,
nasogastric catheter, percutaneous gastrostomy and intra-
venous uid treatment were more common in the patients
with pressure ulcers.
The multivariate analysis showed that the Barthel index
and Norton scale were independently associated with the
presence of pressure ulcers (Table 2).
Mean hospital stay and expenditure
The patients with pressure ulcers had longer mean stays
(13.1 [8.4] days vs. 9 [7.4]; p < .001). The weight of the
DRG, which estimates the hospitalization expenses, was 2.10
(0.96) for the patients with pressure ulcers and 1.58 (0.96)
for those without pressure ulcers (p < .001).
Mortality
Eighty-two patients died during hospitalization. The mortal-
ity was greater for the patients with pressure ulcers (23%
vs. 9.8%; p < .001). At 3 years, 333 (47.6%) patients had
died, with a much greater mortality among the patients with
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Table 1 Characteristics of the included patients.

Variable Total (n = 699) With pressure Without pressure p
ulcers (n = 100) ulcers (n = 599)
Ageb 74.6 (15.2) 82.2 (8.7) 73.3 (15.7) <.001
Sex
Male 333 (47.6) 35 (35.0) 298 (49.7) .006
Female 366 (52.4) 65 (65.0) 301 (50.3)
Living in assisted residence 158 (22.6) 55 (55.0) 103 (17.2) <.001
MDC
Nervous system 66 (9.4) 6 (6.0) 60 (10.0) .204
Respiratory system 152 (21.7) 24 (24.0) 128 (21.4) .555
Circulatory system 96 (13.7) 16 (16.0) 80 (13.4) .477
Gastrointestinal system 126 (18.0) 12 (12.0) 114 (19.0) .090
Liver, bile duct and pancreas 50 (7.2) 1 (1.0) 49 (8.2) .010
Kidneys and urinary tract 57 (8.2) 13 (13.0) 44 (7.3) .056
Infectious diseases 33 (4.7) 9 (9.0) 24 (4.0) .029
Others 119 (17.0) 19 (19.0) 100 (16.7) .570
Barthel index 66.2 (38.4) 21.8 (30.4) 73.4 (34.5) <.001
Norton scalea,b 15.0 (4.6) 9.5 (3.7) 15.9 (4.2) <.001
Delirium 91 (13.0) 22 (22.0) 69 (1.6) .004
Urinary catheter 247 (35.3) 65 (65.0) 182 (30.4) <.001
Intravenous uids 490 (70.1) 89 (89.0) 401 (66.9) <.001
Nasogastric tube 14 (2.0) 6 (6.0) 8 (1.3) 0.002
Percutaneous gastrostomy 5 (0.7) 3 (3.0) 2 (0.3) .003
Abbreviation: MDC, major diagnostic category at discharge.
a Data from 624 patients.

The data are presented with n (%) or

b Mean (standard deviation).

pressure ulcers (83% vs. 41.7%; p < .001) (Fig. 2). Of these,
23% died during the hospitalization, 56% at 6 months and 68%
during the rst year. There were no differences in mortal-
ity during the hospitalization or at the end of the follow-up
among the patients with differing degrees of pressure ulcer
severity.
The multivariate analysis showed that age, ner-
vous system diseases, delirium, the Barthel index and
pressure ulcers were independently associated with
mortality (Table 3). The pressure ulcers present at
admission (HR, 3.069; 95% CI 2.326---4.048; p < .001)
and those that developed during hospitalization were

Table 2 Factors associated with the presence of pressure ulcers.

