Making Pressure Injuries A Thing of the Past

One of the first lights to go on was the realization that this was a pre-operative issue, not just an operating room issue. The pre-op nurses had an important role to play, as did the PACU nurses. Our wound-ostomy-continence (WOC) nurses also helped in several ways, as they tend to be well-versed in this issue. Their first contribution was to help us identify the best evidence-based practices.

In fact, the WOC nurses had recently returned from a conference with some important resources. As a result, the first thing we identified was that the 2-inch-thick mattresses in our ORs were too thin. The recommendation they came back with was that table mattresses be at least 3-inches thick. We’d never thought about that, and probably never would have, but it made sense once it was said out loud.

The revelation also underscored one of the challenges we’d face. We were going to have to justify spending some money. More on that later, but it was unrealistic to think we could immediately buy 35 new mattresses (for our 35 ORs). So, instead, we immediately brought in thicker mattresses where they were most needed. For example, some of our plastic surgery cases can last more than 12 hours. Those ORs got new mattresses right away. And eventually, over time, we replaced them all.

Risk factors

Longer cases are one of the big challenges in preventing pressure injuries, but the research from our WOC nurses also revealed which patients tended to be higher-risk. We needed special precautions with patients who:

• had BMIs of less than 19, or greater than 40;
• had previous or current pressure injuries;
• were 70 or older;
• were bed- or chair-bound; and
• had decreased sensation.

We also learned that while patients with mid-range BMIs were vulnerable to pressure injuries after about 3 hours on the OR table, bariatric patients could develop injuries in half that time.

Furthermore, pressure injuries may not present themselves until 3 to 5 days after surgery, especially deep-tissue injuries, which again pointed to important considerations that went well beyond the OR.

Who does what?

As I said, everyone has a role to play, starting with the pre-op nurses. They began doing skin assessments on every patient, something they hadn’t always done previously, unless patients spoke up and said they’d had pressure injuries in the past. Naturally, we don’t want to get dinged for existing injuries, but we also want to do what we can to address any existing problems. Next, the pre-op nurses place preventative foam dressing wherever it’s needed — especially around the sacral area and any other vulnerable bony areas.

We’ve added that skin assessment to our SBAR (situation, background, assessment, recommendation) handoff communication, so now when patients reach the OR, the nurses there are made aware of any and all skin-related concerns. Then, in the OR, depending on the procedure, we add more foam dressing and gel pads, especially if patients are in the prone position. We make sure to pad their faces, their chests, their hips and their knees.

When the procedure ends, the head OR nurse calls the PACU and gives the report to the charge nurse, but anesthesia actually transports the patient to the PACU. So, if any additional potential skin issues have been identified during the procedure, anesthesia tells the PACU nurses what concerns we had and how we treated them, as well as what the patient position was and how long the surgery lasted.

The PACU nurses then monitor the situation and report to the primary nurse regarding skin findings or other concerns, as well as any prevention plan of care implemented while the patient is in the PACU.

Feedback loop

Before we implemented our new procedures, patients would leave the OR with a potential issue, but we wouldn’t necessarily find out how it turned out — whether the issue was resolved or worsened. Now, we’ve also developed a strong partnership with the caretakers who do follow-up evaluations, so the all-important feedback loop continues for several days. That way, if a problem develops, we can address what we might have been able to do better or differently. As part of the process, we’re continually evaluating different types of positioning equipment to see whether certain products or approaches work better with particular patients.

It’s an elaborate approach, and at first, we got a little bit of pushback. Our physician provider friends weren’t sure everything we were doing was really necessary. We needed to find ways to get them on board. There was also a cost impact that we had to bring through the leadership. Time is money, especially in the OR, and quality preventative dressing is a little pricey. The one we use costs between $6 and $7.

Fortunately, the WOC nurses were very good at providing us with data, which was helpful, because physicians and administrators tend to be very data-driven. We pointed to a pressure-injury case that cost the hospital about $200,000, once you factored in surgical treatment, extended length of stay and required care. That may be more expensive than the typical case, but we were able to demonstrate that prevention was much more cost-effective than treatment.

We’ve also developed a “skin champion” program led by 2 nurses who follow up on every skin issue, work with all the units, and make sure the WOC nurses evaluate whether any given potential injury gets better or worse, so we can learn from the experience.

To me, the most important thing we’ve accomplished, and the thing that will last, is that we’ve created a level of attention that wasn’t there before. Now, pressure injuries are on everybody’s radar every day, and not just with patients who are older or frail. We talk about it, we document what we do, and every month we have a staff meeting where our “skin champions” update us.

As a Level 1 trauma center, we have some amazing technology and some great surgeons who love to use it in what are sometimes very complex cases. That creates more and more challenges when it comes to preventing pressure injuries. But our collaboration is working: We have more positioning equipment than we’ve ever had, our surgeons and anesthesia providers are on board, and our administration makes sure we have the supplies we need to keep our patients safe. OSM