Here are 9 strategies for positioning patients more comfortably and safely so you can all but eliminate pressure injuries in your facility.

1. Feel what patients feel.
New hires at West Virginia University Hospitals are asked to put themselves in all sorts of different positions on the OR table using various positioning devices. "We then look at them and say, "You were awake and got to place yourself in this uncomfortable position or device. Think about your patient — the one who is anesthetized and can't speak for himself,'" says Jay Bowers, RN, BSN, CNOR, clinical preceptor and educator at the Morgantown, W.Va., healthcare system.

2. Understand the risk factors.
When a team of nurses at Lawrence & Memorial Hospital sought to stamp out pressure injuries at the New London, Conn., facility a few years ago, they reviewed the literature and came up with a list of perioperative risk factors for skin breakdown that includes:

• surgical procedure type, duration and positioning;
• pre-existing skin conditions;
• morbid obesity, emaciation or malnourishment;
• a history of medical conditions such as COPD, diabetes, vascular or cardiac disease;
• low blood pressure;
• high body temperature;
• anemia;
• high white blood count; and
• incontinence.

Age is also a factor, says Mr. Bowers, who adds that neonates and older patients are at a higher risk of pressure injuries.

3. Perform pre-operative skin assessments.
Once you understand the risk factors for pressure injury, you can perform an effective pre-operative assessment of patients to determine who is at a heightened risk and what interventions you'll need to make to protect them. Mr. Bowers recommends a head-to-toe assessment of each patient's skin condition; be sure to take note of any changes in the skin color or tone, scrapes, bruises, nicks, existing pressure ulcers — any sign that the skin integrity has already been or is at risk of becoming compromised.

Nurses at Hendricks Regional Health in Danville, Ind., perform skin assessments and risk stratification on all adult patients using the Braden Scale (www.bradenscale.com/images/bradenscale.pdf). "It's very important when you do skin risk assessments that you use a tool that is reliable and valid," says Adult Clinical Nurse Specialist Paula Spoonmore, MSN, RN, CNS-BC. "The Braden Scale is a fairly easy tool; you can complete it in 60 seconds or less."

4. Develop interventions for high-risk patients.
At Hendricks, all patients with a Braden Score of 18 or less (at risk) get a pressure-redistributing static air overlay mattress placed on their beds as a standard of care — an intervention facility leaders credit with drastically reducing the incidence of hospital-acquired pressure injuries since the hospital joined in the statewide Indiana Pressure Ulcer Initiative in 2009.

While Hendricks found the air mattresses to be the best, most cost-effective solution for its patients, you can implement several different types of interventions to protect high-risk patients from developing or worsening pressure injuries. The latest reference guide published last year by the European and National Pressure Ulcer Advisory Panels includes updates on risk factors to watch out for as well as effective patient positioning techniques, such as using pressure redistributing mattresses, offloading the heel and changing the patient's position perioperatively. Consult these evidence-based guidelines to see how they should fit into your facility's policies and procedures, and thoroughly educate and train staff on the products and interventions you choose to implement.

5. Keep accurate records.
Be sure to document your pre-operative assessment of each patient's skin quality and any subsequent assessments and interventions made so you have an accurate record of the patient's skin integrity before, during and after surgery. Thorough documentation not only improves information sharing among caregivers, but also helps protect your facility from liability, notes Mr. Bowers. "Remember, if [a pre-existing injury] is not documented, it was never there to begin with, so that means they can say it was caused in the OR."

6. Incorporate skin assessments in handoff communication.
Skin assessments are included in handoff tools at Hendricks Regional Health to ensure all providers throughout the continuum of care are aware of any risk factors or pre-existing skin conditions the patient might have so they can take the appropriate steps to prevent injury. To further alert caregivers to patients at a high risk for pressure injury, Lawrence & Memorial Hospital uses stickers with sailboats on them to denote the charts of at-risk patients (the sailboats correspond to the hospital's nautical-themed pressure injury initiative).

7. Evaluate and upgrade your table pads and mattresses.
When CMS added pressure injuries to the list of "never events," West Virginia University Hospitals decided to evaluate its equipment and consider investing in softer surfaces for OR beds. "The operating room here sits on the house-wide wound care committee. We realized, first, that some of our patients spend a long time on the OR table and we wanted to do everything that we could to prevent an injury," recalls Mr. Bowers. "And second, we realized that if we didn't do anything to prevent these injuries and one occurred, then we would not get any reimbursement for the whole hospital stay." They ultimately decided that it was better for the patients and for the facility's bottom line to invest in new memory foam mattresses for all the beds in its 19-OR surgical unit.

The hospital started by having staff members of varying sizes and weights lay on the existing OR beds to evaluate the mattresses' "bottoming out" factor, explains Mr. Bowers. "This also gave staff a chance to feel what it was like to be lying in certain positions for hours." The hospital then requested samples from different mattress pad manufacturers and had staff lay on those. "Even though some people say they are all the same, they aren't," says Mr. Bowers of the different mattresses on the market. "We decided the best mattress for us was the memory foam mattress," which didn't "bottom out" on staff members who took turns laying on it. Starting with the oldest tables in the unit, the hospital replaced all the mattress pads over a period of time to stagger the cost.

Keep in mind that the rise in the prevalence of obesity in the United States means you should invest in tables, beds, mattresses, pads and positioners that can accommodate larger and heavier patients, who also happen to be at a heightened risk for pressure injury.

8. Build a pressure ulcer prevention campaign.
Like other quality improvement initiatives, such as hand hygiene, you can reinforce the importance of pressure injury prevention by creating a facility-wide campaign with posters, education, contests and other tools that promote teamwork and awareness. For the entire 12-month run of its pressure ulcer initiative, Hendricks Regional Health hung a large banner in its medical unit that declared, "We will prevent pressure ulcers." The banner was very powerful, says Medical Unit Director Lisa Imlay, RN, BSN. "It informed staff and ancillary staff, and it also informed the families of the patients of what we were doing and what was important."

In addition to the banner, the hospital also provided ongoing education for staff in the form of notices posted with wound facts, treatments and myths — "to keep their pulse on the problem," explains Ms. Imlay — and one-on-one sessions between experienced nurses and staff members in need of a little more guidance on skin assessments and injury prevention.

9. Audit staff compliance.
After implementing a new pressure injury prevention policy or campaign, conduct routine audits to ensure staff truly understand and are following through on the new policies and procedures you've put in place. Hendricks Regional Health audited every patient, every day for the duration of its pressure ulcer prevention initiative. "It was one of the best interventions that we could have done to let us know what was going on with our patients' skin," says Ms. Spoonmore of the audits her nurses conducted. They wouldn't re-assess every patient, but would review charts and follow up on any discrepancies they found in the documentation of patients' skin conditions. When they found lapses in compliance with skin assessments and interventions, they would conduct one-on-one education with staff in a "non-judgmental, non-threatening manner," says Ms. Spoonmore. "It was an eye-opening experience that led us to more education, which led us to remarkable outcomes." While the initiative has since ended, the hospital continues to conduct spot-check audits a few times a week to ensure success is maintained. "For the first time, we've been free of hospital-acquired pressure ulcers for the last 5 quarters," says Ms. Imlay.