Variable Univariate analysis Multivariate analysis

OR (95% CI) p OR (95% CI) p

Age 1.065 (1.040---1.091) <.001 1.020 (0.990---1.052) .192
Female sex 1.839 (1.183---2.858) .007 1.179 (0.668---2.081) .570
Living in residence 5.874 (3.755---9.189) <.001 1.235 (0.672---2.267) .497
MDC gastrointestinal system 0.580 (0.307---1.097) .094 0.852 (0.350---2.075) .725
MDC liver/bile duct/pancreas 0.113 (0.015---0.831) .032 0.298 (0.035---2.507) .265
MDC kidneys/urinary tract 1.885 (0.975---3.642) .059 1.005 (0.418---2.416) .990
MDC infectious disease 2.370 (1.068---5.260) .034 1.676 (0.614---4.573) .313
Delirium 2.158 (1.263---3.687) <.001 0.822 (0.406---1.664) .586
Barthel index 0.963 (0.956---0.970) <.001 0.985 (0.972---0.998) .022
Norton scale 0.731 (0.687---0.779) <.001 0.873 (0.780---0.977) .018
Urinary catheter 4.255 (2.723---6.649) <.001 1.686 (0.915---3.106) .094
Intravenous uids 3.995 (2.087---7.646) <.001 1.603 (0.699---3.677) .265
Nasogastric tube 4.715 (1.600---13.894) .005 1.198 (0.320---4.482) .789
Percutaneous gastrostomy 9.232 (1.523---55.963) .016 4.774 (0.466---48.877) .188
Abbreviations: CI, condence interval; MDC, major diagnostic category; OR: odds ratio.
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Pressure ulcers in patients hospitalized in internal medicine 5

department of internal medicine, whose patients are usu-

1.0
ally older than those of other medical departments, with the
Log-rank P<.001 exception of geriatric medicine units. In fact, in the study by
Toms-Life et al.,18 conducted in the medical departments
0.8 of the Balearic Islands, the prevalence of pressure ulcers
in the age group older than 70 years was 11.4%, which is
Without PU closer to the rate observed in our study. It is known that
0.6 mild pressure ulcers occasionally go unnoticed and are not
recorded in the medical records.19 A meta-analysis found
Survival

