Here's what my facility found out about patient positioning techniques, OR table surface quality and other key factors contributing to pressure ulcers that are within your control.

1. Use thick gel pads and keep sheets smooth. Thirty percent of study patients who laid on thin foam table pads (1.5" to 2") developed pressure ulcers. Look for tables with surface pads 3" to 4" thick to help maintain your patients' skin integrity. Wrinkles in sheets can cause skin breakdown, so be sure to smooth table pad covers before placing patients on them.

2. Keep pressure off heels. Place a pillow or positioning aid under patients' knees to take pressure off the heels, a common problem area. Also place pillows, gel pads or padded pressure-relief boots under patients' ankles to lift them off table surfaces. A word of caution: Place extra padding under the lower back. Our research revealed that elevating patients' ankles actually increased pressure ulcer development risks there.

3. Patients shouldn't remain static during surgeries. Reach underneath drapes to gently shift a patient's extremities several times throughout a procedure, especially during extended cases. Ask anesthesia providers to do the same with the patient's head. It doesn't take long for circulation to return to potential problem areas, so those slight movements can make a huge difference in your efforts to prevent pressure ulcers from developing.

4. Don't lean on patients. When you see unexplained skin breakdowns in the PACU, even after you've taken necessary positioning precautions, perhaps your surgeons, nurses or techs inadvertently leaned on patients during cases in order to improve their views of the surgical site or reach for needed instruments. Make sure your staff is aware that applying even the slightest additional pressure can cause ulcers to develop.

5. Assess the patient's skin. The Braden Scale (www.bradenscale.com/images/bradenscale.pdf) is made up of 6 subscales scored from 1 to 4 that measure a patient's sensory perception, skin moisture, degree of physical activity, ability to change and control body position, usual food intake pattern and amount of assistance they require for moving. Lower scores indicate higher risks of pressure ulcer development. We found that the Day 1 Braden Scale score is highly predictive of pressure ulcers, which is consistent with published literature. Take extra care when handling and positioning patients who are high-risk based on their Braden Scale scores (18 or less). Reassess these patients in PACU to ensure problem areas didn't develop or pre-existing skin conditions weren't exacerbated during surgery.

6. Document breakdowns. Record the positions you place patients in during surgery and complete incident reports whenever skin issues arise — no matter how insignificant they might seem. That way you'll recognize potential factors that cause pressure ulcers and track the progress of the protocols you implement to rectify the problems. Keeping detailed notes in op reports might also show that you took every reasonable precaution to avoid skin-related issues, which could keep you from getting dinged by insurance carriers.

Follow up on all reported incidents of skin breakdown within a day of when they occur. Consider every possible contributing factor. How did staff position the patient? What positioning devices did they use? What was the patient's Braden Scale score? Did the patient have skin issues before surgery or during past surgeries? How was the pressure ulcer treated? What could you have done or what will you do to prevent another incident?

7. Discuss preventative measures. Regularly reinforce the risk factors associated with pressure-ulcer development. Consider appointing a "skin champion" among your staff who's charged with keeping your surgical team aware of maintaining patients' skin integrity and documenting when breakdowns occur. Hang recent pressure-ulcer-related journal articles on a prominent bulletin board or distribute the studies so the surgical team can discuss the findings during staff meetings. Conduct annual in-services on proper positioning techniques, during which surgical team members are placed in common surgical positions so they get a real sense of what patients experience. Pay attention to feedback received from your staff. They're the ones who prep patients on a daily basis and know if certain positions are more problematic than others.

Never say never
No single precaution is 100% effective in preventing pressure ulcers — some patients will suffer skin breakdown no matter how hard you try to prevent it. So should pressure ulcers truly never happen, despite recent mandates handed down by CMS? Maybe not, but it's definitely a goal worth striving for.