POSITION PROPERLY Positioning a patient is one of the biggest ways to help your facility fight pressure ulcers.

If your patients are developing pressure ulcers after surgery, read on for several strategies sure to cut your skin injury rate. A few years ago, when my hospital noticed an unacceptably high number of our patients were developing skin injuries 72 or so hours after surgery, we formed a Perioperative Services Skin Wellness Committee, which I chaired. Based on our experience, here are 7 things you can do to prevent pressure ulcers.

1 Check under the mattress
One of the most impactful changes was updating our OR mattresses. We were using 2-inch foam mattresses with hard plastic covers. To combat the hardness of the mattress, we used gel overlays. To fight the cool temperature of the gel overlays, we placed water-circulating warming blankets underneath them. It was a self-defeating system.

We had a few 3-inch thick, high-quality memory foam mattresses in some of our ORs, but we were sandwiching those between warming blankets and gel overlays. The thin mattresses, gel overlays, and heat and moisture from the blankets created the perfect environment for pressure ulcers and wounds. We educated staff on best practices for using the high-quality memory foam mattresses, with only a single sheet cover instead of the warming blanket and gel overlays, and transitioned all of the ORs to the high-quality memory foam mattresses. We selected the 3-inch versions because we do a number of bariatric procedures, and patients with larger BMIs could bottom out on 2-inch thick mattresses.

2 Rethink your method of patient warming
There was another part of the OR table that we had to correct — our "old-school" water-circulating warming blankets. There were 2 big problems with the thin, blue, plastic warming blankets. First, they were placed underneath the gel overlays, which were often smaller than the blanket in some areas, occasionally causing burns if a patient's skin got in contact with the blanket. Second, the blankets were plastic and circulated warm water. By using them, we were trapping heat and moisture underneath patients, contributing to pressure ulcers.

The new mattresses alleviated our need for these blankets. Because the memory foam mattresses were designed to relieve pressure points and maintain normothermia, we didn't need to put heat underneath the patients to keep the mattresses warm. Instead, to keep patients warm, we switched to forced-air warming blankets.

We use the forced-air warming gowns in pre- and post-op. In the OR, we use warming blankets that target either the upper or lower body. Plus, as an added bonus, we've found that patients are much happier with the new blankets.

BEFORE AND AFTER OR tables at Yale-New Haven Hospital used to be equipped with 2-inch hard foam mattresses that were covered with a plastic water-circulating warming blanket and gel overlays (left). The skin wellness committee at the hospital changed the OR tables to 3-inch memory foam mattresses and used forced air warming blankets on patients.

3 Pay attention to patient positioning
Because patient positioning is so critical to preventing pressure injuries, we now require every new perioperative nurse to attend a hands-on class on positioning. These classes focus on the small details that could lead to the big injuries, such as IV caps that could be accidently positioned under a patient's arm, EKG leads underneath pressure points and proper positioning tools. We also stress that for patients wearing sequential compression boots, the little hoses that attach to the machine can find their way underneath a patient's heel or ankle.

Additionally, some of our surgeons were using blankets as positioning tools. We purchased positioning tools made from the same material as our new mattresses. They were covered in a soft, silky, non-sticky surface.

HEEL ATTENTION One of the ways to protect patients from pressure ulcers is to reduce pressure on bony points of the body, like heels.

4 Include docs in decisions
While we were changing products and practices, we knew it wouldn't be successful if we didn't have the entire surgical team on board, especially surgeons and anesthesia. We collaborated with the doctors to ensure that when purchasing the new skin-saving equipment, the surgeons would have proper exposure and anesthesia would have proper airway access.

One of the best things we did to get doctors on board was to take ideas directly from them. For example, we had a newer orthopedic surgeon who at a previous facility used positioning tools. At the time, we were just using blankets, but knew that we wanted to get away from that practice. We ended up taking his suggestion and looked into new tools he had worked with before.

5 Standardize skin assessments
While some of our surgical staff proactively checked before and after surgery for any signs of a pressure ulcer, others did so inconsistently. We set out to standardize assessment and documentation of skin issues in preadmission testing and intraoperatively. We've set up a process that ensures that skin is assessed before, during and after surgery. Once we position a patient for surgery, staff checks the patient's skin again to see if there is anything unusual (they document any sign of a possible skin injury). During surgery, especially longer procedures, nurses will periodically check the most well-known spots for pressure injuries, like the heels. Anesthesia repositions the head when possible. Finally, after surgery is completed, but before the patient is sent to recovery, we do another check for any signs of skin injury. This thorough skin assessment protocol makes sure that we can catch and document any skin injuries that happen before the patient comes into the facility.

REPOSITIONING COMPLIANCE
Sensor Monitors Your Pressure-Ulcer Prevention Efforts

SENSOR STUDY A new sensor monitors patients' repositioning, a study finds.

A wearable sensor that tracks when hospital staff follow turn protocols may help healthcare workers improve their efforts to prevent hospital-acquired pressure ulcers, a new study finds.

Using the Leaf Healthcare Wearable Sensors, hospital turn protocol compliance improved from 64% to 98%, according to the study done by the El Camino Hospital in Pleasanton, Calif.

The Leaf system is a small, lightweight, wearable sensor that electronically monitors a patient's position and movements, says the company. The sensor then collects data and sends it to central monitoring stations or mobile devices so that healthcare workers can check on patients' positions. It also uses alerts to remind staff to reposition patients.

"Nurses and hospitals are searching for innovative ways to reduce pressure ulcers — which affect more than 2.5 million U.S. patients each year — and this presentation provides valuable insights into how that can be accomplished," says Mark Smith, vice president of sales and marketing at Leaf Healthcare.

— Kendal Gapinski

6 Educate, educate, educate
Once we identified the main problems, we knew we had to continue to educate staff on proper practices. We re-educated staff on the risk factors (elderly, low Braden score, in surgery for more than 2 hours, high BMIs) contributing to pressure ulcers. We made sure to re-introduce these basics to staff, and held classes on pressure ulcer prevention techniques, such as patient positioning, to be sure that everyone followed the same practices. Additionally, it was crucial that staff were using the new products properly. Members of the committee went around to ORs and monitored the products being used. We also created a "Skin Is In" tip. Each month the committee comes up with a tip to prevent skin injuries, such as reminding staff to float patients' heels or accurately document patients' skin before and after surgery. Staff see them everywhere, from the lounge to locker rooms, which make sure that skin integrity is in the forefront of our minds while in the OR.

IV REMINDERS When positioning patients, staff should be aware of IV tubing that can be caught underneath a pressure point.

7 Check your progress
Audit your progress. The safety nurse in our committee reviews charts and checks out skin issues that arise. This lets us pinpoint certain practices or devices that were exacerbating or causing skin injuries. For example, we realized that the pillow we were using for patients in the prone position — which was square with a softer, covered area where the patient's face would go — could cause friction and tearing of the skin. We decided to change to a product that instead cradled the patient's face, with a mirror underneath that let the anesthesia providers see the patient's reflection. Anesthesia ended up liking the new product much more, plus the switch solved a skin injury problem.

'Skin is in'
The changes worked. Since implementing the new protocols and positioning tools, we've dramatically cut the number of pressure ulcers acquired in surgery from 9 in 2011 to just 1 in 2013. We're continuing to assess our progress and develop even better ways to combat skin injuries, making sure that staff remember that "skin is in."