that the exclusive clinical judgment of the nursing staff was

insufcient for detecting pressure ulcers and that the judg-
0.4
ment needed to be combined with the use of a validated
scale.20 Our study falls within a prospective program tar-
With PU geted at the early detection of pressure ulcers using the
0.2 Norton scale. We therefore expect that the physicians and
nurses are more sensitized to detecting and recording pres-
sure ulcers, with a more comprehensive patient assessment,
0.0 as recommended by the clinical practice guidelines.21,22 This
could justify the higher prevalence we observed.
0.00 6.00 12.00 18.00 24.00 30.00 36.00 There are various scales for assessing the risk of pre-
Months senting a pressure ulcer. We employed the Norton scale,
which has one of highest predictive capacities.20 One of the
Figure 2 Cumulative survival curves (Kaplan---Meier) accord- items on this scale is the patients mobility. Length of stay,
ing to the presence or absence of pressure ulcers. Abbreviation: presence of coma, carrying a urinary catheter or nasogas-
PU, pressure ulcers. tric catheter and undergoing intravenous uid treatment are
factors that have been associated with the onset of pressure
Table 3 Factors associated with mortality in the multivari- ulcers.1,6,23 All of these factors are related to immobility.
ate analysis (Cox regression). In the univariate analysis, carrying a urinary or nasogastric
catheter or percutaneous gastrostomy and the intravenous
Variable HR (95% CI) p
administration of uids were associated with the presence
Age 1.028 (1.017---1.040) <.001 of pressure ulcers. It is difcult to establish the causality
MDC nervous system 0.551 (0.340---0.892) .015 because this type of catheter is also placed in patients with
Delirium 1.609 (1.210---2.139) .001 pressure ulcers to administer drugs, nutrition and to avoid
Barthel index 0.990 (0.986---0.994) <.001 contaminating the pressure ulcers with urine. However, we
Pressure ulcers 1.531 (1.140---2.056) .005 believe that all strategies directed toward decreasing the
Abbreviations: CI, condence interval; HR, hazard ratio; MDC, duration of catheterization in patients who do not have pres-
major diagnostic category. sure ulcers can help prevent their onset. Delirium was more
common in the patients with pressure ulcers and can some-
times result in restricted movement with the use of hospital
associated with mortality (HR, 2.340; 95% CI 1.531---3.576;
beds with guardrails and even restraints. However, only the
p < .001).
Norton scale and disability measured by the Barthel index
were factors independently associated with pressure ulcers.
Discussion Another of this studys ndings was that the hospital stay
of patients with pressure ulcers was extended by 4 days. In a
The main ndings of this study were that approximately 1 of study with more than 5 million discharges from departments
every 7 patients hospitalized in internal medicine has pres- of internal medicine in Spain, pressure ulcers were 10 times
sure ulcers at admission or during hospitalization and that more common in patients with a hospital stay longer than 30
patients with pressure ulcers have a high mortality in the days.1 A study conducted in 2007 estimated that the cost of
short, mean and long-term. treating pressure ulcers in Spain was 461 million euros and
Despite the improvements in treating pressure ulcers that 45% of this expenditure was due to prolonged hospital
and the use of various strategies to prevent their onset stays.24 In our study, the weight of the DRG was 0.52 higher
in hospitalized patients, the prevalence of pressure ulcers in the cases with pressure ulcers, which corresponded to an
remains constant in the 3 national surveys conducted in additional expenditure of D 2435.94 according to data from
Spain.7---9 The same phenomenon has been observed in stud- the Ministry of Health.25
ies conducted in acute care tertiary hospitals.6 Age and the Almost half of the patients had died after the 3 years
admitting department have been associated with pressure of follow-up. This is a high mortality rate, which could be
ulcers, which are more common in medical departments explained by the patients mean age and their complexity.
than in surgical ones.6 The prevalence has varied between This complexity was manifested in a high degree of disability
6.3% and 8.6% in the collection of medical departments of and the high weight of the DRG. Pressure ulcers have been
acute care hospitals.15,16 We observed a prevalence of 14.3%, associated with increased mortality. In our series, one of
