All over the world, pressure ulcers remain a common health problem within different health care settings,

especially in the intensive care setting [1]. The intensive care unit population has a high risk of developing
pressure ulcers [2]. Additionally, Jiricka et al. [1] reported an incidence rate of more than 50% in intensive
care patients, while the prevalence was 49% in the study by Weststrate and Heul [3]. Not all pressure
ulcers can be avoided, but it is likely that the incidence can be reduced [4]. The European Pressure Ulcer
Advisory Panel (EPUAP) highlights that the goals for pressure ulcer prevention are to: (1) identify at risk
individuals needing prevention and specific factors placing them at risk; (2) maintain and improve tissue
tolerance to pressure to prevent injury; (3) protect against the adverse effects of pressure; (4) shear and
friction; and (5) improve the outcome for patients at risk of pressure damage through educational
programmes to health care providers, patients and family [5]. There are several organizations which have
developed guidelines for health professionals to prevent pressure ulcers, for
instancetheEPUAPwhichhasbeencreatedtoleadandsupportall European countries in the efforts to prevent
and treat pressure ulcers.Itsmissionstatementreads:‘toprovidethereliefofpersons suffering from or at risk
of pressure ulcers, in particular through research and the education of the public’ [6]. Another
organization is the Agency for Health Care Policy and
Research(AHCPR).AHCPRcarriesoutitsmissionbyconductingandsupportinggeneralhealthservicesresearch,
includingmedical effectivenessresearch,facilitatingdevelopmentofclinicalpractice guidelines and
disseminating research findings and guidelines to health care providers, policymakers and the public [7].
Clinical practice guidelines are systematically developed statements to assist practitioner and patient
decisions about appropriate health care for specific clinical circumstances [8]. The aim of pressure ulcer
guidelines is to make specific recommendations to identify at-risk patients, and to define early
interventions for prevention of pressureulcers.Theguidelinesmayalsobeusedtotreatgradeone pressure
ulcers [7]. The core of any guideline is the systematic review of the evidence to lead the group in an
informed debate about the value of treatment alternatives. The level of evidence consists of four levels:
evidence I (A) from systematic review or metaAnalysis or randomized controlled trials or at least one
randomized controlled trial, evidence II (B) from at least one controlled trial without randomization or at
least one other type of quasi-experimental study, evidence III (C) from non-experimental descriptive
studies, such as comparative studies, correlation studies and case control studies and evidence IV (D) from
expert committee reports or opinion and/or clinical experience of respected authorities [9]. Table 1 shows
that pressure ulcer preventive measures in the guidelines of EPUAP, 1998 (updated in 2001) and AHCPR,
1992 (last revising at November, 2007) are not quietly the same. There is a difference regarding the level
of evidence for some preventive measures, and also some preventive measures are mentioned in EPUAP
guidelines and not mentioned in AHCPR guidelines and vice versa. The preventive measures that have the
same level of evidence in both organizations are pressure ulcer risk assessment, skin inspection, mobility,
massage with moisture cream, cushions, nutrition with evidence level C and reposition with evidence level
B in both of them [7,10]. The preventive measures that have a different evidence level in both
organizations are pressure reducing devices like mattresses and beds.These devices have evidence level
C in EPUAPwhereas their evidence level is B inAHCPR guidelines.Additionally, education regarding
pressure ulcer prevention for patients and family or care givers is C in EPUAP guidelines, while its evidence
level is A in AHCPR guidelines. Massage over bony prominence is not supported in both organizations.The
evidence level for no support is C in EPUAP and B in AHCPR guidelines. Furthermore, elbow protector and
sheepskin are not mentioned in both organizations guidelines. However, heel protector is mentioned in
EPUAP with evidence level C and not mentioned in AHCPR guidelines [7,10]. Recent research has
demonstrated that some of the standard products used in health care settings may provide inadequate
protection against the development of pressure ulcers, and may even exacerbate the risk of developing
such an injury [11]. The aim of this study is to assess the allocation of preventive measures for patients at
risk for pressure ulcers and the evidence of applied preventive measures in intensive care settings
regarding EPUAP and AHCPR guidelines.

HospitalsalloverGermanywereinvitedtoparticipateinthestudy. For the purpose of this study, only adult

intensive care patients in surgical,medicalandinterdisciplinaryspecialitieswereincluded–
atotalof169patientsfrom18hospitals(60patientsfromsurgical, 50 patients from medical and 59 patients
from interdisciplinary wards).An exclusion criterion was patients younger than 18 years of age.

The study results revealed that 83% of all patients were at risk for pressure ulcers based on the total score
of the Braden scale with a cut-off point of 20. The total prevalence of pressure ulcers was 27.2%. The
highest prevalence of pressure ulcers was among surgical patients with 39% (18 patients), while the lowest
prevalence was among interdisciplinary patients with 18.8% (9 patients). There is no significant difference
among intensive care unit (ICU) specialities regarding age, body mass index, Braden score and the number
of patients at risk for pressure ulcers. Table 2 shows no significant differences between the group of
patients with and without pressure ulcer regarding gender, age and body mass index. However, a
significant difference (P =<0.01) was found between patients with and without pressure ulcer regarding
Braden score and patients at risk for pressure ulcer. The preventive measures that were applied in this
study were pressure reducing devices which include 58 (36.5%) special mattresses (alternating pressure
air, low air loss and foam) and four (2.5%) special beds (alternating pressure air and low air loss). Special
cushions (gel, water, foam, circle and air) were applied to 28 (17.6%) patients. Further nursing
interventions that were applied were repositioning 66 (41.5%), mobility 90 (56.6%), skin inspection 130
(81.8%), massage with moisture cream 128 (80.5%), avoidance of nutritional and fluid deficit 109 (68.6%),
patient education 64 (40.3%), family or carer education 33 (20.8%), avoidance of shear and friction by
keeping patient linen as straight as possible 51 (32%) and massage 14 (8.8%). Table 3 shows that pressure
reducing devices such as mattresses (alternating pressure air, low air loss and foam) are the most applied
devices for patients at risk for pressure ulcers. However, more than one nursing intervention is applied
for most of the patients at risk like skin inspection, massage with moisture cream, mobility, nutrition and
education. The other nursing interventions were applied for less than half of the patients at
risk.Additionally, this table shows also a significant difference (P = 0.01) between patients at risk and not
at risk for pressure ulcer regarding the allocation of pressure ulcer preventive measures (special
mattresses, skin inspection, reposition, massage with moisture cream and nutrition). The study results
revealed that all applied pressure ulcer preventive measures are in line with the EPUAP and AHCPR
guidelines except massage which was applied although it should be avoided according to both
organizations. Further measures of the preventive guidelines of EPUAP and AHCPR not applied in this
study are plans and scheduling of care, documentation and minimizing skin exposure to moisture.
Preventive measures that were applied in intensive care but that are not included in the guidelines of
EPUAP and AHCPR were elbow protectors applied to three patients and sheepskin applied to only one
patient