Put Pressure Injuries in the Rearview

There’s no shortage of compelling data and research on exactly what it takes to prevent pressure injuries. The trick is finding practical ways to put that evidence into the day-to-day workflow of your busy facility. To that end, we spoke with two facilities that spearheaded successful pressure injury prevention projects to find how to do just that.

To make it happen, the Sloan Kettering team determined a new risk assessment specific to surgery was needed to provide a structure that identifies patients at risk for OR-acquired pressure injuries. They looked at several established pressure injury assessments specific to the perioperative setting and reviewed each element as a team to determine feasibility and relevance. “We wanted to keep the process streamlined and easy to apply, while capturing critical risk data specific to our patient population,” says Ms. Charles.

The team focused on inpatients and same-day admission patients who have a BMI less than 19, and surgery length greater than four hours. These elements were then standardized in electronic documentation and shared with all staff through comprehensive education on why each element of the risk assessment was important. The team notes the importance of padding based on individual patient needs, such as bony prominences or an existing skin injury identified in preoperative care that could be more prone to a pressure injury.

To identify patients at risk for pressure injuries, the team created a daily report, which is autogenerated and emailed to leadership and the charge nurse, flagging the patient record for the intraoperative staff. The circulating nurse is notified if the patient meets criteria for the application of protective dressings.

The correct application of foam dressings, which is part of the program’s comprehensive education, is reinforced by posting anatomical charts in the OR for prophylactic dressing placement. Ms. Charles says the charts were designed in collaboration with the dressings’ manufacturer to create a visual aid of common surgical positions. “These large, laminated posters show exactly where the minimum number of dressings should be placed and color-code the highest risk areas such as the sacrum, so teams can easily plan for and grab the appropriate dressings, in addition to extra dressings they deem necessary,” she says.

While the goal is to standardize all aspects of pressure injury prevention, the Sloan Kettering team stresses the value of being nimble. Though the team planned to have OR nurses apply foam dressings in the pre-op area, it added extra time to the surgical schedule and created more work, with additional padding needing to be applied in the OR, says Ms. Charles. “We then moved the application of dressings to the intraoperative phase and worked closely with our OR nurses to find the opportunities for dressing application that wouldn’t delay the surgery,” she adds.

For instance, most patients walk into the OR themselves, providing an opportunity for the nurse to place the sacrum padding before the patient is even positioned on the surgical table. Heel padding is also placed when the nurse is applying compression cuffs to complete two steps in concert, all while other staff members are completing different tasks prior to surgery.

Our entire culture regarding skin assessment has collectively moved from retrospective analysis to proactive prevention.
—Beatrice Forlizzi, MSN, RN, CWOCN

Critical thinking also comes into play for any team member assessing the patient’s skin before or after the surgery, a process that is supported through electronic documentation. “Any skin redness or areas of concern aren’t a surprise after surgery because our PACU nurses see the foam dressing in place and read the documentation, which is reiterated in the hand-off and can even be used as rationale to initiate a postoperative wound care consultation,” says Ms. Forlizzi. “Our entire culture regarding skin assessment has collectively moved from retrospective analysis of injuries to proactive prevention.”