Inside Our Pressure Injury Prevention Program

Patient Safety

By: Diane Kimsey

Published: 9/27/2019

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It's been 2 years and counting since a patient has suffered skin-related harm during surgery.


Don’t look past pressure injury risks in outpatient ORs, where skin breakdown is becoming more of a concern now that increasing numbers of heavier patients are undergoing more complex and longer procedures. The clinical team at our large medical center has implemented several prevention protocols that have proven successful in protecting patients’ skin. For the past 2 years, we haven’t had a single patient suffer a pressure injury, thanks to the program’s essential features.

  • Pre-op evaluations. Before surgery, we perform head-to-toe assessments of patients, helping us to identify existing pressure injuries so we can document and address them before surgery. We changed our policy so that any patient in a procedure lasting 3 hours or more is considered high risk, as well as anyone with a score of 16 or below on the Braden Scale for Predicting Pressure Injury Risk (osmag.net/M3BaHo). Those with a BMI of 19 or below, or 35 and above, are also considered high risk. Once we identify patients as high risk, we ask them to wear a bright green bouffant cap instead of our usual blue ones. We also place a green placard in their charts, so it’s clear to all staff which patients are at heightened risk.
  • Positioning aids. If a patient has an existing injury, we use a 5-layer silicone border dressing to help protect the delicate area of skin. We also apply heel protectors to high-risk patients in the supine position, and keep a range of prophylactic foam dressings, gel-based pads and fluidized positioning devices available on our pressure injury cart to use on patients considered high risk.

EXTRA PADDING Surgical teams need easy access to a variety of positioning aids to help prevent skin breakdown in vulnerable areas.   |  Pamela Bevelhymer, RN, BSN, CNOR

We’ve made equipment improvements in response to injuries that occurred in the past. In January 2017, a patient suffered a pressure injury on the occiput. We reviewed the incident and determined the injury was roughly the same size and shape as the donut pillow we were using. So we swapped the pillow out for a fluidized positioner, which is a specialized modality that offloads any pressure points on the patient’s head.

  • Post-op monitoring. We perform a post-op skin assessment and provide any specialized care as needed. While patients recover, we ask them to lay in a position different than that of how they laid in surgery. For example, we’ll move them onto their side if they were supine throughout the procedure.
  • Employee education. Though all nurses went through extensive training when we first rolled out the pressure injury prevention program, we wanted to ensure all new employees had the same buy-in as those who’ve been here for a while. Now, we hold quarterly education sessions, where we cover a range of positioning and pressure injury prevention information, and have included our anesthesia team in these discussions.

We make sure to keep abreast of the latest patient positioning information and include it in these sessions. For example, we recently discussed preventing pressure injuries that can occur when a patient is positioned in such a way that a medical device — such as a Foley line — puts pressure on the patient’s skin and can cause harm.

Thanks to these essential elements, our last pressure injury was more than 2 years ago. It was an injury that was deemed reportable, but unavoidable, due to the length of the surgery, comorbidities of the patient and the patient’s refusal to follow post-op turning and movement strategies.

Outpatient enhancements
SKIN IN THE GAME Pre-op assessments identify at-risk patients who need added layers of protection during surgery.   |  Pamela Bevelhymer, RN, BSN, CNOR

Though our prevention program always applied to the ORs at the medical center, we did not have a program specifically designed for our medical center’s surgery center because surgeries there are typically under 3 hours and most patients were considered healthy with few comorbidities. Over the past 6 months, however, we’ve created a modified protocol that specifically applies to patients undergoing outpatient procedures.

The protocols are very similar to the prevention program we already had in place. If a patient in pre-admission testing has a BMI exceeding 40 or is under 18, the staff will flag them as a possible high-risk patient. They then email both me and the director of the surgery center. We discuss the case together and decide if there’s any chance that the patient could be in the OR for more than 3 hours. If the answer is yes, we perform similar pre-, intra- and post-operative steps that we take in our medical center’s main ORs, including conducting a head-to-toe skin assessment with documentation preoperatively, placing the patient on gel pads and using viscoelastic padding on the OR table.

Intraoperatively, we perform another skin assessment and reposition the patient to protect tender areas, if needed, and use a five-layered silicone border dressing to protect the heels and sacrum. Post-operatively, we perform a final skin assessment before discharge. During the post-op phone call, if the patient had any injuries or redness assessed in PACU, the nurses ask additional questions and refer them to their physicians for further follow-up.

In this surgery center model, we’ve had dozens of patients flagged because of their BMI, but because of the length of surgery, we have only had 6 patients go through the full pressure injury protocol. We also had great buy-in from staff at the surgery center; 2 RNs had transferred there from the main ORs, so they were used to the program. We also held in-service classes for staff, and had vendors come in to show the team how to use preventative dressings and positioning aids. The buy-in was almost instantaneous when we shared how the program benefits patient care in the medical center’s main ORs and how it could do the same in the ASC.

Always striving

Though we have the basics of the program in place, we continue to work to improve the protocol and make the program even stronger. One of the ways we do this is through our auditing process. Every month, an RN reviews 10 cases flagged as high risk to ensure that pre-, intra- and post-op interventions were followed. If the nurse discovers that the prevention protocol was not followed in any case, we conduct a peer-to-peer conversation, which we have found much more effective than having leadership discuss the issue with the staff member. We also include these audit results as an agenda item at every OR staff meeting.

Overall, we’re very proud of our results. Our hospital’s financial department is, too. We’ve recently estimated the costs we’ve avoided with our pressure injury protocol and found, based on the estimations of what the treatments would cost if our patients developed pressure injuries, we’ve saved $136,000 in 2015, $92,000 in 2016 and $90,000 in 2017. In 2018 and so far this year, we’ve spent nothing on treating pressure injuries. Our hospital’s senior leaders have backed our prevention efforts from the start. They understand that the money invested in the program has avoided the costs of treating avoidable skin injuries and provides our patients with safer care. It’s been a win-win for all. OSM

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