RISK GROUP For obese patients, as with the elderly and those with circulation-related co-morbidities, special attention must be paid to padding and support during positioning.

The risk of pressure injuries is often overlooked, especially in outpatient surgery, where patients ambulate so soon after their procedures. But even temporary surgical positioning and immobilization can lead to perioperative skin breakdown, nerve injury, or musculoskeletal or vascular damage. As the skin care champion for my hospital's ORs, I routinely meet with other nurses and managers to identify quality improvement opportunities and reduce our hospital-acquired pressure ulcer rates. To ensure the best outcomes for your patients, and to banish this "never event" from your ORs, ask yourself these 4 questions about pressure injury prevention.

1. Are your patients at risk?
Would you know it if your surgical patients commonly faced the risk of pressure injuries at your facility? It might be advisable to examine the steps of your perioperative process in an effort to adopt best practices and improve patient outcomes.

For a project we eventually developed into a poster presentation at an AORN conference, we consulted with outside skin care experts, including clinical educators and product representatives, and conducted a search of the medical literature. We gathered and reviewed evidence, including appraisals of perioperative standards and recommended practices, to which we could compare our process and from which we could implement changes.

2. How are you reducing the pressure?
One of the most significant findings of our review was that a lot of our OR tables were topped with older mattresses. There were several types, but most of them were made from conventional sponge foam, which led us to ask: What is the best surface for patients to be on throughout surgery? We sometimes see trauma cases in which patients are on their backs for 8 or 10 or 12 hours of surgery, and there's no doubt that pressure plays a role there.

Materials technology has come a long way since those OR mattresses were installed. According to clinical research, viscoelastic "memory" foam, gel-filled cushioning options and products that couple the two offer highly effective pressure redistribution and patient support, which can prevent the restriction of blood flow, insults to peripheral nerves, and their attendant complications.

GO WITH GEL Gel-filled and memory foam positioning devices provide more efficient pressure redistribution than conventional sponge foam.

Our workgroup recommended the replacement of our existing OR table mattresses with gel-and-memory-foam combination mattresses due to their higher-pressure redistribution abilities. This recommendation was put into action in the first quarter of 2012, and we saw our hospital-acquired pressure ulcer rates fall from 0.77 in the first quarter to 0.32 in the second quarter, just for starters.

The same goes for all table accessories and positioning and padding devices. Even though the use of conventional sponge foam, rolled-up towels and other supplies at hand has long been the practice, these methods are outdated and the substances mentioned above are better solutions. Whether you need a donut for the back of the head, positioners for tucking the arms or elbow and heel rests for supine patients, use memory foam or gel products.

In addition, be sure to use these materials alone. Our review of the research found that if, for instance, you have a memory foam mattress and you place sponge foam positioning devices or multiple sheets on top, they decrease the pressure redistribution effect. The more layers you have between the patient and the mattress, the more you impede the ability of the mattress to do its job.

3. Who is most at risk?
To prevent pressure injuries, it's best to know something about the patient. That's why some form of skin care assessment should be a standard part of your pre-op nurses' patient care routines, especially among the patients who are most at risk.

Elderly patients are at particularly high risk, since their skin is frailer and there has been a decrease in subcutaneous tissue. Obese patients' bodies place more weight on their pressure points, so support is essential. Patients with diabetes, high blood pressure or other comorbidities may already suffer from impaired perfusion, which could hinder circulation and result in pressure complications. Malnourished, dehydrated or atrophied patients may have weakened defenses, and previous wound sites or dressings may be especially sensitive areas.

A pre-op skin assessment should take into account the type of surgery. How is the patient's body likely to be positioned to allow optimal access to the surgeon and anesthesia provider? The most important parts of the skin to spot check are the places where the patient is going to be positioned. How long is the case expected to last? General anesthesia tends to dilate blood vessels, which may increase the risk of poor perfusion at pressure points. After conducting the assessment, you should know the areas that will require padding and special caution.

Perioperative hypothermia and pressure injuries can go hand in hand. A decrease in tissue temperature is an indication that it is not being adequately perfused, so make sure you monitor core temperatures and maintain normothermia. If you have forced-air convective warming systems, make sure they're used routinely to keep the patient warm from their arrival in pre-op to their discharge.

4. Is your staff on board?
Preventing pressure injuries — adopting best practices, conducting patient assessments, properly using padding and positioning equipment — depends a lot on nursing judgment. That's why it is essential for perioperative nurses to understand their roles, and the importance of their roles, in patients' skin care.

There should be communication between both ends of the patient experience, pre-op and PACU. For high-risk patients, it may even be valuable to conduct post-op skin assessments. If the discharged patient later complains of a skin or nerve injury that is traced back to surgical positioning, it doesn't reflect well on PACU if they never had an inkling of trouble.

Educate your surgeons and staff on the basics of pressure injury prevention, and the skin care rationale behind them. Facility managers and staff champions should review and evaluate current practices to ensure that they are based on the most recent available evidence. Since few professional organizations' recommendations and standards explore the issue in great depth, evidence-based research in the medical literature should be your guiding source.

Lastly, make sure pressure injury prevention and skin care is a regular topic of discussion in staff safety meetings. This can help to enforce any practice or equipment changes you institute, and ensure that you won't rest on any outcome improvements you achieve.