which was higher than previously reported and possibly due every 4 patients with pressure ulcers died during hospitaliza-
to the fact that the study was performed exclusively in a tion. Two of every 3 had died by the end of a year and more
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6 J. Dez-Manglano et al.
than 8 of every 10 had died by the end of 3 years. We can
therefore consider pressure ulcers as a factor of poor prog-
nosis in the short, medium and long term. Previous studies
have already conrmed this association with mortality.10,26
Recently, pressure ulcers have been included in an index to
establish the prognosis at 6 months in patients with chronic
diseases in advanced phases.27 Given these ndings, we con-
sider that when a patient presents pressure ulcers we must
start planning the start of palliative care, especially if the
patient is elderly, dependent or has delirium or a nervous
system disorder.
We know of no other study published in Spain on the
prevalence of pressure ulcers in a department of inter-
nal medicine. This is one of the strengths of our study,
along with the extended patient follow-up. However, our
study also has a number of limitations. Firstly, the study
was conducted in a single hospital; multicenter studies are
known to provide evidence with greater rigor. This fact could
decrease the extrapolation of the results to other settings.
Secondly, the study was conducted within the framework
of a specic project for monitoring the onset of pressure
ulcers, and its results on prevalence could be different from
those outside this research context. However, this is also
a strength because the results reect data from the real
world, which in other circumstances could go unnoticed. It
is a fact that physicians occasionally ignore the presence of
pressure ulcers in their patients, especially when the pres-
sure ulcers are low-grade, delegating their surveillance and
care to the nursing staff despite the prognostic importance
of pressure ulcers.
In summary, pressure ulcers are very common in patients
hospitalized in internal medicine and are associated with a
poor prognosis. Their assessment is therefore essential for
establishing the short, medium and long-term therapeutic
objectives.
Conict of interests
The authors declare that they have no conicts of interest.
Appendix. List of researchers of the IMPIMI
study*
Jess Dez-Manglano, Patricia Al-Cheikh-Felices, Susana
Alcubierre-Iriarte, Mara Jess Arnal-Longares, Julia
Barranco-Usn, Esperanza Bejarano Tello, Mara Pilar
Carreno-Borrego, Esther del Corral-Beamonte, Fabi-
ola Dez-Mass, Cristina Fernndez-Jimnez, Juan
Carlos Ferrando-Vela, Vanesa Garcs-Horna, Francisco
Javier Gomes-Martn, Mara Soledad Isasi de Isasmendi-
Prez, Mara Pilar Lambn-Aranda, Mara Cristina
Landa-Santesteban, Rosa Mara Martnez-lvarez, Pablo
Martnez-Rods, Mara Pilar Moreno-Garca, Eulalia Munilla
Lpez, Claudia Palazn-Fraile, Mara Jess Pardo-Dez,
Pilar Pueyo-Tejedor, Santiago Alfonso Rubio-Flix, Rogelio
Serrano-Lzaro, Mara Sevil-Puras, Sofa Terrn-Portols,
Carla Toyas-Miazza.
Department of Internal Medicine, Hospital Royo Villanova,
Zaragoza, Spain.
References
1. Barba R, Marco J, Canora J, Plaza S, Juncos SN, Hinojosa J,
et al. Prolonged length of stay in hospitalized internal medicine
patients. Eur J Intern Med. 2015;10:772---5.
2. Casademont J, Francia E, Torres O. La edad de los pacientes
atendidos en los servicios de medicina interna en Espa na: una
perspectiva de 20 a nos. Med Clin (Barc). 2012;138:289---92.
3. Tan C, Ng TS, Koh GCH, de Silva DA, Earnest A, Barbier S. Disabil-
ity impacts length of stay in General Internal Medicine patients.
J Gen Intern Med. 2014;29:885---90.
4. Gardiner JC, Reed PL, Bonner JD, Haggerty DK, Hale DG. Inci-
dence of hospital-acquired pressure ulcers --- a population-based
study. Int Wound J. 2014, doi:10.1111/iwj.12386.
5. Lindgren M, Unosson M, Fredrikson M, Ek AC. Immobility --- a
major risk factor for development of pressure ulcers among
adult hospitalized patients: a prospective study. Scand J Caring
Sci. 2004;18:57---64.
6. Alonso-Lorente C, Barrasa-Villar JI, Aibar-Remn C. Evolucin
de la prevalencia de lceras por presin en un hospital de agudos
de tercer nivel (2006---2013). Rev Calid Asist. 2016;30:135---41.
7. Soldevilla Agreda JJ, Torra i Bou JE, Verd Soriano J, Martnez
Cuervo F, Lpez Casanova P, Rueda Lpez J, et al. 2. Estu-
dio nacional de prevalencia de lceras por presin en Espa na,
2005. Epidemiologa y variables denitorias de las lesiones y
