PRESSURE ULCER PREVENTION Do your nurses know how to use positioning devices appropriately to disperse pressure points, thus decreasing the risk for a pressure ulcer?

A hospital-acquired condition is a nice way of saying that we messed up and gave our patient a complication she didn't have when she checked in for surgery, like the hip she broke when she fell out of bed or the sponge we left inside her abdomen. Of course, Medicare no longer pays facilities for the increased costs of care that result when we harm a patient by one of these conditions. The intent of withholding payment is to force us to prevent such problems in the first place. The 4 hospital-acquired conditions that concern us most in surgery are foreign object retained after surgery, pressure ulcers, surgical site infections and falls. As I'll outline for you, in most cases we can prevent these unwanted, undesirable reminders of surgery.

1 Retained objects. If preventing retained objects is such a high priority among perioperative nurses, why is it still being reported as a common sentinel event occurring daily across our nation? In the perioperative setting, there are numerous distractions throughout a surgical procedure. Distractions are listed as one of the leading reasons for a retained object in a surgical patient. Other potential causes for retained objects are multitasking, not following the established procedure for ensuring no object is left behind, pressure to count quickly so the surgeon can close, the surgeon refusing to stop closing so you can take the count, mixing items to be counted with trash and counting too quickly.

How can we eliminate barriers in our day-to-day practice and ensure an accurate count on every patient? First, we must provide a safe environment for every team member in an OR in order for all team members to feel safe to speak up when policy and procedures are not being followed or when a suspected potential for patient harm is noted. Being able to speak up will not eliminate the problem alone. Leaders and staff need to work together to minimize distractions and multitasking while the surgical count is being performed. Using technology to assist in identifying and counting sponges, laps and other items should be implemented to supplement the manual count procedure. Count policies and procedures should be examined and revised to reflect the AORN Recommended Practices as the standard used in every OR. Leaders should provide education and set expectations to include every member of the perioperative team.

2 Pressure ulcers. I refer to pressure ulcers as a hidden adverse event in an outpatient surgical facility, because we seldom witness or are informed of a pressure ulcer resulting from a surgical procedure in our centers. But they're out there. Of the more than 1 million patients who acquired a pressure ulcer in 2011, one-fourth acquired them in the perioperative setting, according to an article in Ostomy Wound Management. The most common area for a pressure ulcer? The heel.

Preventing pressure ulcers begins with knowing the pathophysiology of a pressure ulcer and the risk factors that could result in one. Your nurses must know how to use positioning devices appropriately to disperse pressure points, thus decreasing the risk for a pressure ulcer. Be sure your team has the appropriate positioning devices to use. Test and document competencies of every perioperative nurse during orientation and at least once annually thereafter.

Inspect the positioning devices before each use to confirm the device is not compromised. Nurses must also know how to transfer a patient from the stretcher to the OR table and the OR table to the stretcher to avoid skin shearing. The literature states that centers performing surgery on patients greater than 157 pounds should have transfer devices available in every OR. Surgery's 2 most common positioning devices are heel pads and wedges to place under the knees.

3 Healthcare-associated infections (HAIs). More than 1.5 million patients acquire surgical site infections while in the care of a perioperative team. The literature reports that 99,000 deaths are associated with HAIs annually. How do we prevent surgical site infections?

Prevention begins with our personal commitment to proper hand hygiene. If each of us commits to washing our hands with soap and water or using an alcohol hand hygiene product on our hands before and after we touch a patient or glove up, we have contributed to stopping the patients we care for from receiving a surgical site infection. Develop a hand hygiene surveillance program. Enforce it daily and address lack of compliance. Let's not overlook patients' self-infecting the wound. Another simple step to preventing SSIs is educating patients and their caregivers to wash their hands before and after they touch the dressing or surgical site. Also address surgical attire, sterile technique, reprocessing processes, patient skin antisepsis, environmental cleaning and traffic patterns in the semi-restricted and restricted areas in the center. Appointing a well-trained infection preventionist is essential to your success in preventing SSIs. Your infection preventionist should not only track patients to determine if the patient has or had an SSI, but should also audit infection prevention practices and educate the team when she identifies a breach.

4 Patient falls. A patient fall is a sudden, uncontrolled, unintentional downward displacement of the body to the ground or other object, excluding falls resulting from violent blows or other purposeful actions. Knowing this definition and understanding the risk indicators are your first steps to preventing falls in your facility. Educate your staff on how to assess and identify fall risks in all patients. Provide education on patient fall prevention during orientation and at least once annually thereafter. Education, evaluation and communication are the 3 elements essential to preventing patient falls and injuries. Benchmark your facility's performance in preventing patient falls.