Pressure Ulcer Prevalence and Care in Indonesian Hospitals: A Multicenter, Cross-sectional Evaluation Using an Extended Donabedian Model

Yufitriana Amir*, Frans E. S. Tan, Ruud Halfens, Christa Lohrmann, Jos Schols

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


Although the number of studies on pressure ulcer (PU) occurrence continues to grow, research regarding the quality of PU care and its effect on outcomes is limited. Using an extended Donabedian model, a 1-day, multicenter, crosssectional evaluation of the quality of PU care was conducted in a convenience sample of Indonesian hospitals among patients >= 18 years of age in the medical, surgical, and intensive care units. Structure (ie, hospital attributes), process (recommended PU preventive measures), and outcome indicators (nosocomial PU prevalence excluding nonblanchable erythema), along with patient characteristics (age, gender, ethnicity, admission days, diseases [per ICD-10], recent surgery, PU categorization [ 4 categories according to National Pressure Ulcer Advisory Panel-European Pressure Ulcer Advisory Panel guidelines], PU history, care dependency, and Braden score) were examined. Patient data were collected by 2 nurses -1 from the patient's unit and 1 from another unit - using the Landelijke Prevalentiemeting ZorgproblemenInternational questionnaire, a paper-and-pencil survey translated into Indonesian. Heads of wards and nursing units completed the questionnaires at institutional and ward levels, respectively. The data were analyzed using descriptive and bivariate analyses, and multilevel logistic regression modeling was applied according to the generalized estimating equation approach. Among the 4 participating hospitals, 66 care units, 36 pairs of nurses, and 1132 adult patients (mean age 48.7 +/- 17.4 years, 40.9% women) were involved. Ninety-one (91) patients developed 1 or more PUs; the nosocomial PU prevalence (excluding nonblanchable erythema, category I) was 3.6%. The most frequently used PU preventive measures were patient education (329, 29.1%), repositioning (269, 23.8%), and skin moisturizing (266, 23.5%). The factors most associated with nosocomial PU rate excluding category I were the inclusion of PU care in patient care files (P =.001), repositioning (P =.002), skin moisturizing (P =.009), age (P =.013), admission days (P =.001), care dependency scores (P =.047), immobility (P =.001), sensory perception limitation (P =.001), moist skin (P =.032, OR 13.74), and friction and shear problem (P =.001). The prevalence of nosocomial PUs in this study was comparable to previous research in the Netherlands and rather low, even though limited structural indicators and suboptimal preventive measures were noted. Also, outdated preventive measures such as massage, donuts, and water-filled gloves were still used. The quality of PU care in these hospitals may be improved by addressing the absence of structural factors, including protocols/guidelines. Future research is needed for guideline implementation programs in Indonesian hospitals.

Original languageEnglish
Pages (from-to)8-23
Number of pages12
JournalOstomy Wound Management
Issue number2
Publication statusPublished - Feb 2017


  • Adult
  • Aged
  • Cross-Sectional Studies
  • Female
  • Hospitals/statistics & numerical data
  • Humans
  • Iatrogenic Disease/epidemiology
  • Indonesia/epidemiology
  • Male
  • Middle Aged
  • Outcome Assessment, Health Care/methods
  • Pressure Ulcer/epidemiology nursing
  • Prevalence
  • Quality of Health Care/standards statistics & numerical data
  • Surveys and Questionnaires

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