Risk Factors for Recurrent Pressure Ulcers: Insights from a Retrospective Study in Vietnam

1. INTRODUCTION

Pressure ulcers (PUs), also known as pressure injuries or bedsores, are localized injuries to the skin and underlying tissue caused by prolonged pressure, shear, or friction [1]. PUs are common in patients with limited mobility, such as those who are bedridden or use wheelchairs, and are associated with significant morbidity, prolonged hospital stays, decreased quality of life, and increased healthcare costs [2, 3]. Globally, the prevalence of PUs ranges from 4% to 23% among hospitalized patients, with rates reaching up to 39% in long-term care facilities [4, 5]. Among patients with PUs, RPUs represent a particularly persistent and costly complication. Despite advancements in wound care, RPUs remain a major healthcare concern, with recurrence rates reported between 21% and 60%, depending on patient populations and care settings [6].

RPUs are defined as ulcerations that reappear at the same anatomical site within 12 months of the initial wound’s complete closure [7]. Multiple factors contribute to PU recurrence, including patient-related aspects (such as advanced age, comorbidities, immobility, and incontinence) and healthcare-related limitations (such as suboptimal wound management, inadequate rehabilitation, and lack of proper nutrition) [8]. Previous studies have emphasized that individuals with spinal cord injuries, diabetes, and cardiovascular diseases are at higher risk for RPUs due to impaired tissue perfusion and delayed wound healing [9, 10]. Gaps in clinical care often compound these risks, for example, failure to implement regular turning schedules, lack of rehabilitation services, and poor nutritional support, all of which have been associated with higher recurrence rates [11, 12].

The economic and social burden of PUs and RPUs is considerable. Treating recurrent or severe PUs is often multiple times more costly than preventing them and/or managing an initial wound [13, 14]. Beyond the financial costs, PUs significantly diminish patients’ quality of life, contributing to pain, restricted mobility, psychological distress, and social isolation [7, 8].

In Vietnam, research on PU recurrence is limited. The Vietnam National Burn Hospital (VNBH) serves as a referral center for patients with chronic wounds across the Northern and Central regions of the country, managing a large volume of PU cases annually. Identifying recurrence predictors in this population is crucial to improve clinical outcomes and develop targeted, patient-specific, and resource-appropriate prevention strategies. Importantly, while PU management typically involves multidisciplinary collaboration, nursing professionals are at the forefront of prevention and daily wound care [15]. Nurses are responsible for performing skin assessments, ensuring timely repositioning, managing moisture and hygiene, providing nutritional support, and educating patients and caregivers regarding. These empirically-based interventions play a central role in mitigating recurrence risk. Yet, limited attention has been given to the direct impact of nursing-specific practices on PU recurrence, particularly in resource-constrained healthcare settings such as Vietnam. This study, therefore, aims to identify prognostic factors associated with RPU at a national referral center and to offer evidence-based recommendations with particular emphasis on nursing roles in PU recurrence prevention.

2. METHODS

3. RESULTS

A total of 583 patients had 681 PUs. In the two groups of patients with RPU and Primary PU (PPU), no statistically significant differences were observed regarding place of residence and occupation. Six variables, age, gender, comorbidities, mobility status, and urination and defecation status, with p < 0.05, were selected for inclusion in the multivariate analysis (Table 2).

Patients without combined therapies (negative pressure wound therapy, hyperbaric oxygen therapy, or both) and those with stage III or IV ulcers had a significantly higher risk of RPUs compared to those who received combined therapies and had only stage II ulcers (p = 0.02 and 0.04, respectively). Other variables, such as the number of ulcers, ulcer location, and surgical treatment with flap reconstruction, did not show statistically significant differences between the RPU and PPU groups (p > 0.05). However, surgical treatment with flap reconstruction (p < 0.2) was retained for inclusion in the multivariate analysis (Table 3). Among 506 patients with mobility impairment, those who received rehabilitation and were turned every 2–4 hours had a statistically significantly lower rate of RPUs compared to those who did not receive these care services (p < 0.05) (Table 4).

4. DISCUSSION

The results indicate that patients over 31 years had a significantly higher risk of RPUs than younger patients. This finding aligns with prior research showing that aging leads to reduced skin elasticity, impaired tissue regeneration, and a decline in immune function, all contributing to delayed wound healing and increased recurrence rates [15, 2]. Although our analysis did not identify specific comorbidities such as diabetes, spinal cord injuries, or cardiovascular diseases as significant predictors of recurrence, previous studies have shown that complications commonly associated with these conditions, such as impaired circulation and peripheral neuropathy, can severely compromise tissue repair [16]. In particular, diabetic neuropathy contributes to RPU risk by reducing protective sensation and impairing microvascular function, which delays wound recognition and healing [17]. Additionally, malnutrition, particularly deficiencies in protein and micronutrients, has been increasingly recognized as a key contributor to delayed wound healing and higher RPU risk, making it a critical target for nutritional interventions [18]. Sarcopenia, often accompanying malnutrition, reduces the muscle mass essential for mobility and effective pressure redistribution, thereby complicating wound healing and elevating the risk of RPUs [19].

