Personalize Your Pressure Injury Prevention Efforts

Too often pressure injuries are thought of as an inpatient problem, an issue that’s highly unlikely to occur during the shorter procedures performed in outpatient facilities on relatively healthy patients. But that mindset fosters a one-size-fits-all approach to the problem, which is a critical flaw in effective pressure injury prevention practices.

“The complexity and dynamics associated with the development of a pressure injury, especially among surgical patients, make it difficult for nurses to take a blanket approach to preventing pressure injuries,” says Dana Tschannen, PhD, RN, a clinical professor at the University of Michigan School of Nursing in Ann Arbor. “We need to focus on ways to individualize care.”

It was the desire to individualize patient care that drove Dr. Tschannen and her colleague Christine Anderson, PhD, RN, a clinical associate professor at the University of Michigan School of Nursing, to pore over pressure injury risk data to identify gaps in assessment capabilities and create a more comprehensive model for predicting when the issues are likely to occur. Their research eventually led to the creation of the Pressure Injury Predictive Model (PIPM), which provides a more accurate picture of the complexity of contextual and process factors associated with pressure injury development. The PIPM uses six factors to determine a patient’s risk for developing a skin injury: pressure, tissue tolerance, friction and shear, patient characteristics, episode of care, and environment.

Drs. Tschannen and Anderson share several best practices that can help you tailor pressure-injury prevention efforts to individual patients:

• Empowered nurses. You can’t underestimate the role nurses play is the prevention of pressure injuries, says Dr. Tschannen, who believes some prevention protocols don’t necessarily give OR nurses the autonomy they need to successfully address the issue at the point of care. “They’re the ones who are there, doing the assessments and implementing the interventions,” she says.

• Thorough assessments. One of the primary ways to empower your nurses is to provide them with the right tools to conduct more thorough assessments that account for the broad range of factors that put patients at an increased risk for a pressure injury. The assessment process is crucial, whether you use the Scott Triggers Scale, the CMUNRO scale or the PIPM. “Surgical patients are three times more likely to develop a pressure injury than non-surgical patients. This in combination with the presence of multiple comorbidities or chronic conditions makes them 13 times more likely to develop an injury,” says Dr. Tschannen. “However, at many outpatient facilities, these additional risk factors aren’t accounted for properly. What we’re trying to achieve is a more personalized predictive model.”

Simply looking at skin pressure and tissue profusion might not be enough, says Dr. Tschannen. “If you have a patient coming in for a procedure, are you capturing information around their comorbidities? Are you thinking about the type of surgery and the amount of time they’ll be on the OR table? Are you thinking about padding potential pressure points to protect the skin?”

• Tailored interventions. By accounting for multiple risk factors, you’ll be able to preemptively react to mitigate patients’ pressure injury risk factors. One example Dr. Tschannen offers is the patient with an extremely low BMI, which tends to get less focus than patients with high BMIs. “If a patient has a very low BMI, consider how you would pad that patient during the intraoperative phase to protect their bony prominences.” One caution when it comes to padding patients: Avoid overdoing it. “Too much padding can increase the interface pressure or cause the body to be out of alignment,” says Dr. Anderson.

• Continual surveillance. After the initial preoperative assessment, nurses must continue to closely monitor patients through the remainder of the perioperative process. “Surveillance is one of the major interventions we have at our disposal,” says Dr. Anderson. “It’s that ability to say, ‘OK, we’ve got a red spot developing on the skin there. We need to watch that.’”

Dr. Anderson also notes that increased surveillance is especially important given the higher rates of pressure injuries she’s seen stemming from medical devices. According to the Joint Commission in 2018, medical device-related pressure injuries accounted for more than 30% of hospital-acquired pressure injuries. A major culprit: oxygen tubing. In fact, research shows that oxygen tubing placed around the ears has long been associated with pressure injuries. It’s an injury that occurs frequently enough to be referred to as a “bedsore of the ear,” so providers must make it a point to regularly check this pressure-injury-prone area on their patients and be ready to intervene before the issue occurs.

The vast majority of pressure injuries are preventable.
— Dana Tschannen, PhD, RN

• Evidence-based guidance. Foam and gel-based positioning aids are readily available, but it’s important to use only products that meet evidence-based standards. “Just because a new positioning aid has been developed by a company doesn’t mean it meets all proper standards,” says Dr. Anderson. 

The standards and protocols for pressure injury prevention can also change over time, says Dr. Anderson, who recommends that surgical leaders regularly review their facilities’ protocols and keep up with what the experts’ best practices. “You need to follow the evidence and adhere to standard recommended practices,” she says.

With longer, more-complex procedures moving to outpatient facilities every year, surgical leaders can’t afford to look at pressure injuries as an inpatient issue. These injuries not only compromise the patient’s quality of life, but they could also lead to life-threatening infections, increased complications and higher costs of care, says Dr. Tschannen. What’s worse, in most cases pressure injuries could’ve been avoided. “The vast majority of pressure injuries are preventable,” says Dr. Tschannen. “In many cases, they’re a consequence of the care the patient received.”

In an industry filled with stiff competition to provide the best possible patient experience, the last thing you want is for a patient to come in to resolve one problem only to go home with an entirely different one. OSM