POSITIONAL PLAY Making sure pre-op nurses know the pressure points associated with a patient's anticipated surgical position can help to prevent pressure ulcers.

I've spent more than 40 years working in health care, and preventing pressure ulcers in the OR has become a priority only recently. We used to think the patient wasn't in the OR long enough to acquire a pressure injury, but these days we're much more aware of how quickly and easily a patient's skin can become compromised — and how costly and potentially dangerous it can be when it does. (see "The Heavy Burden of Pressure Ulcers" on page 59).

Having patients leave your facility with their skin intact requires a multi-pronged approach. Beginning in July 2015, our medical center implemented a bundle of initiatives to prevent pressure ulcers for patients throughout their length of stay, whether they're in ambulatory surgery or one of our critical care or interventional units. These initiatives included:

1. Staff education and communication. Prevention begins with knowing the risk factors and how to effectively manage them. Who's most at risk? Broadly speaking, any patient in a procedure lasting 3 hours or more should be considered high risk, as should anyone with a score of 16 or below on the Braden Scale for Predicting Pressure Sore Risk (osmag.net/ZMs6Cf) and a body mass index of 19 and below or 35 and above.

Resources and toolkits from the Association of periOperative Registered Nurses and the Agency for Healthcare Research and Quality can help you teach pre-op and post-op nurses the ins and outs of prevention and treatment, including how to identify the telltale signs of a pressure injury and how to stage an injury accurately. These tools can also provide guidance on which parts of the body will be vulnerable to pressure injuries based on the patient's anticipated surgical position. After all, if you don't take the time to educate the staff about surgical positions, how will they know how the pressure points differ between, say, lithotomy position and prone position?

UNDER PRESSURE
The Heavy Burden Of Pressure Ulcers

SORE SPOT Besides adding to the cost of care, pressure injuries can affect reimbursements, hurt patient-satisfaction scores and spur litigation.

In our ORs, we take every measure to maintain the integrity of our patients' skin — and for good reason. Consider:

• Hospital-acquired pressure ulcers affect more than 2.5 million people per year, according to the Agency for Healthcare Research and Quality (AHRQ).
• As many as 60,000 people per year die as a result of infections stemming from pressure ulcers. They're among the most-common healthcare-related claims, second only to wrongful death.
• Pressure ulcers are expensive. AHRQ statistics put the cost to the U.S. healthcare system at $9.1 billion to $11.6 billion per year, with each injury adding a minimum of more than $20,000 to a patient's cost of care.
• In addition to treatment-related costs, pressure injuries can result in litigation and government penalties, plus they can negatively affect performance metrics and reimbursements. CMS views pressure injuries as "never events." CMS does not reimburse the cost of treatment for a patient who acquires a new pressure injury.

—Diane B. Kimsey, MSN, MHA, CNOR, CMLSO

2. Pre-op skin evaluation. Through the implementation of this head-to-toe assessment, we discovered that as many as 25% of patients are at risk of developing a pressure ulcer, which was higher than we anticipated. It's also helped us identify existing pressure injuries so we can document and address them before surgery. If a patient comes in with an existing injury but it's not assessed and documented with a pre-op skin evaluation, we have to assume it was generated in the OR. In addition to a full visual assessment, I ask the patient if he has had previous pressure ulcers, because the skin here is more susceptible to breaking down.

3. Making at-risk patients "visible." Once you have assessed a patient as "high risk," all stakeholders must be able to easily identify them as such. We have high-risk patients wear bright green bouffant caps as opposed to the standard blue. We also place a green "alert" placard in each high-risk patient's chart, so even if communication somehow breaks down between departments, it's clear which patients are at risk.

4. Dressings and positioning aids. All our high-risk patients receive heel protectors. We prophylactically pad patients with low BMI on such bony prominences as the heels and sacrum. In the case of an existing injury, we'll use a gentle dressing with a silicone border as a protective barrier.

We keep a dedicated "skin cart" in the pre-op area, complete with a range of prophylactic foam dressings and a "gel cart" in the OR with gel-based pads and fluidized positioning devices. We also use an air-powered transfer device, which is made of an almost parachute-like material. Each of these single-use devices is designed to reduce skin shear and friction. Each is also completely cleanable, so it remains with the patient for the duration of their stay.

5. Repositioning patients. When a procedure tips past the 3-hour mark, we may ask the surgeon to stop so we can perform an intra-operative skin assessment and make any necessary micro-adjustments to the patient's position. This might not be possible for some surgeries — robotic cases, for example — but for most it's a chance to make sure the patient's skin hasn't been compromised and, if it has, to prevent it from worsening.

6. Post-op interventions. A secondary, post-op skin assessment will determine whether a patient needs any specialized care, such as a wound-nurse consult or an alternative support surface. Also, just as we do in pre-op, we'll offload patients from their surgical position — say, having them lie on their side if the procedure had them placed in the supine position. We also educate patients on the need to maintain the offloaded position post-operatively.

GREEN LIGHT At Einstein, a patient who has a high risk of developing a pressure ulcer dons a bright green bouffant cap as opposed to the standard blue.

7. Monitoring compliance. I recommend auditing 100% of patient charts to make sure everyone is complying with the prevention bundle. Our first compliance audits of pre- and post-op documentation screens in our EMRs began in August 2015. After 3 months, once it became clear that staff had embraced the new protocols, we scaled back from the 100% mark. We now audit 10 charts per month, and we're still seeing excellent compliance.

8. Buy-in from all stakeholders. This might be the most important ingredient, because if you're not getting buy-in from everyone — starting with senior leadership, and so on down the line — you're likely to fail. Pre-op nurses are a fine example. We now bring patients into the pre-op area earlier to perform the skin assessment, which means more work for the pre-op nurses. Educating them about what's at stake if we forgo this crucial step — the potential for patient harm and increased costs, for starters — has made them understand the extra 15 or 30 minutes it adds to the process are a necessity rather than a chore.

Your bundle-prevention team should reflect a diversity of patient-care stakeholders — nurses, wound-care specialists, surgeons, risk management and C-suite leaders — with passionate champions in each department. They're the ones who'll explain to their peers, "Here's a rundown of everything we're going to do for patients and why."

Making a difference
Our medical center started creating our pressure-injury bundle in October 2014, and we had all components in place by July 2015. After averaging about 6 per year, we then went a full year without a pressure injury. We had a blip in January 2017, when a cardiac patient developed a pressure ulcer on the back of the head the same size and shape as the foam doughnut device we'd been using for years. We've since switched to a fluidized positioner that redistributes the pressure by conforming to and supporting the patient's head, thereby reducing the injury risk. Today, from the moment a patient enters pre-op to the time they go home, we place a heavy emphasis on protecting each patient's skin. We couldn't say that before, and it's making a big difference in patient outcomes. OSM