Limited mobility was a significant factor associated with RPU risk. The literature indicates that patients with paralysis or prolonged immobility, such as those confined to bed, have nearly a fourfold increased risk of developing PUs due to sustained pressure on bony prominences and compromised tissue perfusion [20]. Impaired microcirculation and localized ischemia are central pathophysiological mechanisms in PU formation [21]. In addition, incontinence, particularly dual urinary and fecal incontinence, has been strongly associated with skin breakdown and PU development, with nearly half of hospital-acquired patients with PUs affected by this condition [22].

The results indicated that ulcer severity was a major determinant of recurrence, with patients with stage III and IV ulcers exhibiting a significantly higher risk of RPUs than those with stage II ulcers. This aligns with observations by Meier et al. (2019), who reported that deep-tissue (stage III/IV) pressure injuries require prolonged healing and are more prone to secondary infections, thereby increasing recurrence risk [23]. Moreover, Kabir et al. (2025) demonstrated that biofilm-driven infection delays wound closure in PUs, substantially increasing the risk of recurrence [24]. In addition, Yang et al. (2024) described how chronic wounds, especially in the elderly, are characterized by cellular senescence and unresolved inflammation, which hinder tissue repair through sustained cytokine signaling and oxidative stress [25]. These mechanisms may also contribute to delayed healing and increased recurrence in PUs.

The results also found that the use of combined therapies, including negative pressure wound therapy (NPWT) and hyperbaric oxygen therapy (HBOT), was associated with a decreased risk of RPUs. A recent meta-analysis confirmed that adjunctive HBOT with NPWT significantly enhances tissue perfusion and granulation tissue formation [26], while HBOT improves oxygen delivery to ischemic tissues, facilitates angiogenesis, and increases collagen synthesis, thereby enhancing wound healing [27]. In our study, HBOT was part of a combined therapy regimen and showed an association with reduced recurrence (OR = 0.31, p < 0.05). While its primary benefit lies in accelerating initial healing, HBOT may also enhance tissue quality post-recovery, potentially lowering susceptibility to future breakdown. However, we acknowledge a potential for selection bias. Patients who received HBOT may have had better baseline conditions, such as mobility, caregiver support, or access to advanced medical care. Although several confounders (e.g., mobility status, ulcer stage, comorbidities, and rehabilitation) were adjusted for in our multivariate analysis, residual confounding related to socioeconomic status or healthcare access cannot be entirely ruled out. This limitation, inherent in our retrospective design, underscores the need for future prospective studies with Rehabilitation strategies, such as structured physical therapy, mobility enhancement, and scheduled repositioning, were found to play a crucial role in reducing the occurrence of RPUs. Patients who received structured rehabilitation programs and were repositioned every 2–4 hours exhibited a significantly lower risk of PU recurrence. These findings are in line with recent evidence from a systematic review and meta-analysis by Avsar et al. (2020), which demonstrated that frequent repositioning at intervals of 2 to 4 hours effectively reduces the incidence of PUs by alleviating prolonged pressure on bony prominences and improving local blood circulation [28]. In addition, there is evidence that the use of advanced pressure-redistribution surfaces, including dynamic air mattresses, is effective in preventing RPUs [29]. Moreover, the importance of education for both professional caregivers, particularly nurses, and informal caregivers, such as family members, has been increasingly recognized in improving PU outcomes. Structured wound care training programs, including those focusing on early detection, repositioning techniques, and dressing protocols, have been shown to significantly enhance care quality and reduce recurrence rates. While earlier studies, such as that by Latimer et al., highlighted the positive impact of caregiver education [30], more recent literature also supports these findings. For instance, Deakin et al. emphasized that structured educational interventions for hospitalized patients significantly improved their knowledge of pressure injury prevention strategies, including repositioning, skin inspection, and nutritional care. This patient-centered approach empowers individuals to participate actively in their care, thereby potentially reducing the risk of PU development and recurrence [31].

5. STUDY LIMITATION

While this study offers valuable insights related to the risk factors associated with RPUs, it has several limitations. First, its retrospective design may introduce bias due to incomplete data recording by healthcare providers. Second, the study was conducted at a single institution, limiting the generalizability of findings to other settings. Third, factors such as nutritional status and psychological well-being, which may also influence PU recurrence, were not assessed. Future studies incorporating these variables and employing prospective designs could provide a more comprehensive understanding of RPU risk factors.

CONCLUSION

This study identified key risk factors for RPUs, including older age, comorbidities, limited mobility, incontinence, and advanced ulcer stages. The absence of combined therapies and the lack of rehabilitation were also associated with higher recurrence risk. These findings highlight the importance of the role nurses play in early risk assessment and implementation of targeted prevention strategies [32, 34]. Enhancing nursing care practices, particularly repositioning, skin monitoring, and patient education, can play a vital role in reducing RPU rates and improving patient outcomes [32, 33, 35].

REFERENCES