Make Pressure Injuries Never Events

Patient Safety

By: Heather Kooiker

Published: 4/16/2020

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Be proactive in protecting skin to prevent avoidable patient harm.


The patient came in for a cystoscopy, a common outpatient procedure that only requires a person to be on the table for about 25 minutes. But the procedure does include slight Trendelenburg positioning, and this patient happened to be at risk for a pressure injury.

On top of the injury risk inherent to the position, he had shearing forces and moisture, which wound up being a perfect storm of injury-inducing factors. In the end, this patient came out of surgery with a Stage 2 pressure injury (PI) as well as a deep tissue injury because there was no intervention when intervention was needed. This example was a real wake-up call for the periop nurses who were in the OR that day because it revealed something most staff — especially outpatient staff who generally don't see pressure and skin injuries as something they need to worry about — often aren't aware of: You can cause great damage to your patients simply by not properly assessing them for pressure injury risks and intervening when necessary.

I'm very passionate about pressure injury prevention, and I truly believe we can create a culture that sees PIs — occurrences that in extreme cases lead to infection, sepsis and even death — as "never events." But getting there depends on breaking down the silos that exist in the care continuum and following a critical three-step PI process for every single patient who comes through our doors: Identify, intervene and prevent. At my previous facility, I combined a thorough, standardized risk assessment with a PI prevention bundle to reduce what we were seeing in far too many patients. Here's how you can do the same at your HOPD or ASC.

Identify at-risk patients

PI prevention all starts with identifying those patients who are most at risk for a pressure injury by using an appropriate risk-assessment tool. The key word here is appropriate. There's a common misconception that the Braden scale, which is still generally the gold standard across this country, is the only way to identify any patients who are at-risk for PIs — even those undergoing shorter outpatient procedures. With this population, you want a tool that will quickly allow you to determine if a patient is at-risk for an injury, as opposed one that measures the patient's specific risk level, which is what the Braden scale gauges). That's why we used the CMUNRO SCALE (osmag.net/RjwK4V). In the critical pre-op phase, you simply have to remember the acronym of the first word, CMUNRO, to assess the six key factors that put a patient at risk for an injury:

C (co-morbidities, current status)
M (mobility)
U (under or over age 60)
N (nutrition)
R (recent weight loss)
O (overweight).

In addition, nurses only examine the specific body parts that will be under stress during the procedure, as opposed to a full patient assessment.

Of course, there are still plenty of fast-paced, high-volume outpatient facilities that don't implement any type of risk assessment because they feel the patients are only in surgery for a short period of time. As the scale above shows, time is far from the only factor that leads to a pressure injury.

Intervene as needed

UP IN THE AIR To avoid pressure injuries on patients in the supine position, float the heels off the surface of the OR table without hyperextending the knee.   |  University of Nebraska Medical Center

Pressure injuries often occur when staff fail to intervene and take specific measures to protect patients' vulnerable areas. I recently had a nurse say to me, "Heather, my patient did really well during the case, but in recovery she was complaining about pain in her heels. What do you think is happening there?" The first thing I asked was whether she floated the patient's heels off the bed. Turns out she didn't, because she was unaware of the new evidence that shows egg crate foam to be ineffective. This was a seven-hour case where the patient was in supine position. The PI bundle I put together following AORN recommendations and evidence-based practice includes a number of position-specific protective measures to reduce the chances of a skin injury. For instance, patients in supine position should have their heels floated without hyperextending the knee. Foam dressings should also be applied to the heels and sacrum, two areas at risk for injury.

Another intervention I've seen make a major difference in PI reduction is using molded foam inserts for the head of prone patients — as opposed to regular square foam inserts. We were regularly seeing patients coming out of surgery with PIs on their forehead and chin area from lying in that prone position for several hours at a time. The shearing forces caused by inserting hardware was obviously a factor, but the insert we used played a role, too. Once we switched over to the molded foam, however, the forehead and chin PIs we were seeing on a regular basis essentially disappeared.

Pressure injuries occur when staff fail to take specific measures to protect patients' vulnerable areas.

You'll also need to gauge the patient's specific risk levels at every stage of the surgical process. Remember, each phase of care carries its own set of PI risks. For example, in pre-op there's the risk of a delay and a patient just sitting there on a stretcher for two hours waiting to go to surgery. Here, you'll want to intervene and offload the patient's pressure point areas (we recommend this be done at least every two hours during the case), encourage them to go to the bathroom, and just remind them of the importance of getting up and moving every now and then.

Just like in the pre-op area, your surgical team can use the CMUNRO SCALE to gauge key risk factors like systolic blood pressure, cord body type, surface type and whether moisture is present underneath the patient. Post-op is another important and overlooked area for intervention. It hinges on the communication between the OR nurse and the PACU nurse. Periop staff must let the PACU nurse know what position the patient was in during the procedure. You'll also want to perform a dual skin assessment of high-risk areas on patients to make sure those vulnerable spots are protected during the offloading process.

Of course, the thread that holds all these efforts together is consistent communication and collaboration among the staff in each phase of care. I can't stress this enough: Bridging the communication gaps between your various departments is the most effective way to change your PI prevention culture and practices.

Empower the frontlines

HEAD START Don't ignore the risk of skin injury in pre-op, especially if a case's start time is delayed.

Pressure injuries are one of the critical nursing sensitive indicators that are reported directly to the National Database of Nursing Quality Indicators and reflect on the overall care your facility provides. And rightly so. By and large, these injuries shouldn't happen — especially to same-day surgery patients. Preventing PIs essentially comes down to empowering those on the frontlines of patient care. These caregivers are the ones who have the biggest impact in implementing patient safety protocols. As facility leaders, we have the responsibility to provide them with the knowledge and the tools they need to protect patients from unnecessary harm. If we do this right and make it a priority, pressure injuries will truly become never events. OSM

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