Skin is the body's largest organ, and its first line of defense against all the harm the environment can offer. But the all-important barrier is susceptible to the rigors of surgery if left unprotected against pressure, friction and shearing forces. Skin injuries increase lengths of stay and needlessly drive up healthcare costs. They're painful, can be disfiguring and lower patient satisfaction scores, which could lead to increased litigation and a negative impact on your facility's reputation. Help protect patients — and your rep — from skin-related harm with these important tenets of patient positioning.
1. Grasp the significance
Stakes are high when it comes to positioning patients properly. Surgical departments account for 42% of all hospital-acquired pressure ulcers, which are becoming more of an issue in the operative setting because we're treating a greater percentage of older patients, people are living longer with chronic illnesses, and more data and regulatory changes are making us more aware of skin-related issues and injuries. Treatment of a single pressure ulcer can cost $3,000 to $30,000, so pay close attention to risk factors and educate staff on ways to position patients properly to lower your pressure ulcer rate. (My hospital did, and dropped our incidence per 100 procedures from 1.51 in 2009 to 0.22 in 2012.) Also keep in mind that pressure ulcers are key clinical indicators of the standard and effectiveness of care. In fact, CMS considers stage III and IV ulcers "never events."
2. Define the problems
A pressure ulcer is a localized injury to the skin or underlying tissue, usually occurring over a bony prominence as a result of pressure and often in combination with shear force and friction, according to the National Pressure Ulcer Advisory Panel (NPUAP).
Pressure injuries often develop when soft tissue is compressed more than 32mmHg between a bony prominence and an external surface such as a surgical table mattress, medical device or piece of equipment, all of which can interfere with capillary blood pressure in the extremities. When normal capillary interface pressure is compromised, tissue surrounding the capillaries is jeopardized. Damage can be seen in a matter of hours or up to 3 days after the circumstances that caused the injury.
Friction is parallel force acting on the skin. It can be especially damaging to the skin's superficial layers and usually affects the dermis. Shear force, meanwhile, exerts a diagonal force to distort and compress tissue; deeper surfaces are more vulnerable to shear force.
Skin tears, which occur on extremities because of shearing or friction forces, are traumatic injuries that separate the epidermis from the dermis. They commonly occur in the very old or very young, and in the critically ill or medically compromised.
3. Identify risk factors
A number of contributing or compounding factors are associated with pressure ulcers and skin injuries, according to NPUAP, although the significance of these risk factors has yet to be fully realized. In fact, notes NPUAP, the development of pressure ulcers can be complex and multifactorial. Not all risk factors can be removed or modified, adds the panel, and some interventions that could lessen risks may be medically contraindicated.
Skin damp with sweat or irrigation solutions becomes macerated and can't easily slide on surfaces. Intraoperative underbody patient-warming devices, which can increase moisture on the skin's surface, have been implicated in pressure ulcer formation. Tubes, cables or medical devices laid across or placed on patients can also jeopardize skin integrity.
Pressure ulcers are less of an issue in short-duration surgeries, but you must still take care to position patients properly, especially if they present with known risk factors (see "Pressure Ulcer Red Flags"). Pressure ulcer risks gradually increase as case times lengthen. For example, the likelihood of pressure ulcers developing jumps from 5.8% to 13.2% between 3-hour and 7-plus-hour cases. Research has also shown that pressure ulcer risk increases 3.3% for every 30 minutes a 4-hour case is prolonged.
Surgery-acquired pressure ulcers are a challenge because of the following intraoperative risk factors:
- time on the OR table
- surgical positions
- intensity and duration of pressure
- patient's immobility
- skin moisture
- underbody warming devices
- prolonged hypothermia
- use of anesthetics that impair mobility and sensation
- peripheral vascular disease or diabetes mellitus
- hemodynamic issues
- advanced age
- use of steroids
- obesity or underweight
- low blood pressure
- vascular disorders
- ASA classification of III or greater
- sensory deficit
- transfer from another facility
- low hemoglobin/hematocrit
- nutritional deficiencies
- low serum protein
— Susan Overman, RN, BSN, CNOR
4. Assess, document and educate
AORN guidelines suggest you position patients in collaboration with anesthesia providers and surgeons. Regularly review policies and procedures pertaining to patient positioning, assign a clinical manager to monitor staff performance, provide yearly staff training on skin injury prevention and conduct periodic competency testing.
In the OR, document the patient's skin condition, the position or positions the patient is placed in and the positioning aids used. Also be sure to note when patients present for surgery with pre-existing pressure ulcers or skin injuries to prove they didn't happen on your watch. (You may also be able to get paid for treating them.) Document what you did to protect these patients from further harm. Alert the surgeon, who'll decide to cancel the case or dress the wounds, proceed with the surgery and write orders to have them treated post-op.
5. Focus on problem areas
Sedated patients can't tell you if they're experiencing pain, which would indicate the potential for skin damage, so ensure their weight is evenly distributed, especially over bony prominences. When positioning patients, keep the body aligned and avoid stretching extremities. Perform routine skin assessments immediately after positioning patients to identify potential trouble spots.
For patients in the supine position, pressure sites include the toes (from bed sheets or drapes), heels, thighs, sacrum, elbows, humerus, vertebrae and occiput. The heels, lower legs, knees, greater trochanter, humerus and ears are at risk on patients placed in the lateral position. Patients placed in the prone position must have their toes, patella, thighs, rib cage and ears protected. Finally, pad the shoulder blades, buttocks, heels and balls of the feet on patients placed in sitting positions.
During longer cases, occasionally lift and massage areas susceptible to pressure ulcers or skin injuries while taking care to ensure the airway is always maintained. Also ensure patients are secured to the surgical surface with safety straps to keep them from moving during procedures, particularly when placed in the Trendelenburg position.
6. Rely on positioning aids
Reducing incidences of pressure ulcers demands collaboration with surgeons and wound care specialists, and a clear understanding of the devices available to limit risks and how they're used in practice.
Always employ appropriate pressure-reduction and positioning tools such as viscoelastic polyethylene-urethane mattresses, absorbent table cover sheets, gel pads, heel suspension boots and soft silicone dressing. Wicking pads and drapes placed between the patient and positioning devices pull moisture from the skin and maintain the skin's microenvironment.
For patients in the common supine position, place heels in suspension boots, which offload the sensitive areas and facilitate circulation. During shorter cases, placing pillows under the calves — and ensuring the calves remain in place — will lift the heels off the surgical surface. Apply absorbent, soft silicone, self-adherent bordered dressings on the sacrum as appropriate — based on identified risk factors — to wick moisture from the skin and decrease friction and shear injury risks. (Also consider applying the dressing to the heels to protect them from the same injury risks.) Specially designed pillows with hollow centers support the patient while limiting pressure on the ears and top of the head.
Viscoelastic foam mattresses decrease interface pressure on patients placed in all positions. Ensure the mattresses on your surgical tables are designed to support the heaviest patients you host. Minimize the layers of fabric between the patient and the mattress; multiple layers increase the pressure gradient and decrease the mattress's pressure-reduction benefits. If you place a sheet over the table's surface, keep the fabric wrinkle-free to limit skin injury risks, especially to elderly or underweight individuals.
Apply under-body warming blankets only when absolutely necessary because they may cause moisture to form on the skin, which accelerates tissue damage. When warming blankets must be used, place a gel pad under the sacral area and place an absorbent sheet between the warming blanket and the patient to absorb moisture from the skin.
Adhesives can damage skin when they're applied and removed. Silicone dressing applied to adhesive pads sticks to, but doesn't pull at, the skin, so your staff can remove pads periodically to check the skin's integrity without worrying about damage.