pacientes. Gerokomos. 2006;17:154---72.
8. Soldevilla Agreda JJ, Torra i Bou JE, Verd Soriano J, Lpez
Casanova P. 3. Estudio nacional de prevalencia de lceras por
presin en Espa na, 2009. Epidemiologa y variables denitorias
de las lesiones y pacientes. Gerokomos. 2011;22:77---90.
9. Pancorbo-Hidalgo PL, Garca-Fernndez FP, Torra i Bou JE, Verd
Soriano J, Soldevilla Agreda JJ. Epidemiologa de las lceras por
presin en Espa na en 2013: 4 estudio nacional de prevalencia.
Gerokomos. 2014;25:162---70.
10. Barba R, Martnez JM, Zapatero A, Plaza S, Losa JE, Canora
J, et al. Mortality and complications in very old patients (90+)
admitted to departments of internal medicine in Spain. Eur J
Intern Med. 2011;22:49---52.
11. Lyder CH, Wang Y, Metersky M, Curry M, Kliman R, Verzier
NR, et al. Hospital-acquired pressure ulcers: results from the
national Medicare Patient Safety Monitoring System study. J Am
Geriatr Soc. 2012;60:1603---8.
12. Jaul E, Calderon-Margalit R. Systemic factors and mortal-
ity in elderly patients with pressure ulcers. Int Wound J.
2015;12:254---9.
13. Dez-Manglano J, Palazn-Fraile C, Sevil-Puras M, Arnal-
Longares MJ, Terrn-Portols S, Alcubierre-Iriarte S. Effects of
a minimal reminder intervention to reduce the length of uri-
nary catheterization and intravenous uids therapy for internal
medicine inpatients: a parallel controlled clinical trial. J Nurs
Educ Pract. 2016;6:74---80.
14. Dez-Manglano J, Palazn-Fraile C, Diez-Mass F, Martnez-
lvarez R, del Corral-Beamonte E, Carre no-Borrego P, et al.
Factors associated with onset of delirium among Internal
Medicine inpatients in Spain. Nurs Res. 2013;62:445---9.
15. Mahoney FI, Barthel DW. Functional evaluation: the Barthel
index. Md State Med J. 1965;14:61---5.
16. Norton D, McLaren R, Exton-Smith AN. An investigation of
geriatric problems in hospital. 3rd ed. London: Churchill-
Livingstone; 1979.
17. Beeckman D, Schoonhoven L, Fletcher J, Furtado K, Gun-
ningberg L, Heyman H, et al. EPUAP classication system
for pressure ulcers: European reliability study. J Adv Nurs.
2007;60:682---91.
18. Toms-Vidal AM, Hernndez-Yeste MS, Garca-Raya MD, Marn-
Fernndez R, Cardona-Rosell J, por el Grupo de trabajo.
Prevalencia de lceras por presin en la Comunidad Autnoma
de las Islas Baleares. Enferm Clin. 2011;21:202---9.
+Model
ARTICLE IN PRESS
Pressure ulcers in patients hospitalized in internal medicine
19. Sebastin-Viana T, Gonzlez-Ruiz JM, N nez-Crespo F, Lema-
Lorenzo I, Gadea-Romero G, Losa-Iglesias ME. La validez de
un registro clnico de lceras por presin. An Sist Sanit Navar.
2014;37:17---24.
20. Garca-Fernndez FP, Pancorbo-Hidalgo PL, Soldevilla-Agreda
JJ. Predictive capacity of risk assessment scales and clinical
judgment for pressure ulcers. A metanalysis. J Wound Ostomy
Continence Nurs. 2014;41:24---34.
21. Generalitat Valenciana, Consellera de Sanitat. Gua de prctica
clnica para el cuidado de personas con lceras por presin o
riesgo de padecerlas. Valencia, 2012. Available at: http://www.
guiasalud.es/GPC/GPC 520 Ulceras por presion compl.pdf
[accessed 07.06.16].
22. National Pressure Ulcer Advisory Panel, European Pressure
Ulcer Advisory Panel and Pan Pacic Pressure Injury Alliance.
In: Haesler E, editor. Prevention and treatment of pressure
ulcers: quick reference guide. Osborne Park, Australia:
Cambridge Media; 2014. Available at: http://www.npuap.org/
wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-
NPUAP-EPUAP-PPPIA-Jan2016.pdf [accessed 07.06.16].
7
23. Perneger TV, Hliot C, Ra AC, Borst F, Gaspoz JM. Hospital-
acquired pressure ulcers. Risk factors and use of preventive
devices. Arch Intern Med. 1998;158:1940---5.
24. Soldevilla Agreda JJ, Torra I, Bou JE, Posnett J, Verdu Soriano
J, San Miguel L, et al. The burden of pressure ulcers in Spain.
Wounds. 2007;19:201---6.
25. Ministerio de Sanidad, Servicios Sociales e Igualdad. Norma
estatal. Resultados segn la versin 27 de los AP-GRD. Avail-
able at: http://www.msssi.gob.es/estadEstudios/estadisticas/
cmbd.htm [accessed 07.06.16].
26. Khor HM, Tan J, Saedon NI, Kamaruzzaman SB, Chin AV,
Poi PJH, et al. Determinants of mortality among older
adult with pressure ulcers. Arch Gerontol Geriatr. 2014;59:
536---41.
27. Bernabeu-Wittel M, Murcia-Zaragoza J, Hernndez-Quiles C,
Escolano-Fernndez B, Guadalupe Jarava-Rol, Oliver M, et al.,
on behalf of the PALIAR Researchers. Development of a six-
month prognostic index in patients with advanced chronic
medical conditions: the PALIAR score. J Pain Symptom Manage.
2014;47:551---65.